Editorial: Beds in Mental Hospitals or Beds in General Hospitals, Where Should They Be Located?
Levav, Itzhak, Grinshpoon, Alexander, The Israel Journal of Psychiatry and Related Sciences
The World Health Organization (WHO) recommends the use of beds in psychiatric wards in general hospitals for all those patients who require inpatient care. At the same time, WHO recommends to reduce the use of beds in mental hospitals for the same purpose. Among the reasons for the latter recommendation are issues related to accessibility, stigma, iatrogenic damage produced by total institutions, and violations of human rights that have often accompanied inpatient care in mental hospitals (1).
Both service strategies, the expansion of the inpatient services in general hospitals and the downsizing or closure of the mental hospital option, are part and parcel of the Psychiatric Reform movement as it has been implemented, among other places, in Germany, Sweden, regions or cities in Spain (e.g., Asturias, Andalucia, Leganes); cities and regions in Italy (e.g., Trieste, Emilia-Romagna); cities in Brazil (e.g., Campinas); and provinces in Argentina (e.g., Rio Negro). With regard to Italy, Cohen and Saraceno (2) noted that following the implementation of Public Law No. 180 passed in 1978, "New admissions to mental hospitals have all but ceased and admissions to psychiatric units in general hospitals are now limited to the care of acute psychotic episodes. Community Mental Health Centers have effectively taken over the long-term care of severely mentally ill persons..." In Germany, Bauer et al. (3) have reported a reduction of about 50% of psychiatric hospital beds since the late 196Os, including the closing of one psychiatric hospital, while 165 general hospital psychiatric units have been established.
In Europe, the proportion of beds in general hospitals varies by the country's income level. Thus, the proportions are 28%, 21%, 10% and 12% respectively for the high income, upper-middle income, lower-middle, and low income countries according to the World Bank classification (4). The corresponding proportions of beds in general hospitals in Israel are lower. Indeed, in Israel, by December 2001 there were 5,207 beds in mental hospitals and 263 in general hospitals, or 4.7%. The respective figures one year later were 5,182 and 257, or 4.8% (5,6). The gap in the proportions between Israel and Europe is overwhelming with regard to every single group of countries.
What does the public prefer? In countries which have implemented the Psychiatric Reform, there is a consensus that professionals need to build partnerships with other relevant stakeholders to program and deliver adequate care. Importantly, this issue of partnership received public sanction by the World Psychiatric Association, as reflected in the adoption of such a theme for its last congress held in Yokohama, Japan (August, 2002). In Israel, the concept of partnership is central to the planning and delivery of services as reflected in the constitution of the two National Councils of the Ministry of Health, with regard to mental health as well as to psychosocial rehabilitation. The two councils include multiple stakeholders. Therefore, the public preference with regard to the best location of psychiatric beds is crucial, if barriers on the way to their use whenever indicated are sought to be lowered.
What evidence of public preference for inpatient care, general or mental hospitals do we possess in Israel? Fortunately, we have some data that could guide service planning and mental health education.
The first source is a country-wide survey conducted in collaboration by the JDC-Brookdale Institute and the Ministry of Health on Stigma and Mental Health in the Israeli Society, with funds from the Israel National Institute for Health Policy and Health Services Research. In this study, a representative sample of the adult population in Israel was asked where they would prefer to obtain inpatient care for themselves or for a close relative. …