A patient who presents no dangerous or troublesome tendencies and who has improved sufficiently to justify his trying to live outside again may be, according to the growing custom of modern institutions, paroled in the custody of relatives or friends for a period which varies but which in the New York state hospital service may be as long as twelve months. If during the parole period his condition requires a return to the hospital no legal procedure for recommitment is necessary; he may be returned by his custodians or by attendants sent from the hospital. If he gets along well during the entire period of his parole he is automatically discharged at its expiration.
1 Paul Dubois. The Psychic Treatment of Nervovs Disorders. English translation by Jelliffe and White. New York, 1905.
No test, no method of examination affords a fairer or more trustworthy and practical means of judging a patient's ability to get along outside of an institution. It is not strange therefore that the practice of paroling patients has become common in all institutions. Thus on June 30, 1918, the number of patients out on parole from the thirteen New York state hospitals was 1890.
The parole system may thus be seen to constitute an important extension of institutional activity. This, as well as the need of further care even for discharged patients, renders advisable for every institution or system of institutions the organization of systematic after-care.
When a patient has recovered from his mental trouble and has been paroled or discharged from the hospital the treatment of his case must not be regarded as finished, for there is still to be dealt with an extreme liability to recurrency.
Of a total of 8700 cases admitted to the New York state hospitals during the year ending June 30, 1918, 1903 were cases of readmission.1 That is to say, that minute fraction of" the population which consists of patients discharged from state hospitals has contributed 21.9% of all the admissions.
To what extent is recurrency preventable?
(1) In some cases recurrency must be regarded as probably inevitable, though perhaps it can be staved off by general hygienic measures; such are cases of general paralysis in remission and some manic-depressive psychoses.
(2) In other cases, in which, in addition to a strong predisposition to mental disturbance, there is a history of some removable exciting cause in the etiology of the first attack, recurrency may often be prevented by avoidance of re-exposure to the original exciting cause. It is true that in many of these cases some cause, other than the original exciting cause, may give rise to recurrency owing to special vulnerability of the patient's mental organization. Yet it cannot be doubted that in a good proportion of these cases prophylactic measures could prove very successful. Among the common avoidable causes may be mentioned: loss of employment, overwork, inanition and exposure due to poverty, childbirth, and neglected somatic disease.
1 Thirtieth Annual Report of the N. Y. State Hospital Commission Albany, 1919,
(3) In still other cases in which the trouble is due chiefly to some avoidable cause, recurrency can be absolutely prevented. This is a large group of cases consisting of the alcoholic psychoses, morphinism, cocainism, etc.
The problem of after-care with a view to the prevention of recurrencies is being met in most hospitals through outpatient clinics and social service departments.