Established 1845
SCIENTIFIC AM E RI CAN
February 1978
Volume 238
Number 2
Deinsti tu tionalization and Mental Health Services The resident population oflarge mental hospitals has been reduced by two-thirds in 20 years, but chronic patients are being discharged to a lonely existence in hostile communities without adequate care by Ellen 1. Bassuk and Samuel Gerson
ifteen years ago the u.s. undertook a massive reform in the delivery of mental health services under the banner of "community mental health."
increases in the rate of admissions to
within reach by the availability of new psychoactive drugs. was the release from institutions and the rehabilitation within their own community of people
to bleak lives in nursing homes. single room-occupancy hotels and skid-row
rooming houses. Does "deinstitutionalization"
achievement is offset. however. by huge
too early for a definitive judgment. but it is not too soon to review the issues
F
A major objective. urged by a spirit of reform and presumed to be brought
with severe mental illness. Today the population of mental hospitals has in deed been reduced by two-thirds. That
600
500
those hospitals (signifying a high turn over of patients through short periods of hospitalization) and in the number of discharged but severely and chronical
ly disturbed former patients consigned
repre
sent an enlightened revolution or an ab dication of responsibility? It is probably
r----------,----------,----------,----------,----------,
w i=
« a. t-z
w
The mandate of those who attend to
the mentally ill has always been shaped by the social. economic. religious and philosophical temper of the times. and in no case is that effect more clearly il
lustrated than in the history of the insti tutional segregation of people who are labeled "mad." The movement toward institutionalization started with the growth of secularism in the 17th and
18th centuries. As the power of the churches waned. so did the view that disturbed behavior was a symptom of
came the belief that deviance was a re flection of sloth and moral turpitude.
best managed by disciplinary measures
and segregation from society. Institu
400
tionalization replaced witch-hunting. but the basic objective continued to be
t:. (f) t-z
er how such a well-intentioned reform as deinstitutionalization could have cre ated so many problems.
demonological possession. to be dealt with by exorcism or death. In its place
1_______
fii 0 z « (f) ::J a I
raised by this aspect of the community mental health movement and to consid
to protect society rather than to care for
300
the individual. It was not until the as
cendancy of "moral treatment." advo cated primarily by Philippe Pinel at the Hopital Salpetriere in Paris. early in the 19th century that concern for the wel fare of the institutionalized person com
200
0
Ui w a: 100
j ------- -
---
peted with concern for the protection of
--- ----
way to a more humane approach. there
0 1900
1915
1930
1945
1960
1975
INPATIENT POPULATION of state and county mental bospitals rosc stcadily from tbe turn of tbe century
society. As inhuman living conditions and harsh punishment began to give
until 1955, since wben it bas decreased sbarply.
These data do not include private
or Federal hospitals, whose population bas held fairly constant at between 50,000 and 75,000.
46 © 1978 SCIENTIFIC AMERICAN, INC
was growing interest in understanding the nature and causes of disturbed be
havior from a medical perspective. Con cepts of illness replaced concepts of social deviance: medical treatment be-
came the new rationale for institutional ization. In the U.S. parallel efforts to treat dis turbed behavior as a medical problem in special hospitals were limited at first to a few large Eastern cities; by the mid1840's only some 25 such hospitals had been established with a total capacity of perhaps 2.500. The great majority of those who were segregated because they could not function appropriately within the community lived under squalid con ditions. sequestered in county homes or almshouses or even in jails with people who were simply poor or old or physi cally sick-in any case without treat ment. In the second half of the 19th cen tury. however. there was a revolution in the care of the mentally ill. brought about by a convergence of social. medi cal and economic influences. Public at tention was drawn to the plight of the severely disturbed by a reform move ment led by Dorothea Dix. which coin cided with the development of new med ical models of disturbed behavior. As the mentally ill began to be transferred from local homes and jails to small county institutions. it became evident to state legislatures that larger state insti tutions would more economically as suage the reform movement. By 1900 more than 100 new state institutions were built. In time the large. cost-effective mental hospitals came to serve as receptacles for a wide range of socially trouble some individuals. including many of the indigent and disturbed-or seemingly disturbed-people among the waves of late- 19th-century immigrants. As the proportion of chronically ill patients increased. the hospitals became over crowded. patient care deteriorated and both psychiatrists and the public lost faith in the possibility of cure and return to the community. The reform move ment. having seen its original objectives apparently accomplished. had ceased to be a significant influence. By early in this century the network of state mental hospitals. once a proud tribute to an era of reform. had largely turned into a bureaucratic morass within which pa tients were interned. often neglected and sometimes abused.
