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Schizophrenia Research

Trends in psychiatric hospitalisation of people with schizophrenia:A register-based investigation over the last three decades

Barbara Lay ⁎, Carlos Nordt, Wulf Rössler

Psychiatric University Hospital Zurich, Research Unit for Clinical and Social Psychiatry,Zurich, Switzerland

Received 14 February 2007; received in revised form 3 July 2007; accepted 4 July 2007Available online 8 August 2007

Abstract

The number of psychiatric beds has declined considerably in many countries over the past decades. Long-term studies on theimpact of these health care changes for the severely mentally ill, however, are still scarce. This epidemiological study investigatesthe use of inpatient psychiatric services by people with schizophrenia, compared to that by people with other mental disorders. Weused psychiatric register data of the Swiss canton Zurich to establish the annual treatment prevalence in the period 1977–2004.

For patients with psychoses, the length of inpatient episodes decreased by half. The annual number of inpatient admissionsdoubled. The proportion of schizophrenia patients, which accounted for 36%–41% of all inpatient treatments up to 1993, droppedto 20% in 2004, while that of other psychoses remained about the same (8%–10%) throughout the study period. This contrasts witha 2–3 fold increase in other patient groups. The annual treatment prevalence for people with schizophrenia declined from 7.3 to 2.2per 10000 population since the 1990s and affected patients of all ages and of both sexes equally. The treatment prevalence for otherpsychoses remained virtually unchanged (1.3 per 10000). For all other mental disorders, there was an up to twofold increase.

The study suggests that the downsizing of psychiatric hospitals has resulted in a far-reaching redistribution of overall inpatienttreatment resources. The considerable decrease in inpatient treatment for people with schizophrenia emphasizes the need to furtherinvestigate the current state of coverage for and the appropriateness of health care available to this patient group.© 2007 Elsevier B.V. All rights reserved.

Keywords: Schizophrenia; Psychosis; Treatment prevalence; Epidemiology; Hospitalisation; Mental health services

1. Introduction

The role of inpatient care in the management of peoplewith a severe mental disorder has changed considerablythroughout the past decades. This development has beendriven primarily by psychiatric reforms intended toprevent long-term residential care and to integrate the

⁎ Corresponding author. Psychiatric University Hospital Zurich, Re-search Unit for Clinical and Social Psychiatry, Militärstr. 8, P.O.Box 1930,8021 Zurich, Switzerland. Tel.: +41 44 296 7372; fax: +41 44 296 7409.

E-mail address: barbara.lay@bli.uzh.ch (B. Lay).

0920-9964/$ - see front matter © 2007 Elsevier B.V. All rights reserved.doi:10.1016/j.schres.2007.07.006

mentally ill into the community. As acute inpatient carecommonly consumes the biggest share of the mentalhealth care budget, these changes in care provision mightalso be understood as a result of the growing pressure tocut health care costs.

In Switzerland, the proportion of the overall healthcare budget earmarked for psychiatric hospitals hasdecreased in recent years to 3.2% in 2005 (SwissFederal Statistical Office, 2007). Since 1980, thenumber of psychiatric beds has declined by almosthalf (Swiss Health Observatory, 2003). A similar trendfrom traditional hospitals to outpatient and community

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services has been observed in many European countries(Balestrieri et al., 1989; De Girolamo et al., 2002; Fürediet al., 2006; Kallert et al., 2006; Sytema and Burgess,1999; Thompson et al., 2004).

