Almost a year ago, on January 30th 2020, the World Health Organisation (WHO) declared the covid-19 outbreak a public health emergency of international concern – the organisation’s highest level of alarm. Incredibly, new vaccines have already been developed and tested, and over 40 million doses have been administered so far. But as the management of the immediate health crisis culminates, we must turn our attention to the wider public health impacts of the pandemic. The toll this virus is taking on the mental health of those who have lived through it will continue to be paid long after widespread immunity has been achieved.
The threat of the disease has increased stress and anxiety levels, as we have feared for our safety and that of our loved ones. More of us have had to deal with grief and the constant reminder of mortality, especially frontline health and care workers who have not only worked superhuman hours, but been faced with death on an unprecedented scale. Job losses, and the disruption to life and business caused by lockdowns and social distancing are expected to affect levels of loneliness, depression and related problems like substance abuse. But as Francesca Papais has already written for Arbury Road, the crisis presents an opportunity for both failure and innovation in health policy.
While it seems that the demand for mental health services is likely to increase a result of the pandemic, services for acute and long-term mental illness have contracted during the crisis as a result of strategies used to mitigate the spread of disease. A recent WHO Europe report showed that 83% of long-stay mental health care institutions in Europe had reduced the scope of their services as a result of the pandemic, and 73% had seen a substantial reduction in admissions. At the same time, requirements for personal protective equipment have generated costs for institutions which are not necessarily covered by strained health budgets.
This pandemic could spell the end of this type of inpatient mental health care, by depriving the remaining large, long-stay psychiatric institutions in Europe of users and funding. In an environment of permanent austerity, public services which do not spend up to their appropriations will typically have future funding clawed back by central governments for reallocation to ‘higher priority’ areas. Many subsidised private and not-for-profit institutions rely on either capitated public funding (based on the number of patients) or patient fees to survive, so such a substantial reduction in admissions will lead to the closure of institutions if they are not provided with additional government support.
Would the closure of these institutions be such a bad thing? Many of them continue to exist in spite of policies of ‘deinstitutionalisation’ implemented since the 1970s. Although the European Union recommends against institutions with places for over fifty residents, there remain hundreds of large psychiatric institutions in Western Europe. We might be tempted to celebrate the last nail in the coffin of the old ‘asylums’, but there are real concerns – in Europe, and around the world – about the unintended consequences of deinstitutionalisation.
The closure of old psychiatric institutions is assumed to imply a lower cost of care in the community, leading to underinvestment in outpatient services for people with complex needs, and potentially contributing to rates of homelessness and incarceration. In central and eastern Europe, where European Union structural funds have been used to support deinstitutionalisation policies over the last two decades, there is emerging evidence that such underinvestment has contributed to both the social isolation of people who have been discharged into the community, and their ‘reinstitutionalisation’ into new facilities with the same management and where practices such as rigid routines and a lack of individualised care remain.
History repeating itself?
The main critique of deinstitutionalisation policy is that the old services which disappeared have simply not been replaced, and that people who were once cared for by the state are now expected to provide for themselves and navigate networks of primary care and pharmaceutical services without adequate support. The shift to care in the community has often resulted in an increased burden on the families of people with mental illness.
Alternative community-based services were in fact established, but they were not always designed around patient needs. Throughout Europe, in both waves of psychiatric deinstitutionalisation, new outpatient services were often developed by the existing hospital service providers and connected to the existing hospital networks. Rather than redesigning services from the top, many national governments left the implementation of deinstitutionalisation policy up to lower levels of government.
This type of bottom-up reform approach can be a strength, because the administrators of existing services have expertise in the problems on the ground and knowledge of patient needs. But the new systems which have emerged have met the interests of those administrators, who have maintained an ongoing role in the system, as well as those of central governments looking to reduce operational costs, and not primarily the needs and interests of service users.
The parallel shift since the 1970s toward more preventive approaches in health policy in general has resulted in more new funding for managing mental health in the general population. Public education about behaviour and habits, access to low-level interventions like talk therapy, and the regulation of work hours and environment as well as employer obligations, can make a big difference for the prevention of illness. Over time, funding has been skewed away from acute and long-term care. But services at a range of levels of intervention are necessary for an effective system. We can’t simply allow the remaining large, long-stay institutions to disappear.
How we can turn this into a positive change…
As a result of the huge expansion of public mental health services and awareness, we now know that mental health policy is for everyone. Given that all citizens, and all voters, have an interest in mental health policy, we have immense power to shape public policy. The difference between the 1970s and today is that the patients of the old asylums were a much smaller and more marginalised part of the population than the clients of our broad-based mental health services today. The users and families groups that were just in their infancy when deinstitutionalisation policy began are now established organisations that should be key actors in service design. These groups are already well-coordinated at the European level, and the European Union should play an important role in promoting their power in national policy contexts.
At an individual level, if we want a mental health system that works for everyone, we need to:
Vote for candidates in local, national, and European-level elections who support increased funding for mental health services at a range of levels of intervention, as well as the involvement of user groups in service design
Support local mental health users and families organisations by engaging with them online and sharing their content
Contribute financially to these organisations or volunteering our time for campaigns if we can
In the short term, long-stay institutions need support to continue. Past experience suggests that the more suddenly that services disappear, the more likely that unintended and life-threatening consequences occur when people in crisis find themselves without any support at all. But if these institutions fail – and, without additional government support, they will – we must seize the opportunity to demand that new services are organised around the interests of users and not the interests of governments and administrators.