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PubMed1995

[Social representation of labels associated to mental illness].

The social context linked to deinstitutionalization brought the authors to study the impact of labels placed on people having undergone psychiatry. The objective of this research is to better understand the subtleties made by the public concerning the following terms: the mentally ill person (malade mental), the ex-psychiatric patient (ex-patient psychiatrique) and the person suffering from a mental health problem (personne souffrant d'un problème de santé mentale). Data collected from 255 francophone residents from the Montréal area show that the expression "ex-psychiatric patient" is less stigmatizing than the expressions "mentally ill person" or "person suffering from a mental health problem" (PSMHP), as it refers to a past event that is over and done with. The expression "mentally ill person" emphasizes the chronic nature of the health problem suffered by the individual, where as the PSMHP focuses on the person's potential for recovery. The expression "ex-psychiatric patient" points to the capacity to function normally in society.

Adolescent↗
PubMedDate not supplied

Social policy and mental illness.

The authors discuss deinstitutionalization of chronic mentally ill patients from public state institutions and the effect of social policy on the care of these individuals. A continuity of care model is suggested for comprehensive consistent care of these individuals.

Continuity of Patient Care↗
PubMed1995

Residential circumstances of older Australians with mental retardation.

Residential circumstances of Australians 55 years or older with mental retardation were investigated. Data were collected via interviews from 446 individuals living in Queensland and Western Australia who were identified following an extensive national search. Although survey results indicated that older people lived in a wide variety of residential settings, the majority still resided in large private or public institutions. There is evidence that deinstitutionalization had occurred, although it affected only 35% of the cohort. One important finding in the study concerns the relatively minor role participants play in determining their future care and residential needs. Interviews established that less than 10% of those in each sample would be involved in future decision-making processes.

Aged↗
PubMed1995

[Community management needs a community that cares--the attitude of the population to psychiatric management and psychiatric patients].

Since community mental health care started public attitudes towards mentally ill and mental health care had been development to an important influencing factor in planning mental health care and in rehabilitation of patients. This paper describes the historical development of research in public attitudes in psychiatry, which started with deinstitutionalization. It discusses the interaction between types and quality of mental health care and public opinions or attitudes towards the care of mentally ill patients, considering own empirical results.

Community Mental Health Services↗
PubMedDate not supplied

[Evaluation of autonomy in chronic mental patients. Problems, assessment tools, results].

The autonomy of adult patients suffering from chronic psychiatric disorders is a notion in which we need to take an interest due to evolutions in patient care. The tendency of deinstitutionalization in the United States, in Italy and to a lesser degree in France has generated certain perverse effects when: capacities for self sufficiency, learning abilities to be developed, and substitutes to be set up, were not correctly evaluated from the outset. Many methods conceived mainly in the United States and in Canada were elaborated with such a diversity of approaches that, even today, for self-sufficiency, an instrument for evaluation which is universally prevalent and used, still does not exist in the way that has been possible for other clinical dimensions. The ability to accomplish the daily tasks for survival, the ability to reach decisions in life, the ability to enter into and sustain relationships with others do not embrace the dimensions explored by the scales of general psychopathology, of functional repercussions or of the quality of life. Moreover, the evaluation of these abilities is highly dependent on cultural characteristics. To adapt the existing methods to the French sociological realities or to conceive and elaborate simple and reliable procedures from our practices in professional and social reinsertion is a compulsory step in developing research in this field. Public Authorities and the teams on the ground should grasp the characteristics for innovation and its abilities for raising the hopes of patients, every bit as much as the actual progress in therapeutic practice.

Activities of Daily Living↗
PubMed1996

Why do states privatize mental health services? Six state experiences. The MEDSTAT Group.

State governments fund more than one-half of public mental health service system costs through mental health departments, other state agencies, and the Medicaid program. They use some of these resources to finance community-based mental health services through purchase-of-service contracts. I explored the reasons why states privatize mental health services and focused on political, economic, and organizational theories as possible frameworks for contracting. I gathered data during site visits to Massachusetts, Michigan, New York, Oregon, Tennessee, and Texas, where I interviewed more than one hundred individual stakeholders about mental health purchase-of-service contracting. I also examined relevant documents about contracting practices for mental health services in each state. My results suggest that state policy makers can use mental health contracting to effect multiple goals. Contracting helps states achieve political, economic, and organizational objectives, such as avoiding the influence of interest groups and leveraging state resources, while avoiding conflict. With contracting, state policy makers can also continue the ongoing mental health policy paradigm shift begun during deinstitutionalization, in which persons with serious and persistent mental illnesses receive services from community-based providers rather than in state hospitals. Finally, my results suggest that contracting will continue to be an important state policy tool in further development of state-supported mental health systems.

