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PubMed1985

General hospital psychiatry and deinstitutionalization: a systems view.

The shift in responsibility for the care of chronic mental patients has generated a variety of problems for general hospital psychiatry. In response to these new demands, general hospital psychiatry has evolved a variety of effective strategies. Nevertheless, widespread concern over the appropriateness of serving chronic patients in an acute care setting persists. The level and direction of general hospital psychiatry's involvement with chronic mental patients will vary according to the specific characteristics of a community's patient population, its goals for those patients, and the resources at its disposal for realizing those goals. General hospital psychiatry must make a serious effort to minimize its being forced into a reactive position by deinstitutionalization policies generated by distant authorities. It must assume, instead, its rightful position as an autonomous, but fully cooperative, element within the psychiatric service system. Only then can its responsibility to the chronically mentally ill, to other patients, and to its own integrity be assured.

Deinstitutionalization↗
PubMed1985

Deinstitutionalization and public policy.

Deinstitutionalization, originally hailed as a major advance in public policy towards mental illness, has recently become increasingly controversial. This paper reviews the implementation of this policy in the United States, providing a critical examination of some of the central issues and problems that are the focus of current debates. It concludes with a pessimistic assessment of the likelihood of substantial improvements occurring in the lot of the chronic mental patient in the contemporary United States.

Chronic Disease↗
PubMed1992

Deinstitutionalization at a large facility: a focus on treatment.

This paper describes deinstitutionalization efforts at a large facility. The implementation of a behavioral model and development of specific training curricula are described. Emphasis was placed on the design of individualized treatment services. The quality assurance mechanisms utilized included internal monitoring systems as well as evaluations conducted by external agencies. Client treatment programs were geared toward the acquisition of skills necessary for successful community integration. Finally, it is emphasized that clients in all facilities are entitled to effective and appropriate treatment based on their individual needs and not based on client building size.

Activities of Daily Living↗
PubMed1997

Deinstitutionalization and criminalization: tinkering in the interstices.

The mental health service system has undergone continuous change for more than three decades. Undoubtedly, some of its problems are related to economic, social and political factors. This contribution discusses problems of deinstitutionalization, homelessness and criminalization of the mentally ill persons. To conclude, it proposes a number of ways by which better services could be rendered to the mentally disordered persons, particularly in areas that interface with the criminal justice system.

Criminal Law↗
PubMedDate not supplied

[The Italian law on psychiatric hospitals. Toward the model of deinstitutionalization].

An evaluation is currently underway concerning the changes which have taken place in Italy in the twenty years following the reform law. The qualitative and quantitative changes are being analyzed based on a possible shared definition of the processes of deinstitutionalization. This theme is generally the object of misunderstandings and cliches. The need for change in clinical and institutional psychiatry is the indispensable premise for the development of community psychiatry and the growth of a culture of public psychiatry in general. In this framework, an attempt is being made to define the meaning of change through the growth of the active participation of person affected with mental disorders and their families in treatment, the participation of ordinary citizens, the spread of services in the community and the quantitative increase of the number of personnel involved in public community services. Emblematic of this change is the increase in the number of psychiatrists working in the public sector, from 700 to 7,000, over this twenty year period. The changes which must take place in psychiatric practice must also be emphasized: the heirarchies, the relationships, the search for non-health resources and enhancing the value of operators as subjects outside of their institutional role. The various forms of resistance which have retarded, and continue to retard, the process of change are also considered: the persistence of clinical cultural models, administrative inertia, the defense of acquired privileges by medical and nursing lobbies, the interests of the private, commercial and religious sectors and political manipulation. In any case, the beginning of a process of change which contains all the potential of a real project for prevention is judged positively.

Community Mental Health Services↗
PubMed2001

Moving out and moving on: some ethnographic observations of deinstitutionalization in an Australian community.

