What is the deinstitutionalization of psychiatry?

Deinstitutionalization of psychiatry - the process of reforming the psychiatric service, which began in a number of Western countries in the 1950s. It consists of a large-scale reduction in the number of psychiatric beds and psychiatric hospitals with a parallel development of various forms of outpatient care for the mentally ill discharged from psychiatric hospitals. This should prevent patients from developing hospitalism, infringement of their rights and detachment from society. The anti-psychiatric movement has contributed to deinstitutionalization in many ways.

According to the WHO position, deinstitutionalization is one of the priorities in reforming the mental health care system in various countries.

The process of deinstitutionalization includes:

• gradual reduction in the number of psychiatric hospitals and beds in them (in some countries, up to complete elimination);
• development of special services to assist the group of non-institutionalized psychiatric patients;
• transfer of patients living in psychiatric hospitals to alternative forms of care in the community;
• prevention of possible cases of psychiatric patients' admission to inpatient care and their referral to various alternative services.

Deinstitutionalization is based on concerns about the unsatisfactory conditions of patients in state psychiatric hospitals, the desire to improve their material and social status, and to make psychiatric care more humane and more medically and financially efficient. The result of deinstitutionalization is a transition from institutional psychiatry, which has many disadvantages, to noninstitutional psychiatry.

Differences between institutional and non-institutional psychiatry

There are a number of important differences between institutional and non-institutional psychiatry. They are illustrated by the following table:

The basis for the process of deinstitutionalization was laid by the activities and works of Italian professor Franco Bazaglia: "Liquidation of the Psychiatric Hospital as a Place of Isolation," "An Institution to be Liquidated," "Closure of the Psychiatric Hospital," and others. All of Bazaglia's theoretical works are aimed at the realization of a single practical goal: to make it impossible to use psychiatry as an institution of isolation. All psychiatric hospitals in Italy, Switzerland and Sweden have now been eliminated. Deinstitutionalization has been most successful in these three countries.

In virtually all countries of North America and Western Europe, there has been a large-scale downsizing of psychiatric hospitals. Nevertheless, in some European countries psychiatric care is still predominantly provided in large psychiatric hospitals. A report of a WHO conference (January 2005) stated: "Like all public health policy in general, mental health policy suffers from an increased emphasis on hospital-based emergency services, which continue to receive most of the resources and emphasis. As of 2005, more than two-thirds of hospital beds in Europe are still in psychiatric inpatient care.

Number of psychiatric beds by country

Number of psychiatric beds by country for every 100,000 people:

The most significant pace and results of the process of deinstitutionalization of psychiatric care are found in Italy, where Law 180 (Bazaglia's Law) was adopted in 1978, which initiated the process. It abolished the admission of patients in public psychiatric hospitals, and limited the number of psychiatric beds in general hospitals in a service area of 100,000 to 120,000 people was limited to fifteen by Act 180. Thus, for every 100,000-120,000 people in Italy there were no more than fifteen psychiatric beds housed in general hospitals. By 1998, when deinstitutionalization was completed in Italy, spending on psychiatric care had more than halved, from 5 billion lire (equivalent in purchasing power to 54 billion lire in 1998) to 25 billion lire. Italian psychiatrist Lorenzo Toresini notes:

...Deinstitutionalization costs society less than maintaining mental hospitals.

The report of the WHO European Conference pointed out that since the adoption of Act 180, patients have had greater opportunities to participate directly in society.

The struggle to abolish psychiatric hospitals in Italy is reflected in Italian documentaries (Gardens of Abel, Scientists: Franco Bazaglia, The Flight) and in feature films (The Second Shadow, Once upon a Time There Was a City of the Insane...).