Community Mental Health Services↗
PubMed1995

The new vision in psychiatric rehabilitation.

In the minds of many people, the nightmare of institutionalization has been replaced by the horrors of deinstitutionalization, and the 'revolving door' syndrome has become a 'spinning door' syndrome. Media coverage, newspaper accounts and literature would suggest that many persons with severe psychiatric disabilities have not been successfully rehabilitated into the community. Programmes to rehabilitate psychiatric clients cannot be adequately implemented and evaluated until mental health professionals improve their understanding of the philosophy and principles of psychiatric rehabilitation. This paper looks at the similarities between physical and psychiatric disabilities and the way the boundaries may be bridged between groups of disabled persons.

Deinstitutionalization↗
PubMed1998

Nursing management of psychotropic drug reactions.

The prevalence of psychiatric disorders in primary care is approximately 22%. These disorders include major depressive disorder, panic disorder, alcohol dependence/abuse, generalized anxiety disorder, and obsessive-compulsive disorder. The deinstitutionalization movement has placed an increasing number of severe and persistently mentally ill persons, defined as those with schizophrenia, psychosis, bipolar, and unipolar disorders, into the community. Nurses working in acute primary care, home health, and long-term medical settings can expect to encounter patients who are using prescriptive psychotropic medications; these patients may be experiencing adverse reactions. This article discusses antidepressants, mood stabilizers, antipsychotics, anxiolytics and specific medications for children and the elderly, and their adverse effects as a way of assisting nurses in making appropriate patient assessments.

Adolescent↗
PubMed1997

Self-help groups, family carers and mental health.

Deinstitutionalization has changed both the setting and delivery of mental health care. Mental health nurses are now providing complex and diverse services in contexts that are often far removed from the traditional realms of health care provision. If they are to meet the challenge of contemporary and future mental health-care needs, it is essential that mental health nurses be aware and understand the changing mental health environment. One specific change that has received limited attention in the literature is the increase in socio-political awareness of family carers of people with mental illness, and the concomitant increase in their collective voice and influence through self-help groups.

Adaptation, Psychological↗
PubMed2005

Crime victimization in adults with severe mental illness: comparison with the National Crime Victimization Survey.

CONTEXT: Since deinstitutionalization, most persons with severe mental illness (SMI) now live in the community, where they are at great risk for crime victimization. OBJECTIVES: To determine the prevalence and incidence of crime victimization among persons with SMI by sex, race/ethnicity, and age, and to compare rates with general population data (the National Crime Victimization Survey), controlling for income and demographic differences between the samples. DESIGN: Epidemiologic study of persons in treatment. Independent master's-level clinical research interviewers administered the National Crime Victimization Survey to randomly selected patients sampled from 16 randomly selected mental health agencies. SETTING: Sixteen agencies providing outpatient, day, and residential treatment to persons with SMI in Chicago, Ill. PARTICIPANTS: Randomly selected, stratified sample of 936 patients aged 18 or older (483 men, 453 women) who were African American (n = 329), non-Hispanic white (n = 321), Hispanic (n = 270), or other race/ethnicity (n = 22). The comparison group comprised 32 449 participants in the National Crime Victimization Survey. MAIN OUTCOME MEASURE: National Crime Victimization Survey, developed by the Bureau of Justice Statistics. RESULTS: More than one quarter of persons with SMI had been victims of a violent crime in the past year, a rate more than 11 times higher than the general population rates even after controlling for demographic differences between the 2 samples (P<.001). The annual incidence of violent crime in the SMI sample (168.2 incidents per 1000 persons) is more than 4 times higher than the general population rates (39.9 incidents per 1000 persons) (P<.001). Depending on the type of violent crime (rape/sexual assault, robbery, assault, and their subcategories), prevalence was 6 to 23 times greater among persons with SMI than among the general population. CONCLUSIONS: Crime victimization is a major public health problem among persons with SMI who are treated in the community. We recommend directions for future research, propose modifications in public policy, and suggest how the mental health system can respond to reduce victimization and its consequences.

