Dr. STEFAN PRIEBE PROFESSOR OF Social and Community Psychiatry London

The paper takes a historical perspective of mental health care reforms and begins with a summary of the history of modem psychiatry in Europe, in particular the mental health care reforms since the 1950s of the last century. In all major western European countries, de-institutionalisation has been' a dominating process, although the exact point of time, pace, methods and resulting community mental health services show substantial variation between countries. Arguments related to de-institutionalisation focussed on civil and human rights, therapeutic effectiveness, costs, potential negative effects for the patients concerned, and public safety. The paper will give an overview of the state of community mental health care in Europe, focussing on Germany and the United Kingdom as examples with very different health care systems.

Whilst de-institutionalisation may still be seen as on going, it has been argued that a new era of re-institutionalisation has already begun. Signs of re-institutionalisation are a rising number of forensic beds, increasing rates of involuntary admissions, initiatives to widen legislation for involuntary treatment, large and still rising numbers of places in residential care and supported housing, and the establishment of assertive outreach and early intervention services.Re-institutionalisation might reflect a tendency to split the traditional functions of psychiatry as an agency for social control and of therapeutic aspirations. In most European countries, there is an increasing provision of a wide range of available treatments for patients with mental disorders inside and outside the traditional medical care system. There also appears to be a significant risk that care for patients with severe mental illness and statutory .services becomes a second rate care that is unattractive to patients and staff alike.

The paper will discuss the impact of evidence-based medicine and post modernism for future developments and consider options for how policy makers and professionals might influence future changes. It will be suggested that - concerning patients with severe mental illness - initiatives for user empowerment, social inclusion and further de-institutionalisation pose chances to influence mental health care of the future against some more negative current trends.

PROFESSOR OF Social and Community Psychiatry London