THE DEVELOPMENT OF DE-INSTITUTIONALIZATION IN EUROPE H a n s Th. U f f i n g , P h . C . , M a r i a M. C e h a , P h . D . , a n d G e r h a r t H. S a e n g e r , P h . D .
In this article movements from institutional to community care for psychiatric patients in various European countries are discussed. Programs considering the welfare of afflicted persons, diminution of psychopathology and improvements of functioning, as well as the costs of deinstitutionalization are reviewed. The review first deals with the prevention of admissions prior to referral to inpatient facilities, looking at the role of general practitioners and ambulatory services in preventing admissions. Secondly, alternatives for hospital care are considered. Thirdly, consideration is given to the possibilities of shortening the time patients stay in hospitals. Next, experiences in discharging long stay patients to alternatives for continued care in psychiatric hospitals are reported. Finally, the advantages are shown of integrating all regional mental health services under one administration. Selected national policies are described as well as the success of present programs are discussed. With few exceptions only European studies are reported.
The authors are affiliated with the University of Limburg. Hans Th. Uffing, is assistant professor, Dept. of Social Psychiatry; Maria M. Ceha, is associate pro~ lessor, Dept. of Clinical Psychiatry; Gerhart H. Saenger, is professor, Dept. of Medical Sociology. Address correspondence to Ha~s Th. Uffing, University of Limburg, PO Box 616, 6200 MD Maastricht, The Netherlands. PSYCHIATRIC QUARTERLY, Vo]. 63, No. 3, Fall 1992 0033-2720/92/0900-0265506,50/0 © 1992 Human Sciences Press, Inc.
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INTRODUCTION Some time ago the WHO in its 1985 report of ~Public Health in Europe" (Freeman, Freyers, Henderson) reported a moderate improvement in mental health care in Europe(l). One measure of progress used was the reduction of beds over time. For most countries information is available as to the number of psychiatric beds per 1000 inhabitants between 1972 and 1982. Particular large decreases were reported from England (33%) and Sweden (37%), relatively small decreases from the Netherlands (13%). The WHO reports that there were relatively more beds in more developed t h a n in less developed countries. This may mean that either in the latter countries fewer persons in need of care can get inpatient services, or that in less developed countries more mentally disordered persons are maintained at home. It may also mean that in countries with few psychiatric beds in psychiatric institutions more patients are admitted to the psychiatric wards of general hospitals. As can be seen from Table 1, a high turnover of beds was reported from Poland and Czechoslovakia, both however, countries with very few beds per 1000 of inhabitants. Reductions in the number of beds may by itself not necessarily be a good indicator of progress. A better measure of progress might be to study the
TABLE 1 Beds Per T h o u s a n d of Inhabitants and Number of Admission Per Bed in Selected European Countries
Belgium Sweden France The Netherlands England Italy Poland Germany Czechoslovakia * = d a t a n o t available.
Beds per 1000 of inhabitants
Number of admissions per bed
2.43 2.06 1.80 1.75 1.68 1.41 1.53 * 1.09
2A1 1.96 * 1.05 2.09 1.50 3.70 2.53 3.71
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number of patients occupying the average bed over the course of a year (number of admissions per bed per year). Comparing countries which do not differ much in the number of beds per 1000 of inhabitants, we find a high turnover in the number of patients per bed in Poland and England, followed by Italy. The lowest rate of the turnover of patients per bed was found in the Netherlands. Another important measure of progress is the decline in the proportion of long stay patients. In England the proportion of patients in psychiatric hospitals who had been residing there for five years or more was reduced dramatically, from 90 in 1975 to 46 per 10,000 in 1985. The WHO does consider it beneficial ff as many patients as possible are treated in psychiatric wards of general hospitals rather t h a n in psychiatric institutions. One main virtue is t h a t it reduces the risk and ill effect of labelling and stigmatization. It facilitates closer interaction between primary medical care and specialists. Also, patients live nearer to their home, facilitating the maintenance of contacts with friends and families. The proportion of beds in general hospitals compared to the percentage of beds in psychiatric hospitals has increased to a considerable extent in all countries reporting. There were, however, considerable differences between countries. For example 13.5% of all psychiatric beds were in general hospitals in France in 1982, compared to 9.7% in England, 7.6% in the Netherlands and 3.2% in Italy. The shifting to community care, leading to a reduction in the number of severely ill psychiatric patients treated in psychiatric institutions can be accomplished in three different ways by: 1. reducing the number of patients admitted to inpatient psychiatric facilities; 2. decreasing length of stay; 3. discharging long stay chronic patients as much as possible from psychiatric hospitals to community based care.
P R E V E N T I O N OF A D M I S S I O N S Prevention of first admissions can be attempted at two different points of time, during the path of the patient to the hospital and at the time the prospective patient appears at the door of the hospital, referred there for admission.
