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PubMed1986

Continuous treatment teams in the care of the chronic mentally ill.

Since deinstitutionalization began, the model of service delivery for the chronic mentally ill has been characterized first by the mere availability of services and then by continuity of care as coordinated through the case manager system. However, there is increasing evidence that the continuity of care model has neglected an element crucial to its success--continuity of caregivers. Continuity of caregivers means that a single, continuous treatment team is responsible for patients in both inpatient and outpatient settings. The author discusses several programs that have successfully used continuous treatment teams, the theoretical considerations supporting use of the teams, and the problems be encountered after trying to implement such teams at a public psychiatric hospital in Washington, D.C.

Australia↗
PubMed1986

Assessing support and stress in the social networks of chronic patients.

The social support network of deinstitutionalized chronic mentally ill patients can help moderate life stresses and reduce the need for rehospitalization. The authors have developed a list of questions that can be used in assessing the various characteristics of a patient's social network, including the number of people in the network, the types of roles assumed in each relationship, and the nature of behavioral exchanges in each relationship. They believe that research on the social networks of chronic patients may provide information that will lead to more effective intervention.

Adult↗
PubMed1986

The challenge of chronic mental illness: a retrospective and prospective view.

The challenge of chronic mental illness lies in developing effective service delivery systems that will preserve patients' functioning and limit their disability. The author uses a review of changes and excesses of the past 30 years--including deinstitutionalization, relocation of patients to nursing homes, the domination of psychodynamic concepts, and the naivety and partial successes of the community mental health movement--as a basis for outlining manageable ways to meet this challenge. Care for the chronic patient must be developed within a long-term rehabilitative context and with wiser use of available benefits and funds, including consolidation of funding sources. Mental health advocates should coordinate activities rather than compete with one another, and case management should be based on more sophisticated concepts and training.

Chronic Disease↗
PubMed1987

Aging parents as caregivers of mentally ill adult children: an emerging social problem.

More than one-third of long-term mentally ill adults live with their families, most with aging parents, a situation that accentuates the need for residential alternatives to home care for deinstitutionalized patients who will out-live their caregivers. The role of parenting mentally disabled adults may also impose undue stress on elderly persons. Objective and subjective parental burden, including fears for the patient's future, are increased by the mental health system's failure to offer education, support, training in problem solving, and a collaborative role in discharge planning to family members. Social policy implications of considering families as primary caregivers include the danger that government will be relieved of responsibility for care of the mentally ill, the creation of a potentially at-risk population among aging parents and other family members affected by the stresses of caregiving, and the reduction of the patient's potential for independent living.

Activities of Daily Living↗
PubMed1987

Psychiatry before the year 2000: the long view.

The author assesses psychiatry's accomplishments during the past quarter century and the challenges the profession faces in a changing political, economic, and medical environment. He believes that several of the policy decisions of the early 1960s, particularly the deinstitutionalization movement, were based on faulty premises and that their consequences hold valuable lessons for future policy planning. Among psychiatry's major challenges are advancing its knowledge base through intensive research; increasing the accessibility and quality of existing therapeutic services despite constrained resources; and enhancing confidence of the voting and paying public, including other physicians, in the field's unique capabilities. Such confidence will be conditioned on a rigorous redefinition of the boundaries of psychiatry, acknowledging both the field's limitations and its responsibilities to other than the "traditional" psychiatric patient.

Deinstitutionalization↗
PubMed1987

Beyond model programs: evaluation of a countywide system of residential treatment programs.

Assessing deinstitutionalization as a social policy requires examining a system of programs rather than single, "model" services. The authors report an evaluation of 19 residential treatment programs in Hennepin County, Minnesota, that provide three different levels of care (intensive, transitional, and supportive) for mentally ill clients. Data on client characteristics, program outcomes, and hospitalization costs were collected in two study periods between 1980 and 1985. The results showed that the programs served three distinct client subpopulations that differed in recidivism, vocational status, discharge setting, and costs according to the type of program. Clients in all programs made substantial gains in community integration, and as a group the programs were cost-effective.

Chronic Disease↗
PubMed1988

Characteristics of state hospital patients who are hard to place.

As a result of deinstitutionalization, acute care beds in state hospitals have become blocked by patients who lack access to appropriate community placements but who have derived maximum benefit from hospital care. To help plan community services for these patients, this study identified and described patients at an Oregon state hospital who were hospitalized longer than therapeutically necessary because no community facility could treat them. A total of 146 patients were identified during a three-month period, and 81 were described; 65 percent were men, 70 percent were schizophrenic, and 90 percent presented a risk to themselves or others. The patients exhibited few strengths, and one-third had a substance abuse problem, at least one counter-therapeutic attitude, or a need for medical monitoring. The authors describe how new community residential facilities can meet the needs of these difficult patients.

Adult↗
PubMed1990

Economic barriers to widespread implementation of model programs for the seriously mentally ill.

