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This past week, Mother Jones‘ Deanna Pan posted a great, although brief, timeline of deinstitutionalization in the United States’ mental health systemi, running from the 1st mental patient admitted to an asylum in the 18th century(1) to the present day. Much of the information presented in the timeline is relevant to a discussion of the decline of the state mental health system in America, but one particular stat jumped out at me: In 2010, there were a mere 43,000 available psychiatric beds in the US, a number which stretches out to about 14 beds per 100,000 citizens. And, while that 14 for every 100,000 number may look bad on the surface, it gets even worse when put into historical context. The current ratio of inpatient psychiatric beds to the general population is the same as existed in 1850, before a sizable movement to take care of the mentally ill had even formed. Keep in mind it was less than 60 years ago that America had in excess of 560,000 occupied mental hospital beds, and that was for a population that was about half of the size it is today. If our inpatient psychiatric capacity had just managed to keep up with population growth, we’d have over 1 million available beds for mentally ill Americans. Instead we don’t even have enough inpatient psychiatric patients to fill a decent sized NFL stadium.

The last time so little attention was paid to inpatient psychiatric treatment, experts though wrapping the mentally ill in wet sheets like little crazy burritos was a good idea.

Given the fact that our country now has the same inpatient psychiatric capacity that it did the year that California was admitted to the union as a state, the $64,000 question becomes, where did all of those beds go? It isn’t as if mental health issues have become less prevalent or less culturally accepted over the past 60 years. You can’t watch TV for more than half an hour without seeing that miraculously happy Zoloft egg bouncing across the screen or watching an ad for Hoarders or Intervention or any of the 1,001 shows dedicated to documenting the “reality” of mental illness in all of its glossy, made-for-TV splendor. In the 21st century, it’s become culturally accepted (with varying amounts of salt) that 1 in 4 people will suffer from some sort of mental illness in their lifetime, so how is it that our psychiatric inpatient facilities have cleared out like Disney World in January?

Well, to paraphrase George Orwell, all mental illnesses are equal, but some mental illnesses are more equal than others. As a society, we have come to accept and even embrace the more palatable mental health issues like depression and anxiety because they’re not too far from our own experience and because they generally occur in folks who are functioning members of society. All of us get sad and nervous from time to time, so it’s not too hard to place ourselves in the shoes of a friend or neighbor who suffers from clinically significant depression or anxiety. Plus, these people generally have a fairly easy time articulating what they’re feeling and are able to develop a good rapport with a therapist or psychiatrist. Put another way, these are middle class mental illnesses.Higher-income countries have much higher rates of depression than low or middle-income countries, in part because these countries generally have time, money and infrastructure to deal with such problems. According to a recent World Health Organization survey, the United States can boast a lifetime depression rate of 19.2%, while China’s was only 6.5%. You can call me crazy, but I have a hard time believing that there are 3 times as many depressed people in the US as there are in China. And, while I’m sure there are myriad factors that go into the creation of a disparity like that, I believe that a good chunk of that depression gap comes from the fact that Americans have been acculturated to look for depression within themselves and others, while the Chinese have not. It’s kind of hard to self-report being depressed if you don’t know what feeling depressed is supposed to look like.

“Doc, I don’t care why she’s anxious. Just give her some benzos or something so she can clean the damn house.

Now, while there has been a great deal more acceptance of disorders like depression and anxiety, the same cannot be said of severe and persistent mental illnesses like schizophrenia, bipolar and various personality disorders. Essentially, the crazier you are, the less people are going to embrace you as you deal with your disorder. An employer who might be sympathetic to an employee suffering from panic attacks that effected his productivity will likely lose most of that sympathy if that same person has a manic episode during a conference and takes the company’s rental car out on a 2 week joyride without telling anyone. Deinstitutionalization was tailor-made for the person suffering from severe anxiety or generalized depression. Any service that a person suffering from either of those disorders could ever need can be found within the context of the community-based clinic. In the majority of cases, placing someone with chronic depression in an inpatient facility constitutes an inappropriate level of care and a waste of resources.

