When there are almost no state hospital beds left

[The fate of patients with very severe and chronic mental disorders when there is no psychiatric hospital: a case study]

The Eastern Townships (Estrie) is an area of Québec which has never had a psychiatric hospital and is thus an extreme example of deinstitutionalization. How can people with the most severe mental illnesses be cared for? Does this system have harmful consequences? The authors present a case study with both qualitative and quantitative data to elucidate their questions. They found 36 patients with very severe mental illness (prevalence 12,4/100 000). This region does not send its most severely ill patients outside and generally succeeds in providing them with care and services in a network of small and medium size residential facilities. On the other hand, the authors have also been able to identify a certain drift of patients towards the correctional system ; cases with double or triple diagnosis do not easily have access to care ; through lack of an alternative, patients with potentially chronic violence often are stuck in a hospital in short stay beds (prevalence 1,6/100 000). It thus appears possible to eliminate the use of a psychiatric hospital for patients with very severe mental disorders as long as they are provided with supervised and long term care facilities (need : 10-20 places/100 000).

Psychosocial rehabilitation in a public psychiatric hospital

Patients with chronic mental illnesses have complex treatment needs that often pose significant challenges to mental health professionals. This paper describes the implementation of a psychosocial rehabilitation program to meet the treatment needs of patients in a public psychiatric hospital providing long-term care. A core group of professional staff adopted psychosocial rehabilitation principles in order to transform a custodial model of care to a highly interactive educational and skills building program. A model of service delivery was established to address patients' skill deficits and barriers to returning to the community. This article describes the major steps and challenges faced in overcoming obstacles and implementing a psychosocial philosophy of treatment in an inpatient setting. It suggests that it is possible for the public hospital to reinvent itself into an environment that can stimulate recovery and hope.

Deinstitutionalization and criminalization: tinkering in the interstices

The mental health service system has undergone continuous change for more than three decades. Undoubtedly, some of its problems are related to economic, social and political factors. This contribution discusses problems of deinstitutionalization, homelessness and criminalization of the mentally ill persons. To conclude, it proposes a number of ways by which better services could be rendered to the mentally disordered persons, particularly in areas that interface with the criminal justice system.

The appropriate role for the state hospital

This article explores the role of the state hospital in providing long-term care. It is argued that long-term care is an important part of a mental health system, specifically for people with severe mental illness. The state hospital can be made to function more efficiently and also provide needed long-term care.

Patterns of psychiatric service use by homeless mentally ill clients

The objective of this study was to describe the patterns of service use of homeless mentally ill clients prior to and for two years following an admission to Skid Row Mental Health (SRMH) services in Los Angeles during a recent year (N = 268). Twenty clients were still at SRMH two years later. These clients were older and more likely to be female; most of their prior service use was at SRMH. For the majority of the 124 clients in the second group, those who had been discharged and not readmitted, the index admission was their only admission. The 124 clients in the third group, these with admissions after the index admission, had long histories in the system. Cluster analysis showed distinct patterns in service use during the follow-up period. Knowledge of patterns of service use by homeless mentally ill persons will enhance understanding of interventions which have the greatest chance of success.

The changing careers of patients with chronic mental illness: a study of sequential patterns in mental health service utilization

The aim of this study was to describe patterns of service use over time by a group of persons with chronic mental illness who were homeless at the time of the index admission. Subjects were all persons admitted to Skid Row Mental Health Services in a recent year who had 25 or more previous admissions to any Los Angeles County Department of Mental Health service (N = 49). Sequences of type of service at each of the 25 admissions were compared with optimal matching and categorized with cluster analysis. Patients in earlier clusters had many inpatient admissions; those in later clusters had many admissions to outpatient, residential, and jail services. Service use by individuals in each cluster showed the same trends. However, there were also different patterns of service use for patients in cluster within the same tie frame. Analyzing multiple admissions sequentially helps to locate likely places to intervene in downward-spiraling careers.