Although deinstitutionalization has been linked with an increase in the number of mentally ill people who are homeless or in jails, several demonstration programs started during the past 30 years have shown that community-based services for the seriously mentally ill can be both humane and cost-effective. Four such programs, none of which has been widely implemented or has significantly influenced service delivery systems, are described. The author contends that the chaotic and illogical funding system for mental health services is primarily responsible for failure of the widespread implementation of demonstrably effective programs. The economic disincentives of the present system include lack of coordination of services at the state and local level and federal policies that favor hospitalization, restrict payment for outpatient and rehabilitation services, and discourage mentally ill persons from working. The author suggests that public services for the mentally ill are unlikely to improve significantly until such disincentives are addressed.

Aftercare↗
PubMed1990

Sociological investigations of mental illness: a review.

Contemporary sociological research has expanded knowledge about how the label of mental illness affects individuals and about how patients' and psychiatrists' social characteristics affect the assessment and treatment of mental disorders. The authors review the recent sociological research dealing with the effect of extrapsychiatric factors such as social class, race, gender, marital status, and age on the development, diagnosis, and treatment of mental illness. They also examine sociological studies of the social role of the state hospital, the consequences of deinstitutionalization for chronic mentally ill patients, and the relationship of mental illness and homelessness. Studies that examine the social aspects of psychiatric practice, including the objectivity of psychiatric diagnosis, are also reviewed.

Deinstitutionalization↗
PubMed1992

What we know about homelessness among mentally ill persons: an analytical review and commentary.

Although extensive research on the homeless mentally ill population has been conducted, existing studies have failed to answer three important questions: the prevalence of chronic mental illness among homeless persons, whether deinstitutionalization has precipitated increased homelessness in this population, and what kinds of services should be offered. The author suggests that future research will require clearer definition of the terms used in discussing this population and calls for increased federal direction in making policies to respond to their problems, especially the problems of those who are geographically mobile. Successful service planning must address the full array of disabilities experienced by homeless mentally ill persons, including psychiatric symptoms, secondary responses to the experience of illness, and disabilities resulting from stigma and lack of societal opportunity.

Chronic Disease↗
PubMed1993

When there are almost no state hospital beds left.

The number of state hospital beds nationwide has been reduced to 40 per 100,000 population; in California, nonforensic state hospital beds have decreased to 8.3 per 100,000. The main effects of this reduction are becoming more evident. Most seriously affected have been the new generation of chronically and severely mentally ill persons who have reached adulthood since deinstitutionalization. Those who need intermediate or long-term hospitalization and cannot receive it may become even more desperate and psychotic; may avoid treatment entirely; and may turn to drug abuse and become homeless or incarcerated in jail. Moreover, the small number of long-stay beds can lead to a breakdown in the public mental health system and attempts to avoid responsibility for persons who need both acute and long-term hospitalization. This avoidance can be manifested by raising admission criteria for acute treatment or shifting responsibility to other systems. The authors recommend providing intermediate and long-stay hospitalization to the extent needed.

Adolescent↗
PubMed1995

A survey of an organization for families of patients with serious mental illness in The Netherlands.

OBJECTIVES: Members of Ypsilon, a Dutch family organization for relatives of patients with schizophrenia or chronic psychosis, were surveyed to determine whether patients whose families were involved in the organization were representative of all patients with schizophrenia in the Netherlands and whether Ypsilon was similar to family organizations in other countries, to learn about members' experience of the course of their relatives' illness, to determine the kinds of mental health care received by the patients, and to discern members' opinions of that care. METHODS: An extended version of the Involvement Evaluation Questionnaire, which measures consequences of psychiatric disorders for patients' relatives, was sent to a random sample of 1,000 Ypsilon members. The response rate was 70 percent. RESULTS: Members of Ypsilon are mainly older mothers of young male patients with a long history of schizophrenia. The patients as a group appeared to be more severely ill than the overall population of patients with schizophrenia in the Netherlands. Many respondents reported dissatisfaction with the quality of mental health care for their relative, particularly with their lack of access to treatment professionals, lack of information about their relative's illness, and lack of family involvement in treatment planning. CONCLUSIONS: Members of Ypsilon represent patients with severe mental illness who do not benefit sufficiently from treatment. Members want a greater role in treatment planning and more information and support from mental health care professionals. Members of Ypsilon and of family organizations in other countries have much in common, even though the extent of deinstitutionalization varies between countries.

Adult↗
PubMed1996

Long-term follow-up of rehabilitated patients with chronic psychiatric illness in Ireland.

In 1994 a 20-year retrospective study was conducted of 297 psychiatric patients admitted to an inpatient rehabilitation program in rural Ireland over a 15-year period (1974 to 1989). All patients were traced. Seventy-six percent had been discharged into the community, and two-thirds required supported housing. Fifty-five percent had experienced acute psychiatric readmissions, and 17 percent became new long-stay patients. The main criticisms of deinstitutionalization did not apply to these patients. No patient became homeless. One patient became involved in possible criminal activity. Four patients committed suicide, and the annual death rate was low-1.8 per 100 patients. The model of care involved was a key factor in the satisfactory outcome.

Adolescent↗
PubMed1996

Old and new: a comparison of state psychiatric hospitals.

