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Deinstitutionalised patients, homelessness and imprisonment: Systematic review

  • Petr Winkler (a1), Barbara Barrett (a2), Paul McCrone (a2), Ladislav Csémy (a3), Miroslava Janousková (a3) and Cyril Höschl (a3)...



Reports linking the deinstitutionalisation of psychiatric care with homelessness and imprisonment have been published widely.


To identify cohort studies that followed up or traced back long-term psychiatric hospital residents who had been discharged as a consequence of deinstitutionalisation.


A broad search strategy was used and 9435 titles and abstracts were screened, 416 full articles reviewed and 171 articles from cohort studies of deinstitutionalised patients were examined in detail.


Twenty-three studies of unique populations assessed homelessness and imprisonment among patients discharged from long-term care. Homelessness and imprisonment occurred sporadically; in the majority of studies no single case of homelessness or imprisonment was reported.


Our results contradict the findings of ecological studies which indicated a strong correlation between the decreasing number of psychiatric beds and an increasing number of people with mental health problems who were homeless or in prison.

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Corresponding author

Dr Petr Winkler, Department of Social Psychiatry, National Institute of Mental Health, Topolová 748, 250 67 Klecany, Czech Republic. Email:


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See editorial, pp. 412–413, this issue.

Declaration of interest




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1 Lamb, HR, Weinberger, LE. Persons with severe mental illness in jails and prisons: a review. Psychiatr Serv 1998; 49: 483–92.
2 Penrose, LS. Mental disease and crime: outline of a comparative study of European statistics. Br J Med Psychol 1939; 18: 115.
3 Banks, SM, Stone, JL, Pandiani, JA, Cox, JF, Morschauser, PC. Utilization of local jails and general hospitals by state psychiatric center patients. J Behav Health Serv Res 2000; 27: 454–9.
4 Swartz, MS. Advancing research at the intersection of two systems. Psychiatr Serv 2010; 61: 431.
5 Conacher, GN. Psychiatric hospital downsizing and the Penrose effect. J Nerv Ment Dis 1996; 184: 708–10.
6 Susnick, LC, Belcher, JR. Why are they homeless? The chronically mentally ill in Washington, DC. Int J Mental Health 1996; 24: 7084.
7 Lamb, HR. Does deinstitutionalization cause criminalization? The Penrose hypothesis. JAMA Psychiatry 2015; 72: 105–6.
8 Mundt, AP, Chow, WS, Arduino, M, Barrionuevo, H, Fritsch, R, Girala, N, et al. Psychiatric hospital beds and prison populations in South America since 1990: does the Penrose hypothesis apply? JAMA Psychiatry 2015; 72: 112–8.
9 Lesage, AD, Morissette, R, Fortier, L, Reinharz, D, Contandriopoulos, AP. Downsizing psychiatric hospitals: needs for care and services of current and discharged long-stay inpatients. Can J Psychiatry 2000; 45: 526–32.
10 Christenfeld, R. Deinstitutionalization and its critics: a commentary on Brown. J Community Psychol 1982; 10: 176–80.
11 Davis, L, Fulginiti, A, Kriegel, L, Brekke, JS. Deinstitutionalization. Where have all the people gone? Curr Psychiatry Rep 2012; 14: 259–69.
12 Leff, J, Dayson, D, Gooch, C, Thornicroft, G, Wills, W. Quality of life of long stay patients discharged from two psychiatric institutions. Psychiatr Serv 1996; 47: 62–7.
13 Sealy, P, Whitehead, PC. The impact of deinstitutionalization of psychiatric hospitals on psychological distress of the community in Canada. J Health Soc Policy 2006; 21: 7394.
