A Case-Based Approach to State Hospital Psychiatry

With adequate resources, government-run facilities can serve both patients and their communities well by providing effective treatment and careful discharge planning. This introduction to modern-day state hospitals and the patients who are treated there works as a guide to how this can be done.
Fact-based discussions are interspersed with case histories of state hospital patients. The case histories are fictional but grounded in clinical experience. Discussions offer thorough and comprehensive summaries of the scientific literature, as well as explanations of how court cases and legislation set the parameters of treatment.
Case studies illustrate how patients can experience their illness and its treatment and give a sense of their personal lives and family relationships. These stories tell us how public psychiatric care can succeed and, at other times, unfortunately fail. Compared to patients in community hospitals, state hospital patients are more likely to be seriously and chronically mentally ill, treatment-refractory, and with a history of involvement in the criminal justice system. With a longer length of stay, state hospitals can provide comprehensive and aggressive treatment, and then thoughtful discharge planning, as well as containment and asylum.
Topics of discussions include insight and other factors associated with medication nonadherence, rates of short-term symptom response and remission with most antipsychotic drugs, multiple possible benefits of clozapine, the relationship between childhood maltreatment and adult psychiatric disorders, risk factors for violence in people with psychiatric illness, ways to manage risk, criminal justice system involvement in people treated in public psychiatry systems, and rates of serious mental illness in jails and prisons.

Preface 1. State hospitals past and present Part one: Active treatment 2. Insight and medication adherence 3. Antipsychotic treatment 4. Schizophrenia or something else? 5. Using clozapine 6. Medication over objection 7. Patients with intensive nursing needs Part two: Discharge planning 8. Discharge to family 9. Discharge to supportive housing 10. Discharge planning and risk assessment 11. Outpatient commitment 12. Intersection with the criminal justice system 13. Discharge decisions near the end of life