Denial of Mental Illness

To the Editor: Dr. Richard Lamb's commentary (1) on the denial of serious mental illness in the November 1997 issue raises serious considerations in the community care debate. It is somewhat paradoxical that the resistance to viewing the major mental illnesses primarily as neurobiological disorders amenable to hospitalization leads to increased patient stigmatization. An almost obsessive preoccupation with psychosocial and community-based programs can, by preventing hospitalization, retard the process of normalization that might have been achieved by an inpatient stay. Deinstitutionalization and community care are not synonymous. Deinstitutionalization connotes self-determination, an ordinary life with a modicum of dependency on state programs.

No one can realistically question that severe mental illnesses have community, social, and psychological antecedents and consequences that can be dramatically altered if good community care programs exist. No one can disagree that community-based programs may influence the natural history and course of mental illnesses. But one can dispute the conceit and hubris of mental health planners whose grandiose paradigms, conceptualizations, and heuristic assumptions and techniques related to the superiority of community-based programming may be entirely for naught. As Dr. Lamb points out, for some patients who suffer from severe mental illnesses, a highly protective and structured environment—hospitalization—is required.

As we know, current research overwhelmingly supports neurobiological interventions, whose administration may require a rather strict regimen and leave no other alternative for a patient save hospitalization. There should be strong caveats when health planners bombard us with their mumbo-jumbo extolling the virtues of more and more community-based programs.