Following Italy, ideas for the deinstitutionalization of psychiatry gained widespread popularity in Brazil. The first step towards the deinstitutionalization of psychiatry in Brazil was the International Symposium on Psychoanalysis, Social Groups and Institutions, held in Rio de Janeiro from 19 to 22 October 1978, to which Franco Bazaglia, the mastermind of deinstitutionalization in Italy and Brazil, was invited. This was followed by a series of speeches by Bazaglia at various institutions, outlining some paths to reform and subsequently published under the title "Brazilian Papers. In 1987, under the slogan "Poruma Sociedade sem Manicômios" (For a Society Without Mental Hospitals), the "Movement against Mental Hospitals" was formed in Brazil. The long-awaited National Law 3657 was submitted to the Chamber of Deputies in 1989 by Paulo Delgado, a member of the Minas Gerais Workers Party representing the Movement against Mental Hospitals. This draft was largely inspired by Law 180, which provided for the elimination of psychiatric hospitals and the creation of other assistance services in their place. In 1979, there were 120,000 beds for 70 million people. In 1997, that number was cut almost in half, to 62,514 beds. But after the enactment of Act 10216, with its "Italian spirit," the number was reduced even further. Currently, there are 39,567 beds housed in 226 hospitals to serve a population of about 170 million people. In 1989, the Franco Bazaglia Institute was founded in the Brazilian city of Rio de Janeiro to analyze and coordinate the reforms of psychiatry in Brazil.

However, the deinstitutionalization of psychiatry in Brazil, modeled on Franco Bazaglia's "Democratic Psychiatry", has been called an example of "the biggest failed social experiment of the 20th century". It was also noted that, fortunately for the medical sphere, the policy did not succeed in completely transforming psychiatry, and several modern inpatient and outpatient departments remained in university hospitals, such as the Institute of Psychiatry at the University of São Paulo. Three years later, in 2008, it was indicated that clear progress is being made, due to the return of civil rights to patients, the expansion of services, the reduction and disaggregation of psychiatric hospitals, better control of hospitalizations, discharges and psychiatric treatments, and the availability of funding to an area that had been neglected in the 1970s.

The transformation of Spain took place in the aftermath of the death of the dictator Franco. The experience of reform in the country was contradictory and characterized by regional differences. Legislation providing for the definitive closure of psychiatric hospitals was absent, and multidirectional processes prevailed: along with the intensive dissolution of inpatient facilities in Asturias and Andalusia, there remained regions, such as Catalonia, in which large psychiatric clinics were seen as the main model of psychiatric care.

The 1986 General Health Law, which included a separate chapter on mental health, favored deinstitutionalization. Mental health centers for outpatient psychiatric care, inpatient departments in general hospitals, and local therapeutic centers for the treatment and rehabilitation of persons with the most severe mental disorders were created. Big changes have occurred, for example, in Andalusia, Asturias, and Madrid: the number of inpatient psychiatric beds has dropped from about 100 to less than 25 per 100,000 people. After an average of 21 years in residential care, 25% of patients were able to return to their families, while another 50% were ready to live in shelters. Approximately 500 mental health centers have been established with an average of 87,000 people. Ninety-five inpatient psychiatric units were established in general hospitals, as well as 108 day-care clinics. In some provinces, social services have developed rehabilitation programs, including socially oriented enterprises with paid employment for people with mental disorders, as well as housing.

In Greece, the reform of psychiatric care began in 1983. From 1984 to 2006, the total number of psychiatric beds was reduced from 7,487 to 2,022, a decrease of 73%, and the number of long-term chronic patients in public psychiatric hospitals was reduced by 80%. By 2012, it was planned to keep only one state psychiatric hospital in Greece, where the number of beds would be reduced to 130.

Since the 1970s, the famous Steinhof Hospital in Vienna has been transformed, modernized and reduced in number of beds; by the beginning of the 21st century, only one small inpatient psychiatric care center remained within the walls of this once enormous hospital.

Between 1974 and 2000, Austria witnessed a large-scale reduction of psychiatric beds: from 12,000 to 5,000. Care had begun to be provided in community-based facilities, which were dominated by multidisciplinary staff: day clinics, crisis intervention centers, hostels for persons with mental disorders. In some parts of the country, there are procedures for systematic monitoring of the activities of the staff of such institutions.

Reform in Sweden was characterized by the radical, rapid and effective dismantling of totalitarian psychiatric institutions. Implemented over several years in the mid-1990s, it took place under the slogan of public ethics and social justice: it advocated the view that mentally incompetent people should have the same rights as the physically incompetent. Experts have noted that, since the reform, persons with mental disabilities are no longer discriminated against in Sweden.

The basis for inpatient care in Sweden is only an acute need for medication that cannot be administered elsewhere. 80% of patients receive specialized psychiatric care on an outpatient basis. The length of stay in a Swedish inpatient unit does not usually exceed 30 days, and the average stay is 2 weeks.

