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PubMed1997

Primary care of adults with mental retardation.

BACKGROUND: There is a national trend to deinstitutionalize mentally retarded adults, placing them in community residential settings. As a result, community-based primary care physicians will assume responsibility for their medical care. Primary care physicians may have uncertainties regarding the medical care of this population. The purpose of this case series is to describe the medical care of a group of adults with mental retardation during their first year of community residence following deinstitutionalization, and to provide practical advice to family physicians who care for these adults. METHODS: Medical diagnoses and medications at the time of deinstitutionalization of a series of 21 adults were abstracted from institutional records and transfer forms. Follow-up data were obtained from office medical records. RESULTS: In the first year following deinstitutionalization, each patient averaged 6.6 office visits to a family physician. Newly identified major health impairments were: chronic persistent hepatitis due to hepatitis B, acid peptic disease, gastroesophageal reflux disease, dysphagia, primary degenerative dementia, absence seizures, bronchiectasis, and idiopathic iridocyclitis. Significant changes in pharmacotherapy included consolidation of multidrug anticonvulsant regimens and discontinuance of psychotropics and laxatives. Health maintenance practices included hepatitis B immunizations, cholesterol determinations, smoking cessation counseling, and calcium supplementation. CONCLUSIONS: Newly deinstitutionalized patients require careful diagnostic and therapeutic reassessment. Family physicians assuming their care need to look for conditions common in this population, including dysphagia, seizure disorders, chronic hepatitis B, and sensory impairments. Previously neglected health maintenance practices need to be instituted. Pharmacotherapies, particularly anticonvulsants, psychotropics, and laxatives, may be amenable to dosage reduction or discontinuance.

Adult↗
PubMed1986

Breaking the circuit of social control: lessons in public psychiatry from Italy and Franco Basaglia.

Much public discourse in the United States and in Canada acknowledges the dismal failure of the policy to 'deinstitutionalize' mental patients and to return them to some semblance of community living. The American Psychiatric Association has recently called for a reassessment of institutional alternatives--a call for a return to the asylum--in response to the needs of the new population of so-called homeless mentally ill. Here we contrast the failures of North American deinstitutionalization with the relative successes achieved in those regions of Italy where deinstitutionalization was grounded in a grassroots alternative psychiatry movement and professional and political coalition, Psichiatria Democratica. Democratic psychiatry challenged both the medical and the legal justifications for the segregative control of the 'mentally ill': madness as disease, and the constant over-prediction of the dangerousness of the mental patient. In addition, the movement challenged traditional cultural stereotypes about the meanings of madness, and was successful in gaining broad-based community support from political parties, labor unions, student groups, and artist collectives that were enlisted in the task of reintegrating the ex-mental patient. The Italian experiment, although flawed and riddled with its own inconsistencies and contradictions, offers evidence that deinstitutionalization can work without recreating in the community setting the same exclusionary logic that was the foundation of the asylum system.

Community Psychiatry↗
PubMedDate not supplied

[Transfer of a child from children's home to family: medical aspects].

The project "Leaving of babies at children's homes and deinstitutionalization" was implemented at the children's home of Tbilisi. The purpose was to find out what influence was produced by deinstitutionalization on the physical and psychomotor development of deprived babies. The study lasted for 12 months. 3 groups of children were investigated. Group 1 comprised children selected for deinstitutionalization, age-matching healthy children who stayed at the children's home were in group 2, and healthy children randomly selected from 2 nurseries of Tbilisi were in group 3. The parameters of anthropometry and psychomotor development were evaluated according to the Denver screening test at the very beginning and in 12 months. The children from the children's home almost caught up, in 12 months after deinstitutionalization, with their control matches. Whereas, the children, who were brought up at the children's home, were behind the group-1 children and controls by all parameters. Projects promoting the upbringing of deprived children in their own or foster families are recommended for implementation.

Child↗
PubMed1999

Closing of a state hospital: an overview and framework for a case study.

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH.

Deinstitutionalization↗
PubMed1992

Some issues in staff training and improvement.

