Seriously Mentally Ill: Moving Away from Institutions to the Community

Homelessness is related to deinstutionalization. Image by mimicry.

In a brief span of time, police shot two mentally ill individuals – would more availability of psychiatric beds have made a difference?

On December 16, 2013 The Salt Lake Tribune reported that the police shot a knife-wielding man. On December 14, 2013, SFGate reported that police in Honolulu shot a man with a blade attached to a twelve-foot pole.

Why were these men not obtaining mental health services?  Perhaps part of the blame lies in a system that has tilted too far in favor of deinstiutionalization.

The Move Away from Institutions to Wrap-Around Care

The number of mentally ill individuals housed in institutions in the United States peaked in the mid-1950s at 560,000 people.  After  philosophical questions about the nature of mental illness, the establishment of better therapies, more potent medications, and the rise of outpatient mental health centers, that number dropped precipitously, with more and more seriously mentally ill people living in the community.

The number of psychiatric beds declined precipitously.  “A March 2008 report by the Treatment Advocacy Center reveals that for every 20 public psychiatric beds that existed in the US in 1955, only one such bed existed in 2005.”

In the period from 1993 to 2003, the cost of treatment for people with a serious mental illness has shifted from hospitals to drug treatment.  The National Institute of Mental Health’s website notes, “the percentage of payments going to specialty hospitals and specialty units within general hospitals decreased notably. During the same period of time, the percentage of mental health payments for retail prescription drugs increased.”  Only 7.5% of the cost for mental health was spent on inpatient treatment in 2008.

In Nebraska,  the population of three mental hospitals housing 2000 to 2500 people has been reduced to two hospitals housing about 200 individuals. According to Jim Jenson, Nebraska state senator in 2005, a bill was passed to provide “subsidized housing and for wrap-around services that will enable people with mental illnesses to live independently and productively. Recovery is the goal.”  Subsidized housing, such as Section 8 programs, reduce the amount paid for rent and utilities while wrap-around services include access to clinics, case workers and other supportive services.

The Risks of Deinstutionalization: Homelessness, Imprisonment, Overuse of Emergency Rooms

Has the movement toward deinstitutionalization has gone too far?  Recent decades have been dominated by discussions of civil rights and budget reductions rather than patient and public safety.  Mentally ill individuals who are not yet diagnosed, or who are not responsive to medication  or who refuse it, are at high risk of homelessness, of overburdening local emergency rooms, or being incarcerated, according to Treatment Advocacy Center.  No one wants to go back to a time when there was a psychiatric bed for every mental patient, but more beds could relieve the burden on emergency rooms and police, as well as provide more appropriate care.

Researchers determined that 50 psychiatric beds per every 100,000 individuals is the minimum to serve a population.  According to Treatment Advocacy Center, “Eight states still don’t have assisted outpatient treatment and many states are in need of additional community mental health services, making 50 public psychiatric beds per 100,000 people a minimum requirement… In 32 states the bed shortage was critical or severe, 42 states had less than half the minimum number of beds needed, and six states had less than 20 percent of the minimum beds needed to provide adequate care..”

The Need for Balance

In 1998, the Treatment Advocacy Center published an article titled, “The Devil in Deinstitutionalizing” which said, “ many proponents of deinstitutionalization now admit that they were over-idealistic at the outset, and grossly underestimated the challenge of helping the mentally ill manage themselves outside a controlled setting, the idealism of the sixties gradually has given way to more realistic assessments and approaches.”   Although the last fifteen years since the piece was published have brought about better psychiatric medications, the shrinking number of psychiatric beds still poses dilemmas.  Civil rights are important.  Being frugal with public funds is important. Safety is important.  It is up to us and our legislatures to find a balance.