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HOSPITAL CARE IN THE ERA OF COMMUNITY TREATMENT

The system of community mental health treatment that has evolved in the wake of deinstitutionalization is dominated by general-hospital mental health services funded by Medicaid and third-party payers. In many locales, state mental hospitals no longer exist. Surviving state facilities serve the forensic population and patients whose illnesses have not responded to services available in general-hospital psychiatric units (Fisher et al., 2009). In keeping with legal mandates, hospital admissions are restricted to people whose psychopathology indicates that there is a grave danger of self-harm or harm to others. Typically, people who do not meet hospital admission criteria are managed with psychiatric medications in emergency departments or outpatient clinics. Access to some general hospital psychiatric services is restricted by insurance type, or area of residence. The legacy of the Reagan administration’s failure to endorse the National Plan for the Chronically Mentally Ill, turning public funding for mental health services over to the states through block grants, has resulted in wide variability across the 50 states in the quality and availability of mental health care (Aron et al., 2009) and lack of uniformity in implementing evidence-based approaches (Drake & Latimer, 2012).

Early studies of brief hospitalization[1] endorsed the merits of briefer hospitalization for most patients. Driven by financial pressures, the average length of a psychiatric hospital stay has been steadily eroded to days rather than weeks or months (Drake et al., 2003), with the limited objectives of crisis stabilization and safety concerns. There is heavy reliance on outpatient care to fully implement long-term medication treatment to achieve the goal of clinical and functional stability. Noting that the definitions of “brief hospitalization” in earlier studies were defined in terms of weeks with little correspondence to the current practice of limiting hospitalizations to days, Glick et al. (2011) have called for a reconsideration of current practices to ensure opportunities for sustained recoveries. A recent Cochrane review of the topic (Babalola et al., 2014) recommended a renewed effort to study the length of hospitalization for people with severe mental illness, investigating outcomes such as employment, criminal behavior, homelessness, treatment satisfaction, family relationships, and cost.

For the most part, the general-hospital psychiatric system of care is not geared to the long-term management of the social welfare needs associated with chronic and disabling conditions. Consequently, people with severe mental illness rely on multiple systems of care to meet their need for housing, income support, and an array of social and support services, which, to the individual, can upstage the need for mental health care.

Although civil commitment procedures can be implemented for mandatory hospitalizations and outpatient treatment when the safety and security of patients or members of the community are at risk, the notion of the right to refuse treatment has widespread currency in twenty-first-century America. Consequently, the system relies in large part on the personal responsibility of the individual in choosing whether to accept care and how to obtain it. Epidemiological studies reveal that many people with mental health problems do not seek treatment (Wang et al., 2005) or discontinue treatment after their initial contact with the service system and subsequently receive minimal mental health care (O’Brien et al., 2009).

Clinical studies of patients in routine-care settings reveal that the treatment received often fails to correspond to evidence-based practice guidelines. More than one-half of patients continue to experience significant symptoms and receive substandard care or no treatment (Mojtabai et al., 2009). Thus, the close monitoring required for effective pharmacological management is often undermined by widespread non-compliance with outpatient follow-up care, increasing the risk of relapse and rehospitalization.

Comorbid substance use disorder is widespread among people with severe mental illness (Caton et al., 2007) and is associated with relapse, interpersonal and adjustment problems, arrests, detention in jails, and homelessness.

Concern for civil liberties has constrained options to enforce treatment in the absence of danger to self or others, leaving some severely ill people to muddle through life without help or support (Torrey, 2012). The problem is particularly acute in minority and impoverished communities. Jails and prisons now house thousands of people suffering from severe mental illness, of whom many also suffer from substance addiction and HIV/AIDS. The most disabled patients rotate through the “institutional circuit” of general-hospital emergency departments, homeless shelters, the streets, and jails (Greenberg & Rosenheck, 2008; Hopper et al., 1997).

  • [1] Example of studies of brief versus standard hospitalization are Glick & Hargreaves,1979, and Herz et al., 1979.
 
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