In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Regional Co ela es o Psychia ic
Inpa ien T ea men
Taina Ala-Nikkola 1,2,3,*, Sami Pi kola 4, Minna Kaila 1,3, Samuli I. Saa ni 5, G igo i Jo e 1,
Raija Kon io 1,6, Olli O an a 5, Minna Sadeniemi 2,7 and K is ian Wahlbeck 2
1Uni e si y o Helsinki and Helsinki Uni e si y Hospi al, Välskä inka u 12, Helsinki FI-00029, Finland;
[email p o ec ed] (M.K.); [email p o ec ed] (G.J.); [email p o ec ed] (R.K.)
2Uni o Men al Heal h, Na ional Ins i u e o Heal h and Wel a e (T.H.L.); Manne heimin ie 168,
Helsinki FI-00270, Finland; [email p o ec ed] (M.S.); [email p o ec ed] (K.W.)
3Public Heal h Medicine, Uni e si y o Helsinki and Helsinki Uni e si y Hospi al,
Helsinki FI-000014, Finland
4Uni e si y o Tampe e School o Heal h Sciences, and Tampe e Uni e si y Hospi al, Lääkä inka u 1,
Tampe e FI-33014, Finland; sami.pi kola@s a .u a. i
5Tu ku Uni e si y Hospi al and Uni e si y o Tu ku, Kiinanmyllynka u 4-8, Tu ku FI-20520, Finland;
[email p o ec ed] (S.I.S.); [email p o ec ed] (O.O.)
6Uni e si y o Tu ku, Tu ku FI-20014, Finland
7Depa men o Social Se ices and Heal h Ca e, Ci y o Helsinki, Helsinki FI-00099, Finland;
[email p o ec ed]
*Co espondence: [email p o ec ed]; Tel.: +358-50-345-8130
Academic Edi o : Paul B. Tchounwou
Recei ed: 21 Sep embe 2016; Accep ed: 30 No embe 2016; Published: 5 Decembe 2016
Abs ac :
Cu en e o ms o men al heal h and subs ance abuse se ices (MHS) emphasize
communi y-based ca e and he downsizing o psychia ic hospi als. Reduc ions in acu e and
semi-acu e hospi al beds a e achie ed h ough sho ened s ays o by a oiding hospi aliza ion.
Unde s anding he ac o s ha d i e he cu en inpa ien ea men p o ision is essen ial.
We in es iga ed how he MHS se ice s uc u e (di e si y o se ices and balance o pe sonnel
esou ces) and indica o s o se ice need (men al heal h index, educa ion, single household, and
alcohol sales) co ela ed wi h acu e and semi-acu e inpa ien ea men p o ision. The Eu opean
Se ice Mapping Schedule-Re ised (ESMS-R) ool was used o classi y he adul MHS s uc u e
in sou he n Finland (popula ion 1.8 million, 18+ yea s). The di e si y o MHS in e ms o ange
o ou pa ien and day ca e se ices o he o e all pe sonnel esou cing in inpa ien o ou pa ien
se ices was no associa ed wi h he inpa ien ea men p o ision. In he uni a ia e analyses, sold
alcohol was associa ed wi h he inpa ien ea men p o ision, while in he mul i a ia e modeling,
only a gene al index o men al heal h needs was associa ed wi h g ea e hospi aliza ion. In he
dehospi aliza ion p ocess, di ec esou ce e-alloca ion and subs i u ing o inpa ien ea men wi h
ou pa ien ca e pe se is likely insu icien , since inpa ien ea men is linked o con ex ual ac o s
in he popula ion and he heal h ca e sys em. Men al heal h se ices e o ms equi e bo h s a egic
planning o se ice sys em as a whole and de ailed unde s anding o e ec s o socie al componen s.
Keywo ds: psychia y; men al heal h se ices; hospi aliza ion; in eg a i e medicine
1. In oduc ion
Men al heal h and subs ance abuse se ices (MHS) ac oss he globe a e unde going changes in
go e nance, s uc u e, and con en [
1
–
3
]. Since he 1990s, he e has been a majo shi om ins i u ional
ca e owa ds ou pa ien communi y ca e, wi h he aim o c ea ing balanced ca e models
[4–6]
and
al e na i es o acu e inpa ien ca e [
7
–
9
]. The exclusi e use o specialized heal h ca e has been
In . J. En i on. Res. Public Heal h 2016,13, 1204; doi:10.3390/ije ph13121204 www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2016,13, 1204 2 o 16
associa ed wi h lowe quali y o li e and ewe social con ac s and ne wo ks [
10
]. The easons
o hospi aliza ion a e linked wi h a ec i e symp oms, suicidal in oxica ion, and poo medica ion
compliance in psychosis pa ien s [
11
]; social wi hd awal and con lic s wi h amily membe s a e also
o en easons o hospi aliza ion [
12
]. Se e e men al heal h illnesses like schizoph enia a e associa ed
wi h longe hospi aliza ions in gene al [
9
,
13
,
14
]. In p ima y ca e, social ne wo king can be suppo ed
di e en ly, so join use o specialized and p ima y ca e has been ecommended [10].
