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PubMed1983

The future of state hospitals: should there be one?

The recognition of the serious problems of state hospitals that dominated public policy in the 1960s has been largely overshadowed in recent years by a preoccupation with the problems of deinstitutionalization. The current backlash against the community movement threatens to legitimize once again the state hospital as an acceptable solution to the problems of the severely mentally ill. The author argues that state hospitals are deficient not simply because they provide an inferior quality of care but because they provide the wrong kind of care for most of their patients. He suggests that most state hospitals be completely replaced by a fundamentally different system.

Deinstitutionalization↗
PubMed1984

Forensic psychiatry and applied clinical ethics: theory and practice.

The authors briefly describe and then apply a new method--applied clinical ethics--for identifying and working with ethical problems. This method, starting from the clinical context, develops ethical constructs that may be tested in clinical practice and revised if required. The work was done in the context of a combined university-county forensic psychiatric service. The authors discuss three of the identified ethical issues: effects of deinstitutionalization, countertransference with forensic populations, and prediction of dangerousness. They discuss the basis for developing ethical norms from clinical experience and suggest ethical guidelines for medical practice.

Adolescent↗
PubMed1984

Asylum and chronically ill psychiatric patients.

The decision to change the primary locus of care for chronically ill psychiatric patients from the state mental hospital to the community has often set off a chain reaction of consequences. Notably, reducing the role of institutions has frequently resulted in destroying needed sanctuary for some patients. The author discusses the relationship between deinstitutionalization and the function of asylum and examines the relevance of three planning principles--functional equivalence, cultural relevance, and potential trade-offs--to the need of chronically ill psychiatric patients for asylum.

Chronic Disease↗
PubMed1987

The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later.

The authors report the latest findings from a 32-year longitudinal study of 269 back-ward patients from Vermont State Hospital. This intact cohort participated in a comprehensive rehabilitation program and was released to the community in a planned deinstitutionalization effort during the mid-1950s. At their 10-year follow-up mark, 70% of these patients remained out of the hospital but many were socially isolated and many were recidivists. Twenty to 25 years after their index release, 262 of these subjects were blindly assessed with structured and reliable protocols. One-half to two-thirds of them had achieved considerable improvement or recovery, which corroborates recent findings from Europe and elsewhere.

Adult↗
PubMed1991

Hidden severe psychiatric morbidity in sentenced prisoners: an Australian study.

OBJECTIVE: The aim of this survey was to estimate the prevalence of severe mental disorders in a representative sample of sentenced prisoners. METHOD: The subjects were selected as a random sample of sentenced prisoners in Melbourne's three metropolitan prisons. Interviews were conducted with 158 men and 31 women. Clinicians used the Structured Clinical Interview for DSM-III-R (SCID) to diagnose psychotic, affective, and substance use disorders. RESULTS: Six prisoners (3%) received current diagnoses of psychotic disorders, and 23 (12%) were diagnosed as having current mood disorders, mainly major depression. A lifetime diagnosis of at least one mental disorder each was made for 82% of the respondents, and in 26% more than one lifetime disorder was diagnosed. Sixty-nine percent received lifetime diagnoses of dependence on or abuse of alcohol, other psychoactive substances, or a combination of these. CONCLUSIONS: These findings do not indicate a large-scale shift of deinstitutionalized psychotically ill people from mental hospitals to prisons. They do, however, highlight the diversion into the corrections system of substance-dependent people and the apparent pool of prisoners with largely untreated major depression.

Adolescent↗
PubMed1992

Psychosocial rehabilitation and psychiatry in the care of long-term patients.

The relationship between psychosocial rehabilitation and psychiatry in the care of long-term mental patients is one that may often be characterized, at best, as an uneasy alliance. The author summarizes the basic concepts that define the discipline of psychosocial rehabilitation and discusses how those concepts have at times been distorted in actual practice. The article concludes with an analysis of the two disciplines' common ground in caring for long-term patients and a commentary on the benefits that each may offer the other. Together psychiatry and psychosocial rehabilitation hold the key to improved circumstances for realizing the promise of deinstitutionalization, which seems largely to have eluded us for the past several decades.

Deinstitutionalization↗
PubMed1992

The relationship between community resources and state hospital recidivism.

