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PubMedDate not supplied

Responding to the needs of the homeless mentally ill.

The homeless mentally ill represent a pivotal and urgent challenge to the mental health field in the 1980s. Those homeless who have extended histories of psychiatric hospitalization stand as harsh reminders of the failures of deinstitutionalization, while young mentally ill homeless adults who never have been treated as inpatients testify to the gaps and unrealized promises of community-based care under deinstitutionalization. Homelessness and mental illness are social and clinical problems, respectively, distinct in some ways but intertwined in others. Some of the factors that contribute to homelessness--such as economic deprivations, a dearth of low-cost housing, discontinuities in social service systems, and radical changes in the composition of American families--are felt particularly keenly by many persons who are mentally ill. And symptoms of mental disorders, in turn, frequently impede an individual's capacities to cope with those, as well as other, stressors. Developing appropriate and effective responses to the needs of homeless people who are mentally ill requires precise definition and identification of the target population, innovations in the mental health service system, encouragement of those who staff it to work with homeless mentally ill patients, and public education. Ultimately, however, fundamental answers will be found in an improved understanding of severe mental illness, enhanced treatment capacities, and greater attention to the rehabilitative needs of mentally ill persons.

Adolescent↗
PubMed1985

Transmission of hepatitis B virus to classroom contacts of mentally retarded carriers.

The risk of the spread of hepatitis B virus infection from deinstitutionalized, mentally retarded carriers to pupil and staff school contacts in the New York City public school system was measured serologically in a three-phase study from 1978 to 1982. In the third phase, undertaken in 1982, blood samples were drawn and questionnaires were completed on students and staff tested in either of the first two phases and on comparison groups with intermediate and no known school exposure to deinstitutionalized carriers. Univariate and logistic regression analyses revealed that staff and pupils with a history of classroom exposure to a hepatitis B virus carrier had significantly increased prevalences of hepatitis B virus infection (13.4%, odds ratio = 1.9; 9.3%, odds ratio = 2.5, respectively). Similarly, yearly seroconversion rates of 1.3% and 0.67% indicate that staff and, to a lesser extent, pupils are at increased risk of infection.

Adolescent↗
PubMed2001

Homicide and schizophrenia: maybe treatment does have a preventive effect.

BACKGROUND: Persons with schizophrenia have been found to be at increased risk for homicide as compared with the general population. The increased risk may be associated with the implementation of the policy of deinstitutionalization. METHOD: Persons with schizophrenia who had committed or attempted homicide in the German state of Hessen from 1992 to 1996 and in the Federal Republic of Germany from 1955 to 1964 were compared. RESULTS: Schizophrenia increased the risk of homicide 16.6 times (95% CI 11.2-24.5) in the recent cohort and 12.7 times (95% CI 11.2-14.3) in the older cohort. These odds ratios are not statistically different. The lack of appropriate services for chronic high-risk patients and the non-use of mental health services by first episode, acutely psychotic patients were associated with homicide. CONCLUSION: There has been no increase in the risk of homicide among persons with schizophrenia since the implementation of the policy of deinstitutionalization. The examination of the recent period suggests that the provision of specialized long-term care to persons with schizophrenia who are at high risk for violent behaviour and the use of mental health services by acutely psychotic persons may reduce the risk of homicide.

Journal Article↗
PubMed1986

Community residential options for the chronically mentally ill.

