INTERNATIONAL COMPARISONS

The countries that led in the postwar revolution in social psychiatry were, according to Maxwell Jones,72 _{Britain, the Netherlands, Norway and Switzerland.}

Table 4.2 lists postwar unemployment statistics for these countries and other parts of Europe and North America; the unemployment figures have been adjusted73 _to

make them reasonably comparable. The four countries that were progressive in psychiatry at that time are among those with low unemployment rates.

Countries, like the United States and Italy, where the rehabilitative movement was delayed, had higher rates of unemployment. Open-door policies and the

deinstitutionalization movement did not reach Italian mental hospitals until the 1960s, arriving in the wake of an economic boom that brought many changes in the social and political climate.74 _{Italian psychiatrist Franco Basaglia introduced}

sweeping innovations, after 1961, in the mental hospitals in Gorizia and then Trieste, as unemployment dropped to a postwar low. The subsequent national psychiatric reforms embodied in law 180 (enacted with the support of both the Italian communist party and the right wing) led to a dramatic decrease in the numbers of mentally ill people in hospital. The reforms were implemented with most success in the industrial north of the country where the labor shortage was most apparent.75

The number of mental hospital beds in use varies substantially from one industrial nation to another. Sweden, in 1974, provided one psychiatric hospital bed for 250 citizens, for example, whereas in Poland one psychiatric bed served more than 800. A number of economic and political factors might be expected to influence mental hospital use and, if the demand for labor was an important stimulus to deinstitutionalization, then unemployment could prove to be one such influence on psychiatric hospital use. In the mid-1960s, in fact, industrial nations with higher unemployment rates tended to use more mental hospital beds (see

Table 4.3). A multiple regression analysis shows that the average national unemployment over a five-year period accounted for 40 per cent of the variance in the provision of psychiatric beds in 1965 in the nine Western industrial nations for which comparable statistics are available (see Table 4.4).76 _{This relationship}

was independent of a number of other economic and demographic variables. After taking into account the influence of per capita gross national product, infant mortality (as an indicator of the national level of health and welfare provisions) and the proportion of elderly in the population, unemployment accounted for 47 per cent of the variance in the use of mental hospital beds. Over the next decade, however, the relationship between mental hospital use and unemployment disappeared. As Table 4.4 shows, by 1974 a combination of two factors—the national infant mortality rate and the proportion of the population over age 65— predicted 71 per cent of the variance in mental hospital beds provided; unemployment accounted for only 1 per cent of the variance.

The link between unemployment and mental hospital use in 1965 suggests that, until that time, the availability of work may have acted as a control on hospital discharge rates. The correlation disappeared after the 1960s because psychiatric hospital populations continued to shrink in Australia, Canada and the United States in the absence of improvements in employment. Elsewhere mental hospital use increased or remained relatively constant. This divergence may be attributed to the degree to which each country exercised the option, offered by disability benefits and drugs, to maintain mentally ill people in the community regardless of the availability of employment. In addition, in the United States the advent of Medicaid in 1965 led to massive reductions in mental hospital beds as patients were transferred to nursing homes. No longer was it essential that mental hospitals control and sustain a large segment of the surplus population. Their use

Table 4.2

Un

emplo

y

ment rates in north

ern

Eur

o

p

e and North America

Sou rce s: A ll unemp loyment stati stics, ex cept t h ose f o r Norway, have be en adjusted to render th em comparable,

and are taken from Maddiso

n,

A., Econ

o

mic Growth

in the West, New York: Twentieth

Century F

und, 1964, p.

220. Unadjusted figures for Norway are taken fro

m Mitchell, B.R., E u rop ean Histor ic al Statis ti cs 1 750 –1 970 , abr

idged edn., New Yo

rk : Co lumbia Un iv ersity Press, 1978, p. 68.

became, to a greater degree, a matter of social policy. The extent of psychiatric institutional care now appeared to be largely a reflection of two factors. One was the national, political commitment to the quality and universality of health and welfare provisions (of which infant mortality is an indicator). The other, since the antipsychotic drugs are of little benefit in the care of senile organic psychosis, was the proportion of the elderly in the general population.

Deinstitutionalization, in some circumstances a sign of progressive efforts towards community care and rehabilitation of the mentally ill, may elsewhere have indicated the opposite—abrogation of responsibility for the welfare of a segment of the poor. In the United States in the 1970s, where health and welfare provisions for the destitute were not well developed, the small numbers of available mental hospital beds represented a refusal to provide adequate psychiatric treatment for the indigent mentally ill. In Sweden, on the other hand, a political commitment to adequate health and welfare provisions coupled with the existence of a large elderly population led to a substantially greater use of mental hospitals. Each of the other Scandinavian countries, like Sweden, maintained comprehensive health and welfare services, low infant mortality rates and substantial numbers of psychiatric hospital beds. Of these four countries Denmark and Norway, with the greatest labor shortages until the mid-1970s, preserved relatively low rates of mental hospital use and the most highly developed community treatment programs.77

It is evident from the figures in Table 4.3 that it was not only the labor shortage in the Eastern Bloc countries in the 1970s that led to their minimal use of psychiatric institutions but also the underdevelopment of their health services in general (witness their high infant mortality rates) and the low proportion of the elderly in the general population. Nevertheless, we know that the labor shortage in these countries, particularly Russia and Poland, at that time led to a very great emphasis on work therapy, intensive community rehabilitation efforts, greater acceptance of the mentally ill in the community and the workplace and efforts to keep the elderly productive.78

Full employment, then, may no longer be a major factor determining the size of mental hospital populations but it may be an important influence on the characteristics of community treatment and the adequacy of rehabilitative efforts. Where the surplus population is large, the conditions established for the person with a psychotic illness tend to be least conducive to his or her recovery. Where the labor of the marginally productive is in demand, there shall we find the most highly developed community treatment programs and the most humane hospital conditions. We shall see to what extent these factors influence the course of schizophrenia.

Table 4.3 Psychiatric ho sp ital bed s p er 10,000 of

the general populatio

n

, average annual unemp

loyment

rates over five-year peri

ods , i n fa nt mortality per 1,000 l ive births, general

population over age 65 and

per cap ita gr oss national product in 1979 US d o ll ars

SUMMARY

• The rate of mental hospital occupancy as a proportion of the general United States population was declining before the introduction of the antipsychotic drugs.

• Revolutionary changes in hospital and community psychiatry in northern Europe preceded the introduction of antipsychotic drugs treatment.

• The discharge rates from progressive hospitals, particularly in northern Europe, were not improved by the arrival of the antipsychotic drugs.

• The delay in the introduction of new social and community psychiatry techniques to the United States created the impression there that drug treatment was vital to community care.

Table 4.4 Variance in psychiatric hospital beds provided in nine Western industrial countries accounted for by different social indicators

* Significant at the .05 level (two-tailed test).

• Deinstitutionalization in the United States relied heavily on the use of drugs and led to the placement of large numbers of the mentally ill in low-cost, inadequate settings.

• Community care for the mentally ill in Britain stagnated and declined after the 1960s.

• Community treatment methods in the United States improved in the 1980s and 1990s.

• The main political and economic driving forces to deinstitutionalization were (a) cost-saving and (b) in northern Europe, the postwar demand for labor. • Comparing Western industrial nations in 1965, the number of mental hospital

beds in each country was correlated with the national unemployment rate. • A decade later, mental hospital use appeared to be less influenced by the labor

market and more affected by national health and welfare policy.

• The unemployment rate may still influence the adequacy of community rehabilitative efforts.