How communi y and hospi al ca e a e bes combined depends on speci ic local ci cums ances
ela ed o men al heal h policy and exis ing se ice s uc u es [
10
,
15
,
16
]. Acco ding o he Wo ld
Heal h O ganiza ion’s (WHO) Men al Heal h Ac ion Plan 2013–2020, policy le el decision-making and
s ong leade ship a e needed o accomplish a ans o ma ion [1].
Finland is a spa sely popula ed coun y o 5.5 million inhabi an s, whe e municipali ies a e
esponsible o social and heal h ca e se ices. Each municipali y is ee o p o ide he public se ices
as a municipal ac i i y, o o pu chase he se ices om an ex e nal p o ide , e.g., ano he municipali y,
a join municipal au ho i y o e en a p i a e p o ide . Fo specialized public heal h se ices, including
specialized men al heal h ca e, he municipali ies join o o m hospi al dis ic s. Finland is di ided in o
21 hospi al dis ic s. The municipal heal h cen es a e he main p o ide s o p ima y ca e se ices, and
he hospi al dis ic s, which a e owned and go e ned by he municipali ies, a e he main p o ide s o
specialis se ices. Cu en e o ms in Finland a e aimed a a p o ound in eg a ion o he p ima y and
specialized men al heal h as well as social se ices (al oge he u he e e ed o as MHS) [17].
Likewise, in Finland, he MHS s a egy 2010–2015 is aimed a de eloping mo e pa ien -cen e ed,
communi y-based and in eg a ed psychia ic and soma ic se ices, while u he limi ing he use
o hospi al-based se ices [
18
–
21
]. Despi e he policy o in es ing in communi y ca e and he
deins i u ionaliza ion p ocess, mos MHS esou ces in Sou he n Finland a e s ill alloca ed o hospi al
and non-hospi al esiden ial se ices, while low- h eshold ou pa ien se ices a e sca ce [21–23].
P e iously we epo ed ha MHS di e si y posi i ely co ela es wi h ca chmen a ea popula ion
size. We also no ed ha ca chmen a eas wi h an ou pa ien -based MHS s uc u e ha e ewe pe sonnel
(in ull- ime equi alen s) han a eas wi h hospi al-cen e ed se ices [
20
]. These indings ha e aised
in e es in he in e ela ionships be ween communi y-o ien ed ca e and inpa ien ca e. In essence, i is
impo an o unde s and which ac o s in he MHS s uc u e and i s clien pool explain he cu en ly
la ge a ia ion in psychia ic hospi al use. Fo he pu poses o he cu en e o ms, including an
ongoing dehospi aliza ion p ocess wi h inc easing ou pa ien ca e and he in eg a ion o psychia y
wi h gene al hospi als, mo e knowledge on he p econdi ions o educing he ela i ely high le el o
psychia ic hospi aliza ion is needed [19].
We hypo hesized ha mo e di e se s uc u e in men al heal h se ices wi h a ela i e emphasis on
ou pa ien and day ca e se ices would be associa ed wi h a educed numbe o inpa ien ea men s
in acu e and non-acu e psychia ic acili ies [4].
The aim o he p esen s udy is o explo e whe he he MHS s uc u e (di e si y o se ices and
balance o pe sonnel be ween communi y and hospi al ca e) and indica o s o men al heal h needs a e
associa ed wi h he p o ision o acu e and ime-limi ed non-acu e psychia ic hospi al ea men in a
egional compa ison.
2. Me hods
2.1. The S udy A ea
REFINEMENT (REsea ch on FINancing sys ems’ E ec on he quali y o MENTal heal h ca e)
is a collabo a i e p ojec o nine EU coun ies ( o he second phase, in e na ionally e e ed o as
CEPHOS-link, six EU coun ies: I aly, No way, Romania, Slo enia, Aus ia, and Finland), cu en ly
led by he Finnish Na ional Ins i u e o Heal h and Wel a e (THL) and pa ly unded by he EC
Se en h Resea ch F amewo k. The s udy is con ibu ing o he e idence base needed o plan
e o ms in inancing and he in eg a ion o he MHS and o e all heal h ca e sys em. De ails o
he FIN-REFINEMENT, he Finnish pa o p ojec , ha e been desc ibed p e iously [
20
,
24
,
25
]. B ie ly,
in his s udy, he s udy a ea included ou hospi al dis ic s ( egions) in he sou he nmos pa
In . J. En i on. Res. Public Heal h 2016,13, 1204 3 o 16
o Finland: he Hospi al Dis ic o Helsinki and Uusimaa, Kymenlaakso (Ca ea), E elä-Ka jala
(Ekso e), and he Hospi al Dis ic o Sou h-Wes e n Finland [
20
]. These hospi al dis ic s consis
o municipali ies (n= 67) ha o m 13 non-o e lapping ca chmen a eas, each equipped wi h
psychia ic inpa ien se ices. The o al popula ion in he s udy a ea is 2.3 million people, wi h
1.8 million adul s, which is app oxima ely 43% o he Finnish adul popula ion (aged 18+ yea s).
