Institutionalization, Deinstitutionalization, and the Penrose Hypothesis

  • Adrian P. Mundt
  • Norbert KonradEmail author


Psychiatry began to emerge as a medical specialty and science after the French revolution with the transinstitutionalization of mentally ill from imprisonment to psychiatric hospitals. Psychiatric hospitals grew in size, many of them housing thousands of people by the end of the nineteenth century. The twentieth century was characterized by psychiatric reforms shifting services from institutions to outpatient care settings and removing large numbers of psychiatric beds. In the year 1939, the British psychiatrist Penrose pointed to a possible inverse relationship between psychiatric bed numbers and prison population rates. Prison populations were on the rise throughout the twentieth century in most countries. By the end of the twentieth century, worries about a transinstitutionalization of people from psychiatric institutions to penal justice institutions came up again. In the beginning of the twenty-first century, the Penrose hypothesis was in the focus of scientific interest again. Studies from Western Europe and South America point to a significant inverse relationship of psychiatric bed numbers and prison population rates in longitudinal data.


Forensic psychiatry Deinstitutionalization Penrose hypothesis Mentally ill offender Transinstitutionalization 



APM was supported by CONICYT, FONDECYT Regular 1160260.


  1. 1.
    Pelletier JF, Davidson L. At the very roots of psychiatry as a new medical specialty: the Pinel-Pussin partnership. Sante Ment Que. 2015;40:19–33.CrossRefPubMedGoogle Scholar
  2. 2.
    Sadler JZ. Vice and mental disorders. In: Fulford B, Davies M, Gipps R, et al., editors. Oxford textbook of philosophy and psychiatry. Oxford: Oxford University Press; 2013. p. 451–80.Google Scholar
  3. 3.
    Wilbraham L. Reconstructing Harry: a genealogical study of a colonial family ‘inside’ and ‘outside’ the Grahamstown Asylum, 1888–1918. Med Hist. 2014;58:166–87. Scholar
  4. 4.
    Nardi AE, Silva AC, Hallak JE, Crippa JA. A humanistic gift from the Brazilian emperor D. Pedro II (1825–1891) to the Brazilian nation: the first lunatic asylum in Latin America. Arq Neuropsiquiatr. 2013;71:125–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Piddock S. Possibilities and realities: South Australia’s asylums in the 19th century. Australas Psychiatry. 2004;12:172–5. Scholar
  6. 6.
    Edginton B. Moral architecture: the influence of the York retreat on asylum design. Health Place. 1997;3:91–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Kosky R. From morality to madness: a reappraisal of the asylum movement in psychiatry 1800–1940. Aust N Z J Psychiatry. 1986;20:180–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Hunter JM, Shannon GW, Sambrook SL. Rings of madness: service areas of 19th century asylums in North America. Soc Sci Med. 1986;23:1033–50.CrossRefPubMedGoogle Scholar
  9. 9.
    Luchins AS. The rise and decline of the American asylum movement in the 19th century. J Psychol. 1988;122:471–86. Scholar
  10. 10.
    Weiss KJ. Asylum reform and the great comeuppance of 1894--or was it? J Nerv Ment Dis. 2011;199:631–8. Scholar
  11. 11.
    Engstrom EJ. History of psychiatry and its institutions. Curr Opin Psychiatry. 2012;25:486–91. Scholar
  12. 12.
    Penrose LS. Mental disease and crime: outline of a comparative study of European statistics. Br J Med Psychol. 1939;18:1–15.CrossRefGoogle Scholar
  13. 13.
    de Girolamo G, Barale F, Politi P, Fusar-Poli P. Franco Basaglia, 1924–1980. Am J Psychiatry. 2008;165:968. Scholar
  14. 14.
    Foot J. Franco Basaglia and the radical psychiatry movement in Italy, 1961–78. Crit Radic Soc Work. 2014;2:235–49. Scholar
  15. 15.
    Scheper-Hughes N, Lovell AM. Breaking the circuit of social control: lessons in public psychiatry from Italy and Franco Basaglia. Soc Sci Med. 1986;23:159–78.CrossRefPubMedGoogle Scholar