Various studies evaluating this process in differentcountries have underlined the advantages for mostpsychiatric patients (Hobbs et al., 2002; Honkonenet al., 2003; Leff and Trieman, 2000; Lesage et al., 2000).However, also a number of questions have been raised.Of concern are the adequacy of levels of serviceprovision (Thompson et al., 2004) and the number ofchronically mentally ill who are left without any mentalhealth care (Lamb, 1993). The professional discoursefocussed on schizophrenia patients, the patient group thattraditionally absorbed a large part of inpatient treatmentcapacities (Lay et al., 2006).Many of these patients (60%to 85%) still exhibit psychotic symptoms several yearsafter discharge, and impairment of social functioning iscommon (De Girolamo et al., 2005; Hobbs et al., 2002;Honkonen et al., 2003; Lesage et al., 2000). Furthermore,many schizophrenia patients have special behaviouralproblems which make it difficult to place and maintainthem in community settings (Honkonen et al., 2003;Lamb, 1993). There is some evidence that schizophreniapatients discharged in later years tend to bemore disabledthan those discharged earlier (Honkonen et al., 2003;Lamb, 1993; Mojtabai et al., 2005). Last not least,persons with serious mental illness run an increased riskof homelessness (Folsom et al., 2005; Lamb, 1993).

Meanwhile, the process of discharging previouslylong-term hospitalised patients has come to an end inmost European countries. A new generation of severelymentally ill patients has grown up that has not spent longyears in psychiatric hospitals. Considering that the down-sizing of psychiatric hospitals continued throughout the1990s, such an ongoing reduction of inpatient resources islikely to impact not only the previous long-stay inpatients.

Although a far-reaching reduction of hospitalresources has been in process for decades, it has yet tobe fully examined which patient groups have borne thebrunt of these changes over the years. In particular, littleresearch exists addressing the question as to what extentthe reduction in inpatient services affected schizophreniapatients. In most studies targeting changes in health caredelivery, patterns of service use were evaluated bymeansof cross-sectional designs. Many studies focussed onparticular patient groups (e.g. long-stay inpatients),subgroups of the population, or people in contact witha mental health service at a specific point of time (Knappet al., 2002; Honkonen et al., 2003; Leff and Trieman,2000; Sytema and Burgess, 1999). Research thatmonitored local psychiatric services over a period of

several years was generally confined to first-admissionor -discharge cohorts only (Balestrieri et al., 1989;Cavanagh and Shajahan, 1999; Sytema and Burgess,1999) and thus does not reflect overall service provision.

This paper addresses inpatient psychiatric service usein a defined catchment area over a 28-year period. Weused psychiatric register data in order to study apopulation-based sample over a longer period and toobtain prevalence estimates. Rather than confiningservice use to admission rates or length of stay only,we focus on patient-years in treatment as the mostmeaningful indicator of the amount of inpatientresources used. Specifically, the study addresses thefollowing questions: (i) To what extent does the use ofinpatient psychiatric care by people with schizophreniaand other psychotic disorder vary over time? (ii) Are thetime trends observed comparable to those for patientswith other mental disorders? (iii) Is variation over timerelated to the age or gender of schizophrenia patients?

2. Methods

2.1. Sample

We included all patients aged 15 to 79 years residing inthe Canton Zurich, Switzerland, who had been admittedto a psychiatric hospital between 1 January 1977 and 31December 2004. Age 15 was set as the lower age limit,since gender- and age-specific data available for thereference population are grouped accordingly. Subjectsolder than 80 years were excluded in order to avoidgender-specific effects due to mortality in very old age.

Patients were traced using the Central PsychiatricRegister, which covers all mental health services in theCanton Zurich (PSYREC, 2006), a catchment areacomprising about 1.2 million inhabitants. Since 1974,all psychiatric hospitals have been legally obliged toreport admissions and discharges to the CentralPsychiatric Register. Data are collected on a standar-dised form, and the completion of forms and theconsistency of information are regularly monitored. Thehospital physicians in charge of the respective patientare responsible for diagnostic assessments and docu-mentation. Each record contains a variety of socio-demographic, clinical, and patient information describ-ing the treatment received during hospitalisation.Because the register provides hospital episode data(including readmissions), the analysis presented is basedon admission episodes rather than on the individualsadmitted. Data on gender, age, and psychiatric diagnosiswere retrieved for each admission (no missing values asto gender and age). To ensure that we did not miss

70 B. Lay et al. / Schizophrenia Research 97 (2007) 68–78

patients due to incomplete data input in the start-upphase of the register, 1977 was taken as the first year.

