[From the psychiatric sector to the mental health territory]

There is currently a noticeable change in public health policy, as well as a paradigm shift with the policy of a mental health territory. From a humanist sector policy, centred on the patient, we are moving towards a policy of a mental health territory, which, although taking into account the changing needs of a group of people, no longer considers the specific needs of the individual. The notion of a geographic breakdown of the organisation of care is becoming predominant.

[Opening up psychiatric care]

The post-war phase of the deinstitutionalisation of psychiatry, which led to the legal recognition of the sector, has been followed by the years of economic crisis. As in the past, such times favour the exclusion of the weakest. As resources dwindle, only the clinical meaning, the dynamism and creativity of the nursing teams can ensure the emergence of new solutions for complex care situations.

The economic consequences of deinstitutionalisation of mental health services: lessons from a systematic review of European experience

Many European mental health systems are undergoing change as community-centred care replaces large-scale institutions. We review empirical evidence from three countries (UK, Germany, Italy) that have made good progress with this rebalancing of care. We focus particularly on the economic consequences of deinstitutionalisation. A systematic literature review was conducted using a broad search strategy in accordance with established guidelines. We searched the International Bibliography of the Social Sciences, Health Management Information Consortium, British Nursing Index and PUBMED/Medline to 2008. The on-line search was supplemented by advice and assistance from contacts with government departments, European Commission, professional networks and known local experts. Community-based models of care are not inherently more costly than institutions, once account is taken of individuals' needs and the quality of care. New community-based care arrangements could be more expensive than long-stay hospital care but may still be seen as more cost-effective because, when properly set up and managed, they deliver better outcomes. Understanding the economic consequences of deinstitutionalisation is fundamental to success. Local stakeholders and budget controllers need to be aware of the underlying policy and operational plan. Joint planning and commissioning or devolving certain powers and responsibilities to care managers may aid development of effective and cost-effective care. People's needs, preferences and circumstances vary, and so their service requirements and support costs also vary, opening up the possibility for purposive targeting of services on needs to improve the ability of a care system to improve well-being from constrained resources. As the institutional/community balance shifts, strategic planning should also ensure that the new care arrangements address the specific contexts of different patient groups. Decision-makers have to plan a dynamic community-based system to match the needs of people moving from institutions, and must take the long view.

[The Italian deinstitutionalization: pathways and challenges]

This article aims to analyze if and how the long-term experience of psychiatric de-institutionalization in Italy has been affected by the neoliberal changes in social policies. And vice versa if and how these policies and especially the service organizations have been shaped by this experience. The first part presents a general picture of the ways the health and welfare system in Italy has been reorganised under the European Union's influence and highlights several differences at the regional level. Can these differences be traced back to different degrees in which a post-asylum mental health system has been achieved? In the second part the pathways of the de-institutionalization are shortly recalled, looking particularly at the displacement of competences and practices from internment to the community, and from curing mental illness to producing mental health. Did the displacement, where it has been accomplished, change the more general cultures and practices of health and welfare services and what has it generated in terms of social organization? It concludes that the de-institutionalization strategies support the construction of local communities as public spaces. In the third part three local cases are analyzed in which the de-institutionalization methodology guides strategies to face and orient the neoliberal principles of the new social policies. These strategies appear to support also the building up of local communities as public spaces. These strategies appear to have strong effects in mobilising local communities and in conferring on them the status of public arena.

Evaluating mental health care and policy in Spain

BACKGROUND

The reform and expansion of mental health care (MHC) systems is a key health policy target worldwide. Evidence informed policy aims to make use of a wide range of relevant data, taking into account past experience and local culture and context.

AIMS

To discuss the organisation, provision and financing of MHC in Spain visa vis the goals of recent psychiatric reforms.

METHOD

We draw upon existing literature, reports and empirical data from regional and national health plans, as well as European reports pertinent to Spain. In addition we have made use of iterative discussion by an expert panel on the features of Spanish MHC services, namely its history, characteristics and determinants in comparison to reforms in other European health systems.

