A History of Private Psychiatric Hospitals in the USA: From Start to Almost Finished

There has been no comprehensive history of the scope and roles of private psychiatric hospitals in the USA. This paper documents the origins, functions, support, and contributions of private psychiatric hospitals from their beginnings in the eighteenth century through 2003. An interesting feature of nineteenth century psychiatry was the interplay between private and public institutions which reveals a pattern of the public purchase of private beds that is conceptually much like what we have today. From the early twentieth century through 1970, advancements in somatic treatments, new ways of using the hospital milieu, the introduction of antipsychotic medications, the shift from institution-based to noninstitution-based loci of acute and long-term treatment and care, the beginnings of day hospitals and a shortage of psychiatrists and nurses, all impacted upon the private psychiatric hospital. While the private psychiatric hospitals expanded in number and in responsibilities during these decades, at the end of the 1960's their future was a matter of serious debate. A comprehension of the history of the private psychiatric hospital since 1970 is based on an understanding of the impact of for-profit hospital chains, managed care, the privatization of traditionally public services, the requirement for “treatment in the least restrictive alternative,” further erosion of the use of any form of inpatient treatment, and an overall decrease in expenditures for mental health services. The future of the private psychiatric hospital may well be based on its ability both to maintain its traditional, patient-centered approach and to create innovative, effective, efficient, novel systems of care and treatment.     

Homelessness among persons with serious mental illness in an enhanced community-based mental health system

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.     

Consultative psychiatry in both private and public general hospitals

Most psychiatric patients obtain care in the nonpsychiatric units of general hospitals. Two groups of 100 psychiatric consultation patients in a private hospital setting and in a public hospital were compared. Significant differences were found. Patients in the public hospital were medically, psychiatrically, and socioeconomically more disabled. In the private setting, psychiatric consultants were usually seen as members of a treatment team. The public facility expected consultants to function as psychiatric triage officers. However, both patient groups had a similar frequency of psychiatric illness and had an equal need for psychiatric services.     

Epidemiology of mental illness in a correctional system

PURPOSE OF REVIEW: Reports of higher than community rates of mental disorder in incarcerated populations first appeared in the mid-1970s. These findings have been confirmed over the past three decades in numerous studies across a wide spectrum of forensic settings. Recent research has benefited from enhanced methodological sophistication, and reliable rates across clinical domains and divergent forensic population groups are now available. This article reviews the literature on the prevalence of mental illness in forensic settings over the past 10 years, with special reference to specific subgroups. RECENT FINDINGS: Overall rates of any mental disorder, including personality disorder and addiction, remain high, in general ranging between 55% and 80%. The findings of recent, systematic surveys and of 22 studies reviewed here reveal rates of psychosis that are several times higher in correctional settings than in the community. Mood disorder rates are elevated also, with higher morbidity reported for women than for men. Findings in specialized populations indicate similarly elevated rates of mental disorder among adolescent and geriatric prisoners, while addiction rates rank highest across all population domains. SUMMARY: The prevalence of psychiatric illness in correctional settings is significantly elevated, with higher than community rates reported for most mental disorders. It is estimated that in the USA one in five incarcerated persons is afflicted with major psychiatric illness; with an estimated 9-10 million persons imprisoned worldwide, the burden of psychiatric illness in this vulnerable and marginalized population poses a serious challenge to researchers and clinicians alike.     

Analysis of U.S. trends in discharges from general hospitals for episodes of serious mental illness, 1995-2002

OBJECTIVE: The aim of this study was to ascertain trends from 1995 to 2002 in general hospital discharges among adults in the United States with serious mental illness. METHODS: As of 2002 the National Hospital Discharge Survey collected data on approximately 327,000 discharges from 445 hospitals. ICD-9-CM codes were used to identify the discharges between 1995 and 2002 associated with serious mental illness. RESULTS: Annual discharge rates involving serious mental illness increased by 34.7%, from 29.1 discharges per 10,000 in the U.S. adult population (18 years and older) in 1995 to 39.2 discharges per 10,000 in the U.S. adult population in 2002. Hospital discharges involving serious mental illness increased significantly in the black population and among young adults. For adults of ages 18 to 24, discharges per 10,000 increased from 19.9 in 1995 to 42.3 in 2002. A substantial increasing trend was seen for the Northeast and South census regions. There was an increase in the proportion of discharges associated with hospitalizations for serious mental illness that were covered by private payers, whereas there was a significant decline in such discharges when patients were covered by government programs. CONCLUSIONS: The increasing trend in general hospital discharges involving serious mental illness has continued into recent years. Further investigations are needed to understand how patient- and system-level factors have contributed to the increasing trend in general hospital discharges involving an episode of serious mental illness.     

