Schanda H, Stompe T, Ortwein-Swoboda G
Psychiatric University Clinic Vienna, 18-20, Währinger Gürtel, 1090 Vienna, Austria.
Eur Psychiatry. 2009 Sep;24(6):365-72. doi: 10.1016/j.eurpsy.2009.07.006. Epub 2009 Aug 29.
During recent decades, there has been a substantial increase in admissions to forensic mental hospitals in several European countries. It is not known if reforms implemented in mental health policies and practices are responsible for this development.
Our study examined the development of mental health care in Austria and the incidence and prevalence of mentally disordered offenders judged not guilty by reason of insanity (NGRI).
We analysed data on service provision and data from criminal statistics between 1970 and 2008 from several national sources.
During the first decade when reforms to mental health practice were implemented, the incidence and prevalence of offenders judged NGRI remained unchanged, despite a reduction of mental hospital beds by nearly 50% and little outpatient care. Surprisingly, the enormous increase in admissions to forensic inpatient treatment began in Austria only after community mental health services were rolled out across the country in the 1990s. This increase was primarily due to admissions of patients who had committed less severe offences, while rates of those who had committed homicide remained unchanged.
Our results cannot be explained by details of the reforms such as the downsizing of mental hospitals or a lack of outpatient facilities, nor by changes to criminal sentencing. Rather, the results provide evidence of an increasingly inadequate provision of comprehensive care for "difficult" but not extremely dangerous psychotic patients living in the community. This may result from the attitudes of mental health professionals who have become less inclined to integrate aggressive behaviour into their understanding of psychosis. As a consequence, increasing numbers of "difficult" patients end up in forensic psychiatric institutions. This development, which can be observed in nearly all European countries, raises concerns with regard to efforts to destigmatize both patients and psychiatry.
在最近几十年里，欧洲几个国家法医精神病医院的收治人数大幅增加。尚不清楚心理健康政策和实践中实施的改革是否是这一发展趋势的原因。
我们的研究考察了奥地利心理健康护理的发展情况，以及因精神错乱而被判无罪（NGRI）的精神错乱罪犯的发病率和患病率。
我们分析了1970年至2008年期间来自几个国家来源的服务提供数据和刑事统计数据。
在实施心理健康实践改革的头十年里，尽管精神病院床位减少了近50%且门诊护理很少，但被判NGRI的罪犯的发病率和患病率保持不变。令人惊讶的是，直到20世纪90年代奥地利在全国范围内推出社区心理健康服务后，法医住院治疗的收治人数才开始大幅增加。这种增加主要是由于较轻罪行患者的收治，而杀人犯的收治率保持不变。
我们的结果无法用改革细节来解释，比如精神病院规模缩小或门诊设施不足，也无法用刑事量刑的变化来解释。相反，结果表明，为生活在社区中的“棘手”但并非极度危险的精神病患者提供全面护理的情况越来越不足。这可能是由于心理健康专业人员的态度所致，他们越来越不愿意将攻击性行为纳入对精神病的理解中。因此，越来越多的“棘手”患者最终进入法医精神病机构。这种在几乎所有欧洲国家都能观察到的发展趋势，引发了对消除患者和精神病学污名化努力的担忧。