We have discussed the problems of the new young chronic patients, deinstitutionalized old chronic patients now living in the community, and some of the groups of hard to place patients. We have talked about problems with community barriers, staff training, a spectrum of facilities, and we have looked at what new sorts of facilities may need to be developed. It seems clear that we have not yet developed a spectrum which can deal with all varieties of the chronically mentally ill. Pepper (1985) has suggested a different, more ideal spectrum of housing particularly suited to the young adult chronic patient. These include crisis residences, supervised 14-bed residences, growth house for 14 beds; support house for 14 beds; supervised apartments (satellite apartments), 14 beds; supportive apartments, 14 beds; (these have less intensive staffing than supervised ones); open community living; and residential congregate care for adults (RCCAs). These RCCAs are large facilities located either in old state hospitals or nursing homes which are primarily oriented towards the homeless mentally ill. According to Pepper, if a program can plan a spectrum of housing situations in the immediate catchment area, it can then actually meet the specific needs of each patient with a specific sort of residential facility. The challenge for community residences is certainly much greater than a decade ago and, with the homeless mentally ill population continuing to grow (Bachrach, 1985), one might be tempted to regard our present situation as one of crisis proportions. Clearly, there is little doubt that a need exists for a wide spectrum of living situations to be made available to the deinstitutionalized or never institutionalized young adult chronic patient. Yet very few incentives exist for those who would try to meet this challenge. To do this effectively will undoubtedly require the development of sizeable amounts of public funding through existing and new channels to provide support for a variety of new types of community living arrangements with varying degrees of structure and treatment. There is also a great need for continued educating of the community about the realities of treating chronic mental patients in tailored facilities who must be protected from harming themselves or others. Finally, we in the field need better continuing education for ourselves and for those staff working in the residential area. Most of us don't ever learn about how to operate outside of our offices.(ABSTRACT TRUNCATED AT 400 WORDS)

Chronic Disease↗
PubMed1988

Treatment, care, and rehabilitation of the chronic mentally ill in Poland.

In Poland primary health settings provide about 71 percent of mental health services, particularly to patients with less serious illnesses, while psychiatry provides specialized mental health care for the chronic mentally ill, the mentally retarded, and patients with alcohol or drug dependence. Poland has a large number of outpatient clinics and an extensive network of sheltered workshops. Most inpatient psychiatric beds are located in mental hospitals; few general hospitals have psychiatric units. Deinstitutionalization has been less extensive in Poland than in many other countries; only about 10 percent of the chronic patients treated in mental hospitals were deinstitutionalized between 1970 and 1981. During that period the proportion of patients hospitalized for a year or more decreased, the number of chronic patients treated in nursing homes increased, and the pattern of hospitalization shifted toward multiple readmissions.

Chronic Disease↗
PubMed1991

Geriatric patients and services in state hospitals: data from a national survey.

Notwithstanding the large-scale deinstitutionalization of the elderly, psychogeriatric patients continue to make up a significant portion of patients in U.S. state hospitals. This paper reports pilot data from a national survey assessing the current status of geriatric populations in state hospitals. Elderly patients still account for one-fifth of state hospital patients, and two-thirds of state hospitals still have separate geriatric units. The data suggest that, while deinstitutionalization of the elderly may be continuing in many state hospitals, in more than one-third of state hospitals the geriatric census is on the rise. Tentative hypotheses suggesting further research are discussed.

Aged↗
PubMed1979

The state mental hospital: a local health department's role.

The publicizing of the abysmal conditions in state mental institutions and the problems precipitated by their deinstitutionalization programs, have challenged local health authorities to develop effective roles in ameliorating these difficulties. Long-view State Hospital is a state mental hospital in Cincinnati, Ohio. The Cincinnati Health Department acted as a change agent to deal with the hospital's many chronic problems and the new difficulties precipitated by moving patients into the community for care. The city conducted its own evaluation of the hospital and its deinstitutionalization program and strongly advocated needed improvements. Problems were encountered in implementing this advocacy role, particularly in relation to the local health department's authority regarding this state-funded and operated institution. However, the many city recommendations that were implemented, the increased funding given the hospital and the community mental health centers, the continuing communication between city and state officials, as well as a follow-up evaluation indicated that the Cincinnati Health Department had played a positive role in the change process. (Am. J. Public Health 69:64-67, 1979.)

Government Agencies↗
PubMed2006

Serious mental illness, aging, and utilization patterns among veterans.

As veterans age, chronic physical and psychiatric conditions increasingly challenge the Veterans Health Administration. We examine influences of age and diagnosis on health care utilization, within the context of the 1995 deinstitutionalization policy of the Veterans Health Administration. Veterans were hospitalized repeatedly over 5 years with diagnoses of schizophrenia, bipolar disorder, depression, or alcohol dependence (N = 7,719). Inpatient days decreased 14% from baseline while outpatient (OP) visits increased 63%, consistent with deinstitutionalization. In adjusted models, OP utilization greatly increased with age, but psychiatric visits-notably alcohol treatment--dropped sharply. Emergency visits rose after 1997, particularly for ethnic minorities. Individuals ages 35-49 and 50-64 years were the greatest consumers of OP care; these large, aging cohorts will continue to require additional services, taxing a burdened system. Utilization patterns evolve across the life course, requiring foresight to address changing demographic demands. Careful attention to mental health utilization patterns may help policy makers and providers understand psychiatric needs in older patients.

