he inpatient model--treating psychiatric problems in hospital settings--continues to play a major role in mental health treatment, despite an almost 40-year movement toward deinstitutionalization, out-patient therapy and community treatment. But the venue has changed. Today, relatively few patients languish for lengthy periods in state psychiatric centers; instead they languish for three- or four-week periods in the acute wards of general hospitals.

General hospitals have become the primary providers of inpatient psychiatric care in the United States in recent years because of the profound reduction in the number of beds in state psychiatric hospitals, according to Dr. David Mechanic, director of the Center for Research on the Organization and Financing of Care for the Severely Mentally Ill at the National Institute of Mental Health at Rutgers University. He estimates that nationally, between 1986 and 1994, the total annual number of days patients spent in mental hospitals declined by more than 12.5 million.

Meanwhile, the pace of psychiatric admissions in New York City hospitals has steadily increased. In 1996, there were 55,281 psychiatric admissions to all New York City hospitals--an increase of more than one-third since 1990, when there were 40,477--according to the United Hospital Fund of New York. During that period, inpatient psychiatric care was the only category of hospital health care that wasn’t cut back. In fact, there was an increase of 161 inpatient psychiatric beds between 1990 and 1996 in New York City. In this decade, it is the only category of care that has maintained consistent occupancy rates above the 90th percentile.

Despite years of public awareness, many of the problems that fueled the deinstitutionalization movement have yet to be resolved. The current inpatient model is remarkably similar to what psychologist David Rosenhan described in his classic study, On Being Sane in Insane Places, published 25 years ago. Based on an experiment in which

participants entered psychiatric hospitals undercover, Rosenhan described an environment where staff members were casually indifferent to patients, abused them verbally and segregated themselves. Patients experienced an almost traumatic sense of depersonalization; admission, discharge and diagnosis criteria were arbitrary; and patients’ natural reactions to staff mistreatment and to the hospital setting were misattributed to their psychiatric disorders. The overall environment was custodial rather than therapeutic.

Today, much of the policy, advocacy and media discussion surrounding inpatient mental health care is focused on the flaws of deinstitutionalization and on fears that managed care organizations will discharge people too soon or deny hospital treatment when it’s needed. This debate about access to care is pushing the question of what that care actually consists of further and further into the background.

“There’s a lot of things that are typical about how an inpatient ward is run, that if you really thought about it doesn’t make a whole lot of common sense in terms of trying to help people get better,” says Penney, whose state job gives her the opportunity to bring the perspective of people who use mental health services into the policy-making process. “From my own experience, the last place I’d want to be if I was in an emotionally distraught state is in an inpatient unit.”

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