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Bring Back the Asylum?

By Paul Gionfriddo

The JAMA headline is pretty sensational: Improving Long-term Psychiatric Care: Bring Back the Asylum.  And the article itself is generating a lot of discussion and debate.

But headlines can be misleading.  As the authors write:

“A return to asylum-based long-term psychiatric care will not remedy the complex problems of the US mental health system, especially for patients with milder forms of mental illness who can thrive with high-quality outpatient care.”

They are right about this.  We should be focusing on high-quality community-based care, not putting people in asylums.  But they are not the first ones to make this point.  Our founder, Clifford Beers, made it more than a hundred years ago.

However, sensational headlines attract attention and sometimes take the air out of the actual arguments being made.

So who will really pay attention to the fact that what the authors are arguing for is a balanced approach to building a system – adding more beds and more community services? 

Or that the real fault in their logic is rooted in their too-narrow perspective:

“For persons with severe and treatment-resistant psychotic disorders, who are too unstable or unsafe for community-based treatment, the choice is between the prison–homelessness–acute hospitalization–prison cycle or long-term psychiatric institutionalization.” 

That’s only the choice for people who are trapped in Stage 4 thinking about mental illness, who believe that people magically become seriously mentally ill all of sudden one day, and who fail to understand that it is a chain of neglect that leads them to prisons, homelessness, acute hospitalizations, and long-term institutionalization. 

We’re not really offering people a choice today, because we are waiting too long to diagnose and respond to mental illnesses instead of intervening as soon as symptoms emerge – and we are failing to offer a full menu of treatments and supports.

So what the authors are really arguing for is a path to institutionalization in the guise of compassion. 

“Reforms that ignore the importance of expanding the role of such institutions will fail mental health patients who cannot live alone, cannot care for themselves, or are a danger to themselves and others.”

Who says they “cannot”?  That assertion is indefensible, and that path to institutionalization for long-term care services is a well-traveled one that has proven expensive and inadequate for people with every chronic condition.  The evidence for this exists both in this country (in historical Medicaid long term care spending, for example) and throughout the world.

But that doesn’t stop the authors from making an argument that made its home in the 19th century.

Comments

Although I don't think long-term institutionalization of people with severe and chronic psychiatric illness is a compassionate or desirable solution, the level of community-based services required to provide the kind of solution you describe is something we've never seen in the history of psychiatric care. And, in a time of what appears to be diminishing support for social safety nets, I'm not very optimistic that we will soon witness the changes you and I would both like to see. What we have seen are broken promises of broad community-based services accompanied by a gradual substitution of prisons for the psychiatric institutions you rightfully deplore. Perhaps early diagnosis and treatment will help many, but it will not be a panacea unless treatments become far more sophisticated and effective than they are today.

I live in Alameda County of California where there are more than 900 "5150" involuntary 72-hour holds for mental evaluation each month. These are actual holds, not the many assessments (if a crisis team is available) that are quickly dismissed because of the narrow criteria "probable cause to believe that the person is, as a result of a mental health disorder, a danger to others, or to themselves, or gravely disabled".

Walk around downtown Oakland or Berkeley and you'll see that to be considered "gravely disabled" you’d have to already be half-dead from starvation, dehydration, or for not washing for a year.

By law we can't arrest someone before a crime is committed, and someone has to volunteer for a psych evaluation—if a bed or evaluator is even available—unless an authority decides that the 5150 criteria applies.

If a person refuses evaluation but is clearly delusional, talking about violence, and their family is begging to have them evaluated after years of untreated erratic behavior, homelessness, and threats, you’d think that would merit a compelled psychiatric evaluation. I’ve learned over eight years that without a diagnosis, authorities don’t take you seriously.

From my experience, it doesn't. Laura's Law would help, but it's only a first step.

From families like mine whom I've spoken with, many 5150ed delusional people are often released asap with or without diagnosis or treatment, only to be later 5150ed and released again and again. Or they are eventually jailed because there aren't enough psychiatric resources available, so they deteriorate and there are plenty of jails.

This is a huge inefficient waste of taxpayers money and a danger to the vulnerable mentally ill who are much more likely to become victims than perpetrators of violence. And without treatment, brain damage from mental illness increases over time.

This cycle seems to be a stop-gap method that has been applied over decades since deinstitutionalization. As quoted in the Sisti/Segal/Emanuel JAMA article, "in 1955, 560,000 patients were cared for in state psychiatric facilities; today there are fewer than 45,000...about the same as it was in 1850". Even if the closing of state hospitals was justified, there has been little provided to replace mental health treatment on the community level.

There is a crisis here and no one is listening. Mental health professionals are so used to saying the same things over and over about what can and can't be done, the truth has gotten lost. "This is how the system works," they say. But it’s not working.

We can try new approaches to treating the mentally ill. A homeless person may refuse evaluation and treatment in a locked hospital environment, but if we had permanent on-site mental health evaluators in homeless shelters as well as the crisis teams who are called in when there’s a “situation”, we might get better evaluation results and cooperation from the homeless population.

Would it be possible to use the money saved from lowering prison populations to convert some jails into unlocked safe shelters or respite centers where people can be evaluated and even treated?

We need to look at the long game, not half-hearted short-term fixes.

Let's be more realistic about the situation. Mentally ill people need more help and sooner. If not, we already know what happens. Look at the streets and look at the news.

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