RESULTS

In contrast to most other European health systems, the Spanish case reveals that political regional devolution leads to a greater heterogeneity in MHC systems, with some of the 17 autonomous communities (ACs) or region states that make up the country moving more rapidly to full de-institutionalisation alongside coverage expansion and policy innovation. There remains a lack of specific earmarked budgets for MHC at a time of under-funding. There has been an imbalance in MHC reforms, with more focus on the principles underpinning the process of de-institutionalisation and less on the actual development of alternative community based mental health services. Moreover there has been a lack of monitoring of the reform process. Common to other countries, attempts to develop a more informed evidence policy have been hampered by a dislocation between the production of research evidence and the timing of actual policy reform implementation.

DISCUSSION

Much of the focus of policy attention is on how to improve coordination within and across sectors, tackle socioeconomic inequalities and thus reduce the gap between perceived and observed need while monitoring any trends suggesting trans-institutionalisation. Other issues include developing and strengthening services to meet the needs of new migrants, as well as those of the rural population. There is also a growing recognition of the need to strengthen the evidence base both through research capacity and mechanisms to encourage the use of health economic information as one key component in the assessment of the system.

IMPLICATIONS FOR HEALTH POLICIES

The evolution of MHC in Spain may be regarded as a useful contextual case study for other countries embarking on reform, including some in Eastern Europe and Latin America. Spain is an example of a country that has undergone substantial economic and democratic transition in a short time frame; it has seen significant economic growth in some areas and has experienced mass immigration. While it is too early to judge the effectiveness of reforms in Spain, work to date clearly indicates some of the challenges that have to be overcome. These include better harmonisation and integration between health and social care, and more attention paid to the development or monitoring mechanisms to assess progress in reform implementation and better identify any widening of geographical disparities.

Transitions clinic: creating a community-based model of health care for recently released California prisoners

Most California prisoners experience discontinuity of health care upon return to the community. In January 2006, physicians working with community organizations and representatives of the San Francisco Department of Public Health's safety-net health system opened the Transitions Clinic (TC) to provide transitional and primary care as well as case management for prisoners returning to San Francisco. This article provides a complete description of TC, including an illustrative case, and reports information about the recently released individuals who participated in the program. From January 2006 to October 2007, TC saw 185 patients with chronic medical conditions. TC patients are socially and economically disenfranchised; 86% belong to ethnic minority groups and 38% are homeless. Eighty-nine percent of patients did not have a primary care provider prior to their incarceration. Preliminary findings demonstrate that a community-based model of care tailored to this disenfranchised population successfully engages them in seeking health care.

[From the asylums to the community: the reform process of National Colony "Dr. Manuel A. Montes de Oca"]

Since 2004, a profound transformation of the asylum care model, characterized by overcrowding, lack of discharge and absence of rehabilitation programs, and social reinsertion, has been developed at National Colony "Dr. Manuel A. Montes de Oca". During this period, a plan that contemplates several programs and projects aimed at restoring the rights of institutionalized people with mental disabilities and promoting opportunities for social inclusion has been implemented.

[P.R.E.A. (Rehabilitation and Assisted Outpatient Care Program): an alternate experience to the "Asylum Logic"]

The purpose of the following article is show the work that has been going on for the past nine years in the Assisted Discharge and Rehabilitation Program (PREA, from its Spanish initials), at the Esteves Hospital, Temperley, Province of Buenos Aires, Argentina. Our aim is to describe the historical and political context that gave rise to this program as well as the different activities carried out through its mechanisms to achieve the program's main objective: institutional discharge and resocialization of long-term patients with high chronicity in the psychiatric facility. This is the account of an experiment which, together with other similar ones already carried out in our country and elsewhere in the world, proves clearly that there are practical and sustainable alternatives to institutionalization and confinement for the treatment of serious mental disorders and chronicity; and that this is feasible within our province's current situation and our public health system.

Theoretical accounts on deinstitutionalization and the reform of mental health services: a critical review

This article offers a comprehensive critical review of the most popular theoretical accounts on the recent processes of deinstitutionalization and reform of mental health services and their possible underlying factors, focusing in the sharp contrast between the straightforward ideas and models maintained by mainstream psychiatry and the different interpretations delivered by authors coming from the social sciences or applying conceptual tools stemming from diverse social theories. Since all these appraisals tend to illuminate only some aspects of the process while obscuring others, or do not fit at all with some important points of the actual changes, it is concluded that the quest for an adequate explanation is far from having been completed. Finally, some methodological and conceptual strategies for a renewed theoretical understanding of these significant transformations are also briefly discussed, including a comprehensive empirical evaluation of the facts, the consideration of the shifting social values and needs involved in mental health care provision and the historical analysis of deinstitutionalization policies within the framework of the broader social and cultural trends of the decades following World War II.

