PHILADELPHIA — As the United States population has doubled since 1955, the number of inpatient psychiatric beds in the United States has been cut by nearly 95 percent to just 45,000, a wholly inadequate equation when considering that there are currently 10 million U.S. residents with serious mental illness. A new viewpoint in JAMA,written by Dominic Sisti, PhD, Andrea Segal, MS, and Ezekiel Emanuel, MD, PhD, of the department of Medical Ethics and Health Policy in the Perelman School of Medicine at the University of Pennsylvania, looks at the evolution away from inpatient psychiatric beds, evaluates the current system for housing and treating the mentally ill, and then suggests a modern approach to institutionalized mental health care as a solution.
“For the past 60 years or more, social, political and economic forces coalesced to move severely mentally ill patients out of psychiatric hospitals,” write the authors. They say the civil rights movement propelled deinstitutionalization, reports of hospital abuse offended public consciousness, and new drugs gave patients independence. In addition, economics and federal policies accelerated the transformation because outpatient therapy and drug treatment were less expensive than inpatient care, and the federal legislation like the Community Mental Health Centers Act and Medicaid led to states closing or limiting the size of so-called institutions for mental diseases.
However, the authors write, “deinstitutionalization has really been transinstitutionalization.” Some patients with chronic psychiatric diseases were moved to nursing homes or hospitals. Others became homeless, utilizing hospital emergency departments for both care and housing. But “most disturbingly, U.S. 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 percent of state inmates are diagnosed with a psychotic disorder.” According to the authors, “this results in a vicious cycle whereby mentally ill patients move between crisis hospitalization, homelessness and incarceration.”
Instead, the authors suggest that a better option for the severely and chronically mentally ill, and the most “financially sensible and morally appropriate way forward includes a return to psychiatric asylums that are safe, modern and humane.” They argue that the term ‘aslyum’ should be understood in its original sense — a place of safety, sanctuary and healing.
“Asylums are a necessary, but not sufficient component of a reformed spectrum of psychiatric services,” write the authors. Reforms need to expand the role of these institutions to address a full range of integrated psychiatric treatment services — from providing care to patients who cannot live alone or are a danger to themselves and others, to providing care to patients with milder forms of mental illness who can thrive with high-quality outpatient care. These fully-integrated, patient-centered facilities do exist in the U.S. today, but more are needed to provide 21st century care to patients with chronic, serious mental illness.
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