14 Herman, NJ, Smith, CM. Mental hospital depopulation in Canada: patient perspectives. Can J Psychiatry 1989; 34: 386–91.
15 Novella, EJ. Mental Health care in the aftermath of deinstitutionalization: a retrospective and prospective view. Health Care Anal 2010; 18: 222–38.
16 Pijl, YJ, Kluiter, H, Wiersma, D. Deinstitutionalisation in the Netherlands. Eur Arch Psychiatry Clin Neurosci 2001; 251: 124–9.
17 Munk-Jorgensen, P. Has deinstitutionalization gone too far? Eur Arch Psychiatry Clin Neurosci 1999; 249: 136–43.
18 Novella, EJ. Theoretical accounts on deinstitutionalization and the reform of mental health services: a critical review. Med Health Care Philos 2008; 11: 303–14.
19 Vazquez-Barquero, JL, Garcia, J, Torres-Gonzalez, F. Spanish psychiatric reform: what can be learned from two decades of experience? Acta Psychiatr Scand 2001; 104: 8995.
20 Priebe, S, Badesconyi, A, Fioritti, A, Hansson, L, Kilian, RT, Torres-Gonzales, F, et al. Reinstitutionalisation in mental-health care: comparison of data on service provision from six European countries. BMJ 2005; 330: 123–6.
21 Saraceno, B. Methodological questions in Italian psychiatric reform. Riv Inferm 1989; 8: 5260.
22 Haug, HJ, Rossler, W. Deinstitutionalization of psychiatric patients in central Europe. Eur Arch Psychiatry Clin Neurosci 1999; 249: 115–22.
23 Rosen, A. The Australian experience of deinstitutionalization: interaction of Australian culture with the development and reform of its mental health services. Acta Psychiatr Scand 2006; 113: 81–9.
24 Young, L, Ashman, AF. Deinstitutionalisation in Australia. Part I: historical perspective. Br J Dev Disabil 2004; 50: 21–8.
25 Joseph, AE, Kearns, RA, Moon, G. Recycling former psychiatric hospitals in New Zealand: echoes of deinstitutionalisation and restructuring. Health Place 2009; 15: 7987.
26 Whitley, R, Hickling, FW. Open papers, open minds? Media representations of psychiatric de-institutionalization in Jamaica. Transcult Psychiatry 2007; 44: 659–71.
27 Hickling, FW. Community psychiatry and deinstitutionalization in Jamaica. Hosp Community Psychiatry 1994; 45: 1122–6.
28 Semrau, M, Barley, EA, Law, A, Thornicroft, G. Lessons learned in developing community mental health care in Europe. World Psychiatry 2011; 10: 217–25.
29 Ito, H, Setoya, Y, Suzuki, Y. Lessons learned in developing community mental health care in East and South East Asia. World Psychiatry 2012; 11: 186–90.
30 Appleby, L, Desai, PN. Documenting the relationship between homelessness and psychiatric hospitalization. Hosp Community Psychiatry 1985; 36: 732–7.
31 Gralnick, A. Build a better state hospital: deinstitutionalization has failed. Hosp Community Psychiatry 1985; 36: 738–41.
32 Scott, J. Homelessness and mental illness. Br J Psychiatry 1993; 162: 314–24.
33 Wallace, C, Mullen, PE, Burgess, P. Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders. Am J Psychiatry 2004; 161: 716–27.
34 Winerip, M. Bedlam on the streets. The New York Times Magazine 1999; 23 May: 42–9, 56, 65–6.
35 Hodgins, S, Muller-Isberner, R, Allaire, JF. Attempting to understand the increase in the numbers of forensic beds in Europe: a multi-site study of patients in forensic and general psychiatric services. Int J Forens Mental Health 2006; 5: 173–84.
36 Raphael, S, Stoll, MA. Assessing the contribution of the deinstitutionalization of the mentally ill to growth in the U.S. incarceration rate. J Legal Stud 2013; 42: 187222.
