Elsevier

Psychiatry

Volume 6, Issue 8, August 2007, Pages 313-316
Psychiatry

Moving out of the asylum
Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare

https://doi.org/10.1016/j.mppsy.2007.05.008Get rights and content

Abstract

The care of patients with mental illness has undergone major changes over the last two centuries. In the 19th century, large asylums were built throughout industrialized countries to provide care for patients with mental illness. Conditions in these asylums worsened during the 20th century and since the 1950s an increasing deinstitutionalization movement has resulted in their closure. Various services in the community were established to provide an alternative form of care. Recently however, reports about new forms of institutionalization have suggested ‘reinstitutionalization’ in mental healthcare is occuring. This contribution traces the changes from asylums to care in the community and describes the process of deinstitutionalization and its shortcomings worldwide. It discusses recent evidence and explains the debate on reinstitutionalization.

Section snippets

The first asylums

The origins of modern psychiatry as a medical specialty date back to the Age of Enlightenment. It emerged around 1800 and its development was closely linked to the establishment of large asylums. There were several reasons for societies to invest in asylums, as detailed below.

Social welfare movement: the developing movement for social welfare was also applied to the mentally ill, and their quality of care tended to reflect the responsibility of states to care for ‘feeble’ people in society.

Outcomes

Deinstitutionalization has led to dramatic and, some would say, long-desired changes in psychiatric services. Health systems in North America, Europe and Australia in particular have embraced the philosophy of community mental healthcare.1, 2, 3, 4 Costs have been reported to be generally the same as for inpatient hospitalization, or even lower for discharged patients living in the community,5 although costs for different forms of care clearly depend on political decisions affecting how well

Re- or transinstitutionalization

Although the number of conventional psychiatric hospital beds has continued to decrease in most Western industrialized countries, recent data suggest that we may already be witnessing a new phenomenon of ‘reinstitutionalization’. Table 1 shows changes in the numbers of conventional psychiatric hospital beds, beds in forensic psychiatry, places in supported housing, involuntary hospital admissions and people in prison in six European countries.9 Although each country has different traditions and

Conclusion

Deinstitutionalization has dominated and marked major changes in mental healthcare provision in the second half of the 20th century. We now face the new phenomenon of re- or transinstitutio-nalization, which is international, expensive and ethically problematic. This calls for both specific research on the provision, costs, potentials and effects of different forms of institutions, including the experience of patients in them, and a professional and public debate on the values, aims, ethics and

References (12)

  • A.B. Rothbard et al.

    The success of de-institutionalisation: empirical findings from case studies on state hospital closures

    Int J Law Psychiatry

    (2000)
  • W. Fakhoury et al.

    The process of de-institutionalisation: an international overview

    Curr Opin Psychiatry

    (2000)
  • P. McCrone et al.

    Limits of de-institutionalisation: experience in England

    Psychiatr Prax

    (2000)
  • M. von Cranach

    Housing for psychiatric patients inside and outside of hospitals

    Psychiatr Prax

    (2000)
  • S.A. Smoyak

    The history, economics and financing of mental health care. Part 2: the 20th century

    J Psychosoc Nurs Ment Health Serv

    (2000)
  • K.S. Yip

    Have psychiatric services in Hong Kong been impacted by the de-institutionalisation and community care movements?

    Adm Policy Ment Health

    (2000)
There are more references available in the full text version of this article.

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