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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by phillipa on September 21, 2012, at 19:57:19
The evolution of de-institutionalism and consequences of Phillipa
Is it Time for Re-institutionalization?
By H. Steven Moffic, MD | April 20, 2012
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All things in moderation Benjamin Franklin
Recently, I was asked to write a request to possibly extend the outpatient commitment of a patient of mine. What for, I said to myself? This would be a waste of time because he had not exhibited any more dangerous behavior, was taking care of himself, and was compliant with his intramuscular medication. However, when as part of the ongoing monitoring of my patients improvement, I asked him to rate on a 0-10 (best) scale how well the medication was working, he said 0. When I asked why, he said it was because he didnt need the medication. Uh, oh, I thought. Could this be Anosognosia? Or, has he read or heard of Robert Whitakers book, Anatomy of an Epidemic (2010), which discusses the potential long-term risks of such medications.
Theres no way hell be committed longer, but will he stay on the medication voluntarily? Without it hed surely relapse into psychosis and possible dangerousness. If he then went inpatient again, would he only stay a few days, not enough to address his ideas about the medication? It didnt help enough the first time around.
Then, there recently was another patient of mine, somewhat on the other end of the hospitalization question. As an outpatient, she was reluctant to stay on her helpful SSRI, especially when she claimed GI Symptoms of unclear etiology. Bouncing back and forth between outpatient psychiatry, GI evaluations, and now almost seeming delusional, I referred her to an inpatient unit for quicker assessment and treatment. However, despite being willing, and having good insurance coverage, she was turned down over and over. The reasons were that hey only took those with acute needs and safety concerns.
These cases left me wondering. Have we gone too far in making it difficult to hospitalize someone, and are our hospitalizations generally too short anyways to help clarify diagnosis and carefully make any medication adjustments?
To try to answer that for myself, I thought Id personally reflect back on almost 50 years of deinstitutionalization, which parallels my career and the dismantling of the state psychiatric hospitals in favor of community mental health centers, which in turn were often dismantled.
1962. In high school, I worked as an aide at a long-term residential facility for children and adolescents. As an activities helper, it was fun, but their behavior seemed to become institutionalized. Would they ever get out and lead more normal lives?
1965. I was in a psychology class at the University of Michigan with my future wife and we visited Northville State Hospital. A ward was teeming with patients, quite psychotic and disheveled. No, I dont think we want to re-institutionalize to that.
1970. I was a medical student at Yale and did my psychiatry rotation at the renowned Connecticut Mental Health Center on an attractive ward, with lots of high powered, knowledgeable staff. Length of stay seemed to vary between a couple of weeks and a couple of months. Also in town was the Yale Psychiatric Institute, where stays for private patients were even much longer, not infrequently longer than a year, and more based on psychoanalytic psychotherapy.
1972-75. I obtain my psychiatric residency training at the University of Chicago. They even have an inpatient ward solely for adolescents, where my wife gets a teaching job. No wonder I think back most fondly on this institution.
1976-77. Im in the Army with my first job as a trained psychiatrist, at Fort McClellan, Alabama. No psychiatric ward here, but we could hospitalize the less severe on the medical ward (with the more severe evacuated to a larger base). Im a bit surprised that this integration with medicine worked out as well as it did.
1977-89. Im starting my academic career at Baylor College of Medicine and become Medical Director of a large community mental health center. Even though the state hospital in Austin has deinstitutionalized, there are very few inpatient beds in Houston itself. We make due, but there are many homeless as a consequence.
1989. I begin my second academic job at the Medical College of Wisconsin. A smaller city than Houston, but it had about six times the number of inpatient beds for the poor. The for-profit private hospitals emerge with reports of bounty hunters rounding up adolescents and the intoxicated for hospital stays as long as their good insurance allowed. And they didnt seem to improve accordingly.
1995. Managed care became established in Milwaukee and stops authorizing and paying for these private for-profit hospitalizations, and one by one they close. Whatever hospitalizations are left go down to a few days, or at best a week or two. There is no corresponding increase in outpatient services. Medication follow-ups by psychiatrists dwindle to 15 minutes about every 3 months. The revolving door begins. I write the book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare (1997, Jossey-Bass) to try to make therapeutic sense of all these changes.
2009. I go to work part-time in a state medium security prison. I find out that about half the prison population has a DSM psychiatric and/or AODA diagnosis. They receive more treatment than I can provide in our public sector clinic in Milwaukee. This is what has been called trans-institutionalization, whereby the mentally ill do into jail and prison instead of a psychiatric hospital.
2012. After several years of a worsening economy, there is downsizing and closings of psychiatric facilities all over the country. The recovery model gains ascendancy as a response. We are supposed to pay special attention to patients desires, but what if they desire more help than resources allow?
So, after 50 years of deinstitutionalization followed by trans-institutionalization, after traditional antipsychotics followed by atypical antipsychotics, and for-profit hospitals followed by for-profit managed care companies, where are we left? I know I wont find out at this years APA meeting. Only one symposium is devoted to inpatient treatment, and this on acute, brief stays, and one workshop. But I do hear of a new public hospital being built in Massachusetts, the birthplace of modern recovery in psychiatry, that will replace three state hospitals. Another new one is planned for Vermont. There are a variety of respite centers being tested out. And, by now, we have better tools for assessing the levels of care needed and for how long. The most comprehensive and public are the Locus system for adults and children developed by the American Association of Community Psychiatrists.If we can learn anything from this history, it is to repeat it in an improved way.
