Mental health policy and practice across Europe: an overview

132 Mental health policy and practice
undoubtedly facilitated the reduction in the number of psychiatric hospital
beds, often contributing to the closure of mental hospitals. They have also
facilitated the building of alternative, community-based treatment systems,
and the adaptation of other forms of interventions, like psychotherapies and
psychosocial rehabilitation. These developments have improved the situation
and quality of life of many people with mental health problems. Adequate drug
treatment, often combined with other modes of treatment and rehabilitation,
allows patients who were previously bound to mental hospitals as long-term
patients to live more or less independently in the community. Of course, drug
developments alone cannot explain all of these positive changes, but it seems
justified to state that without pharmacological treatments they would not have
been possible. Certainly, other factors have been influential, such as the development
of other treatment modes, better understanding of, and knowledge
about, mental disorders, and broader societal changes, such as more positive
attitudes toward people with mental disorders and toward mental health issues
in general (see Chapters 3 and 14).
However, the situation is not always as positive as described above. These
developments have also produced new problems. The closure of hospitals and
the failure to introduce adequate community care systems has marginalized
a substantial number of mental health service users in some countries (see
Chapter 10). Homelessness of people with mental health problems has become
an increasing problem (Gill et al. 2003), especially in many of our large cities.
All this seems to exacerbate other problems like alcoholism and drug abuse,
criminality and the risk of violence. Mentally ill patients have an increased risk
of committing violent acts, but they often also become victims of violence by
others. An increasing number of mentally ill people are in prison which, of
course, is not the right place for ensuring their proper care (Lader et al. 2003)
(see Chapter 3 for a discussion of social exclusion).
Other consequences have accrued from these developments. For families the
burden of care in looking after long-term, mentally ill relatives has increased,
although for many families the possibility to live again with a close family
member is felt to outweigh the greater care responsibilities (see Chapter 16). For
society the closure of many mental hospitals has brought savings, but on the
other hand, building up the alternative community care system also needs
resources. The problem in many European countries has been that the money
saved from hospital closures has not been transferred to the development of
community care, leading to an increased reliance on families and the transfer of
financial responsibility to social care systems (often with fewer entitlements),
plus the risk of marginalization.
Use of antidepressants has increased dramatically during the last 20 years. For
example, in Finland the use of these drugs increased fivefold during the 1990s
(Lehtinen et al. 1993; see also Chapter 7). There are certainly several reasons
for this development: the better recognition of depression both by the general
public and by primary care physicians, the new antidepressants available with
milder and fewer side-effects, and better acceptance by patients – and certainly,
also, the rather aggressive marketing efforts by the drug industry. One positive
consequence has been that, today, people with depression are less likely to go
untreated. According to epidemiological surveys from the 1990s, a third or less