The adul popula ion a ied conside ably by ca chmen a ea, om app oxima ely 18,200 (Tu unmaa)
o 500,000 inhabi an s (Helsinki).
2.2. Da a Collec ion
2.2.1. S uc u e
We classi ied MHS by means o he Eu opean Se ice Mapping Schedule (ESMS-R). The ESMS-R
allows o a s anda dized desc ip ion o he key ea u es o men al heal h se ice s uc u es and
p o ision, including hose se ices p o ided by p ima y ca e and social se ices [
20
,
24
–
28
]. The da a
collec ion and ins umen has been desc ibed p e iously [
20
,
23
,
24
]. B ie ly, men al heal h se ices a e
classi ied in o 89 di e en “Main Types o Ca e” (MTC) in he ESMS-R classi ica ion. The MTC is he
main desc ip o o he ca e unc ion (e.g., mobile acu e eam o acu e hospi al ca e). The MTC a e
o ganized by he “Basic S able Inpu o Ca e” (BSIC); i.e., he o ganiza ional uni s ha p o ide he
se ices (e.g., acu e wa d o day ca e cen e ). MTC a e alloca ed o six main b anches o he ESMS-R:
(1) in o ma ion o ca e; (2) accessibili y o ca e; (3) sel -help and olun a y help; (4) ou pa ien ca e,
(5) day ca e; and (6) esiden ial ca e [28,29].
In addi ion, we collec ed he numbe s o admission a es and o days spen in a hospi al o
esiden ial se ices in one yea as a means o map he inpa ien ea men p o ision in he a eas.
The da a we e collec ed be ween 2012 and 2014 by ained esea che s om public co po a ion da a
sou ces o he yea s 2012 and 2013, wi h co-ope a ion om local s akeholde s. Da a on MHS p o ided
by hi d sec o and p i a e p o ide s we e collec ed by s uc u ed ques ionnai es and ollowed up
whe e necessa y by e-mail and elephone con ac .
2.2.2. Se ice S uc u e Va iables
The di e si y o he MHS s uc u e was measu ed by coun ing he main ypes o ca e (MTC) in
ou pa ien and day ca e b anches, he hypo hesis being ha di e si ied ou pa ien and day se ices
diminish he need o hospi al beds. The used e ms a e de ini e on Re inemen Glossa y [
30
,
31
].
“Ou pa ien se ices: Se ing in which men al heal h se ices a e p o ided on an ou pa ien basis,
wi hou o e nigh s ay, ei he mobile (when he acili y is capable o being mo ed o di e en loca ions)
o ixed (when he pe son seeking ca e mus a el o a ixed se ice si e). The e is con ac be ween
s a and se ice use s o some pu pose ela ed o managemen o hei condi ion and i s associa ed
clinical and social di icul ies. These se ices a e no p o ided as a pa o he deli e y o day ca e
se ices, and hey ha e a leas some quali ied heal h ca e p o essionals as s a membe s. Day ca e:
Ca e p o ision (i) is no mally a ailable o se e al consume s a a ime ( a he han deli e ing se ices
o indi iduals one a a ime); (ii) p o ide some combina ion o ea men o p oblems ela ed o
long- e m ca e needs: e.g., p o iding a s uc u ed ac i i y, o social con ac and/o suppo ; (iii) ha e
egula opening hou s du ing which hey a e no mally a ailable: and (i ) expec consume s o s ay a
he acili ies beyond he pe iods du ing which hey ha e ace- o- ace con ac wi h s a (i.e., he se ice
is no simply based on indi iduals coming o appoin men s wi h s a and hen lea ing immedia ely
a e hei appoin men s). The ca e deli e y is usually planned in ad ance”.
The ESMS-R ool’s esiden ial se ice b anch includes a o al o 21 di e en MTC (Figu e 1).
Acu e wa ds a e de ined by he ESMS-R as high and medium in ensi y acu e ca e acili ies wi h 24-h
physician co e in a egis e ed hospi al. Non-acu e wa ds a e de ined as ime-limi ed acili ies whe e
a ixed maximum pe iod o esidence is ou inely speci ied ( empo a y s ay). A acili y should be
classi ied as ime-limi ed i a maximum leng h o s ay is ixed o a leas 80% o hose en e ing he
acili y [28,30].
In . J. En i on. Res. Public Heal h 2016,13, 1204 4 o 16
In .J.En i on.Res.PublicHeal h2016,13,12047o 17

classi iedas ime‐limi edi amaximumleng ho s ayis ixed o a leas 80%o  hoseen e ing he
acili y[28,30].

Figu e1.The esiden ialca eclassi ica iono  heESMS‐R ool[28].Wa dsincludedin hes udya e
gi eninbold.
Asanindica o o acu eandsemi‐acu epsychia icinpa ien  ea men ,weused he o al
numbe o usedbedsonacu epsychia ichospi alwa ds(ESMS‐Rca ego iesR1andR2)andnon‐
acu e, ime‐limi edpsychia ichospi alwa ds(R4).Thecalcula iono  hepe capi anumbe o 
inpa ien  ea men bedsbyeachca chmen a eapopula ionincluding heinpa ien  ea men beds
physicallyloca edbo hinsideandou sideo  heca chmen a eas.Wealsoexplo ed hep opo ion
o bedsuseda o he  ypeso hospi alwa ds(e.g.,acu enon‐physicianco e )andnon‐hospi al
esiden ialse iceuni s(e.g.,suppo edhousing).