Since the 1950s deinstitutionalization has taken place for people with mental illnesses in the Western world. The growth of community care and residential facilities, as well as planning and implementation of policies, has varied in timing and orientation. An appreciation of the process of change affecting people discharged to the community highlights their strength, resilience, and vulnerabilities. This paper outlines a two and a half year ethnographic qualitative study undertaken in Australia, where 47 long-stay psychiatric inpatients were discharged to the community. The process accompanied the amalgamation of two major psychiatric hospitals, resulting in the closure of one. Findings demonstrated slow but positive change for residents as they reintegrated into the community. A separate quantitative and economic study was undertaken alongside the qualitative study (for results see Hobbs, et al., 2000; Newton, et al, 2000; Lapsley, et al., 2000).

Adult↗
PubMed2002

Deinstitutionalization for long-term mental illness: a 6-year evaluation.

OBJECTIVE: Forty-seven patients with long-term mental illness were transferred to the community following the closure of a psychiatric hospital in Sydney. This 6-year evaluation is an extension of a detailed clinical, ethnographic and economic study of the initial 2-years of community transition. METHOD: Quantitative evaluation was conducted using the Brief Psychiatric Rating Scale, Life Skills Profile, Social Behaviour Scale, Montgomery Asberg Depression Rating Scale and Quality Of Life measures. Assessments were completed prior to discharge and at two- and 6-year intervals following community transfer. Repeated measures analysis was utilized to determine changes in outcome variables over time. The residents' perception of 6-years of community living was explored in qualitative semistructured interviews. Details of accommodation, level of care, readmissions, incidents and medication were also documented. RESULTS: During the 6 years following community relocation a total of seven residents returned to hospital for long-term care, three residents died from medical causes and one resident required detention in a corrective services facility. The 36 residents who remained in the community at the 6-year follow-up no longer required intensive 24-h supervision. Living semi-independently, 23 residents resided in two to three person accommodation with either daily or weekly case manager visits. Clinically, community residents remained stable over the 6 years without significant changes in psychiatric symptoms, depression, living skills or social behaviour problems. Clinical stability was achieved with significant reduction in medication levels over the 6 years. Community-based residents continued to experience improved quality of life and reported their marked preference for living in the community. CONCLUSION: The residents maintained community tenure with significant improvement in quality of life and a reduction in medication, supported by a mental health system with adequate community resources. Issues regarding continuing rehabilitation and social integration need to be addressed. Further deinstitutionalization will require 24-h supervision for most initially and for some on a continuing basis. An ageing population will require specific age related medical and psychiatric services.

Activities of Daily Living↗
PubMed2002

[Schizophrenic patients, who still live in psychiatric hospitals despite decades of deinstitutionalization. Part 1 of the Hessian Deinstitutionalisation Study].

Deinstitutionalization (DI) of most of the chronic long-stay patients has taken place in the last decades in Germany. However, a "residual" group of patients often remains in psychiatric hospitals, with an ongoing controversy on an appropriate type of their care (community based vs. hospital). Clinical, functional and social characteristics of such schizophrenic patients still residing in the long-stay wards in the German state of Hesse after decades of DI are presented. The n = 266 patients investigated displayed a marked degree of negative symptoms and moderate positive symptoms but, however, severe social disabilities. In addition, the patients were very dependent in daily living, had an extremely impoverished social network and leisure activities. The findings contribute to the research on "difficult-to-place" patients described in the literature.

Activities of Daily Living↗
PubMed2006

[The process of deinstitutionalization in German State Mental Hospitals. Critical overview of empirical research studies].

