The new state mental hospitals in the community

Deinstitutionalisation of mental health care in The Netherlands: towards an integrative approach

OBJECTIVE

The objective of this policy paper is to put recent developments in Dutch mental health reform in an international perspective and draw conclusions for future directions in policy. CONTEXT OF THE CASE: The practice of Western psychiatry in the second half and particularly in the last decade of the 20th century has fundamentally changed. Dutch psychiatry has traditionally been prominently bed-based and various policies in the last ten years have been intended to reduce the influence of the mental hospitals. Until the mid-1990s, this had not resulted in reducing the psychiatric bed rate in comparison to other countries. Since then, there have been rapid, dramatic changes.

DATA SOURCES

We summarised two recent national studies on this subject and placed them in a national and international context, using documents on psychiatric reforms, government and advisory board reports and reviews on deinstitutionalisation in different countries.

CASE DESCRIPTION

The practice of psychiatry in the second half, and particularly in the last decade, of the 20th century has fundamentally changed. This has resulted in a spectacular decline in the number of beds in mental hospitals, increased admissions, decreased length of stay, closure of the large asylums and in community treatment away from asylums and in society, although this is a reform process. This article examines how the Dutch mental health care system has developed at the national level. The main topics cover the size, nature, aims and effects of the process of deinstitutionalisation and how alternative facilities have been developed to replace the old-fashioned institutes.

CONCLUSIONS AND DISCUSSION

There are two contrasting aspects of deinstitutionalisation in Dutch mental health care: the tendency towards rehospitalisation in relation to the sudden, late, but rapid reduction of the old mental hospitals and their premises; and a relatively large scale for community-based psychiatry in relation to building mental health care centres. Compared to other countries the bed rate in The Netherlands is still among the highest, although it is rapidly decreasing. Lessons from psychiatric reform in other countries emphasise the counterpart of deinstitutionalisation, especially issues such as the quality of alternative community treatment and increasing compulsory admission, while the closing down of old mental hospitals has caused a decrease in the availability of beds. In The Netherlands less attention has been paid to legislation, societal attitudes towards psychiatry, the roles of other care suppliers, the balancing and financing of care, the fate of psychiatric patients from old hospitals, the way to cope with the ever-increasing demand for psychiatric help and the actual quality of psychiatric help. A more integrative policy that includes all these aspects is desirable.

[The fate of patients with very severe and chronic mental disorders when there is no psychiatric hospital: a case study]

The Eastern Townships (Estrie) is an area of Québec which has never had a psychiatric hospital and is thus an extreme example of deinstitutionalization. How can people with the most severe mental illnesses be cared for? Does this system have harmful consequences? The authors present a case study with both qualitative and quantitative data to elucidate their questions. They found 36 patients with very severe mental illness (prevalence 12,4/100 000). This region does not send its most severely ill patients outside and generally succeeds in providing them with care and services in a network of small and medium size residential facilities. On the other hand, the authors have also been able to identify a certain drift of patients towards the correctional system ; cases with double or triple diagnosis do not easily have access to care ; through lack of an alternative, patients with potentially chronic violence often are stuck in a hospital in short stay beds (prevalence 1,6/100 000). It thus appears possible to eliminate the use of a psychiatric hospital for patients with very severe mental disorders as long as they are provided with supervised and long term care facilities (need : 10-20 places/100 000).

Assaultive behavior in state psychiatric hospitals: differences between forensic and nonforensic patients

Forensic patients are occupying an increasingly large number of beds in state psychiatric hospitals. The presence of these mentally ill offenders has raised concerns about the risk they present to nonforensic patients. This study compared the rate of assaults and factors associated with assaultive behavior among 308 nonforensic patients and two groups of forensic patients including 469 patients found not guilty by reason of insanity and 76 pretrial patients. Consistent with other studies, nonforensic patients had higher rates of assaults than either group of forensic patients. However, being a forensic patient did not affect the odds of assault when controlling for the effects of demographic and clinical variables in a multivariate logistic regression analysis. Factors associated with assaults in each of the three patient groups were identified using multivariate analyses. Implications are presented for treatment of assaultive behavior, mixing of forensic and nonforensic patients within state hospitals, forensic release policies, and future research.

