Mental health policy and practice across Europe: an overview

22 Mental health policy and practice
that numerous non-physician specialists begin to assume a role. It must be
emphasized, though, that mental health care remains firmly within the province
of medicine to the extent that it involves psychopharmacology and procedures
such as electroconvulsive therapy (ECT). Community care, however
praiseworthy as a goal, does not imply the exclusion of medicine.
To what extent are the achievements of community care a result of the advent
of psychopharmacology? Treatment with medication is clearly replacing psychotherapy
as the predominant treatment mode of psychiatry. In the United
States, for example, the percentage of depressed outpatients treated with pharmacotherapy
rose from 44.6 per cent in 1987 to 79.4 per cent in 1997 (Olfson
et al. 2002). Do the gains of community care thus rest on a solid basis of psychopharmaceuticals?
Not really. There clearly is some overlap, because the
depot phenothiazines do facilitate the integration of patients with schizophrenia
into community life. But the one is not a precondition of the other. For
one thing, deinstitutionalization in the form of open-door policies and the
like began before the advent of the antipsychotics in 1954. The emptying out of
the asylums was not really caused by the prescription of chlorpromazine but by
the upswing of social and community psychiatry from the 1940s onwards
(Shorter 1997: 229–39). The growing provision of ECT in the early 1940s and
later also played a cardinal role. Secondly, a certain underlying antipathy has
divided the philosophical orientations of biological psychiatry from those of
community care: the former seeing mental illness as arising in the neurochemistry
of the brain and treatable through medication, and the latter seeing the
origin of mental illness as somewhat inscrutable, and treatable, certainly, not
solely through psychiatrists’ prescriptions but through team efforts and the
beneficent influences of community life. As one WHO consultant observed in
1977 (in remarks published in 1978), ‘Psychiatric training and community
mental health services [are] like ships that pass in the night with only the
briefest awareness of each other’s presence and without communication’ (WHO
1978: 17).
Yet there is a sense in which psychopharmacology did encourage incipient
mental health care reforms, and this was the advent of the depot antipsychotics.
Squibb’s fluphenazine decanoate (Ayd 1991: 75) debuted in 1973, dovetailing
in Britain with the growing network of district-level care. Increased patient
compliance meant better community care. As a World Rehabilitation Fund
report commented in 1986, ‘Easily accessible depo-neuroleptic clinics dispense
these medications to patients living in the community and patients appear less
resistant to medication maintenance’ (Jansen 1986: 3).
What larger trends, if not psychopharmacology, are driving mental health
care in Europe today? The search for a single index of progressive care has
proven to be vexatious. Some writers suggest reductions in length of hospital
stays as an index of forward-looking community care (Uffing et al. 1992). And
indeed the ‘institutionalism’ that accompanies truly long stays is undesirable.
However, David Healy and his associates have discovered, in the catchment area
of a psychiatric hospital in North Wales, that the longer stays of the past were
associated with lower suicide rates than the shorter stays of today (Healy et al.
2005). In general though, the shortening of the average length of stay in hospital
does seem a reasonable proxy for the modernization of care (Rössler et al.