Reinstitutionalisation in mental health care:
comparison of data on service provision from

six European countries
Stefan Priebe, Alli Badesconyi, Angelo Fioritti, Lars Hansson, Reinhold Kilian,Francisco Torres-Gonzales, Trevor Turner and Durk Wiersma 2005;330;123-126; originally published online 26 Nov 2004; BMJdoi:10.1136/bmj.38296.611215.AE Updated information and services can be found at: Data supplement
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Articles on similar topics can be found in the following collections To order reprints of this article go to: Group includes D W Paty, S A Hashimoto, V Devonshire, J Sadovnick AD, Yee IM. Season of birth in multiple sclerosis. Acta Neurol Hooge, J Oger, L Kastrukoff, and T Traboulsee (Vancouver); L Metz (Calgary); S Warren (Edmonton); W Hader (Saskatoon); R Salemi G, Ragonese P, Aridon P, Reggio A, Nicoletti A, Buffa D, et al. Isseason of birth associated with multiple sclerosis? Acta Neurol Scand Nelson and M Freedman (Ottawa); D Brunet (Kingston); J Paul- seth (Hamilton); G Rice and M Kremenchutzky (London); P Torrey EF, Miller J, Rawlings R, Yolken RH. Seasonal birth patterns of O’Connor, T Gray, and M Hohol (Toronto); P Duquette and Y neurological disorders. Neuroepidemiology 2000;19:177-85.
Lapierre (Montreal); J-P Bouchard (Quebec City); V Bhan and C 10 Sadovnick AD, Risch NJ, Ebers GC. Canadian collaborative project on Maxner (Halifax); and W Pryse-Phillips and M Stefanelli (St genetic susceptibility to MS, phase 2: rationale and method. Canadian Collaborative Study Group. Can J Neurol Sci 1998;25:216-21.
11 Rothwell PM, Charlton D. High incidence and prevalence of multiple sclerosis in south east Scotland: evidence of a genetic predisposition. J Funding: This work was part of a larger project funded by the Neurol Neurosurg Psychiatry 1998;64:730-5.
MS Society of Canada Scientific Research Foundation. CJW and 12 Branda RF, Eaton JW. Skin color and nutrient photolysis: an evolutionary hypothesis. Science 1978;201:625-6.
DAD were supported by studentships from the MS Society of 13 Torrey EF, Miller J, Rawlings R, Yolken RH. Seasonality of births in Canada, during the time this study was mainly completed. ADS schizophrenia and bipolar disorder: a review of the literature. Schizophr is a Michael Smith Distinguished Scholar.
14 Acheson ED, Bachrach CA, Wright FM. Some comments on the relation- ship of the distribution of multiple sclerosis to latitude, solar radiation Ethical approval: The study was approved by the University of and other variables. Acta Psychiat (Scand) 1960;35(suppl 147):132.
Western Ontario and the University of British Columbia, which 15 Holick MF, Smith E, Pincus S. Skin as the site of vitamin D synthesis and were the two main sites of data collection. Each Canadian MS target tissue for 1,25-dihydroxyvitamin D3. Use of calcitriol (1,25- clinic obtained ethical approval from their local review board.
dihydroxyvitamin D3) for treatment of psoriasis. Arch Dermatol1987;123:1677-83a.
16 Vieth R, Cole DE, Hawker GA, Trang HM, Rubin LA. Wintertime vitamin Willer CJ, Dyment DA, Risch NJ, Sadovnick AD, Ebers GC. Twin D insufficiency is common in young Canadian women, and their vitamin concordance and sibling recurrence rates in multiple sclerosis. Proc Natl D intake does not prevent it. Eur J Clin Nutr 2001;55:1901-7.
Acad Sci USA 2003;100:12877-82.
17 Cantorna MT, Hayes CE, DeLuca HF. 1,25-Dihydroxyvitamin D3 revers- Ebers GC, Sadovnick AD, Risch NJ. A genetic basis for familial aggrega- ibly blocks the progression of relapsing encephalomyelitis, a model of tion in multiple sclerosis. Canadian Collaborative Study Group. Nature multiple sclerosis. Proc Natl Acad Sci USA 1996;93:7861-4.
