Module 2: A Brief History of Mental Illness and the U.S. Mental Health Care System
The history of mental illness in the United States is a good representation of the ways in which trends in psychiatry and cultural understanding of mental illness influence national policy and attitudes towards mental health. The U.S. is considered to have a relatively progressive mental health care system, and the history of its evolution and the current state of the system will be discussed here.
Early History of Mental Illness(1)
Many cultures have viewed mental illness as a form of religious punishment or demonic possession. In ancient Egyptian, Indian, Greek, and Roman writings, mental illness was categorized as a religious or personal problem. In the 5th century B.C., Hippocrates was a pioneer in treating mentally ill people with techniques not rooted in religion or superstition; instead, he focused on changing a mentally ill patient’s environment or occupation, or administering certain substances as medications. During the Middle Ages, the mentally ill were believed to be possessed or in need of religion. Negative attitudes towards mental illness persisted into the 18th century in the United States, leading to stigmatization of mental illness, and unhygienic (and often degrading) confinement of mentally ill individuals.
Mental Health Hospitals and Deinstitutionalization
In the 1840s, activist Dorothea Dix lobbied for better living conditions for the mentally ill after witnessing the dangerous and unhealthy conditions in which many patients lived . Over a 40-year period, Dix successfully persuaded the U.S. government to fund the building of 32 state psychiatric hospitals.(2)
This institutional inpatient care model, in which many patients lived in hospitals and were treated by professional staff, was considered the most effective way to care for the mentally ill. Institutionalization was also welcomed by families and communities struggling to care for mentally ill relatives.(3) Although institutionalized care increased patient access to mental health services, the state hospitals were often underfunded and understaffed, and the institutional care system drew harsh criticism following a number of high-profile reports of poor living conditions and human rights violations.(4) By the mid-1950s, a push for deinstitutionalization and outpatient treatment began in many countries, facilitated by the development of a variety of antipsychotic drugs.(5) Deinstitutionalization efforts have reflected a largely international movement to reform the “asylum-based” mental health care system and move toward community-oriented care, based on the belief that psychiatric patients would have a higher quality of life if treated in their communities rather than in “large, undifferentiated, and isolated mental hospitals”.(6)
Although large inpatient psychiatric hospitals are a fixture in certain countries, particularly in Central and Eastern Europe, the deinstitutionalization movement has been widespread, dramatically changing the nature of modern psychiatric care.(7) The closure of state psychiatric hospitals in the United States was codified by the Community Mental Health Centers Act of 1963, and strict standards were passed so that only individuals “who posed an imminent danger to themselves or someone else” could be committed to state psychiatric hospitals.(8) By the mid-1960s in the U.S., many severely mentally ill people had been moved from psychiatric institutions to local mental health homes or similar facilities. The number of institutionalized mentally ill patients fell from its peak of 560,000 in the 1950s to 130,000 by 1980.(9) By 2000, the number of state psychiatric hospital beds per 100,000 people was 22, down from 339 in 1955.(10) In place of institutionalized care, community-based mental health care was developed to include a range of treatment facilities, from community mental health centers and smaller supervised residential homes to community-based psychiatric teams.(11)
Though the goal of deinstitutionalization – improving treatment and quality of life for the mentally ill – is not controversial, the reality of deinstitutionalization has made it a highly polarizing issue. While many studies have reported positive outcomes from community-based mental health care programs, (including improvements in adaptive behaviors, friendships, and patient satisfaction,) other studies have found that individuals living in family homes or in independent community living settings have significant deficits in important aspects of health care, including vaccinations, cancer screenings, and routine medical checks.(12)(13) Other studies report that “loneliness, poverty, bad living conditions, and poor physical health” are prevalent among mentally ill patients living in their communities.(14) However, some studies argue that community-based programs that have proper management and sufficient funding may deliver better patient outcomes than institutionalized care, and are “not inherently more costly than institutions”.(15)
Critics of the deinstitutionalization movement point out that many patients have been moved from inpatient psychiatric hospitals to nursing or residential homes, which are not always staffed or equipped to meet the needs of the mentally ill. In many cases, deinstitutionalization has also shifted the burden of care to the families of mentally ill individuals, though they often lack the financial resources and medical knowledge to provide proper care.(16) Others argue that deinstitutionalization has simply become “transinstitutionalization”, a phenomenon in which state psychiatric hospitals and criminal justice systems are “functionally interdependent”. According to this theory, deinstitutionalization, combined with inadequate and under-funded community-based mental health care programs, has forced the criminal justice system to provide the highly structured and supervised environment required by a minority of the severely mentally ill population.(17)
Opponents of the transinstitutionalization theory contend that it applies to a small fraction of mentally ill patients, and that the majority of patients would benefit from improved access to quality community-based treatment programs, rather than from an increase in the number of inpatient state psychiatric beds. These opponents claim that the reduced availability of state hospital beds is not the cause of the high rates of incarceration among the mentally ill, arguing that deinstitutionalized patients and incarcerated individuals with serious mental illnesses are “clinically and demographically distinct populations”. Instead, they suggest that other factors such as “the high arrest rate for drug offenses, lack of affordable housing, and underfunded community treatment” are responsible for the high rates of incarceration among the mentally ill.(18)
Though the deinstitutionalization debate continues, many health professionals, families, and advocates for the mentally ill have called for a combination of more high-quality community treatment programs (like intensive case management) and increased availability of intermediate and long-term psychiatric inpatient care for patients in need of a more structured care environment.(19) Many experts hope that by improving community-based programs and expanding inpatient care to fulfill the needs of severely mentally ill patients, the United States will achieve improved treatment outcomes, increased access to mental health care, and better quality of life for the mentally ill.