In total, the sample comprised 141360 inpatientepisodes. The patients' median age at admission rangedbetween 37–40 years. Whereas in the 1970s a higherproportion of women was treated in psychiatrichospitals (59.6% in 1977), the proportion of bothgenders equalised by the 2000s (49.3% females in2004).

2.2. Diagnostic groups

Patients' diagnoses were based on the InternationalClassification of Diseases, 8th Revision (World HealthOrganisation, 1965) before 1979, on the 9th Revision(World Health Organisation, 1975) subsequently there-to, and on the 10th Revision (World Health Organisa-tion, 1992) since 1992. We translated the data assessedby ICD-8 and ICD-9 according to the conversion tablesof the WHO Division of Mental Health (World HealthOrganisation, 1994). When pooling all diagnosticinformation, it had to be taken into account that thesize of the coding frame increased over the periodstudied and particularly, that its structure had changedfrom the 9th to the 10th Revision. Broad groupings ofICD rubrics therefore had to be used. We grouped allclinical diagnoses into seven categories:

– Schizophrenia (ICD-10 code F20)– Other psychotic disorders, schizotypal and delusionaldisorders (F21–F29)

– Affective disorders (F30–F39)– Mental and behavioural disorders due to alcohol use(F10)

– Mental and behavioural disorders due to otherpsychoactive substance use (F11–F19)

– Organic mental disorders (F00–F09). The smallgroup of patients diagnosed with mental retardation(F7; n=1287; 0.9%) were subsumed under thiscategory.

– All other diagnoses – in the majority neurotic,personality, stress-related, and somatoform disorders– were grouped into the category ‘Other disorders’.

The category Schizophrenia (F20) was narrowlydefined, including only the ICD-9 codes 295.0, 295.1,295.2, 295.3 and 295.6. We subsumed ‘Other-’ and‘Unspecified schizophrenic psychosis’ (ICD-8, ICD-9codes 295.8 and 295.9) under the heading of Otherpsychotic disorders (F21–F29), since in these cases anexact nosological positioning under the F20-category isdifficult, considering that the former ICD versions do

not provide explicit criteria. We placed ‘Unspecifiedmanic-depressive psychosis’ (ICD-9, 296.6) and ‘Otheraffective psychosis’ (ICD-8 and ICD-9, 296.8) withinthe category of Affective disorders (F30–F39).

The primary clinical diagnoses at the time ofdischarge were used. Only if the discharge diagnosiswas unknown (n=979, 0.67%), was the diagnosis atadmission extracted. For 62 (0.04%) of all treatmentepisodes no diagnosis was registered. These wereexcluded for further analysis.

2.3. Population data

Population data were compiled from documentspublished by the Statistical Office of the Canton ofZurich (Statistical Office of the Canton of Zurich, 2005;Statistical Office of the Canton of Zurich, 2006) for eachstudy year. These data encompassing all citizens areaggregated according to gender and age in 5-year bands.For the present study, we used the figures on males andfemales aged 15 to 79 years residing in the CantonZurich (population at risk) to estimate population rates.

2.4. Statistical analyses

We analysed the utilisation of inpatient psychiatricservices annually, in terms of (1) the number of inpatientadmissions per year, (2) the median length of individualinpatient episodes, and (3) the patient-years in treatmentas computed by summing up all treatment days per year.Thus, on a service level, ‘patient-years in treatment’ isthe most comprehensive indicator of the use of inpatientcare, taking into account information on both thenumber of admissions and the length of inpatient stay.To relate this indicator to the reference population, wecalculated the treatment prevalence (4) by dividing thenumber of patient-years per year (numerator) for eachdiagnostic group by the number of the population at risk(denominator) within each factor level. Data weregrouped by the factors “gender” and “age” (at sevenlevels: b20, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79 years).

