Deinstitutionalization and Schizophrenia in Finland: I. Discharged Patients and Their Care

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1 Deinstitutionalization and Schizophrenia in Finland: I. Discharged Patients and Their Care by Raimo K.R. Salokangas and Soile Saarinen Abstract Finland has experienced one of the most rapid psychiatric deinstitutionalization processes in the world. Since 1980, the use of psychiatric beds has decreased about one-third. The effects of this deinstitutionalization were studied in the national Discharged Schizophrenia Patient Project. The study used three representative samples of patients with schizophrenia who were discharged from mental hospitals in 1982, 1986, and 1990, and followed them for 3 years. Patients with schizophrenia discharged at the beginning of the 1990s were older and more disturbed, and had been ill for a longer time than patients discharged at the beginning of the 1980s. The use of outpatient care increased and that of hospital care decreased, but because of the increased residential outpatient care, the total amount of residential care did not change during the study period. However, readmissions to the hospital increased. In patients with a long duration of illness, the increase in readmissions was exceptionally high; these patients also seemed to be losing their share of the residential outpatient services. On the whole, from the point of view of the psychiatric treatment system, deinstitutionalization seemed to have proceeded fairly successfully. The system proved able to redirect and use the available resources more effectively and to modify the structure of services according to the changing needs of patients discharged from hospitals. The well-developed social services have also supported this adaptation to the decreasing use of mental hospital beds. Key words: Deinstitutionalization, services. Schizophrenia Bulletin, 24(3):457-^*67,1998. Deinstitutionalization has been defined by Bachrach (1976, 1978) as the contraction of traditional institutional settings with the concurrent expansion of communitybased services. The prevention of inappropriate mental hospital admissions is also one of its essential components (Thornicroft and Bebbington 1989). Several factors have been put forward to justify deinstitutionalization: (1) harmful effects of large hospitals on patients (Wing and Brown 1970), (2) economic reasons, (3) developments in treatment such as drug therapy (Baldessarini 1985; Kane and Marder 1993) and rehabilitation (Wing and Morris 1981), (4) humanitarian considerations and legal changes, and (5) malpractice revealed in mental hospitals (Barton 1959; Boms 1981; Thornicroft and Bebbington 1989). Since the 1950s, the reduction in mental hospital beds, sometimes resulting in the closure of entire hospitals, has been a general trend in the United States and the United Kingdom (Raftery 1992; Lamb 1993) as well as in many omer European countries (Lindholm 1983; Hafner 1987). In Italy, the enactment of law 180 in 1978 led to a radical change in inpatient services (Bollini and Mollica 1989; Tansella et al. 1991). It has been suggested that the patients' quality of life can be better improved through properly provided community care than by institutional care; however, there seems to be a group of mental patients who need longterm institutional care (Bachrach 1978; Stein and Test 1980; Hafner 1987; Thornicroft and Bebbington 1989; Lamb 1993; Leff et al. 1994). It is important to take all the complex functions of mental hospitals into account (Goldman et al. 1983; Wmg and Furlong 1986; Clifford et al. 1991). Too rapid a reduction in mental hospital beds can cause problems such as repeated admissions (the "revolving door"), social isolation, homelessness, increased crime rates, and lack of adequate treatment for some severely handicapped patients. And in some cases, community care can be more expensive than institutional care (Caton and Goldstein 1984; Hafner 1987; Bachrach 1978; Leff 1992; Lamb 1993; Lamb and Shaner 1993). Reprint requests should be sent to Dr. R.K.R. Salokangas, DepL of Psychiatry, University of Turku, Turku University Central Hospital, FIN Turku, Finland 457

2 Schizophrenia Bulletin, Vol. 24, No. 3, 1998 R.K.R. Salokangas and S. Saarinen In Finland the Law of the Mentally 111 of 1952, enacted only a few years before the discovery of modern neuroleptics, encouraged municipalities to build or expand mental hospitals for chronically ill patients not receiving adequate care. The law also obliged the central government to cover about half of the costs of these hospitals. As a result, the number of mental hospital beds nearly doubled in 15 years. Further, the law emphasized the need for creating outpatient services for patients discharged from hospitals. The deinstitutionalization process began in Finland some 20 years later than in the United Kingdom and many other countries (Salokangas et al. 1985). Since the late 1970s, several government reports (LaakinttShallitus 1977; Mielenterveystydn komitean mietintd 1984; LSakintOhallitus 1988) have strongly emphasized the need to reduce mental hospital beds in exchange for allocation of additional resources for outpatient psychiatric care. The main arguments for reducing beds in mental hospitals were the harmful effects of long hospital stays, the patients' right to live in the community, and the high costs of hospital care. As a result, Finland has experienced one of the most rapid deinstitutionalization processes in the world (figure 1). In the middle