Homesick: residential and care patterns in patients with severe mental illness
Mooij et al. BMC Psychiatry
Homesick: residential and care patterns in patients with severe mental illness
Liselotte D. de Mooij 0
Martijn Kikkert 0
Nick M. Lommerse 0
Jan Theunissen 2
Mariken B. de Koning 1
Lieuwe de Haan 6
Aartjan T. F. Beekman 4 5
Pim W. R. A. Duurkoop 0
Jack J. M. Dekker 0 3
0 Arkin Research Department , Klaprozenweg 111, 1033 NN Amsterdam , The Netherlands
1 Arkin Department Mentrum , Baron G.A. Tindalstraat 27, 1019 TS Amsterdam , The Netherlands
2 GGZ inGeest Research Department , Arent Janszoon Ernststraat 1187, 1081 HL Amsterdam , The Netherlands
3 Vrije Universiteit Department Clinical Psychology , Van der Boechorststraat 1, 1081 BT Amsterdam , The Netherlands
4 GGZ inGeest , Arent Janszoon Ernststraat 1187, 1081 HL Amsterdam , The Netherlands
5 Vrije Universiteit Medical Centre Department Psychiatry , De Boelelaan 1117, 1081 HV Amsterdam , The Netherlands
6 Academic Medical Centre Department Early Psychosis , Meibergdreef 5, 1105 AZ Amsterdam-Zuidoost , The Netherlands
Background: Changes in the residential and care settings of patients with severe mental illness (SMI) are a concern because of the large variety of possible negative consequences. This study describes patterns of changes in the residential and care settings of SMI patients and explores associations between these changes, sociodemographics, and clinical characteristics. Methods: From January 2006 to January 2012, all data relating to changes in residential and/or care setting by SMI patients (N = 262) were collected from electronic case files. Data covering psychopathology, substance use, and medication adherence were assessed in 2006. Results: There were more changes in the residential than in the care setting. In 6 years, only 22% of our sample did not move, 23% changed residence once, 19% twice, 10% three times, and 26% four or more times. Substance use predicted changes of care and/or residential setting and rehospitalisation. The severity of negative symptoms predicted rehospitalisation and duration of hospitalisation. Disorganisation symptoms predicted the duration of hospitalisation. Conclusions: A majority of patients with SMI changed residential and/or care settings several times in 6 years. Patients with substance use or severe negative and disorganisation symptoms may need more intensive and customised treatment. Further research is needed to investigate prevention programmes for highly-frequent movers.
Changes of residential setting; Changes of care setting; Changes in severe mental illness; Address changes; Hospitalisation; Revolving door
The mental health-care system aims to allocate
patients to the most appropriate house setting where
they can stay for a long time. Although this seems
straightforward, studies show that patients change
address frequently [1–3]. Residential stability, the
frequency in which one changes address, is an important
determinant of quality of life in people with SMI and
it is often a pre-condition for effective treatment and
rehabilitation [4–6]. Instability in this domain is therefore
stressful, and it can disrupt the continuity of treatment
and cause social isolation [4, 7] or relapse .
Residential changes are often a consequence of a
change in care setting. Care setting refers to the type of
care and can be generally divided into outpatient care
for independently living patients, sheltered housing,
and psychiatric admission. Changing from one care
setting to another usually involves changing residence too.
Allocating patients to another care setting is related to
changing personal needs and abilities, but may also be
associated with efforts to cut psychiatric beds in mental
health care, which is an important goal in the Western
world. Sheltered housing and outpatient care are used
as alternatives to long-term psychiatric admission [9–12].
This is demonstrated by the fact that the Netherlands,
with a population of 160,000 SMI patients, has 11,427
places in sheltered housing facilities and 18,499 in clinical
care facilities [13, 14]. The Netherlands therefore has
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much more intramural capacity than other Western
Most SMI patients in Western countries live
independently, either sharing a house with others such as
relatives or a partner or living alone . In general,
patients who live independently receive outpatient
treatment in an integrated approach comprising
psychological and psychiatric treatment, and supported
employment where possible. The primary treatment
goals are the stabilisation of symptoms, preventing
acute relapse and psychiatric hospitalisation, and
improvements in social inclusion and structural activities.
