The Problem of the Treatment Resistant Chronically Mentally Ill

I have hit a dry spell recently as far as ideas/inspirations for this more personal, less professional blog. One interfering and mind clogging constant information bombardment of no help has been the daily national political uproar on “both sides of the aisle” that has been, in the current kindest of descriptors: “distracting.”

I have made a personal pledge to myself to try to avoid as much as possible political topics and I am not a political observer or analyst of any value and politics is almost indecipherable to me, as I try to understand the deal making and constant shifting alliances. The poliltical method of functioning is inimical to me and I am just not emotionall built for the world of endeavor.

But lately I have seen remarks in the press and national discourse, much of which are from state leaders and budgeteers trying to cut more monies out of mental health services for the most severely ill who need some of the most help to ensure social functioning on at least a minimally uneventful level.

The remarks I have read have still been based on the persisting and most naive of mistaken attitudes toward the “PSMI,” or persistently severely mentally ill as these patients are sometimes given their own acronym.

It has debatably been obvious that in the last 20-30 years we have mistakenly over-reduced the number of needed inpatient psychiatric acute hospital based by at least 50-75%. Decades ago we had reportedly around 550,000inpatient beds in this country before the advent of effective treatments, psychiatric drugs, many news kinds of group and individual psychotherapies well beyond the limited confines and reaches of traditional psychoanalysis. as well as the first effective psychiatric treatment at least for very severe depressions, ECT, reviled and controversial as it has been.

With the growing advent of new psychiatric treatments especially the near avalanche of new psychotropics, it became possible to discharge inpatients from years of past near incarcerations in hospitals of all genres, and the rapid expansion of outpatient psychological mental health services and methods was on, like the Oklahoma land rush.

The “de-institutionalization” ethos and ideological movement took hold just many other dominant schools of thought had done so (and have continued to do so in the last 50 decades that have also proven to be of short sighted or harmful worth such as “est,” “birthing therapy,” and the many other fads that mental health treatment is no more immune to than any other of human endeavor. The deinstitutionalisation movement held that being hospitalized for long periods of time, especially if harsh methods of frank abuse were utilized, were dehumanizing, severely destructive to the personality and emotional functioning of chronic inpatients. I have no argument with this aspect of this ideological movement as I am old enough to have seen almost unspeakable abuse in hospitals I visited and helped to review often because of scandals and tragedies.

But it had its unforeseen consequences, accelerated by the economic downtown in this country beginning in the Midwest Rustbelt manufacturing states in the 1990’s, then the several other unbelievably costly recessions we have repeatedly experienced as the result of the dark side of our free market’s system’s “dark side,” the institutional greed on a national scale that resulted in the western states’ Savings and Loan Scandal dreamed up  by Charles Keating, the “dot com bust,” the Enron scandal, and then finally the even larger nationwide housing mortgage scandal bubble that lingers with us yet.

States’ revenues did not just decrease, they decreased in the spans of several to a few years like submarines diving to the bottom to avoid depth charges. As a result state coffers shrank to levels not seen since the Great Depression. All kinds of larger and human social services with cut drastically within relatively short periods of time.

This is an old and known “truism” of the ‘mental health crisis’ in this country. What is less appreciated in my view, is that the majority of the historical numerical peak of beds in the ‘old days’ before the advent of modern psychiatric treatment, (which is what made deinstitutionalization and liberation of so many chronically ill patients possible), are now demonstrating that they need still all encompassing humane “institutions” to take care of their complex needs whether it be medical management, speech therapy, social skills building that takes long periods of time for many patients, and a host of other needs including top flight, organized readily available and accessible medical care. This is because the chronically mentally ill have been shown to have far more medical care needs than the average citizen; there are many reasons for this but that is a topic for another occasion.

The takeaway point of this post that I have been working toward is to subtly some of the deinstitutionzation over statements in the long standing set of beliefs about why so many PSMI patients ended up in large psychiatric institutions.

One of the most insoluble reasons that is with us today in even greater numbers (which why we have those unfortunately flooding the homeless enclaves of the streets in cities, the jails at all levels in this country and every ER in the country is the phenomon of the treatment refractory or more simply and in less technical psychiatric-speak, the treatment resistant patient.

Let me offer some backdrop here. Only 60% or less of persons with severe chronic or relapsing depression respond well or “fully” or in my way of looking at treatment results, satisfactorily to the old or the new expensive Prozac era antidepressants.

In the arena of recurring psychosis, which almost all psychotic illness is chronic and relapsing. A very high percentage of the psychotic patients never are completely rid of a substantial portion of their severe and difference producing symptoms and behaviors.

Only with the exception toxic, drug induced psychosis, or that induced as an unpleasant byproduct of a serious but treatable and therefore temporary medical illness, rendering the psychosis similarly short lived.

Epidemiological and long term result studies have shown consistently for generations that somewhere close to half of psychotic patients respond very well to old or new antipsychotics. Many, perhaps more than a majority are left with the symptoms of what used to be called, “chronic” or “undifferentiated” schizophrenia. Nowadays we call their very disabling residual symptoms, the negative or cognitive symptoms. They largely do not respond to anything and worsen inexorably as the patient ages. They become more and more passive socially, asocial (not antisocial, they just socialize, converse and relate in ordinary give and take talking of everyday relationship ‘commerce,’ less and less and less). Their emotional spontaneity, expressivity, ordinary use of facial expressions in conversations decreases to almost nil and is called the “flat affect,” of schizophrenia. They seem lose vocabulary though not in a manner similar to the dementias, they just use far fewer words in conversations’ their range of topics of conversations shrink with time. They usually became more and more socially isolative and isolated. For all these reasons, they are not all violent as so often portrayed in the ill-informed media. This is why they commit far fewer crimes than is attributed to them and why they are far more likely than the average person to be the victims of crimes.

All these treatment resistant factors make them poorly functional in even the most gentle and non-demanding of social settings. And this is why they still need “institutions,” of whatever size. They are almost akin to younger nursing home patients, except they can walk and talk but are also in a world of their own, yet very different.

And there are more than twice as many of them as the years before the advent of modern psychiatric treatment. And until we have true breakthroughs in the treatment of the psychiatric psychoses, that stop and reverse the neurodegenerative “secondary” symptoms of schizophrenia, that likely are still decades distant, we will need to provide for these persons far better than we do now and that means housing and care centers, in other words, modern institutions.