Giving Asylum to the Chronically Mentally Ill?

A couple of miles from our home in Santa Clara, the sprawling campus of the former Agnews mental institution now houses Oracle Corporation and the upscale Rivermark Village housing and retail development. Agnews, which opened in 1885 as an "insane asylum," was less prejudicially known as a "center for the developmentally disabled" by the time it closed in 1972.

A few miles in another direction, several thousand homeless individuals, many of them suffering from severe mental illness, camp along the Guadalupe River and Coyote Creek and squat on the streets of downtown San Jose. Santa Clara County has the fifth largest homeless population in the United States. This situation is replicated in urban areas around California and across the country, with over 600,000 homeless nationally.

Many of these homeless people would otherwise be psychiatric patients. Forty years ago, some of them would have been housed in residential institutions such as Agnews. In the early 1970s, there was a movement in California to close down mental asylums. Some of the motivations for closing them were laudable, such as preventing abuse in institutional settings, taking advantage of new psychopharmaceuticals and integrating the mentally disabled better into the community. Other agendas were simply financial -- to reduce county and state budget outlays.

Recently, a group of bioethicisits at the University of Pennsylvania observed in the Journal of the American Medical Association that the closure of the mental institutions resulted in some patients with chronic psychiatric diseases being moved to nursing homes or hospitals. Others, they noted, became homeless, utilizing hospital emergency departments for both care and housing. But, the ethicists wrote, "most disturbingly, U.S. jails and prisons have become the nation's largest mental health care facilities. Half of all inmates have a mental illness or substance abuse disorder; 15 percent of state inmates are diagnosed with a psychotic disorder."

According to the authors, who include former White House medical advisor Dr. Ezekiel Emmanuel, "this results in a vicious cycle whereby mentally ill patients move between crisis hospitalization, homelessness and incarceration." They call this a system of "transinstitutionalization." The Penn ethicists argue that the current system of handling psychiatric patients is "ethically unacceptable and financially costly" and should be fundamentally changed. Among their conclusions is that "the way forward includes a return to psychiatric asylums" that would be safe, modern, financially prudent and humane. In other words, they say, we should return the concept of an asylum to its true meaning as a place of refuge.

This controversial proposition was endorsed by psychiatrist Christine Montross, in The New York Times in February. She noted the many cases of severely mentally ill people being either hospitalized or incarcerated, and acidly observed that "Both suffer in inappropriate facilities while we pat ourselves on the back for closing the asylums in favor of community care."

The Penn ethicists' proposal deserves serious consideration and debate. It is clear that the current system is untenable. The dominant viewpoint since the 1970s has been that the severely mentally ill should be better supported and integrated within the community. But over the past 40 years, our society has not shown the ability to do that. The legal and policing systems are still not equipped to handle mental illness, and there are not good alternatives for ensuring that the mentally ill get the care they need.

It would be a challenge to create new asylums that draw the best from our society's capabilities, rather than reflecting the dark qualities depicted in One Flew Over the Cuckoo's Nest. To begin with, how would individuals come to be placed in such asylums? The process of commitment has always been fraught with civil rights dangers. How would such institutions be funded? Who would staff them and how would training and management ensure humane care? How could modern psychopharmacology and neuromedicine be applied? How could such institutions be structured to perhaps have different levels of institutionalization, from semi-independent living to more comprehensive care? How could they be made into places where people wanted to be, because their lives would be better than on their own?

I believe all these questions have answers. Living along a stream bed, scrounging for food, using the emergency room for medical care and sometimes committing violent crimes are not viable or humane alternatives for mentally ill individuals or for our society.

Leaving the mentally ill to fend for themselves is certainly not financially prudent. The HUD secretary estimates that each homeless person costs $40,000 per year to be on the streets, or $24 billion overall. The illogical expectation that the chronically mentally ill will take care of themselves creates much more cost for our public safety, law enforcement, the medical system, the environment where homeless encampments take over parks and streamsheds and for other social services than it would cost to provide them with appropriate institutional care.