Hospital & community psychiatry最新文献

Over the past 150 years, support for providing appropriate services for mentally ill persons has waxed and waned. In colonial America, mentally ill persons were institutionalized in jails or almshouses. In the 18th and 19th centuries, asylums constituted the primary psychiatric service. Only in the late 19th and early 20th centuries did alternatives to long-term hospitalization appear. The mental hygiene movement of the early 20th century and the community mental health centers movement of the 1960s and 1970s both increased the number of services and introduced new types of services. Today, however, despite hopeful signs of reduced public prejudice against mentally ill persons, a new "dark age" for support of psychiatric services may be dawning, as negative attitudes about mental illness continue to drive public policy.

American forensic psychiatry was founded in 1838 with the publication of Isaac Ray's Treatise on the Medical Jurisprudence of Insanity. Ray's ideas were influential in the early history of forensic psychiatry but were overlooked in the formulation of the M'Naghten Rules in England, an early parliamentary effort to define criteria for the insanity defense. In the mid-1800s, asylum-based psychiatrists formulated model laws addressing involuntary commitment and debated the definition of mental illness for legal purposes. In the late 1800s, courts became interested in findings of brain pathology in insanity defense cases, and neurologists joined psychiatrists as expert witnesses. Beginning around 1950, increased judicial activism led to a new standards for insanity in criminal cases, advances in the civil rights of mentally ill persons, and refinements in the role of expert witnesses. In 1969 forensic psychiatrists established a professional organization, and board certification in the subspecialty began in 1979.

The author presents his perspectives on the relationship between antipsychiatry and the stigma of mental illness. Stigma has existed at least since biblical times, when madness as demonic possession and punishment for sin became codified in religious belief and practice. The antipsychiatry movement dates from the 18th century, when psychiatry first emerged as a medical specialty and the first mental hospitals were built. Over the years psychiatry has been a target for antipsychiatry groups competing for influence or authority over the mentally ill. At various times these groups have included neurologists, social workers, new religions, consumers, and psychiatrists themselves. Their common ground has been objection to psychiatry as a hospital-centered medical specialty legally authorized to institutionalize and treat patients. In the late 19th century, treatment of hospitalized patients increased the stigma of mental illness and provided fuel for the antipsychiatry movement. During that period psychiatrists began to see heredity as the cause of mental illness, became pessimistic about restoring patients to sanity, and adopted essentially a custodial approach to care that included use of physical restraints. However, recent advances in biological treatments have undercut antipsychiatry and rekindled optimism about recovery that may go far in eliminating stigma.

Objective: The authors' goal was to compare distribution of diagnoses, length of stay, and readmission rates for every 16th patient admitted to the St. Louis County Insane Asylum (now St. Louis State Hospital) between 1886 and 1904 with those for every 16th patient admitted to the hospital between 1978 and 1980.

Methods: A sample of 369 cases was drawn from the archival admission records, and 380 cases were selected from recent admissions. Descriptive data from the archival records were used to make DSM-III diagnoses. Data on length of stay and number of readmissions were collected from case records.

Results: The historical sample had fewer cases of major mental illness, longer mean lengths of stay, and fewer mean readmissions than the modern sample.

Conclusions: Differences in the clinical characteristics of the two samples may be explained by differences between the two periods in treatment philosophies, admitting policies, and presence of alternative resources for accommodating long-term chronic patients.