Annals of Long Term Care

The chronically mentally ill represent one of the most socially disadvantaged segments of our population, which has been subject to the unwelcome consequences of the shifting healthcare policies. The deinstitutionalization program, which started in the late 1950s, has resulted in the closing of many state hospitals or in a drastic reduction in the number of beds in state hospitals, where these persistently mentally ill patients had been cared for. The census of the nation’s state hospitals reached its peak of 560,000 in 1955 and declined dramatically to under 170,000—a decrease of more than 60% in the late 1970s and to about 100,000 in the mid1990s.^1-3 The most important factor that led to this decline was the shift in funding opportunities under Medicaid, Medicare, and Supplemental Security Income that allowed states to shift the fiscal burden of the mentally ill to federal auspices if they moved patients out of state facilities. The other factors included the impact of community mental health philosophy, effectiveness of newer psychotropic agents, and the increasing importance of legal, judicial, and legislative actions defining the circumstances for mental health treatment.^3,4

The chronically mentally ill patients who were essentially unable or unprepared to handle the outside world were released into adult homes, group homes, foster homes, supervised residences, “hotels,” and nursing homes. As patients aged, many of them have been transferred to nursing homes from lesser care settings. A number of patients have become homeless as a result,^5,6 and the number of mentally ill persons in the prison population also increased significantly. Approximately 750,000 patients with chronic mental illness have been placed in nursing homes by the late 1980s.⁷ Eighty-nine percent of the older people with serious mental illness who are institutionalized reside in nursing homes.⁸ Pilgrim State Hospital in New York, which was considered to be the largest mental hospital in the world, once cared for about 10,000 patients. The bed capacity has now shrunk to about 650. States have saved a significant amount of money by these maneuvers, but is this a real saving in terms of true costs, or is it just a shift of fiscal burden from the state to the federal government? What about the consequences—the human suffering and quality-of-life issues—for this underrepresented segment of our population? The taxpayer is still responsible for the monetary burden as a result of the revolving-door situation of these patients.

The Pulitzer Prize–winning series of articles published in The New York Times in 2002 eloquently brought to light part of these problems.⁹ We as psychiatrists and as part of a civilized society need to address these issues in a political forum, to bring forth the necessary changes needed to improve the quality of life for these unfortunate patients.

Long-term care facilities are vastly underserved, resulting from an inadequate number of psychiatrists, psychologists, and social workers treating these patients and a lack of staff awareness and training in these facilities.⁸ In New York State, the problem has been compounded by other developments in the discharge planning of the chronically mentally ill patients in state hospitals and other psychiatric units, and the changes in the reimbursement policies. Around the year 2000, there was a sudden trend of opening “secure units” in nursing homes to care for the “difficult-to-place” patients from state hospitals, particularly in New York State. In late 2002 after The New York Times publication,⁹ the Office of Mental Health fiercely contested the legal representation of these patients in the courts. This, coupled with other reimbursement issues for the nursing homes, resulted in closure of most of these units in New York State.