Community mental health services--the New Zealand experience

This overview focuses on a provision of current mental health services in New Zealand and might help professionals from other countries to become familiar with its community based model of care. New Zealand mental health services have undergone significant changes over the last 40 years. These include the closure of old psychiatric hospitals and the development of community based treatment facilities. The New Zealand government has been closely involved with the organisation of mental health services providing strategic directions and financial support. So far much has been accomplished, however some gaps still remain.

A configuração da reforma psiquiátrica em contexto local no Brasil: uma análise qualitativa

Este estudo focaliza o cotidiano institucional das atividades desenvolvidas pelo Centro de Atenção Psicossocial (CAPS), um serviço municipalizado de saúde mental em Andradas, Minas Gerais, Brasil. O estudo analisa, em particular, as representações sociais dos profissionais de saúde envolvidos com o atendimento do doente mental, face a sua reinserção social, frente às novas propostas preconizadas pela reforma psiquiátrica. Remete a uma análise histórica e conjuntural, partindo-se da hipótese de que avaliar o novo processo de intervenção institucional contribui para a sua implementação e aprimoramento. Focaliza também a postura dos profissionais de saúde, o trabalho interdisciplinar e os fatores que permeiam esta prática. Uma abordagem qualitativa é utilizada em toda a pesquisa.

A clinical alternative to the public health approach to mental illness: a forgotten social experiment

In the last half of the 20th century, the community mental health movement, based on a public health model, came to dominate patterns of care for mental patients. In the process, brutal deinstitutionalization of very ill patients took place, at least in the United States. These events were not inevitable. In 1949, the Menningers of Topeka, Kansas, began administering Topeka State Hospital, which was in deplorable condition. By concentrating expenditures on clinical personnel, the Menningers humanely deinstitutionalized many patients before chlorpromazine, before the entitlement programs of the U.S. federal government such as Medicaid (1965), and before the community psychiatry movement got under way. Topeka State Hospital furnished a model of mental health care that centered a whole system on a last-resort, large, specialized state mental hospital. This inadvertent social experiment suggests that a clinical approach to mental health care offers a hard-headed alternative to present arrangements.

Get Connected: an HIV prevention case management program for men and women leaving California prisons

Individuals leaving prison face challenges to establishing healthy lives in the community, including opportunities to engage in behavior that puts them at risk for HIV transmission. HIV prevention case management (PCM) can facilitate linkages to services, which in turn can help remove barriers to healthy behavior. As part of a federally funded demonstration project, the community-based organization Centerforce provided 5 months of PCM to individuals leaving 3 state prisons in California. Program effects were measured by assessing changes in risk behavior, access to services, reincarnation, and program completion. Although response rates preclude definitive conclusions, HIV risk behavior did decrease. Regardless of race, age, or gender, those receiving comprehensive health services were significantly more likely to complete the program. PCM appears to facilitate healthy behavior for individuals leaving prison.

Coming home from jail: the social and health consequences of community reentry for women, male adolescents, and their families and communities

Each year, more than 10 million people enter US jails, most returning home within a few weeks. Because jails concentrate people with infectious and chronic diseases, substance abuse, and mental health problems, and reentry policies often exacerbate these problems, the experiences of people leaving jail may contribute to health inequities in the low-income communities to which they return. Our study of the experiences in the year after release of 491 adolescent males and 476 adult women returning home from New York City jails shows that both populations have low employment rates and incomes and high rearrest rates. Few received services in jail. However, overall drug use and illegal activity declined significantly in the year after release. Postrelease employment and health insurance were associated with lower rearrest rates and drug use. Public policies on employment, drug treatment, housing, and health care often blocked successful reentry into society from jail, suggesting the need for new policies that support successful reentry into society.

