Consolidate People With Obvious and Severe Mental Illness into Large Psychiatric Hospitals and Lock Them Down


This is a blog about how psychiatric hospitals should be funded and run.

We do not need to spend as much as we were spending on psychiatric care. We should be able to spend less, a lot less, and achieve better outcomes. There are two ways to get there:

– Consolidate people with obvious and severe mental illness into large psychiatric hospitals and lock them down.

– House people locally in apartments and simplify treatment.

This blog is about the first approach. The second approach is the subject of another blog: The Burden of Choice.

Consolidate People With Obvious and Severe Mental Illness into Large Psychiatric Hospitals and Lock Them Down

I have been a psychiatrist for more than 35 years. I began my career in the 1970s, just when the first group of baby boomers was reaching adolescence, and I have watched them grow old. Today they are in their 60s and 70s and are coming to the end of their lives.

The baby boomers were not just the largest generation, but also the wealthiest, healthiest, best-educated, most-traveled and most-privileged generation that had ever lived. They were also the most self-absorbed.

In my practice as a psychiatrist, I’ve seen this self-absorption unfold in many dramatic ways over the years. One of those ways is unexpected: Many boomers are now being diagnosed with dementia in their 60s and early 70s — much earlier than previous generations — because they abused alcohol, drugs and other substances all their lives. (Alcohol is one of the top three causes of dementia.)

This website is a blog about how psychiatric hospitals should be funded and run. I’m a software engineer who used to work in mental health, and I think a lot of what I’ve seen go wrong could be fixed by making some changes to the environment.

This blog has been online since 2011. In that time, I’ve written about 80,000 words on this topic. They are all on this site, but some of them are in old posts buried deep in the archives; others are in the comments of posts that don’t reflect their real importance. So as a service to new readers here is an attempt at a summary.

You can think of the argument in this blog as having two parts: a moral and an economic one. The moral one is that for some people with mental illness, hospitalization might be their best option – but if it is, then putting them there would make them better off than leaving them out and alone on the street.

The economic argument is that despite these people getting much worse care than they need, we’re spending too much money on mental hospitals already – because we have too many of them.

I’ve got two big ideas for psychiatric hospitals.

The first is that they should be run like nursing homes. Nursing homes are for people who can’t take care of themselves, but who are not acutely ill. They should have the same model as nursing homes.

The second is that they should be run like prisons. Prisons are for people who have broken the law and are dangerous to others. Psychiatric hospitals should be for people who are not just a danger to others, but a danger to themselves.

Maybe we need a third thing in between: a place you go when you’re too sick to stay home, but not so sick that you need to be locked up. I don’t know what that would look like.

I have a friend who has severe mental illness. He is smart, talented, interesting, and in the past has been very successful in many ways. He has made large contributions to society, and he could probably do it again.

Unfortunately he also has serious cognitive impairments that make it impossible for him to make much use of his abilities. In particular he can’t hold down a job or take care of himself financially. He spends most of his time wandering around town and talking to people, usually on some kind of errand which he will never finish.

In the past my friend was able to pay for an apartment and support himself because he had a good job. But once he got sick, he lost that job and started losing his money on bad investments, and now he lives in a homeless shelter. It’s not that he doesn’t have skills; it’s that he can’t get himself together long enough to practice them.


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