In Norway, the Mental Health Program has been active in shifting from inpatient to outpatient care; district mental health centers have been established throughout the country as community-based outpatient clinics. A network of comprehensive mental health services provides continuous support with regard to treatment, housing, employment and social protection.

In France, a policy of "sectorization" was formulated in 1960. In each sector (usually about 70,000 people), prevention and treatment were entrusted to multidisciplinary shifts of workers. Each shift composed according to this principle has various structures allowing to react at the right moment to the turn in the course of the illness of each patient: a day hospital, a post-therapeutic observation room, overnight hospitalization, a medical-psychological center, a crisis department, a distribution center, a therapeutic room for temporary accommodation, etc. Thus, a round-the-clock hospital stay for hospitalization became only one form among those available to the sector. It is not uncommon (even in the most remote areas) for a patient to be treated at home by a psychiatrist and a team of nurses assigned to him.

In France as a whole, the number of psychiatric beds has decreased by three quarters, and the cost of services has fallen. Reforms are advancing toward the integration of psychiatry into the general medical network.

In Germany, deinstitutionalization was closely linked to a reflection on the tragic experience of German history that led to the Holocaust and the T-4 Program. The self-reflexivity of a younger generation of doctors who studied the conditions of organization of psychiatric hospitals during the Nazi era influenced the humanization of psychiatric care, leading to the development of new ethical principles underlying physician action: from social utopian priorities to the priority of patient interests; from the principle of group solidarity to the principle of personal moral responsibility; from the policy of isolation to the policy of emancipation and integration of the mentally ill.

The reform process began without the support of the official leading professional community, which was disinclined to acknowledge the tragic experience of German history; it began only with the initiative of a younger generation of doctors and other professionals in the field of psychiatry. Thanks to this initiative, a Commission on Mental Health, approved by the German government and parliament, was established in 1971. These processes were supported by a broad social movement - the atmosphere of aspirations for social and political change in German society (in education, social assistance, democratization, etc.). The reformist movement in Germany was significantly influenced by Klaus Dörner's The Citizen and Madness, the works of Leing, Foucault and Bazaglia, and the English and Italian experience of deinstitutionalization.

In the course of the reform, there was a rapid downsizing and decentralization of psychiatric hospitals, reduction of hospital beds, expansion of outpatient psychiatric care: creation of day hospitals, rehabilitation institutions, hostels, social firms, etc. Intermediate stay homes (halfway houses), consultative institutions, telephone hotlines, self-help and self-support groups were created. In many cities, psychiatric clinics were opened in multidisciplinary hospitals; the number of outpatient psychoneurologists increased very significantly. As of 2014, of the 53,000 beds in inpatient psychiatric units, 21,000 are in general hospitals.

Reform in Germany has reduced the cost of funding psychiatric services and at the same time led to an improvement in the quality of life of the mentally ill and their relatives.

Currently, in Germany, involuntary admission of persons who have not committed unlawful acts to psychiatric clinics is possible only in rare cases: the main criterion for involuntary admission is an immediate threat to oneself or others (when a person with a mental disorder is on the verge of suicide or could take the life of others). According to some estimates, an overwhelming minority of psychiatric patients remain in the closed regime. Wards where patients with a chronic course of illness had stayed for years were closed during deinstitutionalization. Thanks to an extensive network of social services, persons in need of continuous assistance with their basic needs in life receive help and care at home.

Programs of de-hospitalization and community medical and social care began in England as early as the 1950s and spread widely after the Mental Health Act (1959). As part of deinstitutionalization, the vast majority of English psychiatric hospitals were closed.

Significant attention in England is paid to out-of-hospital psychiatric care, with multidisciplinary outpatient teams and social rehabilitation services playing a major role in the treatment of psychosis. In addition to public hospitals, there are private inpatient units as well as private hostels for persons with mental disorders. Studies of outpatient psychiatric care services have shown that the economic benefit compared to traditional inpatient treatment is very modest, but there is a significantly higher degree of acceptance, satisfaction and higher subjective evaluation by patients. As a result of the reform, the quality of life of former patients of psychiatric clinics who now receive care in community-based mental health services has improved.

For non-psychotic disorders, the vast majority of patients are seen by general practitioners (family physicians) who are highly competent in the field of psychiatry, diagnosing and medically treating depression, schizophrenia, bipolar and anxiety disorders. The family doctor's outpatient clinic also employs nurses, psychologists, social workers and medical specialists. All necessary medical services are provided at this stage, and only patients with the most difficult to diagnose cases of comorbid psychiatric disorders, acute psychosis are admitted to specialized psychiatric departments, many of which are located within the structure of multidisciplinary hospitals.