T
hat was the general situation after World War II. when social. econom ic and medical developments prompted a teassessment of the delivery of psychi atric services. The rejection of large numbers of young men from military service on the ground of diagnosed psy chiatric disturbance had made the coun try aware of the prevalence of mental disorders and of the lack of adequate resources for prevention or treatment. The new awareness led to more fund ing of research and training programs in the area of mental health. Then came a major medical development: the wide-
legislatures to reduce the financial bur den of state mental hospitals. These various trends combined to lead Congress to establish in 1955 the Joint Commission on Mental Illness and Health to evaluate services for the men tally ill and to formulate a national men tal health program. The commission's recommendations. reported in 1960. provided the groundwork for a land mark address to Congress by President
spread and effective introduction of an tipsychotic drugs in the early 1950·s. The possibility arose that thousands of patients previously considered manage able only within the confines of an in stitution could now be treated as out patients. That possibility increased the growing pressure for the development of comprehensive programs of commu nity-based treatment. The pressure was further augmented by the desire of state
2.000
z 0 f= � ..J :> Il. 0 Il. U. 0
""
1.500
'" '"
0 0 q
a: UJ Il.
1.000
'\
..J
� t:: Il. en 0 I � en >� Cl
�
500
o
1940
1955
1950
1945
1960
1965
1970
1975
1,000 of U.S. pop hospitals since 1940.
RATE OF HOSPITALIZATION, or the number of days in the hospital per ulation, has decreased by
65
percent in state, county and private mental
4
I
I z o f=
:5
:> Il. o Il. U. o
./
3
q
-
2
-
�
g
a: UJ Il. en z o Ui en � Cl �
-
� �
�
_v
..J
g f-
o
1940
1945
1950
RATE OF ADMISSIONS has increased by
1955
129
1960
1965
1970
1975
percent as the resident population and hospi
talization rate of mental hospitals have dropped. The drop is the result of shorter average stays.
47 © 1978 SCIENTIFIC AMERICAN, INC
PORTRAITS OF MENTAL PATIENTS were engraved by Am broise Tardieu for a two-volume work publisbed in 1838, Des ma-
ladies mentales, cOl/siderees SOliS les rapports medical, ;'ygiel/iqlle et medico-!egal. The author, Jean-E tienne-Dominique Esquirol, was a
of the nation's menta! health status, was to be accomplished largely by preven tive programs originating in the mental health centers, each of which would be
now account for more than 65 percent of all mental health patient-care "epi sodes," an increase from 23 percent in 1955. (An episode is an entry into care;
rolls and the additions to those rolls in
kind of community-based center and
defined "catchment" area. Implicit in these objectives was an ex pectation that mental illness could in deed be prevented and that even chronic
cilities if they provided five essential services: inpatient care, outpatient care,
could be altered. There was a mood of enthusiastic optimism, which in retro
Kennedy urging a "bold new approach" to the management of mental illness,
which led in turn to the passage of the Mental Retardation Facilities and Com
munity Mental Health Centers Con struction Act of 1963. The legislation
and related guidelines from the Depart ment of Health, Education, and Welfare called for the establishment of a new promised Federal funding for such fa
emergency treatment, partial hospital ization and "consultation and educa tion." The legislation marked a momen
tous shift in the ideology of treatment for mental illness and led to radical changes in the delivery of psychiatric
services.
The concept of "community mental health" implied a dual promise: treat
ment and rehabilitation of the severely mentally ill within the community and
the promotion of mental health general ly. The first promise was to be fulfilled
by the development of an extensive sup port system for the mentally ill, based
on community mental health centers and offering comprehensive and coordi nated treatment and rehabilitation ser
vices. These new and "less restrictive" services were to take over the traditional function of large custodial institutions
in caring for chronically disturbed indi viduals. The quantitative goal set for this deinstitutionalization process was a 50 percent reduction in the patient pop ulation of state hospitals for the men
tally ill within two decades-a statis tic that, as we mentioned above, has al
ready been achieved. The second aim of the program, the broad improvement
responsible for a population of 75,000 to 200,000 people in a geographically
the total number of episodes in a year is the sum of the inpatient and outpatient
patterns of severely disturbed behavior
spect can be seen to have bordered on blind faith. The shortcomings of the ini tial legislation, the lack of an adequate
system of follow-up care, the hard reali ties of insufficient funding, the probable
impact of patients on communities and even the uncertainties as to effective therapy that continue to plague psychi
atry-all of these were largely ignored in the rush to implement the new goals.
