Institutionalization of deinstitutionalization: a cross-national analysis of mental health system reform

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Abstract

Background

Policies generate accountability in that they offer a standard against which government performance can be assessed. A central question of this study is whether ideological imprint left by policy is realized in the time following its adoption. National mental health policy expressly promotes the notion of deinstitutionalization, which mandates that individuals be cared for in the community rather than in institutional environments.

Methods

We investigate whether mental health policy adoption induced a transformation in the structure of mental health systems, namely psychiatric beds, using panel data on 193 countries between 2001 and 2011.

Results

Our striking regression results demonstrate that late-adopters of mental health policy are more likely to reduce psychiatric beds in mental hospitals and other biomedical settings than innovators, whereas they are less likely than non-adopters to reduce psychiatric beds in general hospitals.

Conclusions

It can be inferred late adopters are motivated to implement deinstitutionalization for technical efficiency rather than social legitimacy reasons.

Electronic supplementary material

The online version of this article (doi:10.1186/1752-4458-8-47) contains supplementary material, which is available to authorized users.

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Most cited references 182

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Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study.

Christopher Murray, Alan Lopez (1997)

Prevention and control of disease and injury require information about the leading medical causes of illness and exposures or risk factors. The assessment of the public-health importance of these has been hampered by the lack of common methods to investigate the overall, worldwide burden. The Global Burden of Disease Study (GBD) provides a standardised approach to epidemiological assessment and uses a standard unit, the disability-adjusted life year (DALY), to aid comparisons. DALYs for each age-sex group in each GBD region for 107 disorders were calculated, based on the estimates of mortality by cause, incidence, average age of onset, duration, and disability severity. Estimates of the burden and prevalence of exposure in different regions of disorders attributable to malnutrition, poor water supply, sanitation and personal and domestic hygiene, unsafe sex, tobacco use, alcohol, occupation, hypertension, physical inactivity, use of illicit drugs, and air pollution were developed. Developed regions account for 11.6% of the worldwide burden from all causes of death and disability, and account for 90.2% of health expenditure worldwide. Communicable, maternal, perinatal, and nutritional disorders explain 43.9%; non-communicable causes 40.9%; injuries 15.1%; malignant neoplasms 5.1%; neuropsychiatric conditions 10.5%; and cardiovascular conditions 9.7% of DALYs worldwide. The ten leading specific causes of global DALYs are, in descending order, lower respiratory infections, diarrhoeal diseases, perinatal disorders, unipolar major depression, ischaemic heart disease, cerebrovascular disease, tuberculosis, measles, road-traffic accidents, and congenital anomalies. 15.9% of DALYs worldwide are attributable to childhood malnutrition and 6.8% to poor water, and sanitation and personal and domestic hygiene. The three leading contributors to the burden of disease are communicable and perinatal disorders affecting children. The substantial burdens of neuropsychiatric disorders and injuries are under-recognised. The epidemiological transition in terms of DALYs has progressed substantially in China, Latin America and the Caribbean, other Asia and islands, and the middle eastern crescent. If the burdens of disability and death are taken into account, our list differs substantially from other lists of the leading causes of death. DALYs provide a common metric to aid meaningful comparison of the burden of risk factors, diseases, and injuries.

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The need for a new medical model: a challenge for biomedicine.

Andrew G. Engel (1977)

The dominant model of disease today is biomedical, and it leaves no room within tis framework for the social, psychological, and behavioral dimensions of illness. A biopsychosocial model is proposed that provides a blueprint for research, a framework for teaching, and a design for action in the real world of health care.

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Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys.

Philip Wang, Sergio Aguilar-Gaxiola, Jordi Alonso … (2007)

Mental disorders are major causes of disability worldwide, including in the low-income and middle-income countries least able to bear such burdens. We describe mental health care in 17 countries participating in the WHO world mental health (WMH) survey initiative and examine unmet needs for treatment. Face-to-face household surveys were undertaken with 84,850 community adult respondents in low-income or middle-income (Colombia, Lebanon, Mexico, Nigeria, China, South Africa, Ukraine) and high-income countries (Belgium, France, Germany, Israel, Italy, Japan, Netherlands, New Zealand, Spain, USA). Prevalence and severity of mental disorders over 12 months, and mental health service use, were assessed with the WMH composite international diagnostic interview. Logistic regression analysis was used to study sociodemographic predictors of receiving any 12-month services. The number of respondents using any 12-month mental health services (57 [2%; Nigeria] to 1477 [18%; USA]) was generally lower in developing than in developed countries, and the proportion receiving services tended to correspond to countries' percentages of gross domestic product spent on health care. Although seriousness of disorder was related to service use, only five (11%; China) to 46 (61%; Belgium) of patients with severe disorders received any care in the previous year. General medical sectors were the largest sources of mental health services. For respondents initiating treatments, 152 (70%; Germany) to 129 (95%; Italy) received any follow-up care, and one (10%; Nigeria) to 113 (42%; France) received treatments meeting minimum standards for adequacy. Patients who were male, married, less-educated, and at the extremes of age or income were treated less. Unmet needs for mental health treatment are pervasive and especially concerning in less-developed countries. Alleviation of these unmet needs will require expansion and optimum allocation of treatment resources.

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Author and article information

Contributors

Gordon C Shen: Gordon.shen@yale.edu

Lonnie R Snowden: snowden@berkeley.edu

Journal

Journal ID (nlm-ta): Int J Ment Health Syst

Journal ID (iso-abbrev): Int J Ment Health Syst

Title: International Journal of Mental Health Systems

Publisher: BioMed Central (London )

ISSN (Electronic): 1752-4458

Publication date (Electronic): 22 November 2014

Publication date PMC-release: 22 November 2014

Publication date Collection: 2014

Volume: 8

Issue: 1

Electronic Location Identifier: 47

Affiliations

[ ]School of Public Health, Yale University, 60 College Street, P.O. Box 208034, New Haven, CT 06520 USA

[ ]School of Public Health, University of California at Berkeley, 235 University Hall, Berkeley, CA 94720 USA

Article

Publisher ID: 207

DOI: 10.1186/1752-4458-8-47

PMC ID: 4253997

PubMed ID: 25473417

SO-VID: 44b26b91-5792-4097-a3fe-cddf36b49740

License:

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 30 July 2014

Date accepted : 11 November 2014

Custom metadata

ScienceOpen disciplines: Neurology

Keywords: diffusion of innovation,institutional theory,governance,mental health policy

Data availability:

ScienceOpen disciplines: Neurology

Keywords: diffusion of innovation, institutional theory, governance, mental health policy

Institutionalization of deinstitutionalization: a cross-national analysis of mental health system reform

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Abstract

Background

Methods

Results

Conclusions

Electronic supplementary material

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Neuronal Signaling

Most cited references 182

Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study.

The need for a new medical model: a challenge for biomedicine.

Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys.

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Contributors

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