Children with mental disorders are usually treated by family doctors, nurses, social workers with specialized training and skills, and multidisciplinary teams consisting of counselors, psychologists, psychotherapists, social workers, art therapists or - occasionally - neuropsychiatrists. If necessary, the child is referred for treatment to the pediatric ward, whose specialists work in close cooperation with psychiatrists.

In the 1970s, Israel began to reform psychiatric care according to the theoretical principles of community psychiatry. Psychiatric hospitals were reorganized into mental health centers (which include an observation and diagnostic unit; units for intensive care and long-term treatment, for institutional rehabilitative care; a day hospital; an outpatient clinic; and employment therapy workshops and workshops). Clinical psychologists and social workers are assigned to the units.

The number of psychiatric hospitals under municipal-state management was reduced by 2/3, as a result, private hospitals accounted for 40% of psychiatric beds. The system of psychiatric care along the vector "population - family doctor - mental health service - psychiatric hospital" was formed.

The number of outpatient clinics increased by 50% from 1988 to 1993. An extensive network of state-funded rehabilitation services was created; services for children and adolescents, psychogerontological care, EPAN hotlines, etc.

However, the general crisis in Israel has led to cuts in spending on psychiatric services, reducing the scope and quality of services; hospital staff have ignored the new principles of social psychiatry, with no economic incentives in their work. The creation of mental health centers remained the main (and essentially the only) achievement of the reform.

In the 1960s, the deinstitutionalization of psychiatry became a subject of work and discussion in the United States, and was frequently highlighted in the specialized literature. In 1966, F. Alexander and S. Selesnik, writing on the history of psychiatry, noted an increasing trend toward deinstitutionalization: "The prevailing trend in the United States to organize psychiatric departments in general hospitals is encouraging. The leading physicians in such hospitals, psychiatrists and internists alike, are often successful in integrating the somatic and psychiatric treatment of both mental and organic diseases. The psychiatric hospital, isolated both geographically and ideologically from medical centers, is now regarded by many as a relic of the past. Thirty years later, the trend noted by Alexander and Selesnik has led to concrete results. In the United States, deinstitutionalization from 1955 to 1998 reduced the number of beds per 100,000 population in state psychiatric hospitals from 339 to 21. Between 1950 and 2000, 118 of 322 psychiatric hospitals were closed.

American psychiatrist Fuller Tory, in his book Schizophrenia, provides an estimate of the extent of deinstitutionalization in the United States:

The scale of deinstitutionalization is hard to comprehend. In 1955, there were 559,000 chronically ill patients in state psychiatric clinics. Today there are fewer than 90,000. The population grew from 166 million to 258 million between 1955 and 1993, which means that if the same number of hospitalized patients per capita in 1993 as in 1955 had been present, the total number would have been 869,000. Consequently, approximately 780,000 people, more than three-quarters of the million who would have been in psychiatric institutions in 1955, now live among us.

Fuller Tory draws the following conclusion:

Ninety percent of those who would have been admitted to a psychiatric hospital forty years ago are not in one today.

As a result of the reforms, many patients who previously would have faced lifelong isolation have been successfully integrated into society.

The incoherence of the process of deinstitutionalization and changes in the law has resulted in the homelessness of the mentally ill in many states.

The deinstitutionalization movement in Canada began in the first half of the 1960s. In 1961, an article by R. Sommer and H. Osmond (doctors who worked at the Weybum Provincial Psychiatric Hospital in Saskatchewan) was published to great acclaim, arguing that the development of mental illness often had as its cause the hospitalization of patients in psychiatric hospitals. The process of deinstitutionalization continued in the 1970s and 1990s, but not in the way originally envisioned by its proponents: the funds saved by closing psychiatric hospitals were not allocated to assistance in the community, which, as in the United States, caused a rapid increase in the number of homeless people.

In modern Canada, mental health care is often provided by teams of professionals, which must consist of psychiatrists, psychologists, social workers, nurses and (sometimes) therapists. However, the first professional care for a person with any illness, including mental illness, is usually provided by a family physician; he or she also makes referrals to specialized services: family counselling, psychotherapy, group therapy.