Forty years of deinstitutionalization of psychiatric services in Canada: an empirical assessment

OBJECTIVE

To empirically analyze the implementation of the policy of deinstitutionalization of psychiatric services over a 40-year period.

METHOD

We assessed the policy of deinstitutionalization in terms of the following components: 1) population-based psychiatric beds, days of care in psychiatric hospitals (PHs); 2) days of care in psychiatric units in general hospitals (GHs); and 3) per capita expenditures on psychiatric services.

RESULTS

There was a rapid closure of beds in PHs in the 1970s and 1980s, but this was associated with an increasing rate of days of care in psychiatric units in GHs (that is, transinstitutionalization). It was not until the 1990s that the overall days of inpatient care began to decrease. Per capita expenditures on community-based psychiatric services increased throughout this period.

CONCLUSIONS

Standardized rates reveal tremendous variation among the provinces in the timing and intensity of deinstitutionalization.

Trends in acute mental health care: comparing psychiatric and substance abuse treatment programs

This study compared psychiatric and substance abuse acute care programs, within both inpatient and residential modalities of care, on organization and staffing, clinical management practices and policies, and services and activities. A total of 412 (95% of those eligible) Department of Veterans Affairs' programs were surveyed nationwide. Some 40% to 50% of patients in psychiatric and substance abuse programs, in both inpatient and residential venues of care, had dual diagnoses. Even though psychiatric programs had a sicker patient population, they provided fewer services, including basic components of integrated programs, than substance abuse programs did. Findings also showed that there is a strong emphasis on the use of clinical practice guidelines, performance monitoring, and obtaining client satisfaction and outcome data in mental health programs. The author's suggest how psychiatric programs might better meet the needs of acutely ill and dually diagnosed patients (e.g., by incorporating former patients as role models and mutual help groups, as substance abuse programs do; and by having policies that balance patient choice with program demand).

From a 'state mental hospital' to new homes in the city: longitudinal research into the use of intramural facilities by long-stay care-dependent psychiatric clients in Amsterdam

In 1986, the traditional psychiatric hospital where 70% of Amsterdam's intramural treatment took place, was closed down. The progress of two groups of long-stay patients was followed by longitudinal cohort research for five years after their transferral to new small-scale facilities in Amsterdam. The ADL-functioning of the most severely handicapped clients improved and their psychiatric symptoms decreased, while no improvement was seen in the functioning of the more independent and less handicapped clients. Now, thirteen years after closure of the old hospital, the use of the psychiatric facilities by these clients is being evaluated. This evaluation makes clear that the improvement of the severely disabled patients depends on the intensity of care given. Apparently, the improvement in the new facilities is no guarantee for a further development into a less care-intensive environment. The less handicapped and more independent clients, however, could more easily be transferred to less care-intensive facilities.

Characteristics of assaultive psychiatric patients: ten year analysis of the Assaulted Staff Action Program (ASAP)

Nearly thirty years of published research has documented the continuing presence of patient assaults on staff. These studies have included the traditional male patient with a diagnosis of schizophrenia and histories of violence and substance use disorder and the newer female, personality-disordered individual. This study reports on a ten-year longitudinal analysis of assaultive patients in one public-sector mental healthcare system during a period which included the national shift toward managed care initiatives. Data were gathered in the context of the Assaulted Staff Action Program, a crisis intervention program for staff victims. Patient assailants in both inpatient and community settings included both the traditional and newer personality-disordered individuals. The majority of assailants were females. Managed care initiatives appeared to have had little impact on type of assailants. Implications for safety and treatment are discussed.

The state of the state mental hospital at the turn of the century

There is a core of services whose specific content varies from place to place that still appears to belong to the state mental hospital.

