Deinstitutionalisation Debunked

Background and aims: ESMEC (Evaluation of Single and Multiple Episode Care), an innovative procedure for outcome-based evaluation of mental health services, is employed to test empirically whether

1. Care setting choice is a major determinant of outcomes,

2. Hospitalisation is invariably associated with worse outcomes than ambulant care, regardless of diagnosis,

3. This is due to the institutionalisation phenomenon, an inherent property of hospitalisation,

i.e. The propositions on which the deinstitutionalisation philosophy is based.

Method: A one-third alphabetical sample of 2480 patients making first ever contact with a catchment-based psychiatric service is followed up for 48 months through periods of hospital and/or ambulant care. Follow-up is divided into a series of reciprocating implementation-outcome biphases, from 0:48 to 24:24 months, within each of which potential predictors (sociodemography, diagnosis, severity, chronicity and a series of setting usage patterns) and outcomes (morbidity, clearance rate and other setting usage patterns) are measured and tested for significant implementation-outcome associations.

Results: The major findings are:

1. Illness severity is the major predictor of mental illness outcomes, especially in the acute stages;

2. After allowing for severity, other patient-related factors and setting-related effects, setting types are found to have minimal effect on outcomes;

3. Within this minimal “intrinsic” effect, neither setting emerges overall as significantly superior to the other;

4. Associations, regardless of type or significance, in the mentally ill population as a whole, reflect extremely poorly those in component diagnoses, so that

5. The lack of overall significant difference may conceal diagnosis-specific effects which sometimes favour hospitalisation and sometimes ambulant care;

6. Hence, “institutionalisation” must be able to occur in both settings, and be neither inherent nor unique to one.

Conclusions: Findings 1–6 comprehensively refute the preconditions for deinstitutionalisation, while other findings define “institutionalisation” more precisely and correct misconceptions, some historically based, as to its nature.

ESMEC examines factors which earlier studies did not address and demonstrates that the deinstitutionalisation philosophy is based on false or inadequate premises.