37 Kramp, P, Gabrielsen, G. The organization of the psychiatric service and criminality committed by the mentally ill. Eur Psychiatry 2009; 24: 401–11.
38 Hartvig, P, Kjelsberg, E. Penrose's Law revisited: the relationship between mental institution beds, prison population and crime rate. Nord J Psychiatry 2009; 63: 51–6.
39 Bassuk, EL, Lamb, HR. Homelessness and the implementation of deinstitutionalization. New Dir Ment Health Serv 1986; 30: 714.
40 Whitmer, GE. From hospitals to jails: the fate of California's deinstitutionalized mentally ill. Am J Orthopsychiatry 1980; 50: 6575.
41 Maj, M. The rights of people with mental disorders: WPA perspective. Lancet 2011; 378: 1534–5.
42 World Health Organization. Mental Health Action Plan 2013–2020. WHO, 2013.
43 European Commission. Green Paper: Improving the Mental Health of the Population. Towards a Strategy on Mental Health for the European Union. EC, 2005.
44 Prins, SJ. Does transinstitutionalization explain the overrepresentation of people with serious mental illnesses in the criminal justice system? Community Ment Health J 2011; 47: 716–22.
45 David, I. Vládní Reforma - Tentokrát Psychiatrie [Governmental reform – psychiatry this time]; 2013 (—tentokrat-psychiatrie/).
46 Reforma Psychiatrie? Mù_e Vést k Masivnímu Bezdomovectví [Reform of psychiatry? It might lead to massive homelessness];, 2013 (
47 Chystanáreforma psychiatrie je nevyvá_ená, z pacientù se stávajíbezdomovci [Forthcoming psychiatric reform is unbalanced, patients are getting homeless]. Deník, 2013 (
48 Reforma psychiatrie udìláz pacientù bezdomovce, varujíkritici [Reform of psychiatry will drive patients into homelessness, critics warn]; ÈT24, 2013 (
49 Rueníléèeben pole nemocnéna ulici, varuje studie [Closing of mental hospitals will send patients into streets, study warns]; Czech News Agency, 2013 (
50 Leff, J. Care in the Community: Illusion or Reality? Wiley, 1997.
51 Francis, VM, Vesey, P, Lowe, G. The closure of a long-stay psychiatric hospital: a longitudinal study of patients' behavior. Soc Psychiatry Psychiatr Epidemiol 1994; 29: 184–9.
52 McInerney, SJ, Finnerty, S, Avalos, G, Walsh, E. Better off in the community? A 5-year follow up study of long-term psychiatric patients discharged into the community. Soc Psychiatry Psychiatr Epidemiol 2010; 45: 469–73.
53 Jones, K, Robinson, M, Golightley, M. Long-term psychiatric patients in the community. Br J Psychiatry 1986; 149: 537–40.
54 Kunitoh, N. From hospital to the community: the influence of deinstitutionalization on discharged long-stay psychiatric patients. Psychiatry Clin Neurosci 2013; 67: 384–96.
55 Livingston, MG, Bryson, A. The Glasgow rehabilitation survey. Br J Psychiatry 1989; 154: 620–4.
56 Gottheil, E, Winkelmayer, R, Smoyer, P, Exline, R. Characteristics of patients who are resistant to deinstitutionalization. Hosp Community Psychiatry 1991; 42: 745–8.
57 Barr, R, Parker, G. Effects of discharge on long-stay psychiatric hospital patients. Aust NZ J Psychiatry 1975; 9: 47–9.
58 Carta, MG, Agaj, A, Harapej, E, Lecca, ME, Xhelili, G, Altoe, G, et al. Outcomes of discharged females versus those waiting for discharge from Vlore Psychiatric Hospital (Albania). Int J Soc Psychiatry 2013; 59: 682–9.
59 Chan, H, Inoue, S, Shimodera, S, Fujita, H, Fukuzawa, K, Kii, M, et al. Residential program for long-term hospitalized persons with mental illness in Japan: randomized controlled trial. Psychiatry Clin Neurosci 2007; 61: 515–21.
60 Honkonen, T, Saarinen, S, Salokangas, RKR. Deinstitutionalization and schizophrenia in Finland: II. Discharged patients and their psychosocial functioning. Schizophr Bull 1999; 25: 543–51.
