Trends in psychiatric hospitalisation of people with schizophrenia: A register-based investigation over the last three decades
Introduction
The role of inpatient care in the management of people with a severe mental disorder has changed considerably throughout the past decades. This development has been driven primarily by psychiatric reforms intended to prevent long-term residential care and to integrate the mentally ill into the community. As acute inpatient care commonly consumes the biggest share of the mental health care budget, these changes in care provision might also be understood as a result of the growing pressure to cut health care costs.
In Switzerland, the proportion of the overall health care budget earmarked for psychiatric hospitals has decreased in recent years to 3.2% in 2005 (Swiss Federal Statistical Office, 2007). Since 1980, the number of psychiatric beds has declined by almost half (Swiss Health Observatory, 2003). A similar trend from traditional hospitals to outpatient and community services has been observed in many European countries (Balestrieri et al., 1989, De Girolamo et al., 2002, Füredi et al., 2006, Kallert et al., 2006, Sytema and Burgess, 1999, Thompson et al., 2004).
Various studies evaluating this process in different countries have underlined the advantages for most psychiatric patients (Hobbs et al., 2002, Honkonen et al., 2003, Leff and Trieman, 2000, Lesage et al., 2000). However, also a number of questions have been raised. Of concern are the adequacy of levels of service provision (Thompson et al., 2004) and the number of chronically mentally ill who are left without any mental health care (Lamb, 1993). The professional discourse focussed on schizophrenia patients, the patient group that traditionally absorbed a large part of inpatient treatment capacities (Lay et al., 2006). Many of these patients (60% to 85%) still exhibit psychotic symptoms several years after discharge, and impairment of social functioning is common (De Girolamo et al., 2005, Hobbs et al., 2002, Honkonen et al., 2003, Lesage et al., 2000). Furthermore, many schizophrenia patients have special behavioural problems which make it difficult to place and maintain them in community settings (Honkonen et al., 2003, Lamb, 1993). There is some evidence that schizophrenia patients discharged in later years tend to be more disabled than those discharged earlier (Honkonen et al., 2003, Lamb, 1993, Mojtabai et al., 2005). Last not least, persons with serious mental illness run an increased risk of homelessness (Folsom et al., 2005, Lamb, 1993).
Meanwhile, the process of discharging previously long-term hospitalised patients has come to an end in most European countries. A new generation of severely mentally ill patients has grown up that has not spent long years in psychiatric hospitals. Considering that the downsizing of psychiatric hospitals continued throughout the 1990s, such an ongoing reduction of inpatient resources is likely to impact not only the previous long-stay inpatients.
Although a far-reaching reduction of hospital resources has been in process for decades, it has yet to be fully examined which patient groups have borne the brunt of these changes over the years. In particular, little research exists addressing the question as to what extent the reduction in inpatient services affected schizophrenia patients. In most studies targeting changes in health care delivery, patterns of service use were evaluated by means of cross-sectional designs. Many studies focussed on particular patient groups (e.g. long-stay inpatients), subgroups of the population, or people in contact with a mental health service at a specific point of time (Knapp et al., 2002, Honkonen et al., 2003, Leff and Trieman, 2000, Sytema and Burgess, 1999). Research that monitored local psychiatric services over a period of several years was generally confined to first-admission or -discharge cohorts only (Balestrieri et al., 1989, Cavanagh and Shajahan, 1999, Sytema and Burgess, 1999) and thus does not reflect overall service provision.
This paper addresses inpatient psychiatric service use in a defined catchment area over a 28-year period. We used psychiatric register data in order to study a population-based sample over a longer period and to obtain prevalence estimates. Rather than confining service use to admission rates or length of stay only, we focus on patient-years in treatment as the most meaningful indicator of the amount of inpatient resources used. Specifically, the study addresses the following questions: (i) To what extent does the use of inpatient psychiatric care by people with schizophrenia and other psychotic disorder vary over time? (ii) Are the time trends observed comparable to those for patients with other mental disorders? (iii) Is variation over time related to the age or gender of schizophrenia patients?