18 Van der Mei IA, Ponsonby AL, Dwyer T, Blizzard L, Simmons R, Taylor Ebers G, Sadovnick A, Dyment D, Yee I, Willer C, Risch N, et al. A parent BV, et al. Past exposure to sun, skin phenotype, and risk of multiple scle- of origin effect in multiple sclerosis: observations in half siblings. Lancet rosis: case-control study. BMJ 2003;327:316.
19 McGrath JJ, Feron FP, Burne TH, Mackay-Sim A, Eyles DW. Vitamin Ebers GC, Yee IM, Sadovnick AD, Duquette P. Conjugal multiple sclero- D3-implications for brain development. J Steroid Biochem Mol Biol sis: population-based prevalence and recurrence risks in offspring. Cana- dian Collaborative Study Group. Ann Neurol 2000;48:927-31.
20 20McLeod JG, Hammond SR, Hallpike JF. Epidemiology of multiple Kurtzke JF, Beebe GW, Norman JE Jr. Epidemiology of multiple sclerosis sclerosis in Australia. With NSW and SA survey results. Med J Aust in US veterans: 1. race, sex, and geographic distribution. Neurology Dean G. Annual incidence, prevalence, and mortality of multiple sclero- sis in white South-African-born and in white immigrants to South Africa.
BMJ 1967;ii:724-30.
Reinstitutionalisation in mental health care: comparison of
data on service provision from six European countries
Stefan Priebe, Alli Badesconyi, Angelo Fioritti, Lars Hansson, Reinhold Kilian,
Francisco Torres-Gonzales, Trevor Turner, Durk Wiersma
supported housing. The general prison population has substantially increased in all countries.
Objective To establish whether reinstitutionalisation
Conclusions Reinstitutionalisation is taking place in
is occurring in mental health care and, if so, with what European countries with different traditions of health variations between western European countries.
care, although with significant variation between the Design Comparison of data on changes in service
six countries studied. The precise reasons for the phenomenon remain unclear. General attitudes to Setting Six European countries with different
risk containment in a society, as indicated by the size traditions of mental health care that have all of the prison population, may be more important experienced deinstitutionalisation since the than changing morbidity and new methods of mental 1970s—England, Germany, Italy, the Netherlands, Outcome measures Changes in the number of
forensic hospital beds, involuntary hospital Introduction
admissions, places in supported housing, general Since the 1950s, deinstitutionalisation has dominated psychiatric hospital beds, and general prison population between 1990-1 and 2002-3.
Europe. Large asylums have been closed or downsized, Results Forensic beds and places in supported
and the total number of psychiatric hospital beds has housing have increased in all countries, whereas changes in involuntary hospital admissions have been inconsistent. The number of psychiatric hospital beds Data sources are listed on bmj.com has been reduced in five countries, but only in two countries does this reduction outweigh the number of This article was posted on bmj.com on 26 November 2004: additional places in forensic institutions and http://bmj.com/cgi/doi/10.1136/bmj.38296.611215.AE BMJ VOLUME 330 15 JANUARY 2005
fallen dramatically. Mental health services have been Mediterranean countries. We thus included England, established in the community, albeit with significant Germany, Italy, the Netherlands, Spain, and Sweden.
We collected data on forensic beds, involuntary Community mental health care is being further hospital admissions, places in residential care or developed in the United Kingdom through substantial supported housing, conventional psychiatric hospital additional investment in specialised teams such as beds, and the general prison population. For each of assertive outreach and early intervention. It has been these categories, we investigated how numbers have argued, however, that the new era of reinstitutionalisa- changed since 1990. We chose this period of time tion has already begun and has occurred largely unno- because 1990 has a historical significance as the end of ticed by the public and with little professional debate.5 the post-war period in Europe and the beginning of a Major characteristics of reinstitutionalisation are the new political era.7 If reliable data for the period since rising numbers of forensic beds, involuntary hospital 1990 or for the whole country could not be established, we used shorter periods and regional data.