61 Haberfellner, EM, Grausgruber, A, Grausgruber-Berner, R, Ortmair, M, Schony, W. Deinstitutionalization of long-stay psychiatric patients in upper Austria – living situation, social and clinical characteristics more than one year after discharge. Psychiatr Prax 2004; 31: 192–7.
62 Mizuno, M, Sakuma, K, Ryu, Y, Munakata, S, Takebayashi, T, Murakami, M, et al. The Sasagawa Project: a model for deinstitutionalisation in Japan. Keio J Med 2005; 54: 95101.
63 Okin, RL, Borus, JF, Baer, L, Jones, A. Long-term outcome of state hospital patients discharged into structured community residential settings. Psychiatr Serv 1995; 46: 73–8.
64 Thornicroft, G, Bebbington, P, Leff, J. Outcomes for long-term patients one year after discharge from a psychiatric hospital. Psychiatr Serv 2005; 56: 1416–22.
65 McGrew, JH, Wright, ER, Pescosolido, BA, McDonel, EC. The closing of Central State Hospital: long-term outcomes for persons with severe mental illness. J Behav Health Serv Res 1999; 26: 246–61.
66 Hobbs, C, Newton, L, Tennant, C, Rosen, A, Tribe, K. Deinstitutionalization for long-term mental illness: a 6-year evaluation. Aust NZ J Psychiatry 2002; 36: 60–6.
67 Furlan, PM, Zuffranieri, M, Stanga, F, Ostacoli, L, Patta, J, Picci, RL. Four-year follow-up of long-stay patients settled in the community after closure of Italy's psychiatric hospitals. Psychiatr Serv 2009; 60: 1198–202.
68 Donnelly, M, McGilloway, S, Mays, N, Knapp, M, Kavanagh, S, Beecham, J, et al. One and two year outcomes for adults with learning disabilities discharged to the community. Br J Psychiatry 1996; 168: 598606.
69 Farragher, B, Carey, T, Owens, J. Long term follow-up of rehabilitated patients with chronic psychiatric illness in Ireland. Psychiatr Serv 1996; 47: 1120–2.
70 MacGilp, D. A quality of life study of discharged long-term psychiatric patients. J Adv Nurs 1991; 16: 1206–15.
71 Barbato, A, D'Avanzo, B, Rocca, G, Amatulli, A, Lampugnani, D. A study of long-stay patients resettled in the community after closure of a psychiatric hospital in Italy. Psychiatr Serv 2004; 55: 6770.
72 Mastroeni, A, Bellotti, C, Pellegrini, E, Galletti, F, Lai, E, Falloon, IRH. Clinical and social outcomes five years after closing a mental hospital: a trial of cognitive behavioural interventions. Clin Pract Epidemiol Ment Health 2005; 1: 25.
73 Rothbard, AB, Kuno, E, Schinnar, AP, Hadley, TR, Turk, R. Service utilization and cost of community care for discharged state hospital patients: a 3-year follow-up study. Am J Psychiatry 1999; 156: 920–7.
74 Donnelly, M, McGilloway, S, Mays, N, Perry, S, Lavery, C. A three- to six-year follow-up of former long-stay residents of mental handicap hospitals in Northern Ireland. Br J Clin Psychol 1997; 36: 585600.
75 Farragher, B, Carey, T, Owens, J. Long-term follow-up of rehabilitated patients with chronic psychiatric illness in Ireland. Psychiatr Serv 1996; 47: 1120–2.
76 Andrews, G, Teesson, M, Stewart, G, Hoult, J. Follow-up of community placement of the chronic mentally ill in New South Wales. Hosp Community Psychiatry 1990; 41: 184–8.
77 Armstrong, B. A federal study of deinstitutionalization: how the government impedes its goal. Hosp Community Psychiatry 1977; 28: 421–25.
78 Langsley, DG, Barter, JT, Yarvis, RM. Deinstitutionalization: the Sacramento story. Compr Psychiatry 1978; 19: 479–90.
79 Leeman, CP. The ‘least restrictive environment’: from rhetoric to practice. Gen Hosp Psychiatry 1980; 2: 229–32.
80 Okin, RL. Testing the limits of deinstitutionalization. Psychiatr Serv 1995; 46: 569–74.
