Appendix Comparative Deinstitutionalization Data Set – Codebook and Source Information
Description and Aims
This original database compares the process of psychiatric deinstitutionalization across 16 advanced economies with standardized, cross-national data from 1935 to at least 1990. As such, the data allows researchers to better understand the varying patterns of change in mental health care services over time as well as across countries.
As noted in Chapter 2, these countries are the first movers: societies whose early industrialization prompted the rise of the asylum, and whose extraordinary economic prosperity in the 20th century prompted its decline. Their national trends eventually set the international standard. To quantitatively delineate the universe of cases, I selected the most affluent democracies of the postwar period by examining their GDP per capita in 1960. According to the Comparative Welfare States Data Set (Brady et al. Reference Brady, Huber and Stephens2020), this indicator exceeded $12,000 in all countries, averaging around $17,000 in the set (standard deviation: about $4,000, all amounts standardized to contemporary USD; per BLS 2023). A relatively tight distribution, the next wealthiest country on the list (Italy) is almost a full standard deviation (0.7) less than the lowest unit in the range (Finland). Italy is nonetheless included because its 1978 Basaglia law gained attention as a bellwether of the international deinstitutionalization movement (Donnelly Reference Donnelly1992; Foot Reference Foot2015). Moreover, the law was a byproduct of earlier deinstitutionalization trends in the more industrialized North, which paralleled those of the other countries in this study. Italy’s spatially unequitable economic development likely delayed the law’s adoption at the national level. Countries with a population less than 1 million (micro-states) are excluded from the dataset (e.g., Luxembourg).
The dates of the data set span the full-time period during which mental health services transformed. The Second World War was a major turning point in the history of social welfare: The spirit of reform, combined with an economic boom, made for considerable policy changes, especially in the area of mental health. The development of social insurance funds, the increasing medicalization of psychiatry, and the return of war veterans facing profound psychological distress prompted reforms in the asylum. Because this flurry of activity occurred after the war, the series begins in 1935 to obtain a baseline measure of institutionalization. Tracking the series through 1990 captures the effects of the welfare retrenchment since the economic crises of the 1970s, which also prompted reductions in psychiatric care supply. Data on psychiatric hospitals and residents, for example, were much more prevalent in the earlier period than in the later period, when countries started to replace those numbers with data on psychiatric beds and inpatients.
To obtain the requisite information, a research team surveyed national statistical yearbooks for the full universe of cases from 1935 to 1990, supplemented by other official government reports as well as data from the WHO and OECD. Data was recorded in approximately five-year increments, or as otherwise noted. The series mostly describes changes in public (not private) institutions. Country-by-country details about context-specific definitions, measurement, data collection patterns, and source information are provided in the following table.
| Country | Residents | Mental hospitals | Psychiatric beds | Comments | Source(s) |
|---|---|---|---|---|---|
| Australia | 1935–41: Number of patients on books at end of year in hospitals for the insane 1945–60: Number of patients on books at end of year in mental hospitals 1965: Mental patients on the register at June 30 1970–75 Number of inpatients at end of year in mental health institutions 2005: Estimated number of residents in residential mental health care | 1935–41: Number of hospitals for the insane 1945–60: Number of mental hospitals 1965–74: Psychiatric centers, psychiatric hospitals, and mental hospitals (excludes institutions labeled “private,” in particular the New South Wales private psychiatric centers) 1990–2012: (Number of) public psychiatric hospitals | 1935–41: Number of beds and cots in hospitals for the insane 1945–60: Number of beds and cots in mental hospitals 1965–70: Number of beds and cots for patients in mental health inpatient institutions 1990–2000: Available beds in public psychiatric hospitals 2005: Mental health hospital beds in public psychiatric hospitals 2012: Beds in public psychiatric hospitals | Since most of the earlier data (1935–60) appear to exclude data on private institutions, we continued to exclude private institutions for subsequent years (1965–2012). Data for private institutions, though, is available for most of those more recent years as well. | Commonwealth Bureau of Census and Statistics, Official Yearbook of the Commonwealth of Australia (1935–2012). |
