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Thursday, November 12, 2020

Deinstitutionalization of People with Mental Illness: Causes and Consequences

Daniel Yohanna, MD
Virtual Mentor. 2013;15(10):886-891.

Here is an excerpt:

State hospitals must return to their traditional role of the hospital of last resort. They must function as entry points to the mental health system for most people with severe mental illness who otherwise will wind up in a jail or prison. State hospitals are also necessary for involuntary commitment. As a nation, we are working through a series of tragedies involving weapons in the hands of people with severe mental illness—in Colorado, where James Holmes killed or wounded 70 people, Arizona, where Jared Loughner killed or wounded 19 people, and Connecticut, where Adam Lanza killed 28 including children as young as 6 years old. All are thought to have had severe mental illness at the time of their crimes. After we finish the debate about the availability of guns, particularly to those with mental illness, we will certainly have to address the mental health system and lack of services, especially for those in need of treatment but unwilling or unable to seek it. With proper services, including involuntary commitment, many who have the potential for violence can be treated. Just where will those services be initiated, and what will be needed?

Nearly 30 years ago, Gudeman and Shore published an estimate of the number of people who would need long-term care—defined as secure, supportive, indefinite care in specialized facilities—in Massachusetts. Although a rather small study, it is still instructive today. They estimated that 15 persons out of 100,000 in the general population would need long-term care. Trudel and colleagues confirmed this approximation with a study of the long-term need for care among people with the most severe and persistent mental illness in a semi-rural area in Canada, where they estimated a need of 12.4 beds per 100,000. A consensus of other experts estimates that the total number of state beds required for acute and long-term care would be more like 50 beds per 100,000 in the population. At the peak of availability in 1955, there were 340 beds per 100,000. In 2010, the number of state beds was 43,318 or 14.1 beds per 100,000.