81 Ozarin, LD, Sharfstein, SS. The aftermaths of deinstitutionalization: problems and solutions. Psychiatr Q 1978; 50: 128–32.
82 Pilisuk, M. A job and a home: social networks and the integration of the mentally disabled in the community. Am J Orthopsychiatry 2001; 71: 4960.
83 Searight, HR, Handal, PJ. The paradox of psychiatric deinstitutionalization: historical perspective and policy implications. J Health Hum Resour Adm 1988; 11: 249–66.
84 Talbott, JA. Presidential address: our patients' future in a changing world: the imperative for psychiatric involvement in public policy. Am J Psychiatry 1985; 142: 1003–14.
85 Talbott, JA. Deinstitutionalization: avoiding the disasters of the past. Hosp Community Psychiatry 1979; 30: 621–4.
86 Wachholz, S, Mullaly, R. Policing the deinstitutionalized mentally-ill – toward an understanding of its function. Crime Law Soc Change 1993; 19: 281300.
87 Hope, M, Young, J. From back wards to back alleys – deinstitutionalization and the homeless. Urban Soc Change Rev 1984; 17: 711.
88 Durham, ML. The impact of deinstitutionalization on the current treatment of the mentally-ill. Int J Law Psychiatry 1989; 12: 117–31.
89 Dumont, MP, Dumont, DM. Deinstitutionalization in the United States and Italy: a historical survey. Int J Ment Health 2008; 37: 61–7.
90 Knowles, C. Burger King, Dunkin Donuts and community mental health care. Health Place 2000; 6: 213–24.
91 Caldas de Almeida, JM, Horvitz-Lennon, M. Mental health care reforms in Latin America: an overview of mental health care reforms in Latin America and the Caribbean. Psychiatr Serv 2010; 61: 218–21.
92 Dickey, B, Gudeman, JE, Hellman, S, Donatelle, A, Grinspoon, L. A follow-up of deinstitutionalized chronic patients four years after discharge. Hosp Community Psychiatry 1981; 32: 326–30.
93 Rothbard, AB, Kuno, E. The success of deinstitutionalization. Empirical findings from case studies on state hospital closures. Int J Law Psychiatry 2000; 23: 329–44.
94 Gardos, G, Cole, JO, LaBrie, RA. A 12-year follow-up study of chronic schizophrenics. Hosp Community Psychiatry 1982; 33: 983–4.
95 Double, D, Wong, T. What has happened to patients from long-stay psychiatric wards? Psychiatr Bull 1991; 15: 735–6.
96 Nordentoft, M, Ohlenschlaeger, J, Thorup, A, Petersen, L, Jeppesen, P, Bertelsen, M. Deinstitutionalization revisited: a 5-year follow-up of a randomized clinical trial of hospital-based rehabilitation versus specialized assertive intervention (OPUS) versus standard treatment for patients with first-episode schizophrenia spectrum disorders. Psychol Med 2010; 40: 1619–26.
97 Wahlbeck, K, Westman, J, Nordentoft, M, Gissler, M, Laursen, TM. Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. Br J Psychiatry 199: 453–8.
98 Coldwell, CM, Bender, WS. The effectiveness of assertive community treatment for homeless populations with severe mental illness: a meta-analysis. Am J Psychiatry 2007; 164: 393–9.
99 Kertesz, SG, Weiner, SJ. Housing the chronically homeless: high hopes, complex realities. JAMA 2009; 301: 1822–4.
100 Somers, JM, Rezansoff, SN, Moniruzzaman, A, Palepu, A, Petterson, M. Housing first reduces re-offending among formerly homeless adults with mental disorders: results of a randomized controlled trial. PLoS One 2013; 8: e72946.
101 United Nations General Assembly. Convention on the Rights of Persons with Disabilities: Resolution. UN General Assembly, 2007 (
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Deinstitutionalised patients, homelessness and imprisonment: Systematic review

