Although there is broad consensus that the state psychiatric hospital population drastically declined over the past five decades, the destination and well-being of people with serious mental illness (SMI) have been in greater doubt. In this article, we examine the aftermath of the deinstitutionalization movement. We begin with a brief historical overview of the move away from state hospitals, followed by an examination of where people with SMI currently reside and receive treatment. Next, we review recent trends reflecting access to treatment and level of community integration among this population. Evidence suggests the current decentralized mental health care system has generally benefited middle-class individuals with less severe disorders; those with serious and persistent mental illness, with the greatest need, often fare the worst. We conclude with several questions warranting further attention, including how deinstitutionalization can be defined and how barriers to community integration may be addressed.
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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Frank R, Glied S. Better but not well: mental health policy in the United States since 1950. Baltimore: Johns Hopkins University Press; 2006.
Geller J. The last half-century of psychiatric services as reflected in psychiatric services. Psychiatr Serv. 2000;51(1):41–67.
Gronfein W. Incentives and intentions in mental health policy: a comparison of Medicaid and community mental health programs. J Heal Soc Behav. 1985;3:192–206.
Witkin M, Atay J, Manderscheid R. Trends in state and county mental hospitals in the US from 1970 to 1992. Psychiatr Serv. 1996;47:1079–81.
•• Manderscheid R, Atay J, Crider R. Changing trends in state psychiatric hospital use from 2002 to 2005. Psychiatr Serv. 2009;60(1):29–33. This recent article documents important trends related to increases in the state psychiatric hospital population and identifies relevant factors related to this increase (e.g., forensic admissions).
Scull A. Psychiatry and the social sciences, 1940–2009. Hist Polit Econ. 2010;42 suppl 1:25–52.
Accordino M, Porter D, Morse T. Deinstitutionalization of persons with severe mental illness: context and consequences. J Rehabil. 2001;67(2):16–21.
Ray C, Finley J. Did CMHC’s fail or succeed? analysis of the expectations and outcomes of the community mental health movement. Admin Pol Ment Health. 1994;21:283–93.
Gronfein W. Psychotropic drugs and the origins of deinstitutionalization. Soc Probl. 1985;32(5):437–54.
Torrey F. Out of the shadows: confronting America’s mental illness crisis. Oxford: Wiley; 1997.
Rochefort D. From poorhouses to homelessness. Westport: Greenwood Publishing Group, Inc; 1997.
• Harcourt B. Reducing mass incarceration: lessons from the deinstitutionalization of mental hospitals in the 1960s. John M.Olin Law and Economics Working Paper No. 542 (2nd Series) and Public Law and Legal Theory Working Paper No. 335. Chicago: The University of Chicago Law School; 2011. This paper makes important observations regarding the relationship between incarceration trends and the depopulation of state hospitals.
Deutsch A. The shame of the states. New York: Harcourt, Brace; 1948.
Halpern J. The myths of deinstitutionalization: policies for the mentally disabled. Boulder: Westview; 1980.
Breakey W. The rise and fall of the state hospital. In: Breakey WR, editor. Integrated mental health services. New York: Oxford University Press; 1996.
Lora A, Bezzi R, Erlicher A. Estimating the prevalence of severe mental illness in mental health services in Lombardy (Italy). Community Ment Health J. 2007;43(4):341–57.
Steadman HJ, Osher FC, Robbins PC, Case B, Samuels S. Prevalence of serious mental illness among jail inmates. Psychiatr Serv. 2009;60:761–5.
Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The national nursing home survey: 2004 overview. National Center for Health Statistics. Vital Health Stat. 2009;13(167).
Linkins KW, Lucca AM, Housman M, Smith SA. Use of PASRR programs to assess serious mental illness and service access in nursing homes. Psychiatr Serv. 2006;57:325–32.
Mechanic D, McAlpine D. Use of nursing homes in the care of persons with severe mental illness: 1985–1995. Psychiatr Serv. 2000;51:354–8.
McCarthy JF, Blow FC, Kales HC. Disruptive behaviors in veterans affairs nursing home residents: how different are residents with serious mental illness? J Am Geriatr Soc. 2004;52:2031–8.
• Fullerton C, McGuire T, Feng Z, Mor V, Grabowski D. Trends in mental health admissions to nursing homes. Psychiatr Serv. 2009;60(7):965–71. The authors document important trends related to increasing admissions of people with mental illness into nursing homes.
Burrows AB, Satlin A, Salzman C, Nobel K, Lipsitz LA. Depression in a long-term care facility: clinical features and discordance between nursing assessment and patient interviews. J Am Geriatr Soc. 1995;43:1118–22.