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It is believed by m a n y t h a t proper care early in the development of mental disorders might prevent hospitalization later on. Questions not yet answered satisfactorily deal with the extent to which early aid is forthcoming, and how effective it has been. What determines whether appropriate care is provided? Whether or not a person with a psychiatric disorder will receive help early depends in the first place on whether the afflicted person himself or someone in his immediate environment recognizes the presence of his problems. Secondly, when recognition of a mental disorder has taken place, will the afflicted person seek help? A pivotal role in the recognition and also the care of psychosocial disorders is being played by the primary physician. This is especially so in countries as England and the Netherlands where patients (with few exceptions) can go to a medical specialist including a mental health specialist only if referred by a family physician. Some persons with mental disorders of course do not visit any doctor when they begin suffering from a psychiatric disorder, for whatever reason. But even among those who during this time visited a primary (family) physician, only a small proportion, four to five percent, as found in a study by v. Zutphen, Saenger and Hendrix(2), complain about a psychosocial problem. As pointed out by Shepard as well as by Buschboek and Verhaak, many patients are themselves unaware of the real nature of their difficulties or tend to feel that medical doctors are interested only in somatic problems(3,4). Recent studies found t h a t family physicians tend not to recognize that a patient suffers from a psychiatric disorder in association with a somatic problem or a psychiatric disorder by itself. Goldberg and Huxley stated t h a t failure of recognition took place in close to 40% of all cases studies by them(5). It is important to note t h a t there are large differences in doctor's capacity to recognize that a patient suffers from psychological difficulties. Differences in the ability to recognize psychiatric pathology cannot be explained by differences in the populations served by different physicians, but mainly in differences between doctors in their interest in dealing with psychiatric pathology, their attitudes toward treating such patients or to refer them to a mental health specialist, their training, their feeling of being competent to deal with psychological problems. In many European countries it has been considered desirable for these reasons not only to upgrade the capacity of family physicians
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to recognize hidden psychological disorders, but also to improve their ability to treat at least minor psychiatric disorders, and to know better when and to whom to refer patients to outpatient or inpatient services. In the Netherlands the government advocated that family physicians play a larger role in the care of minor mental disorders, in part in order to permit the ambulant services to provide more time for the care of the more severe psychiatric disorders. In reaction m a n y experts argued that most general physicians were quite unable to perform this service. To remedy this difficulty it was suggested t h a t psychiatrists or clinical psychologists should as much as possible be attached to primary health care centers to aid in recognition and treatment. Birley reported that the British in recent years attempted to deal with this problem by upgrading the training of family physicians in the area of psychiatry, and to attach psychiatrists to primary care practices(6). A number of British studies (Strathdee & Williams, Williams and Balestieri) deal with the impact of having psychiatrists attached to family practices(7,8). They report that in England almost 20% of all psychiatrists spent some time in a general practice setting. They undertook both assessments and treatments of patients, either alone or with the general practitioner. A detailed analysis for the whole of England undertaken by Williams and Balestieri studied the proportion of psychiatrists attached to faroily practices as well as the number of treatment sessions provided by them, as it occurred in major regions of England and Wales, in relation to differences in hospital admissions. The results of this study indicated that "in those parts of the country where there has been a general increase in family practice based psychiatry, there has also been a greater decline in admissions of non-psychotic patients between 1972 and 1981." The authors, however, warn t h a t the results may at least in part reflect a "more positive orientation toward community psychiatry." Another successful attempt to reduce admissions is reported by Hoult(9) in Australia. Repeating the earlier American experiment by Test and Stein(10) with some modifications he has been able to substitute homecare for care in an institution. All patients referred to one of the leading hospitals for admission were assigned at random to an experimental group for care in their home setting or to a control group receiving traditional hospital care. The experimental group received intensive care in their home setting by two
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specially trained teams including one psychiatrist, psychiatric residents, nurses, social workers and psychologists. The experimental group also differed in t h a t the team members received two months of t r a i n i n g in homecare of severely ill patients. Since they formerly all had worked in a hospital setting they were only trained in in-patient hospital care. Shortly after the patient was returned home following intake the experimental team spent a very large amount of time in the patient's home in order to form a therapeutic bond between the team, the family and the patient. Throughout the experiment they provided information to family and patients about th nature of the disease, worked on family-patient interaction, provided support, guidance, counselling, controlled medication etc. Each team was available around the clock, upon request of the family or patient, throughout the duration of the experiment which lasted 12 months. Comparing the experimental group with the control group 60% of the experimental group were not admitted at any one time during the duration of the study compared to only 2% of the controls. Hospital admission for more t h a n one week was needed by 18% of the experimental and 73% of the controls, for more t h a n one month by 8% of the experimental and 49% of the controls. At the end of the year, half as m a n y experimental patients showed delusional and hallucinatory syndromes and had a lower PSE (Present State Examination) score t h a n control group patients. Relatives in the experimental group were better able to cope with the patients according to the investigators. In addition 70% of the relatives in the experimental group versus only 28% of the controls expressed t h a t they were now better able to cope with their ill patients. At the end of the year these families prefer to keep their patient at home rather t h a n returning him to the institution. In spite of the large expenditure of staff time required by the experiment, total costs for care was slightly lower than costs for control group patients. Several years later Veldhuizen and Kluiter(11) visited Australia to report about what happened since the Hoult study. They reported t h a t in 1988 there were eight similar teams in operation, making possible a reduction of 40-50% of admissions to the psychiatric hospital of those referred to it. Similar results were reported from the Australian city of Adelaide. The local institution provided 250 beds for a population of 800,000. In contrast to the
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previous study by Hoult, the emphasis was on day treatment or care in protective environments. REDUCING RE-ADMISSIONS Tarrrier et. a1.(12) succeeded to reduce readmissions in their experimental study. The aim was to show how it is possible to reduce the relapse rate of severely ill schizophrenic patients discharged from a psychiatric hospital. As is well known schizophrenics react negatively to high stimulation, excessive emotionality, much criticism. Based on this four different groups were selected from patients discharged from the psychiatric institution, two control groups and two experimental groups. The first control group received only routine out patient services while in the second control groups the parents were exposed to a standardized educational program informing them about the characteristics of schizophrenia and how to manage a patient in the home environment. The two experimen~ tal groups were exposed to "behavioural intervention." The families were taught more appropriate methods of coping, how to react under stress through role playing, how to identify components of high stress and how to avoid highly expressed emotions (EE) including intrusiveness, overprotection, in general poor coping reactions. In addition to reducing high "emotionality" on the part of the parents, the team also encouraged an "increase in the patient's level of functioning through a systematic identification of their needs, and planning how to meet these needs." The results were encouraging. Nine months after the behavioral intervention had been initiated, 12% of the patients in the high EE behavior training group relapsed, compared to 43% of patients where parents were exposed to the standardized educational program and 53% of patients who received exclusively routine outpatient services. DECREASING THE TIME PATIENTS STAY IN THE HOSPITAL Deinstitutionalization is expected to lead to a reduction of beds in psychiatric institutions. It may be possible to accomplish this by reducing the amount of time patients stay in a hospital. Most
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findings indicate that a longer stay does not decrease subsequent hospitalizations and does not clearly improve social adjustment or diminish psychopathology. Long term hospital care may increase the patients, desire for continued psychiatric care (Wing). Short term stay with optimal after care may be just as beneficial(13). Long term hospital care is necessary for some patients, but also following Mattes ~'the evidence is consistent and convincing in indicating that hospitalization should be kept as short as possible"(14). The longer patients stay in the hospital following admission, the greater the chance of developing chronicity, the smaller the chance of re-integration to family and community after discharge. Families of discharged patients rather rapidly develop patterns of reorganization, learning to manage without the patient. The returning patient becomes a threat to the newly developed equilibrium and alienation increases. Extent of stay is found to be related to the organization and staffing of the hospitals (Scholte and Uffing), hospital versus patient orientation: whether the staff is arranging the hospital more to facilitate matters for themselves or are mainly concerned with the welfare of the patients(15).
