In the context of mental illness, the word “asylum” conjures, for many of us, some very negative images. We picture a scene with characters like the abusive Nurse Ratched from the movie “One Flew over the Cuckoo’s Nest,” or even worse, tragic true stories of the overcrowded, understaffed psychiatric hospitals of the last century where healthy, sick, disabled, and poor patients alike were locked away for years with no effective treatment or hope of release.

These images may be the reason that a JAMA viewpoint published last month has garnered so much attention: Bioethicists from the Perelman School of Medicine at the University of Pennsylvania are calling for a return to asylums for long-term psychiatric care.

At Penn, Dominic Sisti, PhD, Andrea Segal, MS, and Ezekiel Emanuel, MD, PhD, have been studying the current system for treating the chronically mentally ill and the evolution over the past half-century away from inpatient psychiatric hospitals. They observe that although the United States population has doubled since 1955, the number of inpatient psychiatric beds has been cut by nearly 95 percent to just 45,000—a very small number when compared to the 10 million U.S. residents who are currently coping with serious mental illness.

According to Sisti and his colleagues, the result of this trend has not be “de-institutionalization” but rather “trans-institutionalization.” That is, people with chronic mental illness are being treated in hospital emergency rooms and nursing homes at best, and more often receiving no treatment and living on the street. “Most disturbingly, U.S. jails and prisons have become the nation’s largest mental health care facilities,” say the authors, in a January 20 Penn Medicine press release. “Half of all inmates have a mental illness or substance abuse disorder; 15 percent of state inmates are diagnosed with a psychotic disorder…. This results in a vicious cycle whereby mentally ill patients move between crisis hospitalization, homelessness, and incarceration.”

As a solution, the authors propose a modern and humane asylum—but they use the word in its original sense, that is, a place of safety, sanctuary, and healing. In addition, they advocate reforms in the psychiatric services offered in such institutions, including both inpatient services, for those who are a danger to themselves and others, as well as outpatient care for those with milder forms of mental illness.

The proposal has been controversial, to say the least.  Some in the mental health community find the idea of a return to asylums misguided and even frightening. In her article called “Asylum or Warehouse?” author Linda Rosenberg, President and CEO of the National Council for Behavioral Health, asserts that although Sisti and his colleagues accurately describe the problems of the current mental health system, their solution is to “just simply lock some people up” and that “the simple solution offered, recreating asylums, is not helpful—it’s dangerous.”

Others have viewed the proposal in a more positive light. Christine Montross, a staff psychiatrist at Butler Hospital in Providence, Rhode Island and author of “Falling into the Fire: A Psychiatrist’s Encounters with the Mind in Crisis” wrote an op-ed piece in the February 18 New York Times in support of a move toward modern asylums.

“The goals of maximizing personal autonomy and civil liberties for the mentally ill are admirable,” says Montross. “But as a result, my patients with chronic psychotic illnesses cycle between emergency hospitalizations and inadequate outpatient care. They are treated by community mental health centers whose overburdened psychiatrists may see even the sickest patients for only 20 minutes every three months. Many patients struggle with homelessness. Many are incarcerated. A new model of long-term psychiatric institutionalization, as the Penn group suggests, would help them.”

What do you think? Are modern, reimagined asylums a potential solution for the chronically mentally ill, or has history proven that institutions cannot work? PAR wants to hear from you, so leave a comment and join the conversation!