| Austria | Series unavailable | 1937: We manually counted all mental hospitals (public and private) in the source book 1951–66: Institutions for nervous and mental illnesses (observations include those both with and without public rights) 1976–90: Institutions for nervous and mental illnesses | 1937: We manually counted all beds in the mental hospitals (public and private) identified in the source book 1951–66: Beds in institutions for nervous and mental illnesses (observations include those both with and without public rights) 1976–90: Beds in institutions for nervous and mental illnesses | Since most of the more recent data (1976–90) appear to include data on private institutions, we also included data on private institutions for previous years (1937–66). Data on public institutions only is nonetheless available for most of those earlier years as well. | Ilberg, G., and H. Laehr (Eds.). 1937. Die Anstalten für Geisteskranke, Nervenkranke, Schwachsinnige, Epileptische, Trunksüchtige usw. In Deutschland, Österreich und der Schweiz einschließlich der psychiatrischen und neurologischen wissenschaftlichen Institute. Berlin and Leipzig: Walter de Gruyter & Co. Österreichischen Staatsdruckerei, Statistisches Handbuch für die Republik Österreich (1950–90). |
| Belgium | 1935–60: Sick patients establishments for the mentally ill (closed services including the establishments of Geel and Lierneux) 1965–83: Patients in psychiatric establishments (closed service) | Series incomplete (missing 1935–60) | Series incomplete (missing 1935–60) | Institut national de statistique, Ministère des affaires économiques, Annuaire statistique de la Belgique (1935–95). | |
| Canada | 1935–55: (Total resident) patients in mental institutions (in Canada) at December 31 1959: Patients in public mental hospitals at December 31 1970–82: Average daily number of patients in public mental hospitals | 1935–45: All mental institutions except for private mental institutions (includes public hospitals, training schools, psychiatric hospitals, community and municipal institutions, and dominion hospitals classified as “mental institutions”) | 1935–45: Normal bed capacity in mental institutions in Canada 1950–75: Beds in public mental institutions 1978: Beds in (reporting) public mental hospitals on January 1 | Although data on private institutions is often available, we privileged the (more commonly) available data on public institutions. | Dominion Bureau of Statistics, The Canada Year Book (1935–90). |
| 1950: Public mental institutions 1955–75: Public mental hospitals 1978: (Reporting) public mental hospitals 1986: Number of mental hospitals (excludes Prince Edward Island, Yukon, and NW Territories; data for Quebec includes allied special, rehabilitation, and extended care hospitals) | |||||
| Denmark | Complete series not available | 1935: State mental hospitals 1945–75: State, municipal, and private mental (psychiatric) hospitals | 1945–75: Beds in state, municipal, and private mental (psychiatric) hospitals 1985–95: Beds in psychiatric hospitals, total | Danmarks Statistik, Statistisk Årbog. (1937–97). |
| Country | Residents | Mental hospitals | Psychiatric beds | Comments | Source(s) |
|---|---|---|---|---|---|
| Finland | 1935–55: Male and female mental defectives in state hospitals, communal hospitals, private hospitals, communal institutions, and private homes 1988: Since resident data is not available for the end of the series, we estimate it for this year. Average length of stay remained high in Finland (125.1 days this year), so we interpret the bed occupancy rate multiplied by the number of mental hospital beds as an acceptable, if imperfect, indicator of the resident population in this year | 1936–40: Total number of state, municipal, and private mental hospitals in cities and in the countryside 1945–90: Total number of state, communal, and private mental hospitals | 1935: Since bed data is not available for the beginning of the series, we estimate it for this year. In the years following the Second World War (1945–50), beds in mental hospitals accounted for about 30 percent (29.6–30.02 percent) of the total number of beds in Finland. The psychiatric bed estimate for 1935 is 30 percent of the total number of general and other hospital beds in that year. 1945–90: Number of beds in state, communal, and private mental hospitals | Although data is often subdivided by institutional type (e.g., state, communal, or private hospital; as well as charity and in-home care), it is not consistently so. We hence provide data for all psychiatric institutions, though most services are provided at the municipal (communal) level. Note also that the population residing in psychiatric care often doubles the number of psychiatric beds. The reason for this discrepancy is unclear; however, it appears that during this period some residential care was available in non-hospital institutions (e.g., charities and private homes). | Tilastokeskus, Suomen tilastollinen vuosikirja (1935–2000). |
