US PUBLIC INPATIENT 1830-1955

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1830 1875 1920 1955

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PUBLIC INPATIENT 1955-2006

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1955 1970 1990 2006

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CAUSES OF DI

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

I. DRUG TREATMENT

• ANTI-PSYCHOTICS THORAZINE AND LITHIUM IN MID-1950’S

• DON’T CURE BUT CONTROL• IMMEDIATE SUCCESS• EASY TO ADMINISTER• NEW HOPE AND OPTIMISM• BUT MAJOR CHANGES 1970 -

II. PHILOSOPHY

• 1. ANTI-MENTAL HOSPITALS - E.G. CUCKOO’S NEST

• 2. PRO-COMMUNITY TREATMENT - 1960’S

• LIBERAL PHILOSOPHY OF GOVERNMENT

• STRONG FEDERAL ROLE – BYPASS STATE MENTAL HOSPITALS

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

CMHC

• NOT INTEGRATED WITH STATE HOSPITALS - FEW PROGRAMS FOR S.M.I.

• CREATED GREAT GAP IN CARE – HOW FILL OLD ROLE OF STATE HOSPITAL?

III. LEGAL

• JUDICIAL AND LEGISLATIVE CHANGES

• 3 ASPECTS - COMMITMENT TO HOSPITAL, CONDITIONS IN HOSPITAL, RELEASE TO COMMUNITY

• MOVE FROM MEDICAL TO LEGAL MODEL

MEDICAL AND LEGAL

• PRIMACY OF HEALTH

• PATERNALISM• BETTER SAFE

THAN SORRY

• PRIMACY OF LIBERTY

• ADVERSARIAL• NO TREATMENT

UNLESS NECESSARY

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

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

• EMERGENCY COMMITMENTS FOR BRIEF PERIODS - 2 WKS OR MONTH

• OLMSTEAD DECISION – 1999: LEAST RESTRICTIVE ALTERNATIVE

• UP TO STATE TO PROVE NEED FOR COMMITMENT

COMMITMENT

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

3. RELEASE FROM HOSPITAL

• BURDEN OF PROOF ON STATE FOR WHY SHOULD KEEP IN HOSPITAL

• HEARINGS AT REGULAR PERIODS – EVERY SIX MONTHS OR SO

COMPARE CUCKOO’S NEST

• MORE TRUE PRE-1970’S THAN NOW• NOW MORE LEGAL THAN MEDICAL:

STATE MUST JUSTIFY HPT.• “VOLUNTARIES” WOULDN’T BE THERE

– OUTPATIENT• CHRONICS IN NURSING HOMES• PROBLEM NOW IS LACK OF FACILITIES

REASONS FOR LEGAL CHANGES

• CIVIL RIGHTS MOVEMENT• ECONOMIC PRESSURE TO REDUCE

HOSPITAL POPULATIONS

IV. ECONOMIC

• STATE HOSPITALS VERY EXPENSIVE• DI CLAIMED TO SAVE MONEY• IN FACT, SHIFTS ECONOMIC BURDEN

FROM STATES TO FEDERAL GOV.• FEDERAL WON’T PAY INPATIENT

TREATMENT IN SMH BUT WILL FOR TREATMENT OUTSIDE HOSPITALS

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

SSI

• SUPPLEMENTAL SECURITY INCOME • FEDERAL PROGRAM• TO INDIVIDUALS FOR LIVING

EXPENSES• NEED DISABILITY, LOSS OF

FUNCTION, DURATION

SSI

• NOW MAJOR FUNDING FOR SERIOUSLY MENTALLY ILL

• ABOUT $700/MONTH• GOOD – PROVIDES SUPPORT• BAD – FOSTERS DEPENDENCY AND

DISINCENTIVE TO WORK

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

SUMMARY

• MANY CAUSES OF DI• MOVEMENT FROM HOSPITAL TO

COMMUNITY• SOME IMPROVEMENT IN LIVING

CONDITIONS AND CHOICE• MANY GAPS