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PubMed1980

Deinstitutionalization and social policy: historical perspectives and present dilemmas.

The influence of social and economic forces on the placement and treatment of the chronically mentally ill is traced historically. This review suggests that minorities and the poor, who have in the past suffered the worst institutional care, will be most at risk in the community during the present era of cutbacks in social services. Deinstitutionalization, in making claims on resources that the larger community is reluctant to grant, seen as jeopardizing needed incremental reforms.

Deinstitutionalization↗
PubMed1987

Moving forward with deinstitutionalization: lessons of an ethical policy analysis.

The formulation, implementation, and evaluation of public policies do not typically include formal ethical analysis. Reconceptualizing from an ethical standpoint the historical and contemporary dilemmas created by the deinstitutionalization policy underscores the need for attention to distributive justice and respect for individuals in developing programs for the chronically mentally ill and in selecting and measuring successful outcomes.

Chronic Disease↗
PubMed1981

Overview: deinstitutionalization of psychiatric patients, a critical review of outcome studies.

The authors performed a critical review of experimental studies on the outcomes for psychiatric patients of 1) alternatives to hospital admission, 2) modifications of conventional hospitalization, and 3) alternatives to continued long-term hospitalization. The internal validity of many of the studies was compromised by shortcomings in design and performance and generalizability limited by selection of patient populations. With these qualifications experimental alternatives to hospital care of patients have led to psychiatric outcomes not different from and occasionally superior to those of patients in control groups. This conclusion is best supported for alternatives to admission and for modifications of conventional hospitalization. The available studies do not permit firm conclusions regarding alternatives to continued long-term hospitalization of chronically ill patients or for a critical analysis of the optimal management of specific subpopulations of psychiatric patients. Satisfactory deinstitutionalization appears to depend on the availability of appropriate programs for care in the community.

Adult↗
PubMed1984

Arson: an unforeseen sequela of deinstitutionalization.

Did the shift from institutional to community-based services brought about by deinstitutionalization affect the nature or function of pathological fire setting? The author studied admissions to a state hospital that were precipitated by arson. During a 200-day period, 14 patients accounted for 16 admissions and 17 fires. The data indicate that fires are set by consumers of public sector mental health services to communicate a wish or a need for a change in location of those services. Communicative arson has caused property damage, personal injury, and death and has resulted in a backlash against community alternatives for psychiatric treatment.

Adolescent↗
PubMed1984

The dynamics of hospitalization in a defined population during deinstitutionalization.

In a sample of 1,032 psychiatric inpatients studied for 1 year, chronic patients (more than 6 months' inpatient stay) represented 17.4%, almost half of whom were discharged during a 2-year follow-up; an additional 19.4% died. The incidence of "new" long-stay patients was 8.6/100,000 population, which, if constant over time, would result in a net increase of long-stay patients. Most chronic long-stay patients had a diagnosis of schizophrenia or organic brain syndrome. The two diagnostic groups had strikingly different patterns of deinstitutionalization. Alcoholic patients and those with "other" diagnoses demonstrated chronic dependence on the hospital, characterized by short inpatient stays and high readmission rates.

Alcoholism↗
PubMed2004

Criminal offending in schizophrenia over a 25-year period marked by deinstitutionalization and increasing prevalence of comorbid substance use disorders.

OBJECTIVE: This study examined the pattern of criminal convictions in persons with schizophrenia over a 25-year period marked by both radical deinstitutionalization and increasing rates of substance abuse problems among persons with schizophrenia in the community. METHOD: The criminal records of 2,861 patients (1,689 of whom were male) who had a first admission for schizophrenia in the Australian state of Victoria in 1975, 1980, 1985, 1990, and 1995 were compared for the period from 1975 to 2000 with those of an equal number of community comparison subjects matched for age, gender, and neighborhood of residence. RESULTS: Relative to the comparison subjects, the patients with schizophrenia accumulated a greater total number of criminal convictions (8,791 versus 1,119) and were significantly more likely to have been convicted of a criminal offense (21.6% versus 7.8%) and of an offense involving violence (8.2% versus 1.8%). The proportion of patients who had a conviction increased from 14.8% of the 1975 cohort to 25.0% of the 1995 cohort, but a proportionately similar increase from 5.1% to 9.6% occurred among the comparison subjects. Rates of known substance abuse problems among the schizophrenia patients increased from 8.3% in 1975 to 26.1% in 1995. Significantly higher rates of criminal conviction were found for patients with substances abuse problems than for those without substance abuse problems (68.1% versus 11.7%). CONCLUSIONS: A significant association was demonstrated between having schizophrenia and a higher rate of criminal convictions, particularly for violent offenses. However, the rate of increase in the frequency of convictions over the 25-year study period was similar among schizophrenia patients and comparison subjects, despite a change from predominantly institutional to community care and a dramatic escalation in the frequency of substance abuse problems among persons with schizophrenia. The results do not support theories that attempt to explain the mediation of offending behaviors in schizophrenia by single factors, such as substance abuse, active symptoms, or characteristics of systems of care, but suggest that offending reflects a range of factors that are operative before, during, and after periods of active illness.