2.2.3.SocioeconomicandHeal hFac o sRela ed oMen alHeal hNeeds
Thesocioeconomic ac o sincludeda e hosecommonly ela ed omen alheal hneeds:
educa ionindex(educa ionyea sa e p ima yschool),alcoholsales(li e so 100%alcoholpe 
pe son),unemploymen  a ein hewo kingagepopula ion,and hep opo iono single‐pe son
households(%).
Themen alheal hindex(MHI)isanindica o o popula ionmen alheal hs a uscalcula ed o 
eachca chmen a eausing h eeyea so da aon(1)numbe o suicidesandsuicidea emp s;(2)
pe sonseligible o special eimbu semen  o an ipsycho icmedica ion;and(3)pe sonsondisabili y
pension(18–64yea sold)due omen aldiso de s.TheMHI o  hewholeo Finlandisse  o100.An
MHIsmalle  han100indica esabe e  hana e ages a eo men alheal h.Thesocioeconomicda a
om2011–2012we ecollec ed o  hepe iod2012–2013 omS a is icsFinlandand om heIndica o 
BankSo kane (www.so kane . i).
2.2.4.Pe sonnelResou ceFac o s
Thealloca edpe sonnel ull‐ imeequi alen s(FTE)pe usedacu eandsemi‐acu ebedindica e
howwell hewa dswe e esou ced, hehypo hesisbeing ha be e  esou cingwouldlead osho e 
hospi aliza ions.Communi yo ien a ionwasope a ionalizedas hep opo iono allpe sonnel
Figu e 1.
The esiden ial ca e classi ica ion o he ESMS-R ool [
28
]. Wa ds included in he s udy a e
gi en in bold.
As an indica o o acu e and semi-acu e psychia ic inpa ien ea men , we used he o al numbe
o used beds on acu e psychia ic hospi al wa ds (ESMS-R ca ego ies R1 and R2) and non-acu e,
ime-limi ed psychia ic hospi al wa ds (R4). The calcula ion o he pe capi a numbe o inpa ien
ea men beds by each ca chmen a ea popula ion including he inpa ien ea men beds physically
loca ed bo h inside and ou side o he ca chmen a eas. We also explo ed he p opo ion o beds used
a o he ypes o hospi al wa ds (e.g., acu e non-physician co e ) and non-hospi al esiden ial se ice
uni s (e.g., suppo ed housing).
2.2.3. Socioeconomic and Heal h Fac o s Rela ed o Men al Heal h Needs
The socioeconomic ac o s included a e hose commonly ela ed o men al heal h needs:
educa ion index (educa ion yea s a e p ima y school), alcohol sales (li e s o 100% alcohol pe
pe son), unemploymen a e in he wo king age popula ion, and he p opo ion o single-pe son
households (%).
The men al heal h index (MHI) is an indica o o popula ion men al heal h s a us calcula ed
o each ca chmen a ea using h ee yea s o da a on (1) numbe o suicides and suicide a emp s;
(2) pe sons eligible o special eimbu semen o an ipsycho ic medica ion; and (3) pe sons on
disabili y pension (18–64 yea s old) due o men al diso de s. The MHI o he whole o Finland
is se o 100. An MHI smalle han 100 indica es a be e han a e age s a e o men al heal h.
The socioeconomic da a om 2011–2012 we e collec ed o he pe iod 2012–2013 om S a is ics
Finland and om he Indica o Bank So kane (www.so kane . i).
2.2.4. Pe sonnel Resou ce Fac o s
The alloca ed pe sonnel ull- ime equi alen s (FTE) pe used acu e and semi-acu e bed indica e
how well he wa ds we e esou ced, he hypo hesis being ha be e esou cing would lead o
sho e hospi aliza ions. Communi y o ien a ion was ope a ionalized as he p opo ion o all
pe sonnel alloca ed o ou pa ien and day ca e se ices, he hypo hesis being ha be e communi y
In . J. En i on. Res. Public Heal h 2016,13, 1204 5 o 16
esou cing would lead o lowe hospi al use. The pe sonnel alloca ion o communi y se ices is
coun ed as wo di e en a iables: (1) he sum o o al FTE alloca ed o ou pa ien and day ca e;
and (2) he communi y-based se ice a io (ou pa ien and day ca e FTEs/di ided esiden ial FTEs),
whe e 100% is an equal alloca ion.
2.3. Da a Analysis
The SPSS s a is ics p og am e sion 22 was used o he analyses. Sca e plo s we e used o
explo e and illus a e he associa ions be ween indica o s. Spea man co ela ion analysis was used o
in es iga e he associa ion be ween acu e and semi-acu e inpa ien ea men p o ision (independen
a iable) and he explana o y MHS se ice s uc u e a iables: di e si y o ou pa ien and day ca e
se ices, pe sonnel FTE alloca ion pe bed, and communi y o ien a ion. The co ela ions be ween
acu e and semi-acu e beds and o he hospi al beds and non-hospi al beds we e also analyzed.