Acute Disease↗
PubMed1999

Unhealthy Acts: interpreting narratives of community mental health care in Waikato, New Zealand.

This paper provides a regional commentary on the progress of deinstitutionalization in an era of restructuring in New Zealand. The commentary focuses on the Waikato region, where the transition to community-based psychiatric care has been underway since the announcement of the closure of Tokanui Hospital in 1993. We use media reports to construct a narrative illuminating the distinctive threads of alternative discourse on the re-placing of people with mental health problems and sites of treatment 'into the community'. Our interpretation of this local narrative is cast against a series of backdrops: firstly, we provide an abbreviated history of deinstitutionalization in New Zealand; secondly, we examine mental health care as a sector within a rapidly evolving health system; and, thirdly, we reflect on the implementation of community mental health care in a re-regulated civil society. We argue that the effective implementation of community care has been hampered by the lack of concerted policy in the mental health care sector, by a fiscal squeeze on the health care system and by the impingement of non-health care legislation (the Commerce Act, the Privacy Act and the Resource Management Act) on the local expression and management of community care. In the Waikato narrative, we also identify administrative practices that have recast people with mental health problems as criminals and re-established prisons as the site of treatment. We conclude that the media in New Zealand have a role that extends beyond simply reporting on events. Indeed, the media act as a reflexive conduit; journalists interpret issues and through their 'stories' help to shape the course of events.

Journal Article↗
PubMed1987

[Seeking refuge in the community.].

One of the many objectives of psychiatrie deinstitutionaliza-tion is to try to ensure that individuals who receive treatment reintegrate their community. The author points out that, for a certain category of young people undergoing treatment, such an objective requires a much broader approach involving more than psychiatric intervention alone; an increasing proportion of young people are left without community support and using prison as their drop-in centre. The situation is examined from the points of view of institutional practice and the life experience of subjects. The author sheds light on another step of psychiatric deinstitutionalization, namely social deinstitutionalization of a community's acceptance, support and accompaniment of the new generation of so-called mental patients.

English Abstract↗
PubMed1981

A study of criminal defendants referred for multiple psychiatric examinations regarding their competency to stand trial.

One of the mainstays of forensic psychiatry has been the determination of a defendant's competency to stand trial. Competency to stand trial is based on the U.S. Supreme Court ruling that a defendant must have sufficient ability to understand court proceedings. Regardless of whether or not the defendant was mentally ill at the time a crime was committed or when the charged, the court can try someone only if that person has the capacity to understand proceedings in order to defend himself. When there is any question as to the competency of the defendant, he is referred for psychiatric evaluation of competency. Very little research has been undertaken in the past to examine this clinically interesting group of subjects. A study was conducted to explore the characteristics of 137 defendants who had been charged and referred for evaluation at least twice to the Court Clinic of the Bronx-Lebanon Hospital Center Department of Psychiatry. It was expected that these would reflect the consequence of deinstitutionalization in New York State. Data were collected for each evaluation with regard to demographic characteristics, criminal history, and psychiatric history. Results are presented and discussed in light of the issue of deinstitutionalization. Note is made of the fact that only very small percentage of these patients have received outpatient psychiatric care. Suggestions for future research are offered.

Crime↗
PubMed1996

Status offenses.

Public policy is unsettled with regard to juvenile status offenders--children who are subject to juvenile court jurisdiction for noncriminal behavior such as running away from home, incorrigibility, truancy, and curfew violation. In 1974, the federal Juvenile Justice and Delinquency Prevention Act initiated a national policy of status offender "deinstitutionalization," supporting the development of community-based treatment programs and prohibiting incarceration of these youths. In the following years, most states embraced this policy, sharply reducing status offender detention levels. This article describes factors that have recently worked to erode the federal and state commitment to a policy of status offender deinstitutionalization. These factors include widespread failure to develop adequate services for youths and families; the tragic deaths of runaway youths; rising fear of juvenile crime; and new statehouse majorities promoting agendas of youth discipline and accountability. The article references recent surveys and press reports on the number of runaways, truants, and curfew violators in the United States. In the author's view, policymakers today are torn between their desire to provide services to at-risk youths and families and public pressure to respond to all forms of youth misbehavior with tough new sanctions, including the incarceration of status offenders.