Adult↗
PubMed1979

The effect of deinstitutionalization on the state hospital.

Recalling the important statement about the bankruptcy of the state hospital system and the need for a multitude of treatment settings made by Harry Solomon, M.D., in 1958, the authors acknowledge that the changes he prophesized have largely come about. Using the Massachusetts Mental Health Center as the model, they describe how an inpatient unit operates as part of a deinstitutionalized network of services for seriously ill patients. They discuss the five general types of patients admitted and the problems of providing adequate care to such a diverse population. Finally, they make a strong plea for the establishment of regional facilities to care for patients with unusual, complicated problems.

Boston↗
PubMed1979

The effect of deinstitutionalization on a general hospital's inpatient psychiatric service.

As a result of the deinstitutionalization movement, increasing numbers of former state hospital patients are being rehospitalized in general hospital psychiatric units. Because of this change in patient population, the general hospital has had to adjust its treatment strategy to emphasize meticulous review of previous psychiatric history, including medications; plans for meeting the patients' posthospital housing, vocational, and social needs; and development of plans with community care-givers for continuing care. General hospital staff members have to be educated to develop competence in working with the new patient population and a tolerance for chronicity; that can be done through several forums ranging from large staff meetings to individual supervision.

Adult↗
PubMed1979

From the hospital to the prison: a step forward in deinstitutionalization?

In Massachusetts there is a growing trend to transfer both direct and indirect mental health service delivery from civil mental hospitals to prison facilities. Three factors associated with deinstitutionalization and a community-based delivery system appear to have contributed to the trend. Those factors are the over-all compromising of programming caused by unitization of state hospitals and the requirement that a full range of psychiatric services be available in every community, the decrease in morale and training of state hospital employees not involved in community treatment, and the lack of outreach to patients in the community who are dangerous or difficult to deal with.

Adult↗
PubMed1980

Deinstitutionalization: who is left behind?

A study of the demographic and clinical characteristics of 137 patients in a state hospital in Massachusetts on a single day in March 1977, well after the state's massive deinstitutionalization program was in effect, showed that the patients who remained in the hospital needed a high level of care, lacked social relationships, were acutely psychotic, or were dangerous to themselves or to others. The author compares this patient population with patients in all other state mental hospitals in Massachusetts and those in the United States. He believes that an answer to the question "Who is left behind?" is essential for state hospital staff members who must treat these patients and is also important for those planning community programs.

Deinstitutionalization↗
PubMed1981

Deinstitutionalization of the retarded: trends in public policy.

Essential public policy features of the national movement to return institutionalized mentally retarded people to community settings include issues related to institutional census trends, class action litigation, cost "savings," and funding. The deinstitutionalization of retarded people is following a different course from that of the mentally ill; it started later and is occurring more gradually. Right-to-habilitation lawsuits in Alabama and Pennsylvania illustrate the class action suit; gains from litigation in the 1970s have been mixed, however. Comprehensive community care is not necessarily any cheaper than comparable institutional care. Trends in state construction expenditures, the Reagan Administration's proposal for block grants, and impending human services budget cuts are current funding issues. So that advocates of the disabled can more closely monitor future developments in state and federal policy, three continuing annual studies are proposed: a comparison of states' funding of programs for retarded people; and evaluation of nationwide data obtained in accreditation surveys; and a historical and contemporary description of the operations of each of the 50 state service systems.

Community Mental Health Services↗
PubMed1983

The impact of deinstitutionalization on California's state hospital population.

Deinstitutionalization has dramatically reduced the state psychiatric hospital population in California from 37,000 in 1955 to only 2,500 at the present time. In 1980 and 1982 the California Department of Mental Health conducted two surveys to assess demographic characteristics, psychiatric diagnosis, health status, and behavioral traits of state hospital patients. The results indicate that most patients are young, male, and diagnosed as schizophrenic and frequently engage in dangerous behaviors. The various patient subpopulations exhibited few differences in diagnostic distribution, although Hispanics did have a significantly higher rate of substance use. The author posits that the current hospital population constitutes a "hard core" of patients who may be difficult to place in community treatment facilities.

