Overview
In the late 20th century western countries such as the United Kingdom, Canada, United States and Australia, adopted deinstitutionalisation. The meaning of deinstitutionalisation is the discharge or movement of patients from psychiatric hospitals or institutions into the community.
Large mental asylums such as Aradale in Ararat, Victoria in the mid-1980s, had 2000 residents. Not only was it a large building, what made the building especially striking was its ornate architecture and manicured gardens set on hundreds of acres of farmland which the residents worked on. Built in 1867, it was the first asylum in Victoria, and it finally closed in 1993 coinciding with the Victorian government’s decision to deinstitutionalise psychiatric services in the state. In fact, there were approximately seven asylums roughly built around the same time in Victoria:
- Willsmere (1870) - 1000 beds,
- Sunbury (1879)-1000 beds,
- Beechworth (1867)-1200 beds,
- Mont Park (1912)-1500 beds
- Ballarat “Lakeside” (1877)-1500 beds,
- Laurundle (1953)-750 beds
- Royal Park (1909) -200 beds
Each one was closed by the early to mid-1990’s. This is a total of almost 10,000 people. Further research of these institutions shows that they looked like ornate palaces or grand homes of the aristocracy. They were built like that to show that that health profession cared for these people.
In 1984, the medical superintendent-psychiatrist of Aradale asylum who was an experienced psychiatrist and had worked overseas in Canada in a similar institution, expressed concern over the closure of the institutions and that the patients would no longer be looked after properly when released. The promise by the government was that they will be looked after in community housing and be much happier, but because of his experience in other countries such as Canada he was worried that this may not be the case and instead they would become homeless or criminalised. In this particular institution patients were very well cared for. They all suffered from severe chronic schizophrenia or severe mental retardation. Some were violent and had to be looked after in “J ward”, the ward for the criminally insane. But these patients were also looked after compassionately; they just needed a great more supervision.
The push to move the patients into the community had worldwide political support because of reasons, for example human rights issues and abuses (which was generated by numerous news stories of abuses), the advent of antipsychotic drugs in the 1950’s and 60’s and the “anti-psychiatry movement”(most notable protagonist was R.D. Laing) which held that most mental illness was due to social/family factors were all pressures to deinstitutionalise. There was also economic pressure; it was thought it would be cheaper for the government to provide care in the community. Also these very large buildings and their grounds were often situated on prime real estate.
Research Articles
“This blanket approach has resulted in an inadequate care of the new cohort of severely mentally ill persons, who have never been institutionalised, and have therefore not learned to accept their treatment (Lamb, 1993). Placed in a community care setting, and without the safe sanctuary offered in principle by institutions, these individuals often end up either incarcerated or homeless (Lamb & Bachrach, 2001).”
Lamb, H. R. (1993). Lessons learned from deinstitutionalisation in the US. The British Journal of Psychiatry, 162(5), 587-592.
Lamb, H. R., & Bachrach, L. L. (2001). Some perspectives on deinstitutionalization. Psychiatric Services, 52(8), 1039-1045.
“In fact, a recent study found a statistically significant correlation between homelessness and deinstitutionalisation (Markowitz, 2006), and a large number of homeless individuals suffering from severe mental disorders such as major depression, psychosis, or schizophrenia, are coming from this new generation (Pepper et al., 1981). The evidence for the trans-institutionalisation of mentally ill individuals from psychiatric hospitals to penal institutions is also well documented, with two meta-analysis research studies examining data from 40 consecutive years finding a significant negative correlation between the number of psychiatric beds and the number of incarcerations (Palermo, et al., 1991; Primeau et al., 2013)”.
Markowitz, F. E. (2006). Psychiatric hospital capacity, homelessness, and crime and arrest rates. Criminology, 44(1), 45-72.