Grabowski DC, Aschbrenner KA, Rome VF, Bartels SJ. Review: quality of mental health care for nursing home residents: a literature review. Med Care Res Rev. 2010;67:627–56.
Li Y, Cai X, Cram P. Are patients with serious mental illness more likely to be admitted to nursing homes with more deficiencies in care? Med Care. 2011;49(4):397–405.
Fleishman M. The problem: how many patients live in residential care facilities? Psychiatr Serv. 2004;55(6):620–2.
Ireys H, Achman L, Takyi A. State regulation of residential facilities for adults with mental illness. DHHS Pub. No. (SMA) 06–4166. Rockville: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2006.
National Survey of Residential Care Facilities (NSRCF) (2010) Data dictionary. resident public-use file (Revised 2/2/12). www.cdc.gov/nchs/nsrcf/nsrcf_questionnaires.htm. Accessed February 2012.
Baillargeon J, Hoge SK, Penn JV. Addressing the challenge of community reentry among released inmates with serious mental illness. Am J Community Psychol. 2010;46:361–75.
Brink J. Epidemiology of mental illness in a correctional system. Curr Opin Psychiatr. 2005;18:536–41.
Torrey EF, Kennard AD, Eslinger D, Lamb R, Pavle J. More mentally ill persons are in jails and prisons than hospitals: a survey of the states. Treatment Advocacy Center and National Sheriffs’ Association. 2010;May:1–18.
James DJ, Glaze LE. Mental health problems of prison and jail inmates. Bureau of Justice Statistics Special Report (Publication No. NCJ 213600). Washington: U.S. Department of Justice; 2006.
Morrissey JP, Cuddeback GS, Cuellar AE, Steadman HJ. The role of Medicaid enrollment and outpatient service use in jail recidivism among persons with severe mental illness. Psychiatr Serv. 2007;58:794–801.
West HC, Sabol WJ. Prisoners in 2007. Bureau of Justice Statistics Bulletin (Publication No. NCJ 224280). Washington: U.S. Department of Justice; 2008.
National Commission on Correctional Health Care. The health status of soon-to-be-released inmates: a report to congress. Chicago: National Commission on Correctional Health Care; 2002.
Hornung CA, Anno BJ, Greifinger RB, Gadre S. The health status of soon-to-be-released inmates: a report to congress, vol. 2. Chicago: National Commission on Correctional Health Care; 2002. p. 1–11.
Beck AJ. State and federal prisoners returning to the community: findings from the Bureau of Justice Statistics. Paper presented at the First Reentry Courts Initiative Cluster Meeting, Washington, DC; April, 2000. bjs.ojp.usdoj.gov/content/pub/pdf/sfprc.pdf. Accessed February 2012.
Prins SJ, Draper L. Improving outcomes for people with mental illnesses under community corrections supervision: a guide to research-informed policy and practice. New York: Council of State Governments Justice Center; 2009.
Prins SJ. Does transinstitutionalization explain the overrepresentation of people with serious mental illnesses in the criminal justice system? Community Ment Health J. 2011;47:716–22.
Goldman HH, Morrissey JP. The alchemy of mental health policy: homelessness and the fourth cycle of reform. Am J Public Health. 1985;75:727–31.
The 2011 Point-in-Time Estimates of Homelessness.
National Law Center on Homelessness and Poverty. Homelessness in the United States and the Human Right to Housing; 2004.
Drake RE, Osher FC, Wallach MA. Homelessness and dual diagnosis. Am Psychol. 1991;46(11):1149–58.
Folsom DP, Hawthorne W, Lindamer L, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. 2005;162:370–6.
US Department of Housing and Urban Development, Office of Community Planning and Development. The third annual homeless assessment report to congress. Washington: US Department of Housing and Urban Development, Office of Community Planning and Development; 2008.
U.S. Department of Housing and Urban Development. The 2008 annual homeless assessment report to Congress. Washington, DC: U.S. Department of Housing and Urban Development. Retrieved from http://www.helpingthepoor.org/homeless-help/homeless-statistics-now-quarterly-by-hud-2008-homelessness-report;2009.
Belcher JR. On becoming homeless: a study of chronically mentally ill persons. J Community Psychol. 1989;17:173–85.
Pasic J, Russo J, Roy-Byrne P. High utilizers of psychiatric emergency services. Psychiatr Serv. 2005;56(6):678–84.
Irmiter C, McCarthy JF, Barry KL, Soliman S, Blow FC. Reinstitutionalization following psychiatric discharge among VA patients with serious mental illness: a national longitudinal study. Psychiatr Q. 2007;78:279–86.