| France | 1935–75: Number of patients hospitalized in psychiatric establishments on December 31 of each year 1985–88: Patients (malades) present on January 1 (in psychiatric establishments) | 1933: National and departmental asylums, hospices, and private asylums 1955: Psychiatric hospitals 1964–96: Public psychiatric hospitals (or specialized psychiatric hospital center) and private psychiatric hospitals acting as public institutions | 1935: We infer this observation from Lauzier and Lafage (Reference Lauzier and Lafage1958, 439), who note that 1,740 psychiatric beds had been added since the interwar period. We hence subtract that number from the 1955 observation to estimate the number of psychiatric beds in this year 1955: Number of beds in psychiatric hospitals 1970–75: Number of beds in public psychiatric hospitals (or specialized psychiatric hospital centers), psychiatric wards in public hospitals, private sanatoriums (maisons de santé), and private psychiatric hospitals acting as public institutions | Institut national de la statistique et des études économiques. Annuaire statistique de la France (1935–2007). Lauzier and Lafage (Reference Lauzier and Lafage1958) Meslé and Vallin (Reference Meslé and Vallin1981) | |
| 1985–96: Number of beds in public psychiatric hospitals (or specialized psychiatric hospital centers), private sanatoriums (maisons de santé), and private psychiatric hospitals acting as public institutions | |||||
| Germany | 1935: Inpatients (Krankenbestand) on December 31 in hospitals for the mentally ill and epileptics 1995: Cases in psychiatric facilities (preventive and rehabilitative care), excludes neurology, psychosomatic, and addiction care | 1935: Sanatoriums and nursing homes for the mentally ill, epileptics, etc., including those who also suffer from nervous disorders, etc. 1995: Total number of hospitals specializing in psychiatry or psychiatry and neurological beds | 1935: Number of regular hospital beds at the end of the year for hospitals for the mentally ill and epileptics 1995: Beds in total number of hospitals specializing in psychiatry or psychiatry and neurological beds | Although the source reports data on the Federal Republic of Germany (West Germany) during the postwar period, it excludes information on the German Democratic Republic (East Germany) during this time. For this reason, we include only data from periods of unification (before and after the split). | Statistischen Reichsamt/ Statistischen Bundesamtes, Statistisches Jahrbuch für Das Deutsche Reich/ Statistisches Jahrbuch für die Bundesrepublik Deutschland (1935–95). |
| Country | Residents | Mental hospitals | Psychiatric beds | Comments | Source(s) |
|---|---|---|---|---|---|
| Great Britain | 1938: Registered persons of unsound mind at January 1 in Institutions provided by County and Borough Councils under the Lunacy Acts in England, Wales, and Scotland (excludes state criminal lunatic asylums and other institutions under the Poor Laws, since their purposes went beyond the medical and custodial to include punishment, commodification, etc.; also excludes data on Northern Ireland for better comparability with the latter part of the series) | Complete series unavailable | Complete series unavailable | See Jones (Reference Jones, Bean and MacPherson1983) on the challenges of collecting historical data on mental health services in the United Kingdom of Great Britain and Northern Ireland. In brief, the Mental Health Act of 1959 significantly altered the basis on which mental health statistics were gathered, rendering the statistical figures before and after that year difficult to compare. Moreover, tables on key variables are often aggregated and disaggregated in succeeding years. For example, sometimes Wales and England are presented together, other times not; “psychiatric services” may or may not include services for the mentally handicapped, and children and people over the age of 65 are sometimes included or excluded; | Central Statistical Office, Annual Abstract of Statistics (1938–90). Government Statistical Service. Health and Personal Social Services Statistics for England (1978). Jones (Reference Jones, Bean and MacPherson1983). |
| 1955: Inpatient average daily occupation of beds (mental and mentally deficient) in England, Wales, and Scotland 1960–85: Average daily occupation of beds in psychiatric departments in England and Wales; mental and mentally deficient in Scotland | some localities mix the data on the mentally ill with data those with physical disabilities, mental disabilities, or even lucid but frail elderly. Additional data collection challenges arose after the late 1970s, when budgetary challenges stalled surveillance efforts. The last detailed Mental Health Inquiry for England and Wales was published in 1978 and only includes data up to then. Any other related publications either ceased publishing around this time as well, only base their information on the 1976 data, or give no mental health statistics at all. | ||||
| Italy | 1938–50: Mentally ill patients hospitalized in institutes of assistance on January 1 | 1955–74: Public neuropsychiatric hospitals 1980–90: Public psychiatric hospitals | 1955–74: Beds in public neuropsychiatric hospitals 1980–90: Beds in public psychiatric hospitals | Although data on private institutions is available for more recent years, we focused our data collection on public institutions, which has been more consistently available since the 1930s. | Ministero dell’interno, Direzione generale di statistica, Annuario statistico italiano (1935–2000). |
| 1957–74: Patients present at the beginning of the year in public neuropsychiatric hospitals 1980–90: Patients present at the beginning of the year in public psychiatric hospitals | |||||
