The post below comes from Russell K. Schutt, co-author with Stephen M. Goldfinger of the recently published Homelessness, Housing, and Mental Illness.
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A recent New York Times article examined the tragic and brutal murder of the group home counselor Stephanie Moulton by Deshawn James Chappell, a group home resident diagnosed with schizophrenia. The circumstances of the murder force our attention to two questions: What is schizophrenia? And what are the prospects for community integration of persons with schizophrenia? We need look no further than the comments elicited by the NYT article to realize the extent of controversy about these questions. But what does scientific research actually show about these issues?
Schizophrenia is a serious mental illness, the causes of which are not yet well understood. It afflicts about 1% of the population, typically emerging in late adolescence or early adulthood. Neuroimaging and functional testing identify diminished brain volume in key areas and declining cognitive and social functioning at the time that symptoms of the disease emerge. After onset, the symptoms persist, although their intensity fluctuates and some long-term research has identified patients in whom symptoms have dissipated many years after onset. Psychotropic drugs relieve symptoms such as hallucinations and paranoid delusions for some patients, but they have no effect on cognitive or social functioning.
Debates over the prospects for community integration of persons with schizophrenia have framed mental health service policies since the 19th century. The first state psychiatric hospitals were designed to provide a protected, humane environment for persons with serious mental illness. Without much quality evidence, state hospital superintendents in the 19th century issued glowing reports about patient improvement. Even still, the hospitals were soon overwhelmed by a rapidly increasing patient census, inadequate resources, and a shift in professional psychiatrists’ focus to private patients. Exposés in the 20th century suggested that the environment of state hospitals was more likely to exacerbate patients’ symptoms and diminish their prospects for return to the community than to restore their health.
The proponents of deinstitutionalization sought to end the warehousing of persons with serious mental illness and to instead provide community-based care that would normalize treatment services and facilitate community engagement. They were motivated as well by the discovery of psychotropic medications that lessened symptoms; state governments’ desire to shift costs to Medicaid-reimbursable community-based care; and the growing demands of advocacy groups for patients’ right to make their own treatment decisions.
Whatever the precise mixture of commendable and crass motives, the goals of deinstitutionalization were only partially achieved. State hospitals were indeed depopulated, but alternative community-based care was only partially funded and psychotropic medications proved to be only partially effective. In addition, rising housing costs and the widespread destruction of cheap single room occupancy hotels made it impossible for many persons with serious mental illness to maintain any type of community residence. The large number of people with serious mental illnesses who became homeless or were incarcerated indicates the failures of this new service system.
