Changes in the provision of institutionalized mental health care in post-communist countries

Psychiatric beds and prison populations in 17 Latin American countries between 1991 and 2017: rates, trends and an inverse relationship between the two indicators

BACKGROUND

In 1990, Latin American countries committed to psychiatric reforms including psychiatric bed removals. Aim of the study was to quantify changes in psychiatric bed numbers and prison population rates after the initiation of psychiatric reforms in Latin America.

METHODS

We searched primary sources to collect numbers of psychiatric beds and prison population rates across Latin America between the years 1991 and 2017. Changes of psychiatric bed numbers were compared against trends of incarceration rates and tested for associations using fixed-effects regression of panel data. Economic variables were used as covariates. Reliable data were obtained from 17 Latin American countries: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Honduras, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, El Salvador, Uruguay and Venezuela.

RESULTS

The number of psychiatric beds decreased in 15 out of 17 Latin American countries (median -35%) since 1991. Our findings indicate the total removal of 69 415 psychiatric beds. The prison population increased in all countries (median +181%). Panel data regression analyses showed a significant inverse relationship -2.70 (95% CI -4.28 to -1.11; p = 0.002) indicating that prison populations increased more when and where more psychiatric beds were removed. This relationship held up when introducing per capita income and income inequality as covariates -2.37 (95% CI -3.95 to -0.8; p = 0.006).

CONCLUSIONS

Important numbers of psychiatric beds have been removed in Latin America. Removals of psychiatric beds were related to increasing incarceration rates. Minimum numbers of psychiatric beds need to be defined and addressed in national policies.

Community-Based Mental Health Services in Azerbaijan: a Course Toward Development: Развитие внебольничной психиатрической службы Азербайджана

Community mental health care in Azerbaijan was established in 2011 in the line with the country's mental health reform. The main directions of the reform, as described in the National Mental Health Strategy, were deinstitutionalization, improving quality of care, integration of mental health into primary healthcare, and implementation of modern community-based services. Over the last decade, the number of beds in psychiatric hospitals has significantly decreased, and many psychiatrists and psychiatric nurses have been transferred to primary care facilities. At the same time, programs focusing on comprehensive care have been implemented in different regions of the country. Community mental health services currently employ various kinds of mental health professional including psychiatrists, clinical psychologists, social workers, occupational therapists, and nurses to ensure a multidisciplinary approach to care provision. Team-based care may focus on crisis resolution, psychosocial rehabilitation, case management, family support, and early intervention for psychosis. Among the barriers preventing development of community mental health services, one should note, in particular, stigma belittling the priority of mental healthcare, uncertainty in distribution of authority between the Ministry of Health and the State Agency for Mandatory Health Insurance, and a general scarcity of human resources, especially in the rural regions. Nevertheless, the mental health care in Azerbaijan is continuing its transition from an institutional model to community-based services.

Changes in national rates of psychiatric beds and incarceration in Central Eastern Europe and Central Asia from 1990-2019: A retrospective database analysis

Background

Numbers of psychiatric beds (general, forensic, and residential) and prison populations have been considered to be indicators of institutionalisation of people with mental illnesses. The present study aimed to assess changes of those indicators across Central Eastern Europe and Central Asia (CEECA) over the last three decades to capture how care has developed during that historical period.

Methods

We retrospectively obtained data on numbers of psychiatric beds and prison populations from 30 countries in CEECA between 1990 and 2019. We calculated the median of the percent changes between the first and last available data points for all CEECA and for groups of countries based on former political alliances and income levels.

Findings

Primary national data were retrieved from 25 out of 30 countries. Data from international registries were used for the remaining five countries. For all of CEECA, the median decrease of the general psychiatric bed rates was 33•8% between 1990 and 2019. Median increases were observed for forensic psychiatric beds (24•7%), residential facility beds (12•0%), and for prison populations (36•0%). Greater reductions of rates of psychiatric beds were observed in countries with lower per capita income as well as in countries that were formerly part of the Soviet Union. Seventeen out of 30 countries showed inverse trends for general psychiatric beds and prison populations over time, indicating a possible shift of institutionalisation towards correctional settings.

Interpretation

Most countries had decreased rates of general psychiatric beds, while there was an increase of forensic capacities. There was an increase in incarceration rates in a majority of countries. The large variation of changes underlines the need for policies that are informed by data and by comparisons across countries.