PROTECTIVE ENVIRONMENTS Placements of chronic patients into protective environments is motivated by humanitarian considerations to improve the quality of their lives, prevent the development of the ~hospitalization syndrome" which includes apathy, withdrawal and regression. Protective environments also are considered less expensive than inpatient care. Protective environments attempt to rehabilitate chronic patients, improve their functioning and reduce also psychopathology as far as possible. The protective environment provides a more humanitarian climate than the psychiatric hospital, at best it leads to independent living in the open community (for shorter or longer periods, ff not permanently). Protective environments were scaled by Wing and Furlong from most to least protective settings: hostels, group homes, supervised flats, or residing in one's own home(16).
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TH. UFFING,
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M. CEHA,
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The extent of protection mentioned by Wennink and v. Wijngaarden(17) include 1. Extent to which housekeeping is provided. 2. Extent to which guidance by staffs is given i.e., direction and/ or support. 3. Amount of independence: told what to do versus deciding ibr themselves (ADL, recreational activities etc.). 4. Type and extent of staff time provided by professionals (e.g. psychiatrists, psychologists, social workers, etc. or lay personnel. 5. Decision making with whom to live, or being assigned to live with fellow patients. 6. Extent to which outside contacts, with the open community (family, friends etc.) are provided. Transfers to protective environments are usually provided for patients who have been hospitalized between one and five years. Uchtenhagen thought that the shorter the period the patient stayed in the hospital the greater his chance of a successful rehabilitation(18). Staffs working in protective environments tend to include professionals such as psychiatrists, psychologists, psychiatric social workers. Nonprofessionals function as house mothers or fathers. They are working there for more or less extended periods of time (per day or week) from most to least or being on call only. There is general agreement that staff should be especially trained for work in protective environments. The work is often heavy and demanding. Burn out of staff is related to the extent and quality of their training. Garety and Morris found that the success of staff in promoting patient improvement and satisfaction depends on optimism as to what can be achieved on avoiding excessive emotionality, on tolerance and on the extent to which there is interaction with patients rather than with colleague staff members. In many protective environments patients were systematically trained to take care of themselves, from housekeeping, shopping, handling money to planning their own activities. This was accomplished step by step by first taking patients along on shopping trips, and finally shopping by themselves. To spoil patients by
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doing things for them which they can well do by themselves is to be avoided (it tends to affect their self-esteem). On the other extreme asking them to do things which they are incapable of doing easily leads to de-compensation(19). All protective environments allow patients when they improve to move to less protective settings and ultimately return to the open community if possible(20). Patients who deteriorate or decompensate, may also move from less to more protective environments or even may require readmission to the inpatient service, for more or less extensive periods. It is hoped that patients can not infrequently be discharged to the open community, reunited with their families and become gainfully employed again. Countries and regions within countries differ widely in the extent to which they were able to move patients from more to less protective living environments and from protective environments to independent living in the community.
INTEGRATION OF SERVICES Less successful community services may result from the co-existence of administratively and financially independent services. This leads to poor communication: delays in shifting patients from one service to the other, duplication of services, or "undesirable" patients obtaining no services. What is needed is the existence within regions of an integrated system of care under one administration. A major factor promoting de-institutionalization is the development of integrating regional inpatient (hospital) services, protective environments, ambulant services etc. Within regions integration avoids the danger of costly duplications of services. Without it, according to Romme, the more difficult patient whom nobody wants may tend to fall between the cracks of the system, being referred by one agency to the other(21). A third equally important reason for integration is t h a t the same patient may need a set of different services consecutively or even at the same time. Transfer of patients from one service to another is strongly facilitated under a well integrated system of care with one administration, making available highly individualized treatment modalities and providing continuity of care.
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One of the earliest integrated systems was established on a national level in France. Beginning in ]960, 800 multidisciplinary teams were formed. Each team provided services in a variety of settings serving a sector with a population of about 70,000 having responsibility for all patients regardless of where he was being seen. Continuity of care was to be safeguarded by having the same team taking care of the patient regardless of where he resided in the region during different periods of his careers, a psychiatric hospital, day or night hospital, various ambulatory services etc. Each team was to include minimally a psychiatrist, 4 physicians in training, one or two psychologists, a social worker, one nurse for each ten thousand inhabitants. Little is known about the successes of the French system; van Lieshout and Meurs, following a visit to France report that not all sectors had all services needed, perhaps because some served only a relatively small population. At its earlier stages staff members assigned to the new system who all their life had worked in either hospital or community based ambulant services, found it difficult to adjust to work in both services(22). Adequate preparation for working in a different setting was needed. Convincing results of the benefits of an integrated system were found, for example, in Mannheim, Germany ( H ~ n e r and RSssler), where a mental health case register made it possible to follow the movement of patients over time through a network of services including inpatient as well as outpatient services(23). In Mannheim three fourths of the schizophrenic patients requiring institutional care for one year or more, were instead admitted to sheltered homes and apartments made possible through the establishment of complementary services in the last fifteen years. The direct costs per case of all the services utilized over one year declined to 43% compared with an uninterrupted stay in a mental institution. Moreover, extent of outpatient care correlated significantly with symptomatology at a later point in time: the more contacts with outpatient facilities in the first year of operation, the fewer symptoms in the following six months. These results were not found after continuous inpatient treatment (a.d. Heiden and Krumm): The length of stay was not an essential factor in reducing symptomatology(24). Similar results (Shepherd) were reported from integrated care services in British regions having mental health case registers(25).