Posted by jono_in_adelaide on September 22, 2012, at 9:59:56
In reply to Is It Time For Re-Institutionalsim? Psychiatric Ti, posted by phillipa on September 21, 2012, at 19:57:19
I agree Phillipa - I think deinstitutionalisation has gone too far, partly driven by cost cutting - there need to be short term beds avaliable for people with severe depression or acute psychosis, to look after them in the time it takes drugs to start working, and i think there is a subgroup of psychotic patients who need long term residential care.
I'm glad the days of One Flew Over the Cuckoos nest are gone, but they needed to be replaced with somthing, not nothing
Posted by sleepygirl2 on September 22, 2012, at 12:00:33
In reply to Is It Time For Re-Institutionalsim? Psychiatric Ti, posted by phillipa on September 21, 2012, at 19:57:19
Something needs to change. Things have swung too far in the opposite direction. Somewhere between deinstitutionalization and institutionalization would be nice.
My concerns go to the folks with things like schiophrenia, schizoaffective, bipolar of the severe and persistent kind.I wouldn't go to a psych hospital if my life depended on it.
Suicide is a much better option.
Posted by jono_in_adelaide on September 22, 2012, at 19:39:38
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti » phillipa, posted by sleepygirl2 on September 22, 2012, at 12:00:33
Australia has a comprehensive national health scheme, but I also pay private medical insurance, mainly so that it i ever have a major episod, I can go into a private clinic like Menninger, not some state hospital like One Flew Over the Cuckoos Nest......its my safety net and security blanket
Posted by sleepygirl2 on September 22, 2012, at 20:26:18
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti, posted by jono_in_adelaide on September 22, 2012, at 19:39:38
Good planning :-)
Posted by phillipa on September 22, 2012, at 20:39:19
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti » jono_in_adelaide, posted by sleepygirl2 on September 22, 2012, at 20:26:18
Never ever a hospital again for anything. Made this decision a long time ago. Phillipa
Posted by sleepygirl2 on September 22, 2012, at 21:05:07
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti, posted by phillipa on September 22, 2012, at 20:39:19
Words cannot express how much I loathe inpatient psychiatry.
There is no help there.
Posted by Christ_empowered on September 22, 2012, at 21:28:21
In reply to Is It Time For Re-Institutionalsim? Psychiatric Ti, posted by phillipa on September 21, 2012, at 19:57:19
I hate hospitals. So abusive, such an extreme waste of time and money. There have to be better alternatives, especially for long-term care.
Posted by phillipa on September 22, 2012, at 23:51:41
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti, posted by Christ_empowered on September 22, 2012, at 21:28:21
I remember when seriously was kind of fun to go inpatient for a simple med change. Lots of groups that talked about really good stuff and sharing. Activities outside, private rooms with showers, That one time time was inpatient and they discovered the lymes and gave me PIC line antibiotics was there for a month. They could have sent me to a real medical floor but wanted me to have things to do to keep busy. Now it's in and out and if not suicidal or danger to self or others will not admit you. Times sure have changed. Phillipa
Posted by sleepygirl2 on September 23, 2012, at 9:45:38
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti » Christ_empowered, posted by phillipa on September 22, 2012, at 23:51:41
Where and when did this place exist?
Posted by phillipa on September 23, 2012, at 9:53:55
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti » phillipa, posted by sleepygirl2 on September 23, 2012, at 9:45:38
I know it seems unreal but this is what it was like for me. Where I was for a month was in a hospital inpatient for a med change. Was in North Carolina. Actually they all were. Also at the time went to a few smaller facilities. Amazing how times changed. I think the lymes one was about 14 years ago. Phillipa
Posted by sleepygirl2 on September 23, 2012, at 10:14:42
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti » sleepygirl2, posted by phillipa on September 23, 2012, at 9:53:55
Wow, sounds like they might have even been helpful.
Posted by emmanuel98 on September 23, 2012, at 19:02:51
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti » phillipa, posted by sleepygirl2 on September 23, 2012, at 10:14:42
I have had several psych hospitalizations in the last few years and found them extremely helpful. Psychiatrists and social workers and occupational therapists all over, all day, all night. Great experienced nurses. Check people experienced and kind. I have never had a bad experience in a psych ward and have been in quite a few.
Posted by sleepygirl2 on September 23, 2012, at 20:49:20
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti, posted by emmanuel98 on September 23, 2012, at 19:02:51
I had one. I'll spare you the details.
Just imagine indifference with a dash of contempt, with a 15,000 dollar price tag.
I really could've used some help.
If I had been a medical patient, maybe someone would believe me.
Posted by jono_in_adelaide on September 24, 2012, at 2:02:46
In reply to Re: Is It Time For Re-Institutionalsim? Psychiatric Ti » emmanuel98, posted by sleepygirl2 on September 23, 2012, at 20:49:20
I maintain my private medicl insurance primerily so that if I do need to go inside for a while, I can go into The Adelaide Clinic, an expensive private psych hospital in Adelaide (the nearest large city to Darwin) and be attended by my private psychiatrist.
However, given that I have decided to stay on reboxetine and sertaline for life I'm hoping it will never happen
This is the end of the thread.
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