However, the argument has as yet not been based on As healthcare systems and legislation in the six countries vary considerably, the precise definitions of This paper presents data from six European coun- forensic beds, involuntary hospital admission, and sup- tries representing different traditions of health care.
ported housing also differ between some countries but We aimed to establish whether reinstitutionalisation is have been consistent over time within each country.
taking place and, if so, to what extent and with what Although supported housing is often regarded as an variation between European countries. We also wished alternative to asylums and therefore a sign of deinstitu- to investigate whether reinstitutionalisation compen- tionalisation, it still represents a form of institutional- sates for the loss of conventional psychiatric hospital beds and how it compares against changes in thegeneral prison population. This rate can be seen as a non-healthcare indicator of societal tendencies to riskcontainment, and data suggest that psychiatric The number of forensic beds and places in supported housing have increased in all countries (table).
Involuntary admissions have risen in England, the Netherlands, and, especially, Germany, but have fallenslightly in Italy, Spain, and Sweden. The number of The study included data from six European countries psychiatric beds has been reduced in all countries. In that fulfilled the following criteria: experience of major England, Spain, and Sweden, the number of psychiatric mental health reforms involving deinstitutionalisation beds that have been closed is greater than the total within the second half of the 20th century; availability number of additional forensic beds and places in sup- of reliable and reasonably complete data; and ported housing that have been established in the same representation of different traditions of mental health period of time. In Italy and the Netherlands, the care, including Scandinavian, central European, and increase in forensic beds and supported housing has Number of forensic beds, involuntary hospital admissions, places in residential care or supported housing, psychiatric hospital beds,and prison population in six countries in 1990-1 and 2002-3. Values are numbers per 100 000 population unless stated otherwise Service provision
See bmj.com for data sources.
*Data refer to restricted patients admitted to all (high security and other) hospitals.
†Data for Emilia-Romagna, a region in northern Italy with a population of 4 million.
‡Data for Drenthe, a rural area with 450 000 inhabitants.
§Data for Andalucia, the second largest region in Spain, with a population of 7 million.
¶Discharges from treatment under the Compulsory Care Act during a six month period.
been much greater than any decrease in conventional What is already known on this topic
psychiatric bed numbers, whereas in Germany the bal-ance is approximately equal. The general prison popu- lation has grown in all countries by between 16% and deinstitutionalisation in mental health care remain 104%, and the two countries with the highest imprisonment rate (England and Spain) have the low-est rate of forensic beds. We found no clear sign of a Isolated aspects of reinstitutionalisation have been harmonisation of provision between countries.
It has been argued that reinstitutionalisation Discussion
reflects a new international pattern, but this is not Limitations of methods
Comparing the absolute numbers of institutionalised What this study adds
patients between countries is difficult because of inter-nationally varying definitions of the reported forms of Reinstitutionalisation in the form of newly care. The differences in definitions, legislation, and established forms of institutionalised mental healthcare systems cannot be overcome by a health care has occurred in different European descriptive study. Consistent definitions were used within each country, however, and no major changes inmental health legislation have occurred that substan- tially altered the threshold for involuntary care. This psychiatric hospital beds and new provision of paper thus focuses only on changes over time, and institutionalised care varies between countries these processes can be synoptically interpreted.
