18. institutionalization

Deinstitutionalization

• State psychiatric hospitals closed, but no humane alternative filled the care gap (at least not to the extent needed).

• Sisti points out that in 1955, 560,000 patients were cared for in

state psychiatric facilities; today there are fewer than 1/10 that number: 45,000.

• Given the doubling of the US population, this represents a 95%

decline, bringing the per capita public psychiatric bed count to

about the same as it was in 1850—14 per 100,000 people.

Lack of beds

• As a result, there are few high-quality, accessible long-term care

options available for the ~10 million US residents with serious

mental illness.

• Sisti: "The void is both ethically unacceptable and financially

costly."

"Transinstitutionalization"

• Dominic Sisti argues that deinstitutionalization has really been

transinstitutionalization:

"As state hospitals were closed, patients with chronic psychiatric

diseases were moved to nursing homes or to general hospitals where they received episodic psychiatric treatment at significantly higher costs.

Others became homeless, utilizing hospital emergency

departments for both care and housing. [...] US jails and prisons have become the nation's largest mental health care facilities.

Half of all inmates have a mental illness or substance abuse disorder; 15% of state inmates are diagnosed with a psychotic disorder."

Sisti: "Bring back the asylum!"

• Comprehensive, accessible, and fully integrated community-based mental health care continues to be an unmet promise.

• Sisti argues that the financially sensible and morally appropriate

way forward includes a return to psychiatric asylum (that are safe,

modern, and humane).

• Bring them back, but make them better.

• Sisti says that asylums are a necessary but not sufficient

component of a reformed spectrum of psychiatric services.

Montrose

- Support for return to asylums

"The ethicists argue that the 'way forward includes a return to psychiatric asylums.' And they are right"

Bagenstos & Pollack

- Against return to asylums

"These complaints are genuine and serious. But they do not argue for a return to institutional care. Rather, they underscore the need to provide the necessary resources and monitoring to develop and improve home- and community-based services."

"It's hardly surprising that those dissatisfied with community care

turn back to the idea of a public institution where, one can hope,

loved ones will at least be safe and taken care of.

But let's also not kid ourselves in imagining that "the modern

asylum" would be immune to the clinical, political, financial, and

administrative challenges that bedevil our current community-

based efforts. Many of the worst problems would surely persist.

Only this time, these problems would arise in the back wards,

blighting lives out of public view."