Wednesday, January 04, 2017
Mistakes were made
I believe the full article is off-limits to you common riffraff, but here at least is the abstract of a recent essay in JAMA about the consequences of the mass shuttering of psychiatric hospitals that happened in the 1990s. This happened for good and just reasons: mental hospitals were inhumane totalitarian institutions, it was generally believed that antipsychotic medications would enable people with serious mental illness to function more independently, and that people had a right to an environment that was the least restrictive and most integrated into the community that they could safely live in.
You may recall that this movement coincided more or less with the movement to liberalize the prescribing of opioid analgesics, also on humanitarian grounds, and you know where that got us.
This is not entirely parallel by any means. The problem with the desintitutionalization of the mentally ill is partly that the second half of the concept -- creating community based supportive living arrangements -- didn't happen. The states saved a lot of money by closing their mental hospitals, but they never got around to spending it on an adequate community based mental health system. The result is that seriously mentally ill people now wind up in jail when they aren't on the street.
What Bastiampillai and colleagues also note is that people do sometimes actually need hospitalization for acute psychiatric episodes. Maybe this is more true than it would be if they had adequate support in the community, but given the current situation, the availability of beds in psychiatric hospitals is simply inadequate. They think this may be associated with rising suicide rates. I don't know, I don't think that's been proven. But I will say that the Affordable Care Act mandated mental health parity and of course, extended coverage to a lot of people who really needed it. It's been a boon to the mental health system. It doesn't provide people with housing and other non-medical services that they also need, however.
Obviously rather than repeal the ACA we need to expand services for people with serious and persistent mental illness, including providing co-located and coordinated mental health and medical care. (They tend to have complex physical comorbidities as well.) The group homes that were supposed to follow deinstitutionalization also need to become real. Maybe if Donald Trump were to pay taxes we could afford it.