  16. 16.
    Papeschi R. The denial of the institution. A critical review of Franco Basaglia’s writings. Br J Psychiatry. 1985;146:247–54.CrossRefPubMedGoogle Scholar
  17. 17.
    Fusar-Poli P, Bruno D, Machado-De-Sousa JP, Crippa J. Franco Basaglia (1924–1980): three decades (1979–2009) as a bridge between the Italian and Brazilian mental health reform. Int J Soc Psychiatry. 2011;57:100–3. Scholar
  18. 18.
    Konrad N. Ethical issues on forensic-psychiatric examinations. Ethics Med Public Health. 2016;2:119–26. Scholar
  19. 19.
    Fakhoury W, Priebe S. Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare. Psychiatry. 2007;6:313–6. Scholar
  20. 20.
    Lamb HR, Weinberger LE. Decarceration of U.S. jails and prisons: where will persons with serious mental illness go? J Am Acad Psychiatry Law. 2014;42:489–94.PubMedGoogle Scholar
  21. 21.
    Turner T, Priebe S. Forget community care--reinstitutionalisation is here. Br J Psychiatry. 2002;181:253.CrossRefPubMedGoogle Scholar
  22. 22.
    Priebe S, Badesconyi A, Fioritti A, Hansson L, Kilian R, Torres-Gonzales F, Turner T, Wiersma D. Reinstitutionalisation in mental health care: comparison of data on service provision from six European countries. Br Med J. 2005;330:123–6.CrossRefGoogle Scholar
  23. 23.
    Kalapos MP. Penrose’s law: methodological challenges and call for data. Int J Law Psychiatry. 2016;49(Pt A):1–9. Scholar
  24. 24.
    Large MM, Nielssen O. The Penrose hypothesis in 2004: patient and prisoner numbers are positively correlated in low-and-middle income countries but are unrelated in high-income countries. Psychol Psychother. 2009;82:113–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Biles D, Mulligan G. Mad or bad? – the enduring dilemma. Br J Criminol. 1973;13:275–9.CrossRefGoogle Scholar
  26. 26.
    Steadman HJ, Monahan J, Duffee B, Hartstone E. The impact of state mental hospital deinstitutionalization on United States prison populations, 1968–1978. J Crim Law Criminol. 1984;75:474–90.CrossRefGoogle Scholar
  27. 27.
    Kalapos MP. Penrose’s law: reality or fiction? Mental health system and the size of prison population – international overview. Orv Hetil. 2009;150:1321–30.CrossRefPubMedGoogle Scholar
  28. 28.
    Hartvig P, Kjelsberg E. Penrose’s law revisited: the relationship between mental institution beds, prison population and crime rate. Nord J Psychiatry. 2009;63:51–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Mundt AP, Chow WS, Arduino M, Barrionuevo H, Fritsch R, Girala N, Minoletti A, Mitkiewicz F, Rivera G, Tavares M, Priebe S. Psychiatric hospital beds and prison populations in South America since 1990: does the Penrose hypothesis apply? JAMA Psychiat. 2015;72:112–8. Scholar
  30. 30.
    Larrobla C, Botega NJ. Psychiatric care policies and deinstitutionalization in South America. Actas Esp Psiquiatr. 2000;28:22–30.PubMedGoogle Scholar
  31. 31.
    Tsai AC, Venkataramani AS. A more robust test of the Penrose hypothesis. JAMA Psychiat. 2015;72:735–6. Scholar
  32. 32.
    Mundt AP, Chow WS, Priebe S. Testing the Penrose hypothesis-reply. JAMA Psychiat. 2015;72:736. Scholar
  33. 33.
    Chow WS, Priebe S. How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990. BMJ Open. 2016;6:e010188. Scholar
  34. 34.
    Blüml V, Waldhor T, Kapusta ND, Vyssoki B. Psychiatric hospital bed numbers and prison population sizes in 26 European countries: a critical reconsideration of the Penrose hypothesis. PLoS One. 2015;10:e0142163. Scholar
  35. 35.
    Mundt AP, Frančiskovič T, Gurovich I, Heinz A, Ignatyev Y, Ismayilov F, Kalapos MP, Krasnov V, Mihai A, Mir J, Padruchny D, Potocan M, Raboch J, Taube M, Welbel M, Priebe S. Changes in the provision of institutionalized mental health care in post-communist countries. PLoS One. 2012;7:e38490. Scholar
  36. 36.
