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PubMed1981

Discharged patients who desire to return to the hospital.

Since the implementation of deinstitutionalization policies began in the early 1960s, large numbers of patients have been discharged from state mental hospitals to the community. Given the negative aspects of institutional life, it was assumed that patients would rather live in the community than remain confined in a state mental hospital. However, little is known about the actual preferences of discharged mental patients. In interviews with 176 patients an average of one year after their release from three state mental hospitals in Massachusetts, the author found that one-fourth indicated a desire to return to the hospital at some time since release. Significant factors associated with the patients' desire to return included self-image, relationships with others, and use of leisure time. The study results suggest that aftercare programs have not adequately met the needs of these patients.

Adolescent↗
PubMed1981

The new chronic patient and the system of community care.

Deinstitutionalization has created a new type of patient--the new young chronic--who has received most or all of his treatment during brief hospital stays and through extended contact with outpatient community care programs. A one-year study of 119 new chronic patients entering treatment in New York City between 1977 and 1979 casts light on their living arrangements, use of mental health services, social functioning, criminal activity, suicide attempts, and symptomatology.

Adult↗
PubMed1983

Family educational intervention in the treatment of schizophrenia.

In the aftermath of deinstitutionalization, when current public policy dictates greater community management of schizophrenia, patients and their families play an increasing role in the treatment of the illness. Since mental health professionals often neglect to educate them on the causes, symptoms, and treatment of schizophrenia, patients and their families are often misinformed, fearful, and ill-equipped to aid in treatment. The authors describe a brief family educational intervention and the questionnaire that was used to compare the knowledge of patients and their families who received the intervention with the knowledge of those who did not. The findings suggest that patients and their families in family treatment programs can acquire and retain information about schizophrenia more readily than patients and families involved in individual treatment. This knowledge enables them to become more effective participants in aftercare and helps surmount the problems associated with posthospital adjustment.

Adolescent↗
PubMed1983

The "chronic" mental hospital patient.

The rapid decrease in the resident population of state hospitals over the last decade has engendered a debate over the future role of the state hospital in the overall mental health services system. The authors report on a 1979 study of more than 2,000 state hospital patients designed to evaluate the characteristics of the current hospital population. Their findings document the existence of a new long-stay population that in many ways is similar to the old long-stay population that existed before deinstitutionalization. Continued hospitalization of the new population of long-stay patients, who now are younger than the old long-stay patient group, could cost more than $500 million dollars a year. The authors discuss the difficulty in predicting future trends from the existing data and outline four areas for future research.

Adolescent↗
PubMed1984

Paraprofessionals and psychiatric teams: an updated review.

Paraprofessionals and psychiatric teams are vital, interrelated, and complex components of the mental health care system. However, the literature on them is meager and contradictory. The authors begin the literature update by defining the relevant terms and describing the evolution of paraprofessionals and psychiatric teams. New developments indicate that paraprofessionals are able to perform many basic treatment tasks as members of psychiatric teams and that they are highly adaptable to addressing the service delivery gaps that have occurred during deinstitutionalization and in the treatment of schizophrenia. Advances in the training, structure, and process of psychiatric teams are discussed, and the authors cite new criteria for cost- and treatment-effective teams. With these developments, the authors discuss the problems still faced by paraprofessionals and psychiatric teams.

Allied Health Personnel↗
PubMed1986

A study of offenses committed by psychotic inmates in a county jail.

Following deinstitutionalization, several studies have documented an increase in the number of mentally ill inmates in prisons. The authors reviewed all referrals to a mental health clinic in a county prison and categorized each case as psychotic or nonpsychotic. The psychotic inmates were four times more likely to have been incarcerated for less serious charges such as disorderly conduct and threats, and they committed fewer sex offenses, property crimes, and drug offenses than nonpsychotic inmates. The authors conclude that the increased number of mentally ill prison inmates does not reflect a greater incidence of serious criminal activity in this group but an increase in the criminalization of psychotic behavior.

Adult↗
PubMed1986

The quality of life of chronic patients in a state hospital and in community residences.

Amidst the controversy about the effects of deinstitutionalization, the well-being of the chronic mentally ill in different treatment settings remains unclear. This study examined objective and subjective quality-of-life experiences of four groups of chronic patients categorized according to whether they were inpatients of a state hospital or residents of a supervised community residence and whether their current length of stay had been less than or greater than six months. Regardless of length of stay, the community residents perceived their living conditions more favorably, had more financial resources, and were less likely to have been assaulted in the past year than the inpatients. The study illuminates the problematic living conditions of state hospitals and the benefits of appropriately designed community-based residences for the chronic mentally ill.

Adolescent↗
PubMed1991

A ten-year perspective on three models of sheltered care.