Funding

Agencia Nacional de Investigación y Desarrollo in Chile, grant scheme FONDECYT Regular, grant number 1190613.

Negative trends in outpatient care of addicted patients in Hungary

OBJECTIVES

This article investigates how the numbers of registered addict patients have changed in the last three decades in Hungary and whether the predicted HIV epidemic among intravenous drug users has occurred.

METHODS

Data were collected from the Annual Reports of the National Bureau of Statistics and National Epidemiological Centre as well as from the medical records of the author.

RESULTS

The total number of registered alcoholics decreased by about 75% during the investigated period. This decrease was more pronounced among males than females. After initial increase, the number of registered drug addicts showed stagnation with an about 50% drop-out rate. Fortunately, the anticipated HIV epidemic did not manifest. The negative effect of a poor political action upon the number of client visits could, however, be documented.

CONCLUSION

In conclusion, negative trends are seen in the Hungarian addiction care. Numerous variables may be taken into consideration as affecting factors, but it is not yet clear to what extent these negative factors are responsible for trends. These data, however, warrant further investigations.

1324 prison suicides in 10 countries in South America: incidence, relative risks, and ecological factors

PURPOSE

Although suicide rates of prison populations and incidence factors have been reported for high-income countries, data from low- and middle-income regions are lacking. The purpose of the study was to estimate suicide rates among prison populations in South America, to examine prison-related factors, and to compare suicide rates between prison and general populations.

METHODS

In this observational study, we collected the numbers of suicides in prison, rates of prison occupancy, and incarceration rates from primary sources in South America between 2000 and 2017. We compared suicide rates among prisoners with incidence rates in the general populations by calculating incidence rate ratios. We assessed the effect of gender, year, incarceration rates and occupancy on suicide rates in the prison populations using regression analyses.

RESULTS

There were 1324 suicides reported during 4,437,591 person years of imprisonment between 2000 and 2017 in 10 South American countries. The mean suicide rate was 40 (95% CI 16-65) per 100,000 person years for male and female genders combined. The pooled incidence rate ratio of suicide between prison and general populations was 3.9 (95% CI 3.1-5.1) for both genders combined, 2.4 (95% CI 1.9-3.1) for men and a higher ratio in women (13.5, 95% CI 6.9-26.9). High occupancies of prisons were associated with lower incidence of suicide (β = - 58, 95% CI - 108.5 to - 7.1).

CONCLUSIONS

Suicides during imprisonment in South America are an important public health problem. Suicide prevention strategies need to target prison populations.

The Penrose Effect and its acceleration by the war on drugs: a crisis of untranslated neuroscience and untreated addiction and mental illness

In 1939, British psychiatrist Lionel Penrose described an inverse relationship between mental health treatment infrastructure and criminal incarcerations. This relationship, later termed the 'Penrose Effect', has proven remarkably predictive of modern trends which have manifested as reciprocal components, referred to as 'deinstitutionalization' and 'mass incarceration'. In this review, we consider how a third dynamic-the criminalization of addiction via the 'War on Drugs', although unanticipated by Penrose, has likely amplified the Penrose Effect over the last 30 years, with devastating social, economic, and healthcare consequences. We discuss how synergy been the Penrose Effect and the War on Drugs has been mediated by, and reflects, a fundamental neurobiological connection between the brain diseases of mental illness and addiction. This neuroscience of dual diagnosis, also not anticipated by Penrose, is still not being adequately translated into improving clinical training, practice, or research, to treat patients across the mental illness-addictions comorbidity spectrum. This failure in translation, and the ongoing fragmentation and collapse of behavioral healthcare, has worsened the epidemic of untreated mental illness and addictions, while driving unsustainable government investment into mass incarceration and high-cost medical care that profits too exclusively on injuries and multi-organ diseases resulting from untreated addictions. Reversing the fragmentation and decline of behavioral healthcare with decisive action to co-integrate mental health and addiction training, care, and research-may be key to ending criminalization of mental illness and addiction, and refocusing the healthcare system on keeping the population healthy at the lowest possible cost.

Assessing the need for a mental health services reform in Moldova: a situation analysis

BACKGROUND

This study describes the Moldovan mental health system and reform needs before and during the initial phase of the MENSANA project (2014-2022) over the period 2007-2017.

