Dr Robert London

Better treatment for chronic mental illness is long overdue

Clinical Psychiatry News - July 23, 2015

News reports about tragedies involving people with chronic mental illness flash across our iPad and television screens with disturbing regularity.

We are constantly reminded that mental disorders are not on par with physical disorders. Instead, those with chronic mental illness are unfairly ignored and inadequately treated, and many continue to sleep in doorways, and live on the streets and in homeless shelters.

This has been the scenario for those with chronic mental illness for quite some time. The advent of antipsychotics such as the prototype phenothiazine (Thorazine) and butyrophenones (Haloperidol) in the 1950s led to the discharging by the 1960s of more and more people with chronic mental illness into the community.

With many of their symptoms decreased, they were deemed ready to live in the community, and thousands were sent to outpatient care throughout the 1960s and 1970s, and continue to be. This trend continued as the number of antipsychotics and antidepressants grew, and became part of treatment protocols for psychotic and mood disorders. Institutional life also proved costly.

Psychiatrists, as well as other humanitarians and politicians, supported the idea of community-based psychiatric care. It would be aimed at allowing people with chronic mental illness to have housing and ongoing care, which, of course, included good medication management and psychosocial rehabilitation.

These ideas appeared compelling – at least on paper. However, as it turns out, the mass discharges from long-term mental health facilities cut costs at a high price. Money saved from deinstitutionalization seldom got put into the community for the proper care, treatment, and maintenance of people with chronic mental illness. Not only that, but patients who needed active care in a crisis usually had acute care short-term hospitalizations and did not have the networking for proper follow-up. Often, they relapsed again while facing everyday challenges.

I spoke recently with Robin Allen Kaynor, a New York City social worker who has spent years assessing clients with chronic mental illness. To her dismay and disappointment, little organized rehabilitative care is provided for these patients. As Ms. Kaynor pointed out, the care patients with chronic mental illness may receive often is administered weeks after their initial visits, if at all. Further complicating their prospects is not having a place to live, and poor nutrition and general health.

What can be done to improve the quality of life for patients with chronic mental illness? First, the psychiatric/psychological community needs to exert influence on policymakers and business leaders so that outpatient care is brought up to the standards envisioned decades ago. The court system and mental health advocates must work together to find ways to monitor those in need of care and to ensure that those who need care continue to receive it. We also must make sure that patients’ civil liberties remain intact.

Secondly, since “reinstitutionalization” has taken the form of shelters and prisons for so many people with chronic mental illness, why not develop more housing in well-staffed and humanistic therapeutic communities? Many of the psychiatric institutions abandoned years ago remain either partly occupied or unoccupied today. Why not modernize, expand, and use those spaces to provide long-term care for those with mental illness and develop a network of mental health rehabilitation centers? This approach would provide these patients with better therapeutic environments and the potential for rehabilitation. It also would lead to financial savings not only in psychiatric care but for physical care as well.

Again, if we implemented these ideas, we would need to make sure that outpatients’ civil liberties remained intact. It is worth noting, however, that today’s improved provider/patient communication might make such voluntary treatments increasingly possible.

Much is at stake, including patients’ physical health. Dr. Fazil Hussain, a New York City internist and infectious disease specialist, said in an interview that people with chronic mental illnesses suffer far more physical illnesses and a much shorter life span than do those in the general population. A recent meta-analysis of reviews and studies about people with serious mental illness found that the mortality gap between patients with serious mental illness and the general population ranges from 13 to 30 years (World Psychiatry 2011;10:52-77).

Longer-term rehabilitation treatments are used routinely in medicine today, particularly after certain surgeries and accidents. It’s time to reexamine the resources taken away decades ago from those with chronic mental illness. Expanding, modernizing, humanizing, and offering genuine long-term inpatient care, better use of medications, and rehabilitation over a longer period of time would be a great beginning to creating successful outpatient community-based treatment. All patients could get individualized psychiatric/medical management, and the psychosocial skills and confidence needed to live and thrive in the community. Psychiatric patients, who are among the most vulnerable people in our society, deserve this.

Dr. London is a psychiatrist who trained at NYU Langone Medical Center and Bellevue Hospital, both in New York, and developed and ran a short-term psychotherapy program at the medical center from 1975 through 1995. He has been a newspaper columnist for more than 30 years. He has no conflicts of interest.