Demographic data refer to vital living conditions, including information on marital status, education, housing and disposal income. In the section psychiatric and social interventions, we present data on both in- and out-patient care provided by the county council and interventions from social services.
Demographic and Economic Data
There are small changes in the survey group regarding marital status, education, housing and economic status during the studied period 2004–2013, see Table 2.
Some 10% of the men and 12% of the women were married over the period. This figure is about one-third compared to the general population in Sweden, where about 33% of the population were married during the same time. The marital status did not change significantly, and the changes that occurred during the 10-year period were an increase in the proportion of divorce and the proportion of those who became a widow/widower. These changes can probably be explained by increasing age.
The level of education was stable during the studied period, and few persons continued to study after 2004. Compared to the general population in Sweden, fewer persons in our studied group (29%) had post upper-secondary education; the corresponding figure for the Swedish population was 43%.
A majority lived in flats, which is most common in this area of Stockholm, throughout the period. In 2004, 6% were residing in supported housing, distributed between men 8% and women 5%. In 2013, the figure had increased to 13% for both sexes. Homelessness is rare in Sweden, especially in groups with SMI (The National Board of Health and Welfare 2017).
The disposal income was based on persons younger than 65 and were thus in working age. The proportion of women and men who had some form of employment income decreased between 2004 and 2013. The number of women declined from 193 (32%) in 2004 to 133 (22%) in 2013. The corresponding figures for men were 161 (26%) in 2004 and 125 (20%) in 2013. The most common source of income was early retirement pension due to disability or sickness. This was the fact for 61% of the women and 66% of the men in 2004, with few changes during the 10-year period. Other sources of income were old age pension, sickness benefit, salary and social allowance. The most salient change during the 10-year period was in social allowance, which declined with 55% for the women and with 63% for the men.
The disposable income, in median value, increased slightly during the 10-year period, from 114,000 to 121,000 SEK for women and from 110,000 to 115,000 for men. By comparison, the average disposable income in Stockholm was more than threefold in 2013.
Psychiatric Care and Social Interventions
Psychiatric care is defined in this paper as in-patient care at psychiatric clinics and out-patient care by psychiatric teams. All psychiatric in-patient care in Sweden was provided by the county council at that time. This holds for out-patient care as well but it can be accomplished by private actors, although they are in a minority. Out-patient care could either be performed at the patient’s home, by home-visiting teams or, more commonly, at the psychiatric out-patient care unit where the patient visits a nurse, psychologist and/or a psychiatrist after an appointment.
Social interventions are defined as support in daily living, including living in supported housing, home help service, occupational support and financial support. Other interventions include transportation service, companion service, etc. The social interventions are provided by teams specialised in working with persons with SMI arranged by the municipalities.
Utilisation of Psychiatric In- and Out-patient Care
During the 10-year period, both in- and out-patient care were reduced. Admittance to psychiatric clinics decreased in the first 4 years 2004–2007, and then remained at a level where 15–18% of the studied population have at least one period of in-patient care per year.
A majority of the persons that were hospitalised had short periods of treatment. On average, each year, 9% of the persons that were hospitalised had treatment durations between 3 and 6 months per year, 5% between 7 and 11 months and 2% the whole year. Being hospitalised the whole year was three times more common among men compared to women; otherwise, there were no differences between the sexes. These percentages did not differ during the 10 years investigated.
All forms of psychiatric, both in- and out-patient, care decreased continuously as seen in Fig. 1. Most notable is the decrease in out-patient care, where the visits were reduced by some 30%. There were no differences between the sexes. There were no major organisational changes in psychiatric care in the region that can affect the numbers in the period 2004–2013.
Prescription of Neuroleptics
Drug treatment is a cornerstone in the treatment for psychosis, and Swedish national guidelines advocate for treatment using neuroleptics in cases of psychosis diagnosis. The national register for medication started in 2005; consequently, there are no data for 2004. The number of persons prescribed with neuroleptics increased from 62% in 2005 to 77% in 2010 and remained at this level.
There are a number of social services interventions available for persons with physical and psychiatric disabilities. Social services are governed by the Social Service Act, and include the most comprehensive of supported housing accommodation, where staff is available 24 h a day. Other interventions include, for example, mobility service, food delivery, companion, personal assistants and emergency medical alarm. In this article, we also address financial support as an important intervention for people with SMI. Poverty is often related to severe psychiatric problems and has a direct impact on the person’s well-being and psychiatric symptoms. In 2004, financial support was an important source of income, and 20% of the investigated population had such support at that time. Ten years later, in 2013, this figure had decreased to 7%, which may be due to the fact that more persons reached the age of 65 years and then received retirement pension. Over the 10-year period, more men than women had financial support; however, in 2013, the figure was 7% for both sexes.
Residing in supported housing increased, especially among men. Nearly twice as many men lived in supported housing compared to women in 2013. Supported housing and employment support decreased, while home services remained at the same level (Fig. 2).
Probation Services and Forensic Psychiatry
A constantly relevant issue is the relation between SMI and crime and if reduced in-patient care implies that people with SMI have instead been sentenced to imprisonment or to forensic psychiatry. According to Swedish law, no person may be sentenced to jail if the crime was committed under the influence of a serious mental disorder, and the court is obliged to sentence the person to care in forensic psychiatry. The crime should in those cases be of a kind that prison would be a "normal" sanction (Table 3).
There are small differences in the number of sanctions during the investigated 10-year period. In total, 18 people have been sentenced to jail: 17 men and 1 woman. Nine persons have more than one prison sentence during this period. During the period, 27 people were sentenced to forensic psychiatry: 24 men and three women. One person has been sentenced to forensic psychiatry twice and two people have been sentenced to both prison and forensic psychiatry. In all, 43 persons, 39 men and 4 women, have been sentenced to prison and/or forensic psychiatry, which represents 3.5% of the studied population.
How Many Have No Contact With Either Psychiatric Care or Social Services?
In this study, we investigate how many people who have an ongoing need, provided by the county council psychiatry and/or municipal social services, or the reverse, have no care or contact at all, as shown in Table 4. We chose to measure how many of the follow-up population who had no periods of institutional care during the last five and two years of the studied 10-year period. In the concept of institutional care, we include in-patient care at psychiatric clinics and living in supported housing. We also have the same cut-off periods regarding how many that had no interventions at all.
As seen in Table 4, a majority of the follow-up population had no periods of institutional care during the last five (51%) and two years (63%), respectively. When we looked at the figures regarding no interventions at all, we found that 14% had no interventions during the last five years of the 10-year period and 22% the last two years. With no interventions, we mean no periods of in-patient care, contact with psychiatric open-care units or interventions from social services. More women than men had periods without institutional care, but when it comes to no interventions at all, the difference between the sexes decreases.