We analysed time trends of treatment prevalence bymeans of Poisson regression. To assess the Goodness ofFit of a model and to compare different models underconsideration, we used the Deviance (value/df). Themost parsimonious model that fitted the data sufficientlyincluded the terms “year”, “age”, “gender”, “diagnosis”and the two-way-interactions “year⁎diagnosis”, “gen-der⁎diagnosis”, “gender⁎age” and “age⁎diagnosis”.Effects of “age” and “year” were modelled by includinga linear, a quadratic and, as for “age”, a cubic term. We

Fig. 1. Patients diagnosed with schizophrenia (ICD-10, F20) or other psychotic disorders (F21–29), compared to other diagnoses: Number of admissions, duration of inpatient episodes, use oftreatment, and treatment prevalence per year.

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Fig. 2. Treatment prevalence (Poisson regression analysis), and age distribution of female and male patients diagnosed with schizophrenia.

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used likelihood ratio statistics to test the significance ofterms. Statistical analyses were carried out by means ofthe PROC GENMOD procedure of SAS version 8.2.

3. Results

3.1. Number of admissions

Fig. 1 (top left) gives the number of admissions topsychiatric hospitals per year (crude rates). After a slowrise, the total number remained stable throughout the1980s, thereafter increasing, however, from 3900 in 1991up to 9636 admissions in 2004. Thus, over the wholestudy period, the number of admissions almost tripled.

For patients with psychosis, however, admissionrates increased to a far lesser extent: Regardingschizophrenia patients (F20), there was a relativelymoderate change only within the last few years of theperiod; between 1977 (679 admissions) and 2004 (1 362admissions), admission rates doubled. By contrast, theincrease was more than fourfold for patients diagnosedwith substance use disorders (F10; F11–F19) andaffective disorders (F3), and still threefold in the“other disorders” group.

3.2. Length of individual inpatient episodes

Overall, the length of stay in hospital declined from45 days (median) in 1977 to 17 days in 2004 (Fig. 1, topright). The reduction in inpatient time, however, variedconsiderably between psychiatric diagnostic groups:For schizophrenia patients, as well as patients withother psychoses, inpatient time was reduced approxi-mately by half (F20: from 47 to 23 days; F21–F29:from 48 to 23 days). For most other diagnoses also, theinpatient time was markedly reduced (F3: from 46 to24 days; F0: from 55 to 25 days; Other: from 25 to9 days), however not for all: For substance usedisorders the duration of inpatient episodes remainedalmost unchanged since the 1980s. This indicates thatschizophrenia patients, the group which in the 1970sstill spent the longest time in hospital, have been treatedas inpatients in the last few years for periods as long asthose for most other diagnostic groups. The earliermarked inter-group differences in inpatient time thushave almost disappeared.

3.3. Proportion of patient-years in treatment bydiagnostic group

Fig. 1 (down left) shows the proportion of inpatienttreatment that is ‘consumed’ by the various diagnostic

groups. Schizophrenia patients (F20) were the mostfrequently treated group, accounting for more than athird (36%–41%) of all inpatient treatments up to theyear 1993. After that, the proportion declined to 20% by2004. Thus, schizophrenia patients were – aside frompatients diagnosed with an “organic mental disorder”(F0) – the only group with marked decreases in the useof inpatient services over time. The proportion of the“other psychotic disorders” group (F21–F29) remainedat about the same level throughout the study period. Aninverse – though less marked – shift is seen for all otherdiagnostic groups: Their proportions increased by afactor of two to three in the period after 1990, afterhaving been stable for several years. Thus, in recentdecades the proportion of patients with schizophreniaand those with other mental diseases treated inpsychiatric hospitals has been considerably redeployed.

