Improving Long-term Psychiatric Care: Bring Back the Asylum

Source: Dominic A. Sisti, Andrea G. Segal, Ezekiel J. Emanuel, Journal of the American Medical Association (JAMA), Vol 313, No. 3, January 20, 2015
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From the abstract:
This Viewpoint discusses new models for patient-centered, long-term psychiatric care in the United States.

During the past half century, the supply of inpatient psychiatric beds in the United States has largely vanished. In 1955, 560 000 patients were cared for in state psychiatric facilities; today there are fewer than one-tenth that number: 45 000.1 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.1 A much smaller number of private psychiatric beds has fluctuated since the 1970s in response to policy and regulatory shifts that create varying financial incentives. …

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. Indeed the current crisis in Nevada –where the lack of psychiatric beds has resulted in overcrowded emergency departments filled to capacity with psychiatric patients – may be a harbinger of the future. Most disturbingly, 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. … At the moment, prisons appear to offer the default option and an inexpensive solution for housing and treating the mentally ill. …. However, correctional psychiatry is rife with legal, ethical, and clinical challenges. …