From the Editor

Bring back the asylums?

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The tragic consequences of deinstitutionalization.


One of psychiatry’s so-called triumphs was the discovery of antipsychotics (starting with chlorpromazine in the 1950s) and the ensuing release of the seriously mentally ill into the community. State hospitals were rapidly evacuated, and patients supplied with the new “miracle drugs” were relabeled as “clients” or “consumers” as if they did not have severe medical illnesses. Asylums that had off ered medical care, refuge, and safety were condemned to the trash heap of psychohistory.

How naïve we were! As we discovered, antipsychotics are so limited in effi cacy and tolerability that most patients eventually stop taking them and relapse, leading to recurrent hospitalizations. Little did we know—although Kraepelin had warned us—that schizophrenia’s dis-ability is caused not by psychosis but by severe cognitive defi cits and negative symptoms that neuroleptics fail to reverse.

We now know that persons with schizophrenia are unable to navigate the complexities of community living because they have frontal lobe pathology, poor executive function, severe memory defi cits, and impaired social cognition. They may have regained their civil rights when they left the institutions, but they could not effectively exercise those rights. Left to their own devices, they were expected to become independent and autonomous, but many were too cognitively disabled to do so.

The results—in my opinion—have been tragic, inhumane, and disastrous for the 3 million Americans who have schizophrenia. Yet I’m perplexed that there is no public outrage about the misery of these seriously mentally ill individuals. Consider deinstitutionalization’s unintended consequences:

Homelessness has risen dramatically since the demise of state hospitals, which had housed persons with psychiatric brain diseases.

Incarceration. Yesterday’s state hospitals have morphed into today’s jails and prisons. Correctional facilities are bulging with mentally ill inmates, and don’t think they are receiving better care than in the old asylums. Their illness behaviors have been criminalized and deemed “illegal” because they live in the community, not in a medical facility.

Poverty. In most cases, the seriously mentally ill live below the poverty level and barely meet their subsistence needs.

Substance abuse has burgeoned among the mentally ill, creating a more severe form of mental illness euphemistically labeled “dual diagnosis.” Alcohol and drug abuse worsens psychosis and bipolar mania and leads to treatment resistance and further deterioration.

Crime. Though the mentally ill are perceived as crime perpetrators, they are more likely to be crime victims.

Medical illness. Persons with serious mental illness suffer high rates of infection, obesity, diabetes, hyper-lipidemia, and hypertension—all of which require intensive and ongoing medical care.

Poor access to primary care. Although at high risk for cardiovascular disease, most persons with schizophrenia do not receive the most basic medical care because they do not have a primary care provider.

Early mortality. Individuals with serious mental illness die much younger than persons in the general population, forfeiting about 28 years of potential life. Interestingly, my colleagues in countries that still have psychiatric institutions tell me their chronically mentally ill patients often live to old age.

Lack of stable or signi?cant relationships. Most of the seriously mentally ill live an isolated life of quiet desperation and loneliness. They do not know how to make friends. State hospitals offered access to social and recreational activities where patients could regularly meet others, make friends, and maybe even find a sexual partner.

Social and vocational disability and stigma. The seriously mentally ill are stigmatized in many ways and have little chance of employment. In state hospitals, supervised work therapy enabled many to work in the bakery, laundry, wood shop, or on the farm and provided the dignity of being part of a work community.

Deinstitutionalization failed because society’s good intentions were guided by legalisms and sociologic notions, rather than scientific principles. Serious mental disorders are neurobiologic diseases that severely limit independent functioning. Until effective treatments are found for schizophrenia’s cognitive deficits and negative symptoms, we should seek a more humane model of care. We should be bold enough to restore comprehensive long-term health care facilities where patients’ mental and physical illnesses can be stabilized and they can achieve supervised autonomy through evidence-based biopsychosocial and rehabilitative therapies.

An institutional model of care is rational for at least some persons with schizophrenia who are suffering under a politically correct system of care. Without medically driven care, the misery will continue.

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