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CAUSES OF DI

CAUSES OF DI. US PUBLIC INPATIENT 1830-1955. PUBLIC INPATIENT 1955-2006. CAUSES OF DI. 1. DRUGS 2. PHILOSOPHICAL CHANGES 3. LEGAL CHANGES 4. ECONOMIC CHANGES. DRUGS. I. DRUG TREATMENT. ANTI-PSYCHOTICS THORAZINE AND LITHIUM IN MID-1950’S DON’T CURE BUT CONTROL IMMEDIATE SUCCESS

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CAUSES OF DI

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  1. CAUSES OF DI

  2. US PUBLIC INPATIENT 1830-1955

  3. PUBLIC INPATIENT 1955-2006

  4. CAUSES OF DI • 1. DRUGS • 2. PHILOSOPHICAL CHANGES • 3. LEGAL CHANGES • 4. ECONOMIC CHANGES

  5. DRUGS

  6. I. DRUG TREATMENT • ANTI-PSYCHOTICS THORAZINE AND LITHIUM IN MID-1950’S • DON’T CURE BUT CONTROL • IMMEDIATE SUCCESS • EASY TO ADMINISTER • NEW HOPE AND OPTIMISM • BUT MAJOR CHANGES 1970 -

  7. II. PHILOSOPHY • 1. ANTI-MENTAL HOSPITALS - E.G. CUCKOO’S NEST • 2. PRO-COMMUNITY TREATMENT - 1960’S • LIBERAL PHILOSOPHY OF GOVERNMENT • STRONG FEDERAL ROLE – BYPASS STATE MENTAL HOSPITALS

  8. CMHC • BUILD LARGE NETWORK OF COMMUNITY MENTAL HEALTH CENTERS (CMHC) • FEDERAL – LOCAL PARTNERSHIP • SERVED DIFFERENT POPULATION THAN STATE MENTAL HOSPITALS - LESS SERIOUS, EASIER TO TREAT

  9. CMHC • NOT INTEGRATED WITH STATE HOSPITALS - FEW PROGRAMS FOR S.M.I. • CREATED GREAT GAP IN CARE – HOW FILL OLD ROLE OF STATE HOSPITAL?

  10. III. LEGAL • JUDICIAL AND LEGISLATIVE CHANGES • 3 ASPECTS - COMMITMENT TO HOSPITAL, CONDITIONS IN HOSPITAL, RELEASE TO COMMUNITY • MOVE FROM MEDICAL TO LEGAL MODEL

  11. PRIMACY OF HEALTH PATERNALISM BETTER SAFE THAN SORRY PRIMACY OF LIBERTY ADVERSARIAL NO TREATMENT UNLESS NECESSARY MEDICAL AND LEGAL

  12. 1. COMMITMENT • UP TO 1970 PRIMACY OF MEDICAL • ANYONE CAN BRING PETITION ASSERTING MENTAL ILLNESS • M.D. MUST SIGN • ROUTINE EXAM BY COURT PSYCH. • BRIEF HEARING • ALMOST ALL COMMITTED

  13. 1970-2006 • EXPANSION OF LEGAL MODEL FOR COMMITMENT • HAD BEEN “MENTAL ILLNESS” • NOW - DANGER TO SELF OR OTHERS • SOMETIMES GRAVELY DISABLED • SPECIFIC AND OVERT ACTIONS • PROCEDURAL PROTECTIONS

  14. COMMITMENT • EMERGENCY COMMITMENTS FOR BRIEF PERIODS - 2 WKS OR MONTH • OLMSTEAD DECISION – 1999: LEAST RESTRICTIVE ALTERNATIVE • UP TO STATE TO PROVE NEED FOR COMMITMENT

  15. 2. WITHIN HOSPITAL • MANDATED STANDARDS OF CARE WITHIN HOSPITAL – TREATMENT, STAFF RATIO, LIVING CONDITIONS • RESTRICTIONS ON SOCIAL CONTROL - FRUMKIN • HITS PT., BLINDS ATTENDANT GETS 2 HOURS OF SECLUSION

  16. 3. RELEASE FROM HOSPITAL • BURDEN OF PROOF ON STATE FOR WHY SHOULD KEEP IN HOSPITAL • HEARINGS AT REGULAR PERIODS – EVERY SIX MONTHS OR SO

  17. COMPARE CUCKOO’S NEST • MORE TRUE PRE-1970’S THAN NOW • NOW MORE LEGAL THAN MEDICAL: STATE MUST JUSTIFY HPT. • “VOLUNTARIES” WOULDN’T BE THERE – OUTPATIENT • CHRONICS IN NURSING HOMES • PROBLEM NOW IS LACK OF FACILITIES

  18. REASONS FOR LEGAL CHANGES • CIVIL RIGHTS MOVEMENT • ECONOMIC PRESSURE TO REDUCE HOSPITAL POPULATIONS

  19. IV. ECONOMIC • STATE HOSPITALS VERY EXPENSIVE • DI CLAIMED TO SAVE MONEY • IN FACT, SHIFTS ECONOMIC BURDEN FROM STATES TO FEDERAL GOV. • FEDERAL WON’T PAY INPATIENT TREATMENT IN SMH BUT WILL FOR TREATMENT OUTSIDE HOSPITALS

  20. FUNDING FOR TREATMENT • MEDICAID – POOR; FEDERAL/STATE • MEDICARE - ELDERLY; FEDERAL PROGRAM • BOTH GO TO PROGRAMS NOT TO INDIVIDUALS • NEITHER PAYS FOR TREATMENT IN MENTAL HOSPITALS

  21. SSI • SUPPLEMENTAL SECURITY INCOME • FEDERAL PROGRAM • TO INDIVIDUALS FOR LIVING EXPENSES • NEED DISABILITY, LOSS OF FUNCTION, DURATION

  22. SSI • NOW MAJOR FUNDING FOR SERIOUSLY MENTALLY ILL • ABOUT $700/MONTH • GOOD – PROVIDES SUPPORT • BAD – FOSTERS DEPENDENCY AND DISINCENTIVE TO WORK

  23. RESULTS OF ECONOMIC CHANGES • NO FEDERAL FUNDING FOR STATE HOSPITAL TREATMENT • MORE TREATMENT IN GENERAL HOSPITALS • MORE TREATMENT OF ELDERLY IN NURSING HOMES • SOME FUNDING FOR COMMUNITY TREATMENT • MUCH MORE CONSUMER CHOICE

  24. SUMMARY • MANY CAUSES OF DI • MOVEMENT FROM HOSPITAL TO COMMUNITY • SOME IMPROVEMENT IN LIVING CONDITIONS AND CHOICE • MANY GAPS

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