Coming home from jail: the social and health consequences of community reentry for women, male adolescents, and their families and communities

Each year, more than 10 million people enter US jails, most returning home within a few weeks. Because jails concentrate people with infectious and chronic diseases, substance abuse, and mental health problems, and reentry policies often exacerbate these problems, the experiences of people leaving jail may contribute to health inequities in the low-income communities to which they return. Our study of the experiences in the year after release of 491 adolescent males and 476 adult women returning home from New York City jails shows that both populations have low employment rates and incomes and high rearrest rates. Few received services in jail. However, overall drug use and illegal activity declined significantly in the year after release. Postrelease employment and health insurance were associated with lower rearrest rates and drug use. Public policies on employment, drug treatment, housing, and health care often blocked successful reentry into society from jail, suggesting the need for new policies that support successful reentry into society.

Capturing intervention effects over time: reanalysis of a critical time intervention for homeless mentally ill men

OBJECTIVES

We analyzed whether a method for identifying latent trajectories--latent class growth analysis (LCGA)--was useful for understanding outcomes for individuals subject to an intervention.

METHODS

We used LCGA to reanalyze data from a published study of mentally ill homeless men in a critical time intervention (CTI) program. In that study, 96 men leaving a shelter's on-site psychiatric program were randomly assigned to experimental and control groups. The former received CTI services and the latter usual services. Each individual's housing circumstances were observed for 18 months after program initiation. Our outcome measure was monthly homelessness: a person was considered homeless in a month if he was homeless for even 1 night that month.

RESULTS

Four latent classes were found among the control group, but just 3 among the experimental group. Control, but not experimental, group individuals showed a small class of chronically homeless men. The size of the never-homeless class was 19 percentage points larger for the experimental than for the control group. J- and inverted-U-shaped patterns were also found among both groups, but with important differences in timing of patterns.

CONCLUSIONS

Our results reveal effects not apparent in the original analysis, suggesting that latent class growth models improve intervention evaluation.

Behavioral health problems, ex-offender reentry policies, and the "Second Chance Act"

The federal "Second Chance Act of 2005" calls for expanding reentry services for people leaving prison, yet existing policies restrict access to needed services for those with criminal records. We examined the interaction between individual-level characteristics and policy-level restrictions related to criminal conviction, and the likely effects on access to resources upon reentry, using a sample of prisoners with Axis I mental disorders (n=3073). We identified multiple challenges related to convictions, including restricted access to housing, public assistance, and other resources. Invisible punishments embedded within existing policies were inconsistent with the call for second chances. Without modification of federal and state policies, the ability of reentry services to foster behavioral health and community reintegration is limited.

Gender-specific behavioral health and community release patterns among New Jersey prison inmates: implications for treatment and community reentry

OBJECTIVES

We describe behavioral health diagnoses and community release patterns among adult male and female inmates in New Jersey prisons and assess their implications for correctional health care and community reentry.

METHODS

We used clinical and classification data on a census of "special needs" inmates (those with behavioral health disorders) in New Jersey (n=3189) and a census of all special needs inmates released to New Jersey communities over a 12-month period (n=974).

RESULTS

Virtually all adult inmates with special needs had at least 1 Axis I mental disorder, and 68% of these had at least 1 additional Axis I mental disorder, a personality disorder, or addiction problem (67% of all male and 75% of all female special needs inmates). Of those special needs inmates released, 25% returned to the most disadvantaged counties in New Jersey (27% of all male and 18% of all female special needs inmates).

CONCLUSIONS

Two types of clustering were found: gender-specific clustering of disorders among inmates and spatial clustering of ex-offenders in impoverished communities. These findings suggest a need for gendered treatment strategies within correctional settings and need for successful reentry strategies.

Glasgow's community care programme: 10 year follow up of discharged patients with schizophrenia

In 1986, the rehabilitation of every long stay psychiatric patient in Glasgow was assessed with a view to reducing bed numbers and developing comprehensive community services. Ten years on, we have attempted to trace 91 patients with a diagnosis of schizophrenia assessed at Gartnavel Hospital, in order to repeat assessments of their psychopathology and levels of functioning. We believe this population represents a unique group in terms of their age, length of hospital stay and chronicity of symptoms. Only two patients were untraced but 36% of the original 91 patients were decreased. Discharge to the community and variations in standards of care appeared to have little impact on the symptomatic presentation of the survivors over ten years. The results provide useful information on the success or otherwise of a large scale discharge and community care programme which is continuing in Scotland.

