Mental health policy and practice across Europe: an overview

Psychopharmaceuticals in Europe 173
these ADHD-related drugs rose from GBP£72,970 in 1980 to a staggering
GBP£29,358,340 in the year 2000. However, although the cost of all these
classes of psychiatric drugs had risen tenfold, from around GBP£50 million per
annum in 1980 to around GBP£530 million in 2000, this was broadly consistent
with the rising cost of the drug bill generally, and expenditure on psychiatric
drugs remains at about 8 per cent of NHS drug expenditure.
Italy
It is interesting to compare these data with the case of Italy, where the move to
community psychiatry was spearheaded by the work of a group of politically
committed young psychiatrists who gathered around Franco Basaglia from the
early 1960s up to his early death in 1980 (Scheper-Hughes et al. 1987). Under the
banner of ‘democratic psychiatry’, they tried to combat what they thought of as
the scientific criminalization of otherness and deviance, which was manifested
in the segregation of the mentally ill in the closed asylum. In Italy, this was
invariably a result of a legal commitment process. Their campaign culminated
in Law 180, enacted in 1978, which put severe legal constraints on any new
compulsory admissions to asylums, and provided for their gradual phasing-out
by the resocialization of their inmates, and the provision of a network of
outpatient services, general hospital provision and community mental health
centres.
According to Michael Donnelly, mental hospital beds in Italy increased consistently
in the post-war period until the mid-1960s to a peak of over 98,000
beds, or 173 beds per 100,000 of the adult population (Donnelly 1992). From
that point on they began to decline by about 1390 beds per year, and the decline
accelerated from 1973 to 1978 to a loss of over 3000 beds per year, and accelerated
even further from 1978 to 1983, to a loss of over 4000 beds per year. The
actual number of hospital residents (as opposed to available beds) reached its
peak in 1993 at almost 92,000 patients, a figure which had declined to about
38,000 by 1981.
There was much debate in the succeeding period as to whether these
reforms had been fully implemented, with their proponents arguing that they
had been blocked and betrayed, while their opponents argued that they had
simply led to a transfer of institutional care to the private sector for those who
could afford it, and to abandonment on the streets of those who could not. 13
Much less debated was the extent to which this new ‘open’ psychiatric system
might be dependent on the prescription of psychiatric drugs to maintain
patients ‘in the community’. Data on prescribing for the early period is hard
to obtain. However, from 1990 to 2000, the data do not support the view that
the decline in hospital beds in Italy is linked to a higher than average level of
prescription of psychiatric drugs: despite a higher level of psychiatric hospital
bed provision in France (even taking the higher Italian figures from the
PROGRES study), the figures in all classes in France run at about twice the
rate of that in Italy (see Table 7.24). In both countries, the increase in prescribing
of antidepressants over this period is entirely produced by the SSRIs:
these have risen sixfold in France over this period from 207 to 1323 SUs per