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The success of integrating services (Systema, Giel and Ten Horn) has been shown impressively by a systematic study comparing patient careers in areas with and without integrated services in catchment areas located in Verona, (Italy) and Groningen (the Netherlands), both having well functioning mental health case registers for over ten years, serving populations matched for socioeconomic status, age, sex etc.(26). Because of the existence of these registers it was possible to ascertain over a period of one year where the patients resided during different periods in time. While the Verona region was completely integrated, integration had not t a k e n place in the Groningen register area, inpatient and outpatient services being not integrated having separate administrations and staffs. The authors note that in the Verona area a large reduction in the number of psychiatric beds had occurred, whereas in the Dutch area only a limited decline in the number of beds was found. The success of the Verona experiment is attributed to the complete integration of inpatient and outpatient services, permitting optimal continuity of care. The same team treats the patient when in the hospital, and when in ambulant care. Integration has t a k e n place in many parts of Northern Italy, but not so in the Netherlands(27). Some figures may be of interest. In Northern Central Italy, during a period of six years (1977-1983) the number of beds per 1000 inhabitants fell from 1.41 to 0.8. In the Italian register area at any one point in time the proportion of patients receiving any type of c a r e - i n p a t i e n t as well as o u t p a t i e n t - w a s four times as high as in the Dutch register area. The incidence rate was still twice as high in the Dutch than as in the Italian register area. While the number of inpatient admissions was the same in both catchment areas, the Italian patients stayed only a very short period of time in inpatient care, much less t h a n the average Dutch patient and thus many more patients could occupy the same bed during the course of a year. At one point in time the amount of patients in Dutch Register Area staying in an institution was four times as high as in the Italian register area. The incidence rate was only twice as high. This means that all Dutch patients stayed longer in inpatient service than the Italian patients. In conclusion as has been shown it is possible both to cut down admissions as well as substantially shorten the time that even
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chronically ill psychiatric patients remain in psychiatric institutions.
REFERENCES 1. Freeman HC, Freyers T, Henderson T. Mental Health Services in Europe. 10 Years on WHO Public Health in Europe. Copenhagen, 25, 1985. 2. Zutphen v W, Saenger G, Hendrix J. Psychological and social complaints reported by Dutch patients to their doctors. Scandinavian Journal of Primary Health Care 6: 73-76, 1989. 3. Shepard M, Cooper A. Psychiatric illness in general practice. Oxford: Oxford University Press, 1966. 4. Buschboek OJ, Verhaak P. Hoe hanteren huisartsen psychische klachten? Maandblad Geestelijke Volksgezondheid 41: 5: 475-492, 1986. 5. Goldberg D, Huxley P. Mental Illness in the Community. London: Tavistock Publications, 1980. 6. Birley, JLT. Personal Communication. London: The Royal College of Psychiatrists, 1988. 7. Strathdee G, Williams P. A survey of psychiatrists in primary care, the silent growth of a new service. Journal of the Royal College of General Practitioners 34: 615-618, 1984. 8. Williams P, Balestieri M. Psychiatric Clinics in General Practice. Do they reduce admissions. British Journal of Psychiatry 154: 67-71, 1989. 9. Hcult J. Community care of the acutely mentally ill. British Journal of Psychiatry 149: 137-144, 1986. 10. Test MA, Stein LI. Alternatives to mental hospital treatment. New York: Plenum Press, 1978. i1. Veldhuizen v JR, Kluiter H. De-institutionalizationin Austratie. Maandblad Geestelijke Volksgezondheid 4: 411-413, 1989. 12. Tarrier N, Barrowclough C, Vaughn C et al. The community management of schizophrenia, a controlled trial of behavioural intervention with families to reduce relapse. British Journal of Psychiatry 154: 625-628, 1989. 13. Wing JK. Institutionalism in Mental Hospitals. British Journal of Social Clinical Psychology 1: 38, 1962. 14. Mattes JP. The optimal length of hospitalization for psychiatric patients: A review of the Literature. Hospital & Community Psychiatry 33-10: 824-828, 1982. 15. Scholte J A ~ I , Uffing J. Langdurig verbtijf in her Algemeen Psychiatrisch Zieker~huis; een vergelijkende studie. Rapport aan de Ziekenfondsraad, 1982. 16. Wing JK, Furlong R. A Haven for the Severely Disabled within the context of a Comprehensive Psychiatric Community Service. British Journal of Psychiatry 149: 449-457, 1986. 17. Wennink HJ, Wijngaarden v B. De zorg Evaluatie Score. Een schaal veer her meten van de tevredenheid met her wonen in institutionele woonvoorzieningen. Gezondheid en Samenleving 4: 266-274, 1987. 18. Uchtenhagen A. Geschtitste Wohn- und Arbeitsm6glichkeiten ffir psychisch Kranken in der Region Ziirich. Angebote, Erfahrungen, Entwicklungen. Psychiatrische Praxis 7: 237-246, 1980. 19. Garety P, Morris I. A new unit for long-stay psychiatric patients organization, attitudes and quality of care. Psychological Medicine 14: 183-192, 1984. 20. Linn MW, Coffey EM, Klett CJ, Hogarty G. Hospital vs Community (Foster) Care for Psychiatric Patients. Archives of General Psychiatry 34: 78-83, 1977. 21. Romme MAJ. Samenwerkingsverbanden in de Ambulante Geestelijke Gezondheidszorg, een noodzaak om alternatieven veer het psychiatrisch ziekenhuis op verant-
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22. 23. 24. 25. 26. 27.
PSYCHIATRIC QUARTERLY woorde wijze te kunnen realiseren. In: Alternatieven voor bet psychiatrisch ziekenhuis. Gent: Nationale Vereniging voor Geestelijke Gezondheidszorg, 1981. Lieshout v P, Meurs P. Geestelijke gezondheidszorg in Frankrijk. Maandblad Geestelijke Volksgezondheid 3: 282-293, 1987. H~fner H, RSssIer W, Mannheim S. Psychiatrische Notfallversorgung und Krisenintervention; Konzepte, Erfahrungen und Ergebnisse. Psychiatrische Praxis, 13:203-212 1986. Heiden an der W, Krumm B. Does outpatient treatment reduce hospital stay in schizophrenics. Archiver of Psychiatry and Neurological Sciences 235: 26-31, 1985. Shepherd G. Changes in the pattern of psychiatric services in the N.K. Symposium: Offenbach: Psychiatric Reforms in Europe, May 1990. Systema S, Giel R, Hoorn ten GHMM (eds). Gebruik in Italie en Nederland. Maandblad Geestelijke Volksgezondheid 4: 368-383, 1989. Grinten vd T. Mental Health Care in the Netherlands. In: Mangen SP, Berkenham (ed), Mental health care in the European Community, Kent: 1985.
