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CAUSES OF DI

This overview explores the multifaceted causes behind changes in U.S. mental health treatment from 1830 to 2006. It highlights significant factors, including the introduction of drugs like Thorazine and lithium, shifts in public philosophy towards community care, legal reforms affecting patient rights, and economic constraints impacting state hospital funding. The transition from inpatient facilities to community mental health centers represents a critical movement, aiming for improved living conditions and consumer choice, albeit revealing gaps in care and access that persist to this day.

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CAUSES OF DI

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  1. CAUSES OF DI

  2. US PUBLIC INPATIENT 1830-1955

  3. PUBLIC INPATIENT 1955-2006

  4. CAUSES OF DI • 1. DRUGS • 2. PHILOSOPHICAL CHANGES • 3. LEGAL CHANGES • 4. ECONOMIC CHANGES

  5. DRUGS

  6. I. DRUG TREATMENT • ANTI-PSYCHOTICS THORAZINE AND LITHIUM IN MID-1950’S • DON’T CURE BUT CONTROL • IMMEDIATE SUCCESS • EASY TO ADMINISTER • NEW HOPE AND OPTIMISM • BUT MAJOR CHANGES 1970 -

  7. II. PHILOSOPHY • 1. ANTI-MENTAL HOSPITALS - E.G. CUCKOO’S NEST • 2. PRO-COMMUNITY TREATMENT - 1960’S • LIBERAL PHILOSOPHY OF GOVERNMENT • STRONG FEDERAL ROLE – BYPASS STATE MENTAL HOSPITALS

  8. CMHC • BUILD LARGE NETWORK OF COMMUNITY MENTAL HEALTH CENTERS (CMHC) • FEDERAL – LOCAL PARTNERSHIP • SERVED DIFFERENT POPULATION THAN STATE MENTAL HOSPITALS - LESS SERIOUS, EASIER TO TREAT

  9. CMHC • NOT INTEGRATED WITH STATE HOSPITALS - FEW PROGRAMS FOR S.M.I. • CREATED GREAT GAP IN CARE – HOW FILL OLD ROLE OF STATE HOSPITAL?

  10. III. LEGAL • JUDICIAL AND LEGISLATIVE CHANGES • 3 ASPECTS - COMMITMENT TO HOSPITAL, CONDITIONS IN HOSPITAL, RELEASE TO COMMUNITY • MOVE FROM MEDICAL TO LEGAL MODEL

  11. PRIMACY OF HEALTH PATERNALISM BETTER SAFE THAN SORRY PRIMACY OF LIBERTY ADVERSARIAL NO TREATMENT UNLESS NECESSARY MEDICAL AND LEGAL

  12. 1. COMMITMENT • UP TO 1970 PRIMACY OF MEDICAL • ANYONE CAN BRING PETITION ASSERTING MENTAL ILLNESS • M.D. MUST SIGN • ROUTINE EXAM BY COURT PSYCH. • BRIEF HEARING • ALMOST ALL COMMITTED

  13. 1970-2006 • EXPANSION OF LEGAL MODEL FOR COMMITMENT • HAD BEEN “MENTAL ILLNESS” • NOW - DANGER TO SELF OR OTHERS • SOMETIMES GRAVELY DISABLED • SPECIFIC AND OVERT ACTIONS • PROCEDURAL PROTECTIONS

  14. COMMITMENT • EMERGENCY COMMITMENTS FOR BRIEF PERIODS - 2 WKS OR MONTH • OLMSTEAD DECISION – 1999: LEAST RESTRICTIVE ALTERNATIVE • UP TO STATE TO PROVE NEED FOR COMMITMENT

  15. 2. WITHIN HOSPITAL • MANDATED STANDARDS OF CARE WITHIN HOSPITAL – TREATMENT, STAFF RATIO, LIVING CONDITIONS • RESTRICTIONS ON SOCIAL CONTROL - FRUMKIN • HITS PT., BLINDS ATTENDANT GETS 2 HOURS OF SECLUSION

  16. 3. RELEASE FROM HOSPITAL • BURDEN OF PROOF ON STATE FOR WHY SHOULD KEEP IN HOSPITAL • HEARINGS AT REGULAR PERIODS – EVERY SIX MONTHS OR SO

  17. COMPARE CUCKOO’S NEST • MORE TRUE PRE-1970’S THAN NOW • NOW MORE LEGAL THAN MEDICAL: STATE MUST JUSTIFY HPT. • “VOLUNTARIES” WOULDN’T BE THERE – OUTPATIENT • CHRONICS IN NURSING HOMES • PROBLEM NOW IS LACK OF FACILITIES

  18. REASONS FOR LEGAL CHANGES • CIVIL RIGHTS MOVEMENT • ECONOMIC PRESSURE TO REDUCE HOSPITAL POPULATIONS

  19. IV. ECONOMIC • STATE HOSPITALS VERY EXPENSIVE • DI CLAIMED TO SAVE MONEY • IN FACT, SHIFTS ECONOMIC BURDEN FROM STATES TO FEDERAL GOV. • FEDERAL WON’T PAY INPATIENT TREATMENT IN SMH BUT WILL FOR TREATMENT OUTSIDE HOSPITALS

  20. FUNDING FOR TREATMENT • MEDICAID – POOR; FEDERAL/STATE • MEDICARE - ELDERLY; FEDERAL PROGRAM • BOTH GO TO PROGRAMS NOT TO INDIVIDUALS • NEITHER PAYS FOR TREATMENT IN MENTAL HOSPITALS

  21. SSI • SUPPLEMENTAL SECURITY INCOME • FEDERAL PROGRAM • TO INDIVIDUALS FOR LIVING EXPENSES • NEED DISABILITY, LOSS OF FUNCTION, DURATION

  22. SSI • NOW MAJOR FUNDING FOR SERIOUSLY MENTALLY ILL • ABOUT $700/MONTH • GOOD – PROVIDES SUPPORT • BAD – FOSTERS DEPENDENCY AND DISINCENTIVE TO WORK

  23. RESULTS OF ECONOMIC CHANGES • NO FEDERAL FUNDING FOR STATE HOSPITAL TREATMENT • MORE TREATMENT IN GENERAL HOSPITALS • MORE TREATMENT OF ELDERLY IN NURSING HOMES • SOME FUNDING FOR COMMUNITY TREATMENT • MUCH MORE CONSUMER CHOICE

  24. SUMMARY • MANY CAUSES OF DI • MOVEMENT FROM HOSPITAL TO COMMUNITY • SOME IMPROVEMENT IN LIVING CONDITIONS AND CHOICE • MANY GAPS

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