U.S. Mental Health Policy(20)
Mental Health America (MHA), originally founded by Clifford Beers in 1909 as the National Committee for Mental Hygiene, works to improve the lives of the mentally ill in the United States through research and lobbying efforts. A number of governmental initiatives have also helped improve the U.S. mental healthcare system . In 1946, Harry Truman passed the National Mental Health Act, which created the National Institute of Mental Health and allocated government funds towards research into the causes of and treatments for mental illness. In 1963, Congress passed the Mental Retardation Facilities and Community Health Centers Construction Act, which provided federal funding for the development of community-based mental health services. The National Alliance for the Mentally Ill was founded in 1979 to provide “support, education, advocacy, and research services for people with serious psychiatric illnesses”. Other government interventions and programs, including social welfare programs, have worked to improve mental health care access. For a discussion of current challenges in mental health care and proposed solutions, please see Module 6: Barriers to Mental Health Care and Module 8: Improving Mental Health Care.
(1) Adapted from PBS Online’s “Timeline: Treatments for Mental Illness”. Retrieved 27 June 2012 from http://www.pbs.org/wgbh/amex/nash/timeline/index.html.
(3) Knapp, M., Beecham, J., McDaid, D., Matosevic, T., Smith, M. (2011). The economic consequences of deinstitutionalisation of mental health services: lessons from a systematic review of European experience. Health and Social Care in the Community, 19(2): 113-125.
(4) Novella, E.J. (2010). Mental health care and the politics of inclusion: a social systems account of psychiatric deinstitutionalization. Theor Med Bioeth, 31: 411-427.
(5) Adapted from PBS Online’s “Timeline: Treatments for Mental Illness”. Retrieved 27 June 2012 from http://www.pbs.org/wgbh/amex/nash/timeline/index.html.
(6) Novella et al. (2010)
(7) Martinez-Leal, R., Salvador-Carulla, L., Linehan, C., Walsh, P., Weber, G., Van Hove, G., Maatta, T., Azema, B., Haveman, M., Buono, S., Germanavicius, A., van Schrojenstein LAntman-de Valk, H., Tossebro, J., Carmen-Cara, A., Berger, D. M., Perry, J., Kerr, M. (2011). The impact of living arrangements and deinstitutionalisation in the health status of persons with intellectual disability in Europe. J Intellect Disabil Res, 55(9): 858-872.
(8) Interlandi, J. 24 June 2012. “A madman in our midst”. The New York Times.
(9) Adapted from PBS Online’s “Timeline: Treatments for Mental Illness”. Retrieved 27 June 2012 from http://www.pbs.org/wgbh/amex/nash/timeline/index.html.
(10) Lamb, H.R.L., Weinberger, L.E. (2005). The shift of psychiatric inpatient care from hospitals to jails and prisons. J Am Acad Psychiatry Law, 33: 529-34.
(11) Novella et al. (2010)
(12) Martinez-Leal et al. (2011)
(14) Novella et al. (2010)
(15) Knapp et al. (2011)
(16) Novella et al. (2010)
(17) Prins, S.J. (2011). Does Transinstitutionalization Explain the Overrepresentation of People with Serious Mental Illnesses in the Criminal Justice System? Community Ment Health J, 47: 716-722.
(19) Sontag, D. 17 June 2011. “A schizophrenic, a slain worker, troubling questions”. The New York Times.
(20) Adapted from PBS Online’s “Timeline: Treatments for Mental Illness”. Retrieved 27 June 2012 from http://www.pbs.org/wgbh/amex/nash/timeline/index.html.