Data from three surveys of California sheltered care residents and facilities were used to determine which of three models best describes the use of sheltered care by residents and the provision of services to residents between 1973 and 1983. The continuum-of-care model emphasizes a person's movement along a treatment continuum to greater independence. In the residual model, the focus is on providing habitation for a chronic population from the era before deinstitutionalization. The developmental model emphasizes providing long-term care to persons who seek supported living arrangements at a particular point in their life cycle. Results indicated that the developmental model best describes the way residents used sheltered care, while service provision was based on the continuum-of-care model. In light of these findings, it should be determined whether service provision reflects the actual needs of this population.

Adult↗
PubMed1991

A personal memoir of the state hospitals of the 1950s.

The author recalls his experiences as an attendant at a state mental hospital in the early 1950s, before the introduction of psychotropic drugs. State hospitals of that era served not only as treatment centers for mentally ill patients but also as de facto nursing homes, retirement homes, orphanages, and shelters for chronic physically ill persons, medically ill poor people and wards of the state, adults and juveniles convicted of crimes, behaviorally disturbed retarded people, and alcoholics. The author argues that the deinstitutionalization movement removed an important, if unrecognized, source of palliative care for dispossessed individuals and recommends redesigning the state hospital to provide compassionate housing and treatment by trained persons for homeless and chronic physically and mentally ill individuals. Four patients typical of the heterogenous population of state hospitals in the 1950s are described.

History, 20th Century↗
PubMed1993

Poverty and the course of schizophrenia: implications for research and policy.

Interest in the relationship between social class and schizophrenia has diminished in recent years. However, these issues can usefully be reconsidered in light of increased recognition that schizophrenia has a protean course, that deinstitutionalization and community support of persons with schizophrenia are linked to welfare programs, and that conceptualizations and measurements of social class and its impact on the daily life of persons with schizophrenia have been rudimentary. The author examines the role that social class, especially poverty, plays in the course and outcome of schizophrenia. He reviews literature on the contributions of social structure and policy to the economic status of persons with schizophrenia, identifies variables associated with poverty that are found disproportionately among persons with schizophrenia, and examines the psychological significance of those variables. The overview is used to develop three approaches to research: examining the role of the chronic stress of poverty in the vulnerability model of schizophrenia, using poverty as a point of departure for investigation by considering persons with schizophrenia as primarily indigent rather than primarily mentally ill, and delineating how poverty and elements of schizophrenia influence each other.

Causality↗
PubMed1993

Mental and physical health of homeless persons who use emergency shelters in Vancouver.

OBJECTIVES: Homelessness is often associated with deinstitutionalization of chronic mentally ill people, but estimates of the number of mentally ill people in the homeless population vary. The purpose of the study was to determine the extent of psychiatric problems among the users of shelters for homeless persons in Vancouver, British Columbia. In addition, the study documented the demographic and physical health characteristics of shelter residents. METHODS: Researchers surveyed 124 emergency shelter users about their self-reported physical and mental health status and assessed their mental health status using the Brief Psychiatric Rating Scale (BPRS). RESULTS: Shelter users in Vancouver were predominantly a young, male, single mobile population. About half reported a current physical health problem, 44 percent reported use of nonprescribed drugs, and 69 percent reported use of alcohol. Nineteen percent reported a current mental or emotional problem, with schizophrenia and bipolar disorder the most common diagnoses reported. BPRS scores indicated that depression, anxiety, and tension were common problems. CONCLUSIONS: Although the number of individuals with mental illness in the population surveyed was lower than in similar populations in the United States, the presence of mentally ill people in Vancouver shelters suggests that shelters should address mental health issues as well as provide services to ensure residents' basic survival.

Adolescent↗
PubMed1994

Issues in American psychiatry reflected in remarks of APA presidents, 1844-1994.

OBJECTIVE: The author reviewed the history of American psychiatry for the first 150 years of the American Psychiatric Association's existence (1844-1994) as reflected in remarks of the association's presidents. METHODS: Presidential addresses or remarks from alternative sources were located for the 120 presidents who served the association between 1844 and 1994. RESULTS: The presidents' remarks on six topics-psychiatric practice, etiology of mental illness, public mental hospitals, alternatives to state hospitals (deinstitutionalization), biologic treatments, and fiscal issues were sampled and arranged chronologically. CONCLUSIONS: American psychiatry's history--its innovations, cyclical repetitions, and self-assessments-can be gleaned from this form of data. The presidents' remarks appear to refute the claim that organized American psychiatry has been negligent in criticizing itself.

History, 19th Century↗
PubMed1996

Case mix in the "downsizing" state hospital.

OBJECTIVE: The study examined whether local variations in levels of community-based services affect the case mix of state hospitals undergoing census reduction. METHODS: Trends in case mix over a 14-year period were analyzed at two Massachusetts state hospitals, one of which underwent more rapid census reduction due to expanded community resources in the catchment area it served. Data on patients' hospital use and on sociodemographic and diagnostic characteristics obtained from 1977, 1986, and 1991 assessments of the hospitals' populations were compared. These time points represented the beginning, midpoint, and end of the census reduction period. Data from 1991 on patients' behavioral and functional status were also examined. RESULTS: Parallel trends on many dimensions were evident at the two hospitals as their censuses fell. By 1986 the hospital operating in the area with greater community services had fewer elderly and long-stay patients but a higher number of admissions per patient. In 1991 this hospital's population also had more patients with high-risk violent behaviors and lower levels of functioning. CONCLUSIONS: Although alternative treatment settings allow diversion of many types of patients from state hospitals, expanded community-based services and alternative inpatient beds have not diverted some patient subgroups, including recidivists and patients with behaviors that present risks in other settings. Plans for meeting the clinical needs and behavioral challenges posed by such patients must be part of any further deinstitutionalization or privatization efforts.

