Deinstitutionalization and NP-Led Mental Health Care in Alabama

Introduction: Deinstitutionalization and Its Community Impact

Deinstitutionalization burdens the community given the lack of sufficient resources and infrastructure to house persons who require permanent care for psychological, neurological, and other behavioral disorders. The complexity of adjusting to community life for people with mental health problems calls for help from social workers and psychiatric rehabilitation professionals, which fosters recovery and hope for patients. Deinstitutionalization also provides prospects for Psychiatric/Mental Health (Psych/MH) Nurse Practitioners to establish their own facilities to care for deinstitutionalized mental health patients. Psych/MH Nurse Practitioners offer primary health care to persons with mental health issues across different settings, and their roles emphasize clinical leadership, research, consultation, and expert clinical practice.

The objective of deinstitutionalization is to enhance the quality of life and treatment of people with mental disorders. In practice, however, deinstitutionalization has become a polarizing concern. While some studies report positive outcomes, others confirm that people living in homes or independent community settings experience significant deficits in crucial aspects of health care. Opponents of deinstitutionalization point out that many patients move from inpatient mental health hospitals to residential or nursing homes that are less equipped or staffed to meet the requirements of the mentally ill.

In several cases, moving patients from mental health institutions shifts the care burden to families. While debate over deinstitutionalization continues, healthcare professionals, advocates for mentally ill persons, and families call for increased accessibility and availability of permanent psychiatric inpatient and intermediate care for persons requiring a more structured care setting. Many experts indicate that by enhancing community-based programs and extending inpatient care to satisfy the requirements of mentally ill people, the state can achieve better treatment outcomes, improved quality of life, and increased access to mental health care.

To achieve the goal of deinstitutionalization, a wellness and recovery center for deinstitutionalized individuals is paramount. Such establishments provide detailed services designed to support people with mental health issues, including skill-building activities and curriculum, community-based peer support, and family education. The expectation is that patients will obtain enhanced overall wellness and health, set and attain personal objectives independently within the community or within their families. Wellness and recovery centers require the services of nurse practitioners, nurse technicians, and social workers to provide psychiatric assessments, medication management, general care, supervision of inpatients and on-site patients, and follow-up care. Nurse technicians monitor the physical wellness of patients. All of these services have the potential to address issues linked to the ongoing deinstitutionalization in Alabama.

Nurse practitioners have the potential to examine their own goals and visions for developing individualized practice models. Factors that affect the healthcare system — including electronic record maintenance, technology, efficient payment systems, high costs, and lack of access to care — have created novel and exciting prospects for nurse practitioners who wish to establish their own practices. In light of issues regarding deinstitutionalization and the closure of state-run psychiatric facilities, Psych/MH Nurse Practitioners can help bridge the growing gap left by state-run psychiatric services through establishing wellness and recovery centers.

Background and Problem Statement

Statistics from the National Alliance on Mental Illness indicate that out of the 4.7 million people in Alabama, 187,000 adults live with critical mental health illnesses, and approximately 51,000 children live with serious mental health conditions (NAMI, 2010). In 2006, five hundred Alabamians committed suicide caused by unmanaged or under-treated mental illnesses. Statistics indicate that the state loses one life every fifteen minutes through suicide, making suicide the 11th leading cause of death overall and the 3rd leading cause of death among young adults and youth aged between 15 and 24 years. Between 2006 and 2007, 64% of Alabama students aged over 14 years and living with critical mental health disorders dropped out of high school despite receiving special education services (NAMI, 2010).

The state of Alabama has closed most of its state-run psychiatric facilities, a decision that creates increased demand for psychiatric services following the deinstitutionalization of mental health patients. Closing all but two state mental health facilities leaves the state with few providers of psychiatric services to meet the increased need for mental health facilities and services. The Alabama Department of Mental Health stresses that it is crucial to prepare the community for the return of patients before they are released from mental health hospitals.