3.4. Treatment prevalence by diagnostic group

To account for demographic changes in the popula-tion during the study period, we estimated treatmentprevalence rates, again stratified by diagnostic group(Fig. 1, down right). For people with schizophrenia(F20), the annual treatment prevalence initially rose forsome ten years, resulting in the late 1980s in rates thatwere almost twice as high. Thereafter, the treatmentprevalence declined markedly from 7.27 per 10000 in1989 to 2.16 per 10000 population in 2004. Forsubstance use disorders (F10; F11–F19), in the ‘otherdisorders’ group, and in affective disorders (F3), thetreatment prevalence slightly increased during theperiod. The rate for affective disorders, e.g., approxi-mately doubled between 1990 and 2004. Thus, thetreatment prevalence for people with schizophrenia inrecent years was similar to that found for those withaffective disorders and for the ‘other disorders’ group. Inpatients with other psychotic disorders, the inpatienttreatment prevalence remained nearly unchangedthroughout the study period.

3.5. Time trends of treatment prevalence

The results of Poisson regression analyses (Table 1)suggest that the treatment prevalence for patientsdiagnosed with schizophrenia has decreased significant-ly over the last 15 years. This variation over time cannotbe explained by effects of the patients' age or gender, orby taking into account that psychiatric diagnoses aredifferent for males and females (interaction “gender⁎ -diagnosis”). As an example for a given age group, Fig. 2(upper panel) gives the estimated prevalence of males

Table 1Model statistics (likelihood ratio for type 3 analysis)

Parameter df chi2 P-value

Gender (Ref: male) 1 146.22 b .0001Diagnosis (Ref: Other disorders) 6 5679.96 b .0001Age (Ref: 30–39 years) 1 448.26 b .0001Age⁎age 1 1023.97 b .0001Age⁎age⁎age 1 450.81 b .0001Year (Ref: 1990) 1 21.42 b .0001Year⁎year 1 259.06 b .0001Year⁎diagnosis 6 1733.59 b .0001Year⁎year⁎diagnosis 6 688.04 b .0001Gender⁎diagnosis 6 1002.65 b .0001Gender⁎age 1 1139.88 b .0001Age⁎diagnosis 6 2546.19 b .0001Age⁎age⁎diagnosis 6 401.02 b .0001Age⁎age⁎age⁎diagnosis 6 184.81 b .0001

Goodness of fit: Deviance 4346.63; df 2694; value/df 1.613.

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and females, stratified for diagnostic group. The similarshapes of the curves for male and female schizophreniapatients show that both sexes alike are affected by thechanges over time, though on a different level.

Results furthermore indicate that the decrease in thetreatment prevalence for schizophrenia patients overtime cannot be ascribed to the loss of a particular agegroup (interaction “age⁎diagnosis”; “age⁎gender”).Fig. 2 (lower panel) gives the age distribution amongmale and female schizophrenia patients for every year ofthe study period. As can be seen from these graphs, thepatients' age distribution in both sexes did not changesubstantially over time. This suggests that the reductionof the inpatient prevalence in schizophrenia affectedschizophrenia patients of all ages equally. Thus, wheninteraction effects between “Age” and “Year” wereadditionally considered in the regression model, theydid not result in a substantial model improvement(value/df=1.606), compared to the model presented(value/df=1.613; see Table 1; supplementary data canbe found in the online version).

4. Discussion

The present study provides epidemiological data onpsychiatric inpatient use by people with schizophreniaas compared to the service use by patients with otherdisorders. To the best of our knowledge, no similarstudies have addressed the effects of decreasinghospitalisation across mental disorder groups coveringa comparable time frame.

This study yields three main findings: Firstly, wefound an inverse relationship between the annualnumber of admissions and the duration of inpatientepisodes: While the length of stay in the hospital

declined in schizophrenia patients by approximately halfbetween 1977 and 2004, the number of inpatientadmissions doubled. Secondly, there was a considerablepatient shift across diagnostic groups over the pastdecades: While the proportion of inpatient use by peoplewith schizophrenia dropped from 40% to 20%, theproportion of inpatient use by patients with ‘affective’–,‘substance use’–, and ‘other disorders’ increased by afactor of two to three. Thirdly, in terms of treatmentprevalence, people with schizophrenia experienced thelargest decline in inpatient use of all diagnostic groups.This decline was not due to shifts in the patients' gendermix over time, nor to higher or lower rates of service useby particular age groups (e.g. the disappearance ofelderly schizophrenia patients in recent years).

