Deinstitutionalization following the introduction of antipsychotic medications in 1954 has received much attention as a major narrative in psychiatry. Little attention has been given, however, to deinstitutionalization before 1954.
Using United States census data on discharge and readmission rates of US mental hospitals from 1935 to 1964, this article analyzes deinstitutionalization using an interrupted time-series model, with particular attention to the statistical significance of trends before and after the advent of antipsychotics.
Discharge rates significantly increased in the period before antipsychotics, indicating that deinstitutionalization began before 1954, although readmissions during that same period increased at the same rate as discharges. A reasonable inference is that patients discharged in the pre-antipsychotic period were unable to live independently outside the hospital.
After 1954, both discharges and readmissions increased significantly, but due to a continuing increase in admissions, no significant decrease in mental hospital populations occurred during the seven-year period after 1954. The decline began in 1961 and coincided with changes in federal policy.
The fate of mental patients discharged from hospitals during this second period of deinstitutionalization is examined. The central conclusions are:
- the overall reduction in the population of mental hospitals did not coincide with the 1954 introduction of antipsychotic medications, and
- deinstitutionalization before and after drugs has been met with inadequate community-based care.
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By: Pow JL1, Baumeister AA, Hawkins MF, Cohen AS, Garand JC.
1From the Departments of Psychology (Drs. Pow, Baumeister, Hawkins, and Cohen) and Political Science (Dr. Garand), Louisiana State University
The deinstitutionalization of individuals with serious mental illness was driven by 4 factors: public revelations regarding the state of public mental hospitals, the introduction of antipsychotic medications, the introduction of federal programs to fund patients who had been discharged, and civil libertarian lawyers.
The result is approximately 3.2 million individuals with untreated serious mental illness living in the community. Beginning in the 1970s in the United States, there began to be reported increasing incidents of violent behavior, including homicides, committed by these untreated individuals. Such incidents became more numerous in the 1980s and 1990s, and have further increased since the turn of the century.
Existing studies suggest that individuals with untreated severe mental illness are responsible for at least 10% of all homicides and approximately half of all mass killings.
Studies have also shown that when these individuals are treated, the incidence of violent behavior decreases significantly. Examples of treatment mechanisms that have proven effective include assisted outpatient treatment (AOT), conditional release, and mental health courts.
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By: Fuller Torrey E1.
- 1Department of Psychiatry,Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland, USA; Stanley Medical Research Institute,Chevy Chase, Maryland, USA.
