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Why this is the worst time ever to have a severe mental illness (in the U.S.)

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Dr. Allen Frances: "Done poorly, as in most of the U.S., deinstitutionalization has led to disastrous trans-institutionalization from dreary hospitals to much worse jails and prisons."

Earlier this month, Dr. Allen Frances, an outspoken American psychiatrist and professor emeritus at Duke University who has taken his professional peers to task on many issues during his long career, published an article entitled “Is This the Worst Time Ever to Have a Severe Mental Illness?”

His answer: “an ashamed ‘Yes’ for the U.S.; a relieved ‘No’ for most of the rest of the developed world.”

“When I first began work as a medical student [40 years ago] on a psychiatric ward, we were very, very optimistic that three new advances would dramatically improve the lives of our patients: 1) the availability of effective medication; 2) the availability of powerful research tools; and 3) the hope that state hospitals would disappear as patients were deinstitutionalized into the community,” he writes.

But his optimism soon “collided with reality”:

The medicines sometimes did work wonders, but often brought only partial relief and caused unpleasant side effects. The research findings were fascinating, but didn’t have any impact at all on patient care. And worst of all, it was clear from the outset that deinstitutionalization was being carried out so badly it was bound to fail. Patients were irresponsibly discharged at breakneck speed with little or no provision for their housing or treatment in the community. They were left to sink or swim on their own and not surprisingly many sank. …

The severely ill are now often jailed or homeless — worse off than they were when I started psychiatry.

In Europe, Frances points out, “deinstitionalization was usually done much better — with a sense of social justice, adequate funding, decent house, and greater family involvement.”

Historical context

Frances turns much of the article over to the perspective of Edward Shorter, a professor of psychiatry and the history of medicine at the University of Toronto.

Shorter notes that when “proper mental hospitals” were first founded — around 1800 — they were actually rather humane institutions.

“Their high walls would grant a sense of safety, and medical reassurance constituted an early form of psychotherapy,” he writes. “The wheels started to come off the wagon when these praiseworthy intentions were overwhelmed by the sheer press of numbers. Yet a core reality remained: For many, the asylum was a place of safety.”

What has happened since then, particularly over the last three or four decades, is, he says, “psychiatry’s dirty secret”:

If you had a severe mental illness requiring hospital care in 1900, you’d be better looked after than you are today. Despite a flurry of media hand-waving about new technologies in psychiatry, the average severely ill patient probably does less well now, despite the new drugs, than the average several ill patient a century ago. …

The crucial factor here is length of stay: the stays then were long (sometimes far too long); the stays now are ultra-brief and patients are discharged well before they are able to cope — especially since so few services are available in the community and adequate housing is in such short supply.

Needed: compassionate treatment

As Frances points out, “responsible deinstitutionalization requires money, time, treatment, social and vocational support, and compassion. Done well, it can work wonders (as in much of Europe). Done poorly, as in most of the U.S., deinstitutionalization has led to disastrous trans-institutionalization from dreary hospitals to much worse jails and prisons.”

“This is the worst of times and places for many people with severe mental illness,” he concludes. “It need not be, if only we put our hearts and minds and pocketbooks behind providing cost effective, compassionate treatment.”

You can read Frances’ article in full on the Psychiatric Times website.

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