Mental health care is totally inadequate in America. It always has been this way it seems. And government policy has led the way to one, then another, inadequate situation. It is a shameful story, and a bit ironic. Today, prisons and jails represent the largest institution that houses and treats persons with mental health in America. This is not something to be proud of. And, the irony is that when the country was young, in the early 1800s, many of the mentally ill were also house guests of the state in jails. Full circle in 200 or so years. And one young female social activist from New England would be rolling over in her grave today to hear that the mentally ill were flocking into prisons again… after she had almost single handedly fixed that problem in America before the civil war. Like social activists before and since, she shined a bright light on an ugly truth, on the conditions and exploitation of the mentally ill housed in prisons and jails in early America. Her light changed policy, to flush these people out, into society, and into the open where they could be cared for and not be the objects of cruel and shameful treatment by the bullies who occupied and managed the jails. She was Dorothea Dix.
A Mainer at birth (1802), daughter of itinerant and alcoholic parents, a sometimes depressed and abused girl. At 12, she moved to Boston to live with a wealthy grandmother. She worked some as a governess. By the age of 19 she had started her own school for girls (from wealthy Boston families). She even wrote some children’s books.
By her mid 30s she had become deeply interested in the fate of socially vulnerable persons, particularly the mentally ill, and was emboldened by a visit to Europe where she met and studied with like-minded female activists. She returned to do a now famous study of the horrible treatment of the mentally ill in the Cambridge MA. jails. She wrote and talked about what she observed there, and even testified on beacon hill: “I proceed, Gentlemen, briefly to call your attention to the present state of Insane Persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience.” This testimony was embarrassing, and led the state to do a large expansion of the Worchester State Mental Hospital. And, it later led to further studies in other states, and eventually the movement to develop the state mental hospital system across the U.S.
Before she died she had not only made her mark on mental health policy, but in her 50s, when duty called, she became the Superintendent of Nurses for the Union Armies during the Civil War where she innovated the hiring, training, management, and rights of female nurses. Another story. She was buried in Mt Auburn Cemetery in Cambridge in 1887. At Simmons University, an adult women’s scholarship program is named after her.
Deinstitutionalization of State Mental Hospitals
By the 1900s the extensive system of state funded mental hospitals had become quite large, housing over 558,000 seriously mentally ill persons in 1960, and serving as a Mental Health training ground for most nurses and doctors in America. But society (and state government budgets) began to wonder if there wasn’t a better (and cheaper) way to deal with mental health needs. Persons in the professions began to talk and write about new, active treatments for some types of patients as an alternative to “asylum care” (referring to the state mental hospitals). Maybe community based care alternatives would be a more effective model of mental health care?
This point of view evolved over several decades and eventually sparked a new public policy that replaced the state Mental hospitals. This “new idea” of using community mental health centers rather than mental hospitals (where patients were generally housed until they died) was fueled by many things, such as:
- the development and use of thorazine in the 1950s, the first psychotropic drug for controlling behavior and symptoms. The idea was that this was going to be first of many miracles of science that would revolutionize mental health treatment and make the “asylums” obsolete forever.
- the provocative book and later film, “One Flew Over the Cuckoos Nest” which angered many people and voters about the conditions and abuses occurring in the state mental hospitals.
- Stories in the press began to appear about cruel and ineffective care like “electro shock” treatment of some patients, and the use of Lobotomy as a “treatment” (the story of the “other” Kennedy daughter’s involuntary lobotomy brought this into the public eye duringc the 1960 campaign of Jack Kennedy for President.
- and, as President, Kennedy supported legislation (passed after his death) to federally fund the development of community based mental health treatment centers throughout America. (it turned out, this was a very empty promise by the feds). The new community approach to mental health was intended to provide a range of inpatient and outpatient services, day programs, home support programs, and essentially a one stop shop for mental health services.
- The promise of federal support for getting rid of the state-funded State Mental Hospitals sounded great to the states, who’s budgets were being taxed heavily by commitments to fund their share of the (new in 1966) Medicaid program signed into law by LBJ.
All of this created nearly a perfect storm of support for shrinking the expensive state asylum system for serious mental health health problems, and replacing it with a new system of community mental health centers, fueled by a stream of effective treatments, better opportunities for active family support, a to-be-expected flow of new miracle drugs, all fueled by lots of federal money and provider support and public opinion. A perfect storm led to the closure of much of the state mental hospital beds in America over the next 20 years. The new policy was called “deinstitutionalization.” And it went on for years after the Kennedy-inspired new law was signed in 1963 (Community Mental Health Construction Act 1963).
It worked: sort of. It caused legislators to begin to shrink budgets of the State Hospitals, close down wards, and discharge patients. But, it didn’t do so well in replacing all this capacity by building and operating community based mental health (CMHC) infrastructure. Yes, thousands were built and operated, but hardly a system large enough to be accessible to all who were discharged from state hospitals, nor others needing mental health services….Only about 50% of the state mental hospital infrastructure was replaced by new CMHCs. Like the VA system and Medicare it was hard for the government to keep up with budget demands of rapid population growth, unanticipated aging of that population, and changing diversity of the population—all of this changed very fast in the 1960-2000 period, taxing our government’s ability to keep up political support for the promises it made during the 1960s. But the state mental hospitals did shrink, losing most (90%) of their peak patient census.
