University of Pennsylvania. US: 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.