Fisher W, Geller J, Pandiani J. The changing role of the state psychiatric hospital. Heal Aff. 2009;28(3):676–84.
State Forensic Mental Health Services: 2004, State Profile Highlights, Alexandria, Va., National Association of State Mental Health Program Directors Research Institute, 2005.
Schmelling S. The person and prison, mental illness discussion highlights needs for change. NIH record 59(15), July 2007. Available at nihrecord.od.nih.gov/newsletters/2007/07272007.
Lutterman T. Trends in SMHA mental health services. Presented at the National Grantee Conference on the Mental Health Block Grant and Data, Leading Change in Mental Health Systems, Washington DC, May 20–22;2008.
Lamb HR, Weinberger LE. Meeting the needs of those persons with serious mental illness who are most likely to become criminalized. J Am Acad Psychiatr Law. 2011;39:549–54.
Torrey EF, Entsminger K, Geller J, Stanley J, Jaffe DJ. The shortage of public hospital beds for mentally ill persons: a report of the Treatment Advocacy Center. Arlington: Treatment Advocacy Center; 2008.
Geller J, et al. The rights of state hospital patients: from state hospitals to their alternatives. Admin Pol Ment Health. 1998;25(4):387–401.
•• Glied S, Frank R. Better but not best: recent trends in the well-being of the mentally ill. Heal Aff. 2009;28(3):637–47. This recent article provides important analyses that demonstrate disparities in well-being and mental health care access between those with less severe mental health conditions and those with mental health impairments.
• Novella E. Mental health care in the aftermath of deinstitutionalization: a retrospective and prospective view. Ment Health Care Anal. 2010;18:222–38. This review provides a comprehensive overview of significant changes in the mental health field since deinstitutionalization.
Frank R, Goldman H, McGuire T. Trends in mental health cost growth: an expanded role for management? Heal Aff. 2009;28(3):649–59.
Frank R, Glied S. Changes in mental health financing since 1971: implications for policymakers and patients. Heal Aff. 2006;25(3):601–13.
Druss B. The changing face of U.S. mental health care. Am J Psychiatry. 2010;167(12):1419–21.
Hogan M. Transforming mental health care: realities, priorities, and prospects. Psychiatr Clin N Am. 2008;31(1):1–9.
Sederer L. Mental health policy and services 5 years after the President’s Commission Report: an interview with Michael F. Hogan. Psychiatr Serv. 2008;59(11):1242–4.
Verdier J, Barrett A. How Medicaid agencies administer mental health services: results from a 50-state survey. Psychiatr Serv. 2008;59(10):1203–6.
Engelhardt H. Long-term care: the family, post-modernity and conflicting moral life-worlds. J Med Philos. 2007;32:519–32.
Salinsky E, Loftis C. Shrinking inpatient psychiatric capacity: cause for celebration or concern? National Health Policy Form, Issue Brief No. 823;2007.
• Aschbrenner K, Grabowski D, Cai S, Bartels S, Mor V. Nursing home admissions and long-stay conversions among persons with and without serious mental illness. J Aging Soc Pol. 2011;23:286–304. The authors highlight deficiencies in care provided in nursing homes for people with SMI.
Bartels S, Moak G, Dums A. Models of mental health services in nursing homes: a review of the literature. Psychiatr Serv. 2002;53(11):1390–6.
Shea D, Russo P, Smyer M. Use of mental health services by persons with a mental illness in nursing facilities: initial impacts of OBRA 87. J Aging Health. 2000;12(4):560–78.
• Danziger S, Frank R, Meara E. Mental illness, work, and income support programs. Am J Psychiatry. 2009;166(4):398–404. This article provides up-to-date information on the use of income support programs for people with SMI.
•• Mojtabai R. National trends in mental health disability, 1997–2009. Am J Public Health. 2011;101(11):2156–63. In this review of mental health disability trends, the author uses recent data to highlight the need for improved access to mental health care services for those impaired by mental illness.
Pleis J, Lucas J, Ward B. Summary health statistics for US adults: National Health Interview Survey, 2008. Vital Health Stat. 2009;10(242):1–157.
Leff J, Warner R. Social inclusion of people with mental illness. Cambridge: Cambridge University Press; 2006.
Wu EQ, Birnbaum HG, Shi L, et al. The economic burden of schizophrenia in the United States in 2002. J Clin Psychiatr. 2005;66:1122–9.
Drake RE, Bond GR. The future of supported employment for people with severe mental illness. Psychiatr Rehabil J. 2008;31:367–76.
