HISTORY OF MENTAL INSTITUTIONS

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CAUSES OF DI
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US PUBLIC INPATIENT 1830-1955
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PUBLIC INPATIENT 1955-2006
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CAUSES OF DI

• 1. DRUGS
• 2. PHILOSOPHICAL CHANGES
• 3. LEGAL CHANGES
• 4. ECONOMIC CHANGES

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DRUGS
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I. DRUG TREATMENT

• ANTI-PSYCHOTICS THORAZINE AND LITHIUM IN
  MID-1950S
• DONT CURE BUT CONTROL
• IMMEDIATE SUCCESS
• EASY TO ADMINISTER
• NEW HOPE AND OPTIMISM
• BUT MAJOR CHANGES 1970 -

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II. PHILOSOPHY

• 1. ANTI-MENTAL HOSPITALS - E.G. CUCKOOS NEST
• 2. PRO-COMMUNITY TREATMENT - 1960S
• LIBERAL PHILOSOPHY OF GOVERNMENT
• STRONG FEDERAL ROLE BYPASS STATE MENTAL
  HOSPITALS

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CMHC

• BUILD LARGE NETWORK OF COMMUNITY MENTAL HEALTH
  CENTERS (CMHC)
• FEDERAL LOCAL PARTNERSHIP
• SERVED DIFFERENT POPULATION THAN STATE MENTAL
  HOSPITALS - LESS SERIOUS, EASIER TO TREAT

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CMHC

• NOT INTEGRATED WITH STATE HOSPITALS - FEW
  PROGRAMS FOR S.M.I.
• CREATED GREAT GAP IN CARE HOW FILL OLD ROLE OF
  STATE HOSPITAL?

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III. LEGAL

• JUDICIAL AND LEGISLATIVE CHANGES
• 3 ASPECTS - COMMITMENT TO HOSPITAL, CONDITIONS IN
  HOSPITAL, RELEASE TO COMMUNITY
• MOVE FROM MEDICAL TO LEGAL MODEL

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MEDICAL AND LEGAL

• PRIMACY OF HEALTH
• PATERNALISM
• BETTER SAFE THAN SORRY

• PRIMACY OF LIBERTY
• ADVERSARIAL
• NO TREATMENT UNLESS NECESSARY

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1. COMMITMENT

• UP TO 1970 PRIMACY OF MEDICAL
• ANYONE CAN BRING PETITION ASSERTING MENTAL
  ILLNESS
• M.D. MUST SIGN
• ROUTINE EXAM BY COURT PSYCH.
• BRIEF HEARING
• ALMOST ALL COMMITTED

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1970-2006

• EXPANSION OF LEGAL MODEL FOR COMMITMENT
• HAD BEEN MENTAL ILLNESS
• NOW - DANGER TO SELF OR OTHERS
• SOMETIMES GRAVELY DISABLED
• SPECIFIC AND OVERT ACTIONS
• PROCEDURAL PROTECTIONS

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COMMITMENT

• EMERGENCY COMMITMENTS FOR BRIEF PERIODS - 2 WKS
  OR MONTH
• OLMSTEAD DECISION 1999 LEAST RESTRICTIVE
  ALTERNATIVE
• UP TO STATE TO PROVE NEED FOR COMMITMENT

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2. WITHIN HOSPITAL

• MANDATED STANDARDS OF CARE WITHIN HOSPITAL
  TREATMENT, STAFF RATIO, LIVING CONDITIONS
• RESTRICTIONS ON SOCIAL CONTROL - FRUMKIN
• HITS PT., BLINDS ATTENDANT GETS 2 HOURS OF
  SECLUSION

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3. RELEASE FROM HOSPITAL

• BURDEN OF PROOF ON STATE FOR WHY SHOULD KEEP IN
  HOSPITAL
• HEARINGS AT REGULAR PERIODS EVERY SIX MONTHS OR
  SO

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COMPARE CUCKOOS NEST

• MORE TRUE PRE-1970S THAN NOW
• NOW MORE LEGAL THAN MEDICAL STATE MUST JUSTIFY
  HPT.
• VOLUNTARIES WOULDNT BE THERE OUTPATIENT
• CHRONICS IN NURSING HOMES
• PROBLEM NOW IS LACK OF FACILITIES

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REASONS FOR LEGAL CHANGES

• CIVIL RIGHTS MOVEMENT
• ECONOMIC PRESSURE TO REDUCE HOSPITAL POPULATIONS

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IV. ECONOMIC

• STATE HOSPITALS VERY EXPENSIVE
• DI CLAIMED TO SAVE MONEY
• IN FACT, SHIFTS ECONOMIC BURDEN FROM STATES TO
  FEDERAL GOV.
• FEDERAL WONT PAY INPATIENT TREATMENT IN SMH BUT
  WILL FOR TREATMENT OUTSIDE HOSPITALS

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FUNDING FOR TREATMENT

• MEDICAID POOR FEDERAL/STATE
• MEDICARE - ELDERLY FEDERAL PROGRAM
• BOTH GO TO PROGRAMS NOT TO INDIVIDUALS
• NEITHER PAYS FOR TREATMENT IN MENTAL HOSPITALS

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SSI

• SUPPLEMENTAL SECURITY INCOME
• FEDERAL PROGRAM
• TO INDIVIDUALS FOR LIVING EXPENSES
• NEED DISABILITY, LOSS OF FUNCTION, DURATION

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SSI

• NOW MAJOR FUNDING FOR SERIOUSLY MENTALLY ILL
• ABOUT 700/MONTH
• GOOD PROVIDES SUPPORT
• BAD FOSTERS DEPENDENCY AND DISINCENTIVE TO WORK

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RESULTS OF ECONOMIC CHANGES

• NO FEDERAL FUNDING FOR STATE HOSPITAL TREATMENT
• MORE TREATMENT IN GENERAL HOSPITALS
• MORE TREATMENT OF ELDERLY IN NURSING HOMES
• SOME FUNDING FOR COMMUNITY TREATMENT
• MUCH MORE CONSUMER CHOICE

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SUMMARY

• MANY CAUSES OF DI
• MOVEMENT FROM HOSPITAL TO COMMUNITY
• SOME IMPROVEMENT IN LIVING CONDITIONS AND CHOICE
• MANY GAPS