Adolescent↗
PubMed1996

The spectre of criminalization: remand admissions to the Forensic Psychiatric Institute, British Columbia, 1975-1990.

The history of the Forensic Psychiatric Institute (FPI) of British Columbia is reviewed through a description of the 3,500 remand admissions to the Institute between 1975 and 1990. Individuals charged with only minor offences and those who were certified under the Mental Health Act 1983 and subsequently had their charges stayed are examined in more detail. Results appear to suggest that these two groups are particularly vulnerable to the process of criminalization. The possible link between criminalization of the mentally ill and deinstitutionalization is explored.

British Columbia↗
PubMed1992

Planning mental health services: II. Current Canadian initiatives.

A brief overview of recent policy developments across Canada and a discussion of the common themes and challenges they address demonstrates the scope of activity in this field. The federal level of mental health planning and a summary of recent of policy developments in each province are described. Significant progress has been made in Canada in the development of mental health services since deinstitutionalization. Major challenges remain, however, which are being addressed to varying degrees across the country. The challenges related to the key issues of major mental illness, integration and consumerism are illustrated.

Canada↗
PubMed2004

A review of clinical characteristics and residential treatments for adolescent delinquents with mental health disorders: a promising residential program.

As treatment systems throughout the country have deinstitutionalized, under-use of community-based residential treatment systems has escalated. Reliance on juvenile justice systems for the care of the mentally ill adolescent has increased. There is considerable overlap between the mentally ill adolescent population within the community-based mental health systems and the offender population within the juvenile justice systems. With the inconsistent epidemiological prevalence and longitudinal treatment data, mental health treatment providers have also begun addressing this problem. This is currently being done by designing and implementing community-based residential mental health programs for delinquent adolescents of the juvenile justice system as well as nondelinquent adolescents within the mental health treatment systems. Providers have relied on both systems' literature in establishing theoretical treatment programs. The authors review critical treatment components currently used by both the treatment and juvenile justice systems. A promising integrative program is described.

Adolescent↗
PubMed2006

The quality of life among persons with severe mental illness enrolled in an assertive community treatment program in Japan: 1-year follow-up and analyses.

BACKGROUND: Toward effective community care for persons with severe mental illness and deinstitutionalization in Japan, we assessed the impact of the first trial of an assertive community treatment program on the lives and subjective perceptions of persons with mental illness without closing hospitals. METHODS: Forty-three subjects were enrolled from the newly admitted patients of a hospital, who met our criteria of problematic hospital use, severity of psychiatric disorders, and behavioral problems. The intervention team aimed to intensively support them in various life domains in their communities to decrease clients' admissions. The Quality of Life Interview was administered at baseline and after 12 months. Data were analyzed to assess the pre-post changes in their QOL, and were explained in association with other descriptive variables. RESULTS: The objective changes included increase in persons whose longest residence in a year were in communities, increase in income, and decrease in family contacts. Most subjective items were not changed except the decrease in satisfaction with family relationships. Satisfaction with family relationships was negatively correlated with hospital days at 1 year follow-up after controlling for symptoms, but was not so at baseline. Also, correlation between satisfaction with family relationships and global well-being was attenuated. A change in the positioning of family by clients and the autonomy of clients were suggested. However, previous studies showed that dissatisfaction with family relationships predicted rehospitalizations independently from symptoms, and our findings suggest our subjects' characteristics and a possible improvement in community-based care. CONCLUSION: Our program predominantly fulfilled the primary goal, but it must be further refined to reflect the detailed characteristics of the target population and resource distribution. Assessing subjective perceptions, or the QOL of clients is useful for evaluating the program localization.

Journal Article↗
PubMed2006

Constructing a morality of caring: codes and values in Australian carer discourse.

In this analysis I apply a Foucauldian approach to ethics to examine the politically prescribed moral and ethical character required of carers of aged persons at home in Australia and the role of nurses in shaping these behaviours. The work that spousal carers provide, although often founded on love and/or obligation, has been formalized through a variety of policy initiatives and technologies that serve to construct the moral approach they must adopt. This shaping of conduct at the most personal level takes place through the application of codes of behaviour policed largely by nurses. These codes redefine the mode of coexistence between an aged husband and wife and propose a new form of relationship that is derived from and supports policies of the deinstitutionalization of care services for elderly persons. In this way modern carer policy has drawn on knowledge and governance of the self to produce a morality of caring that is both authoritative and scientific.

Aged↗