“We Need Modern Day Asylums!” – Dr. Ezekiel Emanuel’s Suggestion Shakes Things Up But Is It Realistic?

 

Dr. Ezekiel J. Emanuel and two of his colleagues from the Department of Medical Ethics and Health at the University of Pennsylvania, have caused a dust up by suggesting that one way to improve long-term psychiatric care is by bringing back mental asylums.

They raised this premise in an article published in the Journal of the American Medical Association in January.

As you might suspect, a call for resurrecting mental asylums outraged many advocates who have been pushing for decades to close all state hospitals in favor of community based treatment services.

Here is a sampling of what Emanuel, along with Dominic A. Sisti, PhD., and Andrea G. Segal, MS, wrote:

“…The original meaning of psychiatric ‘asylum’ – (was) a protected place where safety, sanctuary, and long term care for the mentally ill would be provided. It is time to build them –again. At the moment, prisons appear to offer the default option and an inexpensive solution for housing and treating the mentally ill.

…A better option for a person with serious mental illness is assisted treatment in the community…However, comprehensive, accessible, and fully integrated community mental health care continues to be an unmet promise.

…At best, community treatment can provide high-functioning mentally ill persons a foundation for recovery. At worst, severely mentally ill persons drawing Medicaid and Supplemental Security Income risk becoming “commodities” in a profit-driven conglomeration of boarding houses reminiscent of the private madhouses of 18th century England.

Even well-designed community-based programs are often inadequate for a segment of patients who have been deinstitutionalized. For severely and chronically mentally ill persons, the optimal option is long-term care in a psychiatric hospital, which is costly…The annual rate at St. Elizabeth’s Hospital — a forensic psychiatric hospital in the District of Columbia– averages about $328,000 per patient annually.

Emmanuel and his colleagues cite a transformed state hospital in Massachusetts — the Worcester Recovery Center and Hospital — as an example of what states need to begin building.

The public’s perception of institutionalized mental health care remains dissonant. It is characterized by beliefs about the dangerousness of persons with mental disorders, combined with images of abuse and institutional warehousing. Realistically, the deployment of both private and public resources is now imperative to provide appropriate care and refuge for seriously mentally ill persons. These individuals cannot help themselves or live independently, and they deserve a safe place to live with proper supports — not cycling between the streets, emergency departments, and prisons.

Asylums are a necessary but not sufficient component of a reformed spectrum of psychiatric services….Reforms that ignore the importance of expanding the role of such institutions will fail mental health patients who cannot live alone, cannot care for themselves, or are a danger to themselves and others.

Dr. Lloyd  I. Sederer, the Medical Director of the New York State Office of Mental Health (OMH), the nation’s largest state mental health system, has taken issue with the JAMA article. Drs. Emanuel and Sederer were scheduled to have a friendly debate about asylums at the National Council For Behavioral Health’s conference last week in Orlando, Florida. You can watch that thirty minute debate here. 

In a blog entitled The Future of Mental Health Care, published by The Huffington Post in April 2014, Sederer wrote:

The use of hospitals, which by their nature abridge liberty, is the least desirable alternative for someone with an acute mental illness.

 In recent years, several states have quietly either remodeled or reopened state hospitals, including Virginia. 

So is Emanuel a prophet accurately predicting what will come?

Before anyone gets too excited (either arguing for or against a return to the asylums), they might wish to consider our current lack of adequate funding for mental health services.  Few states adequately fund existing community services. Will they be willing to finance and fund  state hospitals? The authors of the JAMA article write that the Worcester Recovery Center and Hospital has 320 private rooms and offers clients a recovery-inspired residential design and treatment agenda. The center cost $300 million to build and has a $60 million annual budget.

I doubt states will, especially because of a predicted shift in mental health funding that is in the works. Under the Affordable Care Act, millions of Americans are becoming insured.  Forecasters are predicting there will be a shift from public financing of mental health care by state agencies to private providers who will be hired by insurance companies.

I have been raising a red flag about this predicted shift.  I do not believe that insurance companies are going to provide the wrap-around services that persons with severe mental illnesses often require to fully recover. I’m talking about job programs, housing, and such beneficial services as peer-to-peer support and clubhouses. I have been assured that insurance companies will see the value in providing these services because they will result in fewer  hospital readmissions.  Medicare also will require providers to include wrap around services.

Sorry, I am not convinced.

Debating the pros and cons of building modern day “asylums” for long term care of the severely ill  — as part of overall mental health care reform strategy — will be a futile argument unless someone comes up with a way to finance them.

Reference: eine schickes Vergleichstool für Broker