If independent housing is not feasible, SMI patients rely
on residential care in sheltered housing. Sheltered
housing often provides a range of housing options and
care intensity . If possible, patients are guided into
independent housing; otherwise, the goal is to stabilise
patients in long-term sheltered housing . When
sheltered housing is not an option, admission to a
psychiatric hospital will be necessary. If these patients
recover, independent housing or sheltered housing is
Some studies have examined the risk factors for
highly-frequent hospital admissions and discharges:
“revolving door” cases . The leading risk factors are
being male , being younger [1, 21], substance
abuse, and medication non-adherence [19, 22].
However, there is a relative paucity of studies looking at the
link between health and changes in the setting because
of a lack of detailed information about health status
and residential changes over time , particularly for
patients with SMI . Many studies have limited
follow-up periods of only 2 years or less .
Furthermore, these studies often report the number of changes
but failed to provide information about stay duration
or longer-term patterns . It is important to
understand when and why the mental health-care system
succeeds in providing patients with a stable home
situation. A clearer picture will allow us to adapt our
treatment and prevent frequent moves by SMI patients.
This study describes patterns of changes in care
settings and in residential mobility in SMI patients over a
follow-up period of 6 years. Secondly, we explored
potential sociodemographics and clinical risk factors of
(a) changes in care setting and (b) residential changes,
(c) number and (d) total duration of psychiatric
admissions. Hypotheses on patterns of change were based on
policy and objectives of the different care settings, and
on opinions of experts in this field such as clinicians and
policy makers. This allowed us to specify the following
patterns in care setting movements during the 6 years
follow up period: (a) 25% of patients in sheltered
housing will move to independent housing, (b) 65% of
patients in sheltered housing will be long-term residents,
and (c) 80% of inpatients will move to sheltered housing
or to independent housing. Finally, we expected patients
with more severe psychopathology and higher indices of
substance use to be more likely to change residence
and/or care setting more often. To the best of our
knowledge, this is the first study to examine changes of
residence, the relationship with the care setting and the
This longitudinal study conducted between 2005 and
2011 was based on a survey sample of SMI patients
treated by the mental health-care institutions Arkin,
GGZ InGeest, RIBW and HVO Querido in Amsterdam
(Netherlands). These institutions are jointly
responsible for the treatment of SMI patients residing in
Amsterdam. The principal objectives of the study were
to evaluate changes in quality of life, disease
characteristics, general functioning, care needs, social networks
and inclusion in society, and victimisation . The
current study is based on data relating to patient
movements between 01/01/2006 and 01/01/2012. Data
for severity of psychopathology, quality of life,
substance use, and medication adherence were assessed at
baseline in 2006. The study was approved by the Dutch
Association of Medical-Ethical Appraisal Committees
(NVMETC) for mental-health organisations.
Population, inclusion and exclusion criteria
Included patients fulfilled the criteria for a DSM-IV
diagnosis of schizophrenia, psychotic disorder, substance
use, severe mood or anxiety disorders and a history of
intensive mental health care during the previous 2 years.
Further inclusion criteria were: adequate mastery of
Dutch or English and residence in the Amsterdam district
for at least one year. Exclusion criteria included being
unable to understand questions or communicate, or being
unable or unwilling to give informed consent. Patients
with comorbid substance use disorders were also
included when they fulfilled these criteria . The
attending psychiatrist made the diagnoses.
In this study, 876 patients were randomly selected from
2846 patients treated by outpatient teams, or in
sheltered housing facilities and inpatient care facilities. The
aim was to include equal numbers of patients from the
three care settings. A total of 553 patients (63.1%) were
not included in the study. Some patients refused to
participate (25.9%); others did not participate for unknown
reasons (25.5%). Another 2.9% of the patients were
excluded because their clinicians deemed that inclusion
would affect their clinical status. Patients who were no
longer receiving treatment (8.9%) were also excluded.