OBJECTIVE: The authors examined the propositions that a revolving state hospital door is an inevitable consequence of deinstitutionalization and that enhancing resources for community-based care can limit this phenomenon. METHOD: They analyzed the recidivism patterns of state hospital patients in a region of Massachusetts where, because of a federal court consent decree, the level of funding for community programs was more than twice as high as it was in other regions in the state and compared the pattern of recidivism in this region with that observed in the other areas of the state. RESULTS: Despite the fact that the average daily state hospital census in the resource-rich region was only half that of the other regions, longitudinal data on hospital use showed that the readmission patterns were similar in all state regions. CONCLUSIONS: The authors suggest that attributes of serious and persistent mental illness may have more effect on hospital readmission patterns than service system variables.

Community Mental Health Services↗
PubMed2003

Community integration of elderly mentally ill persons in psychiatric hospitals and two types of residences.

OBJECTIVE: Deinstitutionalization policy in the Netherlands has given rise to two new living arrangements for elderly long-term psychiatric patients. Both involve accommodation in mainstream residential homes for elderly persons, either concentrated in a specialized care unit or dispersed throughout the facility. The authors studied the effectiveness of these two housing models for the community integration of such residents compared with accommodation in a psychiatric hospital. METHODS: Three subsamples were selected: 49 residents in six units of concentrated housing, 47 residents in 12 units of dispersed housing, and 78 patients in 24 psychiatric hospital units, for a total sample of 174 participants. These samples were compared in a quasi-experimental, posttest-only design that used four measures of community integration: amount of perceived influence over one's daily life, involvement in social activities, social network size, and frequency of visits received from members of the network. To adjust for differences in the populations, the hospital patients were matched to the residential home residents, and confounding factors were controlled for. RESULTS: Residential homes afforded more privacy, were closer to public services, and had a more diversified population than psychiatric hospitals. Participants in dispersed housing experienced more personal influence over their lives than did hospital patients. Concentrated-housing participants were less enterprising and had smaller social networks. The three groups did not differ in the frequency of visits received from network members. CONCLUSIONS: Community-integrated facilities do not necessarily imply community-integrated residents. Only dispersed-housing residences were an improvement over hospitals, and then solely in terms of residents' influence over their own daily lives. The advantage of the dispersed-housing model is that it resembles independent living while its institutional nature offers structure and protection.

Aged↗
PubMed1986

Future of the chronic schizophrenic patient: prediction and recommendations.

A glimpse into the future for the schizophrenic patient requires a grasp of the history of American psychiatry and the many factors which led to the deinstitutionalization process and its negative effects. The paper reviews this material in some depth. It covers in detail the past forty years of legislation which saw psychiatry rise to heights of good care and then slowly decline to its present state. Some predictions are made about the continuing fate of the state system, how schizophrenic patients are likely to be viewed and treated, and where they will tend to live. Long-term psychotherapy increasingly will fall into disrepute, hospital care will be increasingly brief, biologic in its emphasis and the numbers of chronically ill schizophrenics will grow out of control. It is predicted that there will not be a breakthrough in either the biologic or social fields, and pessimism will reign.

Chronic Disease↗
PubMed1979

National trends in hospitalization.

The past two decades have witnessed several important trends in mental health care: a decline in the resident census in public mental hospitals, an increase in outpatient treatment and facilities, relative stability in the number of hospitalization episodes per 100,000 population, and briefer duration of hospitalization. The combined result of these trends is increased pluraslism, diversity, and deinstitutionalization in mental health care. The changes are primarily the consequences of the success of psychopharmacologic agents, new forms of psychotherapy, changing attitudes of the public and the profession, and increased financial support by the federal government.

Community Mental Health Centers↗
PubMed1979

Planning mental health services for chronic patients.

At the present time, deinstitutionalized services for the chronically mentally ill are less than satisfactory. If planning for the future is to reverse the trend of incomplete service delivery for this population, it must start with the recognition and application of certain fundamental concepts. Effective planning requires idealism, vision, and a sense of reality. Six separate but interrelated dimensions of reality must be taken into account: the need for mental hospital; the importance of precise planning goals; the unique service needs of the chronically mentally ill; the need for interagency planning; the importance of a functioning and sensitive patient tracking system; and appreciation of the attitudinal structure within which services are delivered. Wherever the chronically mentally ill live, whether in the hospital or in the community, their requirements must be made the primary focus in mental health planning.

Attitude of Health Personnel↗
PubMed1980

Time-limited residential treatment: issues and evaluation.

The trends toward deinstitutionalization and community care have increased the need for short-term residential programs, and the literature supports their effectiveness as an alternative to longer-term care. The authors describe an innovative short-term residential treatment program at Florida Mental Health Institute. Called the Early Intervention Project and limited to nine weeks, it uses a combination of behavioral and psycho-educational techniques for building skills in younger patients who have not received extensive prior treatment. It includes training modules in assertiveness, communication, problem-solving, managing anxiety and depression, medication, relaxation, and nutrition, and also incorporates a peer-managed token economy. A series of research studies have demonstrated the program's effectiveness in changing patient behavior.