Adult↗
PubMed1998

The public sector and mental health parity: time for inclusion.

BACKGROUND: In the United States, there is an uneasy division of responsibility for financing mental health care. For most illnesses, employer-sponsored health insurance and the large federal health insurance programs (Medicare, Medicaid) cover the costs of care. However, most employer-sponsored plans and Medicare provide only limited coverage for treatment of mental illness. A possible cause and result of this limited coverage in mental health is that states, and in some cases local (county) governments, finance a separate system of mental health care. This separate "public mental health system" provides a "safety net" of care for indigent individuals needing mental health care. However, there are potential negative consequences of maintaining separate systems. Continuity of treatment between systems may be impaired, and costs may be higher due to duplicate administrative costs. Maintaining a separate system managed by government may exacerbate the stigma associated with mental illness treatment. Most significantly, since eligibility for care may be linked to poverty status, and since having a serious mental illness may preclude regaining private coverage, maintaining a separate system may contribute to the poverty rate among persons with mental illnesses. AIMS OF THE PAPER: These potential problems have not been widely considered, perhaps because other problems and controversies in mental health care have captured our attention. In particular, controversies over deinstitutionalization in mental health have dominated the policy debate, especially when linked to related problems. These have included conflicts over authority and financial responsibility among federal, state and local governments, sensationalized media coverage of incidents involving people with mental illness, problems with siting community facilities, concern about mental illness among prisoners and the like. However, with the substantial reform of public mental health care in some states and localities, it is now possible to consider the implications of public and private integration. This paper considers such an approach. METHODS: This paper addresses the question of public and private integration, considering the state of Ohio as a case study. Ohio is a large state (population 11.2 million) and shares demographic, cultural and political characteristics with many other states. Ohio's successful experience implementing community mental health reform makes it a good candidate to use in evaluating issues in the potential integration of insurance-paid and public mental health care. RESULTS: The analysis indicates that the resources now used in Ohio's public system may be sufficient to support insurance financing of inpatient and ambulatory mental health treatment (the types of health care usually paid by insurance) while maintaining supportive services (e.g. housing, crisis care) as a residual safety net. DISCUSSION: At the current time, these resources are in state and local mental health budgets, and in the Medicaid program that finances health care for low income and disabled individuals. The analysis indicates that the aggregate level of resources expended on inpatient and ambulatory mental health treatment are substantially greater than expenditures for such care in an insurance plan for Ohio State employees. A substantial limitation of the analysis is that it is not possible to compare the need for care in a relatively healthy employed population versus a poor and disabled population. CONCLUSION: The paper concludes that there are substantial structural, economic and social problems associated with the "two-tiered" system of commercial/employer-paid insurance and public mental health care in the United States. Examining data from one state's public system, the paper further concludes that it might be feasible to finance a single system of acute and ambulatory mental health benefits, if public resources were redeployed and private contributions were continued. IMPLICATIONS FOR POLICY AND RESEARCH: Given the substantial problems associated with the two-tiered American approach to mental health care, further consideration and analyses of the feasibility of public and private integration are suggested. Given the complexity of this effort, much more sophisticated analysis is needed. However, given the possibility that sufficient resources may now be available to accomplish integration, further work is suggested.

Journal Article↗
PubMed1985

Clinical need variations of disabled persons residing in group homes.

Group home research has generally entailed comparison of these settings and their residents to institutions and their residents. Group home residents have frequently been treated as a homogeneous cohort of individuals. When group home development began, initial residents--usually individuals recently deinstitutionalized--were probably relatively homogeneous in regard to functional abilities and service needs, and generally similar to other disabled persons living in the community. Today, the residents of one group home may bear little resemblance to those of another. This report presents information about the types of group homes within a state system based upon the characteristics and service needs of 1,050 persons in 118 group homes and questions the role of community mental health centers in addressing certain service needs of group home residents.

Analysis of Variance↗
PubMed1993

Social control doctrines of mental illness and the medical profession in nineteenth-century America.

