Is it Time for Re-institutionalization?

“All things in moderation” –Benjamin Franklin

I can just sense the uproar now. Dr Moffic wants state hospitals again? Has he lost it? Well, yes. I do, sort of. Here’s why.

Recently, I was asked to write a request to possibly extend the outpatient commitment of a patient of mine. What for, I said to myself? This would be a waste of time because he had not exhibited any more dangerous behavior, was taking care of himself, and was compliant with his intramuscular medication. However, when as part of the ongoing monitoring of my patient’s improvement, I asked him to rate on a 0-10 (best) scale how well the medication was working, he said “0”. When I asked why, he said it was because he didn’t need the medication. Uh, oh, I thought. Could this be Anosognosia? Or, has he read or heard of Robert Whitaker’s book, Anatomy of an Epidemic (2010), which discusses the potential long-term risks of such medications.

There’s no way he’ll be committed longer, but will he stay on the medication voluntarily? Without it he’d surely relapse into psychosis and possible dangerousness. If he then went inpatient again, would he only stay a few days, not enough to address his ideas about the medication? It didn’t help enough the first time around.

Then, there recently was another patient of mine, somewhat on the other end of the hospitalization question. As an outpatient, she was reluctant to stay on her helpful SSRI, especially when she claimed GI Symptoms of unclear etiology. Bouncing back and forth between outpatient psychiatry, GI evaluations, and now almost seeming delusional, I referred her to an inpatient unit for quicker assessment and treatment. However, despite being willing, and having good insurance coverage, she was turned down over and over. The reasons were that hey only took those with acute needs and safety concerns.

These cases left me wondering. Have we gone too far in making it difficult to hospitalize someone, and are our hospitalizations generally too short anyways to help clarify diagnosis and carefully make any medication adjustments?

To try to answer that for myself, I thought I’d personally reflect back on almost 50 years of deinstitutionalization, which parallels my career and the dismantling of the state psychiatric hospitals in favor of community mental health centers, which in turn were often dismantled.

1962. In high school, I worked as an aide at a long-term residential facility for children and adolescents. As an activities helper, it was fun, but their behavior seemed to become institutionalized. Would they ever get out and lead more normal lives?

1965. I was in a psychology class at the University of Michigan with my future wife and we visited Northville State Hospital. A ward was teeming with patients, quite psychotic and disheveled. No, I don’t think we want to re-institutionalize to that.

1970. I was a medical student at Yale and did my psychiatry rotation at the renowned Connecticut Mental Health Center on an attractive ward, with lots of high powered, knowledgeable staff. Length of stay seemed to vary between a couple of weeks and a couple of months. Also in town was the Yale Psychiatric Institute, where stays for private patients were even much longer, not infrequently longer than a year, and more based on psychoanalytic psychotherapy.

1972-75. I obtain my psychiatric residency training at the University of Chicago. They even have an inpatient ward solely for adolescents, where my wife gets a teaching job. No wonder I think back most fondly on this institution.

1976-77. I’m in the Army with my first job as a trained psychiatrist, at Fort McClellan, Alabama. No psychiatric ward here, but we could hospitalize the less severe on the medical ward (with the more severe evacuated to a larger base). I’m a bit surprised that this integration with medicine worked out as well as it did.

1977-89. I’m starting my academic career at Baylor College of Medicine and become Medical Director of a large community mental health center. Even though the state hospital in Austin has deinstitutionalized, there are very few inpatient beds in Houston itself. We make due, but there are many homeless as a consequence.

1989. I begin my second academic job at the Medical College of Wisconsin. A smaller city than Houston, but it had about six times the number of inpatient beds for the poor. The for-profit private hospitals emerge with reports of “bounty hunters” rounding up adolescents and the intoxicated for hospital stays as long as their good insurance allowed. And they didn’t seem to improve accordingly.

1995. Managed care became established in Milwaukee and stops authorizing and paying for these private for-profit hospitalizations, and one by one they close. Whatever hospitalizations are left go down to a few days, or at best a week or two. There is no corresponding increase in outpatient services. Medication follow-ups by psychiatrists dwindle to 15 minutes about every 3 months. The revolving door begins. I write the book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (1997, Jossey-Bass) to try to make therapeutic sense of all these changes.

2009. I go to work part-time in a state medium security prison. I find out that about half the prison population has a DSM psychiatric and/or AODA diagnosis. They receive more treatment than I can provide in our public sector clinic in Milwaukee. This is what has been called trans-institutionalization, whereby the mentally ill do into jail and prison instead of a psychiatric hospital.

2012. After several years of a worsening economy, there is downsizing and closings of psychiatric facilities all over the country. The “recovery” model gains ascendancy as a response. We are supposed to pay special attention to patient’s desires, but what if they desire more help than resources allow?

So, after 50 years of deinstitutionalization followed by trans-institutionalization, after traditional antipsychotics followed by atypical antipsychotics, and for-profit hospitals followed by for-profit managed care companies, where are we left? I know I won’t find out at this year’s APA meeting. Only one symposium is devoted to inpatient treatment, and this on acute, brief stays, and one workshop. But I do hear of a new public hospital being built in Massachusetts, “the birthplace of modern recovery in psychiatry,” that will replace three state hospitals. Another new one is planned for Vermont. There are a variety of respite centers being tested out. And, by now, we have better tools for assessing the levels of care needed and for how long. The most comprehensive and public are the Locus system for adults and children developed by the American Association of Community Psychiatrists.

If we can learn anything from this history, it is to repeat it in an improved way.