In some programs established by the legislation ignoring the realities has only made for confusion and waste. For thousands of hospitalized patients re
leased haphazardly to a nonsystem of community aftercare, however, it has meant real hardship and even tragedy. As of mid-I975, 507 community men tal health centers were in full oper ation; an additional 96 centers had re ceived large grants from the National Institute of Mental Health for construc
£\..
tion and staff. (According to NIMH esti mates, however, the 603 centers would provide coverage for only some 40 per
cent of the U.S. population; some 1,500 centers are needed.) Outpatient facili ties, which include the community cen
ters, other clinics and emergency rooms,
48 © 1978 SCIENTIFIC AMERICAN, INC
FIRST STATE HOSPITAL built expressly for the humane custodial care of chronically disturbed patients under medical supervision
are illusory, however. Although the an
nual census was decreasing. admissions to state hospitals increased from 178.-
000 in 1955 to a peak of 390,000 in
1972 and had declined only to 375,000
by 1974. That trend reflects a new phi
and frequently not even in communica
admissions were readmissions (in 1972.
charges are inadequately coordinated
released inpatients are readmitted with
cilities. Moreover, in the rush to reduce
64 percent of them); about half of the
in a year of discharge. Those statistics must surely refiect the lack of a fully effective community-based support sys tem. As a matter of fact, the Depart ment of Mental Health in Massachu setts, where we work (at Beth Israel Hospital and Cambridge Hospital and
doubling between 1955 and 1975, there
was a 65 percent decrease in the census of resident patients in state mental hos pitals. from 5 59.000 to 193,000. The
deinstitutionalization
statistics
with the availability of community fa
their census the hospitals discharged pa
tients long before most of the commu
nity centers had been established and
before supporting programs had been developed.
fourths of the readmissions could have been avoided if comprehensive commu
and made more explicit in an amend
grams are few. however, and they are the result of efforts by particular indi
nity facilities had existed. And they generally do not exist. As contemplated in the 1963 legislation
the course of the year.) At the same time that outpatient episodes were more than
tion with each other. so that the dis
here are, to be sure. a few centers have devised innovative pro grams to enhance the quality of life for chronically ill patients; there are some experimental programs that offer total
the Harvard Medical School), has esti mated that between half and three
illnesses and advocated humane treatment.
been administered without connection
with the state hospitals; the two systems are most often completely unintegrated
losophy of short-term hospitalization.
Moreover, a growing proportion of the
pioneer in psychiatry who classified mental
of patients returned to the community. There are some obvious reasons. One is that the centers developed and have
ment in 1975, the deinstitutionalized pa tient was to be supported by a spectrum of aftercare services delivered by half way houses, family and group homes. therapeutic residential centers, foster
care arrangements and so on. with the local community mental health center
as the coordinator. In 1977 a report is sued by the General Accounting Office concluded that the centers have not ful
filled their intended function in behalf
T that
care for discharged patients in a com munity setting. Such centers and pro
viduals or institutions. special funding or other special circumstances rather
than of any consistent plan. In part this inconsistency results from a deliberate
choice: the development of community services was not based on data collected by systematic research; rather, it was as sumed that each center would be shaped
by the particular needs of its area as they were perceived by the community itself. A major problem in gauging the ef-
,� , C"
M.""��> l�""",.,, -._. " " ..
fI�!�,*,Wal�,"",Pu.,H_, H� ".... ..
, l*I�. M-ra;JiW4u>t "'
!trW«t.�. k�'4K_
�_ 'lt1
,VUoMH_ IIStuH_
was the Willard Asylum for the Insane, opened in 1869 at Ovid in
commodated 1,500 patients, many more than any earlier U.S. mental
western New York. Its sprawling plant, which included a central build
institution. This engraving of the hospital grounds was an illustration
ing, farm buildings and "detached blocks" for men and women, ac-
in the ninth annual report of the board of trustees, published in 1878.