Bond G. Supported employment: evidence for evidence-based practice. Psychiatr Rehabil J. 2004;27:345–59.
Newman S, Goldman H. Housing policy for persons with severe mental illness. Pol Stud J. 2009;37(2):299–324.
Braconi F. 2001. Comments to the millennial housing commission. Govinfo.library.unt.edu/mhc/hearings/testimony/chpc.doc. January 19, 2012.
Parks, Svendsen, Singer, & Foti, 2006.
Dickerson F, Brown C, Daumit G, Lijuan F, Goldberg R, Wohlheiter K, Dixon L. Health status of individuals with serious mental illness. Schizophr Bull. 2006;32(3):584–9.
Lester H, Tritter J, Sorohan H. Providing primary care for people with serious mental illness: a focus group study. Br Med J. 2005;330:1122–8.
Dalmau A, Bergman B, Brismar B. Somatic morbidity in schizophrenia—a case control study. Publ Health. 1997;111:393–7.
Brunero S, Lamont S. Health behaviour beliefs and physical health risk factors for cardiovascular disease in an outpatient sample of consumers with a severe mental illness: a cross-sectional survey. Int J Nurs. 2010;47:753–60.
Deakin B, Ferrier N, Holt R, et al. The physical health challenges in patients with severe mental illness: cardiovascular and metabolic risks. J Psychopharmacol. 2010;24 suppl 1:1–8.
Brown V. Untreated physical health problems among women diagnosed with serious mental illness. JAMWA. 1998;53(4):159–60.
Dickerson F, Goldberg R, Brown C, et al. Diabetes knowledge among persons with serious mental illness and type 2 diabetes. Psychosomatics. 2005;46(418–424):418.
Desai M, Rosenheck R, Druss B, Perlin J. Mental disorders and quality of diabetes care in the veterans health administration. Am J Psychiatry. 2002;159:1584–90.
Dickerson F, Brown C, Goldberg R, Kreyenbuhl J, Wohlheiter K, Dixon L. Quality of life in individuals with serious mental illness and type 2 diabetes. Psychosomatics. 2008;49:109–14.
Bazelon Center for Mental Health Law. Get it together. How to integrate physical and mental health care for people with serious mental disorders. Washington, DC;2004.
Cuddeback GS, Scheyett A, Pettus-Davis C, Morrissey JP. General medical problems of incarcerated persons with severe and persistent mental illness: a population-based study. Psychiatr Serv. 2010;61(1):45–9.
Wolff N, Draine J. Dynamics of social capital of prisoners and community reentry: ties that bind? J Correct Healthc. 2004;17(4):457–90.
Frank R, McGuire TG. Mental health treatment and criminal justice outcomes (NBER Working Paper 15858). Cambridge: National Bureau of Economic Research; 2010.
Lurigio AJ. Examining prevailing beliefs about people with serious mental illness in the criminal justice system. Fed Probat. 2011;75(1):11–8.
Petersilia J. When prisoners come home: parole and prisoner reentry. Oxford: Oxford University Press; 2003.
Travis J. Invisible punishment: an instrument of social exclusion. In: Mauer M, Chesney-Lind M, editors. Invisible punishment: the collateral consequences of mass imprisonment. New York: The New; 2002. p. 15–36.
Uggen C, Manza J, Behrens A. ‘Less than the average citizen’: stigma, role transition and the civic reintegration of convicted felons. In: Maruna S, Immarigeon R, editors. After crime and punishment: pathways to offender reintegration (261293). Portland: Willan Publishing; 2004.
Kurzban S, Davis L, Brekke J. Vocational, social, and cognitive rehabilitation for individuals diagnosed with schizophrenia: a review of recent research and trends. Curr Psychiatr Rep. 2010;12(4):345.
Yanos P, Moos R. Determinants of functioning and wellbeing among individuals with schizophrenia: an integrated model. Clin Psychol Rev. 2007;27:58–77.
• Smith T, Sederer L. A new kind of homelessness for individuals with serious mental illness? the need for a “mental health home”. Psychiatr Serv. 2009;60(4):528–33. This article describes an important model to address fragmentation in the current mental health care system: the “mental health home” concept.
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Davis, L., Fulginiti, A., Kriegel, L. et al. Deinstitutionalization? Where Have All the People Gone?. Curr Psychiatry Rep 14, 259–269 (2012). https://doi.org/10.1007/s11920-012-0271-1
- Serious mental illness
- Mental health services
- Mental health spending
- Community integration
- Nursing homes