Section snippets
Sample
We included all patients aged 15 to 79 years residing in the Canton Zurich, Switzerland, who had been admitted to a psychiatric hospital between 1 January 1977 and 31 December 2004. Age 15 was set as the lower age limit, since gender- and age-specific data available for the reference population are grouped accordingly. Subjects older than 80 years were excluded in order to avoid gender-specific effects due to mortality in very old age.
Patients were traced using the Central Psychiatric Register,
Number of admissions
Fig. 1 (top left) gives the number of admissions to psychiatric hospitals per year (crude rates). After a slow rise, the total number remained stable throughout the 1980s, thereafter increasing, however, from 3900 in 1991 up to 9636 admissions in 2004. Thus, over the whole study period, the number of admissions almost tripled.
For patients with psychosis, however, admission rates increased to a far lesser extent: Regarding schizophrenia patients (F20), there was a relatively moderate change only
Discussion
The present study provides epidemiological data on psychiatric inpatient use by people with schizophrenia as compared to the service use by patients with other disorders. To the best of our knowledge, no similar studies have addressed the effects of decreasing hospitalisation across mental disorder groups covering a comparable time frame.
This study yields three main findings: Firstly, we found an inverse relationship between the annual number of admissions and the duration of inpatient
Role of the funding source
The psychiatric register data was funded by the Department of Public Health of the Canton of Zurich (Gesundheitsdirektion des Kanton Zürich, GD). The Research Unit for Clinical and Social Psychiatry of the Psychiatric University Hospital Zurich is authorised by the GD to do analyses for scientific purposes. The GD had no further role in the study design; in the collection; analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Contributors
BL and CN designed the study; BL and WR managed the literature searches and analyses; BL and CN undertook the statistical analyses; BL wrote the first draft of the manuscript; all authors contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgement
None.
References (43)
- et al.
Prediction of in-patient use in first-admitted patients with psychosis
Eur. Psychiatry
(2006) - et al.
First incidence depression in the Lundby Study: a comparison of the two time periods 1947–1972 and 1972–1997
J. Affect. Disord.
(2005) - et al.
Increase in first admissions for schizophrenia and other major psychoses in Italy
Psychiatry Res.
(2000) - et al.
Patterns of psychiatric care in south Verona and Groningen. A case-register follow-up study
Acta Psychiatr. Scand.
(1989) - et al.
Incidence of schizophrenia in south-east London between 1965 and 1997
Br. J. Psychiatry
(2003) Variations in utilization and cost of inpatient Psychiatr. Serv. among adults in Maryland
Psychiatr. Serv.
(2001)- et al.
Trends in service use and treatment for mental disorders in adults throughout Great Britain
Br. J. Psychiatry
(2004) - et al.
Increasing rates of hospital admission for men with major mental illnesses: data from Scottish mental health units, 1980–1995
Acta Psychiatr. Scand.
(1999) Research reports of the Psychiatric University Hospital Zurich. PSYREC report 2002, vol. 8 no. 5.
- et al.
Research reports of the Psychiatric University Hospital Zurich, vol. 1 no. 1
Residential care in Italy: National survey of non-hospital facilities
Br. J. Psychiatry
The severely mentally ill in residential facilities: a national survey in Italy
Psychol. Med.
Psychiatrische Versorgung heute
Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system
Am. J. Psychiatry
Psychiatry in selected countries of Central and Eastern Europe: an overview of the current situation
Acta Psychiatr. Scand.
Research reports of the psychiatric university hospital Zurich. PSYREC report 2004, vol. 10 no. 2
Deinstitutionalization for long-term mental illness: a 6-year evaluation
Aust. N. Z. J. Psychiatry
Schizophrenic patients in different treatment settings during the era of deinstitutionalization: three-year follow-up of three discharge cohorts in Finland
Aust. N. Z. J. Psychiatry
Diagnostic shifts of functional psychoses in the transition from ICD-9 to ICD-10
Nervenarzt
The process of deinstitutionalization in German State Mental Hospitals. Critical overview of empirical research studies
Fortschr. Neurol. Psychiatr.
Increasing rates of depression
JAMA
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