of the 1980s, when deinstitutionalization was proceeding rapidly, the treatment and lifestyle of patients with schizophrenia discharged from hospitals into the community began to receive increasing attention in Finland. To analyze the situation in greater detail, a national research study called the Discharged Schizophrenia Patient (DSP) Project was launched in Its Figure 1. Use of psychiatric beds In Finland: Study cohorts of the Discharged Schizophrenia Patient Project /10OO Inhabitants 0 ' ' i i i i i i i i i i i i i i i i i i i i i i i i i i S S0 YEARS Schizophrenia patients discharged in 1982 (S82), in 1986 (S86), and 1990 (S90). aim was to explore how the lifestyle, clinical and functional state, and use of and need for care of discharged patients with schizophrenia had changed and will change during ongoing rapid deinstitutionalization, forecasted to proceed far into the 1990s. The DSP Project has produced four larger reports (Salokangas et al. 1992, 1996; Stengard et al. 1993; Honkonen 1995). Material and Methods The DSP samples consisted of patients with schizophrenia aged 15 to 64 years, discharged from the psychiatric hospitals of 20 mental health/health care districts in Finland in 1982 (S82), in 1986 (S86), and 1990 (S90). Within each district, which together have a total population of about 4 million (the total population of Finland is 5 million), consecutive patients with schizophrenia discharged from the psychiatric hospitals in the study areas after January 1 of each year of study were included until the samples consisted of 30 patients per 100,000 total population. In one district, the samples were half this size and in another, double. The demographic structure and socioeconomic situation of the population in the study districts as well as the health care services available in these districts were comparable with those for the entire country. The sampling procedure was~based on the hospital discharge registers. The required number of consecutive patients was selected from among those with a diagnosis of functional psychosis, based on ICD-8 (World Health Organization 1967) classification in 1982 and 1986 and on DSM-IH-R (American Psychiatric Association 1987) in The researcher-physicians in each district reviewed the case records and rediagnosed the patients using the Finnish Disease Classification 1987 (LSakintohallitus 1986; DSM-III-R criteria). The patients suffering from schizophrenic disorders only (disorganized, 2951; catatonic, 2952; paranoid, 2953; residual, 2956; and undifrerentiated, 2959) were included. The expected numbers of patients with schizophrenia were 1,109 (S82), 1,109 (S86), and 1,170 (S90). Because of small sampling errors, the total numbers of patients with schizophrenia included in the study were 1,081 (S82), 1,097 (S86), and 1,129 (S90). Using all the patients' psychiatric case records, data were collected on their psychiatric history and use of services during the 3-year period before discharge and during the 3-year period afterward. Data on the patients' global psychofunctional state (Global Assessment Scale [GAS]; Endicott et al. 1976), somatic health, working ability, and medication at discharge were also collected. With a few exceptions, complete data could be collected by the psychiatric treatment teams from the records. 458

3 Deinstitutionalization and Schizophrenia in Finland Schizophrenia Bulletin, Vol. 24, No. 3, 1998 The S86 and S90 patients were interviewed 3 years after their hospital discharge. With the exception of two districts in 1986, the interviews were conducted by each district's psychiatric team using a structured interview schedule specifically designed for the purposes of this study. It included well-defined questions concerning the patient's clinical and functional state, personal relationships, disturbances in social behavior, use of and need for various psychiatric, medical, and social services (including a detailed list of various services and treatments), and satisfaction with his or her psychiatric care. The S86 patients from two districts (114 patients, or 13% of the S86 cohort) were interviewed by a researcher-psychiatrist who was not a member of a psychiatric team. These results, published elsewhere (Honkonen 1995), have been used in this study to evaluate the differences between the assessments made by the psychiatric teams and those made by an independent researcher. A total of 775 patients (71%) of die S86 cohort were interviewed; 40 (4%) were examined by other means, 233 (21%) refused to participate in the study or were not located, and 49 (4%) had died. The corresponding figures for the S90 cohort were 742 (66%), 96 (9%), 219 (19%), and 72 (6%), respectively. In terms of sociodemographic background factors, there were no statistically significant differences between the patients who took part in the followup study and those who did not At the time of discharge, the global psychofunctional ability (GAS) was lower and the daily dose of neuroleptic drugs higher among the patients followed up. They had also used psychiatric services to a greater extent both before and, in particular, after the discharge. The subjects were also classified according to the duration of illness and the length of the index hospital stay. The analyses were carried out on the groups at the extreme ends of these variables, that is, the group with a short duration of illness (SDI) (duration of illness <5 years) versus that with a long duration of illness (LDI) (>20 years) and the group with a very short stay (VSS) in the hospital (index stay 30 days or less) versus that with a very long stay (VLS) (over 3 years). Differences between the distributions of the categorical variables were analyzed by die chi-square test and in the case of the numerical variables by one-way analysis of variance. Results Discharged Patients and Their Backgrounds. As forecast in 1987, the reduction in the number of mental hospital beds in Finland continued throughout the study period, and the study cohorts thus covered the years of the most rapid deinstitutionalization (figure 1). The 1-month discharge rates based on the number of patients discharged in January of each study year per 100,000 total population aged 15 to 64 years were 13.1 (1982), 16.0 (1986), and 15.9 (1990). The rate thus increased between 1982 and 1986 but not thereafter. The discharge rate was higher for males, with single and divorced, and for individuals from a low social class (blue-collar workers) than for others. The age group with the highest rates was the 30- to 34-year-olds in 1982, the 35- to 39-year-olds in 1986, and the 40- to 44-year-olds in The mean age of discharged patients widi schizophrenia clearly rose during the study period, although no clear changes occurred in the sex and marital status distributions; the proportion of unmarried patients was extremely high throughout the study period (table 1). There were no significant changes over time in die diagnostic distributions or in die mean age at first admission, whereas the mean duration of illness (from the first admission to the index discharge) increased by over 4 years. And the proportion of patients ill for less than 10 years decreased during the study period, while the proportion of LDI patients increased markedly (table 1). VSS patients showed increasingly lengthy durations of illness, while such a trend was not found for VLS patients. Patients' History of Illness and Clinical and Functional State at Discharge. As expected, the mean duration of the index hospitalization was considerably longer in the S86 than in the S82 cohort, but later on patients were hospitalized for somewhat shorter periods. This was explained by differences between the patient populations: From 1982 to 1986 there was a clearly increasing tendency to discharge VLS patients, but between 1986 and 1990 the proportion of VSS patients increased considerably (table 2). In SDI patients the length of the index hospitalization decreased slightly (S82: 100 days, S86: 89, S90: 85; p = 0.391). Indeed, the figures for the LDI patients (S82: 327 days, S86: 806, S90: 391; p = 0.003) indicated that, in 1986, the patients who had been ill for a long time were also discharged after long hospital stays, while in 1990 diese LDI patients were discharged after clearly shorter stays. During the study period there was a clear decline in patients' clinical and functional (GAS, somatic illness, retired) state at discharge, especially regarding the increased proportion of patients discharged in poor psychofunctional condition (GAS score 2-3). The decline in the clinical state was especially pronounced in the case of VLS patients (S82: GAS score 4.4, S86: 4.0, S90: 3.8; p = 459

4 Schizophrenia Bulletin, Vol. 24, No. 3, 1998 R.K.R. Salokangas and S. Saarinen Table 1. Soclodemographic and clinical background factors of patients with schizophrenia discharged from hospital Gender Male Female Age Mean (years) Marital status Single Married Divorced or separated Widowed Social class I II III IV Other Diagnosis Mean age at first admission (years) Duration of illness (years) = 20 Mean (years) 1982, n = 1,079 (%) Note. p values are based on the X 2 test and analysis of variance ), but not, however, statistically significant. With the exception of neuroleptics, psychotropic drugs were also prescribed more often. For a majority of the patients, after-care consisted of treatment provided at community mental health centers (CMHCs). However, during the study period their number decreased considerably, and the number of patients discharged to community-based residential care (rehabilitation homes, hostels, or group homes) or day care facilities clearly increased (table 2). Day care or community-based residential care was typical for VLS patients (S82: 56%, S86: 70%, S90: 73%; 1986, n= 1,097 (%) , n= 1,129 (%) P p = 0.515) and LDI patients (S82: 16%, S86: 24%, S90: 25%; p = 0.088); the differences between the cohorts were not, however, significant. The corresponding figures for VSS patients (S82: 6%, S86: 13%, S90: 21%; p = 0.000) and SDI patients (S82: 6%, S86: 11%, S90: 17%; p = 0.000) were lower, but the increases in day and residential patients were highly significant Use of Psychiatric Services Before and After Discharge. The use of both residential and outpatient services by patients with schizophrenia before the index discharge increased clearly over the study period; however, 460

