Background

Major reforms have changed mental health care in Europe over the last five decades. As part of the deinstitutionalisation movement, large asylums were abolished or downsized, and services in the community have been established.

The development of this movement varies greatly across countries. Research suggests that the process of deinstitutionalisation has ended and might have been replaced by a development known as re-institutionalisation, characterised by an increased number of forensic psychiatric beds, number of prisoners, and places in residential care and supported housing. More research is required to understand this process.

This study aimed to examine the potential trend of re-institutionalisation in mental health care where the main objective was to examine how different types of institutionalised mental health care, i.e. care provided by institutions that are defined by bricks and mortar, have changed since 1990. Potential driving factors influencing the provision of mental health services were also be explored. Several countries were taken into account to avoid a false focus on national factors for an international phenomenon.

Research questions

• How is the term 'institutionalisation' conceptualised in modern psychiatry?
• Is there a trend of 're-institutionalisation' in the provision of institutionalised psychiatric care from 1990-2010 in Western Europe?
• Is there an association between psychiatric hospital bed numbers and the prison population?
• What are the underlying mechanisms determining the trend of ‘re-institutionalisation’ in psychiatric care over the last 20 years?

Research activities

• Four main themes were identified in how the term 'institutionalisation' is conceptualised in modern psychiatry: i) bricks and mortar of care institutions, ii) policy and legal frameworks regulating care, iii) clinical responsibility and paternalism in clinician-patient relationships, and iv) patients' adaptive behaviour to institutionalised care.
• Longitudinal data indicate a trend of increasing forensic beds, places in supported housing and prison populations in Western Europe from 1990-2010.
• An association was found between psychiatric hospital bed numbers and prison population.
• Six interrelated themes were revealed from the qualitative analysis as reasons for changes in institutional care: (i) overall philosophy of the mental health care model in the given country, (ii) cost factors, (iii) government policy changes, (iv) organisation of the mental health care system, (v) psychiatric morbidity, and (vi) a growing emphasis on clinical risk assessment.

Conclusion

• Psychiatric hospital bed numbers appear to be linked to prison population, although we do not know why.
• Driving factors behind the development of institutional mental health care are similar across countries, however with different emphasis in different settings.

Associated papers

Priebe, S., Badesconyi, A., Fioritti, A., Hansson, L., Kilian, R., Torres-Gonzales, F., Turner, T., Wiersma, D. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ. 2005;330:123-126.

Priebe S, Frottier P, Gaddini A, Kilian R, Lauber C, Martínez-Leal R, Munk-Jørgensen P, Walsh D, Wiersma D, Wright D. Mental Health Care Institutions in Nine European Countries, 2002 to 2006. Psych Serv. 2008;59:570-573.

Mundt AP, Franciskovic T, Gurovich I, Heinz A, Ignatyev Y, Ismayilov F, Kalapos MP, Krasnov V, Mihal A, Mir J, DPadruchny D, Potocan M, Raboch J, Taube M, Welbel M, Priebe S. Changes in the provision of institutionalized mental health care in post-communist countries. PLoS One 2012;7:6.
doi:10.1371/journal.pone.0038490.

Mir J, Priebe S, Mundt AP. Psychisch Kranke in Ost- und Westdeutschland. Nervenarzt 2013; 84:844
doi:10.1007/s00115- 012-3657-8.

Chow WS, Priebe S. Understanding psychiatric institutionalization: a conceptual review. BMC Psychiatry 2013;13:169. doi:10.1186/1471-244X-13-169.

Mundt AP, Chow WS, Arduino M, et al. Psychiatric Hospital Beds and Prison Populations in South America Since 1990: Does the Penrose Hypothesis Apply? JAMA Psychiatry. 2014. doi:10.1001/jamapsychiatry.2014.2433.

Funder

East London NHS Foundation Trust