Project results

Mental health services have undergone a major structural change in the last two decades, i.e. decentralisation of mental health services accompanied by deinstitutionalisation and downsizing of psychiatric hospitals. In this era of change, the MERTTU project aimed to examine municipal level effectiveness of mental health services provided for the working-age population.

The project performed a nationwide mapping of mental health using the standardised European Service Mapping Schedule. The use of mental health services was investigated by analysing the numbers of psychiatric inpatients, care days, admissions, referrals to compulsory care and mental health outpatient visits. Outcomes of interest included suicide mortality and premature retirement due to mental disorders.

The restructuring and downsizing of psychiatric hospitals was not associated with any increase in suicides immediately or one year postdischarge. Instead, the risk of these suicides decreased significantly during the reform. Our results indicate, in terms of post-discharge suicides, that the downsizing of psychiatric hospitals and the shortening hospitalisations has been a success. However, our results also show that more mentally ill young people end up in prison as the prison population diminishes. The mortality rate of young prisoners with a psychiatric history is alarmingly high. This reflects a failure of the mental health services in helping this vulnerable group of young delinquent men.

Clear differences were observed between municipalities in organisation of mental health services and diversity of service delivery. Large cities offered the broadest range of services; in fact, in order for an area to be able to provide diversified services it should have a sufficient population base. Generally, there was a lack of diversity of mental health services provided. No alternatives for traditional hospital acute care are usually available. Outpatient services are mostly traditional permanent services by appointment, although there is a need for more diversified advanced mobile and emergency outpatient services. Organised day activities were also in rather short supply.

The most common administrative change in mental health services has been the complete or partial transfer of psychiatric outpatient services from specialised health-care units to municipal health centres. This change is reported in more than half of the respondent municipalities. Our results indicate that the change has increased co-operation between different service sectors in the municipalities, whereas it has not created diversity in mental health services.

Our results indicate that despite the long-standing efforts to further develop outpatient care, the diversity of mental health services is still unsatisfactory in many municipalities. The emphasis on inpatient care is still prevalent and outpatient services have not developed in the desired direction. Finland still has areas where determined efforts should be undertaken to reduce inpatient care and to reallocate resources to psychiatric outpatient care. 24-hour service units outside hospitals should be increased, as well as organised day activities and mobile and emergency outpatient services. The restructuring of mental health services is still under way. The development of mental health work and services will continue to pose a great challenge to municipalities.