METHODS

A situation analysis was performed on: (1) the comparative need based on a country comparison using publicly available mental health system data; (2) the normative need based on a document review comparing the Moldovan mental health services structure with the norms of the WHO on the ideal mix of services, and a content analysis of interview and survey data from professionals (n = 93); (3) the felt need based on a content analysis of survey data from service users and carers (n = 52).

RESULTS

The main finding from the comparative analysis is that mental health care remains largely institutionalized with little alternative care options in the community. Moldova has large mental hospitals and a high number of psychiatric beds per 100.000 population (59.8) in comparison with the South-eastern European Health Network and EU15 average in 2014 (47.63 and 36.61). The country also shows an inversion of the ideal mix of services. This points to the potential need for a mental health system reform which was confirmed by the perspectives of the professionals, service users and carers. The majority of respondents favour a mental services reform (82.8% of the professionals and 92.3% of the care recipients) and express numerous issues and reform needs with the most frequently mentioned being the need to: (1) reintegrate service users in society, community and family; (2) deinstitutionalise and implement CBMHS; (3) improve the accessibility and quality of services, and; and 4) address health workforce issues.

CONCLUSION

All three types of need explored in the situation analysis (e.g. comparative, normative and felt) point towards the necessity to reform the mental health system in Moldova. However, it is emphasized that this will only materialize when underlying socio-economic challenges that both constrain the implementation of community-based mental health services and foster the dependence of people with a mental illness on inpatient services are addressed.

What drives changes in institutionalised mental health care? A qualitative study of the perspectives of professional experts

BACKGROUND

Since 1990, the provision of mental healthcare has changed substantially across Western Europe. There are fewer psychiatric hospital beds and more places in forensic psychiatric hospitals and residential facilities. However, little research has investigated the drivers behind these changes. This study explored qualitatively the perspectives of mental health professional experts on what has driven the changes in Western Europe.

METHODS

In-depth interviews were conducted with twenty-four mental health experts in England, Germany and Italy, who as professionals had personal experiences of the changes in their country. Interviewees were asked about drivers of changes in institutionalised mental health care from 1990 to 2010. The accounts were subjected to a thematic analysis.

RESULTS

Four broad themes were revealed: the overall philosophy of de-institutionalisation, with the aim to overcome old-fashioned asylum style care; finances, with a pressure to limit expenditure and an interest of provider organisations to increase income; limitations of community mental health care in which most severely ill patients may be neglected; and emphasis on risk containment so that patients posing a risk may be cared for in institutions. Whilst all themes were mentioned in all three countries, there were also differences in emphasis and detail.

CONCLUSIONS

Distinct factors appear to have influenced changes in mental health care. Their precise influence may vary from country to country, and they have to be considered in the context of each country. The drivers may be influenced by professional groups to some extent, but also depend on the overall interest and attitudes in the society at large.

European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders

Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders (MDOs) are often cared for in secure psychiatric environments or prisons. In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective. We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings: The forensic psychiatrist as expert witness, risk, treatment settings for mentally disordered offenders, and what works for MDOs. We undertook a rapid review of the literature with search terms related to: forensic psychiatry, review articles, randomised controlled trials and best practice. We searched the Medline, Embase, PsycINFO, and Cochrane library databases from 2000 onwards for adult groups only. We scrutinised publications for additional relevant literature, and searched the websites of relevant professional organisations for policies, statements or guidance of interest. We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified. We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only. Practitioners need to follow general psychiatric guidance as well as that for offenders, adapted for the complex needs of this patient group, paying particular attention to long-term detention and ethical issues.

Prevalence and predictors of involuntary psychiatric hospital admissions in Ontario, Canada: a population-based linked administrative database study

BACKGROUND

Involuntary admissions to psychiatric hospitals are common; however, research examining the trends in prevalence over time and predictors is limited. Aims To examine trends in prevalence and risk factors for involuntary admissions in Ontario, Canada.

METHOD

We conducted an analysis of all mental health bed admissions from 2009 to 2013 and assessed the association between patient sociodemographics, service utilisation, pathway to care and severity characteristics for involuntary admissions using a modified Poisson regression.

RESULTS

We found a high and increasing prevalence of involuntary admissions (70.7% in 2009, 77.1% in 2013, 74.1% overall). Individuals with police contact in the prior week (risk ratio (RR) = 1.20) and immigrants both experienced greater likelihood of being involuntarily admitted, regardless of control for other characteristics (RR = 1.07) (both P < 0.0001).