In this article movements from institutional to community care for psychiatric patients in various European countries are discussed. Programs considering the welfare of afflicted persons, diminution of psychopathology and improvements of functioning, as well as the costs of deinstitutionalization are reviewed. The review first deals with the prevention of admissions prior to referral to inpatient facilities, looking at the role of general practitioners and ambulatory services in preventing admissions. Secondly, alternatives for hospital care are considered. Thirdly, consideration is given to the possibilities of shortening the time patients stay in hospitals. Next, experiences in discharging long stay patients to alternatives for continued care in psychiatric hospitals are reported. Finally, the advantages are shown of integrating all regional mental health services under one administration. Selected national policies are described as well as the success of present programs are discussed. With few exceptions only European studies are reported.
The authors are affiliated with the University of Limburg. Hans Th. Uffing, is assistant professor, Dept. of Social Psychiatry; Maria M. Ceha, is associate pro~ lessor, Dept. of Clinical Psychiatry; Gerhart H. Saenger, is professor, Dept. of Medical Sociology. Address correspondence to Ha~s Th. Uffing, University of Limburg, PO Box 616, 6200 MD Maastricht, The Netherlands. PSYCHIATRIC QUARTERLY, Vo]. 63, No. 3, Fall 1992 0033-2720/92/0900-0265506,50/0 © 1992 Human Sciences Press, Inc.
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INTRODUCTION Some time ago the WHO in its 1985 report of ~Public Health in Europe" (Freeman, Freyers, Henderson) reported a moderate improvement in mental health care in Europe(l). One measure of progress used was the reduction of beds over time. For most countries information is available as to the number of psychiatric beds per 1000 inhabitants between 1972 and 1982. Particular large decreases were reported from England (33%) and Sweden (37%), relatively small decreases from the Netherlands (13%). The WHO reports that there were relatively more beds in more developed t h a n in less developed countries. This may mean that either in the latter countries fewer persons in need of care can get inpatient services, or that in less developed countries more mentally disordered persons are maintained at home. It may also mean that in countries with few psychiatric beds in psychiatric institutions more patients are admitted to the psychiatric wards of general hospitals. As can be seen from Table 1, a high turnover of beds was reported from Poland and Czechoslovakia, both however, countries with very few beds per 1000 of inhabitants. Reductions in the number of beds may by itself not necessarily be a good indicator of progress. A better measure of progress might be to study the
TABLE 1 Beds Per T h o u s a n d of Inhabitants and Number of Admission Per Bed in Selected European Countries
Belgium Sweden France The Netherlands England Italy Poland Germany Czechoslovakia * = d a t a n o t available.
Beds per 1000 of inhabitants
Number of admissions per bed
2.43 2.06 1.80 1.75 1.68 1.41 1.53 * 1.09
2A1 1.96 * 1.05 2.09 1.50 3.70 2.53 3.71
HANS TH. UFFING, MARIA M. CEHA, AND GERHART H. SAENGER
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number of patients occupying the average bed over the course of a year (number of admissions per bed per year). Comparing countries which do not differ much in the number of beds per 1000 of inhabitants, we find a high turnover in the number of patients per bed in Poland and England, followed by Italy. The lowest rate of the turnover of patients per bed was found in the Netherlands. Another important measure of progress is the decline in the proportion of long stay patients. In England the proportion of patients in psychiatric hospitals who had been residing there for five years or more was reduced dramatically, from 90 in 1975 to 46 per 10,000 in 1985. The WHO does consider it beneficial ff as many patients as possible are treated in psychiatric wards of general hospitals rather t h a n in psychiatric institutions. One main virtue is t h a t it reduces the risk and ill effect of labelling and stigmatization. It facilitates closer interaction between primary medical care and specialists. Also, patients live nearer to their home, facilitating the maintenance of contacts with friends and families. The proportion of beds in general hospitals compared to the percentage of beds in psychiatric hospitals has increased to a considerable extent in all countries reporting. There were, however, considerable differences between countries. For example 13.5% of all psychiatric beds were in general hospitals in France in 1982, compared to 9.7% in England, 7.6% in the Netherlands and 3.2% in Italy. The shifting to community care, leading to a reduction in the number of severely ill psychiatric patients treated in psychiatric institutions can be accomplished in three different ways by: 1. reducing the number of patients admitted to inpatient psychiatric facilities; 2. decreasing length of stay; 3. discharging long stay chronic patients as much as possible from psychiatric hospitals to community based care.
P R E V E N T I O N OF A D M I S S I O N S Prevention of first admissions can be attempted at two different points of time, during the path of the patient to the hospital and at the time the prospective patient appears at the door of the hospital, referred there for admission.