Persons with severe mental illness in jails and prisons: a review

One of the greatest problems of deinstitutionalization has been the very large number of persons with severe mental illness who have entered the criminal justice system instead of the mental health system.

Deinstitutionalization at the beginning of the new millennium

This overview of deinstitutionalization explores its accomplishments and disappointments.

Community treatment of severely mentally ill offenders under the jurisdiction of the criminal justice system: a review

Community treatment of severely mentally ill offenders who fall under the jurisdiction of the criminal justice system has important differences from treatment of non-offenders. It is critical to identify a treatment philosophy that strikes a balance between individual rights and public safety and includes clear treatment goals.

Characteristics of assaultive psychiatric inpatients: updated review of findings, 1995-2000

The present paper reviewed the studies of the characteristics of assaultive psychiatric inpatients from 1994 to the present. These studies partially confirmed earlier findings that assaultive patients are older persons with a diagnosis of active psychosis or other neurological abnormality and histories of violence toward others and substance-use disorder. However, the recent studies also document the profile of a second group of assaultive patients: younger females with personality disorders and histories of violence toward others, substance-use disorder, and personal victimization. Since there is a paucity of published empirical research on Alzheimer's and dementia patients for this topic, the implications from the present findings for long-term care and clinical intervention are examined.

Tertiary mental health services: I. Key concepts

There are some individuals with severe and persistent mental illnesses who cannot be managed by primary and secondary services and who require tertiary care. Such clients are characterized by aggressiveness, noncompliance with medication, and dangerousness. Tertiary care program elements include psychosocial rehabilitation, sophisticated medication management, and behavioural approaches. Tertiary care may be delivered through assertive community treatment and/or specialized outreach teams, community residential programs, or hospital-based services. Increasingly, organized systems have been developed to ensure that individuals meet criteria for tertiary care and receive the most appropriate level of care. Most importantly, the delivery of tertiary care must not be tied to particular settings or time frames, and level of care must be delinked from model or location of care in order to create flexible, efficient, effective mental health services.

The state of the state mental hospital at the turn of the century

There is a core of services whose specific content varies from place to place that still appears to belong to the state mental hospital.

Closing of a state hospital: an overview and framework for a case study

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH.

The closing of Central State Hospital: long-term outcomes for persons with severe mental illness

This study examined the clinical/community functioning of long-stay patients following closing of a large state psychiatric hospital. Two overlapping samples were followed: (1) the tracking project collected information on patient location, treatment provision, legal contacts, and level of functioning (LOF) and followed all discharged patients and (2) the research study subsample, drawn from the final group of discharged patients, gathered information on quality of life (QOL), LOF, and general physical and mental health. At follow-up, patients were functioning equal to or better than prior to discharge. There were consistent improvements in QOL (especially safety and occupational satisfaction) and LOF (especially housing and income/benefits). Fewer than 27% of patients discharged into the community were rehospitalized, and fewer than 4% were either in jail or homeless after 24 months. The study demonstrates that even persons who have been hospitalized for extremely long periods can do well in the community.

Ethics in community psychiatry

OBJECTIVE

The aim of this paper is to clarify the ethical challenges resulting from new models of community psychiatry and to examine practical approaches aimed at meeting them.

METHOD

Review of the literature and observations both as clinician and medical director of community services.

RESULTS

Assertive community treatment presents ethical dilemmas relating to privacy, confidentiality, 'coercion' and conflicts of duty to the patient versus others, including carers and the wider community. Their acuity is influenced by the context in which services are provided, especially community fears of the consequences of care in the community for the severely mentally ill. Approaches to resolving ethical problems include increasing patient involvement in their care, clarifying the grounds for'paternalistic' interventions, and re-examining grounds for acting to reduce the risk of harm to others.

CONCLUSIONS

The ethical dilemmas are not new, but they present in sufficiently different guises to warrant reconsideration in their new context. There has been a reluctance to face them, but if community psychiatric practice is to survive, it must rest on a sound ethical base.