CONCLUSIONS

We identified numerous modifiable and non-modifiable risk factors for involuntary admissions. The prevalence of involuntary admissions was high, linearly increasing over time. Declaration of interest The authors have completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. This study was conducted using funding entirely from public sources. P.K. has received operational support via an Ontario Ministry of Health and Long-Term Care (MOHLTC) Health Services Research Fund Capacity Award to support this project. The Institute for Clinical Evaluative Sciences (ICES) is funded by the Ontario MOHLTC. The study results and conclusions are those of the authors, and should not be attributed to any of the funding agencies or sponsoring agencies. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. All decisions regarding study design, publication, and data analysis were made independent of the funding agencies.

Barriers to delivering mental health services in Georgia with an economic and financial focus: informing policy and acting on evidence

Background

Whilst there is recognition that the global burden of disease associated with mental health disorders is significant, the economic resources available, especially in Low and Middle Income Countries, are particularly scarce. Identifying the economic (system) and financial (individual) barriers to delivering mental health services and assessing the opportunities for reform can support the development of strategies for change.

Methods

A mixed methods study was developed, which engaged with a range of stakeholders from mental health services, including key informants, service managers, healthcare professional and patients and their care-takers. Data generated from interviews and focus groups were analysed using an existing framework that outlines a range of economic and financial barriers to improving mental health practice. In addition, the study utilised health financing and programmatic data.

Results

The analysis identified a variety of local economic barriers, including: the inhibition of the diversification of the mental health workforce and services due to inflexible resources; the variable and limited provision of services across the country; and the absence of mechanisms to assess the delivery and quality of existing services. The main financial barriers identified were related to out-of pocket payments for purchasing high quality medications and transportation to access mental health services.

Conclusions

Whilst scarcity of financial resources exists in Georgia, as in many other countries, there are clear opportunities to improve the effectiveness of the current mental health programme. Addressing system-wide barriers could enable the delivery of services that aim to meet the needs of patients. The use of existing data to assess the implementation of the mental health programme offers opportunities to benchmark and improve services and to support the appropriate commissioning and reconfiguration of services.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2912-5) contains supplementary material, which is available to authorized users.

Criminalization Through Transinstitutionalization: A Critical Review of the Penrose Hypothesis in the Context of Compensation Imprisonment

In 1939, the Penrose hypothesis suggested that the number of psychiatric hospital beds was inversely related to the size of prison populations. Central to a causal interpretation of the Penrose hypothesis is the idea that a small proportion of any population requires institutional mental care. Several studies re-examining longitudinal and cross-sectional data found that a fall in available psychiatric hospital beds occurred over the same period as a rise in prisoner numbers. The observed inverse relationship was mostly interpreted as being the consequence of a lack of compassion for the disadvantaged in society, while other studies concluded that the correlation was spurious and determined by confounders. In Germany, Austria, and Switzerland, lawbreakers who are unwilling or unable to pay a fine for committing a petty crime such can face compensation imprisonment. Every tenth German detainee serves compensation imprisonment with an average incarceration time of 2-3 months. We analyzed the social-economic backgrounds and the levels of mental disorders in four populations of compensation prisoners, consisting of 100 participants each, in the German capital Berlin in 1999, 2004, 2010, and 2017. Largely, the compensation prisoners were homeless, single, and unemployed, exhibited a high degree of substance abuse and showed an extraordinary high prevalence of mental disorders. Unfortunately, as the average stay in prison is short, there are no decisive concepts for social rehabilitation after imprisonment. In addition to a lack of resocialization, potential job loss, and social stigmatization, the newly acquired subcultural contacts facilitate reoffending. This study aims to give an overview of the medical, sociologic, and psychopathologic examinations on compensation prisoners. By analyzing trends in the prevalence of mental disorders, we will discuss the medical appropriateness and sociologic sense of compensation imprisonment with respect to the Penrose hypothesis. Thereby, we aim at shedding light on the question whether compensation imprisonment is an indispensable tool for law enforcement or if it is a punishment of the poor or mentally ill, which further deteriorates their unfavorable socio-economic situation. Finally, we will propose measures to reduce the number of reoffenders and to enable the compensation detainees to reintegrate successfully into society.