The study examined whether state hospitals in operation before deinstitutionalization still carry vestiges of older models of psychiatric care. Using a national database, the authors compared 166 state hospitals built before 1949 with 80 state hospitals built after that time. The old hospitals treated fewer children and adolescents, received more state funding and less third-party funding, had fewer professional clinical staff, spent less on salaries and maintenance, and had more beds, a lower turnover rate, and a longer average length of stay. Findings suggest that planners and policymakers should take into account a facility's history when attempting to introduce innovations.

Adolescent↗
PubMed1998

Persons with severe mental illness in jails and prisons: a review.

OBJECTIVE: The presence of severely mentally ill persons in jails and prisons is an urgent problem. This review examines this problem and makes recommendations for preventing and alleviating it. METHODS: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1970, and all pertinent references were obtained. RESULTS AND CONCLUSIONS: Clinical studies suggest that 6 to 15 percent of persons in city and county jails and 10 to 15 percent of persons in state prisons have severe mental illness. Offenders with severe mental illness generally have acute and chronic mental illness and poor functioning. A large proportion are homeless. It appears that a greater proportion of mentally ill persons are arrested compared with the general population. Factors cited as causes of mentally ill persons' being placed in the criminal justice system are deinstitutionalization, more rigid criteria for civil commitment, lack of adequate community support for persons with mental illness, mentally ill offenders' difficulty gaining access to community treatment, and the attitudes of police officers and society. Recommendations include mental health consultation to police in the field; formal training of police officers; careful screening of incoming jail detainees; diversion to the mental health system of mentally ill persons who have committed minor offenses; assertive case management and various social control interventions, such as outpatient commitment, court-ordered treatment, psychiatric conservatorship, and 24-hour structured care; involvement of and support for families; and provision of appropriate mental health treatment.

Commitment of Persons with Psychiatric Disorders↗
PubMed2000

The last half-century of psychiatric services as reflected in psychiatric services.

The last half-century of psychiatric services in the United States is examined through developments and trends reported in the 50 years of publication of Psychiatric Services. The journal, earlier named Mental Hospitals and then Hospital and Community Psychiatry, was launched by the American Psychiatric Association in January 1950 and marks its 50th anniversary this year. The author organizes his review of psychiatric services largely around the locus of care and treatment because the location of treatment--institution versus community--has been the battleground for the ideology of care and for the crystallization of policy and legal reform. He uses "dehospitalization" to describe the movement of patients out of state hospitals, rejecting the widely used term "deinstitutionalization" as inappropriate; one reason is that the term wrongly implies that many settings where patients ended up were not institutional. Also covered in detail, as reflected in the journal, are community care and treatment, economics, patient empowerment, and the interface issues of general hospitals, outpatient commitment, and psychosocial rehabilitation. The author notes that some concepts, such as outpatient commitment and patient empowerment, emerged earlier than now assumed, and that others, like psychosocial rehabilitation, recurred in slightly different forms over time. He concludes that even after 50 years of moving patients out of state hospitals and putting them somewhere else, mental health policymakers and practitioners remain too myopically focused on the locus of care and treatment instead of on the humaneness, effectiveness, and quality of care.

Deinstitutionalization↗
PubMed2002

Discharging older adults with a severe and chronic mental illness in the community.

In recent years, a deinstitutionalization movement has been occurring in Canadian psychiatric institutions. Occupational therapists, experts in evaluating occupational performance, are key contributors to the selection of appropriate community housing environments. This study describes the global functioning, performance in activities of daily living, social behavior, cognitive status, and quality of life of 33 older adults with a severe and chronic mental illness, who were transferred from a psychiatric hospital to community facilities between 1995 and 1998. Evaluations were repeated five times, twice before discharge and three times after the transfer. Participants demonstrated stability in their global, social and ADL functioning over time. In general, participants required occasional intervention for management of social behaviors, moderate assistance in activities of daily living, and were highly satisfied with their community accommodation. The transfer to community settings did not lead to a significant deterioration in the participants' levels of global functioning and quality of life.

Activities of Daily Living↗
PubMed2000

Utilization of psychiatric inpatient care in Greece: a nationwide study (1984-1996).

This report examines the trends in the utilization of psychiatric inpatient care for the period 1984-1996, when the implementation of the psychiatric reform programme was initiated in Greece. Admissions in public mental hospitals declined by 7.2%. However discharges have been increased by 30.6% with a parallel decrease of the length of stay by 53.7% followed by an increase in discharges of patients diagnosed as suffering from schizophrenia and affective psychoses by 61.1% and 123.8% respectively. In the private sector a remarkable reduction in both admissions and discharges was noticed. Admissions in psychiatric departments of general hospitals for the same years have been increased by 1054.1%. It seems that the recent deinstitutionalization process resulted in increasing trends in the discharges of patients suffering from psychoses. Additionally, a substantial increase in the number of extramural psychiatric services and rehabilitation places between 1994-1996 was observed. The demand for the mental health care services expressed as the urbanization index was found to be related with mental health professionals and the extramural units ratios. The higher degree of urbanism is, the greater the number of extramural services exist. The models explained variance reached 50.6%.

Affective Disorders, Psychotic↗