Long-Term Psychiatric Beds Are Needed: Are State Hospitals The Solution?

A modern asylum: the Worcester Recovery Center and Hospital

Dear Pete,

Why not bring back a state hospital system where clients have a safe place to live, can progress, work, and receive compensation? Involve patients rights groups, and THROW AWAY the “our pill can cure everyone” lie bought by Congress and even the Surgeon General. Big Pharma sure sold us the Brooklyn Bridge and we have paid way too much for it. Our loved ones still are paying for it.

“There used to be state hospitals. some better than others. I can only cite the old Napa State Hospital in California. It used to be where individuals could stabilize in locked units (for their safety and other’s). As they became more stable, they moved to less restrictive units where they could gain employment or move into the community. As they continued on their recovery path, they could get housing in the community. At one point, the hospital had a working farm where individuals could work, including a dairy, garden, etc. This community had their own coin laundry, canteen, salon, a lake you could walk to and sit by, tennis courts….and a general post office, all on grounds.

“I worked there, long after it ceased to be a working and partially self-sustaining entity. By then the ‘patients’ had nothing to look forward to, nothing to increase their self-esteem, nothing but the same daily routine every day. If they did improve and work, they had to be paid minimum wage but many were not reliable, not fire-able, in short, everyone lost.”

Sincerely, Vickie Williams, wife, mother, daughter, Psychiatric Tech, BSN/RN retired.

Why does talk about bringing back state hospitals make me nervous?

I suggested in my book, CRAZY: A Father’s Search Through America’s Mental Health Madness, that we needed to reconsider shuttering state hospitals.

I am in favor of repealing the IMD Exclusion that prevents most psychiatric facilities from getting Medicaid if they have more than 16 beds. We are in the midst of a national psychiatric bed shortage. As was pointed out last week in a Manhattan Institute analysis, it’s obvious that many individuals with serious mental illnesses, such as schizophrenia, are not getting treatment in community settings because they need longer term care. Plus, a lack of long-term beds contributes to jails and prisons housing individuals whose only real crime is that they got sick.

We know that long-term hospitals can be healing places. Consider McLean Hospital or facilities such as CooperRiis and Gould Farm.  Jessie Close’s son, Calen, who was diagnosed with schizophrenia, spent more than two years at McLean Hospital getting the help he needed to recover, his mother told me.

Shouldn’t others receive that sort of benevolent, comprehensive long-term care rather than the band aids we now offer them?

One of the last times I checked, the average stay in a Virginia state hospital – if there was a bed available – was three days. 15 days if you were really ill. Let’s remember that many anti-psychotic drugs take 14 days to reach their therapeutic level.

And as Vickie Williams pointed out in her email to me, just sticking a pill in someone’s mouth isn’t a solution.

The debate about bringing back “mental asylums” is not new.

Six years ago, Dr. Ezekiel J. Emanuel and two of his colleagues from the Department of Medical Ethics and Health at the University of Pennsylvania, caused a dust up by suggesting that one way to improve long-term psychiatric care was by bringing back “mental asylums.” They presented their case in a Journal of the American Medical Association article.

Dr. Emanuel, along with Dominic A. Sisti, PhD., and Andrea G. Segal, MS, wrote:

“…The original meaning of psychiatric ‘asylum’ – (was) a protected place where safety, sanctuary, and long term care for the mentally ill would be provided. It is time to build them –again. At the moment, prisons appear to offer the default option and an inexpensive solution for housing and treating the mentally ill.

…A better option for a person with serious mental illness is assisted treatment in the community…However, comprehensive, accessible, and fully integrated community mental health care continues to be an unmet promise.

…At best, community treatment can provide high-functioning mentally ill persons a foundation for recovery. At worst, severely mentally ill persons drawing Medicaid and Supplemental Security Income risk becoming “commodities” in a profit-driven conglomeration of boarding houses reminiscent of the private madhouses of 18th century England.

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, which is costly…The annual rate at St. Elizabeth’s Hospital — a forensic psychiatric hospital in the District of Columbia– averages about $328,000 per patient annually.

Emmanuel and his colleagues cite a transformed state hospital in Massachusetts — the Worcester Recovery Center and Hospital — as an example of what states need to begin building.

The public’s perception of institutionalized mental health care remains dissonant. It is characterized by beliefs about the dangerousness of persons with mental disorders, combined with images of abuse and institutional warehousing. Realistically, the deployment of both private and public resources is now imperative to provide appropriate care and refuge for seriously mentally ill persons. These individuals cannot help themselves or live independently, and they deserve a safe place to live with proper supports — not cycling between the streets, emergency departments, and prisons.

Asylums are a necessary but not sufficient component of a reformed spectrum of psychiatric services….Reforms that ignore the importance of expanding the role of such institutions will fail mental health patients who cannot live alone, cannot care for themselves, or are a danger to themselves and others.

Dr. Lloyd  I. Sederer, the former Medical Director of the New York State Office of Mental Health (OMH), the nation’s largest state mental health system, challenged that opinion. Drs. Emanuel and Sederer engaged in a friendly thirty minute debate at a National Council For Behavioral Health’s conference. In a blog entitled The Future of Mental Health Care, published by The Huffington Post in April 2014, Sederer wrote:

The use of hospitals, which by their nature abridge liberty, is the least desirable alternative for someone with an acute mental illness.

So why am I jittery?

 I don’t trust politicians, insurance companies or the general public to properly fund psychiatric hospitals.

McLean Hospital, CooperRiis, Gould Farm and other longer term facilities are expensive to operate. There was a reason why too many state hospitals in the past turned into snake pits. They weren’t adequately funded.

Sadly, most states do not sufficiently fund community based mental health care, housing, or wrap around services, such as Assertive Community Treatment teams. Even when studies show that millions of dollars are being wasted by locking up Americans whose mental illnesses got them into trouble (those tax dollars would be better spent on community treatment services) politicians drag their feet.

A solution would be for states to implement funding that couldn’t be tampered with whenever legislators want to divert funding away from mental health into a pet project.  California’s millionaire’s tax is an example of how states can lock in funding purely for mental health services, although it’s questionable how successful those funds have been in actually improving the lives of the seriously mentally ill because of arguments about how the money can be spent.

I believe we need robust community services.  I believe we need longer term facilities.

But until we can find a way to insure that longer-term facilities will be fully funded, I’ll remain watchful.

(I don’t accept comments here, but I do on my Facebook page and would love to hear your thoughts.)

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.