Pepper, B., Kirshner, M. C., & Ryglewicz, H. (1981). The young adult chronic patient: Overview of a population. Psychiatric Services, 32(7), 463-469.Pepper, B., Kirshner, M. C., & Ryglewicz, H. (1981). The young adult chronic patient: Overview of a population. Psychiatric Services, 32(7), 463-469.Pepper, B., Kirshner, M. C., & Ryglewicz, H. (1981). The young adult chronic patient: Overview of a population. Psychiatric Services, 32(7), 463-469.Pepper, B., Kirshner, M. C., & Ryglewicz, H. (1981). The young adult chronic patient: Overview of a population. Psychiatric Services, 32(7), 463-469.Pepper, B., Kirshner, M. C., & Ryglewicz, H. (1981). The young adult chronic patient: Overview of a population. Psychiatric Services, 32(7), 463-469.Pepper, B., Kirshner, M. C., & Ryglewicz, H. (1981). The young adult chronic patient: Overview of a population. Psychiatric Services, 32(7), 463-469.
Palermo, G. B., Smith, M. B., & Liska, F. J. (1991). Jails versus mental hospitals: A social dilemma. International Journal of Offender Therapy and Comparative Criminology, 35(2), 97-106.
Primeau, A., Bowers, T. G., Harrison, M. A., & XuXu. (2013). Deinstitutionalization of the mentally ill: evidence for transinstitutionalization from psychiatric hospitals to penal institutions. Comprehensive Psychology, 2, 16-02.
“Schizophrenia And Other Psychotic Disorders (Sj Siegel, Section Editor)
- Published: 18 April 2012
- Current Psychiatry Reports volume 14, pages259–269 (2012)
Abstract:
Although there is broad consensus that the state psychiatric hospital population drastically declined over the past five decades, the destination and well-being of people with serious mental illness (SMI) have been in greater doubt. In this article, we examine the aftermath of the deinstitutionalization movement. We begin with a brief historical overview of the move away from state hospitals, followed by an examination of where people with SMI currently reside and receive treatment. Next, we review recent trends reflecting access to treatment and level of community integration among this population. Evidence suggests the current decentralized mental health care system has generally benefited middle-class individuals with less severe disorders; those with serious and persistent mental illness, with the greatest need, often fare the worst. We conclude with several questions warranting further attention, including how deinstitutionalization can be defined and how barriers to community integration may be addressed.”
“There remains a minority of persons who have chronic and severe mental illness who need highly structured 24-hour care, often in locked facilities, and these individuals must not be overlooked. The fact that a significant proportion of this minority are not receiving sufficient care but are instead living in jails, on the streets, or in other unacceptable situations is evidence that adequate community care has not been provided for some of the most severely ill persons.”
Lamb HR: The new state mental hospitals in the community. Psychiatric Services 48:1307-1310, 1997 Link, Google Scholar
Research and Breakthroughs
There has been no pharmacological breakthroughs in successfully treating psychiatric conditions. Treatment is aimed at the relief of symptoms as medical science does not know what is causing severe mental illness. Although there is increasing interest in medicinal cannabis, or mdma (“ecstasy”) and psilocybin (“magic mushrooms”), they are experimental at this stage with little clinical support for their benefit. They are being evaluated in the treatment of anxiety and depression but are contraindicated in schizophrenia as they all can cause psychosis. Currently medicinal cannabis is highly politicised issue. Doctors and regulators are urged to monitor and research the link between cannabis and schizophrenia.
Treatments For Schizophrenia
Schizophrenia is a severe mental illness where individuals have different and severe perceptions of reality. Hallucinations, voices, and highly disordered thinking and behaviour are all possible symptoms of schizophrenia, which can make it challenging to carry out daily tasks and the condition can be disabling.
Schizophrenia patients need ongoing medical care. Early intervention may help manage symptoms prior to the emergence of serious complications and may enhance the prognosis over the long run.
Diagnosis
In order to diagnose schizophrenia, it is necessary to rule out other mental health conditions and establish that the symptoms are not brought on by drug use, prescription medicine, or a physical ailment. Identifying a schizophrenia diagnosis could involve:
Health Check-Up. This could be carried out to help rule out other issues that could be the source of the symptoms and to look for any associated consequences.
Tests. These might include screening for alcohol and drugs as well as tests that help rule out illnesses that have symptoms that are comparable. The doctor might also ask for imaging tests like an MRI or CT scan.
Mental Health Assesment. A doctor or mental health specialist will examine the patient's look and demeanour and ask questions about their thoughts, moods, delusions, hallucinations, drug use, and propensity for violence or suicide. This also covers a talk of personal and family history.