Characteristics of assaultive psychiatric inpatients in an era of managed care

Prior to managed care, extensive research documented the characteristics of assaultive inpatients in traditional state mental hospital settings as primarily older, male, psychotic patients with histories of violence toward others and of substance abuse. Recent early studies in rural and urban hospital settings have suggested that the characteristics of assaultive patients may be changing to include younger, more frequently female, patients with personality disorders and histories of personal victimization. This two-points-in-time study sought to assess the nature of assaultive patients in a suburban traditional state mental hospital after the implementation of managed care initiatives, and compared to the nature of the assaultive patients before and after the downsizing of this state mental health facility. Before census reduction, the assaultive patients were of the traditional type. After census reduction, the assaultive patients reflected more recent trends. The implications of the findings are discussed, and strategies for fostering facility safety in light of the newer violent patient are outlined.

Emerging trends in mental health policy and practice

The continuing deinstitutionalization of patients in public mental hospitals and the growth of managed care are fundamentally altering mental health practice. Managed care provides opportunities for achieving parity of insurance coverage between mental and physical illness, but serious problems persist in integrating mental health, substance abuse, and general medical care and assuring an appropriate range of services and programs for persons with serious mental illness residing in community settings. Hospital and community care are poorly coordinated, and hospital care needs to be integrated into a more balanced system of services. Important new roles are emerging for purchasers, patient advocates, and mental health authorities.

Comparing the value of service between a state hospital and a private, for-profit psychiatric hospital: a clarified role for tertiary care

We apply pattern-recognizing artificial neural networks (ANNs) to the patients of two psychiatric hospitals, a private, for-profit hospital (PH) and a state hospital (SH), both serving the southern tier of Maine (approximately two-thirds of the state's population, i.e., 800,000 persons) over a 19-month period. In our data from the PH, N = 837 admissions, and at the SH, N = 834. Unique patient identifiers were assigned to patients so that their individual patterns of care could be incorporated into our ANNs. We used a previously reported methodology to measure quality of care (Q), and developed a measure of value of service (V) from the patients' perspective for both facilities. A random portion of the demographic and outcome data of patients from each hospital was sequestered as a test set, whereas the remainder was used to train ANNs with length-of-stay (LOS) as an outcome measure. Q, and V normalized for risk (RR), i.e., V/RR, were calculated for each test set, which included multiple admissions of individual patients to each hospital. The methodology for V accounts for the severity of illness with the calculation of a metric called U/G, for the differences in case-mix by exchanging "virtual patients" between ANNs, and for entropy in the health care system by using a metric called the risk ratio (RR). Results showed that V/RR was 2.4 times greater at the SH than at the PH. This advantage is likely due to prior knowledge of individual patient patterns of treatment by the SH's staff. Data sets from each hospital using only single admissions for each patient in the study period (thereby eliminating unique patient patterns of LOS), yielded a V/RR that was only 21% greater at the SH. We hypothesize that this difference is due to the SH's ability to use treatment and discharge based upon patient strengths and level of clinical improvement, unfettered by insurance deadlines. Approximately 5% of the admissions to our studied PH went on to our SH, namely, the most severely impaired and indigent patients. The SH not only had twice the value, but also had half the cost of the PH, despite the greater number of treatment non-responders and non-compliants at the SH. The reasons for this are skilled staff and specialized ancillary services, staff knowledge of patients' responses to previous therapy, and individualized LOSs. These are features that create a caring environment and better compliance with treatment. This study emphasizes the value of tertiary care psychiatric facilities in a comprehensive mental health care delivery system. There are few studies of the effects of excessive downsizing of SHs on the community, but reports from Massachusetts (in 1995) suggest a 79% increase in suicides when the closing of SH beds exceeded 98% of maximum historical census. Routine use of pattern-recognizing tools such as ANNs would serve to inform the public about the value of mental health services so that the most vulnerable in our society are not neglected.