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It is believed by m a n y t h a t proper care early in the development of mental disorders might prevent hospitalization later on. Questions not yet answered satisfactorily deal with the extent to which early aid is forthcoming, and how effective it has been. What determines whether appropriate care is provided? Whether or not a person with a psychiatric disorder will receive help early depends in the first place on whether the afflicted person himself or someone in his immediate environment recognizes the presence of his problems. Secondly, when recognition of a mental disorder has taken place, will the afflicted person seek help? A pivotal role in the recognition and also the care of psychosocial disorders is being played by the primary physician. This is especially so in countries as England and the Netherlands where patients (with few exceptions) can go to a medical specialist including a mental health specialist only if referred by a family physician. Some persons with mental disorders of course do not visit any doctor when they begin suffering from a psychiatric disorder, for whatever reason. But even among those who during this time visited a primary (family) physician, only a small proportion, four to five percent, as found in a study by v. Zutphen, Saenger and Hendrix(2), complain about a psychosocial problem. As pointed out by Shepard as well as by Buschboek and Verhaak, many patients are themselves unaware of the real nature of their difficulties or tend to feel that medical doctors are interested only in somatic problems(3,4). Recent studies found t h a t family physicians tend not to recognize that a patient suffers from a psychiatric disorder in association with a somatic problem or a psychiatric disorder by itself. Goldberg and Huxley stated t h a t failure of recognition took place in close to 40% of all cases studies by them(5). It is important to note t h a t there are large differences in doctor's capacity to recognize that a patient suffers from psychological difficulties. Differences in the ability to recognize psychiatric pathology cannot be explained by differences in the populations served by different physicians, but mainly in differences between doctors in their interest in dealing with psychiatric pathology, their attitudes toward treating such patients or to refer them to a mental health specialist, their training, their feeling of being competent to deal with psychological problems. In many European countries it has been considered desirable for these reasons not only to upgrade the capacity of family physicians
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to recognize hidden psychological disorders, but also to improve their ability to treat at least minor psychiatric disorders, and to know better when and to whom to refer patients to outpatient or inpatient services. In the Netherlands the government advocated that family physicians play a larger role in the care of minor mental disorders, in part in order to permit the ambulant services to provide more time for the care of the more severe psychiatric disorders. In reaction m a n y experts argued that most general physicians were quite unable to perform this service. To remedy this difficulty it was suggested t h a t psychiatrists or clinical psychologists should as much as possible be attached to primary health care centers to aid in recognition and treatment. Birley reported that the British in recent years attempted to deal with this problem by upgrading the training of family physicians in the area of psychiatry, and to attach psychiatrists to primary care practices(6). A number of British studies (Strathdee & Williams, Williams and Balestieri) deal with the impact of having psychiatrists attached to family practices(7,8). They report that in England almost 20% of all psychiatrists spent some time in a general practice setting. They undertook both assessments and treatments of patients, either alone or with the general practitioner. A detailed analysis for the whole of England undertaken by Williams and Balestieri studied the proportion of psychiatrists attached to faroily practices as well as the number of treatment sessions provided by them, as it occurred in major regions of England and Wales, in relation to differences in hospital admissions. The results of this study indicated that "in those parts of the country where there has been a general increase in family practice based psychiatry, there has also been a greater decline in admissions of non-psychotic patients between 1972 and 1981." The authors, however, warn t h a t the results may at least in part reflect a "more positive orientation toward community psychiatry." Another successful attempt to reduce admissions is reported by Hoult(9) in Australia. Repeating the earlier American experiment by Test and Stein(10) with some modifications he has been able to substitute homecare for care in an institution. All patients referred to one of the leading hospitals for admission were assigned at random to an experimental group for care in their home setting or to a control group receiving traditional hospital care. The experimental group received intensive care in their home setting by two
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specially trained teams including one psychiatrist, psychiatric residents, nurses, social workers and psychologists. The experimental group also differed in t h a t the team members received two months of t r a i n i n g in homecare of severely ill patients. Since they formerly all had worked in a hospital setting they were only trained in in-patient hospital care. Shortly after the patient was returned home following intake the experimental team spent a very large amount of time in the patient's home in order to form a therapeutic bond between the team, the family and the patient. Throughout the experiment they provided information to family and patients about th nature of the disease, worked on family-patient interaction, provided support, guidance, counselling, controlled medication etc. Each team was available around the clock, upon request of the family or patient, throughout the duration of the experiment which lasted 12 months. Comparing the experimental group with the control group 60% of the experimental group were not admitted at any one time during the duration of the study compared to only 2% of the controls. Hospital admission for more t h a n one week was needed by 18% of the experimental and 73% of the controls, for more t h a n one month by 8% of the experimental and 49% of the controls. At the end of the year, half as m a n y experimental patients showed delusional and hallucinatory syndromes and had a lower PSE (Present State Examination) score t h a n control group patients. Relatives in the experimental group were better able to cope with the patients according to the investigators. In addition 70% of the relatives in the experimental group versus only 28% of the controls expressed t h a t they were now better able to cope with their ill patients. At the end of the year these families prefer to keep their patient at home rather t h a n returning him to the institution. In spite of the large expenditure of staff time required by the experiment, total costs for care was slightly lower than costs for control group patients. Several years later Veldhuizen and Kluiter(11) visited Australia to report about what happened since the Hoult study. They reported t h a t in 1988 there were eight similar teams in operation, making possible a reduction of 40-50% of admissions to the psychiatric hospital of those referred to it. Similar results were reported from the Australian city of Adelaide. The local institution provided 250 beds for a population of 800,000. In contrast to the
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previous study by Hoult, the emphasis was on day treatment or care in protective environments. REDUCING RE-ADMISSIONS Tarrrier et. a1.(12) succeeded to reduce readmissions in their experimental study. The aim was to show how it is possible to reduce the relapse rate of severely ill schizophrenic patients discharged from a psychiatric hospital. As is well known schizophrenics react negatively to high stimulation, excessive emotionality, much criticism. Based on this four different groups were selected from patients discharged from the psychiatric institution, two control groups and two experimental groups. The first control group received only routine out patient services while in the second control groups the parents were exposed to a standardized educational program informing them about the characteristics of schizophrenia and how to manage a patient in the home environment. The two experimen~ tal groups were exposed to "behavioural intervention." The families were taught more appropriate methods of coping, how to react under stress through role playing, how to identify components of high stress and how to avoid highly expressed emotions (EE) including intrusiveness, overprotection, in general poor coping reactions. In addition to reducing high "emotionality" on the part of the parents, the team also encouraged an "increase in the patient's level of functioning through a systematic identification of their needs, and planning how to meet these needs." The results were encouraging. Nine months after the behavioral intervention had been initiated, 12% of the patients in the high EE behavior training group relapsed, compared to 43% of patients where parents were exposed to the standardized educational program and 53% of patients who received exclusively routine outpatient services. DECREASING THE TIME PATIENTS STAY IN THE HOSPITAL Deinstitutionalization is expected to lead to a reduction of beds in psychiatric institutions. It may be possible to accomplish this by reducing the amount of time patients stay in a hospital. Most
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findings indicate that a longer stay does not decrease subsequent hospitalizations and does not clearly improve social adjustment or diminish psychopathology. Long term hospital care may increase the patients, desire for continued psychiatric care (Wing). Short term stay with optimal after care may be just as beneficial(13). Long term hospital care is necessary for some patients, but also following Mattes ~'the evidence is consistent and convincing in indicating that hospitalization should be kept as short as possible"(14). The longer patients stay in the hospital following admission, the greater the chance of developing chronicity, the smaller the chance of re-integration to family and community after discharge. Families of discharged patients rather rapidly develop patterns of reorganization, learning to manage without the patient. The returning patient becomes a threat to the newly developed equilibrium and alienation increases. Extent of stay is found to be related to the organization and staffing of the hospitals (Scholte and Uffing), hospital versus patient orientation: whether the staff is arranging the hospital more to facilitate matters for themselves or are mainly concerned with the welfare of the patients(15).