49 © 1978 SCIENTIFIC AMERICAN, INC
fectiveness of the community support programs is the paucity of follow-up studies whose data can be generalized and compared and that trace the move ment of discharged patients through the labyrinth of psychiatric facilities and living conditions after their release. The existing evidence is clear. however. par ticularly to those of us who are engaged in the emergency care of severely dis turbed people in outpatient departments of city hospitals. Time and time again we see patients who were released from state hospitals after months or years of custodial care; who then survived pre cariously on welfare payments for a few months on the fringe of the communi ty. perhaps attending a clinic to receive medication or intermittent counseling; who voluntarily returned to a hospital or were recommitted (which in Massa chusetts is possible only if the patient is acutely suicidal or homicidal or mani festly unable to care for himself); who were maintained in the hospital on an tipsychotic medication and seemed to improve; who were released again to an isolated "community" life and who. having again become unbearably de spondent. disorganized or violent. either present themselves at the emergency room or are brought to it by a police officer. Then the cycle begins anew. The generally ineffective functioning of community mental health centers in caring for discharged patients means that there is an inadequate system of fol-
low-up psychiatric treatment for them. or even of basic guidance in coping with the mechanics of daily living. The fail ure to establish sheltered housing shunts former patients into nonpsychiatrical Iy oriented facilities. Most patients are placed in nursing homes (a category that includes skilled nursing facilities. inter mediate-care facilities. rest homes and homes for the aged). a process the De partment of Health. Education. and Welfare has labeled "reinstitutionaliza tion." since most homes have more than 100 beds (and yet offer only custodi al care). A national survey in 1974 of skilled-nursing facilities revealed that 22 percent of their 284.000 patients less than 65 years old were diagnosed as be ing mentally ill or retarded. Of the pa tients 65 years and over. a third had chronic brain disease and a tenth were diagnosed as being neurotic or psychot ic. The inappropriate occupying of nurs ing-home beds by these former patients means that the beds are not available for patients with chronic physical illnesses. whose stay in general hospitals is there fore unnecessarily prolonged. Untherapeutic though many nursing homes are. living conditions in most of them are at least tolerable. Conditions may be worse for discharged patients living on their own. without enough money and usually without any possibil ity of employment. Many of them drift to substandard inner-city housing that is overcrowded. unsafe. dirty and isolated.
450 NET RELEASES 400
3 50
$ Cl z
SCIENTIFIC AM E RI CAN
February 1978
Volume 238
Number 2
Deinsti tu tionalization and Mental Health Services The resident population oflarge mental hospitals has been reduced by two-thirds in 20 years, but chronic patients are being discharged to a lonely existence in hostile communities without adequate care by Ellen 1. Bassuk and Samuel Gerson
ifteen years ago the u.s. undertook a massive reform in the delivery of mental health services under the banner of "community mental health."
increases in the rate of admissions to
within reach by the availability of new psychoactive drugs. was the release from institutions and the rehabilitation within their own community of people
to bleak lives in nursing homes. single room-occupancy hotels and skid-row
rooming houses. Does "deinstitutionalization"
achievement is offset. however. by huge
too early for a definitive judgment. but it is not too soon to review the issues
F
A major objective. urged by a spirit of reform and presumed to be brought
with severe mental illness. Today the population of mental hospitals has in deed been reduced by two-thirds. That
600
500
those hospitals (signifying a high turn over of patients through short periods of hospitalization) and in the number of discharged but severely and chronical
ly disturbed former patients consigned
repre
sent an enlightened revolution or an ab dication of responsibility? It is probably
r----------,----------,----------,----------,----------,
w i=
« a. t-z
w
The mandate of those who attend to
the mentally ill has always been shaped by the social. economic. religious and philosophical temper of the times. and in no case is that effect more clearly il
lustrated than in the history of the insti tutional segregation of people who are labeled "mad." The movement toward institutionalization started with the growth of secularism in the 17th and
18th centuries. As the power of the churches waned. so did the view that disturbed behavior was a symptom of
came the belief that deviance was a re flection of sloth and moral turpitude.
best managed by disciplinary measures
and segregation from society. Institu
400
tionalization replaced witch-hunting. but the basic objective continued to be
t:. (f) t-z
er how such a well-intentioned reform as deinstitutionalization could have cre ated so many problems.
demonological possession. to be dealt with by exorcism or death. In its place
1_______
fii 0 z « (f) ::J a I
raised by this aspect of the community mental health movement and to consid
to protect society rather than to care for
300
the individual. It was not until the as
cendancy of "moral treatment." advo cated primarily by Philippe Pinel at the Hopital Salpetriere in Paris. early in the 19th century that concern for the wel fare of the institutionalized person com
200
0
Ui w a: 100
j ------- -
---
peted with concern for the protection of
--- ----
way to a more humane approach. there
0 1900
1915
1930
1945
1960
1975
INPATIENT POPULATION of state and county mental bospitals rosc stcadily from tbe turn of tbe century
society. As inhuman living conditions and harsh punishment began to give
until 1955, since wben it bas decreased sbarply.
