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Concept: Deinstitutionalisation


In the 1960s Franco Basaglia, the Director of a Psychiatric Hospital in a small city on the edge of Italy (Gorizia), began to transform that institution from the inside. He introduced patient meetings and set up a kind of Therapeutic Community. In 1968 he asked two photographers - Carla Cerati and Gianni Berengo Gardin - to take photos inside Gorizia and other asylums. These images were then used in a photobook called Morire di Classe (To Die Because of your Class) (1969). This article re-examines in detail the content of this celebrated book and its history, and its impact on the struggle to reform and abolish large-scale psychiatric institutions. It also places the book in its social and political context and as a key text of the anti-psychiatry movement of the 1960s.

Concepts: Hospital, Mental disorder, Psychiatry, Anti-psychiatry, Psychiatric hospital, Involuntary commitment, Deinstitutionalisation, Psychiatric survivors movement


The Forensic Therapeutic Outpatient Clinic (FTA) in Berlin targets the professional aftercare treatment of classified high-risk violent and sexual offenders released from prison or forensic psychiatric hospitals.

Concepts: Hospital, Mental disorder, Psychiatry, Anti-psychiatry, Clinic, Psychiatric hospital, Involuntary commitment, Deinstitutionalisation


Studies indicate that risk of mortality is higher for patients admitted to acute hospitals at the weekend. However, less is known about clinical outcomes among patients admitted to psychiatric hospitals.

Concepts: Patient, Hospital, Mental disorder, Psychiatry, Anti-psychiatry, Psychiatric hospital, Involuntary commitment, Deinstitutionalisation


Adherence to antipsychotic medication is a significant challenge among homeless patients. No experimental trials have investigated the impact of Housing First on adherence among patients with schizophrenia. We investigated whether Housing First in congregate and scattered-site configurations resulted in superior adherence compared to usual care. Adult participants (n = 165) met criteria for homelessness, schizophrenia, and initiation of antipsychotic pharmacotherapy prior to recruitment to an unblinded, 3-arm randomized controlled trial in Vancouver, Canada. Randomization arms were: congregate Housing First (CHF) with on-site supports (including physician and pharmacy services); scattered-site Housing First (SHF) with Assertive Community Treatment; or treatment as usual (TAU) consisting of existing services. Participants were followed for an average of 2.6 years. Adherence to antipsychotic medication was measured using the medication possession ratio (MPR), and 1-way ANOVA was used to compare outcomes between the 3 conditions. Data were drawn from comprehensive pharmacy records. Prior to randomization, mean MPR among participants was very low (0.44-0.48). Mean MPR in the follow-up period was significantly different between study arms (P < .001) and approached the guideline threshold of 0.80 in SHF. Compared to TAU, antipsychotic adherence was significantly higher in SHF but not in CHF. The results demonstrate that further implementation of SHF is indicated among homeless people with schizophrenia, and that urgent action is needed to address very low levels of antipsychotic adherence in this population (trial registration: ISRCTN57595077).

Concepts: Pharmacology, Randomized controlled trial, Antipsychotic, Schizophrenia, Homelessness, Homelessness in the United States, Housing first, Deinstitutionalisation


Psychotic and affective exacerbations associated with synthetic cannabinoid (SC) use are becoming an emerging concern in psychiatric hospitals. However, data are lacking regarding whether clinical manifestations of SC use differ from those associated with cannabis use.

Concepts: Hospital, Mental disorder, Psychiatry, Anti-psychiatry, Psychiatric hospital, Cannabinoid, Involuntary commitment, Deinstitutionalisation


Objectives. We studied housing retention and its predictors in the single-site Housing First model. Methods. Participants (nā€‰=ā€‰111) were chronically homeless people with severe alcohol problems who lived in a single-site Housing First program and participated in a larger nonrandomized controlled trial (2005-2008) conducted in Seattle, Washington. At baseline, participants responded to self-report questionnaires assessing demographic, illness burden, alcohol and other drug use, and psychiatric variables. Housing status was recorded over 2 years. Results. Participants were interested in housing, although a sizable minority did not believe they would be able to maintain abstinence-based housing. Only 23% of participants returned to homelessness during the 2-year follow-up. Commonly cited risk factors-alcohol and other drug use, illness burden, psychiatric symptoms, and homelessness history-did not predict resumed homelessness. Active drinkers were more likely to stay in this housing project than nondrinkers. Conclusions. We found that single-site Housing First programming fills a gap in housing options for chronically homeless people with severe alcohol problems. (Am J Public Health. Published online ahead of print October 22, 2013: e1-e6. doi:10.2105/AJPH.2013.301312).