Moving from a long-stay hospital to the community

This article offers an understanding of the experiences and needs of people with severe learning disabilities as they are moved from long-stay institutions to alternative provision in the community. The article draws upon a research study whose preliminary findings suggest that important information about people with learning disabilities is lost in transition. The consequences of such a loss of information are discussed and suggestions offered to improve practice.

[Community-based rehabilitation for severely ill psychiatric patients?]

A central aim of reformatory efforts, as a consequence of the "Psychiatrieenquete" 1975 (a fundamental report of the situation of psychiatry in Germany), had been dehospitalisation of patients with chronic mental illness and their reintegration into the community. Despite a meanwhile well-developed range of community-based services, patients with severe mental illness only rarely get adequate care by these services. This holds especially true for patients with an unfavourable course of disease such as schizophrenia, severe personality disorder, skid-row alcoholism with multiple problems or for patients with double diagnosis. The reasons are barriers set up by the various services and their underlying concepts as well as structural problems in the health care system. Adapted to the special needs for help of these patients, we present a model for the community-based care of this group, combining elements of community psychiatry, addiction treatment and help for the homeless.

[Perspectives of psychiatric care in Leipzig--deinstitutionalization from the viewpoint of neurologist/psychiatrist in private practice and the work of consortium of community psychiatric services]

Two perspectives of mental health care in Leipzig are outlined. Critical aspects of deinstitutionalization are discussed from the point of view of an office-based Nervenarzt (neurologist and psychiatrist). The limitations of office-based practice in providing care for the severely mentally ill (SMI) are described, i.e. lack of a multidisciplinary community mental health team, community psychiatric nursing and social work back-up in particular. Residential service and nursing homes are often under-staffed and ill-prepared for caring for people with SMI. A second view-point describes the Verbund Gemeindenahe Psychiatrie, a community psychiatric service for the just under 500,000 population of Leipzig in seven community mental health centers each combining day hospital, out-patient clinics and multidisciplinary community psychiatric care. This service is unique in Saxony and well accepted by service users and professionals.

[Where are the limits? From institution to deinstitutionalization exemplified in Saarland]

In 1998, the 1876 founded "preussische Provinzialirrenanstalt", a large asylum in Merzig (Germany), was closed down. Instead several psychiatric departments were founded in the rural county ("Bundesland"). On the asylum's former area in Merzig a new and modern general hospital including a psychiatric department was established. The present article will show up the former psychiatric hospital's genuine working fields, treating violent, self-harming and mental ill people needing help. It will describe in a differentiating way how the new services for the different groups of mental ill persons run: Decentralized general psychiatric care in defined regional areas (without forensic patients), central treatment for the forensic patients, regional care for people with mental retardation. In completion of this network there exist regional solutions for the themes "living in a own home", "Working and occupation" and "day-structuring". In conclusion, deinstitutionalization will not have any limits, despite of a few exceptions, if the limits of institutional thinking can be overcome.

[Limits of deinstitutionalization: experience in England]

Psychiatric reform and the current system of mental health care in England are outlined, the system context of the National Health Service (NHS) is described. Recent institutional change in the NHS has introduced internal market elements. More than 90 mental hospitals have been closed. The TAPS study, a longitudinal study evaluating mental hospital closure is described. Results show a range of advantages of the post-discharge care arrangements. Studies evaluating services with a home treatment and community focus (DLP, PRiSM) suggest that community mental health care is feasible. Shortages and problems of the current system of care (acute beds, intensive residential and rehabilitation services) are outlined.

Mental health care reforms in Britain and Italy since 1950: a cross-national comparative study

This paper discusses a cross-national comparative study, which compares the implementation and geographical outcomes of mental health reforms in Britain and Italy since 1950. Working within a cross-national framework, the research adopts a sensitivity to the role of place by exploring the social and spatial restructuring of mental health care service provision in two localities - Sheffield and Verona. By focusing upon the local experiences of mental health care reform, the research strives to gain a clearer understanding of why local geographies of mental health care provision appear to vary across space, both within national boundaries and across them.

'Breaking out of the asylum': developments in the geography of mental ill-health--the influence of the informal sector

This paper focuses on the changing role of the voluntary sector in the provision of care and support to community-based individuals with mental ill-health (MIH) in contemporary Scotland. In doing so, it reflects on the ways in which deinstitutionalisation is contributing to changing interrelationships between the formal and informal sector, the influence of the voluntary sector in the development of the locational geographies of individuals with MIH, and factors contributing to geographical variations in access and availability of voluntary sector supports. These developments are considered within the framework of the shadow state.