  • Petr Winkler (a1), Barbara Barrett (a2), Paul McCrone (a2), Ladislav Csémy (a3), Miroslava Janousková (a3) and Cyril Höschl (a3)...
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Deinstitutionalisation of mentally ill in times of increasing imprisonment? Author's reply

Petr Winkler, Researcher, Department of Social Psychiatry, National Institute of Mental Health, Czech Republic; King's Health Economics, KCL
12 July 2016

Dear Editor – I am grateful for the eLetter published by Mundt (1) as it raises several important points. I agree that the mental health of prison populations is of serious concern and it deserves to be urgently addressed by developing and implementing cost-effective services.

I also agree that in countries which underwent deinstituionalization and were included in our review (2), excessively long time hospitalizations of psychiatric patients no longer commonly occur. After all, this was one of the main reasons why deinstitutionalization was pursued. However, in the Czech Republic, for instance, 16% of inpatients with schizophrenia are still hospitalized for more than a year and hundreds are hospitalized in psychiatric hospitals for decades (3). Therefore, unfortunately, our review is not just of historical value but conveys an important message for current mental health systems in the majority of Central and Eastern European countries.

I acknowledge that neither our review nor ecological studies can (dis)prove whether new cohorts of patients who became imprisoned in the era after deinstitutionalization would have also become imprisoned if the mental care systems were still hospital based. We have also admitted that the cohort of patients followed or traced in studies included in our review are not representative of all deinstitutionalized patients (2). However, what our study shows is that – contrary to some interpretations – there is scant evidence of adverse consequences for people who have been discharged from long-term institutional care. Our main point is that despite the important data provided by ecological studies, these can be hardly helpful in showing whether there is a direct link between deinstitutionalization and criminality. Moreover, it seems that ecological studies testing the Penrose hypothesis may have further important limitations (4), and as such are arguably of inherently limited value. Indeed, linkage studies could be theoretically much more relevant, but, regrettably, Mundt (1) does not cite any of them.

Our review (2) casts doubts on statements such as "the general prison population has increased in all the countries, and this may be linked to the processes of deinstitutionalisation and reinstitutionalisation" (5) or "changes in capacities of psychiatric hospitals and prisons appear to be linked" (6) contained in discussions and conclusions of some of the ecological studies. Our paper shows that at the individual level these statements have negligible empirical support and they might be detrimental to mental health care reforms in countries of Central and Eastern Europe (2). As Salisbury and Thornicroft (7) argued, individual countries should focus on developing optimally balanced mental health care systems suitable to their setting.

There seems to be a clear consensus that substantial investment in community care is a conditio sine qua non of successful deinstitutionalization, which is why I suggest that cost-effective investments into mental health should replace the number of psychiatric beds as the ‘hydraulic’ in the updated Penrose hypothesis.

1.Mundt A. LETTER TO THE EDITOR: Deinstitutionalisation of mentally ill in times of increasing imprisonment? Br J Psychiatry. 2016; 330(7483): 123-6.

2.Winkler P, Barrett B, McCrone P, Csémy L, Janoušková M, Höschl C. Deinstitutionalised patients, homelessness and imprisonment: systematic review. Br J Psychiatry. 2016;208(5):421-8.

3.Winkler P, Mladá K, Krupchanka D, Agius M, Ray MK, Höschl C. Long-term hospitalizations for schizophrenia in the Czech Republic 1998–2012. Schiz Res. 2016 Apr 16. doi:10.1016/j.schres.2016.04.008

4.Tsai, A. C., & Venkataramani, A. S. (2015). LETTER TO THE EDITOR: Penrose Hypothesis not supported. JAMA Psychiatry, 72(7), 735–736.