Thus, the present study suggests that the downsizingof psychiatric hospitals over a period of almost threedecades has resulted not only in a reduction in the lengthof hospital stay for people with schizophrenia, but alsoin a far-reaching redistribution of overall inpatienttreatment resources. It has led to a greater reduction ininpatient treatment for schizophrenia patients as com-pared to the other diagnostic groups. The demand forinpatient treatment by schizophrenia patients hasmeanwhile even fallen below that by patients withaffective disorders.

4.1. Shift to outpatient or alternative treatment

The most obvious explanation for this trend is thatthe intensified treatment and care in the community hascounterbalanced the decline in inpatient use. As was thecase in other European countries, Switzerland hasrestructured its mental health and social services inorder to prevent long-term hospitalisation and toencourage less restrictive community-based treatment.Within the past decade, the number of psychiatricinstitutions providing community mental health care hasincreased from 4 to 10 in the Canton of Zurich (Christen,2003), while the number of psychiatrists in officepractice has roughly doubled (Swiss Medical Associa-tion, 2006). Data from the register covering communitymental health institutions in this catchment area,however, suggest that schizophrenia patients have notparticularly benefited from the development of outpa-tient services: The proportion of treatment episodes ofschizophrenia patients as reported by psychiatricoutpatient facilities decreased steadily from 19.2% in1995 to 14.8% in 2004 (Christen et al., 1996; Hamel andRössler, 2005).

Unlike in other countries, there are no PsychiatricUnits in General Hospitals in the Canton of Zurich.

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Thus it is most unlikely that an increasing number ofpatients diagnosed with schizophrenia have been treatedin General Hospitals in recent times. The same holdstrue for treatment by psychiatrists in office practice:According to several Swiss surveys (Ernst, 1998), thistreatment sector is largely engaged in providing long-term psychotherapies for less severely ill, i.e. as ageneral rule not persons with schizophrenia. Thissuggests that the marked reduction in inpatient treatmentby patients with schizophrenia has not been compen-sated by a higher density of office-based psychiatrists,either.

Comparably, there is evidence from large scalestudies from the US that the reduction of long-termhospital care does not necessarily result in a shift tocommunity mental health care: According to a longitu-dinal epidemiological study of patients with psychoticdisorders, the decline in inpatient service use was notaccompanied by an increase in the number of outpatientvisits. Moreover, a lower proportion of the patients inthe later admission cohorts received continuous outpa-tient care (Mojtabai et al., 2005). In the same vein, anational US study on mental health care use and costsunder private insurance found a significant decline in theuse of inpatient services, but no corresponding increasein the use of outpatient services, even for severely illpatients requiring hospitalisation (Leslie and Rosen-heck, 1999). On the part of schizophrenia patients, thenumber of bed-days per patient fell by 20% during aperiod of 3 years, while outpatient mental health serviceuse and costs remained virtually unchanged (Leslie andRosenheck, 1999).

In contrast to other countries, where the lack of healthinsurance coverage represents a major barrier to healthcare utilisation, psychiatric treatment in Switzerland iscovered by compulsory health insurance. Access to themental health care system is not limited by the level ofincome of the mentally ill seeking treatment. Hence, thedecline in the use of inpatient services by schizophreniapatients observed in Switzerland cannot be attributed tothe lack of financial resources of this patient group. It isremarkable, therefore, that the trend towards decreasingpsychiatric inpatient treatment for the chronicallymentally ill is observed in countries with completelydifferent health care systems (e.g. Hobbs et al., 2002;Honkonen et al., 2003; Lamb, 1993).

