Psychiatric reform revisited

Abstract

The trend towards the establishment of community psychiatric services seems to be universal. However, before closing down a mental hospital, it is necessary to establish the appropriate alternative facilities in the community. Every de-institutionalization program should have a diachronic component, and cultural issues should be taken into consideration. Care for each patient has to be decided upon on the basis of the characteristics of that patient. Finally, de-institutionalization is just one aspect of psychiatric reform. Primary psychiatric prevention is equally or even more important

Provision of psychiatric services has undergone many changes, in keeping with the prevailing scientific ideas, social changes, political decisions, economic considerations and a number of other parameters. What was good a hundred years ago is no longer good and can be very bad indeed. Take for example the asylum. When the asylum was introduced to psychiatry it served a good purpose, and this purpose was the integration of psychiatry into general medicine. This kind of mental health services provision was supported by the scientific community of that time because it was a true liberation of patients from being ridiculed in the streets and from serving as means for the entertainment of the rest of the citizens. The etymology of the word asylum (from the Greek) points to this direction. People like Emil Kraepelin were very supportive of this change and, indeed, the system worked for a considerable period of time. However, after some time (mainly for reasons associated with inadequate funding and staff shortages), the asylum started deteriorating in its function, developing negative characteristics and acquiring its present connotation. This inevitably led to the gradual abandonment of the asylum and to an effort at organizing psychiatry along community lines. This trend was reinforced by the understanding that the disintegration of the personality of schizophrenic patients was not so much the consequence of the illness but to a great degree a consequence of the institutional living of the patients. The prevailing humanistic attitudes of the public at that time also contributed a lot.

Establishment of community psychiatric services followed a different pace in Europe and elsewhere, but the trend seems to have been universal in all countries. It is characteristic that even in the statutes of the Psychiatric Association for Eastern Europe and the Balkans, an association composed of psychiatric societies with traditional mental health services, establishment of psychiatric services in the community has been given great prominence and priority, with the agreement of all founding psychiatric associations (www.paeeb.com).

In the last years there have been voices challenging the principles, but especially the practices of community psychiatry. The main points of criticism are the following:

– It is being increasingly recognized that the change from asylum to community cannot be applied to all patients. Some patients have to be accommodated in special units or small psychiatric hospitals, and the care for each patient has to be individualized and decided upon on the basis of the characteristics of each patient.

– The idea is not to close down the hospital and consider this as a great achievement. Hospital closure should not be an aim by itself. “Any fool can close a mental hospital”, remarked a senior UK health official in the 1980s 1. Hospital closure should not obey to political, “non-authoritarian” ideologies or to financial concerns that satisfy the managers. It is the patient’s well-being that counts and nothing else. If the quality of life of the patient is better and if the degree of satisfaction is greater in hospital as compared to the community, we have an ethical obligation to allow our patient to make an informed choice and continue treatment in a setting of his choice. The psychiatric community must have the courage to express an evidence-based opinion on this very important matter. It is true that under the term “psychiatric hospital” some of the ugliest forms of asylum are hiding, but it is also true that under the term “community” often the prison or the street are hiding.

– Before closing down the hospital, it is absolutely necessary to establish the appropriate alternative facilities in the community for residence, rehabilitation and, if possible, employment. Continuous monitoring by an independent authority and readiness (and courage) to modify, drastically change or even reverse the de-institutionalization plan, in keeping with the recommendations of the monitoring authority, is a sine qua non necessity.

– Every de-institutionalization program should have a diachronic component. It is unwise to start a rehabilitation program without guaranteeing adequate and continuous flow of resources to support the patients in the community. Careful and responsible planning should precede every decision, and it is important to realize that, without consistent and diachronic support, re-institutionalization in hospital or, even worse, institutionalization in the community is waiting behind the door.

– Cultural issues should be taken into consideration. What is good for patients in Western societies is not necessarily good for other patients. Parameters like mode, degree and pace of de-institutionalization should be considered in harmony with the cultural setting of each patient.

– It must, additionally, be realized that de-institutionalization is just one aspect of psychiatric reform, belonging to tertiary prevention. Yet, primary psychiatric prevention is equally or even more important 2, 3. It is unfortunate that this crucial stage of prevention (prevention par excellence) has not been given the priority it deserves. Primary care, genetic counseling, prevention at school, in the family, in the workplace, prenatal and postnatal care, preventive interventions for vulnerable groups like women, aged persons and poor people have unfortunately not developed to the desired extent.