Adolescent↗
PubMed1983

Deinstitutionalization and the survival of the state hospital.

Despite vigorous efforts at deinstitutionalization, the state mental hospital continues to be the locus of care for a wide variety of patient populations. The authors examined the changes in one state hospital's clientele between 1972 and 1980 and discovered a 50 percent reduction in long-stay patients, a 27 percent increase in admissions, and the emergence of a new long-stay population. The authors say that the modern state hospital can be conceptualized as several different facilities under a single administrative roof rather than as a monolithic structure. They conclude that mental health planners must acknowledge the continued existence of a group of patients whose needs are perhaps best served by the state hospital. Strategies must be developed to use the existing hospital resources in the most efficient and effective manner.

Adolescent↗
PubMed1985

Build a better state hospital: deinstitutionalization has failed.

The author cites increasing numbers of chronic, homeless, and neglected mentally ill people as evidence of the failure of deinstitutionalization and community care to live up to their promise to reduce chronicity, the need for long-term hospitalization, and even mental illness itself. He believes the state hospital system, despite having been maligned and nearly destroyed, has great therapeutic potential. It could provide extended care to acutely ill patients before they become chronically ill; restore the ability to pinpoint responsibility for patient care, which has been lost under community care; and provide a stimulating academic environment conducive to research into treatment of the mentally ill.

Chronic Disease↗
PubMed1987

Rehabilitation outcome of long-term hospital patients left behind by deinstitutionalization.

In 1979 a Massachusetts state hospital initiated a plan to transfer 54 long-term residents of two wards to the community through a series of increasingly independent working and living arrangements. This study assesses the patients' residential and vocational status and living skills over a five-year period beginning in February 1979. The patients demonstrated a significant increase in living independence, but only eight were able to live continuously in the community after their discharge, and 24 never left the hospital. Overall, vocational status did not improve, and living skills improved only slightly. Living skills and vocational status were predictive of living independence. The authors identify several steps that the mental health field should take to promote success among chronic patients, deinstitutionalized or not.

Activities of Daily Living↗
PubMed1988

A ten-year follow-up study of the effects of deinstitutionalization.

The Cambridge-Somerville unit of the Massachusetts state hospital system, which was studied by the author in 1977, was resurveyed to examine changes in the clinical characteristics of the patient population between 1977 and 1987. Although the number of patients in the hospital remained almost the same, there were striking increases in the percentages of male patients and of patients on involuntary legal status. There was a decrease in the number of patients who had hospital stays of 30 days or less or of more than five years and an increase in the number of patients staying between one and 12 months. These findings demonstrate that the effects of deinstitutionalization continue long after trends toward reduction of census have stabilized.

Adolescent↗
PubMed2003

Survey of nursing and medical profile prior to deinstitutionalization of a population with profound mental retardation.

During the planning stages of deinstitutionalization, the importance of nursing services must be recognized and given priority consideration in the community placement of persons with serious developmental disabilities. The objective of this study was to survey the medical and nursing profile of a group of nonambulatory, institutionalized individuals with profound mental retardation in anticipation of their nursing and medical needs in the community. Data were collected from the Individual Habilitation Plans of 55 individuals who had resided in a residential facility for individuals with mental retardation and were scheduled for community placement Serious medical problems in decreasing frequency were constipation (96%), seizure disorder (70%), poor dental hygiene (67%), cerebral palsy (62%), scoliosis (61%), contractions (41%), aspiration (44%), skin lesions (40%), and dysphagia (22%). Considering the complexity of health issues encountered in this population, adequate nursing and medical planning are critical to the wellness and successful community placement of a population with special needs.

Adult↗
PubMed2003

Deinstitutionalization and mortality: findings of a controlled research design in New Jersey.

In previous studies of the mortality of deinstitutionalized persons with disabilities in California and Pennsylvania, investigators failed to employ a prospective controlled research design. We identified a sample of 150 "movers" scheduled for placement from an institution and a matched sample of 150 institutional "stayers." The matching and other risk variables were measured in 1994. Visits to all residences occurred between 1997 and mid-2000 at specified intervals after movers left the institution. Logistic regression analyses identified the 1994 preclosure risk variables of age, low self-care, medical conditions, and epilepsy/seizure disorders as the best ones for explaining all deaths. Adding mover/stayer status and community/institutional placement to the analyses did not enhance the model. Nursing home placements emerged as a postclosure risk variable.

Adolescent↗