Reform of psychiatry in Poland began in the early 1990s and was strongly supported by the adoption of the Mental Health Act in 1994. In a few years, the number of beds in psychiatric clinics was reduced by a third, and the conditions of patients' stay in clinics were improved. Psychiatric departments in general hospitals, a network of day hospitals, patient clubs, community support centers, social therapy workshops, hotels for persons with mental disorders, special guarded apartments were created. The organization of psychiatric care is based on the idea that patients must actively participate in the process of treatment and rehabilitation. Non-professional community organizations and self-help organizations play an important role.

As of 2015, there are 144 psycho-neurological boarding schools and seventy psychiatric hospitals, with about sixty thousand people living in them. The rate of hospitalized morbidity was, as of 2011, one of the highest compared to other post-Soviet countries - 531.1 per 100,000 population.

Deinstitutionalization and neuroleptics

It has often been suggested that deinstitutionalization was only possible due to the widespread use of neuroleptics. This assumption has been repeatedly challenged, in particular in the book Models of Insanity by J. Reed, L.R. Mosher, R.P. Bentall, who pointed out that in a number of countries a dramatic reduction in the number of beds occurred even before the introduction of neuroleptics into clinical practice, and in some countries the number of beds in the first years after neuroleptics were widely used increased dramatically.

One of the reasons for the dramatic reduction of beds was revolutionary innovations in patient care: the emergence of day hospitals, the creation of hostels and "halfway houses," the development of therapeutic communities, and industrial therapeutic organizations. This was one of the factors that made it possible to replace the secondary goals with the primary one of providing patients with care.

Mistakes in Deinstitutionalization and Common Criticisms

Deinstitutionalization can be fraught with errors. In the United States, for example, the reduction in the number of patients in hospitals has not been accompanied by the creation of sufficient community-based services. Consequently, a significant number of persons with mental disorders ended up in boarding schools, joined the ranks of the homeless, or began to abuse alcohol and drugs. With modern psychopharmacological treatment and the availability of psychosocial assistance, the vast majority of people with mental disorders can be adapted to society either completely or partially: living with families, in their own apartment or in boarding houses and rehabilitation centers. However, some people with chronic severe disorders require highly structured round-the-clock care: either in inpatient settings or in the form of out-of-hospital care. Reform in the U.S. and Canada has been deemed a failure, while in Italy psychiatric care reform, with broad public, professional and political support, has been a success.

In the popular press in Western countries, as well as by some politicians, the opinion is often expressed that the process of deinstitutionalization inevitably leads to an increase in crime among persons with mental disorders. In reality, there is no scientific basis for such an assertion: there are no studies confirming an increased risk of delinquency during deinstitutionalization; those prone to antisocial and violent acts, both during the existence of institutional psychiatry and subsequently, were most often imprisoned.

In the UK, media coverage of sensational crimes attributed by the press to persons with mental disorders has raised public safety concerns. A movement emerged against continued deinstitutionalization and for greater oversight of patients in psychiatry; changes to the UK Mental Health Act have been proposed.

In some countries, health officials have often suggested the idea of not closing psychiatric hospitals as an alternative to deinstitutionalization, and viewed it as a great achievement. With the view that closing hospitals should not be an end in itself, in the 1980s a senior British health official stated, "Any fool can close a psychiatric hospital.

For professionals working in the system of psychiatric care (psychiatrists, clinical psychologists, etc.), a negative attitude toward the process of deinstitutionalization and the model of community-based medical and social care is often characteristic. Resistance by medical staff unions in a number of countries has hindered the reform of psychiatric services. The WHO contribution indicates the reasons for this negative attitude:

• Many professionals have been trained to work in hospitals, most often in psychiatric hospitals, and for the most part have only a partial understanding of the process, taking as a model for the development of pathology extremely severe mental disorders.
• In reforming, hospital staff fear losing their jobs or some of the benefits that hospital-based professionals enjoy: higher salaries, research facilities, further training, and opportunities to engage in teaching.
• Ideological attitudes against institutionalization are often combined with accusations against hospital staff, which, in turn, causes resentment among professionals working in hospitals.

However, as stated in the WHO materials, these reasons are surmountable: in particular, guarantees should be created that during the reform none of the hospital staff will lose their jobs or lose their pay, financial incentives for the work of medical and social care staff, etc.