Investigation of deinstitutionalization and functioning and needs indicated that results varied depending on the time metric considered: (a) year of first entry into a mental hospital, (b) total accumulated time of inpatient care, or (c) changes resulting from aging with SMI. Year of first admission tended to predict outcomes of the survey in 1996. Additionally, aging contributed to prediction of functioning for about half the outcome variables. However, the most important time metric was length of stay in a mental hospital, which predicted outcomes in every case even when psychosis diagnosis was taken into account. Moreover, the pre-sectorization group was much more likely to have experienced extensive time in a mental hospital. All in all, compared to the post-sectorization group, the pre-sectorization group were found to be disadvantaged in that a significantly higher percent of the pre-group had died at the time that the mortality data were collated, their level of functioning was lower, and they had more unmet needs.
The fact that the two groups are identical in terms of both the average year of birth (1937) and birth year range (1910-1951) means that the post-sectorization group was significantly older when first admitted at the psychiatric clinic (average 54 years old), compared to the pre-sectorization group who on average was 38 years old at the time of first admission. This means that the studied groups belong to the same generation in terms of age, at the same time as they constitute two completely different “patient generations” in relation to psychiatry care ideology and organization of psychiatric care. Based on the development of psychiatric care, the pre-group belongs to an “older generation” of patients who in many cases encountered a form of care that to varying degrees was characterized by what Goffman (25) called the total institution, which was both a place meant to separate patients from society and to provide treatment (26; cf. Author). The care provided at the mental hospitals included all aspects of a person's life, both material and social welfare - no activity at the mental hospital was carried out without being thought of as part of the treatment (Author). According to the mental hospital care ideology, work, leisure activities, housing, spiritual experience, etc. were part of the patient's treatment.
The post-sectorization group, on the other hand, belongs to a “younger patient generation” in relation to psychiatric care, despite the fact that they are part of the same generation as the pre-sectorization group in terms of age. That the post-sectorization were significantly older at the time for first being admitted to psychiatric inpatient care probably also meant more opportunities and higher probabilities for being established in society. We found no differences concerning education or source of income. However, the fact that the post-sectorization group significantly more often were married (23%), or a widow/-er (11%) compared to the pre-sectorization group (15% and 5% respectively) indicate that the post-sectorized group might have had a more stable and securing family life and when comparing living conditions. The post-sectorization group had shorter accumulated time of hospitalization but with no differences in number of stays. This meant that the long-stay hospitalization was not replaced by frequent admissions, so called revolving door-patients (27). The new care ideology, which the post-sectorization group met when they were first admitted to psychiatric inpatient care, was characterized by optimism among the staff and an explicit effort to avoid hospitalization (28) as well as maintain continuity in the patient-staff relationship.
Previous research has argued that people with SMI did not benefit from the outpatient care as part of the sectorization (10). However, results from our analyses, showing the post-sectorization group to have stays in inpatient one-tenth as long as the pre-sectorization group, on average, might indicate the opposite. That is, the post-sectorization group more likely benefited from open psychiatric care before, after, or in between periods of hospitalization. At least two organizational changes might work as explanations. First, at the time of the post-sectorization group’s first admission, the new care ideology pleaded for outpatient care instead of hospitalization as far as possible (16, 28, 29). Secondly, the reduction in the number of beds, as part of the ongoing process of deinstitutionalization probably meant greater resistance to the admission of patients without a previous history of hospitalization (16, 30, 31), while the availability of outpatient care speaks in favour of their use.
The probability of experiencing more time in mental hospital during the era of a care ideology characterized as that of the total institution, not only meant longer periods of admission but also being at greater risk to develop institutional syndrome, which Bean and Mounser (32) present from Barton’s (33) and Goffman’s (25) work. This resembles the Swedish term “hospitaliseringsskador” (15) which captures the idea of being harmed or changed by medical or psychiatric care, such as the psychological changes that result from long-term stay in any institutional setting. Patients with long-term stay in a mental hospital will develop a “hospital mentality”: apathy, lack of initiative, loss of interest, lack of individuality, submissiveness, reduced motor function, and loss of ability for long-term planning. This might partly explain why the pre-sectorization group was rated by staff as having lower social, occupational, and psychological functioning (GAF), and in need of more support, while growing older, compared to the post-sectorization group. It is likely that the experience of extensive time in a mental hospital, besides being stigmatising, worked as a double jeopardy: aging and a long history of institutionalization combined to create poorer outcomes. The concept of double jeopardy has been used to examine the interaction of gender, race, socioeconomic position, as well as diabetes mellitus, with mental health care and outcomes (e.g. 34, 35-37), but this study may represent the first attempt to examine how aging and long-term institutionalization interact to affect outcomes. Differences between the pre-sectorization group and the post-sectorization group increased during the follow-up study 1996 – 2011 with regard to satisfied and unsatisfied needs and global functions.
Given that time in a mental hospital is the most important predictor of functional level and the number of unmet needs, and that first admission to a mental hospital prior to the implementation of the sectorization resulted in significantly longer hospital stays, it means that the sectorization of psychiatric care to a large extent also had a positive effect on the group with SMI, and thus not only did the “worried well” benefit as previously described (9–10). In other words, in our study the “younger generation” of patients with SMI did benefit from the more open and society-based psychiatry and thereby did benefit from the sectorized psychiatry. The reform of psychiatric care in the studied municipality meant in parallel both an expansion of outpatient clinics in various places in the municipality and a gradual reduction of care places in the large old mental hospital. One possible explanation for the differences between the two groups examined is that the post-sectorization group probably also received psychiatric treatment in outpatient care, while many in the pre-sectorization group to a greater extent remained in the mental hospital.