Concepts: Schizophrenia, Homelessness, Homelessness in the United States, Housing first, Deinstitutionalisation


In the 1980s, the combined effects of deinstitutionalization from state mental hospitals and the economic recession increased the number and transformed the demographic profile of people experiencing homelessness in the United States. Specialized health care for the homeless (HCH) services were developed when it became clear that the mainstream health care system could not sufficiently address their health needs. The HCH program has grown consistently during that period; currently, 208 HCH sites are operating, and the program has become embedded in the federal health care system. We reflect on lessons learned from the HCH model and its applicability to the changing landscape of US health care. (Am J Public Health. Published online ahead of print October 22, 2013: e1-e7. doi:10.2105/AJPH.2013.301586).

Concepts: Health care, Health economics, United States, Homelessness, Unemployment, Late-2000s recession, Deinstitutionalisation


Objective: Housing First is a groundbreaking approach to ending chronic homelessness among people with mental illness. This article presents one-year findings from a multisite randomized controlled trial (RCT) comparing Housing First with treatment as usual. Methods: The study was a nonblind, parallel-group RCT conducted in five Canadian cities. A sample of 950 high-need participants with severe mental illness, who were either absolutely homeless or precariously housed, was randomly assigned to Housing First (N=469) or treatment as usual (N=481). Housing First participants received a rent supplement, assistance to find housing, and assertive community treatment. Treatment-as-usual participants had access to all other existing programs. Results: At one-year follow-up, 73% of Housing First participants and 31% of treatment-as-usual participants resided in stable housing (p<.001, odds ratio=6.35, covariate adjusted difference=42%, 95% confidence interval [CI]=36%-48%). Improvement in overall quality of life was significantly greater among Housing First participants compared with treatment-as-usual participants (p<.001, d=.31, CI=.16-.46). Housing First participants also showed greater improvements in community functioning compared with treatment-as-usual participants (p=.003, d=.25, CI=.09-.41). Conclusions: Compared with treatment as usual, Housing First produced greater improvements in housing stability, quality of life, and community functioning after one year of enrollment. The study provides support for adopting Housing First as an approach for ending chronic homelessness among persons with severe mental illness, even if they are actively symptomatic or using substances.

Concepts: Epidemiology, Randomized controlled trial, Randomness, Mental illness, Homelessness, Homelessness in the United States, Housing first, Deinstitutionalisation


To understand staff factors associated with patient aggression towards the staff of an inpatient forensic psychiatric hospital.

Concepts: Hospital, Mental disorder, Psychiatry, Anti-psychiatry, Psychiatric hospital, Involuntary commitment, Deinstitutionalisation


BACKGROUND: Since Goffman’s seminal work on psychiatric institutions, deinstitutionalization has become a leading term in the psychiatric debate. It described the process of closure or downsizing of large psychiatric hospitals and the establishment of alternative services in the community. Yet, there is a lack of clarity on what exactly the concept of institutionalization means in present-day psychiatry. This review aims to identify the meaning of psychiatric institutionalization since the early 1960s to present-day. METHOD: A conceptual review of institutionalization in psychiatry was conducted. Thematic analysis was used to synthesize the findings. RESULTS: Four main themes were identified in conceptualizing institutionalization: bricks and mortar of care institutions; policy and legal frameworks regulating care; clinical responsibility and paternalism in clinician-patient relationships; and patients' adaptive behavior to institutionalized care. CONCLUSIONS: The concept of institutionalization in psychiatry reflects four distinct themes. All themes have some relevance for the contemporary debate on how psychiatric care should develop and on the role of institutional care in psychiatry.

Concepts: Hospital, Sociology, Mental disorder, Psychiatry, Anti-psychiatry, Psychiatric hospital, Involuntary commitment, Deinstitutionalisation