PROTECTIVE ENVIRONMENTS Placements of chronic patients into protective environments is motivated by humanitarian considerations to improve the quality of their lives, prevent the development of the ~hospitalization syndrome" which includes apathy, withdrawal and regression. Protective environments also are considered less expensive than inpatient care. Protective environments attempt to rehabilitate chronic patients, improve their functioning and reduce also psychopathology as far as possible. The protective environment provides a more humanitarian climate than the psychiatric hospital, at best it leads to independent living in the open community (for shorter or longer periods, ff not permanently). Protective environments were scaled by Wing and Furlong from most to least protective settings: hostels, group homes, supervised flats, or residing in one's own home(16).
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The extent of protection mentioned by Wennink and v. Wijngaarden(17) include 1. Extent to which housekeeping is provided. 2. Extent to which guidance by staffs is given i.e., direction and/ or support. 3. Amount of independence: told what to do versus deciding ibr themselves (ADL, recreational activities etc.). 4. Type and extent of staff time provided by professionals (e.g. psychiatrists, psychologists, social workers, etc. or lay personnel. 5. Decision making with whom to live, or being assigned to live with fellow patients. 6. Extent to which outside contacts, with the open community (family, friends etc.) are provided. Transfers to protective environments are usually provided for patients who have been hospitalized between one and five years. Uchtenhagen thought that the shorter the period the patient stayed in the hospital the greater his chance of a successful rehabilitation(18). Staffs working in protective environments tend to include professionals such as psychiatrists, psychologists, psychiatric social workers. Nonprofessionals function as house mothers or fathers. They are working there for more or less extended periods of time (per day or week) from most to least or being on call only. There is general agreement that staff should be especially trained for work in protective environments. The work is often heavy and demanding. Burn out of staff is related to the extent and quality of their training. Garety and Morris found that the success of staff in promoting patient improvement and satisfaction depends on optimism as to what can be achieved on avoiding excessive emotionality, on tolerance and on the extent to which there is interaction with patients rather than with colleague staff members. In many protective environments patients were systematically trained to take care of themselves, from housekeeping, shopping, handling money to planning their own activities. This was accomplished step by step by first taking patients along on shopping trips, and finally shopping by themselves. To spoil patients by
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doing things for them which they can well do by themselves is to be avoided (it tends to affect their self-esteem). On the other extreme asking them to do things which they are incapable of doing easily leads to de-compensation(19). All protective environments allow patients when they improve to move to less protective settings and ultimately return to the open community if possible(20). Patients who deteriorate or decompensate, may also move from less to more protective environments or even may require readmission to the inpatient service, for more or less extensive periods. It is hoped that patients can not infrequently be discharged to the open community, reunited with their families and become gainfully employed again. Countries and regions within countries differ widely in the extent to which they were able to move patients from more to less protective living environments and from protective environments to independent living in the community.
INTEGRATION OF SERVICES Less successful community services may result from the co-existence of administratively and financially independent services. This leads to poor communication: delays in shifting patients from one service to the other, duplication of services, or "undesirable" patients obtaining no services. What is needed is the existence within regions of an integrated system of care under one administration. A major factor promoting de-institutionalization is the development of integrating regional inpatient (hospital) services, protective environments, ambulant services etc. Within regions integration avoids the danger of costly duplications of services. Without it, according to Romme, the more difficult patient whom nobody wants may tend to fall between the cracks of the system, being referred by one agency to the other(21). A third equally important reason for integration is t h a t the same patient may need a set of different services consecutively or even at the same time. Transfer of patients from one service to another is strongly facilitated under a well integrated system of care with one administration, making available highly individualized treatment modalities and providing continuity of care.
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One of the earliest integrated systems was established on a national level in France. Beginning in ]960, 800 multidisciplinary teams were formed. Each team provided services in a variety of settings serving a sector with a population of about 70,000 having responsibility for all patients regardless of where he was being seen. Continuity of care was to be safeguarded by having the same team taking care of the patient regardless of where he resided in the region during different periods of his careers, a psychiatric hospital, day or night hospital, various ambulatory services etc. Each team was to include minimally a psychiatrist, 4 physicians in training, one or two psychologists, a social worker, one nurse for each ten thousand inhabitants. Little is known about the successes of the French system; van Lieshout and Meurs, following a visit to France report that not all sectors had all services needed, perhaps because some served only a relatively small population. At its earlier stages staff members assigned to the new system who all their life had worked in either hospital or community based ambulant services, found it difficult to adjust to work in both services(22). Adequate preparation for working in a different setting was needed. Convincing results of the benefits of an integrated system were found, for example, in Mannheim, Germany ( H ~ n e r and RSssler), where a mental health case register made it possible to follow the movement of patients over time through a network of services including inpatient as well as outpatient services(23). In Mannheim three fourths of the schizophrenic patients requiring institutional care for one year or more, were instead admitted to sheltered homes and apartments made possible through the establishment of complementary services in the last fifteen years. The direct costs per case of all the services utilized over one year declined to 43% compared with an uninterrupted stay in a mental institution. Moreover, extent of outpatient care correlated significantly with symptomatology at a later point in time: the more contacts with outpatient facilities in the first year of operation, the fewer symptoms in the following six months. These results were not found after continuous inpatient treatment (a.d. Heiden and Krumm): The length of stay was not an essential factor in reducing symptomatology(24). Similar results (Shepherd) were reported from integrated care services in British regions having mental health case registers(25).