Experience of stigma in the public life of relatives of people diagnosed with schizophrenia in the Republic of Belarus

PURPOSE

Mental health-related stigma affects people with mental disorders and their families. We aimed to investigate the experience of stigma among relatives of patients with schizophrenia in Belarus and formulate recommendations for anti-stigma interventions.

METHODS

We conducted and thematically analysed 20 interviews with relatives of people diagnosed with schizophrenia. Experience of discrimination, strategies to cope with it, and requests for interventions were examined.

RESULTS

A number of themes related to the experience of stigma in the public life of relatives of people with schizophrenia were elicited in relation to: (1) mental health care (difficulties in contacting mental health professionals; in getting appropriate information; lack of alternatives to hospital treatment; absence of appropriate long-term care services); (2) employment of people living with schizophrenia and (3) contact with the police. Analysis of the strategies used to overcome difficulties revealed resignation and passive acceptance, self-reliance, and emotional containment during crises. Despite the passivity and scepticism in expressing needs, participants suggested a number of interventions that could reduce the burden of stigma.

CONCLUSIONS

With respect to the public domain of life, substantial stigma and discrimination perceived by families of people living with schizophrenia in Belarus is associated with structural issues of the country's mental health care system. To reduce the stigma-related burden, action must be taken to: (1) educate and support families and (2) deal with structural issues, by reorganising mental health services to better meet the needs of the families of people diagnosed with schizophrenia, and by including them in decision making at all levels.

Penrose's law: Methodological challenges and call for data

The investigation of the relationship between the sizes of the mental health population and the prison population, outlined in Penrose's Law, has received renewed interest in recent decades. The problems that arise in the course of the deinstitutionalization have repeatedly drawn attention to this issue. This article presents methodological challenges to the examination of Penrose's Law and retrospectively reviews historical data from empirical studies. A critical element of surveys is the sampling method; longitudinal studies seem appropriate here. The relationship between the numbers of psychiatric beds and the size of the prison population is inverse in most cases. However, a serious failure is that almost all of the data were collected in countries historically belonging to a Christian or Jewish cultural community. Only very limited conclusions can be drawn from these sparse and non-comprehensive data: a reduction in the number of psychiatric beds seems to be accompanied by increases in the numbers of involuntary admissions and forensic treatments and an accumulation of mentally ill persons in prisons. A kind of transinstitutionalization is currently ongoing. A pragmatic balance between academic epidemiological numbers and cultural narratives should be found in order to confirm or refute the validity of Penrose's Law. Unless comprehensive research is undertaken, it is impossible to draw any real conclusion.

Inpatient forensic-psychiatric care: Legal frameworks and service provision in three European countries

Laws governing the detention and treatment of mentally disordered offenders (MDOs) vary widely across Europe, yet little information is available about the features of these laws and their comparative advantages and disadvantages. The purpose of this article is to compare the legal framework governing detention in forensic psychiatric care in three European countries with long-established services for MDOs, England, Germany and the Netherlands. A literature review was conducted alongside consultation with experts from each country. We found that the three countries differ in several areas, including criteria for admission, review of detention, discharge process, the concept of criminal responsibility, service provision and treatment philosophy. Our findings suggest a profound difference in how each country relates to MDOs, with each approach contributing to different pathways and potentially different outcomes for the individual. Hopefully making these comparisons will stimulate debate and knowledge exchange on an international level to aid future research and the development of best practice in managing this population.

Experience of stigma in private life of relatives of people diagnosed with schizophrenia in the Republic of Belarus

PURPOSE

Family stigma constitutes a major problem in schizophrenia worldwide. Data on first-hand experience of stigma in families is necessary for planning and implementing interventions to reduce its burden. The aim of the study was to investigate the experience of stigma among relatives of persons with schizophrenia in Belarus.

METHODS

Qualitative research methods, such as the thematic analysis of in-depth semi-structured interviews with 20 relatives of people diagnosed with schizophrenia, were used. Experience of discrimination, strategies used to cope with it, and requests for interventions were investigated.

RESULTS

The most salient themes in experience of stigma in the private domain of life elicited in the narratives included anticipated stigma and dissolution of families. The experience of stigma was associated with burdensome feelings of guilt, tiredness and loneliness, together with fear and anxiety due to uncertainty in the future and sorrow because of frustrated hopes in past. Analysis of the strategies used to overcome the difficulties revealed concealment and "life behind closed doors", avoidance of the rest of the family, taking full responsibility and sacrificing one's personal life.