5 Deinstitutionalization and Schizophrenia in Finland Schizophrenia Bulletin, Vol. 24, No. 3, 1998 Table 2. Duration of Index hospital stay, clinical and functional state, and psychotroplc drugs at discharge and after-care in patients with schizophrenia discharged from the hospital 1982, n= 1, , n= 1, , n=1,129 Index stay < 31 days days days 6-11 months 1-4 years 15 years Mean (days) Mean GAS score (1-9) Retired Somatic illness Psychotropic drugs Neuroleptics Antidepressants Antimanics Anxiolytics Hypnotics Mean (preparation) Neuroleptics Any injections CPZ equivalents (mg) After-care Residential care Day care Visit to CMHC Health center Other None Note. p values are based on the X 2 test and analysis of variance. GAS = Global Assessment Scale (Endicott et al. 1976); CPZ - chlorpromazine; CMHC - Community Mental Health Center. the increase in hospital days was very small (table 3). After discharge, the total amount of residential care did not change during the study period; nevertheless, there was a clear shift toward an increasing use of communitybased residential services and a resultant reduction in hospital care. Only a few patients (S82: 6%, S86: 4%, S90: 3%) spent over 2 years of the 3-year followup in hospital. The proportion of rehospitalized patients (S82: 72%, S86: 73%, S90: 70%) was high but did not increase. The outpatient care received by the patients became increasingly intensive during the study period but again, the proportion of patients attending outpatient clinics (S82: 87%, S86: 87%, S90: 85%) did not increase. A comparison between the use of treatment services before and after the index discharge showed that residential care decreased because of reduced hospital care and that outpatient care increased steadily throughout the study period. The hospital admission rate, although it was lower after the discharge than before, showed a tendency toward increase. The duration of illness did not correlate with the amount of hospital care but did correlate with a greater extent of residential outpatient care (S82: 0.16, p = 0.000; S86: 0.10, p = 0.001; S90: 0.04, p = 0.210), except in the S90 cohort. As expected, the VSS patients used both hospital inpatient (mean 132 days) and residential outpatient (25 days) services during the followup period to a lesser extent than the VLS patients (159 hospital days and 363 residential days on average). However, there was a major change in the use of residential outpatient care for these short-term patients: Their use of residential outpatient care (S82: 12 days, S86: 32, S90: 30; p = 0.030) and also by the SDI patients (S82: 13 days, S86: 55, S90: 32; p = 0.002) increased significantly from 1982 to 1986 but not thereafter. Readmissions to the hospital increased slightly in SDI patients (S82: 1.9, S86: 1.7, S90: 2.1; p = 0.388), but steeply in LDI patients (S82: 1.9, S86: 2.3, S90: 3.1; p = 0.008). Contrary to the general trend, the use of outpatient services by these LDI patients did not increase. Use of and Need for Psychiatric Services at Followup. Of the latest cohort, less than 20 percent were receiving hospital inpatient care and nearly 20 percent were using community-based residential or day care, while 50 per- 461

6 Schizophrenia Bulletin, Vol. 24, No. 3, 1998 R.K.R. Salokangas and S. Saarinen Table 3. Use of psychiatric services during 3 years before and after discharge from the hospital by schizophrenia patients, by the year of discharge (means) Before discharge Inpatient care (days) Residential outpatient care (days) All residential care (days) Admissions to hospital Visits to CMHC Day-care visits Workshop visits All outpatient visits After discharge Inpatient care (days) Residential outpatient care (days) Total residential care (days) Admissions to hospital Visits to CMHC Day-care visits Workshop visits All outpatient visits 1982, n = 1, , n= 1, Note. p values are based on analysis of variance. CMHC - Community Mental Health Center. cent were using services provided by the CMHCs only. Somewhat over 10 percent were receiving no psychiatric care (table 4). The proportion of hospitalized patients, those attending the CMHCs and those out of contact with psychiatric services at followup, decreased during the study period, while the proportions of patients receiving residential or day care clearly increased. According to the psychiatric teams' assessments, which were made with the S86 and S90 patients only, the need for community-based residential care and day care still exceeded the actual provision of such services. 1990, n = 1, P <0.05 Psychopharmacologic drugs and various modes of psychiatric treatment and rehabilitation were used more often by the latest cohort (S90) than by the earlier ones. In the case of drug therapy, the needs assessments corresponded quite closely to the actual use of drugs, whereas the need for various modes of psychotherapy and for rehabilitation was much greater than the actual provision of these services (table 4). One-fourth of the patients were using medical services and less than half, social services (the need for these services seemed to be adequately met). The need for sup- Table 4. Use of and need for care and support at followup In patients with schizophrenia discharged from the hospital: Treatment contact In hierarchical order Treatment setting Inpatient Nonhosprtal residential Day care Outpatient No care Psychiatric treatments Drug therapy Psychotherapy Rehabilitation Other Medical care Social services Support from voluntary organizations Note. p values are based on the X 2 test. 1985, n = Use 1989, n = , n= P < , n = Need 1993,

