Relevant Question but Precious Little Data to Answer It

The burden of mental disorders is high around the globe. Service coverage for these disorders is low not only in low- and middle-income countries but also in high-income countries (1). Therefore, availability, access, location, and quality of mental health services are important issues to discuss. In her Global Mental Health Reforms column in this issue, Perera (2) asks a relevant question but provides precious little data to illuminate the discussion in a substantial way.

Perera bases her argument on an analysis that compared outpatient and day treatment facilities with inpatient bed capacity in 15 countries. The data are far from recent, derived from the World Health Organization (WHO) Mental Health Atlas from the year 2011, even though 2017 data were available. It is unclear why the analysis covered only 15 high-income countries given that the atlas provides data on nearly all countries in the world and represents all income groups. The article does not disaggregate the inpatient facilities into mental hospitals and inpatient units in general hospitals. It does not analyze other variables, such as average size of or duration of stay in inpatient facilities, nor does it account for the longitudinal trajectory of change in the number of inpatient beds in the selected countries. In the absence of these essential data, hardly any inference can be made with the question being asked.

WHO depicts mental health services for the public as a pyramid (3), where the base consists of self-care and informal community care (needed in the largest amount), the middle part represents mental health care offered in primary health care, and the tip represents specialist outpatient and inpatient care (needed in smaller amount). This model also conforms to efficient utilization of available resources—self-care and informal care cost the least, primary care costs more, and specialist mental health care costs the most. Within specialist care, outpatient care of course costs much less than inpatient care, and the latter should be used only when other forms of care are not feasible to provide or are not effective. In many low- and middle-income countries, a large majority of human and financial resources are “locked into” the inpatient care provided by large psychiatric hospitals. The question of how much inpatient care is needed should be answered with consideration of all other forms of mental health care—not only outpatient care—and of efficient use of resources.

Historically, inpatient beds have been concentrated in psychiatric hospitals and have been used largely for custodial long-term care. WHO’s atlas provides data on the distribution of inpatient beds in general hospitals and psychiatric hospitals and for the latter, distribution by the average duration of stay. For example, in 2017, France reported 6.98 beds per 100,000 population in psychiatric hospitals compared with 22.34 beds in general hospitals, and of the patients in psychiatric hospitals, 91.3% stayed for less than 1 year and 2.1% for more than 5 years. These data are very useful to assess location and utilization of inpatient beds. To make any conclusion on the role of inpatient care without consideration of these details is likely to be misleading.

There is also the issue of human rights of persons with mental disorders, which are at much higher risk of being violated in psychiatric hospitals than in other psychiatric facilities. This is one of the prominent reasons for the movements for deinstitutionalization (4). On a global basis, psychiatric hospitals still receive a large number of involuntary admissions. The use of physical restraints and violence against people with mental disorders is also common. Many countries are employing new methods to decrease involuntary and coercive practices (5). It should be noted that the Convention on the Rights of People With Disabilities, ratified by 181 countries, has elaborate safeguards to protect the rights of people with psychosocial disabilities, and coercive methods of treatment are explicitly prohibited. The United States is a notable exception; it signed the Convention but failed to ratify it.

WHO’s Comprehensive Mental Health Action Plan (MHAP) was adopted in 2013 by the World Health Assembly, which consists of all member states of WHO. One of the objectives of this plan is to provide comprehensive, integrated, and responsive mental health and social care services in “community-based settings.” Psychiatric wards in general hospitals providing acute care with short stays of weeks to months are considered a part of care in community settings (6). It is imperative that the policy objectives of MHAP be implemented expeditiously and effectively. Data and evidence are needed to assist implementation of these objectives in all countries at all income levels.