| Netherlands | 1935–40: Total (population) on December 31 in institutions for the insane 1945: Total (population) under care (in institutions for the insane) | 1935–40: Number of institutions for the insane 1945: Number of mental hospitals 1953–64: Hospitals for mental defectives 1966–88: (Number of) mental hospitals | Complete series unavailable | Centraal Bureau Voor de Statistiek, Jaarcijfers voor Nederland (1940–90). | |
| 1950–60: (Population) Under care on December 31 in hospitals for mental defectives 1965–70: Patients in mental hospitals on December 31 1970–87: Inpatients in mental hospitals on December 31 | |||||
| New Zealand | 1935–50: Number of patients remaining at the end of the year in public mental hospitals and the (one) private mental hospital 1955: Number of patients resident and voluntary boarders in public mental hospitals and the private mental hospital at the end of the year | 1935–55: Public mental hospitals and the (one) private mental hospital 1960–65: Mental hospitals (excludes hospitals and training schools for the mentally subnormal) 1990: Psychiatric hospitals | Complete series unavailable | Department of Statistics, New Zealand Official Yearbook (1935–90). | |
| 1960–65: Average number of resident patients and voluntary boarders on the register (in mental hospitals) 1974–80: Average number of people resident in psychiatric hospitals during year 1985–90: Average number of resident patients in psychiatric hospitals and hospitals for the mentally handicapped |
| Country | Residents | Mental hospitals | Psychiatric beds | Comments | Source(s) |
|---|---|---|---|---|---|
| Norway | 1935: Mental health patients treated at asylums (remaining at end of year) 1945: Mental health patients at mental health hospitals at the end of the year | 1935: Mental asylums 1945–55: Mental hospitals 1965–85: Psychiatric hospitals (excludes psychiatric nursing homes) | 1935: Beds in mental asylums 1945–55: Beds in mental hospitals 1965–85: Beds in psychiatric hospitals (excludes psychiatric nursing homes) | As Chapter 6 discusses, in the postwar period Norway expanded custodial care for elderly psychiatric patients by constructing psychiatric nursing homes. For cross-national consistency (and since these nursing homes served a primarily custodial, | Statistisk sentralbyrå, Statistisk årbok for Norge (1937–97). |
| 1965–75: Patients in psychiatric hospitals (in total) at the end of the year 1985: Patient population in psychiatric hospitals, clinic, sanatoria (including the state clinic for drug addicts) at the end of the year | 1995: Beds in psychiatric hospitals (including psychiatric departments in somatic hospitals and psychiatric clinics; excludes beds in psychiatric nursing homes) | not medical, function), we excluded data on those institutions, beds, and residents. | |||
| Sweden | Complete series not available | 1935–45: Civilian health care facilities – state mental hospitals 1965: State mental hospitals for mentally diseased 1975: Mental hospitals | 1935–45: Civilian health care facilities – state mental hospitals: beds 1965: State mental hospitals for mentally diseased: beds 1975: Mental hospitals: beds | Although Sweden developed other forms of institutional care in the postwar period, this series presents data on state mental hospitals, which was consistently collected during the period of interest and provided the largest portion of mental health care during that time. | SCB-Statistiska centralbyrän. Statistisk årsbok för Sverige (1937–97). |
| Switzerland | 1936–65: Patients treated in specialized establishments for mental and nervous illness | 1936–56: Specialized establishments for patients with mental and nervous illness | 1936–65: Beds in specialized establishments for mental and nervous illness | Office fédéral de la statistique. Annuaire statistique de la Suisse (1935–98). | |
| 1983: Hospitalized patients in psychiatric clinics | 1965–75: Institutions/ establishments for mental illness 1983: University psychiatric clinics and other psychiatric clinics | 1975: Number of beds for the sick in establishments for the mentally ill 1983: Beds in university psychiatric clinics and other psychiatric clinics 1995: Beds in psychiatric clinics | |||
| United States | 1935: Patients present on January 1 in state hospitals for mental disease 1950–85: Resident patients at end of year in state and county mental (care) hospitals | 1938: State, county, and city hospitals 1950–2000: State and county mental hospitals | Complete series not available | For consistency, our data collection focuses on the population in and absolute number of state and county mental hospitals, the historical anchor of the US mental health system. Some data is periodically available on other public institutions (e.g., federal institutions, veterans; facilities) and private hospitals as well. | National Institute of Mental Health. Patients in mental institutions (1938). US Department of Commerce, Statistical Abstract of the United States (1935–2000). |
| President’s Commission on Mental Health. Task Panel Reports, Volume 2 (1978). US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. Mental Health, United States (2002). |
Open access