The remaining 323 patients (37% of the
randomlyselected sample) were included in the study . Once
these patients had given written informed consent, the
assessment was performed in a face-to-face interview.
The interviews were conducted at the centre for mental
health care or, if preferred by the patient, at the patient’s
home. The interview took one and a half hours and the
patients received €15. The interviews were conducted by
a trained psychologist, research assistants, and a senior
researcher. The patients included were assessed again
for the purposes of follow-up 6 years after inclusion.
Data about residential mobility and care setting came
from electronic case files. Case notes were examined
by a psychologist and a senior researcher to identify all
address changes between 01/01/2006 and 01/01/2012,
and all changes in care settings; living independently,
sheltered housing and psychiatric hospital. Changes in
the residential setting were defined as physical moves
to another address, or a transfer to another department
or ward within a housing facility such as a sheltered
housing accommodation or a psychiatric hospital.
Temporary moves, lasting less than 14 days, were not
recorded as a change in address or care setting.
Patients can change address but remain in the same
care setting. For instance, a patient may move from one
sheltered housing facility to another. Moves of this kind
were registered as a residence change but not as a
change in care setting.
Severity of psychopathology was measured with the
Brief Psychiatric Rating Scale-Expanded (‘BPRS-E’)
[26, 27], which consists of 24 symptoms assessed on a
scale from 1 to 7. Items are grouped in four subscales
- positive symptoms, negative symptoms, depression
and disorganisation  - and scored on the basis of
observations during the interview and patient self-reports.
The BPRS-E is a sensitive instrument with good
interrater reliability (r = 0.74, p < .001) and validity [26, 28, 29].
Use of alcohol and drugs, substance dependence and
abuse were assessed with the Measurements in the
Addictions for Triage and Evaluation, or MATE ,
which assesses the use of psychoactive substances,
lifetime and current substance abuse and dependence on
the basis of DSM-IV . The MATE is a valid
instrument: inter-rater reliability ranges between 0.75 and
0.92, and interviewer reliability ranges from 0.34 to
0.73 . Patient files were also consulted to identify
patients with a DSM-IV diagnosis of substance abuse
or dependence. Patients were classified as having a
dual diagnosis when the MATE indicated substance
abuse or dependence or when a patient had already
been diagnosed with a substance use disorder.
Medication adherence was assessed with the Medication
Adherence Questionnaire (MAQ). The MAQ consists of
four yes/no questions about ways in which patients may
fail to take their prescribed medication: forgetting,
carelessness, stopping the medication when they feel better
and or stopping the medication because they believe it
makes them feel worse . Patients with a score ≤ 3 on
the MAQ were defined as non-adherent [32–34]. The
MAQ is a valid and reasonable instrument for detecting
non-adherence [32, 35].
Analyses were conducted using SPSS 22 (SPSS Inc.,
2009). Frequency distributions were used to describe the
data, chi-square analyses were used for categorical
variables and ANOVA analyses were used to analyse
continuous variables. When the expected cell count was too
low to perform a chi-square test, Fisher’s exact test was
used. A Kruskal-Wallis test was used when ANOVA
assumptions were violated and a Mann-Whitney test was
used when t-test assumptions were violated. Generalised
linear regression models (BACKSTEP method) were
used to derive prediction models for the following three
dependent variables: number of admissions, residential
movements, and number of hospitalisation days. This
analysis was considered appropriate since our data do
not match the assumptions for multivariate linear
regression models. The independent sociodemographic
and clinical variables were age, gender, ethnicity,
education, diagnosis, dual diagnosis, medication adherence,
positive symptoms, negative symptoms, depression and
anxiety, disorganisation, alcohol, cannabis, and hard
drugs. Independent variables were removed stepwise
during the statistical analyses when they did not
contribute to the fit.
