Care Settings, Autonomy, and Costs in Severe Mental Illness: A Cross-Sectional Comparison of Hospital, Residential, and Community Care in Romania

Background and Objectives: Romania’s transition from long-stay psychiatric care to more balanced community-oriented care remains incomplete, and comparative patient-level data are limited. The primary objective was to compare mental health-related quality of life, autonomy, perceived coercion, and direct mental health costs across hospital, residential, and community care settings. Secondary objectives were (i) to compare hospital care with deinstitutionalized care taken together (residential + community), and (ii) to examine whether autonomy and perceived coercion were associated with mental health-related quality of life. Methods: In this cross-sectional study, 128 adults with severe mental illness (42 hospital, 43 residential, 43 community) completed the Romanian SF-36 v2.0 and two brief study-specific rating scales for autonomy and perceived coercion. Service-use and cost data for the previous 12 months were extracted from records. Results: Community participants had higher SF-36 mental scores than hospital patients (63.3 ± 7.6 vs. 52.8 ± 9.1) and higher autonomy (72.1 ± 10.0 vs. 53.0 ± 8.6), with lower perceived coercion (4.2 ± 1.3 vs. 6.4 ± 1.5; all p < 0.001). Mean combined direct costs in residential and community settings were approximately USD 1000 lower than in hospital care (USD 2671.6 vs. 3666.2; p < 0.001). When residential and community participants were analyzed together as a deinstitutionalized group, they also had higher SF-36 mental scores (59.7 ± 8.9 vs. 52.8 ± 9.1; p < 0.001). In multivariable models (R2 = 0.316), each 10-point higher autonomy score was associated with a 2.8-point higher SF-36 mental score, whereas each 1-point higher coercion score was associated with a 1.3-point lower score. Exploratory mediation analysis suggested that autonomy statistically attenuated the association between deinstitutionalized care and mental quality of life. Conclusions: In this sample, residential and community arrangements outside hospital wards were associated with better mental health-related quality of life, higher autonomy, lower perceived coercion, and lower direct costs than long-stay hospital care. These findings support the study objective of comparing Romanian care settings and suggest that autonomy is an important correlate to target in future service reconfiguration and longitudinal research.