In need of shelter

It is one of the ruling orthodoxies of the age that everyone not only can but wants to live independently: therefore institutions by definition are bad and oppressive. Yet every doctor is regularly confronted by patients who, through no fault of their own, need shelter from the harsh exigencies of modern daily life. The trouble is that there are no longer any institutions where they can be looked after with kindness and humanity.

A Swedish study, published last week in the British Medical Journal, suggests that deinstitutionalisation might not have been so good for patients with schizophrenia. As the number of psychiatric in-patient beds in Stockholm declined, by 64% between 1976 and 1994, so the death rates of schizophrenics relative to the rest of the population increased equally dramatically. This was the case for natural causes and deaths by violence.

One possible explanation for the increase in the relative risk of schizophrenics dying from cardiovascular disease and other natural causes is that as their admission to hospital has become less frequent, so contact with the medical profession has become more irregular. Practically all schizophrenics smoke; at large in what is called the community, but is actually an impersonal agglomeration of strangers, they adopt a lifestyle that is not conducive to good health. Then when they become sick, their very psychiatric condition inhibits them from seeking medical help.

Relative to the rest of the population, schizophrenics in Stockholm are increasingly likely to die from suicide and "unspecified violence". For example, male schizophrenics first diagnosed between 1976 and 1980 were 13.2 times more likely to die by their own hand, and 12.1 times more likely to die of "unspecified violence", as their non-schizophrenic peers. The ratios for schizophrenics first diagnosed between 1991 and 1995 were 47.8 and 45.2 respectively.

Of course, the study has to be interpreted with care. Numbers of deaths in the schizophrenics first diagnosed between 1991 and 1995, while relatively large, were small in absolute terms: therefore chance occurrences might have played a part in the production of so alarming an impression.

Moreover, the paper in the BMJ does not allow us to determine whether the health of schizophrenics was improving or deteriorating in the absolute sense. It is possible for the health of schizophrenics to have deteriorated relative to that of non-schizophrenics, and yet to have improved absolutely. These figures could merely mean that the health of schizophrenics has not improved as far or as fast as that of the non-schizophrenic population. From the point of view of the individual, however, it is the absolute improvement or deterioration that is the more important.

Nevertheless, the paper from Stockholm will increase the scepticism of those who believe that care in the community - that welcoming phrase again that seems to deliberately and dishonestly disguise the nature of the world that schizophrenics will actually be discharged into - has not been the success it has often been cracked up to be.

In my experience, there are quite large numbers of people, not necessarily with psychiatric illnesses, who are more at home in institutions than floating free in an indifferent world outside. Oddly enough, I meet quite a number of them in prison: poor souls who actually prefer to be incarcerated, with three meals a day and no confusing choices to make, than at large in the wider world where everything they do is wrong.

No one doubts that the old mental hospitals were in many ways appalling institutions: that the wards for patients were an impoverishing environment. But the old hospitals had advantages too. They really were asylums for those who needed asylum. To have concluded that they were not necessary because they were in many ways so bad, and that therefore their former residents should have been made to fend for themselves, was a bit like concluding that because our schools are so bad, children should be sent down the mines.

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