Adolescent↗
PubMed1980

Foster home characteristics and psychiatric patient outcome. The wisdom of Gheel confirmed.

Even with the emphasis on deinstitutionalization, mental health services are still skewed toward hospital and nursing home care. A relatively untapped resource that is likely to receive more attention is the foster home. We previously demonstrated, in a controlled study of psychiatric patients randomly assigned to foster care or continued hospitalization, that foster care produced better social adjustment within four months. From that study we examine characteristics of foster homes associated with the improvement in social functioning. Improved outcome was related to more children in the homes, fewer boarders, and smaller size. Too much stimulation in the environment, more supervision by foster care sponsors, and more intensive follow-up by social work staff was bad for schizophrenic patients but good for nonschizophrenic patients. Neither the sponsors' tolerance and expectation nor the cost of foster care was related to outcome. The size and composition of homes are important and attention needs to be given to finding an enriched environment that is neither too stimulating nor too sterile for schizophrenic patients.

Adult↗
PubMed1985

Nursing home care as an alternative to psychiatric hospitalization. A Veterans Administration cooperative study.

Nursing homes have played a major role in deinstitutionalization, and their increased use for the mentally ill has been questioned. We performed a controlled study of nursing homes as an alternative to continued psychiatric hospitalization. Men (N = 403) referred for nursing home placement from eight Veterans Administration medical centers were randomly assigned to community nursing homes (CNHs), Veterans Administration nursing care units, continued care on the same ward, or transfer to another psychiatric ward. Patients met defined criteria for schizophrenia or organic brain disease. Data were collected before random assignment and six and 12 months later, covering physical and mental function, psychopathology, mood, social adjustment, satisfaction with care, as well as drug use, characteristics of settings, and movement in and out of settings. Significant differences between settings were found in self-care, behavioral deterioration, mental confusion, depression, and satisfaction with care. Results were strikingly consistent, showing the group transferred to another ward doing better and the CNH group doing worse. Drug use did not differ from six months before entering the study or later between the settings. Cost showed a marked advantage for the CNH group. Thus, the less costly community nursing home alternative must be viewed in the context of the nonmonetary costs of less favorable patient outcome.

Aged↗
PubMed1986

The homeless mentally ill. The perspective of the American Psychiatric Association.

The homeless mentally ill have become one of the greatest problems of present-day society. The American Psychiatric Association's Task Force on the Homeless Mentally Ill concluded that this is not the result of deinstitutionalization per se but of the way it has been carried out; homelessness among the chronically and severely mentally ill is symptomatic of the grave problems facing them generally in this country. Thus, the problem will not be solved until the basic underlying problems are addressed and a comprehensive and integrated system of care for the chronically mentally ill is established. Specific recommendations of the Task Force include an ample range of graded, supervised community housing; comprehensive and accessible psychiatric care and rehabilitation; the availability of general medical assessment and care, crisis services, and a dependable source of income; a system of case management in which one mental health worker is responsible for each patient; changes in commitment laws to make them more responsive to clinical needs; coordination between the various community resources; and ongoing asylum and sanctuary for that small proportion who require it.

Chronic Disease↗
PubMed1989

Critics and dissenters: reflections on "anti-psychiatry" in the United States.

During the 1970s various professionals and social activists adopted an explicitly anti-psychiatry position which was perceived by many as a new phenomenon. Hostility to psychiatry actually predates the establishment of psychiatry as a profession in 1844, and organized opposition to psychiatric practices appeared in the late nineteenth century. The deinstitutionalization of the 1970s, which was aided by development within psychiatry, had a strong anti-psychiatry component, but the novel aspect was the organization of ex-mental patients themselves. By the 1980s the decline of psychiatric power, dissension among ex-patients, and new social trends vitiated the anti-psychiatry movement.

Deinstitutionalization↗