So , what caused the feds to withdraw promises? Well, they didnt directly do it. The main mechanism for implementing a funding reduction was President Reagan and the Congress changed the funding mechanism for the Community Mental Health Center Law (CMHC) to make it a block grant to the states, not requiring the states to spend the money on CMHC infradtructure and operations. Essentially, the block grants allowed the states to to use the money in whatever way the wanted. So, many (all) states took parts of the money and used it for other things, building schools, fixing roads, etc. So the states cutback the previously earmarked CMHC money. Mental health is still, to this day, something states are backing away from–see the states making cutbacks in recent years.
mh states still cutting bugets
Prisons.
A snapshot from today shows an almost uncanny correlation between the shrinkage of patients in state mental hospitals and the rise in number of persons housed in prisons and jails. Its not like the prisons and jails are preferred places to run treatment programs for mental illness. But, seriously mentally ill persons can’t hold jobs, often have little recourse but to live on the streets, and when their antisocial behavior irritates or harms others, and sometimes leads to drug abuse and illegal activities — they get arrested and they get sent to jail. Sometimes, when they broke the law, and sometimes because we have no place else to send them. Its like a return to why they were in Dorothea’s Cambridge County jail 200 years ago: same reason. No place else to send them. Here are the mirror image trend lines:
video on prison health https://www.pbs.org/wgbh/frontline/film/showsasylums/
The prisons house a disproportionately large fraction of the mentally ill in America. Of course, we are stuck with the effect now of opioid addiction problems in the current numbers. Of the 1,350,000 prisoners in state prisons in America, well over half have mental illness or a history of it. This is the defining Health System problem with mental health care in the current U.S. system.
And, the trend in housing the mentally ill persons in prisons has come back to what upset Dorothea so much.
Snapshot Of Mental Health in the U.S. health System
While prisons dominated by nearly a million mentally ill Americans, the current state of mental health in America is not good for four other reasons. Here are the four other challenges.
- mental health illnesses are the most burdensome health issues in America, responsible for the most burden of disease (premature death and disability), higher than cardio vascular disease, or cancer,etc. One reason the burden is so high is that most disease onset occurs when people are young (unlike other diseases which occur later in life, which dramatically reduces the potential burden of the disease. Another big factor in Mental Health is that probably about 55% of the people affected by mental health are not treated. This is because insurance policies limit coverage for mental health (though the ACA tried to create parity) and poor aceess in general.. Even with insurance, or ability to pay there is a stigma about seeking help.
The incidence of mental illness is high. About 20% or so of Americans have a mental illness of some sort, and about 2.8% have a serious, life altering illness.As the chart shows, the prevalence of mental illness is higher for women and for men, both in the community, and in prison populations. This may be one of the reason why insurance coverage is so bad. And, the prevalence of serious mental illness is much higher among prison populations than civilian populations.As shown here, nearly a third of female prisoners have serious mental illness, while 1 on 7 male prisoners are seriously mentally ill.
2. Mental health is very expensive. It is expensive in two ways. Not only does treatment, drugs, and programs of care cost a lot. But, when mental illness is a comorbidity, it contributes to the costs of treatment of the other diseases the patient may have (diabetes, cardio, etc.). This is one of the reasons why capitated health plans (and the ACA) advocate for integrating behavioral health into primary care practices— there are substantial cost savings available premium based plans for identifying and treating mental illness, particularly if the patient has other chronic diseases .
3. Access to mental health care services is very limited in many areas and populations. In Montana, for example, there were no psychiatrists in the eastern half of the state (an area the size of new england). Child psychiatry is particularly in short supply, largely due to the extensive training requirements, residencies in Medicine, Pediatrics, and Psychiatry coupled with low salaries/incomes. Social workers, nurses and psychologists are more available, but they are prevented from prescribing, an important feature of mental health in todays treatment regimes. Poor sections of cities are also underserved. In the chart below, see that many people surveyed dont know where to access services, and many doctors have trouble knowing how to refer to mental health providers.
4. Illustration of the problem. So, every community has a story like this these days. But, here is mine from my town where i lived and raised my family. A young man, early twenties, was seriously mentally ill, with a history of episodes of “acting out” while in school, at community events, at home. Police were called to the home, to the school, by neighbors over several years. The parents tried, but were not wealthy. The child was not violent, and every time there was an episode and the police were called, they filed a report and took the kid home to the parents or to the local hospital, to be checked out— and then the child would be discharged home to the parents. This pattern persisted. He graduated from high school, had some occasional counseling, some drug therapy, but for the most part was living with parents and was OK most of the time. The police didnt really have a good alternative for this sick kid, who was “most of the time” able to function at home, and in the community.
But it wasnt enough. One day he showed up at the town library with a knife. He stabbed a young college student he didnt know who was studying there. She died from 19 stab wounds. She died and two families were ruined because there really wasnt much else the police could do than take the young man home every time he behaved badly. I guess they could have charged him at some point with a “crime” — gotten a conviction, and sent him off to jail. That wouldnt have likely done much for his mental health problem, but it might have saved at least one of the 2 families some misery. And, quite frequently that is exactly what police do at the behest of school officials, neighbors and others. Send them to prison. Thats why the prisons are full. Either send “misbehaving” mentally ill persons off to jail or give them back to the family. A very poor choice to have.
Sending them to the local community mental health center might have been better. A place with a wide variety of short term inpatient and outpatient treatment options. A place that provided day treatment programs. A place with home based follow up programs, and a place that can integrate support teams across schools, home, and health care service providers. A place where police could have taken him to get help.
professorgaumer 