PUBLIC INPATIENT 1955-2000

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1955 1970 1990 2000

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CAUSES OF DI

• 1. DRUGS

• 2. IDEOLOGICAL CHANGES

• 3. LEGAL CHANGES

• 4. ECONOMIC CHANGES

I. DRUG TREATMENT

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

• IMMEDIATE SUCCESS

• DON’T CURE BUT CONTROL

• EASY TO ADMINISTER

• NEW HOPE AND OPTIMISM

• BUT MAJOR CHANGES 1970 -

II. IDEOLOGY

• 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 MODEL

• ANYONE CAN BRING PETITION ASSERTING MENTAL ILLNESS

• M.D. MUST SIGN

• ROUTINE EXAM BY COURT PSYCH.

• BRIEF HEARING

1970-2003

• 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

• LEAST RESTRICTIVE ALTERNATIVE

• OLMSTEAD DECISION - 1999

• 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

• “VOLUNTARIES” WOULDN’T BE THERE – OUTPATIENT

• HEARING WHERE STATE MUST JUSTIFY KEEPING IN HOSPITAL

• CHRONICS IN NURSING HOMES

• PROBLEM NOW IS LACK OF INPATIENT 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 $600/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

SUMMARY

• MANY CAUSES OF DI

• MOVEMENT FROM HOSPITAL TO COMMUNITY

• SOME IMPROVEMENT

• MANY GAPS