The last half-century of psychiatric services in the United States is examined through developments and trends reported in the 50 years of publication of Psychiatric Services. The journal, earlier named Mental Hospitals and then Hospital and Community Psychiatry, was launched by the American Psychiatric Association in January 1950 and marks its 50th anniversary this year. The author organizes his review of psychiatric services largely around the locus of care and treatment because the location of treatment—institution versus community—has been the battleground for the ideology of care and for the crystallization of policy and legal reform. He uses "dehospitalization" to describe the movement of patients out of state hospitals, rejecting the widely used term "deinstitutionalization" as inappropriate; one reason is that the term wrongly implies that many settings where patients ended up were not institutional. Also covered in detail, as reflected in the journal, are community care and treatment, economics, ...

The last half-century of psychiatric services as reflected in psychiatric services.

Psychiatric units in general hospitals are exempt from diagnosis-related groups (DRGs), a system of per case prospective payment that is used for the majority of patients covered by Medicare. The American Psychiatric Association purchased a large hospital discharge data base and studied the potential impact of DRGs on psychiatric patients and inpatient psychiatric units in general hospitals. There was substantial inaccuracy in the psychiatric DRGs' prediction of resource use, which could lead to inappropriate discharge of patients and financial risk to hospitals that treat more severe cases. The authors advocate further research because psychiatry must anticipate prospective payment in the future.

Diagnosis-related groups and general hospital psychiatry: the APA Study.

General hospital psychiatry in Britain began in 1728, and thereafter several new voluntary hospitals provided separate wards for lunatics, but none survived beyond the middle of the 19th century. Less severe nervous organic disorder has always been common in the general wards of voluntary hospitals, and was accepted as the responsibility of neurologists and other physicians; all forms of disorder were admitted to the infirmaries of workhouses. During the present century psychiatrists began to take an interest in non-certifiable mental illnesses and in working in general hospitals. Out-patient clinics became more common following the Mental Treatment Act 1930. The growth of general hospital psychiatric units in the last 30 years began amidst controversy, but has received little recent critical attention.

The history of general hospital psychiatry.

American psychiatry has reached its bicentennial. Holistic-medical foundations have been its hallmark, inspiration, and source of preeminence. Incorporated by psychobiology, the American school, they enabled the growth of psychiatry as a medical specialty and scientific discipline and stimulated unparalleled growth of general hospital psychiatry, psychiatric research and teaching, and psychosomatic medicine and liaison psychiatry. Holistic conceptions, a product of a democratic system and the liberal mind, continue to provide the best framework for psychiatry and an antidote to dogma and fanaticism.

Holistic-medical foundations of American psychiatry: a bicentennial.

As deinstitutionalization has proceeded, it has left in its wake a variety of basic changes in patterns of service delivery to chronic mental patients. Although all components of the psychiatric service system have been affected by the diminishing utilization of state mental hospitals, changes are perhaps most marked in the psychiatric services of general hospitals. The effects of deinstitutionalization on general hospital psychiatry are examined, and some future implications are discussed.

The effects of deinstitutionalization on general hospital psychiatry

Despite the network of community mental health centers, the general hospital has become the focal point for the delivery of mental health care in the U.S. The author presents an overview of the psychiatric unit in the general hospital, including its history, structure, and function, and its relationship to the hospital itself and to the continuum of mental health services in the community. The units' goals are not clearly defined, but appear to be crisis intervention, acute treatment, correction of decompensation, prevention of chronicity, and speedy return of the patient to the community; there is little attempt to serve chronic patients. Paradoxically, the psychiatric unit also does not serve the hospital it is part of, as it rarely accepts patients from medical-surgical wards. The author summarizes evaluation studies related to general-hospital psychiatric units and recommends, among other points, truly evaluating the effects of short-term treatment and eliminating the current competition for the short...

Psychiatric Units in General Hospitals: 1979

SMaurice H. Greenhill’s excellent review article on general hospital psychiatry in the March issue of Hospital & Community Psychiatry is both informative and timely (1). Dr. Greenhill asserts that the psychiatric inpatient unit in the general hospital is the “core service to succeed the state hospital.” The central role of general hospitals in deinstitutionalization is frequently overlooked. While community mental health centers have defined for thefl iseIves a broad role in which services to chronic patients play only a part of total services i#{241} some specific cases, a minor part-the role of general hospital psychiatry has been increasingly determined; as Dr. Greenhill points out, by state hospital population shifts. The phenomenal growth of outpatient psychiatric care in the United States has sometimes clouded the fact that inpatient care, too, has been increasing, albeit at a slower rate. Thus statistics from the National Institute of Mental Health reveal that between 1971 and 1975 additions (admissions and readmissions plus returns from extended leave) to inpatient psychiatric services increased by 19 per cent, and those to outpatient services by 73 per cent. It is altogether possible that general hospitals are providing the bulk of community-based psychiatric inpatient care for state hospital dischargees and for other chronically ill individuals who are effectively barred from state hospital admission by deinstitutionalization policies. Dr. Greerihill’s thought-provoking article does not take into account some of the major differences between general hospital psychiatric inpatient units operated under public and nonpublic auspices. I should like to provide an addendum by citing some recent statistics from the NIMH Division of Biometry and Epidemiology. In 1976 there were 791 psychiatric inpatient units in general hospitals (excluding 167 units in hospitals affihiated with federally funded community mental health centers and 89 units located in Veteraiis Administration general hospitals). They consisted of 157 facilities operated under public auspices and 634 under private auspices. Together they accounted for 35 per cent of all inpatient psychiatric settings, in contrast to federally funded community mental health centers, which constituted only 23 per cent. Additions to the psychiatric inpatient units of general hospitals totaled 543,731 in 1975. This figure represented 36 per cent of additions to all psychiatric in-

Maurice H. Greenhill

Papers

Psychiatric Units in General Hospitals: 1979

General hospitals taking greater role in providing services for chronic patients.

Additional data supplied on length of stay in general-hospital units.