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The success of integrating services (Systema, Giel and Ten Horn) has been shown impressively by a systematic study comparing patient careers in areas with and without integrated services in catchment areas located in Verona, (Italy) and Groningen (the Netherlands), both having well functioning mental health case registers for over ten years, serving populations matched for socioeconomic status, age, sex etc.(26). Because of the existence of these registers it was possible to ascertain over a period of one year where the patients resided during different periods in time. While the Verona region was completely integrated, integration had not t a k e n place in the Groningen register area, inpatient and outpatient services being not integrated having separate administrations and staffs. The authors note that in the Verona area a large reduction in the number of psychiatric beds had occurred, whereas in the Dutch area only a limited decline in the number of beds was found. The success of the Verona experiment is attributed to the complete integration of inpatient and outpatient services, permitting optimal continuity of care. The same team treats the patient when in the hospital, and when in ambulant care. Integration has t a k e n place in many parts of Northern Italy, but not so in the Netherlands(27). Some figures may be of interest. In Northern Central Italy, during a period of six years (1977-1983) the number of beds per 1000 inhabitants fell from 1.41 to 0.8. In the Italian register area at any one point in time the proportion of patients receiving any type of c a r e - i n p a t i e n t as well as o u t p a t i e n t - w a s four times as high as in the Dutch register area. The incidence rate was still twice as high in the Dutch than as in the Italian register area. While the number of inpatient admissions was the same in both catchment areas, the Italian patients stayed only a very short period of time in inpatient care, much less t h a n the average Dutch patient and thus many more patients could occupy the same bed during the course of a year. At one point in time the amount of patients in Dutch Register Area staying in an institution was four times as high as in the Italian register area. The incidence rate was only twice as high. This means that all Dutch patients stayed longer in inpatient service than the Italian patients. In conclusion as has been shown it is possible both to cut down admissions as well as substantially shorten the time that even
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chronically ill psychiatric patients remain in psychiatric institutions.
REFERENCES 1. Freeman HC, Freyers T, Henderson T. Mental Health Services in Europe. 10 Years on WHO Public Health in Europe. Copenhagen, 25, 1985. 2. Zutphen v W, Saenger G, Hendrix J. Psychological and social complaints reported by Dutch patients to their doctors. Scandinavian Journal of Primary Health Care 6: 73-76, 1989. 3. Shepard M, Cooper A. Psychiatric illness in general practice. Oxford: Oxford University Press, 1966. 4. Buschboek OJ, Verhaak P. Hoe hanteren huisartsen psychische klachten? Maandblad Geestelijke Volksgezondheid 41: 5: 475-492, 1986. 5. Goldberg D, Huxley P. Mental Illness in the Community. London: Tavistock Publications, 1980. 6. Birley, JLT. Personal Communication. London: The Royal College of Psychiatrists, 1988. 7. Strathdee G, Williams P. A survey of psychiatrists in primary care, the silent growth of a new service. Journal of the Royal College of General Practitioners 34: 615-618, 1984. 8. Williams P, Balestieri M. Psychiatric Clinics in General Practice. Do they reduce admissions. British Journal of Psychiatry 154: 67-71, 1989. 9. Hcult J. Community care of the acutely mentally ill. British Journal of Psychiatry 149: 137-144, 1986. 10. Test MA, Stein LI. Alternatives to mental hospital treatment. New York: Plenum Press, 1978. i1. Veldhuizen v JR, Kluiter H. De-institutionalizationin Austratie. Maandblad Geestelijke Volksgezondheid 4: 411-413, 1989. 12. Tarrier N, Barrowclough C, Vaughn C et al. The community management of schizophrenia, a controlled trial of behavioural intervention with families to reduce relapse. British Journal of Psychiatry 154: 625-628, 1989. 13. Wing JK. Institutionalism in Mental Hospitals. British Journal of Social Clinical Psychology 1: 38, 1962. 14. Mattes JP. The optimal length of hospitalization for psychiatric patients: A review of the Literature. Hospital & Community Psychiatry 33-10: 824-828, 1982. 15. Scholte J A ~ I , Uffing J. Langdurig verbtijf in her Algemeen Psychiatrisch Zieker~huis; een vergelijkende studie. Rapport aan de Ziekenfondsraad, 1982. 16. Wing JK, Furlong R. A Haven for the Severely Disabled within the context of a Comprehensive Psychiatric Community Service. British Journal of Psychiatry 149: 449-457, 1986. 17. Wennink HJ, Wijngaarden v B. De zorg Evaluatie Score. Een schaal veer her meten van de tevredenheid met her wonen in institutionele woonvoorzieningen. Gezondheid en Samenleving 4: 266-274, 1987. 18. Uchtenhagen A. Geschtitste Wohn- und Arbeitsm6glichkeiten ffir psychisch Kranken in der Region Ziirich. Angebote, Erfahrungen, Entwicklungen. Psychiatrische Praxis 7: 237-246, 1980. 19. Garety P, Morris I. A new unit for long-stay psychiatric patients organization, attitudes and quality of care. Psychological Medicine 14: 183-192, 1984. 20. Linn MW, Coffey EM, Klett CJ, Hogarty G. Hospital vs Community (Foster) Care for Psychiatric Patients. Archives of General Psychiatry 34: 78-83, 1977. 21. Romme MAJ. Samenwerkingsverbanden in de Ambulante Geestelijke Gezondheidszorg, een noodzaak om alternatieven veer het psychiatrisch ziekenhuis op verant-
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PSYCHIATRIC QUARTERLY woorde wijze te kunnen realiseren. In: Alternatieven voor bet psychiatrisch ziekenhuis. Gent: Nationale Vereniging voor Geestelijke Gezondheidszorg, 1981. Lieshout v P, Meurs P. Geestelijke gezondheidszorg in Frankrijk. Maandblad Geestelijke Volksgezondheid 3: 282-293, 1987. H~fner H, RSssIer W, Mannheim S. Psychiatrische Notfallversorgung und Krisenintervention; Konzepte, Erfahrungen und Ergebnisse. Psychiatrische Praxis, 13:203-212 1986. Heiden an der W, Krumm B. Does outpatient treatment reduce hospital stay in schizophrenics. Archiver of Psychiatry and Neurological Sciences 235: 26-31, 1985. Shepherd G. Changes in the pattern of psychiatric services in the N.K. Symposium: Offenbach: Psychiatric Reforms in Europe, May 1990. Systema S, Giel R, Hoorn ten GHMM (eds). Gebruik in Italie en Nederland. Maandblad Geestelijke Volksgezondheid 4: 368-383, 1989. Grinten vd T. Mental Health Care in the Netherlands. In: Mangen SP, Berkenham (ed), Mental health care in the European Community, Kent: 1985.