In 1988, Norway's parliament instituted the systematic deinstitutionalization of the nation's health care system for mentally retarded persons. Professionals have recognized that deinstitutionalization will succeed only if treatment personnel can provide effective treatment for their clients. A study is presented in which 152 hands-on staff members were assigned to 76 clients with moderate to severe mental retardation. The study asked whether staff training in behaviorally oriented treatment and assessment would produce greater improvement in the behavior of clients and staff than would training in treatment alone. Data failed to support this hypothesis, but did provide clear evidence that both clients and staff improved with staff training. The assessment of such programs is seen to be of great importance in view of the fact that deinstitutionalization will leave the majority of mentally retarded clients in Norway in the care of persons who have received such limited forms of training.

Activities of Daily Living↗
PubMed2004

Pilot study on the use of psychotropic medication in persons with mental retardation.

OBJECTIVE: To explore the status of the psychotropic medication in persons with mental retardation 6 years after their deinstitutionalization. METHOD: The authors compared the profiles of psychotropic medication of 60 persons with mental retardation deinstitutionalized (D-sample) from our local mental hospital 6 years ago, to their actual pharmacological profile. Later, we compared our results to the ones of persons with mental retardation on an in-patient (In-sample) unit where existed a concerted team effort to lower the medication when deemed appropriate. RESULTS: Six years post-deinstitutionalization, the authors observed that the same percentage of patients remained on antipsychotic and benzodiazepine medication in our D-sample, and a threefold increase of those using antidepressive medication. However, we observe a general decrease of all types of psychotropic medication in the In-sample with complete withdrawal in a substantial number of patients. CONCLUSIONS: The authors take these pilot data to mean that a concerted team effort at lowering medication in persons with mental retardation makes a significant difference. The possibility of other factors (age, sex, severity of mental retardation, psychiatric diagnosis) explaining the difference in the results is discussed.

Adult↗
PubMedDate not supplied

Evaluating the closure or downsizing of psychiatric hospitals: social or clinical event?

OBJECTIVES: The evaluation matrix recently proposed by Tansella and Thornicroft suggests that the field of social and epidemiological psychiatry has focussed more on the individual/patient level of mental health care services than the system level. Moreover, phenomena such as deinstitutionalization have been examined more as clinical events than as social ones. The aims here are to deepen our understanding of deinstitutionalization, particularly as regards the downsizing/closure and role of psychiatric hospitals. METHODS: I begin by reviewing the manifest and latent functions of psychiatric hospitals. This is followed by a discussion of how these functions must be met by any comprehensive community-oriented system of mental health care for severely mentally ill patients. Also, in order to reframe the downsizing/closure of psychiatric hospitals as a social event for the field of social psychiatry and psychiatric epidemiology, I posit that the process of deinstitutionalization is driven today by the same forces that were present at the outset of the movement. RESULTS: I review four recent series of studies addressing primarily the outcomes, but also other aspects, of the downsizing/closure of psychiatric hospitals, with a view to illustrating the methods used, the results obtained and the blind angles missed in this research. CONCLUSIONS: Lessons are drawn on how to fill certain vacant cells of the matrix.

Community Psychiatry↗
PubMed1997

Victimization of people with enduring mental illness in the community.

The deinstitutionalization of care for the mentally ill has been in vogue for about fifty years. Broadly speaking, this transition can be seen to exhibit the following main trends: a dramatic decline in the inpatient population of psychiatric hospitals, coupled with a corresponding increase in community facilities such as psychiatric units in general hospitals, day hospitals, and day centres. It has been claimed that deinstitutionalization ends previously enforced seclusion, enhances human dignity and allows individual privacy. The deinstitutionalization movement has inevitably led both to large numbers of former long-stay patients being cared for in the community and to significant numbers of individuals developing enduring mental illness in the community without ever having had a long inpatient tenure. The findings of recent studies (Gould 1992, Brockington et al. 1993) suggest that there is a positive public attitude towards the mentally ill. However, Kelly (1997), while carrying out Quality of Life research, found that over half of the community-based long-term mentally ill he surveyed reported that they had experienced harassment/victimization. This paper is not a report on the Quality of Life research but a discussion on the theme of victimization that has emerged from the study. The extent of the problem is discussed as are the implications for mental health professionals.

Attitude to Health↗