These data do not include private
or Federal hospitals, whose population bas held fairly constant at between 50,000 and 75,000.
46 © 1978 SCIENTIFIC AMERICAN, INC
was growing interest in understanding the nature and causes of disturbed be
havior from a medical perspective. Con cepts of illness replaced concepts of social deviance: medical treatment be-
came the new rationale for institutional ization. In the U.S. parallel efforts to treat dis turbed behavior as a medical problem in special hospitals were limited at first to a few large Eastern cities; by the mid1840's only some 25 such hospitals had been established with a total capacity of perhaps 2.500. The great majority of those who were segregated because they could not function appropriately within the community lived under squalid con ditions. sequestered in county homes or almshouses or even in jails with people who were simply poor or old or physi cally sick-in any case without treat ment. In the second half of the 19th cen tury. however. there was a revolution in the care of the mentally ill. brought about by a convergence of social. medi cal and economic influences. Public at tention was drawn to the plight of the severely disturbed by a reform move ment led by Dorothea Dix. which coin cided with the development of new med ical models of disturbed behavior. As the mentally ill began to be transferred from local homes and jails to small county institutions. it became evident to state legislatures that larger state insti tutions would more economically as suage the reform movement. By 1900 more than 100 new state institutions were built. In time the large. cost-effective mental hospitals came to serve as receptacles for a wide range of socially trouble some individuals. including many of the indigent and disturbed-or seemingly disturbed-people among the waves of late- 19th-century immigrants. As the proportion of chronically ill patients increased. the hospitals became over crowded. patient care deteriorated and both psychiatrists and the public lost faith in the possibility of cure and return to the community. The reform move ment. having seen its original objectives apparently accomplished. had ceased to be a significant influence. By early in this century the network of state mental hospitals. once a proud tribute to an era of reform. had largely turned into a bureaucratic morass within which pa tients were interned. often neglected and sometimes abused.
T
hat was the general situation after World War II. when social. econom ic and medical developments prompted a teassessment of the delivery of psychi atric services. The rejection of large numbers of young men from military service on the ground of diagnosed psy chiatric disturbance had made the coun try aware of the prevalence of mental disorders and of the lack of adequate resources for prevention or treatment. The new awareness led to more fund ing of research and training programs in the area of mental health. Then came a major medical development: the wide-
legislatures to reduce the financial bur den of state mental hospitals. These various trends combined to lead Congress to establish in 1955 the Joint Commission on Mental Illness and Health to evaluate services for the men tally ill and to formulate a national men tal health program. The commission's recommendations. reported in 1960. provided the groundwork for a land mark address to Congress by President
spread and effective introduction of an tipsychotic drugs in the early 1950·s. The possibility arose that thousands of patients previously considered manage able only within the confines of an in stitution could now be treated as out patients. That possibility increased the growing pressure for the development of comprehensive programs of commu nity-based treatment. The pressure was further augmented by the desire of state
2.000
z 0 f= � ..J :> Il. 0 Il. U. 0
""
1.500
'" '"
0 0 q
a: UJ Il.
1.000
'\
..J
� t:: Il. en 0 I � en >� Cl
�
500
o
1940
1955
1950
1945
1960
1965
1970
1975
1,000 of U.S. pop hospitals since 1940.
RATE OF HOSPITALIZATION, or the number of days in the hospital per ulation, has decreased by
65
percent in state, county and private mental
4
I
I z o f=
:5
:> Il. o Il. U. o
./
3
q
-
2
-
�
g
a: UJ Il. en z o Ui en � Cl �
-
� �
�
_v
..J
g f-
o
1940
1945
1950
RATE OF ADMISSIONS has increased by
1955
129
1960
1965
1970
1975
percent as the resident population and hospi
talization rate of mental hospitals have dropped. The drop is the result of shorter average stays.
