Background and history

Psychiatric disorders require different systems of care from physical ones, because many psychiatric disorders are chronic, impair patients' ability to meet their own practical and social needs, and may tend to evoke rejection or ridicule from other people, rather than understanding and sympathy.

Until the 'asylum movement' of the eighteenth and nineteenth centuries, most mentally ill and mentally handicapped people were looked after by their relatives, with private nursing at home (see Jane Eyre, 1847), or in a private 'madhouse' for the minority who could afford it. Some were rejected by their families to become 'vagrants' and be put in the workhouse, or possibly taken in by religious or charitable institutions.

Asylums (hospitals for the mentally ill and mentally handicapped), set up with the help of charitable support amid much initial enthusiasm, were large impressive buildings usually sited in the countryside with their own gardens and farms. However, in the absence of any really effective treatments for psychiatric illness until the mid-twentieth century, their wards soon became overcrowded, and standards and morale declined. Long-stay patients, including many who would not be considered to merit even a brief psychiatric hospitalization nowadays, became apathetic and lacking in simple skills of daily living ('institutionalized'). A major stigma was attached to admission.

The gradual closure of asylum beds began in the 1950s, was accelerated in the 1960s and 1970s by several scandals and a fashionable 'anti-psychiatry' movement, and has continued to the present day under government policy of 'community care'.

In the 1970s, many modern inpatient units attached to district general hospitals (DGH units) were built to replace the old mental hospitals. DGH units offered the advantages of enabling psychiatric services to be integrated with medical and surgical ones, close to main centres of population. However, the typical DGH unit environment, with its compact unlocked wards, proved unsuitable for certain patients such as the behaviourally disturbed, and accumulation of 'new long-stay' cases soon caused blocked beds.

The more recent trend has been development of community mental health centres, plus crisis teams, and assertive outreach teams, with the aim of reducing inpatient admissions further still. In the context of managerial reorganization of the NHS as a whole, profound organizational changes to psychiatric services have been introduced. Debate continues as to which model is best, and what future policy should be.

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