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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)...
Abstract
Background

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

Aims

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

Method

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.

Results

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.

Conclusions

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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Copyright
Corresponding author
Dr Petr Winkler, Department of Social Psychiatry, National Institute of Mental Health, Topolová 748, 250 67 Klecany, Czech Republic. Email: petr.winkler@nudz.cz
Footnotes
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See editorial, pp. 412–413, this issue.

Declaration of interest

None.

Footnotes
References
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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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eLetters

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. http://bjp.rcpsych.org/content/208/5/421.e-letters

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. http://doi.org/10.1001/jamapsychiatry.2015.0212

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.

References

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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Conflict of interest: None Declared

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