The process of discharging previously long-term hospitalized patients from German state mental hospitals, and of transferring these patients to other forms of supported housing has meanwhile come to its end. Therefore, this paper presents an overview of the scientific evaluation of this process. By using clearly defined research methodological criteria, eight empirical studies from several German federal states are assessed focusing on the meaningfulness of their results. Because of the heterogeneity of the aims regarding contents of this transformation process, of the research methodological approaches, and of the characteristics of the assessed patient groups, only few general results could be identified. Chronically mentally ill patients (mostly suffering from schizophrenic disorders) who had been successfully discharged to the community were younger, and showed shorter periods of illness and hospitalization than control patients. After discharge they might have experienced positive changes of their objective and subjective quality of life and of their perceived needs of care. Referred to several other outcome domains, no homogeneous tendencies concerning clinically relevant improvement or deterioration were found. In particular, changes related to psychopathological symptoms and social competencies were generally small. However, mortality and re-hospitalization rates of de-hospitalized patients were considerably high, and ranged between 3-24 %, and 4-46 %, respectively. The assessed studies could not identify replicated predictors of successful de-hospitalization. Female sex and long-term last hospitalization seemed to be important for stable placement in forms of supported housing requiring a higher level of autonomy. From the generally unclear procedural quality of the German deinstitutionalization process, the authors deduce implications for the scientific evaluation of future projects of restructuring mental health care services. Besides the clear definition of empirically assessable aims which should be based on theoretical considerations, it is of utmost priority to guarantee high performance quality of research methodological standards.

Adult↗
PubMed2006

Deinstitutionalization of long-stay patients with schizophrenia: the 2-year social and clinical outcome of a comprehensive intervention program in Japan.

OBJECTIVES: The Sasagawa Project aimed to investigate the effects of deinstitutionalization and evidence-based strategies for the treatment of mental disorders among long-stay patients after their discharge from a mental hospital using a quasi-experimental longitudinal study design and to assess the patients' social and clinical outcomes over a 2-year post-discharge period. METHOD: Seventy-eight patients with schizophrenia were transferred to a community facility (Sasagawa Village) following the closure of Sasagawa Hospital in Koriyama in March 2002. The patients had undergone psychosocial training following the protocol outlined by the Optimal Treatment Project. All evaluations were performed prior to the patients' discharge and were repeated 12 and 24 months after discharge using the Positive and Negative Syndrome Scales, the Global Assessment for Functioning, the Schedule for Assessment of Insight, the Rehabilitation Evaluation Hall and Baker Scale, the Social Functioning Scale, the Drug Attitude Inventory, and the Mini-Mental State Examination. RESULTS: During the 24-month study period, 18 residents had incidents that made their continued stay at Sasagawa Village impossible. Only four (5.1%) of these residents were readmitted to psychiatric wards because of exacerbations of their conditions. Twelve residents were admitted to hospital because of serious physical illnesses. The 60 residents who remained in the community facility for 2 years demonstrated significant improvements in not only their psychiatric symptoms, but also their social functioning, as evidenced by their scores for Social Activity, Speech Skills, Disturbed Speech, Self-Care and General Behaviour on the Rehabilitation Evaluation Hall and Baker Scale and Withdrawal, Independence (Performance), Independence (Competence), and Employment on the Social Functioning Scale. CONCLUSIONS: Careful planning that minimized social and clinical dislocation may have contributed to the successful transition from mental hospital to community facility assessed in this study. Patients with a long history of illness showed favourable outcomes with little clinical deterioration and various improvements in their psychiatric symptoms and social functioning.

Adult↗
PubMed1987

Multipurpose Senior Service Program Deinstitutionalization Screen.

The Multipurpose Senior Services Program Deinstitutionalization Screening Instrument has been designed to identify easily and quickly those patients in nursing homes who are likely to be returned to the community through case-management efforts. The six-item screen and tables allow the interviewer to determine the probability of a patient being successfully discharged from a nursing home.

Activities of Daily Living↗
PubMed1988

Relationship between the deinstitutionalization model, psychiatric disability, and homelessness.

A follow-up study that tracked a sample of 133 people released from a state mental hospital showed that 35 percent became homeless within three months, supporting the theory that deinstitutionalization contributes to homelessness. An in-depth, qualitative tracking procedure provides data to describe key characteristics of the homeless person and the process by which people become homeless. These data point to solutions for improved care of severely mentally disabled people for whom the aftercare system has failed.

Adult↗
PubMed2000

The NIMBY phenomenon: community residents' concerns about housing for deinstitutionalized people.