The general prison population has increased in all Changes over time
the countries, and this may be linked to the Involuntary hospital admissions have not increased in all investigated countries, and no clear link exists between changes in involuntary admission rates andchanges in numbers of hospital beds. Institutions asdefined by bricks and mortar—that is, forensic hospital a mere shifting of placements from one structure to beds and places in supported housing—have shown another) remains debatable. It might depend on the national balance between further reduction of hospital The extent of the new process varies, with no clear beds on the one hand, and newly established institution- pattern of differences between northern and southern alised care on the other. To clarify this, research is Europe. We could speculate as to whether the increase needed on the type of patients using each of the current in institutionalised care since 1990 has compensated designations (forensic, supported housing, psychiatric for the loss of psychiatric beds in the three decades of hospital, prison) and how many patients with severe deinstitutionalisation before that. However, within the mental illness are cared for outside of these defined same period of time more or less comprehensive serv- ices for community care have also been established to Potential explanations
treat in the community patients with severe mental ill- Several potentially testable hypotheses exist as to why ness who, without these services, may well have been former deinstitutionalisation now tends to be compen- admitted to hospital.3 4 Research suggests that these sated, or even over-compensated, for by reinstitution- developments have indeed embraced care for a alisation. The need for institutionalised care may have number of patients with severe mental illness.9 Why risen because of a greater frequency of illness, severity health commissioners in six different countries have of illness, or both, possibly influenced by increasing use still decided to invest heavily in additional institutional- of illegal drugs. Another reason may be the loss of ised care is therefore unclear. This is particularly strik- social support for mentally ill people in traditional ing with respect to expensive forensic beds, as no families—for example, because of women taking evidence exists to show that the number of homicides professional roles instead of being domestic carers.
committed by mentally ill people in the community Mental health care may have widened its remit and has risen in the process of deinstitutionalisation.10–13 taken patients that it would not have considered as its Reinstitutionalisation or trans-institutionalisation?
clientele 20 years ago, such as patients with personality Most of the data are consistent with the assumption that disorders, but no evidence exists that substantial num- deinstitutionalisation, the defining process of mental bers of these new patients have ended in supported healthcare reforms since the 1950s, has come to an end.
housing and forensic beds. Furthermore, private Although the number of psychiatric hospital beds has providers may have successfully widened their share of further decreased in five of the six studied countries the market and secured profitable funding for an since 1990, this was partly or more than compensated increased supply of institutionalised care.8 for by additional places in other forms of institutional- The substantial increase in the general prison popu- ised care. This evidence indicates, therefore, that a lation, however, suggests that reinstitutionalisation in degree of new institutionalisation does exist as an inter- mental health care might not be due to specific factors national phenomenon, despite wide differences in of morbidity or healthcare delivery, but might rather be healthcare systems between the countries studied here.
driven by a “zeitgeist” towards risk containment in 21st Whether this process should be described as reinstitu- century European society. This pertains even though we tionalisation or only as trans-institutionalisation (that is, do not know how the proportion of mentally ill prison- BMJ VOLUME 330 15 JANUARY 2005
ers among the prison population has changed over Becker T, Vazquez-Baquero JL. The European perspective of psychiatricreform. Acta Psychiatr Scand 2001;410(suppl 1):8-14.
time. Whatever the case, the data provided here Fakhoury W, Priebe S. The process of de-institutionalisation: an interna- underline the need for more specific research into the tional overview. Curr Opin Psychiatry 2002;15:187-92.
Freeman H. Community psychiatry. In: Freeman H, ed.
phenomenon and causation of reinstitutionalisation. In psychiatry. London: Mosby-Wolf, 1999:213-8.
addition, a professional and public debate is needed on Jones K. Asylums and after. London: Athlone Press, 1993.
the ethical basis for detaining and “institutionalising” Priebe S, Turner T. Reinstitutionalisation in mental health care. BMJ2003;326:175-6.
patients with severe mental illness.
Fazel S, Danesh J. Serious mental disorder in 23,000 prisoners: a system-atic review of 62 surveys. Lancet 2002;359:545-50.
Levy C. Three post-war eras in comparison: western Europe 1918-1945-1989.
Contributors: The study idea originated from SP and was further developed in discussions with TT and specified in communication Priebe S. Institutionalisation revisited—with and without walls. Acta with all authors. All authors agreed on the study design and are Psychiatr Scand 2004;110:81-2.
guarantors for data from their country: AF for data from Italy, LH Leff J, Trieman N, Knapp M. The TAPS project: a report on 13 yearsresearch, 1985-1998.
for Sweden, RK for Germany, FT-G for Spain, DW for the Nether- Psychiatr Bull 2004;24:165-8.