Deinstitutionalization has led to the elimination of state mental health hospitals and a ninety percent decrease in psychiatric hospital facilities and resources. It places a great burden on communities that lack the resources and infrastructure to treat people with mental health needs. The state also faces resistance to the placement of transitional homes in residential communities, as these homes can become a source of community tension. However, most communities accept facilities that are well managed and have sufficient resources to cater for the needs of former patients.

Mental health officials in Alabama planned to dismiss 948 employees and terminate operations of all but two state psychiatric hospitals. One of the hospitals remaining operational handles only forensic patients, while the other handles geriatric patients (Plotnik & Kouyoumdjian, 2010). As a result, mentally ill patients are blocked from accessing psychiatric treatment from state facilities unless they are elderly or have committed crimes. The Alabama Department of Mental Health asserts that this move allows the state to expand community care. The ongoing deinstitutionalization has led to a reduction of state hospital beds by 90% in favor of community services and less-restrictive treatment (Plotnik & Kouyoumdjian, 2010).

Law enforcement facilities are under serious pressure because of problems linked to untreated mental illness. State hospital emergency rooms are full of persons in psychiatric crisis who cannot be accommodated given the scarcity of beds. Alabama communities have experienced tragic incidents instigated by rampage killings perpetrated by people with untreated mental illnesses. Deinstitutionalized persons with chronic mental illness live in the streets, in prisons, or jails, suffer neglect, and commit suicide. The state is challenged with handling deinstitutionalized persons as well as new mental health patients emerging from the community.

Yanos et al. (2001) confirm that there is a critical public health issue for deinstitutionalized people. About 60% of deinstitutionalized people suffer premature deaths from health conditions such as cardiovascular, infectious, and pulmonary diseases that could be managed and treated. Thirty to forty percent of mortality is attributable to accidents, injuries, and suicide. Deinstitutionalized persons suffering from schizophrenia die of cardiovascular diseases promoted by smoking and excessive obesity. According to Yanos et al. (2001), people with critical mental illness lead marginal lives because of stigma, social isolation, and fear, making deinstitutionalized people especially vulnerable to social and health problems.

Deinstitutionalization refers to the release of mental patients from mental hospitals and their return to the community to build more self-sufficient and fulfilling lives. In 1950, there were 550,000 patients in mental hospitals in the United States. Following deinstitutionalization, the number of patients in mental hospitals dropped to approximately 150,000 in 1970 and about 80,000 in 2000 (Yanos et al., 2001). Relocating patients from state-run psychiatric hospitals back to communities began in the 1960s, initiated in part by the establishment of civil rights legislation, resulting in the enormous relocation of mentally ill persons. Although deinstitutionalizing mentally ill people appeared to be a humane act, this decision has left many people in far worse situations compared to those they endured while in psychiatric hospitals. Following deinstitutionalization, people face homelessness, poverty, stigma, inadequate treatment, and social isolation.

The objective of deinstitutionalization is only partly achievable. Some former mental patients do live in well-run halfway houses, but past studies show that halfway houses remain poorly maintained, employ untrained staff, and offer little or no treatment to patients. Major problems include lack of funding and poor supervision. Because of insufficient and inadequate halfway houses, many deinstitutionalized patients end up on the streets and become homeless. Twenty-five to eighty percent of homeless people in the United States have serious mental disorders and receive little or no treatment (Plotnik & Kouyoumdjian, 2009). To offer mental health treatment for the homeless and those released from psychiatric hospitals, community mental health centers facilitate treatment and care for these individuals. According to Plotnik & Kouyoumdjian (2010), there is a need to provide treatment to the homeless, county prisoners, and deinstitutionalized individuals, and one way to do so is through the establishment of wellness and recovery centers.

Deinstitutionalized patients report that while most are being maintained on medication, very few have their medication carefully monitored (Weisbrod & Komesar, 1978). In numerous cases, family members pick up prescription renewals, and many patients are maintained in the community not because of mental health services they receive, but because of the dedication of friends and family members. The constant deinstitutionalization of patients in the state calls for adequate facilities to offer in-home and on-site care for adults. Basic deficiencies in the provision of mental health services are attributable to the lack of proper facilities, resources, leadership skills, and organization of mental health services in the state.