This article reports the findings of a study on community opposition to group homes in Montreal, Canada. This qualitative study set out to explore the underlying dynamics of what happens when a community rejects a group home. With the use of a naturalistic paradigm, three actual incidents of community opposition were studied. Nineteen interviews were conducted with community residents, elected officials, and group home developers. Community residents did not support deinstitutionalization and social integration policies and argued against group homes. The findings of this study, never reported before in previous research, have important implications for social workers and social planners.

Attitude to Health↗
PubMed1979

Deinstitutionalization: those left behind.

Whether a retarded child can be cared for at home depends primarily on the ability of his or her family to function as primary caretakers. Not surprisingly, then, the rate at which retarded children are deinstitutionalized is being slowed by this country's failure to emphasize programs that are supportive of these children's families. After examining the discrepancy between the needs of families with retarded children and services currently being provided, the author proposes various changes in policy to increase assistance and support to the family as a unit.

Child↗
PubMedDate not supplied

Victimization of the mentally ill: an unintended consequence of deinstitutionalization.

Twenty years ago, legal interventions and dramatic advancements in psychopharmacology provided the impetus for a mass exodus from public mental health institutions to community settings. This well-intended move was predicated on the development of a community mental health center network. An unintended consequence, however, is that many deinstitutionalized mentally ill clients have been forced onto the street with little or no treatment. Moreover, a new wave of never treated youth and elderly have joined the street subculture. Without adequate clinical treatment, these people are vulnerable to victimization and to arrest and incarceration. In this article, the history of the problem is reviewed and steps to create a more responsive clinical network to cope with the problem are discussed.

Community Mental Health Services↗
PubMed1979

Evaluating outcome measures for deinstitutionalization programs.

Since deinstitutionalization has become a feature of many state and county mental health programs, suitable and effective measures are needed for evaluating the success of patients in adjusting to community life. This study attempted to identify the factors linked with satisfactory adjustment or return to the hospital and evaluated the usefulness of various measures of success in the community.

Community Mental Health Services↗
PubMed1996

Life after the mental hospital: the way of life of deinstitutionalized psychiatric patients.

This article describes and analyses the way of life of deinstitutionalized long-term psychiatric patients in Northern Finland. The major focus of the paper is the central areas of life of the outpatients as one dimension of subjectivity. The data were collected by interviewing 25 discharged long-term psychiatric patients. The findings suggest that home was the central area of life for the outpatients but they differed in their relation to it. Some of the patients were actively building their home. For some others home was an asylum in which to hide from social life. Many patients had hobbies that only took place inside their homes. One of the problems that the outpatients had to face was lack of work. The elderly patients who generally regarded work as a virtue experienced difficulties in finding something to do in their modern suburban homes. Social participation was mostly labelled by the old and familiar hospital models. The patients had no new acquaintances. They kept contact with their former fellow patients.

Adaptation, Psychological↗
PubMed2006

The Australian experience of deinstitutionalization: interaction of Australian culture with the development and reform of its mental health services.

OBJECTIVE: To describe the Australian experience of deinstitutionalization of the Australian National Mental Health Strategy in the context of the history of mental health services in Australia, and of Australian culture. METHOD: The development of Australian Mental Health Services is described with reference to developments in both psychiatric intervention research and Australian culture. The effects and achievements of national mental health reforms are described and critically examined. RESULTS: The relationship in Australia between the development of mental health services and the development of Australian society includes the stories of colonization, gold rush, suppression of indigenous peoples' rights, incarceration of mentally ill people, and incompatible state service systems. Mental health services required reform to provide consistent services and support for full citizenship and rights for such individuals who are still on the margins of society. Recent national developments in service models and service system research have been driven by the Australian National Mental Health Strategy. The translation of national policy into state/territory mental health service systems has led to a 'natural' experiment between states. Differing funding and implementation strategies between states have developed services with particular strengths and limitations. CONCLUSION: The effects of competition for limited resources between core mental health service delivery and the shift to a population-based public health approach (to prevention of mental illness and promotion of mental health), leaves our services vulnerable to doing neither particularly well. The recent loss of momentum of these reforms, due to failure of governments to continue to drive and fund them adequately, is causing the erosion of their considerable achievements.

Australia↗