With the APA journal Psychiatric Services celebrating its golden anniversary this month, Jeffrey Geller, M.D., M.P.H., its book review editor and a member of its editorial board, took the opportunity to review major issues and changes in the delivery of psychiatric services that the journal chronicled over its 50-year history. Geller’s retrospective appears in this month’s edition of the journal.

The major trends he reviews that have exerted a substantial impact on how psychiatry is practiced include community-based treatment, economics, patient empowerment, and "the interface issues of general hospitals, outpatient commitment, and psychosocial rehabilitation." He also traces the development and consequences of the movement that is usually referred to as "deinstitutionalization" but for which he maintains a more accurate label is "dehospitalization." The latter term, Geller says, better addresses the common situation in which patients discharged from a state psychiatric hospital often end up being cared for in another institutional setting and thus have not been "deinstitutionalized."

He points out as well that much of the debate during the last half century over the optimal setting for treating mentally ill people has centered on the tug-of-war between the benefits and risks of treating psychiatric patients in the community versus the hospital—at least when hospital care was geared to prepare patients to live and work in the community. The community-treatment partisans clearly have won that battle as evidenced by the data in the chart above.

But when the first issue of the journal’s earliest incarnation, the A.P.A. Mental Hospital

Service Bulletin, appeared in 1950, it was at hospitals where almost all psychiatric treatment took place. Throughout the 1950s, Geller notes, "overcrowding and underfunding were rampant, standards were low to nonexistent, and the rehabilitation effort could not be sustained." Only a few pioneering hospital programs focused on psychosocial and vocational rehabilitation.

By the 1970s, advocates of closing state hospitals gained the ear of health policy experts, the courts, and politicians and successfully spearheaded the disappearance of thousands of psychiatric hospital beds. The debate over how far to take this dehospitalization effort raged through the 1970s. Often, Geller points out, "the 30-year debate on [the role of the psychiatric hospital] has been driven more by ideology than by patient care needs," a reason for everyone to feel ashamed, he adds.

Also driving the shape of mental health care through all five decades of the journal’s existence and inseparable from treatment issues was the issue of economics. Unfortunately, Geller explains, in not one of these decades "did there appear to be any widespread endorsement of a major intervention that will cost more and be the right thing to do. Rather, new, more humane, or more respectful interventions have been consistently tied to cost savings."

Cost was a factor driving the community treatment movement in the 1950s, as hospital costs grew dramatically. In the following decade, psychiatrists and health policymakers pushed for better insurance for mental health care, such as the inclusion of partial hospitalization and sufficient funds to run community mental health centers.

The most recent economic force driving health care is, of course, managed care, a juggernaut few foresaw on the horizon as recently as the 1980s—when HMOs were the center of most experts’ attention—and a development that blindsided those trying to deliver optimal mental health care.

Geller indicates that despite a half century of progress, "mental health policymakers and practitioners remain all too myopically focused on the locus of care and treatment. We have yet to heed the advice that [sociologist Leona] Bachrach expressed 22 years ago: ‘The emphasis must be moved away from programs and places toward the patients themselves.’ We remain entrenched in concerns about locus of care, confusing it with the humaneness, effectiveness, and quality of care."