OBJECTIVE: The study examined a 95-bed locked community facility (an
institute for mental disease), one of 40 such facilities in California to
which patients with increasingly difficult problems in management have been
referred over the past few years as an alternative to more highly
structured state hospitals. The purpose was to determine the
characteristics of patients admitted to such facilities and assess whether
the facilities are adequate for treating them. METHODS: A hundred and one
randomly selected patients in one institute for mental disease were studied
by record review and by discussion of each case with staff. RESULTS: The
patients were characterized by psychotic diagnoses; the presence of
psychotic symptoms even though they took antipsychotic medications in the
facility; and histories of previous hospitalizations, serious violence
against persons, poor medication compliance, and substance abuse.
Ninety-nine percent had been admitted under psychiatric conservatorship.
Forty-four percent had been violent toward persons during the current
admission, and the level of bizarre, socially inappropriate behavior in the
facility was high. CONCLUSIONS: Despite a high-quality rehabilitation
program, treating and rehabilitating difficult-to-manage patients normally
treated in state hospitals in a facility that had a considerably lower
degree of structure had become increasingly difficult and dangerous. The
use of community alternatives to state hospitalization, which is often
driven by lower costs and an ideology that highly structured care is seldom
needed, is not suitable for all patients.