7 Deinstitutionalization and Schizophrenia in Finland Schizophrenia Bulletin, Vol. 24, No. 3, 1998 port provided by voluntary organizations was assessed to be greater than what was actually received. A comparison of the results obtained by the psychiatric teams with those of the independent researcher showed that the latter assessed the need for psychotherapies to be 1.6 times greater and the need for social rehabilitation to be 2.6 times greater than was found by the psychiatric teams. In the case of psychotropic drugs, no differences were found in the assessments. When the effect of the independent researcher on the results of the S86 cohort was controlled for, the figures showed that in 1989 unmet needs for various modes of treatment and support were very similar to those found in Finally, the treatment situation at followup was considered in relation to the duration of illness (figure 2). Among the LDI patients, the proportion of those receiving no care remained relatively high, while among the patients with a shorter duration of illness, this proportion clearly declined. The proportion of LDI patients receiving residential care did not change during the study period, while among the patients with a shorter duration of illness, the proportion clearly increased. Discussion In Finland, Health Districts (at the time of the study, Mental Health Districts; mean population of 250,000) form catchment areas that have, under the same administration, one or more hospitals and several CMHCs responsible for the psychiatric care of all people living in the district There are no, or very few, private sources of psychiatric care, especially for discharged patients with schizophrenia; thus, the case records produced in the psychiatric units reliably reflect the total use of services. Figure 2. Use of psychiatric services at followup by duration of Illness IN-PATIENT CARE CMHC CARE E RESIDENTIAL CARE DAY CARE NO CARE CMHC = Community Mental Health Center. The local DSP researchers had access to all case records of these services, and if there was any indication that a patient moved to another district, staff members contacted staffs in these districts and, with the permission of the patient, collected the data. Further, it is known that migration within Finland is much less common than in many other countries. These facts give us good reason to believe that the data on the use of services are fairly comprehensive and that there is no systematic bias among cohorts in this respect. The main purpose of the study design was to obtain three comparable cohorts from different years; therefore, we decided to take the same starting point for sampling. January 1 was a natural choice because December 31 is an official census day and, if necessary, the discharge rates could also have been evaluated against the total hospital population. Before and during the study, there was no indication that the Januaries in these sampling years were different in any important respect. Although it is possible that the discharge rate in January is lower than in other months, this does not violate comparisons between Januaries in different years. It would have been epidemiologically correct to take a random sample from the total number of annual discharges. However, this kind of study would have been much more difficult to carry out in practice; therefore, we decided to take consecutive patients after an established starting point. Assessments of the need for treatment and support were based on interviews with the patients of the S86 and S90 cohorts. The S86 and S90 data are thus comparable, although 13 percent of the S86 patients were examined by the independent researcher. The differences between the results she obtained and those obtained by the psychiatric teams could be controlled for by comparing the data obtained on the S86 and S90 cohorts in other study areas. It was thereby also possible to evaluate the differences between the assessments made by the treatment teams and those made by an uninvolved researcher. Analyses of dropouts showed that the patients examined at followup were more severely disturbed and used psychiatric services more often. This has to be taken into account when considering the results of the assessments of treatment use and need at followup. There was no indication, however, that this difference between discharged and followed patients was systematically different in the studied cohorts. All in all, the DSP study is based on three representative samples of patients with schizophrenia discharged from Finnish mental hospitals; the study period covers the years of one of the most rapid deinstitutionalization processes in the world. The results of the DSP study can thus be extrapolated to the total population of discharged patients with schizophrenia in the country and can throw 463

8 Schizophrenia Bulletin, Vol. 24, No. 3, 1998 R.K.R. Salokangas and S. Saarinen light on the deinstitutionalization process in Finland. It must be remembered, however, that the study dealt with discharged patients, and the results obtained in a study of this type are thus not applicable to the problems of the chronically mentally ill not admitted to hospitals, an issue that has also been pointed out by Lamb and his colleagues (Lamb 1988; Lamb and Shaner 1993). Most of the discharged patients with schizophrenia were males, unmarried individuals, and/or from the lower social classes. It is well known that the outcome of schizophrenia is poorer in males than in females and that unmarried apd divorced persons and those in the lower social classes are overrepresented among patients with schizophrenia (Hollingshead and Redlich 1958; Salokangas 1977, 1978, 1983, 1993; Bland and Orn 1978; Alanen et al. 1986; Seeman 1986; Angermeyer et al. 1989; Salokangas and Stengard 1990); studies of hospitalized patients throw these characteristics into even greater relief. One major change found was related to age and duration of illness: In the course of the rapid reduction in mental hospital beds, the age of patients with schizophrenia at discharge became higher and the history of illness, longer. Furthermore, the patients discharged into the