The SMI cohort included 323 patients in 2006. In 2012,
patient files were not available or incomplete for 49
patients. Data for six patients were not included because
these patients were homeless for a longer period of time
and another six patients were excluded because they did
not give permission for the use of their patient files. As
a result, complete data about residential and care setting
changes were available for 262 patients. Patients were
grouped into the categories ‘living independently’,
‘sheltered housing’ and ‘psychiatric hospital’ on the basis of
their situation on 01–01–2006. In this sample, 100
patients were in a psychiatric hospital at baseline (87% in a
long-stay facility, 11% in a short-stay facility and 2% in
an acute facility). Ninety per cent of the patients living
in sheltered housing lived there with ten or more
patients and only 10% lived with nine patients or fewer.
Table 1 provides a summary of the main
sociodemographic and clinical characteristics.
As expected, the different care settings differed (P < .05)
at baseline in terms of diagnosis, symptom severity,
gender, education, diagnosis, cannabis and hard-drug use.
However, standardised residual values showed no
significant discrepancies for the different groups or for gender.
Patients living independently were more highly educated
than patients in a psychiatric hospital or sheltered housing
(χ2(4) = 13.9), and these patients were also more likely to
have mood disorders, anxiety disorders or axis II
disorders than inpatients (χ2(4) = 7.5). Patients in sheltered
housing were more often diagnosed with a dual
diagnosis than patients living independently and patients in a
psychiatric hospital (χ2(2) = 14.2). Inpatients had more
severe positive (H(2) = 16.1), negative (H(2) = 49.9) and
disorganisation (H(2) = 41.9) symptoms and a higher
total psychopathology score (H(2) = 31) than patients
living in sheltered housing or independently. Patients in
sheltered housing had more days of cannabis (H(2) = 9.8)
and hard-drugs (H(2) = 15.3) use in the past month than
patients living independently and patients in a psychiatric
Changes in care setting
Patterns in changes of care setting during the six-year
follow-up period were analysed to establish a clearer
picture of how patients switch between different settings
Age, mean (SD)
Ethnicity, n (%)
Education, n (%)b
Diagnosis, n (%)b
Schizophrenia and other psychotic disorders
Mood disorders/anxiety disorders/axis II disorders
Substance use disorders
Comorbid substance use disorders, n (%)
Symptoms (BPRS-E), mean (SD)c
Depression & Anxiety
Substance use (MATE), mean (SD)c,d
Hard drugs (cocaine, stimulants,
3,4-methylenedioxy- methamphetamine, opiates)
BPRS-E, Brief Psychiatric Rating Scale – Expanded; MATE Measurements in the Addictions for Triage and Evaluation
aP is the result of ANOVA for continuous variables and χ2 test for categorical variables. Significant findings at P = 0.05 or less are shown in italics
bExpected cell count too low (<5) for accurate chi-square, Fisher’s exact test was performed
cAssumptions of ANOVA were violated, Kruskal-Wallis test was performed. Number of days of substance use in the last month
(Fig. 1). Patients were assigned to independent housing,
sheltered housing, or psychiatric hospital groups on the
basis of their situation on 01–01–2006. These three
different settings were adopted as the starting point for
every change. Residential changes within the same type
of care setting were not included in these analyses. Some
patients were admitted to general hospitals for somatic
disorders (n = 30). These movements were not classified
as changes in care setting.
We studied the movement patterns between three
different types of care setting in each of the three
groups described above. Patients who lived in one type
of care setting throughout the follow-up period were
considered stable. As clearly shown in Fig. 1, the
patterns are similar in some of the groups described above:
the group of patients switching between independent
housing and a psychiatric hospital and patients
switching between a psychiatric hospital and sheltered housing.
