Durées d'hospitalisation des patients souffrant de schizophrénie : implication des systèmes de soin et conséquences médicoéconomiques

A striking reduction in hospital beds can be seen as the defining characteristic of mental health services in many western countries during the last 30 years. The politic of shortening hospital stays for persons with psychosis has been questioned by a number of authors. Studies of patients returning to the community compared to those remaining in institutions show not only better quality of life and larger friendship networks, but also reductions in dependence on pharmacotherapies and lower mortality rates. An interesting comparison between three contrasting mental care systems in Holland, Italy and Australia concluded not surprisingly that hospital stays are shortest where community care is more developed, although long term hospitalization will always be required for a small number of very severe patients. The general conclusion was that shorter stays work best if and only if there is high quality community care which comes into play immediately on discharge. The central issue appears to be that the beneficial effects of short stays are modulated by conditions of discharge. That is, in the absence of a planned discharge policy, patients appear to be better off staying longer, in order that a structured rehabilitation plan may be put in place. The process of deinstitutionalisation has been driven by a variety of forces. One is to reduce costs, since hospital inpatient costs are very high. Generally, between one- and two-thirds of the total health care cost of schizophrenia is for hospitalization, even in countries that have already substantially reduced their inpatient provision. Recent years have seen a trend toward mental health services provided from community-based settings for defined catchment areas. The development of these services has a heavy cost, with the opening of replacement accommodation and other community facilities and large teams. While few patients or clinicians would contest today that a return to normal community life is preferable to institutionalization, the adoption of shorter hospital stays was not an evidence-based policy and no adequate evaluation study was ever put in place to predict the social, clinical and economic consequences of this widespread practice.