Adolescent↗
PubMed1980

Building a network of aftercare services.

When a state hospital in New York began returning long-term psychiatric patients to community living in Westchester County in 1974, the staff of the hospital, local community mental health providers, administrators of a private proprietary home for adults that received many of the patients, and local citizens worked to develop an integrated system of aftercare services. The local mental health council served as the umbrella group for the coordination of the various providers and consumers. The council's aftercare committee investigated several troubling aspects of the deinstitutionalization process including patient selection, the program and staffing of the home, transportation for residents, the physical structure of the home, and its licensing. The authors report the committee's findings and resolutions of some of the problems, and discuss some of the financial difficulties of residents in the home. While some problems remain, the authors feel that the council structure was a crucial element in facilitating a coordinated network of aftercare services.

Aftercare↗
PubMed1981

Changing public attitudes about the mentally ill in the community.

The public's often negative response to two decades of deinstitutionalization policies remains a substantial barrier to the integration of the mentally ill into the community. Both mental health policymakers and public education specialists must support new programs to promote public acceptance. To do this, new research on the linkages between public attitudes and public behaviors is needed. Two research agendas should be established. First, there must be more specific research on how public attitudes about the mentally ill translate into community receptivity. Second, research must determine whether collaborative approaches to attitude-behavior change--involving communities in the process of changing themselves--or structural approaches--utilizing legal and social pressures--are more effective in promoting community integration.

Attitude to Health↗
PubMed1981

Community support for the psychiatrically disabled: a state perspective.

The National Institute of Mental Health initiated the community support systems program in 1977 to improve services to the mentally disabled living in the community as a result of the deinstitutionalization movement. Georgia was one of several states to receive a contract for a community support implementation project. The project has focused on helping local, regional, and state personnel reorder their priorities and policies in program planning and implementation, documenting the extent and severity of the need for services, and building a foundation for community support systems among citizens' groups and direct service agencies. Specific project activities during the first and second years are described.

Community Mental Health Services↗
PubMed1981

Alternatives to hospitalization developed by an urban mental health center: an overview.

For 150 years public institutions, caught between society's insistence that all needy persons receive some kind of services and taxpayers' reluctance to support such services, have been forced to take in all patients who have no place to go, without adequate resources for providing services to them. This long experiment on the effects of underfunding has led to the move to develop alternatives to large public institutions. Massachusetts Mental Health Center, which serves its urban catchment area without a backup hospital, has set up a comprehensive system of alternatives to hospital care; serving the chronic patient is a major concern. This paper and the following four papers describe certain aspects of the center's alternatives to hospitalization. They include a four-year follow-up of deinstitutionalized patients, a Quarterway House for patients with persistent severe disabilities, a network of residential placements, and a program for training psychiatric residents in the care of chronic patients.

Boston↗
PubMed1981

Alternative to the back ward: the quarterway house.

The Quarterway House was founded in December 1978 to deinstitutionalize and provide rehabilitation services to a small group of long-term, seriously ill inpatients of the Massachusetts Mental Health Center. The purposes of the residential program are to provide a less institutional therapeutic environment and to develop a psychosocial treatment program that might enable some patients to move toward more independent settings in the community. In a randomized experimental study, with center inpatients as the control group, the effectiveness of the program was assessed by multiple outcome measures before the program began and at one year. Although neither group moved rapidly to more independent community living, Quarterway House patients showed improvement in general functioning and socialization-survival skills and decreased medication and seclusion. They did not show a decline in psychotic symptoms, obstreperousness, or antisocial behavior. Over-all, the findings suggest the program may prove useful for the long-term rehabilitation of severely ill patients.

Activities of Daily Living↗
PubMed1981

The complicated business of setting up residential alternatives.

To meet the housing needs of deinstitutionalized clients characterized by low incomes, isolation from their families, and inability to function independently, the Massachusetts Mental Health Center has developed a range of community residential settings. Among them are the independent living apartment program, partly supported by section 8 rent subsidies from the Department of Housing and Urban Development, and group homes for 12 to 18 clients. Factors that have contributed to the success of the program include diligent cultivation of relationships with housing developers, innovative support from the staff of the state housing and finance agency, clear delineation of rights and responsibilities of tenants and owners, and the center's system of backup services for clients. The center is currently developing additional housing under HUD's section 202 demonstration program for housing of the handicapped through rehabilitation of existing buildings.

Boston↗