[Limits of deinstitutionalization?--perspective of the specialty clinic]

Deinstitutionalization is a complex process that in the past was often misunderstood solely as a run down or even closure of psychiatric hospitals. Although chronically mentally ill patients were prevented from long term hospitalisation some fundamental mistakes were repeated often: patients were simply discharged without any preparations and outpatient care was badly organised. In some cases this led to therapeutic neglect, social disintegration, homelessness, incarceration or other forms of dramatic loss of quality of life. These findings are internationally confirmed although there are remarkable differences between various health care systems. Especially when primarily determined by purely economic interests deinstitutionalization constitutes a severe danger for the whole psychiatric system of care and in particular for chronic patients. Intensive research is required to avoid severe disadvantages for the further development of psychiatry.

[Social welfare in the care of chronically ill psychiatric patients]

The article shows the development of the long-stay departments at the psychiatric hospitals in Eastern Germany from the perspective of a local government. Against the apparently increasing scepticism of concepts of de-institutionalisation, the example of the city Leipzig is used to show how the process of reintegrating residents of long-stay institutions can be supported, and how decentralized out-patient psychosocial services--which can also be used by the community inhabitants--can be built up at the same time. Reference is also made to the well-developed out-patient services and clearly structured treatment offers for the inpatient sector which have already existed in the city before the political changes in Eastern Germany. Further, the role of the local Social Welfare Office in the realization of de-institutionalisation projects will be outlined.

Contracting opportunities: interpreting post-asylum geographies of mental health care in Auckland, New Zealand

In New Zealand, the process of deinstitutionalization is continuing to unfold as a specific manifestation of welfare state restructuring rather than as a discrete process within the health care sector. In this paper we consider the geography of mental health care in Auckland, New Zealand's only metropolitan city. Here, a highly fluid and competitive housing market has profoundly (re)shaped the opportunities for community care. We report on findings from a survey of representatives of the key agencies providing mental health care in central Auckland. We argue that the re-placing of mental health care into the community has often involved the separation of residential and treatment issues, to the detriment of the communities, institutions and (especially) individuals involved. We trace this fragmentation back to the primacy of the ideology of restructuring over the philosophy of deinstitutionalization. We build our argument around a discussion of the Mental Health (Compulsory Assessment and Treatment) Act 1992 and the apparent subordination of the Act to the emerging of a 'contract state' and broader legislation, such as the Resource Management Act 1991, the Privacy Act 1992 and the Commerce Act 1986, which underpins the re-regulation of New Zealand society.

'Building up safe havens... around the world': users' experiences of living in the community with mental health problems

Deinstitutionalization moved the focus of psychiatric care away from hospital institutions to community settings. Mental health services are no longer driven by a policy of illness containment, although detention and coercion retain legislative and cultural legitimacy, because the conceptual and practical focus of caring for people in the 1990s is built around journeys to(wards) ordinary 'independent' living. This paper draws upon the experiences of people with enduring mental health problems to explore the positions, roles and therapeutic benefits established by socio-spatial networking in the community. Social isolation and community integration are polar extremes, two very different 'locations' on a 'theoretical' rehabilitation pathway shaping mental health policy and community care practices. The paper assesses these two locations and searches for the middle-ground in practice. It draws on the concept of normality to compare service user and professional perspectives on the rehabilitation process. The paper argues, with optimism, that spaces of rehabilitation are being found 'in the community' but notes that until mental illness is de-stigmatised and society celebrates difference, creating space for 'Mad Pride', the post-asylum landscape must continue to evolve in search of models of good community care practice and potential landscapes of caring. The research presented in the paper was carried out with Rehabilitation and Community Care Services (RCCS) in Nottingham (1994-1997), and is based upon fieldwork observations and in-depth interviews with RCCS staff and 25 service users.