The schizophrenic diagnostic standards. The categories in the Psychiatric Diagnostic and Statistical Manual of Mental Disorders may be used by a docor or mental health specialist.
Treatment & Medication
Even after symptoms have subsided, schizophrenia needs lifelong treatment. Psychosocial therapy and medical treatment can help control the condition. Hospitalisation may be necessary in some circumstances.
The most frequently recommended drugs are antipsychotics. By influencing the brain neurotransmitter dopamine, they are believed to control symptoms.
Using the least amount of antipsychotic medicine necessary will allow for the most effective management of symptoms and signs. In order to accomplish the desired outcome, the psychiatrist may gradually experiment with various medications, doses, or combinations. Antidepressants and anxiety medicines, for example, may also be beneficial. Any change in symptoms may not be seen for several weeks.
People with schizophrenia may be reluctant to take medications because they can have severe side effects. Drug selection may be influenced by one's willingness to participate in therapy. For instance, a patient who struggles to take their medicine consistently might require injections rather than pills.
Second-generation antipsychotics
Second-generation medications claim to have a lower risk of severe side effects, the following are second-generation antipsychotics:
- Aripiprazole (Abilify)
- Asenapine (Saphris)
- Brexpiprazole (Rexulti)
- Cariprazine (Vraylar)
- Clozapine (Clozaril, Versacloz)
- Iloperidone (Fanapt)
- Lurasidone (Latuda)
- Olanzapine (Zyprexa)
- Paliperidone (Invega)
- Quetiapine (Seroquel)
- Ziprasidone and risperidone (Risperdal) (Geodon)
First-generation antipsychotics
The frequent and potentially serious neurological side effects of these first-generation antipsychotics include the potential for the emergence of a movement condition (tardive dyskinesia) that may or may not be curable. Antipsychotics of the first group include:
- Chlorpromazine
- Fluphenazine
- Haloperidol
- Perphenazine
When long-term treatment is required, the cost of these antipsychotics can be a crucial factor. They are frequently less expensive than second-generation antipsychotics, particularly the generic versions.
Long-acting injectable antipsychotics
Some antipsychotics may be given as an intramuscular or subcutaneous injection. They are usually given every two to four weeks or yearly, depending on the medication. Ask your doctor about more information on injectable medications. This may be an option if someone has a preference for fewer pills and may help with adherence
Common medications that are available as an injection include:
- Aripiprazole (Abilify Maintena, Aristada)
- Fluphenazine decanoate
- Haloperidol decanoate
- Paliperidone (Invega Sustenna, Invega Trinza)
- Risperidone (Risperdal Consta, Perseris)
Social-psychological treatments
After psychosis has subsided, it is crucial to continue taking medication and engage in psychological and social treatments (psychosocial interventions). They might consist of:
Personal counseling. Normalizing thought processes may be aided by psychotherapy. People with schizophrenia may benefit from learning stress management techniques and how to spot early indications of recurrence.
Training in social intelligence. This emphasises enhancing social interactions and communication as well as enhancing participation in everyday activities.
Counselling for families. Families dealing with schizophrenia can use this to get help and information.
Supported work and vocational rehabilitation. Helping people with schizophrenia get ready for, obtain, and keep jobs is the main goal of this.
Most people with schizophrenia need some kind of assistance with everyday activities. Programs for individuals with schizophrenia in many communities can assist them with finding employment, housing, and other forms of self-care.
Conclusion
According to estimates, 800,000 individuals, or 5% of the population, suffer from a severe mental illness, of which 500,000 have episodic mental illness and 300,000 have persistent mental illness. The second biggest contributor to the non-fatal burden of disease in Australia (24%) was mental and substance use disorders.
With such large numbers of people suffering with debilitating mental illness, the evidence shows that deinstitutionalisation has failed, and society is no longer looking after its most vulnerable members. Gone are the mansions in which we used to house them. Now they are out on the streets!
The growing rate of psychiatric problems are not being addressed properly. Most psychiatric issues are related to drug induced psychosis caused by irresponsible cannabis prescribing or other drugs. For acute conditions there are no public psychiatric facilities available at all. If the patient is at risk to themselves or others the current remedy is call the police and they would be arrested. That is the current state of affairs now.
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