Manejo de IVU según la CONASA.

The antipsychotic drugs had a more revolutionary impact in the United States, where there were relatively more backward asylums in 1955, than in those parts of northern Europe where social therapy prevailed. The subsequent course of deinstitutionalization in America also differed from that in northern Europe. Despite the development in the United States of a network of community mental health centers after 1965, the welfare of the chronically and severely mentally ill was, for decades, largely overlooked. A substantial proportion of those discharged

from US mental hospitals were merely transferred to another category of institution—nursing homes.

For many patients the switch was to their disadvantage. Nursing-home staff were generally low-paid and had no training in mental health, wards were often locked and overcrowded, the environment was frequently shabby, there were generally no attractive grounds for recreation, and psychosocial treatment and activity programs were deficient or absent. In general, the only treatment offered was drugs; and it was the advent of the antipsychotic drugs, facilitating control of the florid features of patients’ psychosis even when the patients were in grossly inadequate settings, that allowed huge numbers of the mentally ill to be shunted to cheaper nursing-home care. Thus, although the number of patients in US state and county mental hospitals declined from 505,000 in 1963 to 370,000 in 1969, the number of patients with mental disorders in nursing homes increased to such an extent that the total institutionalized population of the mentally ill was actually higher in 1969. Mentally ill residents of mental hospitals and nursing homes combined rose from 726,000 in 1963 to 797,000 in 1969. Many patients were elderly but large numbers of younger adults were also transferred to nursing homes. The number of patients under the age of 65 in state and county mental hospitals fell by nearly 100,000 between 1963 and 1969 but the number of mentally ill patients in this age group in nursing home accommodation increased by more than 25,000 during the same period.19 _{Ellen Bassuk and Samuel Gerson}

pointed out, however:

Untherapeutic though many nursing homes are, living conditions in most of them are at least tolerable. Conditions may be worse for discharged patients living on their own, without enough money and usually without any possibility of employment. Many of them drift to substandard innercity housing that is overcrowded, unsafe, dirty and isolated. Often they come together to form a new kind of ghetto subpopulation, a captive market for unscrupulous landlords.20

Newspaper reports exposed the impoverished condition of formerly hospitalized patients leading lives of isolation and fear in the community—100 discharged patients in Washington, DC, without therapeutic rehabilitation programs; 200 ex- patients of Agnews State Hospital in California housed in boarding homes in San Jose with no medical care; 300 to 1,000 patients in rooming houses and hotels in Long Beach, New York, without supervision. A survey of discharged mental patients conducted in 1970 in California’s San Mateo County found 32 per cent living in board and care homes.21 _{These “small wards in the community” were}

generally sordid and bare establishments in poor, inner-city areas where theft was rampant. One-third of the chronic mental patients in a large sample of residents of board and care homes in Los Angeles had been robbed or assaulted or both during the previous year.22 _{Each such establishment housed more than fifty ex-hospital}

received no psychiatric treatment other than a supply of drugs and had no employment or worthwhile social activity. A typical boarding home resident, reported California psychiatrists Theodore Van Putten and James Spar,

spends 8.46 hours of the day in bed, a time limited primarily by the sponsor’s continual efforts to keep him out of his bedroom, and 1.46 hours at the dining table. He spends the rest of the day in virtual solitude, either staring vacantly at television (few residents reported having a favorite television show; most were puzzled at the question), or wandering aimlessly around the neighborhood, sometimes stopping for a nap on a lawn or park bench.24

Patients who suffered a psychotic relapse were likely to be treated briefly in hospital with drugs and were discharged again to an inadequate setting or to live on the street. As this cycle repeated itself they become known as “revolving-door patients.” About half of the patients released from US psychiatric hospitals in the early 1970s were readmitted within a year of discharge.25 _{As public mental}

hospital beds were cut back, it became increasingly difficult for acutely psychotic patients to gain readmission. For example, in 1981 the state hospital in Denver, Colorado—Fort Logan Mental Health Center—had a waiting list for admission of more than 100 adult cases. Since the hospital’s discharge rate was around one adult every week or two, patients at the bottom of the waiting list could expect admission within two to four years.

In consequence of the nationwide bed shortage and rapid-discharge policy, many people with psychosis ended up in jail, usually charged with offenses associated with trying to survive on the streets without money—trespass (sleeping in the hallway of a public building) or defrauding an innkeeper (eat and run). Around six to eight per cent of the 147,000 inmates of local jails in the United States in the 1970s were suffering from psychosis.26 _{Similarly, eight per cent of a}

large sample of federal prisoners surveyed in 1969 were diagnosed as suffering from psychosis.27

Such was the plight of a substantial proportion of the “deinstitutionalized” mentally ill across the United States. It is scarcely surprising that, as revealed in the last chapter, the overall social functioning of people with schizophrenia did not improve with the introduction of antipsychotic drugs. But in northern Europe, also, the picture changed after the early days of the social psychiatry revolution.