community in the later phases of the study were more disturbed and received more psychotropic drugs than those discharged in the early 1980s. Parallel to the change in the clinical condition, community-based residential and day-care services were used increasingly often in the posthospital period. The rapid deinstitutionalization process thus led to a major change in the characteristics of discharged patients with schizophrenia and concomitantly in their need for services. Our results showed that deinstitutionalization is followed by a considerable increase in the need for structured community care, which has previously been pointed out, for example, by Lamb (1988). The psychiatric treatment system seemed to respond fairly adequately to this increased demand; after-care was provided for discharged patients as often in the 1990s as in the beginning of the deinstitutionalization period. In view of the deterioration in the patients' clinical and functional condition during the study period, an increase in the use of psychiatric services during the followup was to be expected. Indeed, there was an increase mainly in the use of outpatient and community-based residential services, which seemed to replace the expected increase in hospital care. In the 1990s, the proportion of hospital inpatient care of all residential care was less than 70 percent, while in the early 1980s it was 85 percent. The use of community-based services, including residential care, day care, and outpatient visits to the CMHCs, seemed to reduce the use of hospital services, a finding also obtained by Stein and Test (1980). It is worth noting, however, that this reduction in hospital care did not mean a reduction in readmissions. Despite a more intensive provision of outpatient treatment, there was no decline in the number of readmissions; instead, the number increased, particularly for patients with a long history of illness. The community-based services could not break the circle of repeated hospitalizations; on the contrary, the rotating-door syndrome was increasingly evident, especially in the 1990s. Fairly similar study results have been obtained by Solomon and Davis (1985). Unexpectedly, the proportion of patients with a long history of illness who used residential and day care services was smaller in the two later cohorts than in the first Among the patients whose illness had lasted for shorter periods, however, the proportion of patients receiving such care increased steadily during the study period. At the same time, the need for community-based residential care and day care was assessed by the teams to be clearly greater than the actual use of these services. This discrepancy might be explained in terms of competition for such complementary services. The patients with a shorter duration of illness were taking up a greater share of these services, and the patients with a longer duration were losing out. The sharp increase in the number of readmissions seen specifically in the patients with a long history of illness supports this explanation. Although patients with schizophrenia discharged in the 1990s were more disturbed than those discharged some 10 years earlier, the number of patients totally out of contact with psychiatric services did not increase, but rather decreased. From the viewpoint of the efficacy of the psychiatric treatment system in reaching the patients in need of care, the finding was fairly positive: Taking psychiatric, medical, and social services into account, less than 10 percent of discharged patients were out of touch with all services, a figure similar to that obtained by Johnstone et al. (1984, 1991) in their later followup study. The results for the patients with a long history of illness, however, were somewhat disappointing: Their proportion among patients out of contact with the psychiatric services was higher in the two later cohorts than in the firit one, while for patients with a shorter duration of illness, the situation at the followup of the latest cohort was the reverse. This finding, together with those on the use of residential outpatient care and rehospitalizations, may suggest that as time went on there was a larger and larger proportion of patients with a long history of illness being discharged: That is, patients who were resistant to treatment and residential outpatient care, refused or avoided participating in these services, and, as a result, were subsequently rehospitalized. This is clearly a challenge to the community care system. 464

9 Deinstitutionalization and Schizophrenia in Finland Schizophrenia Bulletin, Vol. 24, No. 3, 1998 The amount of outpatient care and services complementary to hospital care provided by the psychiatric treatment system was steadily increasing during the period of deinstitutionalization; yet the need for the latter services was not fully met. Similarly, a greater degree of various modes of psychotherapy and rehabilitation was provided for the patients, the need for such care, especially for various rehabilitation measures and for support from voluntary organizations, was nevertheless assessed to be clearly greater than could be offered by the treatment system or the organizations. It is also important to note that the need for these services as assessed by the independent researcher was even greater than that found by the psychiatric teams. The present results agree with those obtained in an earlier Finnish study of outpatients with psychotic disorders (Salokangas et al. 1991a, 1991Z>). In addition, another study of discharged