Consequently, we conclude that there are six main
patterns of changes in care setting: 1. living independently
throughout the follow-up period, 2. sheltered housing, 3. a
psychiatric hospital, 4. switching between a psychiatric
hospital and living independently, 5. switching between
psychiatric hospitals and sheltered housing and 6. moving
from psychiatric hospitals to sheltered housing. Over a
period of 6 years, half the patients stayed in the same care
setting. Twenty-one per cent of SMI patients changed care
setting once, 11% twice, 5% three times, and 14% four or
Residential changes in were more frequent than
changes in care setting: 78% changed address one or
more times. Twenty-three per cent of patients with
SMI changed address once, 19% twice, 10% three times
and 26% four times or more. For each of the the six
main patterns derived from Fig. 1, we looked at
changesresidence, hospitalisation days, and number and type of
admissions (Table 2). Patients moving back and forth
between different care settings were included as a single
group. These patients had the highest rates for residence
changes, number of admissions and acute admissions.
Fig. 1 Changes between independent housing, psychiatric hospital and sheltered housing over 6 years (N = 262). a Patients moving back and
forth between a psychiatric hospital and independent housing. b Patients moving back and forth between independent housing and a
psychiatric hospital. c Patients moving back and forth between sheltered housing and a psychiatric hospital. d Patients moving back and forth
between a psychiatric hospital and sheltered housing. e Each type of care setting counts as 100%. f ‘Stable’ refers to patients who lived in one
type of care setting during the entire follow-up period. g ‘Not subdivided’ refers to patients who do not fit in any of the patterns shown in the
Type of admissionc
Mean Range SD Mean Range SD Mean Range
Acute stay Short stay Long stay
Patients in independent housing
Patients in a psychiatric hospital
Patients in sheltered housing
Patients moving back and forth
between different care settings
Patients moving from psychiatric
hospitals to sheltered housing
Patients moving from psychiatric
hospitals to independent housing
0.2 1365.1 318–2101 516.0 5.3
0.3 1298.2 437–1977 531.8 57.1
aChanges in care setting affecting fewer than 6% of patients are not presented in this table
bMoves to other address, changes in the type of care setting, or moves to another department in the same care setting were considered to be changes in the
cThe percentages are the proportion of patients with acute admissions, or patients admitted for short or long stays in psychiatric hospitals
d‘Stable’ refers to patients who spent the entire follow-up period in one type of care setting
To improve our understanding of which patients are
more likely to change care setting and residence
frequently, we performed four generalised linear model
(GLM) analyses (Table 3) to predict changes in care
setting, residential changes, number of admissions, and
days in a psychiatric hospital. More frequent changes in
the type of care setting were found in younger patients
with a Western background and substance use in the
last month. Patients with more admissions were younger
and had a Western background, substance use disorders,
and fewer negative symptoms. Finally, younger patients
with fewer mood disorders/anxiety disorders or axis II
disorders, with less medication non-adherence, with
more negative and disorganisation symptoms, and with
less alcohol and hard drugs use in the last month were
more likely to stay longer in psychiatric care facilities.
This study reports on unique data about patterns of
changes in residential and care settings in SMI patients.
Over a period of 6 years, 33% of patients living
independently switched from their own homes to a
psychiatric hospital, and vice-versa. Twenty-seven per cent of
patients in sheltered housing were admitted at least
once to a psychiatric hospital, often for a short
admission. Furthermore, 15% of the inpatients switched
between psychiatric hospitals, independent and
We hypothesized that 25% of patients in sheltered
housing would move to independent housing during the
6 years follow-up. As can be seen in Fig. 1, only 5% of
patients made this move. The majority (65%) of
sheltered housed patients were expected to stay in sheltered
homes. Although we found a slightly lower proportion
of 58%, our results confirm this hypothesis. We also
hypothesized that 80% of patients in psychiatric hospitals
would move to sheltered or independent housing. We
found that only 47% of inpatients moved successfully to
sheltered (38%) or independent (9%) housing.
The data yielded another important findings. We
found patients who lived stably in independent housing
(59%), sheltered housing (58%), or in psychiatric
hospitals (36%). However, over the period of 6 years we
studied, half of the patients failed to achieve care stability,
changing care setting one or more times. Residential
changes were even more frequent: almost 80% moved
one or more times and these patients had an average of
almost six address changes in 6 years. This is in sharp
contrast with the general population, which changes
address an average of once every 10 years . Those
patients who moved back and forth between different
care settings were most likely to change residence and
to have the highest number of short admissions.