CONCLUSION

To reduce the burden of stigma in the private life of the family members of people living with schizophrenia in Belarus, important steps should be taken to promote the empowerment of families including: reforming mental health services; provision of better access to information; family support services, community care; development of family organisations; assistance in communication, re-socialisation and independent living for people diagnosed with schizophrenia.

How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990

OBJECTIVES

It has been suggested that since 1990, de-institutionalisation of mental healthcare in Western Europe has been reversed into re-institutionalisation with more forensic beds, places in protected housing services and people with mental disorders in prisons. This study aimed to identify changes in the numbers of places in built institutions providing mental healthcare in Western Europe from 1990 to 2012, and to explore the association between changes in psychiatric bed numbers and changes in other institutions.

SETTINGS AND DATA

Data were identified from 11 countries on psychiatric hospital beds, forensic beds, protected housing places and prison populations. Fixed effects regression models tested the associations between psychiatric hospital beds with other institutions.

RESULTS

The number of psychiatric hospital beds decreased, while forensic beds, places in protected housing and prison populations increased. Overall, the number of reduced beds exceeded additional places in other institutions. There was no evidence for an association of changes in bed numbers with changes in forensic beds and protected housing places. Panel data regression analysis showed that changes in psychiatric bed numbers were negatively associated with rising prison populations, but the significant association disappeared once adjusted for gross domestic product as a potential covariate.

CONCLUSIONS

Institutional mental healthcare has substantially changed across Western Europe since 1990. There are ongoing overall trends of a decrease in the number of psychiatric hospital beds and an increase in the number of places in other institutions, including prisons. The exact association between these trends and their drivers remains unclear. More reliable data, information on the characteristics of patients in different institutions, long-term pathway analyses and effectiveness studies are required to arrive at evidence-based policies for the provision of institutional mental healthcare.

Postsocialism, the psy-ences and mental health

Over the past decades, the formerly socialist countries of East Central Europe and Eurasia have experienced a range of transformations which bear directly upon the domains of mental health, psychiatry, and psychology. In particular, the disciplines and professions concerned with the human mind, brain, and behavior ("the psy-ences") were strongly affected by sociopolitical changes spanning the state-socialist and postsocialist periods. These disciplines' relationship to the state, their modes of knowledge production, and the epistemic order and subjectivities they contributed to have all undergone dramatic ruptures. In this essay, we trace the literature on these issues across three thematic domains: (a) history and memory; (b) the reform of psychiatry in an era of global mental health; and (c) therapy and self-fashioning. We argue for a closer articulation between the social science and historical literature on socialism and its "posts" and the literature among anthropologists, sociologists, and historians on the sciences of the mind and brain, and we suggest that each of these literatures helps to critically open up and enrich the other.

Psychiatric Hospital Bed Numbers and Prison Population Sizes in 26 European Countries: A Critical Reconsideration of the Penrose Hypothesis

Background

Recently, there has been a revived interest in the validity of the Penrose hypothesis, which was originally postulated over 75 years ago. It suggests an inverse relationship between the numbers of psychiatric hospital beds and the sizes of prison population. This study aims to investigate the association between psychiatric hospital beds and prison populations in a large sample of 26 European countries between 1993 and 2011.

Methods

The association between prison population sizes and numbers of psychiatric hospital beds was assessed by means of Spearman correlations and modeled by a mixed random coefficient regression model. Socioeconomic variables were considered as covariates. Data were retrieved from Eurostat, the statistical office of the European Union.

Outcomes

Mean Spearman correlation coefficients between psychiatric beds and prison population showed a significant negative association (-0.35; p = <0.01). However, in the mixed regression model including socioeconomic covariates there were no significant fixed parameter estimates. Meanwhile, the covariance estimates for the random coefficients psychiatric beds (σ² = 0.75, p = <0.01) and year (σ² = 0.0007, p = 0.03) yielded significant results.

Interpretation

These findings do not support the general validity of the Penrose hypothesis. Notably, the results of the mixed-model show a significant variation in the magnitude and direction of the association of psychiatric hospital bed numbers and the prison population sizes between countries. In this sense, our results challenge the prevalent opinion that a reduction of psychiatric beds subsequently leads to increasing incarcerations. These findings also work against the potential stigmatization of individuals suffering from mental disorders as criminals, which could be an unintentional byproduct of the Penrose hypothesis.