10 Munro E, Rumgay J. Role of risk assessment in reducing homicides by lands, and SP for the United Kingdom. AB coordinated the data people with mental illness. Br J Psychol 2000;176:116-20.
collection. Data interpretation was agreed among all authors. SP is 11 Taylor PJ, Gunn J. Homicides by people with mental illness: myth and the overall guarantor for the paper.
reality. Br J Psychol 1999;174:9-14.
12 Safety first: five year report of the National Confidential Inquiry into Suicide and Funding: East London and the City Mental Health Trust. The Homicide by People with Mental Illness. London: Department of Health, funding was through the R&D budget of the trust. East London and the City Mental Health Trust did not influence the design of 13 Shaw J, Amos T, Hunt IM, Flynn S, Turnbull P, Kapur N, et al. Mental ill- the study, data collection, or presentation of the findings in any ness in people who kill strangers: longitudinal study and national clinicalsurvey. BMJ 2004;328:734-7.
Competing interests: None declared.
Use of clomifene during early pregnancy and risk of
hypospadias: population based case-control study
Henrik Toft Sørensen, Lars Pedersen, Mette Vinther Skriver, Mette Nørgaard, Bente Nørgård,
Elizabeth E Hatch
Clomifene is widely used for inducing ovulation.1 It is diseases, eighth revision) until the end of 1993 and structurally related to diethylstilbestrol, which has been ICD-10 after 1993. The codes for hypospadias in linked to vaginal and cervical clear cell adenocarci- ICD-8 are 752.20, 752.21, 752.22, 752.28, and 752.29; noma in women exposed in utero. The adverse effect is in ICD-10, the codes are Q54.0, Q54.1, Q54.2, Q54.3, less severe in sons, although links to testicular cancer and urogenital anomalies, such as epididymal cysts, We found a total of 319 cases of hypospadias (any have been reported.2 3 A recent study also found an time post partum) in the four counties. From the Dan- increased risk of hypospadias in the sons of women ish birth registry, which contains information on all exposed to diethylstilbestrol in utero.4 Clomifene has a births in Denmark since 1 January 1973, we selected a half life of about five days, but its metabolites have been control group of 10 records of male births without a found in blood samples on day 22 of the menstrual diagnosis of hypospadias and with a full prescription cycle and in faeces up to six weeks after administra- history during the same period. We matched cases and tion.5 The occurrence of hypospadias may be controls for birth month, birth year, and county of resi- Bente Nørgårdassociate professor increasing. Little is known about the risk of hypospadias in boys born to women who have used The Danish national health service reimburses part of patients’ expenditure on many prescribed drugs, including clomifene. The four counties have pharma- Methods and results
cies equipped with electronic systems that record information on the drug, dose, personal identification Our case-control study was done in the Danish number, and date of dispensing of the drug. All data counties of North Jutland, Aarhus, Viborg, and are transferred to a research database at Aarhus Ringkjoebing (population 1.6 million, with 65 383 University Hospital. The data from the four counties male births in the study period: 1989 to 2002, North are electronically available from 1 January 1989 (North Jutland 34 859; 1996-2002, Aarhus 20 382; and 1998- Jutland), 1 January 1996 (Aarhus), and 1 January 1998 2002, Viborg 4148 and Ringkjoebing 5 994).
(Ringkjoebing and Viborg). We took data on all We identified all cases of hypospadias that had a prescriptions for clomifene during the first trimester full prescription history in the period 1989-2003 from and 90 days before conception. To avoid confounding, the Danish hospital discharge registry, which contains we also took data about prescriptions for antidiabetic all discharges from hospitals in Denmark since 1977and includes 10 digit personal identifiers, surgical pro-cedures, and up to 20 discharge diagnoses classified This article was posted on bmj.com on 21 December 2004: according to ICD-8 (international classification of http://bmj.com/cgi/doi/10.1136/bmj.38326.606979.79 BMJ VOLUME 330 15 JANUARY 2005

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