2. US PUBLIC INPATIENT 1830- 1955

3. PUBLIC INPATIENT 1955-2000

4. CAUSES OF DI 1. DRUGS 2. PHILOSOPHICAL CHANGES 3. LEGAL CHANGES 4. ECONOMIC CHANGES

7. I. DRUG TREATMENT ANTI-PSYCHOTICS THORAZINE AND LITHIUM IN MID-1950’S IMMEDIATE SUCCESS DON’T CURE BUT CONTROL EASY TO ADMINISTER NEW HOPE AND OPTIMISM BUT MAJOR CHANGES 1970 -

8. II. PHILOSOPHY 1. ANTI-MENTAL HOSPITALS - E.G. CUCKOO’S NEST 2. PRO-COMMUNITY TREATMENT - 1960’S LIBERAL PHILOSOPHY OF GOVERNMENT STRONG FEDERAL ROLE – BYPASS STATE MENTAL HOSPITALS

9. CMHC BUILD LARGE NETWORK OF COMMUNITY MENTAL HEALTH CENTERS (CMHC) FEDERAL – LOCAL PARTNERSHIP SERVED DIFFERENT POPULATION THAN STATE MENTAL HOSPITALS - LESS SERIOUS, EASIER TO TREAT

10. CMHC NOT INTEGRATED WITH STATE HOSPITALS - FEW PROGRAMS FOR S.M.I. CREATED GREAT GAP IN CARE – HOW FILL OLD ROLE OF STATE HOSPITAL?

11. III. LEGAL JUDICIAL AND LEGISLATIVE CHANGES 3 ASPECTS - COMMITMENT TO HOSPITAL, CONDITIONS IN HOSPITAL, RELEASE TO COMMUNITY MOVE FROM MEDICAL TO LEGAL MODEL

12. MEDICAL AND LEGAL PRIMACY OF HEALTH PATERNALISM BETTER SAFE THAN SORRY PRIMACY OF LIBERTY ADVERSARIAL NO TREATMENT UNLESS NECESSARY

13. 1. COMMITMENT UP TO 1970 PRIMACY OF MEDICAL MODEL ANYONE CAN BRING PETITION ASSERTING MENTAL ILLNESS M.D. MUST SIGN ROUTINE EXAM BY COURT PSYCH. BRIEF HEARING

14. 1970-2003 EXPANSION OF LEGAL MODEL FOR COMMITMENT HAD BEEN “MENTAL ILLNESS” NOW - DANGER TO SELF OR OTHERS SOMETIMES GRAVELY DISABLED SPECIFIC AND OVERT ACTIONS PROCEDURAL PROTECTIONS

15. EMERGENCY COMMITMENTS FOR BRIEF PERIODS - 2 WKS OR MONTH OLMSTEAD DECISION – 1999: LEAST RESTRICTIVE ALTERNATIVE UP TO STATE TO PROVE NEED FOR COMMITMENT COMMITMENT

16. 2. WITHIN HOSPITAL MANDATED STANDARDS OF CARE WITHIN HOSPITAL – TREATMENT, STAFF RATIO, LIVING CONDITIONS RESTRICTIONS ON SOCIAL CONTROL FRUMKIN HITS PT., BLINDS ATTENDANT GETS 2 HOURS OF SECLUSION

17. 3. RELEASE FROM HOSPITAL BURDEN OF PROOF ON STATE FOR WHY SHOULD KEEP IN HOSPITAL HEARINGS AT REGULAR PERIODS – EVERY SIX MONTHS OR SO

18. COMPARE CUCKOO’S NEST MORE TRUE PRE-1970’S THAN NOW NOW MORE LEGAL THAN MEDICAL: STATE MUST JUSTIFY HPT. “VOLUNTARIES” WOULDN’T BE THERE – OUTPATIENT CHRONICS IN NURSING HOMES PROBLEM NOW IS LACK OF FACILITIES

19. REASONS FOR LEGAL CHANGES CIVIL RIGHTS MOVEMENT ECONOMIC PRESSURE TO REDUCE HOSPITAL POPULATIONS

20. IV. ECONOMIC STATE HOSPITALS VERY EXPENSIVE DI CLAIMED TO SAVE MONEY IN FACT, SHIFTS ECONOMIC BURDEN FROM STATES TO FEDERAL GOV. FEDERAL WON’T PAY INPATIENT TREATMENT IN SMH BUT WILL FOR TREATMENT OUTSIDE HOSPITALS

21. FUNDING FOR TREATMENT MEDICAID – POOR; FEDERAL/STATE MEDICARE - ELDERLY; FEDERAL PROGRAM BOTH GO TO PROGRAMS NOT TO INDIVIDUALS NEITHER PAYS FOR TREATMENT IN MENTAL HOSPITALS

22. SSI SUPPLEMENTAL SECURITY INCOME FEDERAL PROGRAM TO INDIVIDUALS FOR LIVING EXPENSES NEED DISABILITY, LOSS OF FUNCTION, DURATION

23. SSI NOW MAJOR FUNDING FOR SERIOUSLY MENTALLY ILL ABOUT $600/MONTH GOOD – PROVIDES SUPPORT BAD – FOSTERS DEPENDENCY AND DISINCENTIVE TO WORK

24. RESULTS OF ECONOMIC CHANGES NO FEDERAL FUNDING FOR STATE HOSPITAL TREATMENT MORE TREATMENT IN GENERAL HOSPITALS MORE TREATMENT OF ELDERLY IN NURSING HOMES SOME FUNDING FOR COMMUNITY TREATMENT

25. SUMMARY MANY CAUSES OF DI MOVEMENT FROM HOSPITAL TO COMMUNITY SOME IMPROVEMENT MANY GAPS