Hope for the Severely Mentally Ill?

Deinstitutionalization has progressed since the 1950's. It has been successful for many individuals, but it has been a failure for others. The failure of the system is shown by the drastic increase in homelessness, suicide, and violent acts among persons with severe mental illness.   Deinstitutionalization has hurt the mentally ill so seriously that there are many who are increasingly re-admitted to hospitals. It is common to find persons who have been hospitalized 15-20 times over a 10 year period. There are more persons with mental illness in jails and prisons than there are in state hospitals.
In the 1950's, new treatment beliefs which put into practice short-term and community based treatments. However, the community supports which were necessary to maintain persons with severe mental illness in the community have not been developed in most communities. Also, the legal development of an environment  which has often been described as independent living for all patients, regardless of whether the setting is based on a clinical foundation
About 2.8% of the US adult population suffers from severe mental illness in a year. Among these persons, there are those who do not respond to traditional community treatment. It is estimated that this high risk group includes an estimated 1,000,000 individuals. Unfortunately, research of this group has been neglected. The most severely disabled have been forgotten by society, and by most mental health advocates,
Medical illnesses frequently go undiagnosed and untreated among persons with severe mental illness. The degree to which medical problems interfere with treatment and rehabilitation efforts and the danger that the presence of mental illness creates in the management of medical disorders has not been researched adequately.  Clients are often unable to communicate their symptoms and give a coherent account because of their psychiatric illness and the illness may become severe before it is recognized and treated. Medical problems may also result as a consequence of the poor health habits of these persons and the side effects of medications. For example, many persons with severe mental illness are overweight from side effects of their medications. This and heavy smoking leads to additional cardiac risks.  
The most commonly cited medical diagnoses were arthritis, hypertension, and diabetes.  Medical problems were frequently made worse by lack of a protective setting.  Bad health habits and side effects of medications are commonly contributing to poor physical health.
Many people with a diagnosis of severe mental illness also have a diagnosis of substance abuse disorder.  These people may self medicate because symptoms of the illness are not under control or as a way to deal with their social isolation. Consequences include noncompliance with medications, frequent re-hospitalization and homelessness. The occurrence of substance abuse may be caused by a variety of factors, including lack of case management and social isolation.   The consequences of noncompliance account for at least 40% of all episodes of schizophrenia relapse and for at least one-third of all in-patient treatment. The reasons clients do not take their medication are varied and may include lack of insight, side-effects of medications and inadequate structure and support within the environment that surrounds them.  Lack of insight into the illness was often associated with noncompliance.  Discharging the client prematurely from the hospital or removing the ill person from a highly structured setting resulted in noncompliance.  Noncompliance resulted in a progressively lower level of functioning.
The duration of stays in hospitals has become shorter under managed care standards. . Patients are often diverted from a familiar hospital to an available bed in another hospital where staff is unfamiliar to them. Stability and consistency is a requirement of quality care.
Recent studies of persons with schizophrenia point out that about one-third will attempt suicide, and about 1 in 10 will complete suicide. The suicide rate for those with mood disorders is 15%. This is in contrast to the suicide rate for the general population which is 1%.  Of those who attempted suicide, most had made 2 or more attempts.  Many are primarily male, single, unemployed and often live alone. They also have chronic, relapsing illness which requires frequent hospitalization; have poor response to their medications and feel hopeless about their future.  Suicide and attempts were attributed to lack of adequate services and medication non-compliance.
A fact that is seldom discussed but alarmingly true is that the death rate is significantly higher for those who are severely mentally ill than it is for the general population.  It has been established that individuals with schizophrenia die at a younger age than do individuals who don't have schizophrenia. The largest single contributor to this statistic is suicide which is 10-15% as compared with 1% in the general population. Also contributing to early death are poor health habits including heavy smoking, obesity and alcohol abuse. The presence of undiagnosed and untreated diseases; heart disease and diabetes, account for a significant number of those who die young. Homelessness also increases the mortality rate because of increased susceptibility to accidents and diseases.
There is a need for both a structured and long-term care environment for these high risk people.  Research indicates that many persons with schizophrenia lack the ability to create their own internal structure.  If placed in the community in a living arrangement without sufficient structure they may quickly decompensate and return to the hospital or to the streets.  Medication supervision was identified as the most important on-site service.
 The federal Medicaid exclusion of institutions of mental diseases is a major barrier to the development of long term care facilities with adequate structure and support services for individuals suffering from severe mental illnesses. This law has become a major barrier to the availability of economical long-term settings which can provide structure and professional supervision and should