psychiatric patients showed a great need for rehabilitative services, including social and vocational rehabilitation, and for supportive residential services. The same study showed that almost half of the basic needs for aftercare were met, while the need for rehabilitation usually remained unmet (Solomon and Davis 1985). The need for structured community care during the deinstitutionalization process has been emphasized by many authors (Hafner 1987; Lamb 1988; Thornicroft and Bebbington 1989; Lamb and Shaner 1993). Despite some negative development, the deinstitutionalization process seemed on the whole to have proceeded fairly successfully in Finland, from the point of view of the psychiatric treatment system. Although according to the official statistics, there was a reduction (14%) in total personnel resources during the study period after 1987, the proportion of outpatient personnel from the total psychiatric staff increased from 10 to 22 percent In 1993 there were 5 outpatient staff members per 10,000 total population in Health Care Districts on average. At the same time, the number of visits to the CMHCs increased even more than the increase in personnel. The psychiatric treatment system seemed to have been able to redirect and use the available resources more effectively and to modify the structure of services according to the changes in the condition of patients discharged from hospitals. The well-developed system of social services in Finland and its frequent use have undoubtedly supported this adaptation to the decreasing use of mental hospital beds. References American Psychiatric Association. DSM-IH-R: Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., revised. Washington, DC: The Association, Alanen, Y.O.; RSkkOlainen, V.; Laakso, J.; Rasimus, R.; and Kaljonen, A. Towards Need-Specific Treatment of Schizophrenic Psychoses. Heidelberg, Germany: Springer- Verlag, Angermeyer, M.C.; Goldstein, J.M.; and Kuehn, L. Gender differences in schizophrenia: Rehospitalization and community survival. Psychological Medicine, 19: , Bachrach, L.L. Deinstitutionalization: An Analytical Review and Sociological Perspective. Washington, DC: Superintendent of Documents, U.S. Government Printing Office, DHEW Publication No. (ADM) , Bachrach, L.L. A conceptual approach to deinstitutionalization. Hospital and Community Psychiatry, 29: , Baldessarini, R.J. Chemotherapy in Psychiatry. Cambridge, MA: Harvard University Press, Barton, R. Institutional Neurosis. Bristol, England: John Wright & Sons, Bland, R.C., and Orn, H. 14-year outcome in early schizophrenia. Acta Psychiatrica Scandinavica, 58: , Bollini, P., and Mollica, R.F. Surviving without asylum: An overview of the studies on the Italian reform movement. Journal of Nervous and Mental Disease, 177: , Borus, J. Deinstitutionalization of the chronically mentally ill. New England Journal of Medicine, 305: , Caton, C, and Goldstein, J. Housing changes of chronic schizophrenic patients: A consequence of the revolving door. Social Science and Medicine, 19(7): , Clifford, P.; Charman, A.; Webb, Y.; and Best, S. Planning for community care: Long-stay populations of hospitals scheduled for rundown or closure. British Journal of Psychiatry, 158: , Endicott, J.; Spitzer, R.L.; Fleis, J.L.; and Cohen, J. The Global Assessment Scale: A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33: , Goldman, H.H.; Taube, C.A.; Regier, D.A.; and Witkin, M. The multiple functions of the state mental hospital. American Journal of Psychiatry, 140: , HSfner, H. Do we still need beds for psychiatric patients? An analysis of changing patterns of mental health care. Acta Psychiatrica Scandinavica, 75: , Hollingshead, A.B., and Redlich, F.C. Social Class and Mental Illness: A Community Study. New York, NY: John Wiley & Sons,

10 Schizophrenia Bulletin, Vol. 24, No. 3, 1998 R.K.R. Salokangas and S. Saarinen Honkonen, T. "Need for Care and Support in Schizophrenia. " Unpublished dissertation, Acta Universitatis Tamperensis, Johnstone, E.C.; Owens, D.G.C.; Gold, A.; Crow, T.J.; and Macmillan, J.F. Schizophrenic patients discharged from hospital: A follow-up study. British Journal of Psychiatry, 145: , Johnstone, E.C.; Owens, D.G.C.; and Leary, J. Comparison of the cohort with the cohort. British Journal of Psychiatry, 159(Suppl. 13):34-36, Kane, J.M., and Marder, S.R. Psychopharmacological treatment of schizophrenia. Schizophrenia Bulletin, 19(2): , LSakintohallitus. Psykiatrisen terveydenhuollon kehittdminen. [National Board of Heath: Development of Psychiatric Health Care. Work Group Report] Tyo'ryhma'mietintS. Helsinki, Finland: Laakintohallitus, LMkintbhallitus. Tautiluokitus [National Board of Health: Classification of Diseases 1987] Helsinki, Finland: Valtion painatuskeskus, Laakintohallitus. Skitsofreniaprojekti Skitsofrenian tutkimuksen, hoidon ja kuntoutuksen valtakunnallisen kehittamisohjelman loppuraportti. LaakintShallituksen opassarja no. 4. [National Board of Health: The Schizophrenia Project Final report of the national program for the study, treatment, and rehabilitation of schizophrenic patients in Finland]. Series handbooks no. 4. National Board of Health in Finland. Helsinki, Finland: Valtion painatuskeskus, Lamb, H.R. Deinstitutionalization at the crossroads. Hospital and Community Psychiatry, 39(9): , Lamb, H.R. Lessons learned from deinstitutionalization in the U.S. British Journal of Psychiatry, 162: , Lamb, H.R., and Shaner, R. When there are almost no state hospital beds left. Hospital and Community Psychiatry, 44(10): , Leff, J. Problems of transformation. International Journal of Social Psychiatry, 38(1): 16-23, Leff, J.; Thornicroft, G.; Coxhead, N.; and Crawford, C. The TAPS Project. 