6.1 Introduction
Treatment settings for patients with psychiatric illnesses have undergone great upheaval since the 1960s, with inpatient psychiatric beds declining dramatically and the focus of care shifting from institutionalization to community-based management. In this chapter we describe the current role of inpatient settings and the continuum of care available to psychiatric patients and their families. Although effective services and pockets of excellence exist, care is uneven, and the situation described by the US Surgeon General over a decade ago, when he described the system as a “non-system,” is too often the norm.
The movement to bring mentally ill people out of institutions was made possible by the development of effective drugs, along with some change in attitude about the mentally ill. With the de-institutionalization movement, greater emphasis has been placed on viewing mentally ill people as members of families and communities. A significant catalyst of de-institutionalization was the Community Mental Health Act of 1963. It has been used by some governments and their agencies to attempt to save money by closing down, scaling back or merging psychiatric inpatient units. In 1999, the Supreme Court of the United States ruled in L.C. & E.W. v. Olmstead that states are required to provide community-based services for people with mental disabilities if treatment professionals determine that it is appropriate and the affected individuals do not object to such placement.
People who must be hospitalized are less likely to be isolated and restrained than in the past, and they are often discharged early into day treatment centers. These settings are less expensive because fewer staff members are needed, the emphasis is on group rather than individual therapy, and people sleep at home or in halfway houses.
In 2004, the Subcommittee on Acute Care of the New Freedom Commission (see Chapter 1) examined summary data regarding total inpatient bed capacity nationwide. They reported that from 1990 through 2000 the number of inpatient beds per capita declined by 44% in state and county mental hospitals, 43% in private psychiatric hospitals, and 32% in nonfederal general hospitals.
At this writing, for patients to receive inpatient care or hospital-based treatment, they must meet specific criteria which third-party payers (including private, state and federal insurance) have developed. Patients most likely to receive inpatient treatment are those who pose a risk of harm to themselves or others. Patients who qualify for admission may need short-term (acute) or long-term hospitalization depending on their unique circumstances.
Acute-care psychiatric hospitals provide highly structured settings in which staff can monitor patients. Patients who are experiencing suicidal or homicidal ideation, acute psychoses, disorientation, or confusion, or those in need of detoxification under close scrutiny, are candidates for these settings.
Some large general hospitals offer psychiatric services. These are used to stabilize patients who are triaged through the emergency department, or they serve as a safe environment in which patients can be evaluated and medicated until they can be sent to an acute psychiatric hospital.
Many facilities offer partial or day hospitalization programs (PHPs). These alternatives have been developed for patients who need some supervision but who are not appropriate candidates for long-term treatment. Partial hospitalization programs provide activities and therapy sessions for 6–8 hours per day. Patients then return to their homes or workplace. PHPs are a means of mainstreaming patients back to their communities.
Some patients are in need of longer term hospitalization due to the chronicity of their illnesses. If short-term stabilization cannot be achieved in an acute-care psychiatric hospital, patients may need longer term care. Most long-term facilities are state supervised.
Residential treatment facilities (RTFs) are institutions that provide intensive services, often focused at a specific population. They are often considered a “last resort” when other forms of treatment have been ineffective. Treatment is long-term and stays range from a few weeks to several months. Residential facilities have rules and regulations that facilitate the safety of patients, teach adaptive behaviors, and promote movement towards independence. They are not the optimal choice for patient care, especially when family involvement in therapy is crucial, as behaviors learned in RTFs tend not to generalize when patients return to their homes. Insurance coverage for this level of care varies and they are often expensive. Moreover, there have been a steady stream of abuses reported in some of these facilities. Hence clinicians should carefully investigate and evaluate the facility to which they may be referring patients and families. (See: Alliance for the Safe and Appropriate Use of Residential Treatment at http://astart.fmhi.usf.edu/.)
6.4 Community Support Programs
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