Aging of severely mentally ill patients first admitted before or after the reorganization of psychiatric care in Sweden

BACKGROUND: The concept of deinstitutionalization started in the 1960s in the US to describe closing down or reducing the number of beds in mental hospitals. The same process has been going on in many countries but with different names and in various forms. In Europe, countries like Italy prescribed by law an immediate ban on admitting patients to mental hospitals while in some other European countries psychiatric care was reorganized into a sectorized psychiatry characterized by open psychiatric care. This sectorization has not been studied to the same extent as the radical closures of mental hospitals, even though it entailed major changes in the organization of care. The deinstitutionalization in Sweden is connected to the sectorization of psychiatric care, a protracted process taking years to implement. METHODS: Older people, with their first admission to psychiatric care before or after the sectorization process, were followed using three different time metrics: (a) year of first entry into a mental hospital, (b) total years of institutionalization, and (c) changes resulting from aging. Data from surveys in 1996, 2001, 2006, and 2011 were used, together with National registers. RESULTS: Examination of date of first institutionalization and length of stay indicates a clear break in 1985, the year when the sectorization was completed in the studied municipality. The results show that the two groups, despite belonging to the same age group (birthyears 1910–1951, mean birthyear 1937), represented two different patient generations. The pre-sectorization group was institutionalized at an earlier age and accumulated more time in institutions than the post-sectorization group. Compared to the post-sectorization group, the pre-sectorization group were found to be disadvantaged in that their level of functioning was lower, and they had more unmet needs, even when diagnosis was taken into account. CONCLUSIONS: Sectorization is an important divide which explains differences in two groups of the same age but with different institutional history: “modern” and “traditional” patient generations that received radically different types of care. The results indicate that the sectorization of psychiatric care might be as important as the Mental Health Care Reform of 1995, although a relatively quiet revolution.