What’s the impact of deinstitutionalisation on patient outcomes?

Deinstitutionalisation – which can be defined as the diversion of people with a mental disorder to community mental health services, reducing the population of psychiatric hospitals, the number of psychiatric bed-days, and broadening the responsibilities of other service entities such as general hospitals and residential care (Bachrach, 1989) – started in Italy in the 1960s and had begun in most affluent economies by the 1970s (Russo et al., 2009).

There is extensive evidence that this long-term process was cost-effective, with community settings costing one-third to one-half of state run psychiatric hospital settings (Lapsley et al., 2000), but the impact on patient outcomes is still debated amongst researchers, and appears to vary widely depending on the patients and the socio-economic environment.

Resulting in better psychiatric coverage, reduced stigma around mental disorders, and overall better symptoms relief, deinstitutionalisation is thought by many to have been generally beneficial in terms of patient care (Eisenberg & Guttmacher, 2010). In fact, some case studies suggest that many patients express greater satisfaction levels with community care compared to their life circumstances inside of psychiatric hospitals (Warner, 1995).

But, despite some attempts to create an objective measure of progress towards deinstitutionalisation – such as the Mental Health Services Deinstitutionalisation Measure – the lack of consensus regarding the exact implementation strategies to be used acts as a barrier to reliably evaluate the benefits of deinstitutionalisation across countries and local communities (Salisbury et al., 2016). As a result, some researchers have expressed doubts as to the robustness of the evidence in favour of deinstitutionalisation, and have denounced the process as a policy for the systematic cutting of mental health budgets, rather than a strategic approach to community mental health (Bachrach, 1983).

Deinstitutionalisation, the way it has been executed in most countries, often treats patients as two distinct groups: the ones who have already been hospitalised and are thus removed from their institutional environments to be transferred into the community, and the ones who may be considered potential candidates for institutionalisation, and who are instead redirected towards alternative service entities (Bachrach, 1976). But there are many more groups of patients to be considered, such as patients entering institutions for the first time today and most likely to be released within a short period of time, or patients who have remained in institutions despite deinstitutionalisation efforts (Bachrach, 1983). This blanket approach has resulted in an inadequate care of the new generation of severely mentally ill persons, who have never been institutionalised, and have therefore not learned to accept their treatment (Lamb, 1993). Placed in a community care setting, and without the safe sanctuary offered in principle by institutions, these individuals often end up either incarcerated or homeless (Lamb & Bachrach, 2001).

In fact, a recent study found a statistically significant correlation between homelessness and deinstitutionalisation (Markowitz, 2006), and a large number of homeless individuals suffering from severe mental disorders such as major depression, psychosis, or schizophrenia, are coming from this new generation (Pepper et al., 1981). The evidence for the trans-institutionalisation of mentally ill individuals from psychiatric hospitals to penal institutions is also well documented, with two meta-analysis research studies examining data from 40 consecutive years finding a significant negative correlation between the number of psychiatric beds and the number of incarcerations (Palermo, et al., 1991; Primeau et al., 2013).

In conclusion, there seems to be more evidence highlighting the failures of deinstitutionalisation, especially in the case of individuals with severe mental illnesses, but many researchers believe that a poor implementation caused by a lack a funding is at fault, rather than a fundamental philosophical error (Kliewer et al., 2009). While psychiatric institutions were characterised by an absence of expectation that patients would ever recover (Patrick, et al., 2006), community mental health services may offer the opportunity for new and potentially more effective evidence-based programmes. Awaiting further research, many countries are currently adopting a blended approach, overcoming the false dichotomy between institutions and communities, with strategies that are adapted to a particular place, time, and individual (Thornicroft & Tansella, 2002). Finally, the implementation of slow-stream rehabilitation approaches allows some long-stay psychiatric in-patients to successfully resettle in community care homes (Trieman & Leff, 2002).

References:

Bachrach, L. L. (1976). Deinstitutionalization: An analytical review and sociological perspective, 1-2.

Bachrach, L. L. (1983). An overview of deinstitutionalization. New directions for mental health services1983(17), 5-14.

Bachrach, L. L. (1989). Deinstitutionalization: A semantic analysis. Journal of Social Issues45(3), 161-171.

Eisenberg, L., & Guttmacher, L. B. (2010). Were we all asleep at the switch? A personal reminiscence of psychiatry from 1940 to 2010. Acta Psychiatrica Scandinavica, 122(2), 89-102.

Kliewer, S. P., Melissa, M., & Trippany, R. L. (2009). Deinstitutionalization: Its Impact on Community Mental Health Centers and the Seriously Mentally Ill. Alabama Counseling Association Journal35(1), 40-45.

Lamb, H. R. (1993). Lessons learned from deinstitutionalisation in the US. The British Journal of Psychiatry162(5), 587-592.

Lamb, H. R., & Bachrach, L. L. (2001). Some perspectives on deinstitutionalization. Psychiatric Services52(8), 1039-1045.

Lapsley, H. M., Tribe, K., Tennant, C., Rosen, A., Hobbs, C., & Newton, L. (2000). Deinstitutionalisation for long-term mental illness: cost differences in hospital and community care. Australian & New Zealand Journal of Psychiatry, 34(3), 491-495.

Markowitz, F. E. (2006). Psychiatric hospital capacity, homelessness, and crime and arrest rates. Criminology44(1), 45-72.

Palermo, G. B., Smith, M. B., & Liska, F. J. (1991). Jails versus mental hospitals: A social dilemma. International Journal of Offender Therapy and Comparative Criminology35(2), 97-106.

Patrick, V., Smith, R. C., Schleifer, S. J., Morris, M. E., & McLennon, K. (2006). Facilitating discharge in state psychiatric institutions: A group intervention strategy. Psychiatric rehabilitation journal29(3), 183.

Pepper, B., Kirshner, M. C., & Ryglewicz, H. (1981). The young adult chronic patient: Overview of a population. Psychiatric Services32(7), 463-469.

Primeau, A., Bowers, T. G., Harrison, M. A., & XuXu. (2013). Deinstitutionalization of the mentally ill: evidence for transinstitutionalization from psychiatric hospitals to penal institutions. Comprehensive Psychology2, 16-02.

Russo, G., Carelli, F., Barnet, V. T. S., & Deanery, L. (2009). Dismantling asylums: The Italian job. London Journal of Primary Care.

Salisbury, T. T., Killaspy, H., & King, M. (2016). An international comparison of the deinstitutionalisation of mental health care: Development and findings of the Mental Health Services Deinstitutionalisation Measure (MENDit). BMC psychiatry,16(1), 54.

Thornicroft, G., & Tansella, M. (2002). Balancing community-basedand hospital-based mental health care. World Psychiatry1(2), 84.

Trieman, N., & Leff, J. (2002). Long-term outcome of long-stay psychiatric in-patients considered unsuitable to live in the community: TAPS Project 44. The British Journal of Psychiatry181(5), 428-432.

Warner, R. E. (1995). Alternatives to the hospital for acute psychiatric treatment. American Psychiatric Association.