[Many faces of deinstitutionalization--sociological interpretation]

The article summarizes in an international perspective what kind of results psychiatric deinstitutionalization has brought so far: a profound change of size and functions of the psychiatric hospital; better services for people with less severe problems; and the failing of community services to compensate for some of the functions of the former asylums, resulting in trans-institutionalization and/or neglect for many chronic patients. Three different sociological versions to explain the background and typical outcomes of psychiatric deinstitutionalization have been brought forward so far: political economy, professional dominance and post-structuralism. They are confronted with an approach using the concept of medicalisation which offers a more comprehensive understanding of the process.

Organizational analysis of deinstitutionalization in a psychiatric hospital

BACKGROUND

Few studies have been conducted of the organizational aspects that impact on the course of psychiatric deinstitutionalization.

METHOD

A case study was undertaken of 10 years of deinstitutionalization in a Montreal psychiatric hospital.

RESULTS

Deinstitutionalization has forged ahead in the hospital over the past few years, although the course it has taken is not the one initially plotted by its promoters. Care management of deinstitutionalized patients remains under the control of the psychiatric hospital and its physicians. However, the patients' well-being has remained a focus of concern and does not seem to have been detrimentally affected by this development.

CONCLUSION

Deinstitutionalization is both a solution to the criticisms levelled at the hospital-psychiatric approach of managing persons with severe and persistent mental disorders and an extremely useful tool in the power struggle among the various stakeholders in mental health services reform. Deinstitutionalization has become unavoidable.

The unique roles of state hospital programs: keeping what works in an evolving system

Ultimately, the outcome and cost-effectiveness research should convince a compassionate public that rehabilitation is worthwhile, wherever it takes place.

The psychiatric hospital and therapeutic jurisprudence: applying the law to promote mental health

If the law provided for accessible and efficient means to facilitate mental health treatment, the law itself could be a component of the comprehensive care system.

The state hospital and the community: an essential continuum for persons with severe and persistent mental illness

Assertive Community Treatment and related approaches will have a defining impact on state hospitals, now and in the future.

[The bases for the sociomedical rehabilitation of patients with affective disorders]

Different views are presented on the issue of delivering psychiatric services under present-day conditions. The necessity is substantiated to develop medical and social services to be provided to mental patients. The author submits data on the prevalence of mental disturbances, degree of disability, efficiency of biologic methods of therapy. Described in the paper are problems of organization of psychiatric services intended for patients with affective disorders, with objectives and tasks of medical and social rehabilitative services on a town/city scale being substantiated.

Closing of a state hospital: an overview and framework for a case study

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH.

New and borrowed strategies for mental health systems in the decade of the 1990s

Use of the paradigm shifts advocated by futurists and the supporters of total quality management can facilitate access to new options for mental health systems. New views and innovative systems, however, become difficult to maintain in the context of increasingly rapid and unexpected change occurring in the environment. One strategy that can be employed is the use of leverage, a term usually associated with finance or politics.

A descriptive survey to identify the perceived skills and community skill requirements of mental health staff

Throughout the 1990s mental health care has shifted from a hospital to a community-based service. Government policy indicates that staff require further education as a result of the shift to community care. However, none of the United Kingdom policy documents or mental health literature prescribes what education is required. Consequently this multidisciplinary study aimed to identify what skills, if any, were required by hospital-based staff to move to a community-based working environment. Study findings suggest advantages in perceiving skills as overlapping and interconnecting. Five common core skills and skill differences between professional groups are identified. It is argued that core skills are central and common to all groups and specialist skills are those that distinguish professional groups one from another and different grades of staff within professional groups. While problems of multidisciplinary education are considered, nevertheless a case is made for educating staff in core skills within a multidisciplinary environment which may be beneficial in achieving community care goals.

Chronically mentally ill individuals re-entering the community after hospitalization

The purpose of this phenomenological study was to increase the understanding of the experiences of chronically mentally ill individuals who are re-entering the community after hospitalization. Ten individuals from an acute care psychiatric hospital who had had two or more admissions within a 12-month period were interviewed, shortly before discharge and subsequently between two and four times while in the community. Three interrelated themes emerged. First, at the time of discharge, the optimism of the participants about returning home was tempered by a realistic recognition of their problems. As time passed, their problems seemed to become their preoccupying focus and optimism faded. Second, for most of the participants, relationships with others, positive, negative or both, played an important role in their return to home and community. Third, participants who experienced more positive social relationships also described individual achievements and community involvement. The re-entry process was not a smooth transition for these individuals.