The main ou come in he analyses was he p o ision o acu e and semi-acu e inpa ien ea men ,
coun ed by used beds pe 1000 (18+) on acu e and semi-acu e wa ds. The dependences be ween he
explana o y a iables and he p o ision o inpa ien ea men we e analyzed using linea eg ession
analysis. Fi s , uni a ia e analyses we e pe o med o each explana o y ac o sepa a ely. Nex ,
analyses we e con olled o MHI. The signi icance le el was se o p< 0.05. The analyses we e ca ied
ou wi h S a is ical Package o Social Sciences (SPSS) e sion 22 (IBM, A monk, NY, USA).
3. Resul s
3.1. The Inpa ien T ea men P o ision and he Men al Heal h Se ice S uc u e
3.1.1. Inpa ien T ea men P o ision and Communi y (Ou pa ien and Day Ca e) Se ice Di e si y
The p o ision o ea men in di e en wa d le els is p esen ed in Table 1. The p o ision o
acu e and semi-acu e hospi al beds a ied ou - old, be ween 0.27 and 1.00 beds pe 1000 adul s.
The p o ision o o he hospi al beds a ied om 0.0 o 0.08. The median leng h o s ay was 18.7 days
(mean 22.7, SD 7.7, ange 20.02).
The highes p o ision o acu e and semi-acu e beds was ound in he small Tu unmaa a ea (1.00),
bu no ably his is based on only one wa d si ua ed in he a ea, and he pe capi a o al o hospi al
p o ision by bed (1.06) is close o he a e age le el pe 1000 adul s (mean 0.78).
In sca e plo s, he smalles dis ic o Tu unmaa, which also used he acu e wa d o long- e m
ca e, appea ed o be mo e o less an ou lie . The e o e, we also analyze and discuss i s ole sepa a ely
whe e app op ia e, while excluding i om all linea eg ession analyses. Figu e 2a–c p esen he
sca e plo and eg ession line be ween pe capi a acu e o semi-acu e bed p o ision and he a ailabili y
o di e en ou pa ien and day ca e and o al communi y (ou pa ien and day ca e) se ices. The e was
a weak di ec ela ionship be ween he di e si y o day ca e se ices and he p o ision o hospi al beds
(Figu e 2b). The same e ec is shown o o al communi y se ices and he p o ision o hospi al beds
(Figu e 2c). The se ice s uc u e o he smalles Tu unmaa a ea, wi h only one wa d o all esiden ial
ca e, a ec ed he model, in ensi ying he signi icance ( isible in Figu e 2a,c). A sensi i i y analysis was
pe o med, excluding he Tu unmaa a ea, in which no signi ican ela ions we e ound.

In . J. En i on. Res. Public Heal h 2016,13, 1204 6 o 16
Table 1. P o ised beds on di e en ypes o psychia ic wa ds and non-hospi al se ices pe 1000 (18+) and communi y se ice di e si y.
Ca chmen A ea Länsi-
Uusimaa (1)
Lohja
(2)
Hy inkää
(3)
Po oo
(4)
Helsinki
(5)
Jo i
(6)
Peijas
(7)
Ca ea
(8)
Ekso e
(9)
Tu ku
(10)
Salo
(11)
Vakka-
Suomi (12)
Tu unmaa
(13) SD Weigh ed Mean
Size o ca chmen a ea
18+ popula ion 35,296 70,379 139,734 74,611 501,929
230,005
187,332
143,265
109,379
151,616 128,039
81,392 18,200
Beds on acu e and semi-
acu e wa ds (R2, R4) * 0.44 0.27 0.44 0.32 0.53 0.33 0.28 0.42 0.46 0.66 0.29 0.53 1.00 0.20 0.45
Beds on o he hospi al
wa ds (R3, R6) 0.44 0.80 0.54 0.39 0.44 0.22 0.48 0.26 0.14 0.42 0.11 0.00 0.06 0.22 0.33
Beds on non-hospi al
se ices ** 2.30 4.15 4.26 5.23 7.07 3.48 3.70 3.62 3.65 3.67 2.08 3.93 1.65 1.38 3.75
To al beds in
all ca ego ies 3.18 5.22 5.24 5.94 8.04 4.03 4.46 4.30 4.25 4.75 2.48 4.46 2.71 1.44 4.54
Communi y se ice
di e si y *** 10 8 12 8 14 12 12 13 14 17 15 9 1
*
R1 Wa ds we e no ound;
**
ESMS-R codes: R0, R3.1, R3.1.1, R3.1.2, R5, R7, R8, R8.1, R8.2, R9.1, R9.2, R10.1, R10.2, R11, R12, R13, R14;
***
Di e en se ices (main ypes o ca e) on
communi y se ices (ou pa en and day ca e se ices).
