Deinstitutionalization of Mental Health Care – Availability of Bed Space and Involuntary Admissions
As developed nations around the world have attempted to deinstitutionalize mental health care, the number of beds available for inpatient treatment has declined. A recent survey of mental health care reported that the decrease in bed space leads to more involuntary admissions for mental health care.
Wealthy, developed nations throughout the world, including the United States and European countries, have spent decades deinstitutionalizing mental health care, offering, instead, a range of outpatient services such as community mental health programs, improved outreach, crisis resolution centers, and early interventions services. Accordingly, there has been a decrease in voluntary inpatient admissions for mental health care. This effect has removed some of the stigma previously associated with mental health care, and patients with mental illnesses are no longer locked away in asylums, as they still are in less developed nations.
Yet, an evaluation of mental health care provision in England reported that this decrease in available inpatient treatment has led to an increase in involuntary admissions for mental health care. In the 20-year study period, the available inpatient space decreased by 60%, and involuntary admissions increased by 60%. The correlation was strongest when a lag time of one year was evaluated. The association was most evident for civil involuntary admissions and non-secure beds. (Forensic involuntary admissions did not increase during the study period.) In all, for every 2-bed reduction in inpatient mental health care, one additional involuntary admission was made in the following year. Nearly four out of ten beds in psychiatric facilities are now occupied by involuntary admissions, up from slightly more than two out of ten 15 years ago. Such compulsory detention is objectionable to many clinicians and patients, and the high costs of inpatient mental health care are worrisome to service providers. Also, outpatient mental health care leads to improved outcomes, including reduced hospitalizations and shorter lengths of stay, increased receipt of psychotropic medication, and fewer episodes of seclusion ad restraint.
The authors posit that the rise in involuntary admissions may be due to a shift, not in the absolute prevalence of mental illness, but a change in the types of mental health disorders diagnosed. An increasing number of inpatient cases are now associated with psychotic and substance misuse disorders, corresponding to a societal increase in the illicit use of drugs and alcohol.
The goal of deinstitutionalized methods of mental health care provision is to provide care in the least restrictive setting possible. The goal of deinstitutionalization is appropriate, but not if it leads to worse outcomes for patients. Simply delaying institutionalization until it is involuntary is not effective intervention. Additionally, the high costs associated with involuntary admissions take funding away from outpatient services that have proved valuable and beneficial. It is not clear what will happen to the future of mental health care if bed space continues to disappear.
Arguably, the health care systems in these studies differ markedly from the health care system in the United States, but, at a time when an overhaul of the health care system and its funding sources seems inevitable, analyzing such trends is imperative. Assessing the actions and reactions of other countries, both positives and negatives, will provide support for moving forward with changes at home.
Abramowitz M, Grinshpoon A, Priebe S, & Ponizovsky AM (2008). New institutionalization as a rebound phenomenon? The case of Israel. The Israel journal of psychiatry and related sciences, 45 (4), 272-7 PMID: 19439832
Craw J, & Compton MT (2006). Characteristics associated with involuntary versus voluntary legal status at admission and discharge among psychiatric inpatients. Social psychiatry and psychiatric epidemiology, 41 (12), 981-8 PMID: 17041737
Keown P, Mercer G, & Scott J (2008). Retrospective analysis of hospital episode statistics, involuntary admissions under the Mental Health Act 1983, and number of psychiatric beds in England 1996-2006. BMJ (Clinical research ed.), 337 PMID: 18845592
Keown P, Weich S, Bhui KS, & Scott J (2011). Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988-2008: ecological study. BMJ (Clinical research ed.), 343 PMID: 21729994
Priebe S, Badesconyi A, Fioritti A, Hansson L, Kilian R, Torres-Gonzales F, Turner T, & Wiersma D (2005). Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. BMJ (Clinical research ed.), 330 (7483), 123-6 PMID: 15567803
Priebe S, Frottier P, Gaddini A, Kilian R, Lauber C, Martínez-Leal R, Munk-Jørgensen P, Walsh D, Wiersma D, & Wright D (2008). Mental health care institutions in nine European countries, 2002 to 2006. Psychiatric services (Washington, D.C.), 59 (5), 570-3 PMID: 18451020
Swartz MS, Wilder CM, Swanson JW, Van Dorn RA, Robbins PC, Steadman HJ, Moser LL, Gilbert AR, & Monahan J (2010). Assessing outcomes for consumers in New York’s assisted outpatient treatment program. Psychiatric services (Washington, D.C.), 61 (10), 976-81 PMID: 20889634
Zanni GR, & Stavis PF (2007). The effectiveness and ethical justification of psychiatric outpatient commitment. The American journal of bioethics : AJOB, 7 (11), 31-41 PMID: 18027299