5.Priebe S, Badesconyi A, Fioritti A, Hansson L, Kilian RT, Torres-Gonzales F, et al. Reinstitutionalisation in mental-health care: comparison of data on service provision from six European countries. Br Med J. 2005; 330(7483): 123-6.

6.Mundt AP, Chow WS, Arduino M, Barrionuevo H, Fritsch R, Girala N, et al. Psychiatric hospital beds and prison populations in South America since 1990: does the Penrose hypothesis apply? JAMA psychiatry. 2015; 72(2): 112-8.

7.Salisbury TT, Thornicroft G. Deinstitutionalisation does not increase imprisonment or homelessness. Br Journal Psychiatry 2016; 208: 412-41
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Conflict of interest: None Declared

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Deinstitutionalisation of mentally ill in times of increasing imprisonment?

Adrian P Mundt, Psychiatrist, Medical Faculties Universidad Diego Portales, Universidad San Sebastián and Universidad de Chile
01 July 2016

Dear editors,

In May 2016, Winkler et al. published a systematic review on cohort studies following up patients after discharge from long-term psychiatric hospitalisation (1). The study did not show relevant numbers of imprisonment or homelessness after discharge. The authors concluded that the study contradicted ecological studies reporting a relationship between prison populations rates and psychiatric bed numbers. They propose ecological fallacies as a possible explanation. In the editorial it is referred to the ecological studies as arguing against deinstitutionalisation (2).

As an author of one of those ecological studies, I would like to comment. Rather than arguing against deinstitutionalisation, the studies express concern that deinstitutionalisation of mentally ill in societies with massively increasing prison populations (3) and very high rates of severely mentally ill among prisoners (4) does not occur. Whereas the relationship between psychiatric bed numbers and prison population rates in South America was rather strong, findings from Europe were less robust (5). In quantitative terms, prisons have become the most important facilities institutionalizing mentally ill in the Americas. Mentally ill in prisons cause much more concern with respect to human rights than mentally ill in psychiatric hospitals. A way forward could mean to improve care for people while in prison and improving community care for mentally ill at risk of criminal justice involvement to prevent imprisonment. There is broad consensus that short-term hospitalization is more efficient than long-term stay and that psychiatric hospitalization should be linked with community services in care systems. In the ecological studies all types of psychiatric hospital beds were acknowledged (3). Including in low- and middle-income settings, the majority of beds is nowadays used to provide short-term care. Long-term hospitalization in general psychiatry is not a common type of service provision any more in the countries, in which the studies were conducted that Winkler et al. included in the review (1). Therefore, the study seems rather of historical value.

It does not surprise that elderly people after decades of hospitalization have low criminogenic energy. Young people with severe mental illness and comorbid substance use disorders are of much more concern. For the understanding of the interdependence of penal justice systems and psychiatric inpatient care systems, recently published large linkage studies of registries are more relevant. They show very high rates of psychiatric hospitalization prior imprisonment and in the year after release from imprisonment. They also show markedly elevated risks for people with mental disorders to commit violent crimes and to be victims of violence compared to the general population. What contribution short-term hospitalization can make to postpone or prevent criminal justice involvement and to protect people with mental disorders is still unresolved. Concluding to reject findings from ecological studies from Winkler et al.’s review may be a fallacy of categories.

1.Winkler P, Barrett B, McCrone P, Csemy L, Janouskova M, Hoschl C. Deinstitutionalised patients, homelessness and imprisonment: systematic review. Br J Psychiatry. 2016;208(5):421-8.

2.Salisbury TT, Thornicroft G. Deinstitutionalisation does not increase imprisonment or homelessness. Br J Psychiatry. 2016;208(5):412-3.