22: A five-year follow-up of long-stay psychiatric patients discharged to die community. British Journal of Psychiatry, 25(Suppl.): 13-17, Lindholm, H. Sectorized psychiatry: A methodological study of the effects of reorganization on patients treated at a mental hospital. Acta Psychiatrica Scandinavica, 304(Suppl.): 1-127, Mielenterveystydn komitean mietintd. [Government Report on Mental Health] Committee Reports. 17:1-11, Helsinki, Finland: Valtion painatuskeskus, Raftery, J. Mental health services in transition: The United States and the United Kingdom. British Journal of Psychiatry, 161: , Salokangas, R.K.R. Skitsofreniaan sairastuneiden psykososiaalinen kehitys. Kansaneldkelaitoksen julkaisuja AL 7. [The Psychosocial Development of Schizophrenic Patients] Turku, Finland: Publications of the Social Insurance Institution, Finland AL: 7, Salokangas, R.K.R. Psychosocial Prognosis in Schizophrenia. Formation of the Prognosis for Schizophrenic Patients: A Multivariate Analysis. Vol. 9, Series D. Turku, Finland: Acta Universitatis Turkuensis, Salokangas, R.K.R. Prognostic implications of die sex of schizophrenic patients. British Journal of Psychiatry, 12: , Salokangas, R.K.R. First-contact rate for schizophrenia in community psychiatric care: Consideration of the oestrogen hypothesis. European Archives of Psychiatry and Clinical Neuroscience, 242: , Salokangas, R.K.R.; Der, G.; and Wing, J.K. Community psychiatric services in England and Finland. Social Psychiatry, 20:23-29, Salokangas, R.K.R.; Palo-oja, T.; and Ojanen, M. The need for social support among outpatients suffering from functional psychosis. Psychological Medicine, 21: , 1991a. Salokangas, R.K.R.; Palo-oja, T; Ojanen, M.; and Jalo, K. Need for community care among psychotic outpatients. Acta Psychiatrica Scandinavica, 84: , Salokangas, R.K.R.; Saarinen, S.; and Ojanen, M. Sairaalasta kotiutetut skitsofreniapotilaat (SKS-projekti) I: Vuonna 1986 kotiutettujen potilaiden kliininen ja toiminnallinen tila, hoito- ja tukipalveluiden kdytto sekd niiden arvioitu tarve. [Discharged Schizophrenia Patients (DSP-Project) I: Patients Discharged in 1986 From Hospital: Clinical and Functional Status, Use of Treatment and Support Services, and Evaluated Need for Services] Reports of Psychiatrica Fennica 19%, No. 97. Helsinki, Finland: Foundation for Psychiatric Research, Salokangas, R.K.R.; Saarinen, S.; and Stengard, E. Sairaalasta kotiutetut skitsofreniapotilaat (SKS-projekti) II: Aikatrenditutkimus vuosina 1982, 1986 ja 1990 kotiutettujen potilaiden kliinisen ja toiminnallisen tilan seku, hoito- ja tukipalveluiden ka'yton muutoksista. [Schizophrenic Patients Discharged From Hospital (DSP- Project) II: A Study of Time Trends in the Clinical and 466

11 Deinstitutionalization and Schizophrenia in Finland Schizophrenia Bulletin, Vol. 24, No. 3, 1998 Functional Status of Patients Discharged in 1982, 1986, and 1990 and in the Use of Treatment and Supportive Services] Foundation for Psychiatric Research Publication Series, Report III. Helsinki, Finland: Foundation for Psychiatric Research, ' Salokangas, R.K.R., and Stengfird, E. Gender and shortterm outcome in schizophrenia. Schizophrenia Research, 3: , Seeman, M.V. Current outcome in schizophrenia: Women vs men. Ada Psychiatrica Scandinavica, 73: , Solomon, P., and Davis, J. Meeting community service needs of discharged psychiatric patients. Psychiatric Quarterly, 57(1):11-17, Stein, L.I., and Test, M.A. Alternative to mental hospital treatment: I. Conceptual model, treatment program, and clinical evaluation. Archives of General Psychiatry, 37: , Stengard, E.; Saarinen, S.; and Salokangas, R.K.R. Skitsofrenia-potilaan selviytyminen omaisen ndkdkulmasta. SKS- ja USP-projektien tuloksia. [Survival of Schizophrenia Patients From the View Point of Relatives] Reports of Psychiatrica Fennica, No Helsinki, Finland: Foundation for Psychiatric Research, Tansella, M.; Balestrieri, M.; Meneghelli, G.; and Micciolo, R. Trends in the provision of psychiatric care Psychological Medicine Monograph, 19(Suppl.):5-16, Thornicroft, G., and Bebbington, P. Deinstitutionalisation From hospital closure to service development. British Journal of Psychiatry, 155: , Wing, J.K., and Brown, G. Institutionalism and Schizophrenia. Cambridge, England: Cambridge University Press, Wing, J.K., and Furlong, R. A haven for the severely disabled within the context of a comprehensive psychiatric community service. British Journal of Psychiatry, 149: , Wing, J.K., and Morris, B. Handbook of Psychiatric Rehabilitation Practice. Oxford, England: Oxford University Press, World Health Organization. Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death. Vol. 1, 8th ed. Geneva, Switzerland: The Organization, Acknowledgments The authors are indebted to the psychiatric teams of the study districts for the invaluable help they gave us in the data collection. The authors are also grateful to the National Board of Health, the Association of Finnish Mental Hospitals, the League of Hospitals in Finland, and the Academy of Finland for their financial support. The Authors Raimo K.R. Salokangas, M.D., Ph.D., M.S., is Professor of Psychiatry, Department of Psychiatry, University of Turku, Turku, Finland. Soile Saarinen, M.S. (deceased), was Research Assistant, Public School of Health, University of Tampere, Tampere, Finland. 467

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