4.2. Advances in antipsychotic pharmacotherapy

Another factor that might account for the decline ininpatient use is the introduction of new treatments,namely treatments such as second generation antipsy-

chotics. Large-scale studies on expenditures in psychi-atric treatment for schizophrenia have reported asignificant increase in (overall) prescription drug costsover time, concurrent with decreases in inpatientexpenditures (Miller and Martin, 2004). We do nothave data on the prescription trends of antipsychoticdrugs in Switzerland over the past 30 years to examinesuch a relationship. It should be considered, however,that atypical antipsychotics were not first introduced in1990, but some were already in use before then. Inparticular, the prescription of clozapine has beenwidespread in Switzerland since the 1970s. Nor arethere any financial restrictions with regard to drugprescription in Switzerland. All the more striking, then,is that inpatient treatment prevalence still increased inthe 1980s.

It is noteworthy that such a decline of inpatienttreatment prevalence was not observed for patients with(unipolar) depression. For patients diagnosed withdepressive or anxiety disorders, a significant increasein psychotropic medication, in particular in antidepres-sants, was also demonstrated between 1993 and 2000 intwo national surveys throughout the UK (Brugha et al.,2004). Thus, we doubt whether the decline in inpatienttreatment observed for schizophrenia patients should belargely ascribed to a new management of psychotropicmedication or an improved efficacy of psychopharma-cological treatment.

4.3. Changed morbidity rates

To explain variations in the use of mental health careservices, changed morbidity also has to be considered.There is some evidence that the incidence of schizo-phrenia fluctuates over time (McGrath et al., 2004).Studies covering the last two decades, however, do notsuggest a lower prevalence of psychotic disorder inrecent years (South-east London: Boydell et al., 2003;UK: Brugha et al., 2004; Singleton et al., 2003; Italy:Preti and Miotto, 2000). It is therefore unlikely that thedecreased treatment prevalence observed over the last15 years in Switzerland is due to a declining morbidityrate. Moreover, a decrease in morbidity would first of allaffect the younger age groups, who would sample out inthat case. The present findings, however, do not supportsuch an (differential) age effect.

In contrast, research suggests that the incidence ratesfor affective disorders have increased within the lastfifty years (Klerman and Weissman, 1989; Mattissonet al., 2005; Olsen et al., 2004). Moreover, unipolardepression is associated with a high hospitalisation rate(Brown, 2001). The rise in the inpatient treatment of

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people with affective disorders (annual number ofinpatient admissions; treatment prevalence) in thepresent study therefore might be an indicator of anincreased need for treatment in recent years among thispatient group. This increase, however, was confined tounipolar depressive disorder: of all inpatient admissions,the proportion of bipolar disorders decreased from 5.3%to 2.9% over the study period (within the group ofaffective disorders, their proportion decreased from33.4 % to 13.9%). This suggests that the time trend overthe study period operated for patients with bipolar dis-orders in the same direction as for schizophrenia patients.

4.4. Diagnostic shifts

A further possible explanation might concerndiagnostic shifts. Since throughout the period studieddiagnoses were made according to the InternationalClassification of Diseases, we have no reason to assumethat changes in diagnostic tradition within the hospitalshave affected the tendency to diagnose schizophrenia.Nevertheless, different versions of the ICD were in useduring the period studied. If the introduction of moreexplicit diagnostic criteria would have promoted a morerestricted use of a diagnostic category, this should bereflected in the admission rates. The examination of thenumber of annual admissions, however, does not revealsignificant changes for schizophrenia following theintroduction of ICD-10, nor a decrease of schizophreniaand a crossover to other less specified psychoticdisorders. This is not striking, considering that a highrate of diagnostic agreement between ICD-9 and ICD-10 codes for narrowly defined schizophrenia – as usedin this analysis by allocating acute and transient as wellas schizo-affective disorders to the ‘other psychosis'category – has been established in validation studies(Jäger et al., 2003). We are therefore quite confident thatthe changes regarding the treatment prevalence ob-served after 1990 are not due to diagnostic artefacts.

