Doctors Want to Bring Back Asylums

Deinstitutionalizing the mentally ill has been underway since the 1950s. But University of Pennsylvania medical ethicists are calling for reopening inpatient psychiatric facilities to provide long-term care for some patients.

“Few high-quality accessible long-term care options are available for a significant segment of the approximately 10 million US residents with serious mental illness,” Dominic Sisti, PhD and colleagues write in a JAMA opinion piece.

One of the co-authors is Ezekiel "Zeke" Emanuel, MD, PhD, a former White House health policy advisor known as the architect of the Affordable Care Act. He and his co-authors work at the Department of Medical Ethics and Health Policy at the UPenn Perelman School of Medicine. Emanuel has made a lot of headlines recently. In October, 2014 he wrote "Why I Want to Die at 75," a piece in the Atlantic. More recently he wrote a New York Times op-ed in which he said annual physicals are a waste of money: costly to the health system as a whole, mostly a revenue-enhancer for physicians, and not very helpful for patients.

In the JAMA piece, the co-authors say the people who need asylums include adults who are “lacking insight and chronically psychotic, unable to care for themselves, and potentially dangerous to themselves and the public,” such as those suffering from refractory schizophrenia and bipolar disorder. “The void is both ethically unacceptable and financially costly,” they write.

The number of publicly sponsored inpatient psychiatric beds has dropped by 95% since 1955, from 560,000 to 45,000, even as the US population has doubled.

“Most disturbingly US jail and prisons have become the nation’s largest mental health care facilities,” they write, “Half of all inmates have a mental illness or substance abuse disorder; 15% of state inmates are diagnosed with a psychotic disorder.”

Prisons are not the best place to provide care, since the environment there is “often unsafe, violent, and designed to both control and punish.”

Once they are out of prison, these mentally ill people are likely to be incarcerated again, they say.

Still, effective and affordable care is hard to come by, they write.

The “optimal option” is care in an accredited psychiatric hospital and that can cost hundreds of thousands of dollars per patient annually—compared to about $40,000 a year in a state prison in Texas.

“Asylums are a necessary but not sufficient component of a reformed spectrum of psychiatric services,” they write. But the role of asylums should be expanded as other models of care are considered.

They offer the Worcester Recovery Center and Hospital in Worcester, MA, as an example of a new model of effective care for patients who might otherwise be “cycling between the streets, emergency departments, and prisons”. The hospital is a $300 million state project.