Although the psychiatric profession often receives the blame for the incredible rise in the number of mental patients during this era, the real responsibility likely rests with the public policy makers who made the asylum system possible. Psychiatrists still acted as the gatekeepers who oversaw admissions (and the far rarer discharges) as well as being the final authority for how patients were treated in the asylums. There was also a self-fulfilling prophecy at work on the part of psychiatrists in dealing with the chronic mental patients in their charge: since these patients were considered largely incurable, the extent to which their conditions deteriorated while in the asylum simply reinforced the medical preconceptions about the unlikelihood that any psychotic patients could truly recover from their illness.
The perception that mental patients were a burden on society had fatal consequences in many countries. Not only were they a prime target for the eugenics movement in terms of sterilization, but Nazi Germany specifically targeted mental patients and other "undesirables" in Aktion T4 leading to the deaths of thousands of patients at the start of World War II. Even in more "civilized" countries, psychiatrists weren't afraid to try radical methods to treat mental patients. The serious overcrowding in psychiatric hospitals and the financial burden that governments faced in supporting them provided ample incentive. From psychosurgery to ECT, these new treatments always began with a flourish of optimism that mental illness would finally be curable and that psychiatry would take its proper place with the other, more scientifically oriented, medical professions. Suffice it to say, they were often disappointed.
While the more primitive treatments methods failed to live up to their early promise, the rise of psychiatric medications finally began the deinstitutionalization movement in the late 20th century. Beginning with the antibiotics that prevented syphilis from proceeding to the devastating neurosyphilis stage, the serious overcrowding that characterized asylums at the beginning of the 20th century slowly began to be reversed. Despite medical problems associated with long-term psychiatric medication use (including tardive dyskinesia and neuroleptic malignant syndrome), newer medications have been developed to avoid these devastating side-effects (albeit with some controversy over safety issues). While mental illness continued to be viewed as incurable, many chronic mental patients are successfully managed in the community. Unfortunately, early enthusiasm over deinstitutionalization was disastrous for many mental patients who had spent their entire lives in psychiatric hospitals and lacked the resources to cope on their own
As for the psychiatric hospitals, those that couldn't be converted into short-term acute care units were usually closed and abandoned hospitals became common in many jurisdictions. Despite efforts to preserve many of these old hospitals for their historic value, most have been either demolished or converted to other uses. These derelict buildings have a strange cultural fascination due to their sinister reputation and have often been used as sets for horror movies and television shows.
As community-based mental health clinics became established in most metropolitan settings, basic problems in reintegrating formerly "incurable" mental patients into society remained. Not only was the stigma surrounding mental illness as strong as ever, but policy makers continued to be reluctant in recognizing the need for funding community initiatives properly. For all that community health program continues to be touted as a viable alternative to institutionalization, they often don't have the necessary resources to provide adequate support for patients. Once again, the problem often lies with public policy makers who fail to take the actual needs of psychiatric patients into consideration when drafting mental health legislation.
Legal battles also continue to be fought over basic issues such as forced institutionalization and medical treatment of mental patients. The rise of the psychiatric survivor movement and anti-psychiatry activists (including Thomas Szasz and the Church of Scientology) of the past several decades has attempted to curb what they considered to be human rights abuses perpetrated by mental health professionals and pharmaceutical companies. Civil rights legislation has largely restricted forced psychiatric treatment which, paradoxically, has meant that more mental patients than ever are now finding their way into prison systems and homeless shelters around the world. If psychiatric institutions are seen as poorly suited for dealing with mental patients, these alternatives are even less so.
Not only have psychiatric hospitals seen a rise in more violent cases (due to placement in hospitals by the courts), they have also seen a rise in patients who really have no business being in psychiatric hospitals at all. This is especially true with the growing use of civil commitment legislation for indefinitely holding convicted sex offenders in psychiatric hospitals in many US states. While some jurisdictions are starting to segregate sex offender and psychiatric populations, the potential conflict between these populations is making psychiatric institutions more problematic than ever. Worldwide, the trend towards using psychiatric hospitals to hold political prisoners seems as strong as ever. Human rights organizations such as Amnesty International has protested the use of forced hospitalization of dissidents in countries such as China, North Korea, Russia (before and after the breakup of the Soviet Union), and Turkmenistan. Despite widespread condemnation, the practice is likely to continue.
Psychiatric hospitals has come a long way since their asylum days although they are still in a state of flux. As for what the next phase of their long history will bring, that's anybody's guess.
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