Hospitalization for psychiatric illness under Medicare, 1985

National and state-level data on Medicare-covered hospital discharges after treatment for psychiatric illness in 1985 were analyzed to determine the distribution of cases among various types of psychiatric and general hospitals. In most states, 80 to 90 percent of Medicare patients with psychiatric conditions received care in a setting that provided specialized treatment for psychiatric illness. However, the distribution of discharges among public and private psychiatric hospitals and general hospitals with psychiatric units varied substantially among states. Between 1984, the first year of Medicare's prospective payment system, and 1985, the number of discharges decreased overall, and a shift toward treatment in specialized psychiatric facilities and toward settings exempt from the prospective payment system was apparent.     

Dramatic changes in care: the experience of one psychiatric hospital

Recent and dramatic changes in this country's mental healthcare service are widely documented. To assess the extent and timing of those changes at one private psychiatric hospital, the authors examined length of stay, number of admissions, and patient age for general trends between 1980 and 1990 and more closely examined trends between July 1990 and December 1991. We related our findings to data for other private psychiatric hospitals and compared them with data from psychiatric units in general hospitals. The results are discussed in terms of changes in insurance coverage, changing utilization by different age groups, and a national shift from inpatient to outpatient care.     

Treatment of acute schizophrenia in open general medical wards in Jamaica

OBJECTIVE: The study assessed the efficacy of treating acute psychotic illness in open medical wards of general hospitals. METHODS: The sample consisted of 120 patients with schizophrenia whose first contact with a psychiatric service in Jamaica was in 1992 and who were treated as inpatients during the acute phase of their illness. Based on the geographic catchment area where they lived, patients were admitted to open medical wards in general hospitals, to psychiatric units in general hospitals, or to acute care wards in a custodial mental hospital. At first contact, patients' severity of illness was assessed, and sociodemographic variables, pathways to care, and legal status were determined. At discharge and for the subsequent 12 months, patients' outcomes were assessed by blinded observers using variables that included relapse, length of stay, employment status after discharge, and clinical status. RESULTS: More than half (53 percent) of the patients were admitted to the mental hospital, 28 percent to general hospital medical wards, and 19 percent to psychiatric units in general hospitals. The three groups did not differ significantly in geographic incidence rates, patterns of symptoms, and severity of psychosis. The mean length of stay was 90.9 days for patients in the mental hospital, 27.9 days in the general hospital psychiatric units, and 17.3 days in the general hospital medical wards. Clinical outcome variables were significantly better for patients treated in the general hospital medical wards than for those treated in the mental hospital, as were outpatient compliance and gainful employment. CONCLUSIONS: While allowing for possible differences in the three patient groups and the clinical settings, it appears that treatment in general hospital medical wards results in outcome that is at least equivalent to, and for some patients superior to, the outcome of treatment in conventional psychiatric facilities.     

Use of nursing homes in the care of persons with severe mental illness: 1985 to 1995

OBJECTIVE: The study examined patterns of care for persons with mental illness in nursing homes in the United States from 1985 to 1995. During that period resident populations in public mental hospitals declined, and legislation aimed at diverting psychiatric patients from nursing homes was enacted. METHODS: Estimates of the number of current residents with a mental illness diagnosis and those with a severe mental illness were derived from the 1985 and 1995 National Nursing Home Surveys and the 1987 and 1996 Medical Expenditure Surveys. Trends by age group and changes in the mentally ill population over this period were assessed. RESULTS: The number of nursing home residents diagnosed with dementia-related illnesses and depressive illnesses increased, but the number with schizophrenia-related diagnoses declined. The most substantial declines occurred among residents under age 65; more than 60 percent fewer had any primary psychiatric diagnosis or severe mental illness. CONCLUSIONS: These findings suggest a reduced role for nursing homes in caring for persons with severe mental illness, especially those who are young and do not have comorbid physical conditions. Overall, it appears that nursing homes play a relatively minor role in the present system of mental health services for all but elderly persons with dementia.     

Characteristics of assaultive patients in private hospitals

A study of two large private psychiatric hospitals showed rates and patterns of assaultive behavior by patients comparable to those found earlier in a study of public hospitals; this was especially true in the hospital that admitted involuntary patients. The targets of assault were predominantly family members other than spouses or children and persons outside the family. Seclusion was commonly used to manage assaultive patients in the private hospitals and the seclusion rates were higher than those found for public hospitals, probably reflecting a staff preference for seclusion over heavy medication. The need for staff education and support in the management of assaultive patients exists in private hospitals as well as public hospitals.     