In . J. En i on. Res. Public Heal h 2016,13, 1204 7 o 16
In .J.En i on.Res.PublicHeal h2016,13,12047o 17

Insca e plo s, hesmalles dis ic o Tu unmaa,whichalsoused heacu ewa d o long‐ e m
ca e,appea ed obemo eo lessanou lie .The e o e,wealsoanalyzeanddiscussi s olesepa a ely
whe eapp op ia e,whileexcludingi  omalllinea  eg essionanalyses.Figu e2a–cp esen  he
sca e plo and eg essionlinebe weenpe capi aacu eo semi‐acu ebedp o isionand he
a ailabili yo di e en ou pa ien anddayca eand o alcommuni y(ou pa ien anddayca e)
se ices.The ewasaweakdi ec  ela ionshipbe ween hedi e si yo dayca ese icesand he
p o isiono hospi albeds(Figu e2b).Thesamee ec isshown o  o alcommuni yse icesand he
p o isiono hospi albeds(Figu e2c).These ices uc u eo  hesmalles Tu unmaaa ea,wi honly
onewa d o all esiden ialca e,a ec ed hemodel,in ensi ying hesigni icance( isibleinFigu e
2a,c).Asensi i i yanalysiswaspe o med,excluding heTu unmaaa ea,inwhichnosigni ican 
ela ionswe e ound.

a
b
In .J.En i on.Res.PublicHeal h2016,13,12047o 17


Figu e2.Associa ionbe weenacu e‐andsemi‐acu e( ime‐limi ed)inpa ien  ea men p o isionand
di e en ;(a)ou pa ien ‐,(b)dayca e‐,and(c) o alcommuni yse ices‐a ailable.Thenumbe sin
b acke sa e ca chmen a easindica e heda acollec iono de andwe eusedinap e iousa icle
[20].

Thep o isiono o he  esiden ialse icesando he hospi albedsandnon‐hospi albedswe e
no signi ican lyassocia edwi hacu eandsemi‐acu einpa ien  ea men p o ision(Figu e3a,b).

Figu e3.Associa ionsbe weenacu e‐andsemi‐acu e( ime‐limi ed)inpa ien  ea men p o ision
and;(a)o he hospi albed‐and(b)non‐hospi albed‐p o isionpe 1000adul s(18+).Thenumbe s
inb acke sa e ca chmen a easindica e heda acollec iono de andwe eusedinap e iousa icle
[20].
3.1.2.TheInpa ien T ea men P o isionandPe sonnelResou ceFac o s
Thehighes pe capi auseo  o alpe sonnel esou ceswas oundinLänsi‐Uusimaa(5.1)and
helowes inJo i(2.1)( ange2.1–5.1,mean3.3).Thehighes pe capi auseo communi y‐based
pe sonnel esou ces,coun edas hesumo ou pa ien anddayca e esou ces,was oundinLänsi‐
Uusimaa(1.9)and helowes inTu unmaa(0.8)andLohja(0.9)( ange0.8–1.9,mean1.3).Theg ade
o communi yo ien a ion a ied om0.9 o0.3(Table2).

c
ab
Figu e 2.
Associa ion be ween acu e- and semi-acu e ( ime-limi ed) inpa ien ea men p o ision and
di e en ; (
a
) ou pa ien -, (
b
) day ca e-, and (
c
) o al communi y se ices- a ailable. The numbe s in
b acke s a e ca chmen a eas indica e he da a collec ion o de and we e used in a p e ious a icle [
20
].
In . J. En i on. Res. Public Heal h 2016,13, 1204 8 o 16
The p o ision o o he esiden ial se ices and o he hospi al beds and non-hospi al beds we e
no signi ican ly associa ed wi h acu e and semi-acu e inpa ien ea men p o ision (Figu e 3a,b).
In .J.En i on.Res.PublicHeal h2016,13,12047o 17


Figu e2.Associa ionbe weenacu e‐andsemi‐acu e( ime‐limi ed)inpa ien  ea men p o isionand
di e en ;(a)ou pa ien ‐,(b)dayca e‐,and(c) o alcommuni yse ices‐a ailable.Thenumbe sin
b acke sa e ca chmen a easindica e heda acollec iono de andwe eusedinap e iousa icle
[20].

Thep o isiono o he  esiden ialse icesando he hospi albedsandnon‐hospi albedswe e
no signi ican lyassocia edwi hacu eandsemi‐acu einpa ien  ea men p o ision(Figu e3a,b).

Figu e3.Associa ionsbe weenacu e‐andsemi‐acu e( ime‐limi ed)inpa ien  ea men p o ision
and;(a)o he hospi albed‐and(b)non‐hospi albed‐p o isionpe 1000adul s(18+).Thenumbe s
inb acke sa e ca chmen a easindica e heda acollec iono de andwe eusedinap e iousa icle
[20].
3.1.2.TheInpa ien T ea men P o isionandPe sonnelResou ceFac o s
Thehighes pe capi auseo  o alpe sonnel esou ceswas oundinLänsi‐Uusimaa(5.1)and
helowes inJo i(2.1)( ange2.1–5.1,mean3.3).Thehighes pe capi auseo communi y‐based
pe sonnel esou ces,coun edas hesumo ou pa ien anddayca e esou ces,was oundinLänsi‐
Uusimaa(1.9)and helowes inTu unmaa(0.8)andLohja(0.9)( ange0.8–1.9,mean1.3).Theg ade
o communi yo ien a ion a ied om0.9 o0.3(Table2).

