The new state mental hospitals in the community

OBJECTIVE: The study examined a 95-bed locked community facility (an institute for mental disease), one of 40 such facilities in California to which patients with increasingly difficult problems in management have been referred over the past few years as an alternative to more highly structured state hospitals. The purpose was to determine the characteristics of patients admitted to such facilities and assess whether the facilities are adequate for treating them. METHODS: A hundred and one randomly selected patients in one institute for mental disease were studied by record review and by discussion of each case with staff. RESULTS: The patients were characterized by psychotic diagnoses; the presence of psychotic symptoms even though they took antipsychotic medications in the facility; and histories of previous hospitalizations, serious violence against persons, poor medication compliance, and substance abuse. Ninety-nine percent had been admitted under psychiatric conservatorship. Forty-four percent had been violent toward persons during the current admission, and the level of bizarre, socially inappropriate behavior in the facility was high. CONCLUSIONS: Despite a high-quality rehabilitation program, treating and rehabilitating difficult-to-manage patients normally treated in state hospitals in a facility that had a considerably lower degree of structure had become increasingly difficult and dangerous. The use of community alternatives to state hospitalization, which is often driven by lower costs and an ideology that highly structured care is seldom needed, is not suitable for all patients.