Bearing in mind that an admission or an address change
may disrupt the continuity of care, the unfortunate
conclusion is that the patients most affected are
precisely those for whom continuity of care is most
important. However, many patients also have favourable,
stable, housing patterns.
Our results indicate that only limited numbers of
patients (5%) move from sheltered to independent housing,
contrary to the aims of the deinstitutionalisation process
Table 3 Results of GLM analyses for predictors of changes in care setting, residential changes, number of admissions, and days in a
psychiatric hospital between 01/01/2006 and 01/01/2012 (N = 262)
Dependent factor: Changes in care settinga,1
Dependent factor: Residential changesb,2
Dependent factor: Number of admissions3
Dependent factor: Days in psychiatric hospital4
aChanges of care setting include all moves between independent and sheltered housing, and psychiatric hospitals
bMoves to other address, or moves to another department or ward in the same care setting were considered to be changes in the residential setting
cCI = confidence interval
dSignificant findings at P = 0.05 or less are shown in italics
1Omnibus test; P = 0.000, 2Omnibus test; P = 0.024, 3Omnibus test; P = 0.001, 4Omnibus test; P = 0.000
. This is a remarkable finding since the goal of
sheltered housing has been to encourage patients to live as
independently as possible. Given our data, it can be
concluded that this goal is seldom achieved. One explanatory
factor could be the shortage of affordable independent
housing in Amsterdam. Another factor meriting
consideration is the desirability of maximising the numbers of
patients moving into independent housing: it is conceivable
that forcing a patient to live independently without
intensifying outpatient care could exacerbate a patient’s
After psychiatric admission, the majority of inpatients
were expected to move (back) to independent housing or
sheltered housing. There was indeed a relative large
outflow (38%) of patients from a psychiatric hospital to
sheltered housing. Most of these patients came from long stay
departments. Moving from a psychiatric hospital to
independent housing seems more difficult and was observed a
lot less than expected. Only 9% of inpatients moved
successfully to independent housing. Compared to inpatients
who moved to sheltered housing, these patients came
from an acute or short stay ward more often.
We found a relatively large group of patients living
stably in psychiatric hospitals. This conflicts with the
aims of deinstitutionalisation and is due to the fact that
Amsterdam, although less than in other parts of the
Netherlands, still has a relatively large number of
psychiatric beds [14, 37]. Instigated partly by changes in policy
objectives, regulations and funding, there is now
consensus among policy makers that mental health care should
shift more towards placing the care of psychiatric
patients in the community rather than in institutions.
Therefore a national innovation programme has recently
been developed to improve care of severe mental illness,
recovery of health, participation and personal identity,
and to help people with serious mental health issues
catch up with the rest of society .
Furthermore, our data identified modifiable predictors
for frequent care and residential changes. Substance use at
baseline predicted both re-hospitalisation, changes in care
setting and residential changes. In addition, more severe
negative symptoms predicted re-hospitalisation and longer
hospitalisation. Longer hospitalisation was predicted by
more severe disorganisation. These results are consistent
with other studies [3, 39–41]. Medication adherence and
less substance use were predictors for longer
hospitalisation. We think this is a spurious finding, since psychiatric
hospitals provide more supervision and guidance in the
areas of medication and the restriction of substance use.
Our findings also showed that patients who failed to
achieve stability were more frequently admitted to
shortstay hospitals than to long-stay hospitals. Revolving-door
patients may be admitted for shorter periods of time when
substance use or medication non-adherence are the main
cause of admission. When relief from acute intoxication
or the regulation of medication are achieved, most
patients will be ready to leave the hospital after a short
This study had several limitations. First, the
observational design means that we cannot demonstrate
causation. The other issue is that we included only
patients who receive psychiatric care; this may have
resulted in the underestimation of the prevalence of
changes. Moreover, we excluded patients who were
homeless because we could not track them during the
six-year study period. Homeless patients change care
setting most frequently. More than half of the randomly
selected patients were not included in our study. High
dropouts are a common problem in studies with
psychiatric patients and can reduce the external validity.
