Living conditions and quality of care in residential units for people with long-term mental illness in Portugal – a cross-sectional study

This is the first report on residential units for people with longer term mental health problems in Portugal. A major strength of the study is the fact that all units providing high and medium levels of support in the country, as well as a large proportion of their service users, participated in the study.

The number of units had increased by 75 % (from 24 to 42) since 2009 (Killaspy et al., 2012) [14]. This is probably due to the implementation of the National Mental Health Plan (2007/2016), that has promoted a greater variety of services and more adequate care for people with severe mental illness. Most of the units were based in the community rather than hospital settings, suggesting that the process of deinstitutionalisation of mental health care in Portugal is taking place. The fact that service users’ functioning was similar in hospital and community settings suggests that this trend should continue since community based units appear able to manage people with similar levels of disability to hospital based units. Most units provided access to a multidisciplinary team and a wide range of staff training. Although it is encouraging that the quality ratings (QuIRC domain scores) were similar to the average scores across Europe, our findings suggest some important areas for improvement, especially with regard to Recovery Based Practice and Therapeutic Environment. In comparison with units in England, where the implementation of community based care has been ongoing for longer, Portuguese units scored lower on all QuIRC domains.

Although most of the units were located in urban and suburban areas, the fact that one third were in rural areas may present particular logistic difficulties in terms of access to public transport and community activities that promote social inclusion. As a comparison, in England, only 8 % of similar units are in rural areas [23]. However, this should take into account that, in 2012, Portugal’s rural population was 38 % compared to 18 % in the UK [24].

The fact that over half the units had no single bedrooms needs to be addressed since this does not comply with the Convention on the Rights of Persons with Disabilities (CRPD) [25] recommendations, such as privacy and dignity. In addition, although the number of units had increased in recent years, the model of care being used had not changed for many years in many services, suggesting that institutional practices continue. This might explain the lower scores for Therapeutic Environment and Recovery Based Practice. For example, although most services reported using individualised care plans to support service users, activity plans tailored to the individual were not usual. In addition, managers predicted that only a minority of their service users were likely to move on to more independent settings. This suggests a degree of therapeutic pessimism that requires challenging, since holding and promoting hope for a person’s recovery is a key component of recovery-based practice [26]. A further marker of recovery based practice is the employment of peer support workers in a service, yet only one unit had an ex-service user amongst their staff.

The high percentage of Portuguese service users taking more than two anti-psychotics (48.9 %) compared to those in similar units in England (3.9 %) [23] is of concern. Due to the risks involved, this issue needs to be addressed in future interventions to train the residential facilities’ staff, particularly psychiatrists. Moreover, specific Portuguese guidelines for the prescription of antipsychotics are available [27], but are clearly not being followed.

The community units in this study scored higher than hospital based units on the QuIRC domains Living Environment, Treatments and Interventions, and Self-Management and Autonomy. This finding concurs with previous studies that have found that community based units provide more homely and therapeutic environments [15]. Service users’ age was negatively associated with all but one of the QuIRC domain scores (a reduction in the score of between two and five percent for every five year increase in mean age). The level of service users’ disability was also associated with two QuIRC domains; i.e. higher mean GAF scores (more able residents), were positively associated with Living Environment and Self-Management and Autonomy. However, the gender of service users had little influence on ratings of the units’ quality.

We also found that greater quality of care on all the QuIRC domains was positively associated with service users’ autonomy, ratings of the unit’s therapeutic milieu and experiences of care. However, the only aspect of care that positively influenced service users’ quality of life was the Therapeutic Environment score. In sum, lower quality units were more likely to be situated in hospitals and contain older residents who despite having no greater disability, report lower autonomy, and rate their unit lower on therapeutic milieu. This suggests that the recent expansion in residential facilities in Portugal have superseded older, less community-focused units that have a residue of older residents. Although clearly this reform has been a positive development, the older hospital based units may need more resources to come up to European standards. This provides important evidence for continued investment to ensure higher quality of care is provided to those with longer term mental health problems.