Institutionalization of deinstitutionalization: a cross-national analysis of mental health system reform

Background

Policies generate accountability in that they offer a standard against which government performance can be assessed. A central question of this study is whether ideological imprint left by policy is realized in the time following its adoption. National mental health policy expressly promotes the notion of deinstitutionalization, which mandates that individuals be cared for in the community rather than in institutional environments.

Methods

We investigate whether mental health policy adoption induced a transformation in the structure of mental health systems, namely psychiatric beds, using panel data on 193 countries between 2001 and 2011.

Results

Our striking regression results demonstrate that late-adopters of mental health policy are more likely to reduce psychiatric beds in mental hospitals and other biomedical settings than innovators, whereas they are less likely than non-adopters to reduce psychiatric beds in general hospitals.

Conclusions

It can be inferred late adopters are motivated to implement deinstitutionalization for technical efficiency rather than social legitimacy reasons.

Electronic supplementary material

The online version of this article (doi:10.1186/1752-4458-8-47) contains supplementary material, which is available to authorized users.

Prevalence rates of mental disorders in Chilean prisons

OBJECTIVE

High rates of mental disorders have been reported for prison populations worldwide, particularly in low- and middle-income countries (LMICs). The present study aimed to establish prevalence rates of mental disorders in Chilean prisoners.

METHOD

A nationwide random sample of 1008 prisoners was assessed in 7 penal institutions throughout Chile. Twelve-month prevalence rates were established using the Composite International Diagnostic Interview (CIDI) and compared to the prevalence rates previously published for the general population.

RESULTS

Prevalence rates were 12.2% (95% CI, 10.2-14.1) for any substance use disorder, 8.3% (6.6-10.0) for anxiety disorders, 8.1% (6.5-9.8) for affective disorders, 5.7% (4.4-7.1) for intermittent explosive disorders, 2.2% (1.4-3.2) for ADHD of the adult, and 0.8% (0.3-1.3) for non-affective psychoses. Significantly higher prevalence rates among prisoners as compared to the general population in Chile were seen for major depression (6.1% vs. 3.7% males, Z=2.58, p<0.05) and illicit drug use (3.3% vs. 0.6% males with drug abuse, Z=2.04, p<0.05; 2.6% vs. 0.1% females with drug abuse, Z=5.36, p<0.001; 3.4% vs. 1.1% males with drug dependence, Z=3.70; p<0.001). Dysthymia (6.5% vs. 15.6%, Z=-2.39, p<0.05), simple (3.3% vs. 11.5%, Z=-3.13, p<0.001) and social phobias (3.9% vs. 9.7%, Z=2.38, p<0.05) were significantly less frequent in the female prison population than in the general population. One-year prevalence rates of alcohol abuse (2.3% vs. 3.9%; Z=-2.04; p<0.05) and dependence (2.7% vs. 8.2%; Z=-5.24; p<0.001) were less prevalent in the male prison population than in the general population.

CONCLUSIONS

Service provision for prison populations in Chile should acknowledge high rates of depression and illicit drug use. Overall prevalence rates are lower than reported in other LMICs. Previous research in prison populations in LMICs might have overestimated prevalence rates of mental disorders.

Understanding psychiatric institutionalization: a conceptual review

BACKGROUND

Since Goffman's seminal work on psychiatric institutions, deinstitutionalization has become a leading term in the psychiatric debate. It described the process of closure or downsizing of large psychiatric hospitals and the establishment of alternative services in the community. Yet, there is a lack of clarity on what exactly the concept of institutionalization means in present-day psychiatry. This review aims to identify the meaning of psychiatric institutionalization since the early 1960s to present-day.

METHOD

A conceptual review of institutionalization in psychiatry was conducted. Thematic analysis was used to synthesize the findings.

RESULTS

Four main themes were identified in conceptualizing institutionalization: bricks and mortar of care institutions; policy and legal frameworks regulating care; clinical responsibility and paternalism in clinician-patient relationships; and patients' adaptive behavior to institutionalized care.

CONCLUSIONS

The concept of institutionalization in psychiatry reflects four distinct themes. All themes have some relevance for the contemporary debate on how psychiatric care should develop and on the role of institutional care in psychiatry.