Mental health policy and practice across Europe: an overview

Historical development of mental health services 23
1994), as shorter stays usually mean more intensive attempts to provide therapy
and return the patient to the community. However, average stay-duration data
are not available for all countries.
This chapter proposes a ratio – the number of mental hospital beds as a percentage
of all psychiatric beds – as a possible measure of the shift away from
classical forms of care. Table 2.1 suggests certain trends over the past three
decades among the old and newer EU member states on the basis of this measurement.
These figures give some indication of the progression of care away
from the asylum. To the extent that psychiatry beds are established in general
hospitals, psychogeriatric settings, private sanatoriums and charitable psychiatric
hospitals – among other sites of non-asylum residential care – mental
health care is being ‘de-asylumized’. (Of the three WHO surveys which reported
statistics on psychiatric beds for these years, the 1972 survey by Anthony R. May
is the least reliable [WHO 1979: 18]. Yet the bed data in even this questionable
report should be more or less useful for the analysis of change over time within
a given country. In any case, differences in data collection from country to
country probably mean that one would not want to push fine cross-national
comparisons too far.)
It must be emphasized that ‘de-asylumizing’ residential care does not necessarily
imply deinstitutionalization, for we are measuring merely the presence of
beds in other residential settings, not ambulatory care. Yet the shift away from
the asylum is progressive in historical terms, and the numbers in Table 2.1 do
give us a rough measure of this trend.
Essentially three patterns emerge from Table 2.1:
1 Countries where the asylum never predominated. These include Hungary and
other east European countries where, as we have seen, non-asylum settings
such as general hospitals provided residential care going back to the beginning
of the twentieth century.
2 Countries where the ice began to break up very rapidly after the 1970s, in the
form of a massive political and cultural assault upon the very notion of public
mental hospital care. These include Italy – the best known case – where Law
180 in 1978, driven forward by ideological forces, abolished the asylum
(Barbato 1998); Finland, where residential psychiatric care became largely
shifted to community general hospitals; 2 and Denmark, where principles of
community care took hold very rapidly after a 1976 law shifted responsibility
for psychiatric hospitals from the state to the local government counties.
In Denmark, the number of psychiatry beds dropped 43 per cent between
1980 and 1991 while the number of ambulatory psychiatric visits rose by 74
per cent (EOHSP 2001b: 15–16, 50). The experience of these three countries
does not yet reveal whether the pessimism that the national mental health
directors expressed in 1979 at a WHO meeting in Bielefeld about abolishing
the asylum was justified: ‘There [is] little confidence in the idea that an inpatient
psychiatric service based only on a district general hospital could meet
all the needs of a sector for inpatient psychiatric care’ (WHO 1979: 9). Indeed,
the Danish experience suggests that a precipitous dismantling of residential
care can have adverse effects. Responding to a doubling of the suicide rate in
Denmark between 1970 and 1987, in 1997 the Danish Psychiatric Society