National trends in use of psychotherapy in psychiatric inpatient settings

The use of individual, family, and group psychotherapy at a national sample of state and county mental hospitals, private psychiatric hospitals, and psychiatric services in nonfederal general hospitals in 1975 and in 1980 or 1981 was studied. Patients with organic or alcohol-related disorders were generally less likely to receive psychotherapy than were those with schizophrenia. Patients' educational level, gender, or race did not appear to influence the use of psychotherapy, but older patients were less likely to receive psychotherapy, particularly group or family therapy. During the study period, the percentage of patients receiving psychotherapy at nonfederal public general hospitals rose dramatically and by 1981 was almost equal to or even a little higher than the percentages at nonpublic general hospitals and private hospitals, a sign that public general hospitals have made an impressive adjustment to their increased role in caring for the severely mentally ill.     

The pathways to primary mental health care in high-density suburbs in Harare, Zimbabwe

The pathways to care for mental illness are diverse and are dependent on sociocultural and economic factors. The objective of this study was to describe the pathways to primary care for patients with common mental disorders in Harare. One hundred and nine consecutive patients with conspicuous psychiatric morbidity identified by general nurses in three primary health care clinics (PHC) and by four traditional medical practitioners were interviewed with the Pathways to Care Schedule. Other than those patients with an acute illness, most patients consulted more than one care provider; three-quarters of those with a history of prior consultations had consulted both traditional and biomedical care providers. Biomedical care providers were the most common first care provider consulted; if this treatment failed, then patients tried other biomedical or traditional care providers. Different factors operated in the decision-making process in choosing between consulting biomedical and traditional care providers. Traditional care providers provided explanations more often than biomedical care providers; explanations given were most often spiritual. Injectable treatments were often prescribed for mental illness, especially by private general practitioners (GPs). Such treatments, and many oral treatments, were non-specific. Dissatisfaction with consultations was most commonly due to lack of symptomatic improvement. The costs of consultation were highest for private GPs, general hospitals and traditional healers; faith-healers, PHCs and hospital psychiatric departments were the cheapest.     

Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services

We studied the medical comorbidity among individuals with serious mental illness who were receiving community-based psychiatric treatment. A total of 200 psychiatric outpatients divided between those with schizophrenia and affective disorder diagnoses were recruited from samples receiving outpatient care at two psychiatric centers. Interviews used questions from national health surveys. Logistic regression analyses compared responses from each sample with those of matched subsets of individuals from the general population. Both patient groups had greater odds of having many medical conditions. The odds of respiratory illnesses remained elevated in the patient groups even after controlling for smoking, as did the odds of diabetes in the affective disorder group after controlling for weight. Persons with serious mental illness who are in outpatient care are more likely to have comorbid medical conditions than persons in the general population. The odds of diabetes, lung diseases, and liver problems are particularly elevated. These findings underscore the need for intensified preventive health interventions and medical services for this population.     

Privatization of psychiatric services

The authors provide an overview of privatization, a major trend in mental health policy, focusing in particular on the reasons for and consequences of substantial growth and change in ownership of private psychiatric hospitals; the proportion of all nonfederal psychiatric inpatient beds in private facilities has increased from less than 10% in 1970 to 35% today. It is estimated that between 1970 and 1986, the proportion of total nonfederal psychiatric inpatient beds in the United States that were under corporate for-profit auspices increased from about 1% to 15%. The authors distinguish and examine several aspects of privatization and assess the implications of these changes for psychiatry and for public policy and research.     

Has the public taken notice of psychiatric reform? The image of psychiatric hospitals in Germany 1990–2011

Purpose

In the context of mental health care reform in Germany, psychiatric hospitals have been transformed in terms of their infrastructure, staffing levels and therapeutic culture. The question arises as to what extent these improvements had an impact on the public image of these institutions.

Methods

In 1990 and 2011, population surveys were conducted in the “old” states of Germany, using the same sampling procedure, interview mode and measures.

Results

Over the last two decades, attitudes toward psychiatric hospitals have improved considerably. This improvement was particularly pronounced among those who had been in treatment for mental health problems. The public is now more inclined to regard psychiatric hospitals as similar to other hospitals, more ready to expect effective treatment in psychiatric hospitals, and less inclined to support the stereotype that psychiatric hospitals are primarily places where patients are locked away. However, there was a stronger tendency to agree with the notion that psychiatric hospitals are necessary to protect society from persons with mental illness.

Conclusions

The improvement of psychiatric care seems to pay off as regards the image of psychiatric hospitals among the general public. Further efforts are necessary to reduce the stigma attached to mentally ill people.     