47 © 1978 SCIENTIFIC AMERICAN, INC
PORTRAITS OF MENTAL PATIENTS were engraved by Am broise Tardieu for a two-volume work publisbed in 1838, Des ma-
ladies mentales, cOl/siderees SOliS les rapports medical, ;'ygiel/iqlle et medico-!egal. The author, Jean-E tienne-Dominique Esquirol, was a
of the nation's menta! health status, was to be accomplished largely by preven tive programs originating in the mental health centers, each of which would be
now account for more than 65 percent of all mental health patient-care "epi sodes," an increase from 23 percent in 1955. (An episode is an entry into care;
rolls and the additions to those rolls in
kind of community-based center and
defined "catchment" area. Implicit in these objectives was an ex pectation that mental illness could in deed be prevented and that even chronic
cilities if they provided five essential services: inpatient care, outpatient care,
could be altered. There was a mood of enthusiastic optimism, which in retro
Kennedy urging a "bold new approach" to the management of mental illness,
which led in turn to the passage of the Mental Retardation Facilities and Com
munity Mental Health Centers Con struction Act of 1963. The legislation
and related guidelines from the Depart ment of Health, Education, and Welfare called for the establishment of a new promised Federal funding for such fa
emergency treatment, partial hospital ization and "consultation and educa tion." The legislation marked a momen
tous shift in the ideology of treatment for mental illness and led to radical changes in the delivery of psychiatric
services.
The concept of "community mental health" implied a dual promise: treat
ment and rehabilitation of the severely mentally ill within the community and
the promotion of mental health general ly. The first promise was to be fulfilled
by the development of an extensive sup port system for the mentally ill, based
on community mental health centers and offering comprehensive and coordi nated treatment and rehabilitation ser
vices. These new and "less restrictive" services were to take over the traditional function of large custodial institutions
in caring for chronically disturbed indi viduals. The quantitative goal set for this deinstitutionalization process was a 50 percent reduction in the patient pop ulation of state hospitals for the men
tally ill within two decades-a statis tic that, as we mentioned above, has al
ready been achieved. The second aim of the program, the broad improvement
responsible for a population of 75,000 to 200,000 people in a geographically
the total number of episodes in a year is the sum of the inpatient and outpatient
patterns of severely disturbed behavior
spect can be seen to have bordered on blind faith. The shortcomings of the ini tial legislation, the lack of an adequate
system of follow-up care, the hard reali ties of insufficient funding, the probable
impact of patients on communities and even the uncertainties as to effective therapy that continue to plague psychi
atry-all of these were largely ignored in the rush to implement the new goals.
In some programs established by the legislation ignoring the realities has only made for confusion and waste. For thousands of hospitalized patients re
leased haphazardly to a nonsystem of community aftercare, however, it has meant real hardship and even tragedy. As of mid-I975, 507 community men tal health centers were in full oper ation; an additional 96 centers had re ceived large grants from the National Institute of Mental Health for construc
£\..
tion and staff. (According to NIMH esti mates, however, the 603 centers would provide coverage for only some 40 per
cent of the U.S. population; some 1,500 centers are needed.) Outpatient facili ties, which include the community cen
ters, other clinics and emergency rooms,
48 © 1978 SCIENTIFIC AMERICAN, INC
FIRST STATE HOSPITAL built expressly for the humane custodial care of chronically disturbed patients under medical supervision
are illusory, however. Although the an
nual census was decreasing. admissions to state hospitals increased from 178.-
000 in 1955 to a peak of 390,000 in
1972 and had declined only to 375,000
by 1974. That trend reflects a new phi
and frequently not even in communica
admissions were readmissions (in 1972.
charges are inadequately coordinated
released inpatients are readmitted with
cilities. Moreover, in the rush to reduce
64 percent of them); about half of the
in a year of discharge. Those statistics must surely refiect the lack of a fully effective community-based support sys tem. As a matter of fact, the Depart ment of Mental Health in Massachu setts, where we work (at Beth Israel Hospital and Cambridge Hospital and
doubling between 1955 and 1975, there
was a 65 percent decrease in the census of resident patients in state mental hos pitals. from 5 59.000 to 193,000. The
deinstitutionalization
statistics
with the availability of community fa
their census the hospitals discharged pa
tients long before most of the commu
nity centers had been established and
before supporting programs had been developed.
fourths of the readmissions could have been avoided if comprehensive commu
and made more explicit in an amend
grams are few. however, and they are the result of efforts by particular indi
nity facilities had existed. And they generally do not exist. As contemplated in the 1963 legislation
the course of the year.) At the same time that outpatient episodes were more than
tion with each other. so that the dis
here are, to be sure. a few centers have devised innovative pro grams to enhance the quality of life for chronically ill patients; there are some experimental programs that offer total
the Harvard Medical School), has esti mated that between half and three
illnesses and advocated humane treatment.
been administered without connection
with the state hospitals; the two systems are most often completely unintegrated
losophy of short-term hospitalization.