c
ab
Figu e 3.
Associa ions be ween acu e- and semi-acu e ( ime-limi ed) inpa ien ea men p o ision
and; (
a
) o he hospi al bed- and (
b
) non-hospi al bed- p o ision pe 1000 adul s (18+). The numbe s in
b acke s a e ca chmen a eas indica e he da a collec ion o de and we e used in a p e ious a icle [
20
].
3.1.2. The Inpa ien T ea men P o ision and Pe sonnel Resou ce Fac o s
The highes pe capi a use o o al pe sonnel esou ces was ound in Länsi-Uusimaa (5.1) and he
lowes in Jo i (2.1) ( ange 2.1–5.1, mean 3.3). The highes pe capi a use o communi y-based pe sonnel
esou ces, coun ed as he sum o ou pa ien and day ca e esou ces, was ound in Länsi-Uusimaa (1.9)
and he lowes in Tu unmaa (0.8) and Lohja (0.9) ( ange 0.8–1.9, mean 1.3). The g ade o communi y
o ien a ion a ied om 0.9 o 0.3 (Table 2).
3.2. The Inpa ien T ea men P o ision and Men al Heal h Need Indica o s
The e we e some di e ences be ween ca chmen a eas ega ding socioeconomic ac o s (Table 3).
The a e age MHI was 90.3 (SD 21.9), indica ing ha in he s udy a ea as a whole, he need o men al
heal h se ices may be lowe han in Finland o e all. The a eas loca ed in he Helsinki and Uusimaa
Hospi al Dis ic , nea Finland’s capi al, had a lowe MHI han he na ional a e age. Fu he away
om he capi al, i.e., in Kymenlaakso, E elä-Ka jala, and Sou h-Wes e n Finland (A eas 10–13), he
MHI was highe han he na ional a e age.
In Spea man’s co ela ion analysis, he sold alcohol in li e s pe adul was signi ican ly associa ed
wi h he p o ision o acu e and semi-acu e hospi al beds (
ρ
= 0.606, p= 0.028). The educa ion indices
o numbe o single pe son households we e no signi ican ly associa ed wi h he pe capi a p o ision
o acu e and semi-acu e beds (Table 4).
In . J. En i on. Res. Public Heal h 2016,13, 1204 9 o 16
Table 2. Pe sonnel ull ime equi alen s (FTE) esou ces on men al heal h se ices pe 1000 (18+).
Ca chmen A ea Länsi-
Uusimaa (1)
Lohja
(2)
Hy inkää
(3)
Po oo
(4)
Helsinki
(5)
Jo i
(6)
Peijas
(7)
Ca ea
(8)
Ekso e
(9)
Tu ku
(10) Salo (11) Vakka-
Suomi (12)
Tu unmaa
(13)
S udy
A ea
Size o ca chmen a ea
18+ popula ion 35,316 70,192 138,973 74,079 497,814
227,605
185,984 141,085 107,612 151,616
128,039.2815
81,392 18,200 1,857,907
Pe sonnel FTE esou ces
pe 1000 (18+)
Day ca e (D) FTE
pe 1000 0.6 0.2 0.4 0.3 0.3 0.1 0.1 0.2 0.6 0.4 0.4 0.3 0.0 0.3
Ou pa ien ca e (O) FTE
pe 1000 1.3 0.7 0.9 0.7 1.1 0.9 0.9 0.9 0.8 1.4 1.2 1.0 0.8 1.0
Residen ial ca e (R) FTE
pe 1000 3.2 2.6 2.9 1.8 2.0 1.1 1.5 2.8 1.6 2.9 1.7 2.4 2.2 2.0
Communi y-based
se ices = FTE D + O
pe 1000
1.9 0.9 1.3 0.9 1.4 1.0 1.0 1.1 1.4 1.8 1.6 1.2 0.8 1.3
Communi y o ien a ion
(FTE a io
ou pa ien / esiden ial)
0.6 0.3 0.5 0.5 0.4 0.9 0.7 0.4 0.9 0.4 0.5 0.3 0.3 0.5
To al FTE pe 1000 5.1 3.5 4.2 2.7 3.4 2.1 2.6 4.0 3.1 4.7 3.3 3.6 3.0 3.3
FTE: ull- ime equi alen . The numbe s in b acke s a e ca chmen a eas indica e he da a collec ion o de and we e used in a p e ious a icle [20].
In . J. En i on. Res. Public Heal h 2016,13, 1204 16 o 16
35.
Rez yy, G.; Oies old, T.; Pa niako , A.; Ponoma e , O.; Lazu ko, O.; Ols ad, R. The Ba en s P ojec
in psychia y: A sys ema ic compa a i e men al heal h se ices s udy be ween no he n No way and
A changelsk Coun y. Soc. Psychia y Psychia . Epidem. 2007,42, 131–139. [C ossRe ] [PubMed]
36.