3.Mundt AP, Chow WS, Arduino M, Barrionuevo H, Fritsch R, Girala N, et al. Psychiatric hospital beds and prison populations in South America since 1990: does the Penrose hypothesis apply? JAMA Psychiatry. 2015;72(2):112-8.

4.Mundt AP, Kastner S, Larrain S, Fritsch R, Priebe S. Prevalence of mental disorders at admission to the penal justice system in emerging countries: a study from Chile. Epidemiol Psychiatr Sci. 2015.

5.Chow WS, Priebe S. How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990. BMJ Open. 2016;6(4):e010188.

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Conflict of interest: None Declared

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Hospital discharge and homelessness

Philip W Timms, Consultant Psychiatrist, START Team, South London and Maudsley NHS Foundation Trust, London SE5 7UD
Tom K J Craig, Professor of Social Psychiatry, Institute of Psychiatry, London SE5 8AF
02 June 2016

Dear Sir,

As the authors of a previous review of deinstitutionalisation and homelessness 1, we were interested to see our 1992 findings confirmed by Winkler et al's recent paper 2 and the accompanying commentary 3. We particularly agree with the notion that apparent relationships between deinstitutionalisation and homelessness can often be mediated by substantial confounding factors. In London, in the 1980s, it was the unheralded and unpublicised closure of most of the city's homeless hostel beds that seemed the most likely culprit.

Although this issue may well still be pertinent in other health and social systems, it was of decreasing relevance in the UK even when we published our paper in 1992. The process of deinstitutionalisation was, by then, irreversible and substantially accomplished. Which leads us to our concern that these papers might support an unhelpful sense of complacency.

Taylor Salisbury's statement that "instances of homelessness among those discharged …. are rare" is clearly correct in referring to the institutional closures and hospital discharges that are now several decades in the past. However, it is at odds with the situation with hospital discharge as it stands today, at least in London. PT works in a psychiatric outreach team for homeless people in South London, where homelessness following hospital discharge is common amongst referrals to our service. We looked at 3 months of our referral data last year and found 60% of our homeless referrals (mainly with a diagnosis of psychosis) had had previous contact with our local mental health service. They had had, on average:

oContacts with 4 separate trust services.

o35 contacts (face to face/phone triage) - 2 of these would have been emergency contacts, seen in in A&E or in a 136 suite.

o65 days as an in-patient in the local trust service.

These people had sometimes been discharged to the street, sometimes referred to local community services, but without effective plans to prevent them becoming homeless again.

We note that observations we made in 1992 still stand - the excessive bed-occupancy of in-patient services driving an emphasis on short episodes of in-patient treatment.

So, it seems clear that a small but significant number of people are simply ill-served by the existing format of mainstream mental health services. It may be (as I have heard in a European "quality" forum) that such people are just peculiarly difficult. This seems unlikely given a recent outcomes study we did of the most alienated and intractable of our referrals - people who live on the street and who have not been engaged by the sustained efforts of experienced street outreach teams. The intervention concerned was involuntary admission to hospital under a section of the MHA4. One year later, the majority were still engaged with the specialist mental health team and were still in accommodation. Here is an area ripe for research - the vital factors that enable such teams to engage effectively, and maintain that engagement, with homeless people with psychotic disorders.


1.Craig, T. K. J. & Timms, P.W. (1992) Out of the wards and onto the streets? Deinstitutionalization and homelessness in Britain. Journal of Mental Health 1992, 1, 265-275.

2.Winkler P, Barrett B, McCrone P, Csémy L, Janousková M, Höschl C. Deinstitutionalised patients, homelessness and imprisonment: systematic review. Br J Psychiatry 2016; 208: 421-8.

3.Tatiana Taylor Salisbury, Graham Thornicroft. Deinstitutionalisation does not increase imprisonment or homelessness. Br Journal Psychiatry 2016; 208: 412-413.

4.Timms P. & Perry, J. Sectioning on the street - futility or utility? BJPsych Bull Apr 2016, pb.bp.115.052449

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