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Perpetuating a vicious circle

Vol. 7, No. 5 / May 2008

I could not agree more with Dr. Nasrallah’s editorial on deinstitutionalization. My opinion is based on >50 years experience in psychiatry.

I started my career in l954 at Eastern State Hospital in Williamsburg, VA. As a first-year resident, I was ordered to assist Dr. Walter Freeman in performing transorbital lobotomies. I also administered hundreds of electroconvulsive treatments. After completing my training in child psychiatry and obtaining board certification, I spent 13 years training in psychoanalysis at the Washington Psychoanalytic Institute in Washington, DC. Today I am semi-retired but still give lectures to medical students and evaluate patients for possible involuntary commitment.

In the 1950s when I evaluated patients for inpatient commitment in Richmond, VA, we used completely different criteria than are used today. For example, persons needing treatment for psychiatric disorders that would endanger their health such as alcoholism were sent to a state hospital. Today patients are sent to state hospitals only if they present an imminent danger of suicide or homicide or are incapable of self-care.

Now we are treating patients who have a variety of conditions and are released as soon as they are not suicidal or homicidal and have a protective environment. Many stop taking medication or decompensate and are repeatedly brought back for assessment.

Psychiatry has changed thanks to pharmaceuticals and insurance companies. Today, psychiatrists establish a diagnosis at the phenomenological level following the DSM-IV-TR and then prescribe the latest medication. There is no time for psychodynamic formulation or another treatment approach. Social workers, not psychiatrists, perform psychotherapy because it costs less for the insurance companies. The courts buy into the idea that sociopsychiatric problems can be solved with medication. Because of the high cost of hospitalization, as soon as a patient can function he or she is discharged.

In the 1950s the idea was that patients have a right to treatment and therefore were hospitalized in state facilities. Today patients have the right to civil liberties as long as they do not present an imminent danger to society. Although I can remember some cases when patients stayed in state hospitals longer than was strictly necessary, often for the convenience of the patient and family, today I see many more cases when the patient would be better treated in state hospitals at a lower cost to the taxpayers.

Manuel Hernandez, MD
McLean, VA

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