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Key points
- President Kennedy championed the Community Mental Health Act of 1963.
- Large numbers of seriously ill inpatients were discharged onto the streets, becoming homeless.
- This is an opportunity for a more effective, as well as cost-effective, service infrastructure.
How did we come to a place where a large percentage of consumers, providers, and even third-party payers characterize the current mental health system of care as broken? A brief, if necessarily simplified, history is in order.
During the colonial period, the “poor” (a term broadly encompassing widows, orphans, the aged, the sick, the insane, and the physically and cognitively disabled) were cared for by private charities or local institutions such as villages and parishes. The results ranged from compassionate to cruel. During the 1840s, reformers such as Dorothea Dix fostered a national asylum movement (implemented at a state level) to create specialized institutions to care for the mentally ill and cognitively challenged.
The earliest state mental health hospitals adhered to an asylum model with a pastoral setting and high staff-to-patient ratios. They were largely self-sufficient with inmates working in fields, dairies, and workshops. Comparatively humane for their day, they reported successful discharge rates exceeding anything since. After the civil war, PTSD together with waves of immigrants from famine- and poverty-stricken European countries overwhelmed asylums, which devolved into the backward snakepits commonly associated with state mental hospitals.
President John F. Kennedy’s oldest sister suffered from serious mental health problems resulting in her institutionalization. In a desperate effort, she was lobotomized. The results horrified the Kennedy family and led President Kennedy to champion the Community Mental Health Act of 1963, the last piece of legislation that he signed days before his assassination.
The Community Mental Health Act
The Act had profound implications for the delivery of mental health care, although after Kennedy’s death, it largely disappeared from public attention. The intention of the Act was the “deinstitutionalization” of the hospitalized mentally ill, together with the closure of state asylum warehouses. In their place were to be local community mental health centers, that would provide outpatient treatment (using newly discovered medications such as Thorazine) and offer services such as housing, and social and occupational support.
A new bureaucracy—Alcohol, Drug Abuse, and Mental Health Administration—was created to increase federal mental health funding. The long-term result, however, was that ADAMHA budgets lagged far behind general funding increases. States were expected to redirect the money saved by closing the asylums to support community mental health services, but there was no robust lobby for the mentally ill so that never happened.
As funds for state mental health hospitals dried up without corresponding increases in outpatient services, large numbers of seriously ill inpatients were discharged onto the streets, and many became homeless. The number of inpatient mental health beds went from 1/300 Americans in 1955 to 1/3000 Americans in 2010. Although more likely to become crime victims than criminals, many chronic ex-inpatients eventually came to be housed in jails, often for repeated minor infractions or drug abuse. Today the three largest institutions housing mentally ill individuals are the Los Angeles County, the California jails, the Cook County, Illinois jails, and Riker’s Island prison in New York City. Untold numbers of mentally ill individuals repeatedly cycle in and out of their local penal facilities.
In addition, rates of serious mental health problems appear to have recently exploded among youth, especially teenagers (subject of a future post). The Covid pandemic has exacerbated an already devastating opioid addiction crisis. As a result, the current system has far more patients and far fewer resources than at any time in recent history.
No Viable Community Center-Based Replacement
The Community Mental Health Act of 1963 succeeded in ending the state asylum system but failed grievously at creating a viable community center-based replacement. If we are going to come to grips with the current situation, we must embrace this failure as an opportunity and be willing to examine imaginative new possibilities in search of a new, more effective, and more cost-effective service infrastructure.
Future posts will examine infrastructure under four general categories: people, places, policies, and payment—although not necessarily in that order. Future mental health services infrastructures must recognize that primary care is currently delivered by a wide range of providers, trained in a variety of treatment models that are supported by varying levels of scientific evidence. mental health services are currently provided across a wide range of settings, from traditional offices and clinics to telehealth and 12-step groups.
Federal policies (and their degree of enforcement), especially as they define eligibility and reimbursement, are determinant, in that they specify a regulatory framework within which a services infrastructure must function. And finally, payment (and profit) is the fuel that drives these services and systems, as well as setting limits on what is sustainable. Ultimately, we must ask ourselves whether we have the political will to provide the resources needed to care for people suffering from mental illness.
References
The Psychiatric Bed Crisis in the US, American Psychiatric Association