Training persons with schizophrenia in illness self-management: a randomized controlled trial in Japan

Despite the worldwide shift from inpatient to community-based treatment for individuals with severe mental illness, Japanese psychiatric services remain hospital based. In 1998, Japan had 29 psychiatric beds per 10,000 persons, twice as many as in most European countries and five times as many as in the United States (1).The reasons for Japan's slow transition to a community-based mental health system are both economic and cultural. For instance, 90 percent of psychiatric beds are in private for-profit hospitals. There is little incentive for inpatient facilities to discharge patients promptly, because the Japanese health care system provides universal coverage with virtually unlimited reimbursement for inpatient services, and the government does not have a mechanism for financing the relocation of resources from hospitals to communities (2). In addition, the stigma associated with mental illness in Japanese families is high (3). Thus a patient's primary residence is the psychiatric hospital, and opportunities are provided for periodic visits from the family.However, psychiatric rehabilitation principles and practices are beginning to take root in Japan. Anzai and his colleagues at the Matsuzawa Psychiatric Hospital in Tokyo have adapted an empirically validated skills training program to prepare patients with schizophrenia for life in the community after discharge from the hospital. In this column, they report the results of a randomized controlled trial of this approach in an inpatient facility serving a large urban center.     

Treatment, care, and rehabilitation of the chronic mentally ill in Poland

In Poland primary health settings provide about 71 percent of mental health services, particularly to patients with less serious illnesses, while psychiatry provides specialized mental health care for the chronic mentally ill, the mentally retarded, and patients with alcohol or drug dependence. Poland has a large number of outpatient clinics and an extensive network of sheltered workshops. Most inpatient psychiatric beds are located in mental hospitals; few general hospitals have psychiatric units. Deinstitutionalization has been less extensive in Poland than in many other countries; only about 10 percent of the chronic patients treated in mental hospitals were deinstitutionalized between 1970 and 1981. During that period the proportion of patients hospitalized for a year or more decreased, the number of chronic patients treated in nursing homes increased, and the pattern of hospitalization shifted toward multiple readmissions.     

Sex differences in psychiatric morbidity: an analysis of Victorian data

This study examined relevant Victorian data in the light of overseas findings on sex differences in psychopathology and utilisation of psychiatric treatment resources. Data sources included community health surveys and treatment statistics from the State psychiatric services, general hospitals and general practitioners. It was revealed that more Victorian women than men reported and were treated for psychiatric problems, and that women were most often diagnosed as depressed and otherwise neurotic, whereas men more often had alcohol and personality disorders. Married women had higher rates of mental illness than married men, whereas single and divorced men had higher rates of psychiatric morbidity than their female counterparts. Occupational status was related to men's, but not women's mental health. Various explanations for the findings are discussed, with some stress on the possible contribution of the sex role socialisation and cultural expectations of men and women.     

Familiarity with and social distance from people who have serious mental illness.

OBJECTIVES: This study examined the effects of familiarity with and social distance from persons who have serious mental illness on stigmatizing attitudes about mental illness. METHODS: A total of 208 community college students completed three written measures about familiarity, perception of dangerousness, fear, and social distance. Path analysis with manifest-variable structural modeling techniques was used to test a version of a model in which familiarity influences the perception of dangerousness, which in turn influences fear, which influences social distance from persons with serious mental illness. RESULTS: Most of the participants reported experience with mental illness. Scores on the three written measures largely supported the path model. Correlations between the perception of dangerousness and fear as well as between fear and social distance were particularly strong. CONCLUSIONS: Approaches to social change that increase the public's familiarity with serious mental illness will decrease stigma. Further studies are warranted that focus on how contact between members of the general public and persons who have serious mental illness may be facilitated.     

Health status of individuals with serious mental illness

We examined indices of the health of persons with serious mental illness. A sample of 100 adults with schizophrenia and 100 with major mood disorder were recruited from randomly selected outpatients who were receiving community-based psychiatric treatment. Participants were surveyed about health indicators using items from the National Health and Nutrition Examination Study III and the National Health Interview Survey. Their responses were compared with those of matched samples from the general population surveys. A total of 1% of persons with serious mental illness, compared with 10% from the general population sample, met criteria for all 5 of selected health indicators: nonsmoker, exercise that meets recommended standards, good dentition, absence of obesity, and absence of serious medical co-occurring illness. Within the mentally ill group, educational level, but not a diagnosis of schizophrenia versus mood disorder, was independently associated with a composite measure of health behaviors. We conclude that an examination of multiple health indicators may be used to measure overall health status in persons with serious mental illness.