I. Downsizing psychiatric hospitals: Needs for care and services of current and discharged long-stay inpatients

Background: With the psychiatric deinstitutionalization movement in its fourth decade, questions are being raised concerning its relevance for long-stay inpatients with severe disabilities and the risk that those discharged into the community may be abandoned. Methods: A random sample taken in 1989 of long-stay inpatients at Louis-H Lafontaine Hospital made it possible to examine 96 pairs of patients. Each pair included 1 patient discharged between 1989 and 1998 and 1 patient hospitalized. Pairs were matched for sex, age, length of stay, and level of psychiatric care in 1989. Patients and staff were interviewed using standardized questionnaires, and case notes were reviewed to assess symptoms, daily living skills, residential status, quality of residential setting, and clinical and social problems and needs. Results: The investigation revealed that discharged patients moved to highly supervised settings, which included professionally supervised group homes, supervised hostels, and foster families. About 20% went to nursing homes owing to loss of autonomy from physical disorders. Only 4 discharged patients were lost to follow-up, of whom 2 were probable vagrants. Both those discharged and those remaining as inpatients presented with major clinical problems and daily living skill deficits. The care needs of discharged patients were generally met. and placement in the community was considered appropriate. Of those who had remained hospitalized, over one-half could be moved to supervised settings immediately, or after 1 to 2 years' preparation in a discharge unit, while 13% could be moved to nursing homes. Over 25% required intensive, individualized rehabilitation treatment targeting engagement, psychotic symptoms, withdrawal, and dangerous and socially embarrassing behaviours. Conclusion: Deinstitutionalization in the largest Canadian psychiatric hospital did not lead to patient abandonment in the community.