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 The Mental Healthcare System In The United States

     As long as there has been mental illness there has been problematic treatment of mental illness.

     In 1796 William Tuke, a Quaker and an abolitionist, opened the Retreat in York, England. It was a non-profit psychiatric hospital in England dedicated to the treatment of the mentally ill through “Moral Treatment” approach.

     Moral Treatment meant treating people with mental illness humanely. Patients received personalized attention and therapy aimed at improving their social skills, self-control, and self-worth. The personal in the retreat were staunchly against the use of physical restraints and harsh discipline.

     Tuke’s Retreat inspired a number of other Moral Treatment facilities, including the Brattleboro Retreat in Vermont, and the Hartford Retreat in Connecticut.

     The Moral Treatment facilities were labor-intensive and quite expensive to run. Therefore, as time went on and the Industrial Revolution forever changed life for Americans, the need for mental health exploded.

     Throughout the 19^th century, the number of Americans in mental institutions increased tenfold, to over 150,000 by 1904. There were simply not enough resources to treat all the new patients. Whereas Tuke’s ideas of mental health treatment was akin to an expensive handbag being handmade by caring craftsmen, institutional care by the turn of the 20^th century had become more like an assembly line cost-cutting factory.

     The seeds of deinstitutionalization began being sowed early in the 20^th century, with the advent of early medical and surgical therapies for  mental illness. Electroconvulsive therapy was introduced in 1938, not long after barbiturate drugs became widely used for insomnia and anxiety. Around this time, the unfortunate practice of prefrontal lobotomies also became widely used and was seen as therapy[RW1] .

     Psychosis had long been one of the principle reasons for institutionalization. However, in 1950 chlorpromazine, the first antipsychotic was synthesized, which enabled people live in the community. Chlorpromazine was followed by many other revolutionary psychiatric medications, including antidepressants and mood stabilizers.

     Deinstitutionalization began to happen spontaneously. From 1955-1967, the populations in psychiatric hospital dropped by 30%, with much of the reduction attributable to the new antipsychotics that allowed people with schizophrenia to live outside of asylums.

     Mental institutions were also becoming increasingly unpopular. In 1946 Life magazine published “Bedlam 1946”, an expose of the dilapidated, overcrowded conditions that some state mental hospitals were exposing their patients to. The report was complete with photos and stories of patient suffering that horrified many Americans and created a sense of urgency to help these people.

     President John F. Kennedy signed into law the Community Mental Health Act (CMHA), in 1963. The purpose of the CMHA was to shift the setting of mental healthcare from mental hospitals to the community, through increased funding for community-based outpatient mental health treatment centers. The law was successful in facilitating deinstitutionalization. However, the bill was not successful in accommodating the massive need for community-centered mental healthcare that exploded following the release of the mental health patients from the institutions. Only about half of the community centers proposed in the law were ever actually built, and none were ever fully funded. As a result, many mental health patients never received the services that they were promised. To this day, however, community-based mental healthcare resources are far too scarce, and the consequences have been tragic.

     Twenty-five percent of the homeless population have severe mental illnesses like schizophrenia or bipolar 1 disorder. Furthermore, many homeless people are reliant on Medicaid for mental healthcare. Establishing care with a psychiatrist can take several months, especially for patients who have Medicaid. Many homeless people rely on their primary care physicians to provide them with psychotropic medications, which the doctors are reluctant to do.

     The history of institutionalization and deinstitutionalization is filled with good intentions and poor results. Deinstitutionalization has led to homelessness for many people.

     Yet despite the grim picture of many mentally ill homeless people, the situation of the people can be improved if healthcare workers push for policies that increase resources for community-based mental health services, as CMHA intended. Clinicians can volunteer at free clinics or contact local organizations that work directly with the homeless populations and inquire about how they can help. Primary care physicians and psychiatrists can communicate via telemedicine to better serve their patients who have mental illness. Newer, long-acting injectable antipsychotics are available and are particularly useful for populations with limited capacity for compliance, including homeless people.

Signed: Renee D. Warring of Uniquely and Wonderfully Made Ministries

RESOURCES:

https://www.medpagetoday.com/psychiatry/generalpsychiatry/84796