Return to Asylums? NEVER!

This July, I debated medical ethicist Dominic Sisti, Ph.D., at the Commonwealth Club of California, the nation’s oldest and largest public affairs forum. The topic was whether we should bring back asylums for the treatment of patients who suffer from serious mental illness. Dr. Sisti, an assistant professor of medical ethics and health policy at the University of Pennsylvania School of Medicine, and his colleagues had written an article, published in the January 20 issue of JAMA, that stated that asylums are needed for the improvement of long-term care.

In the article, the authors argued, “Even well-designed community-based programs are often inadequate for a segment of patients who have been deinstitutionalized. For severely and chronically mentally ill persons, the optimal option is long-term care in a psychiatric hospital. … For persons with severe and treatment-resistant psychotic disorders, who are too unstable or unsafe for community-based treatment, the choice is between the prison-homelessness-acute hospitalization-prison cycle or long-term institutionalization. The financially sensible and morally appropriate way forward includes a return to psychiatric asylums that are safe, modern, and humane. … Asylums are a necessary but not sufficient component of a reformed spectrum of psychiatric services.”

I agree with Dr. Sisti about the problem, but definitely not the solution. With the de-funding and closure of state mental hospitals, the nation’s jails and prisons have become the de facto hospitals for people with mental illness. The statistics are staggering. Many studies have consistently demonstrated that about 16 percent of inmates in jails and prisons have serious mental illness, and there are 10 times more people with serious mental illness in state prisons (207,000) and county jails (149,000) than in state mental hospitals (35,000). Individuals with serious mental illness do not fare well in correctional facilities. They tend to be victimized and are likely to stay incarcerated longer and return to prison more rapidly than peeople without mental disorders. In addition, some of the patients who used to reside in state mental hospitals are homeless and live on the streets. Despite these alarming statistics, asylum care is not the answer.

The effects of long-term institutionalization are well known. Individuals become dependent and infantilized. They are told when to eat and when to sleep and when to go to recreational activities. The goal of treatment should be to foster independence and autonomy, not regression.

The solution is to develop and adequately fund community programs so that individuals with serious mental illness can be re-integrated into their communities. Federal funding for community mental health centers ended in 1981, and block grants were given to states. Unfortunately, local programs have been inadequate and poorly coordinated. Community initiatives that promote prevention and early intervention such as the American Psychiatric Association Foundation’s program “Typical or Troubled” need to be supported. This particular program helps teachers and other school personnel identify children who may be at risk for mental health problems and make referrals for evaluation and treatment.

In addition, adequate housing needs to be provided for individuals with mental illness who are homeless. Acute short hospitalizations are appropriate and indicated when an individual needs symptom relief and stabilization. Discharge planning and referral to appropriate community care should be an essential part of every acute hospitalization. Of course, adequate community programs need to be developed and funded.

Another solution is to increase the use of diversion programs and collaborative courts, such as mental health courts and drug courts. These programs help move people out of the criminal justice system and into treatment. Studies from my research group and from other investigators have shown that collaborative courts decrease recidivism and violence.

In 1999, the U.S. Supreme Court ruled in Olmstead v. L.C. that people with disabilities should be able to live like people without disabilities and that discrimination is illegal. If mental health services exist in the community, people with mental illness should be able to use them. Needless institutionalization and isolation from society is a form of discrimination.

Dr. Sisti and his co-authors also seem unaware of the legal implications of their proposal. What commitment standards would they propose to authorize the long hospitalizations they recommend? Would they recommend we move to a vague “need for treatment” standard? Not even the newer, broader standards focused on preventing deterioration adopted in some jurisdictions would justify such long-term involuntary treatment, unless one characterizes someone as always likely to deteriorate if released into the community.

I believe that a return to asylums is unacceptable. Instead, what is needed is a coordinated, well-funded system of care with housing and collaborative courts plus diversion programs. Our patients need hope and re-integration. ■

“Improving Long-Term Psychiatric Care: Bring Back the Asylum” by D.A. Sisti et al. can be accessed here. A podcast of the Commonwealth Club debate is available here.