The Mental Health Asylum: The Pendulum Swings Back?

pendulum-clock-flickr-dave-fThis article entitled “Improving Long Term Psychiatric Care: Bring Back the Asylum,” in the Journal of the American Medical Association (JAMA) caught my eye, given that it’s Martin Luther King Jr Week 2015 [1]:

The reason I made the comment in the above tweet saying “The pendulum swings back,” is because of a 1983 JAMA article entitled “From mental hospitals to jails: the pendulum swings.” The truncated abstract reads as follows:

“Irresponsible deinstitutionalization”—release of mentally ill patients from psychiatric hospitals—is turning this country’s 4,000 county and local jails into the new mental hospitals and returning care of the mentally ill to the deplorable conditions that prevailed more than 300 years ago, according to clinical psychologist Lawrence M. Cohen, MEd.

Speaking at the Seventh National Conference on Medical Care and Health Services in Correctional Institutions sponsored in Chicago by the American Medical Association and American Health Care Consultants, Cohen, who is director of the Psychological Social Services Unit at Burlington County Jail, Mount Holly, NJ, said, “We are still in the Stone Age as regards treating the mentally ill in jails.”

Statistics show that patients dismissed from mental hospitals have begun to merge with the populations of local lockups. Writing in the 1983 edition of Crime and Justice, an annual review of research in the field, John Monahan, PhD, a professor of… [2]”

This reminded me of a recent news item about Iowa Governor Terry Branstad who has been trying to close state mental hospitals in this state for years and recently quietly cut funding for two of them, although not without opposition from many stakeholders. Now I’m just a geezer consulting psychiatrist looking at the microcosm but I can tell you that expecting The University of Iowa Hospitals & Clinics (UIHC) to pick up the slack for bed closings at two of Iowa’s mental health institutes is short-sighted. Acute psychiatric beds are in short supply all over the state and that’s why we’ve recently begun a new, hopefully value-added but admittedly reactive, service on weekends and holidays to care for patients with acute psychiatric illness boarding in our emergency room waiting to be sent to other psychiatric hospitals in the state when UIHC acute psychiatric beds are full–which is most of the time. Nigella ready for her walkThis has become the psychiatry consult service’s responsibility and I take it very seriously (uh oh, now I’m going to have to walk Nigella). Where do these patients go? Where can they go? Those are questions for Governor Branstad and the Iowa Department of Health and Human Services. And by the way, the Affordable Care Act means increasing coverage, but coverage is not necessarily care.

Many people probably think the governor is just bent on breaking the state mental health system into fewer and fewer pieces, focusing on the mental health institutes and expecting UIHC to come to the rescue.

It’s interesting to compare this piece with an article published in the Pennsylvania Enquirer, which makes the opposing point, based on the JAMA paper by Sisti et al.

This prompts a sort of sketchy historical look back at previously published articles in JAMA in the past starting with one in 1939 which has a definitely positive tone about the role of state mental hospitals contributing to psychiatric research.

The abstract follows:

“By information collected through questionnaires, personal interviews and visits, a survey was made of existing facilities for research in mental problems in private hospitals and public institutions. This book constitutes an appraisal of that review. It was found that twenty of the 273 public institutions could be designated as research centers because of the character and quality of their investigatory work, the caliber of their personnel and the resources at their disposal for scientific study. In addition there are thirty-two public-supported hospitals that offer distinct possibilities for research work. Furthermore the report estimates that there are 150 of the 1,700 staff physicians in the public mental institutions of the country who show a definite interest in and ability for investigative work. The survey furnishes tangible evidence that a creditable beginning has been made in the development of research in public institutions and that further desirable expansion might be fostered with…”

Moving to 1948, see the following paper which exposes the darker side of state mental asylums which probably contributed to the drive to deinstitutionalization in the 1960s. It suggests that it is not just public officials who fail to understand the importance of caring for those with chronic, severe mental illness–but “public indifference” as well, meaning all of us:

The abstract for this paper is as follows:

“The Committee on Public Health Relations of the New York Academy of Medicine1 has recently reported on problems of the New York state mental hospitals system. Administrators of such hospitals face numerous problems, but they are especially concerned with provision of care for more patients than the rated capacities of their institutions. Public indifference to the fate of mental patients is still reflected by the depersonalization of care rendered in mental hospitals. Research programs connected with the mental hospital system are badly needed. The principal problems are overcrowding, understaffing, insufficient funds and deteriorated physical plants. Immediate recommendations call for correction of existing overcrowding by systematic review of patients, with discharge of patients in convalescent state or to family care. Expansion of the program of family care is desirable to secure increase in numbers of foster homes for mental patients and establishment of proper levels of payment. An effort should be…”

And there is this piece about the pattern of the discharge of patients from Norwegian long-term mental hospitals before the introduction of modern drugs, which in turn also accelerated the move toward deinstitutionalization.

The reference is available only in pdf format. Patients admitted for the first time to psychiatric hospitals between 1955 and 1959 were followed up regarding the pattern of discharge and readmission until the end of 1960. This was during the period when effective psychiatric drugs were discovered. The writers call these “ataractic drugs.” These patients were then compared to those treated during the predrug era between 1948 and 1953. “Ataractic” refers to tranquility and ataractic drugs were what they called the major tranquilizers, one example being chlorpromazine.

I found an article on drugs that produce a state of ataraxy (which the authors say is “freedom from confusion and anxiety”) in a 1956 article by H. Angus Bowes, published in The American Journal of Psychiatry.

