Trends in psychiatric hospitalisation of people with schizophrenia: A register-based investigation over the last three decades

https://doi.org/10.1016/j.schres.2007.07.006Get rights and content

Abstract

The number of psychiatric beds has declined considerably in many countries over the past decades. Long-term studies on the impact of these health care changes for the severely mentally ill, however, are still scarce. This epidemiological study investigates the use of inpatient psychiatric services by people with schizophrenia, compared to that by people with other mental disorders. We used psychiatric register data of the Swiss canton Zurich to establish the annual treatment prevalence in the period 1977–2004.

For patients with psychoses, the length of inpatient episodes decreased by half. The annual number of inpatient admissions doubled. The proportion of schizophrenia patients, which accounted for 36%–41% of all inpatient treatments up to 1993, dropped to 20% in 2004, while that of other psychoses remained about the same (8%–10%) throughout the study period. This contrasts with a 2–3 fold increase in other patient groups. The annual treatment prevalence for people with schizophrenia declined from 7.3 to 2.2 per 10 000 population since the 1990s and affected patients of all ages and of both sexes equally. The treatment prevalence for other psychoses remained virtually unchanged (1.3 per 10 000). For all other mental disorders, there was an up to twofold increase.

The study suggests that the downsizing of psychiatric hospitals has resulted in a far-reaching redistribution of overall inpatient treatment resources. The considerable decrease in inpatient treatment for people with schizophrenia emphasizes the need to further investigate the current state of coverage for and the appropriateness of health care available to this patient group.

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)

  • G. De Girolamo et al.

    Residential care in Italy: National survey of non-hospital facilities

    Br. J. Psychiatry

    (2002)
  • G. De Girolamo et al.

    The severely mentally ill in residential facilities: a national survey in Italy

    Psychol. Med.

    (2005)
  • K. Ernst

    Psychiatrische Versorgung heute

    (1998)
  • D.P. Folsom et al.

    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

    (2005)
  • J. Füredi et al.

    Psychiatry in selected countries of Central and Eastern Europe: an overview of the current situation

    Acta Psychiatr. Scand.

    (2006)
  • G. Hamel et al.

    Research reports of the psychiatric university hospital Zurich. PSYREC report 2004, vol. 10 no. 2

  • C. Hobbs et al.

    Deinstitutionalization for long-term mental illness: a 6-year evaluation

    Aust. N. Z. J. Psychiatry

    (2002)
  • T. Honkonen et al.

    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

    (2003)
  • M. Jäger et al.

    Diagnostic shifts of functional psychoses in the transition from ICD-9 to ICD-10

    Nervenarzt

    (2003)
  • T.W. Kallert et al.

    The process of deinstitutionalization in German State Mental Hospitals. Critical overview of empirical research studies

    Fortschr. Neurol. Psychiatr.

    (2006)
  • G.L. Klerman et al.

    Increasing rates of depression

    JAMA

    (1989)
  • Cited by (30)

    • Long-term hospitalizations for schizophrenia in the Czech Republic 1998–2012

      2016, Schizophrenia Research
      Citation Excerpt :

      In Denmark 2006, only 9.8% of lifetime schizophrenia patients were institutionalized and their mean number of bed days for that year was 24.9 days (Uggerby et al., 2011). In Zurich canton 2004, median length of inpatient hospitalization for schizophrenia, schizotypal and delusional disorders was 24 days (Lay et al., 2007). This study benefits from both the health and death registers, which include Czech nation-wide data on inpatient hospitalizations and details about all-cause deaths that occurred in a given year or time period.

    • Variation in use of coercive measures in psychiatric hospitals

      2011, European Psychiatry
      Citation Excerpt :

      High rates of involuntary placements therefore cannot be attributed to a shortage of health resources or of community services. The register data, on the other hand, clearly show that people with the highest risk of a compulsory admission belong to those patient groups that also have been mainly affected by the downsizing of psychiatric hospitals in the Canton of Zurich over the last 15 years: just for patients with schizophrenia and with organic mental disorders marked decreases in treatment prevalence (from 7.3 to 2.2 per 10,000 population) over the last 15 years have been found [19]. Of all diagnostic groups, people with schizophrenia experienced the largest decline in inpatient service use.

    View all citing articles on Scopus
    View full text