Ja man, B.; Hi sch, S.; Whi e, P.; D iscoll, R. P edic ing psychia ic admission a es. BMJ
1992
,304, 1146–1151.
[C ossRe ] [PubMed]
37.
Zanjani, F.; Smi h, R.; Sla o a, S.; Cha nigo, R.; Schoenbe g, N.; Ma in, C.; Clay on, R. Concu en alcohol
and medica ion poisoning hospi al admissions among olde u al and u ban esiden s. Am. J. D ug
Alcohol Abuse 2016,42, 422–430. [C ossRe ] [PubMed]
38.
Whi e, A.M.; Hingson, R.W.; Pan, I.J.; Yi, H.Y. Hospi aliza ions o alcohol and d ug o e doses in young
adul s ages 18–24 in he Uni ed S a es, 1999–2008: Resul s om he na ionwide inpa ien sample. J. S ud.
Alcohol D ug 2011,72, 774–786. [C ossRe ]
39.
Pe ala, J.; Su isaa i, J.; Saa ni, S.I.; Kuoppasalmi, K.; Isome sa, E.; Pi kola, S.; Pa onen, T.;
Tuulio-Hen iksson, A.; Hin ikka, J.; Kieseppa, T.; e al. Li e ime p e alence o psycho ic and bipola I
diso de s in a gene al popula ion. A ch. Gen. Psychia y 2007,64, 19–28. [C ossRe ] [PubMed]
40. Myklebus , L.H.; Ols ad, R.; Bjo bekkmo, S.; Eisemann, M.; Wynn, R.; So gaa d, K. Impac on con inui y o
ca e o decen alized e sus pa ly cen alized men al heal h ca e in no he n No way. In . J. In eg . Ca e
2011,11, e142. [C ossRe ] [PubMed]
41.
Ma shall, M.; C ow he , R.; Alma az-Se ano, A.; C eed, F.; Sledge, W.; Klui e , H.; Robe s, C.; Hill, E.;
Wie sma, D.; Bond, G.R.; e al. Sys ema ic e iews o he e ec i eness o day ca e o people wi h se e e
men al diso de s: (1) Acu e day hospi al e sus admission; (2) oca ional ehabili a ion; (3) day hospi al
e sus ou pa ien ca e. Heal h Technol. Assess. 2001,5, 1–75. [C ossRe ] [PubMed]
42.
Douzenis, A.; Se e is, D.; Nika, S.; Nikolaidou, P.; Papadopoulou, A.; Rizos, E.N.; Ch is odoulou, C.;
Tsopelas, C.; Mi chell, D.; Lykou as, L. Fac o s a ec ing hospi al s ay in psychia ic pa ien s: The ole o
ac i e como bidi y. BMC Heal h Se . Res. 2012,12. [C ossRe ] [PubMed]
43.
Lloyd-E ans, B.; Slade, M.; Jagielska, D.; Johnson, S. Residen ial al e na i es o acu e psychia ic hospi al
admission: Sys ema ic e iew. B . J. Psychia y 2009,195, 109–117. [C ossRe ] [PubMed]
44.
Johnson, S.; Gilbu , H.; Lloyd-E ans, B.; Osbo n, D.P.; Boa dman, J.; Leese, M.; Shephe d, G.;
Tho nic o , G.; Slade, M. In-pa ien and esiden ial al e na i es o s anda d acu e psychia ic wa ds in
England. B . J. Psychia y 2009,194, 456–463. [C ossRe ] [PubMed]
45.
S ulz, N.; Bielinski, D.; Junghan, U.M.; Hepp, U. Hea y use o psychia ic hospi als and he use o ou pa ien
se ices in Swi ze land. Psychia . P ax. 2012,39, 332–338. [PubMed]
46.
Zhang, J.; Ha ey, C.; And ew, C. Fac o s associa ed wi h leng h o s ay and he isk o eadmission in
an acu e psychia ic inpa ien acili y: A e ospec i e s udy. Aus . N. Z. J. Psychia y
2011
,45, 578–585.
[C ossRe ] [PubMed]
47.
Ha is, M.G.; Buckingham, W.J.; Pi kis, J.; G o es, A.; Whi e o d, H. Planning es ima es o he p o ision o
co e men al heal h se ices in Queensland 2007 o 2017. Aus . N. Z. J. Psychia y
2012
,46, 982–994. [C ossRe ]
[PubMed]
48.
Die e ich, M.; I ing, C.B.; Pa k, B.; Ma shall, M. In ensi e case managemen o se e e men al illness.
Coch ane Da abase Sys . Re . 2010,10. [C ossRe ]
49.
Wahlbeck, K. Public men al heal h: The ime is ipe o ansla ion o e idence in o p ac ice. Wo ld Psychia y
2015,14, 36–42. [C ossRe ] [PubMed]
©
2016 by he au ho s; licensee MDPI, Basel, Swi ze land. This a icle is an open access
a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion
(CC-BY) license (h p://c ea i ecommons.o g/licenses/by/4.0/).