treatment located closer to the person’s home, family,
and friends. These centers provided emergency care,
inpatient care, outpatient services, partial hospital-
ization, screening services, and education. Therefore,
deinsitutionalization had three components: release
of individuals from state institutions, diversion from
hospitalization, and development of alternative com-
munity services (Lamb & Bachrach, 2001).
In addition to deinstitutionalization, federal leg-
islation was passed to provide an income for disabled
persons: Supplemental Security Income (SSI) and
Social Security Disability Income (SSDI). This allowed
people with severe and persistent mental illnesses
to be more independent financially and not have to
rely on family for money. States were able to spend
less money on care of the mentally ill than they had
in state hospitals, because these programs were fed-
erally funded. Also commitment laws changed in the
early 1970s, making it more difficult to commit people
for mental health treatment against their will. This
further decreased the state hospital populations and,
consequently, the money that states spent on them
(Torrey, 1997).
MENTAL ILLNESS
IN THE 21ST CENTURY
The Department of Health and Human Services (2002)
estimates that 56 million Americans have a diagnos-
able mental illness. Furthermore, mental illnesses or
serious emotional disturbances impair dailyactivities
for an estimated 10 million adults and 4 million chil-
dren and adolescents. For example, attention deficit/
hyperactivity disorder affects 3% to 5% of school-age
children. More than 10 million children younger than
7 years grow up in homes where at least one parent
suffers from significant mental illness or substance
abuse, which hinders the readiness of these chil-
dren to start school. The economic burden of mental
illness in the United States, including both health
care costs and lost productivity, exceeds $170 billion
(Department of Health and Human Services [DHHS],
2002). Four of the ten leading causes of disability in the
United States and other developed countries are men-
tal disorders: major depression, bipolar disorder, schiz-
ophrenia, and obsessive-compulsive disorder (NIMH,
2002). Yet only one in four adults and one in five chil-
dren and adolescents in need of mental health ser-
vices get the care they need.
Some believe that deinstitutionalization has had
negative as well as positive effects (Torrey, 1997).
Although deinstitutionalization reduced the number
of public hospital beds by 80%, the number of admis-
sions to those beds correspondingly increased by 90%
(Appleby & Desai, 1993). Such findings have led to
the term revolving dooreffect. While people with
severe and persistent mental illnesses have shorter
hospital stays, they are admitted to hospitals more
frequently. The continuous flow of clients being ad-
mitted and discharged quickly overwhelms general
hospital psychiatric units. In some cities, emergency
department visits for acutely disturbed persons have
increased by 400% to 500%.
Shorter hospital stays further complicate fre-
quent, repeated hospital admissions. People with
severe and persistent mental illness may show signs
of improvement in a few days but are not stabilized.
Thus they are discharged into the community with-
out being able to cope with community living. The re-
sult frequently is decompensation and rehospitaliza-
tion. In addition, many people have a “dual” problem
of both severe mental illness and substance abuse.
Use of alcohol and drugs exacerbates symptoms of
mental illness, again making rehospitalization more
likely. Substance abuse issues cannot be dealt with
in the 3 to 5 days typical for admissions in the cur-
rent managed care environment.
Many providers believe today’s clients to be more
aggressive than those in the past. Four to eight per-
cent of clients seen in psychiatric emergency rooms
are armed (Ries, 1997), and people with severe and
persistent mental illness who are not receiving ade-
quate care commit about 1,000 homicides per year
(Torrey, 1997). Ten to fifteen percent of those in state
prisons have severe and persistent mental illness
(Lamb & Weinberger, 1998).
Homelessness is a major problem in the United
States today. The Department of Health and Human
Services (2002) estimates that 750,000 people live
and sleep in the streets. Estimates of the prevalence6 Unit 1 CURRENTTHEORIES ANDPRACTICE
Revolving door