Friday, 11 April 2014

Mental Health, the strongest transformation

The provision of mental health services have taken a dramatic shift in the last 40 years, which is why I think a blog like this, specialized in "Advances in clinical management," is bound to echo.

The mass closure of asylums

The critique of institutionalizing psychiatric patients in mental hospitals began in the late ‘60s, although the closure of beds was observed during the ‘80s, and especially ‘90s, as seen in the following graph:

According to a report by the London School of Economics and Political Science (Medeiros 2008), where the above graph came from, psychiatric deinstitutionalization has three main components:
  • The transfer of patients from psychiatric hospitals to the community
  • The involvement of general hospitals
  • The deployment of alternative community services
The cited document reflects the vicissitudes that European countries came across when trying to address these policies, starting especially with the famous Italian Law 180 of 1978 which ordered the dismantling of psychiatric institutions. The document admits however, that despite the success of this policy, the difficulties in the operation of each of the three components mentioned above have been large.

The basis for the transformation

A fairly current document from the European Union (Caldas 2011) speaks of the foundations set by these radical changes. Here’s a summary:

Reasons for the deinstitutionalization of mentally ill patients
  1. Improves the patient’s accessibility to services
  2. Improves patient satisfaction
  3. Adjusts the services to the real needs
  4. Improves the care continuum
  5. Improves treatment adherence
  6. Reduces stigma
  7. Promotes rehabilitation
  8. Stabilizes symptoms more easily
Some studies show that these community policies improve cost/effectiveness, but this proof isn’t entirely clear, and in any case, if there  are  some isolated results they should not to be generalized.

It's gone too far?

Peter Tyrer, Professor of Community Psychiatry at Imperial College of London, in an article published in the British Medical Journal (Tyrer 2011), already asks in the headline: Have we gone to too far with the closure of psychiatric beds? And you’ll see how, from his 45 years experience as a  community psychiatrist, the answer is a blunt: Yes.

In the United Kingdom, 155,000 psychiatric beds became 27,000 which, says Professor Tyrer, is an exaggeration. He says the situation has changed from "out of sight, out of mind" to "out of hospital, don’t mind". The professor’s opinion is that a well-designed mix of community services and institutional support services is necessary to preserve a good quality of services. He also admits that he longs for the old residential resorts with Balearic weather.

Strategies to develop good services for the mentally ill

Appreciating the personal opinions as those of Professor Tyrer, it seems appropriate for an end of post to take a look at the strategies that the European Union proposes in order to continue with reforms and to improve clinical outcomes (Caldas 2011):
  1. The existence of a mental health policy that establishes the vision, values ​​and principles developed by a global plan.

  2. Deployment of community services for mental health and networks of psychosocial services for home and family support.

  3. Integrating mental health services within the primary care teams and deploying Psychiatry units in the general hospitals.

  4. Offer of institutional services specialized for the mentally ill with more complex needs (maybe these would be the services that Professor Tyrer longs for). In addition strategies to improve the physical health care for the chronically mentally ill.

These four strategic lines are the main ones according to the EU’s statement although, as you may feel, the report speaks widely on many other strategic aspects, as it is the the greater involvement of patients in their own therapeutic and rehabilitation process or the need for more research and evaluation, but for reasons of brevity these topics have no room in this post.

For my part I congratulate colleagues in mental health. They had a serious problem with services clearly based on medieval values ​ and in a few years they have managed a spectacular overturn (despite all the limitations) of which we who are now worried about how we can reorient health services towards chronic disease, would have a lot to learn and so for this reason, I thought it appropriate to write this post.


Medeiros H, McDaid D, Knapp M and the MHEEN Group. Shifting care from hospital to the community in Europe: Economic challenges and opportunities. Londons School of Economics and Political Science january 2008.

Caldas JM, Killaspy H. Long-term mental health care for people with severe mental disorders. European Union 2011. 

Jordi Varela

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