We believe that those who were not included will
generally be the more severely ill patients and they may
change care and residential setting even more often.
Furthermore, inpatients were over-represented in our
sample group (38%) by comparison with the general
SMI population (13%) . Our results may therefore
not be representative for the general SMI population.
Despite our elaborate assessment of all changes in care
and residential setting as registered in patient files,
some patient files may have been incomplete.
Incomplete information about addresses and accommodation
status codes are a feature of routine clinical records .
Conclusions and implications
Our study shows that half the patients underwent
multiple changes of care setting in 6 years. Approximately
half the patients in each subgroup were stable in terms
of the type of care setting. However, this does not mean
that they always lived at the same address. Patients living
stably in psychiatric hospitals and patients moving back
and forth between different care settings changed
residence most frequently.
Residential instability may be the consequence of how
mental health care is usually organized. For each care
setting different housing facilitites have been realized in
most western countries. Consequently, if a patient’s
needs change and a different form of housing is
required, one needs to move to another housing facility on
another address. Approximately half of patients with
schizophrenia will have an episodic course  which
may result in many address changes over time. A care
system which is able to provide a wider range of
psychiatric and housing support on the same address, would
make it possible for patients to stay in one place longer.
There are some developments in this direction such as
Intensive Home Treatment which allows patients to stay
in their homes during crisis instead of being admitted to
Unstable residential and care patterns were
predicted by substance use and the severity of negative
symptoms. It is important to note that frequent moves
are an underestimated stress factor and contribute to
psychological instability. Adapting to new living
conditions may contribute to stress, estrangement and an
impoverishment of the social network . Our
secondary analysis did indeed confirm that patients with
more re-hospitalisations had less frequent contact with
people in their social network.
Given the ongoing process of deinstitutionalisation in
most Western countries, we argue that more should be
done to prevent unstable residential and care patterns in
large groups of patients of the kind found in this study.
Deinstitutionalisation should therefore be accompanied
by flanking support programmes that can reduce the risk
associated with frequent changes of care and residence.
Our findings underline, for instance, the importance of
integrating treatment and the prevention of substance
use in treatment programmes.
Living independently is often seen as a desirable
outcome in SMI patients but our results indicate that this
aim should be reconsidered in some patients, who may
be better off in sheltered housing. One could also argue
that mental health care for those patients, who undergo
highly frequent admissions and residential changes,
needs improvement. This may imply that some patients
need more support to live successfully in a stable
situation. Future research should look at why the
residential and care patterns of some patients are so turbulent
and how we can help them to establish stable and safe
BPRS-E: The Brief Psychiatric Rating Scale-Expanded; GLM: Generalised linear
model; MAQ: Medication Adherence Questionnaire; MATE: Addictions for
Triage and Evaluation; SMI: Severe mental illness
The authors thank all patients and mental health workers for their participation in
this study. We also thank Pim Duurkoop for his contribution to the data collection.
Availability of data and materials
As our data contained personal addresses/postal codes and health locations,
the raw data is not anonymous and might personally identify participants.
Therefore, raw data will not be made publically available.
Conceived the study: LD, MK, JD, MK, JT, MK, LH, AB, PD, JD. Designed the
assessment: MK, JD, JT. Carried out the data acquisition: LD, NL, PD. Drafted
the manuscript: LD. All authors read and approved the final manuscript.
The authors declare that they have no competing interests and they report
no financial relationships with commercial interests.
Ethics approval and consent to participate
The study was approved by the Dutch Association of Medical-Ethical Appraisal
Committees (NVMETC) for mental-health organisations. All participants were
provided with a participant information sheet and provided their signed
informed consent to participate in the study.
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