Moreover, a growing proportion of the
pioneer in psychiatry who classified mental
of patients returned to the community. There are some obvious reasons. One is that the centers developed and have
ment in 1975, the deinstitutionalized pa tient was to be supported by a spectrum of aftercare services delivered by half way houses, family and group homes. therapeutic residential centers, foster
care arrangements and so on. with the local community mental health center
as the coordinator. In 1977 a report is sued by the General Accounting Office concluded that the centers have not ful
filled their intended function in behalf
T that
care for discharged patients in a com munity setting. Such centers and pro
viduals or institutions. special funding or other special circumstances rather
than of any consistent plan. In part this inconsistency results from a deliberate
choice: the development of community services was not based on data collected by systematic research; rather, it was as sumed that each center would be shaped
by the particular needs of its area as they were perceived by the community itself. A major problem in gauging the ef-
,� , C"
M.""��> l�""",.,, -._. " " ..
fI�!�,*,Wal�,"",Pu.,H_, H� ".... ..
, l*I�. M-ra;JiW4u>t "'
!trW«t.�. k�'4K_
�_ 'lt1
,VUoMH_ IIStuH_
was the Willard Asylum for the Insane, opened in 1869 at Ovid in
commodated 1,500 patients, many more than any earlier U.S. mental
western New York. Its sprawling plant, which included a central build
institution. This engraving of the hospital grounds was an illustration
ing, farm buildings and "detached blocks" for men and women, ac-
in the ninth annual report of the board of trustees, published in 1878.
49 © 1978 SCIENTIFIC AMERICAN, INC
fectiveness of the community support programs is the paucity of follow-up studies whose data can be generalized and compared and that trace the move ment of discharged patients through the labyrinth of psychiatric facilities and living conditions after their release. The existing evidence is clear. however. par ticularly to those of us who are engaged in the emergency care of severely dis turbed people in outpatient departments of city hospitals. Time and time again we see patients who were released from state hospitals after months or years of custodial care; who then survived pre cariously on welfare payments for a few months on the fringe of the communi ty. perhaps attending a clinic to receive medication or intermittent counseling; who voluntarily returned to a hospital or were recommitted (which in Massa chusetts is possible only if the patient is acutely suicidal or homicidal or mani festly unable to care for himself); who were maintained in the hospital on an tipsychotic medication and seemed to improve; who were released again to an isolated "community" life and who. having again become unbearably de spondent. disorganized or violent. either present themselves at the emergency room or are brought to it by a police officer. Then the cycle begins anew. The generally ineffective functioning of community mental health centers in caring for discharged patients means that there is an inadequate system of fol-
low-up psychiatric treatment for them. or even of basic guidance in coping with the mechanics of daily living. The fail ure to establish sheltered housing shunts former patients into nonpsychiatrical Iy oriented facilities. Most patients are placed in nursing homes (a category that includes skilled nursing facilities. inter mediate-care facilities. rest homes and homes for the aged). a process the De partment of Health. Education. and Welfare has labeled "reinstitutionaliza tion." since most homes have more than 100 beds (and yet offer only custodi al care). A national survey in 1974 of skilled-nursing facilities revealed that 22 percent of their 284.000 patients less than 65 years old were diagnosed as be ing mentally ill or retarded. Of the pa tients 65 years and over. a third had chronic brain disease and a tenth were diagnosed as being neurotic or psychot ic. The inappropriate occupying of nurs ing-home beds by these former patients means that the beds are not available for patients with chronic physical illnesses. whose stay in general hospitals is there fore unnecessarily prolonged. Untherapeutic though many nursing homes are. living conditions in most of them are at least tolerable. Conditions may be worse for discharged patients living on their own. without enough money and usually without any possibil ity of employment. Many of them drift to substandard inner-city housing that is overcrowded. unsafe. dirty and isolated.
450 NET RELEASES 400
3 50
$ Cl z
