From the hospital into the community and back again - a trend towards re-institutionalisation in mental health care?

BACKGROUND: Despite numerous and indispensable advantages, the shift from hospital-based to community mental healthcare has engendered problems. To analyse whether or not the process of de-institutionalization has gone too far, studies are needed that cover general psychiatry, forensic psychiatry, and penitentiaries as interlocked systems, but these are still scarce.

METHOD: We combined epidemiological and service utilization data from three recent European studies that explored the legal frameworks for and the practices with regard to involuntary treatment in general mental healthcare, to the care of mentally disordered offenders in forensic care and to the care of mentally ill inmates in the European prison systems, and used more specific data from one country to illustrate how changes to the legal frameworks in one sector may potentially affect the others.

RESULTS: Time series from European Union (EU) member states suggest that civil detention rates remained more or less stable during the 1990s, though on rather different levels internationally. Admissions to forensic psychiatric facilities increased during the same period. Data on the mental state (or changes in rates of psychiatric morbidity) in European prison populations are not available-aside from the prison suicide rate. Data from selected countries are likely to suggest that changes to the legal framework in one sector may considerably affect admission rates in others.

CONCLUSIONS: National or regional studies are needed to analyse the linkage between sectors and to identify inappropriate patient shifting. National and international data bases need to be implemented or improved.