Social control doctrines of mental disorders have influenced a generation of psychologists and have shaped attitudes and discussions about how to treat the mentally ill. In light of the failure of deinstitutionalization as a public policy and the contemporary concern with the medical or biological bases of psychiatric disorders, this paper re-examines social control doctrines. Reviewing mid-nineteenth century statistical accounts, the author challenges claims of social control theorists and shows that in recent years some former social control advocates and revisionists have "recanted" and criticized their earlier use of the concept of social control, particularly the characterization of the asylum as a "total institution."

Health Policy↗
PubMed2003

The identification of trends in the utilisation of mental health services by elderly: a Dutch case register study.

OBJECTIVE: In view of the rapid ageing of the population any changes in the use of mental health services by the elderly became increasingly important for policy development. This study aimed at the supply of information about trends in the numbers of elderly clients, the services they used and the volume and pattern of service utilisation. METHODS: Details of elderly users and their use of community- and hospital-based services between 1990 and 1999 were retrieved from the Groningen case register. Developments in population size and age distribution in the register area were taken into account, as were the unit costs of mental health services. RESULTS: Large age specific changes were found that caused only the expenditures on the oldest elderly to increase due to a shift from outpatient clinics to prolonged psychogeriatric day treatment and inpatient care. Comparatively young elderly used fewer inpatient services and more community care. The number of new elderly clients declined progressively. In some age groups treated prevalence also decreased, but to a lesser extent, because of a prolonged use of mental health services. CONCLUSIONS: Study results seemed well in accordance with mental health policy as to deinstitutionalization and active ageing. Research on the effect of mental health care on life expectancy and the time lag between the intake of mental health providers and treated prevalence was proposed in order to improve the prediction of future service use by elderly.

Aged↗
PubMed1991

Emergency psychiatric intervention on the street.

The development of outreach approaches to engage and provide services to the homeless mentally ill must account for the heterogeneity of the population. The homeless mentally ill as a group are symbols of the failure of a comprehensive and integrated system of community-based care to develop in conjunction with the widespread proliferation of deinstitutionalization policies over the past several decades. Life in a community is far more complex and less easily controlled than life in an institution. People are free to reject the label of patient and refuse all mental health services. An engagement strategy must therefore be devised from the knowledge of specific aspects of a person's life in that community, so that outreach and networking efforts can be sensitive to the total context of the problems experienced by that patient. A multidisciplinary team approach is essential to the effort to engage and monitor those chronically mentally ill individuals who are at risk for psychiatric and/or medical decompensation. A variety of skills are needed, and team members must be flexible about their roles on the team. The clinician, while maintaining expert psychiatric, diagnostic, and treatment skills, must at the same time be able to adapt to people in their own environments, provide them with necessary social and medical services, and interface with other agencies working with these persons. The work is very labor intensive. It may involve two or more clinicians spending entire days with one patient. During a crisis state, these patients will require even more intensive attention from multiple team members to prevent decompensation and rehospitalization. In conclusion, there is no one intervention style in the work of psychiatric outreach. While the type of intervention offered follows from the mission of the outreach program, all outreach teams must be able to address the totality of needs of people who are fragile and at risk for psychiatric and medical decompensation. Case management services cannot be segregated easily from the task of crisis intervention in the work with the seriously mentally ill. The failure to establish an accessible network of community-based services for those chronically disaffiliated populations of mentally ill gives the outreach team the critical role of brokering any available services needed to support the individual in the community. The flexibility required of the outreach team derives both from the scarcity of community-based resources and the heterogeneity of the population of chronically ill adults who will most need these services.(ABSTRACT TRUNCATED AT 400 WORDS)

Community Mental Health Services↗
PubMed1992

LAMP in L.A.'s skid row: a model for community-based support services.

In most states, we reneged on our promise to provide community-based program support to persons deinstitutionalized from psychiatric hospitals. Now many people are blaming those with mental illness for their failure to thrive and have begun creating new laws and methods for reinstitutionalization. This chapter describes a community-based program that is demonstrably effective. It involves the full participation of homeless people diagnosed with mental illness and attests to what can work.

Community Mental Health Services↗
PubMed1994

Planning mental health services: background and key issues.

Deinstitutionalization in Canada produced a shift in locus of care from provincial psychiatric hospitals to general hospital psychiatric units. As a result of this approach, a number of key planning issues have emerged that most provinces are attempting to address.

Canada↗