I think the abstract is fascinating, not just because it shines a light on the history of deinstitutionalization, but on the balanced thinking of the time:

The ataractic drugs are so called from their ability to produce ataraxy: freedom from confusion and anxiety. In a veterans psychiatric unit of 550 beds with a high rate of admissions and discharges, chlorpromazine and reserpine have been intensively studied during the past 2 years and since June 1955, Frenquel has been given to 130 patients, and Pacatal to over 250, in an effort to clarify the indications for these ataraxics in the treatment of acute and chronic psychoses.

Our experiences with Frenquel are described in some detail as the originally hopeful and eventually disillusioning results obtained may explain many ambiguous findings in this complex field of research. Frenquel appears to have antihallucinatory and physically tonic effects in a small minority of regressed schizophrenics but to be of no value in the treatment of acute psychoses. Reserpine has also failed to fulfill earlier expectations. It is now reserved for the tranquillization of arteriosclerotics and as an adjuvant in the psychotherapy of some withdrawn schizophrenics.

Pacatal, a phenothiazine derivitive recently developed in Europe, and chlorpromazine are virtually interchangeable and synergistic. Pacatal is almost twice as strong a tranquillizer but a weaker hypnotic. It is mildly euphoriant and strongly parasympatholytic unlike chlorpromazine, a sympatholytic and depressant. Both are indicated in the symptomatic relief of psychomotor excitation, aggression, destructiveness, restlessness, and tension in acute and chronic psychoses. A combination of both, in which their mutually antagonistic autonomic effects reduce the incidence of complications and abolish the Parkinsonian syndrome, is yielding promising results.

In this study these drugs have significantly reduced the need for ECT and lobotomy without replacing these valuable methods of treatment. The seclusion of disturbed patients has been reduced to one-tenth. Since July 1955, insulin coma therapy has been replaced by group psychotherapy using ataraxics as adjuvants. Over twice the number of patients can be treated, so far with better results. Our discharges during 1955 outnumbered our admissions; the hospital atmosphere is calmer, and there is increased confidence and optimism. These latter factors cannot be ignored.

Alone, ataraxics merely modify symptoms but in conjunction with psychotherapy they open up wide vistas of therapeutic promise.

I think the last sentence is especially important. “Alone, ataraxics merely modify symptoms but in conjunction with psychotherapy they open up wide vistas of therapeutic options.”

Returning to the Pattern of Discharge from Norwegian Mental Hospitals paper, the authors noted a “…very slight increase in the discharge rates and also a tendency toward shorter stay in mental hospitals during the drug era.” But they also seemed to notice improvement prior to the appearance of the ataractic drugs, starting even in 1936, which they attributed to improvement in employment rates.

If you want a less impressionistic and more cohesive historical description of what led to the deinstitutionalization of state mental hospitals and what resulted, you can’t do better than Dr. George Dawson’s post. But Sisti et al have a higher vision for state psychiatric hospitals, citing an example in Massachusetts:

Fortunately, new models of fully integrated, patient-centered long-term psychiatric care now exist in the United States. For instance, a transformed state hospital that is now the Worcester Recovery Center and Hospital provides a full range of integrated treatment services, psychiatric research, and medical education programs and has been at the forefront of using electronic medical records and patient-centered treatments. With its 320 private rooms and recovery-inspired residential design and treatment programs, the hospital cost $300 million to build and has a $60 million annual budget. More facilities like this one are needed to provide 21st-century care to patients with chronic, serious mental illness.

The new Worcester Recovery Center and Hospital was built, in part, using the bricks and mortar of the old state mental facility.

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So what do you think? Is the pendulum swinging back?

 

References:

1. Sisti, D. A., et al. (2015). “Improving Long-term Psychiatric Care: Bring Back the Asylum.” JAMA 313(3): 243-244.

2. Goldsmith, M. F. (1983). “From mental hospitals to jails: the pendulum swings.” JAMA 250(22): 3017-3018.

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Comments

  1. I should probably mention that here in Minnesota we did build a new state hospital – Anoka Metro Regional Treatment Center (AMRTC). It is one of the few remaining state hospitals in Minnesota. Like most areas of medicine, Minnesota takes a managed care approach to the treatment of mental illnesses. The system is chronically under the threat of closing down all of the hospitals despite the fact that there is a long and actively managed waiting list to get into AMRTC. That eventually leads to community hospitals being used as long term care hospitals despite the fact that they are not funded to do that. That in turn backs up all the way to the ED. There is evidence that I am aware of that some patients who are ill enough to still be hospitalized are being managed in small group homes. There was a movement at one point to open smaller community based state facilities, but they could not get adequate staffing especially in the case of highly aggressive individuals.

    The overriding management philosophy always seems to be rationing rather than planning the level of services and trying to assure that they are first rate. They are also the recipient of cost shifting from a health care environment that probably has more managed care coverage than most other states. Managed care generally translates to no comprehensive care for people with severe or chronic mental illnesses.

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  2. Well said as usual, George. I’ll be interested in how the Worcester facility does as well over the next several years.

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  3. Great post Jim.

    There is still a lot of resistance to the pendulum swing.

    The main problem is that nobody wants to recognize this as a problem with rationing. That is an issue because once you have a reasonable state hospital it is immediately overwhelmed by pent up demand from the last 30 years and and there is no place to discharge the patients to. Your modern hospital is always teetering between being an actual hospital and a group home or residential center. There is also the problem that there are some people who are so ill it takes them years to stabilize. If you use a rationing approach at some point you just declare them hopeless and say it is time for them to move on. A third problem is that the patients are so ill that it takes a staff with a high level of expertise. From a staffing standpoint there has to be a good environment to attract and retain this kind of staff because they can obviously practice anywhere.

    I would be very interested in finding out how the Worcester facility handles those problems because they are always politically driven. Current funding from the feds and what that implies is also a problem.

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