    Sisti DA, Segal AG, Emanuel EJ. Improving long-term psychiatric care: bring back the asylum. JAMA. 2015;313:243–4. Scholar
  37. 37.
    Bastiampillai T, Sharfstein SS, Allison S. Increase in US suicide rates and the critical decline in psychiatric beds. JAMA. 2016;316:2591–2. Scholar
  38. 38.
    Fazel S, Seewald K. Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis. Br J Psychiatry. 2012;200:364–73. Scholar
  39. 39.
    Fazel S, Danesh J. Serious mental disorder in 23000 prisoners: a systematic review of 62 surveys. Lancet. 2002;359:545–50.CrossRefGoogle Scholar
  40. 40.
    Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a systematic review. Addiction. 2006;101:181–91. Scholar
  41. 41.
    Mir J, Kastner S, Priebe S, Konrad N, Ströhle A, Mundt AP. Treating substance abuse is not enough: comorbidities in consecutively admitted female prisoners. Addict Behav. 2015;46:25–30. Scholar
  42. 42.
    Brink J. Epidemiology of mental illness in a correctional system. Curr Opin Psychiatry. 2005;18:536–41.CrossRefPubMedGoogle Scholar
  43. 43.
    Mundt P, Kastner S, Mir J, Priebe S. Did female prisoners with mental disorders receive psychiatric treatment before imprisonment? BMC Psychiatry. 2015;15:5.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Sodhi-Berry N, Knuiman M, Preen B, Alan J, Morgan A. Predictors of post-sentence mental health service use in a population cohort of first-time adult offenders in Western Australia. Crim Behav Ment Health. 2014;50(7):1097–110.Google Scholar
  45. 45.
    Alan J, Burmas M, Preen D, Pfaff J. Inpatient hospital use in the first year after release from prison: a Western Australian population-based record linkage study. Aust N Z J Public Health. 2011;35:264–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Baillargeon J, Binswanger IA, Penn JV, Williams BA, Murray OJ. Psychiatric disorders and repeat incarcerations: the revolving prison door. Am J Psychiatr. 2009;166:103–9.CrossRefPubMedGoogle Scholar
  47. 47.
    Botha UA, Koen L, Joska JA, Parker JS, Horn N, Hering LM, Oosthuizen PP. The revolving door phenomenon in psychiatry: comparing low-frequency and high-frequency users of psychiatric inpatient services in a developing country. Soc Psychiatry Psychiatr Epidemiol. 2010;45:461–8. Scholar
  48. 48.
    Winkler P, Barrett B, McCrone P, Csemy L, Janouskova M, Hoschl C. Deinstitutionalised patients, homelessness and imprisonment: systematic review. Br J Psychiatry. 2016;208:421–8. Scholar
  49. 49.
    Mundt AP. Deinstitutionalisation, imprisonment and homelessness. Br J Psychiatry. 2016;209:349. Scholar
  50. 50.
    Frick U, Frick H, Langguth B, Landgrebe M, Hubner-Liebermann B, Hajak G. The revolving door phenomenon revisited: time to readmission in 17′145 [corrected] patients with 37′697 hospitalisations at a German psychiatric hospital. PLoS One. 2013;8:e75612. Scholar
  51. 51.
    Fazel S, Wolf A, Palm C, Lichtenstein P. Violent crime, suicide, and premature mortality in patients with schizophrenia and related disorders: a 38-year total population study in Sweden. Lancet Psychiatry. 2014;1:44–54. Scholar
  52. 52.
    Moberg T, Stenbacka M, Tengstrom A, Jonsson EG, Nordstrom P, Jokinen J. Psychiatric and neurological disorders in late adolescence and risk of convictions for violent crime in men. BMC Psychiatry. 2015;15:299. Scholar
  53. 53.
    Joseph PL, Potter M. Diversion from custody. I: psychiatric assessment at the magistrates’ court. Br J Psychiatry. 1993;162:325–30.CrossRefPubMedGoogle Scholar
  54. 54.
    Konrad N, Lau S. Dealing with the mentally ill in the criminal justice system in Germany. Int J Law Psychiatry. 2010;33:236–40.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Medical Faculties, Universidad Diego Portales and Universidad de ChileSantiagoChile
  2. 2.Institut für Forensische Psychiatrie, Charité – Universitärsmedizin BerlinBerlinGermany

Personalised recommendations