4.5. Limitations

Several methodological limitations of this studyrequire a comment. First, our analysis was based onroutinely collected register data. We assume that thePsychiatric Register covers all hospital admissions inthe catchment area. Even so, hospital admissionstatistics do not permit statements on the true prevalenceof mental disorders. To address this problem further, apopulation-based survey would be necessary.

Second, our analysis was on an aggregate servicelevel; we did not assess inpatient service use on the

individual patient level. The question for instance,whether or not the shortened length of inpatient stay andthe increased number of admissions observed in recentyears are due to high rates of readmissions of the samesubjects, needs to be addressed in another analysis.Moreover, we have no information on the appropriate-ness of care for the individual patient, nor can weestimate the effects of these time trends on treatmentoutcomes or patient satisfaction. Further research isneeded to evaluate effects on these quality dimensions.

Finally, the analysis was confined to inpatienttreatment in psychiatric hospitals and did not examinepatterns of care on the interface between inpatient andoutpatient services. Regarding outpatient facilities, thereare no data that would encompass a comparable timeframe for such an analysis. Therefore, the question ofwhether or not a higher percentage of people withschizophrenia currently goes untreated or is cared for inother treatment settings, remains largely unaddressed bythis study. Considering that the chronically mentally ill,with their particular risk of dropping out of treatmentprogrammes, represent the most difficult patient group inoutpatient care (Honkonen et al., 2003; Lamb, 1993),special attention should be paid to ensuing difficulties inthe community, such as homelessness. Further studiestherefore would be essential to determine the conse-quences of such a reduction of inpatient treatment for theseverely mentally ill, in particular for people withschizophrenia.

4.6. Conclusions

Despite some limitations, this study clearly docu-ments that the decades-long downsizing of psychiatrichospitals has affected patients across mental diseasesquite differentially: the decline in hospital care formental disorders has mainly affected schizophreniapatients. This might be justified, if clinical outcomes,social adjustment and the quality of life were equal to orbetter in conjunction with a lower rate of inpatientservice use. From the perspective of social psychiatry,this is what was intended by promoting the idea of de-institutionalisation. Also from an economist's point ofview, it is worthwhile to reduce health care costs bysubstituting expensive hospital care with appropriate,but less costly community services.

The marked decline in the use of inpatient services,however, is a matter of concern as long as the‘therapeutic whereabouts’ of people with schizophrenia,i.e. their access to care and the appropriateness of theavailable psychiatric and medical treatment alternativesare not known. After all, what is at issue here – not only

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for clinical, but also for ethical reasons – are patients atthe more severe end of the spectrum of psychiatricdisorders, who are in most urgent need of care. Withal,the described trends are not specific to Switzerland (withits comprehensive systems of social security and healthcare), but have also been observed in countries withquite different health care systems.

To conclude, the present findings therefore bearimportant implications for both clinical practice andhealth policy: The lower prevalence of inpatienttreatment for people with psychosis accentuates theneed for efforts to ensure that all patients with severemental disorders receive adequate treatment and assis-tance, including continuity of care in communitysettings.

Role of the funding sourceThe psychiatric register data was funded by the Department of

Public Health of the Canton of Zurich (Gesundheitsdirektion desKanton Zürich, GD). The Research Unit for Clinical and SocialPsychiatry of the Psychiatric University Hospital Zurich is authorisedby the GD to do analyses for scientific purposes. The GD had nofurther role in the study design; in the collection; analysis andinterpretation of data; in the writing of the report; and in the decision tosubmit the paper for publication.

ContributorsBL and CN designed the study; BL and WRmanaged the literature

searches and analyses; BL and CN undertook the statistical analyses;BL wrote the first draft of the manuscript; all authors contributed toand have approved the final manuscript.

Conflict of interestAll authors declare that they have no conflicts of interest.

AcknowledgementNone.

Appendix A. Supplementary data

Supplementary data associated with this article canbe found, in the online version, at doi:10.1016/j.schres.2007.07.006.

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