What deinstitutionalization has ignored to a criminal degree are those folks suffering form severe and persistent illness who truly need long term inpatient care and, if they are to live in the community, need to have a much more intensive array of services at their disposal. 60 years of mental health policy from Kennedy to Reagan to Clinton has emptied our psychiatric hospitals and kept deferred prospective patients to alternative systems of care without ever taking care to build these alternative systems to anything approaching the capacity needed to deal with the length and breadth of the problem. In the absence of such services, those most affected by mental illness have been forced into other institutions that are unsuited to deal with their needs or are simply cast out on the street. In 1955, there were 560,000 occupied inpatient psychiatric beds in America compared to around 250,000 prison and jail beds. Today, America sports 43,000 psychiatric beds and 2,239,800 prison and jail beds, with an estimated 320,000 of those being occupied by people suffering from severe mental illness. After 60 years of “progress”, America now has more severely mentally ill prisoners in 2013 than it did total prisoners in 1955.

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1As an aside, the people with the ignominious distinction of being the first two mental hospital patient in our nation’s history are Zachariah Mallory, a 42-year old man from Hanover County, VA and Catherine Harvey of New Kent County, VA, who were described by the first court of directors responsible for the reception of patients to mental hospitals in October of 1772 as being, “persons of insane and disordered minds.” Mallory, for his part, would be dead within a year of being committed to the asylum, while Harvey’s ultimate fate is unknown.

Originally posted to Virally Suppressed on Thu May 02, 2013 at 05:30 PM PDT.

Also republished by Mental Health Awareness and Community Spotlight.

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Comment Preferences

  •  Reagan Cut funding for (5+ / 0-)

    Mental Health Services didn't he?

  •  Republished to Mental Health Awareness (7+ / 0-)

    VS, I'm going to send you an invitation to be part of the Mental Health Awareness Group. That way, when you write a diary, you can republish it to the queue, send me a message and I can publish it. Otherwise, if I don't see it, or someone else from the group, it will be missed. :) If you prefer not to, that's cool. Just ignore it. But I think it might be easier for your diary to get to the group.

    I'd like to start a new meme: "No means no" is a misnomer. It should be "Only 'Yes' means yes." Just because someone doesn't say "No" doesn't mean they've given consent. If she didn't say "Yes", there is no consent.

    by second gen on Thu May 02, 2013 at 08:58:09 PM PDT

  •  Thank you for writing this. (6+ / 0-)

    It is a very good overview of the problem. A friend of mine has worked night shift in a residential unit in a small KS establishment since the late '80s. When I first met him, most of the people working there had both degrees and empathy. The clients were being trained over a period of years to responsibly hold work and to survive in an apartment with some oversight. These people were genuinely helped by deinstitutionalisation. Over the years it has slowly become a warehouse situation for the clients and the employees are high school dropouts with the kind of cruel streak that would make them prefer that kind of minimum wage work instead of cashiering at a truck stop.
    My friend inherited multiple millions of dollars at one point, and he is getting older and is not particularly fit. He only sticks with it because he is kind, and knows that if he leaves there will be no brakes on the others' behaviour at all.
    The mental health situation is a disgrace. People with cognitive disability end up at places like that or, even worse, prison.

    You..ought to be out raising hell. This is the fighting age. Put on your fighting clothes. -Mother Jones

    by northsylvania on Fri May 03, 2013 at 01:20:56 AM PDT

  •  Well written overview, thank you (5+ / 0-)

    I have first-hand experience with a family member suffering with mental illness, a personality disorder hard to diagnose and treat. As you noted, employers soon lose patience with odd behavior and emotional outbursts. Like so much else in our country today, the responsibility and costs for coping with the mentally ill have been shifted to their families.

    My heart goes out to the mentally ill who have no one looking after them. They are the ones we often see living on the street.

    If a free society cannot help the many who are poor, it cannot save the few who are rich. - President John F. Kennedy

    by laurel g 15942 on Fri May 03, 2013 at 05:37:03 AM PDT

    •  Mental hospitals in the 1960's (3+ / 0-)

      In New Jersey back in the early 1960's I recall newspaper articles and editorials warning of a huge impending state budget crisis caused by the growth of the state mental hospital system.

      Then a "miracle" happened in the form of better drugs for the mentally ill. The hospitals began to empty during the 1970's.

      Later in the 1980's during the Reagan Adminsitration legislation was passed that the patients had to be housed in the "least restrictive environment." This gave the cost cutters just the excuse to start dumping patients wholesale out onto the streets.

      Problem solved, the budget was saved!

      Now we have the huge homeless mentally ill problem.

      "Humankind cannot bear very much reality." - T.S. Eliot

      by fixxit on Fri May 03, 2013 at 08:35:58 AM PDT

      [ Parent ]

  •  Overcorrecting (6+ / 0-)

    There is no doubt that the peak of mental hospital usage included some people who shouldn't have been there. It was a convenient place to shove people and forget them.

    OTOH, the current alternative is to shove them off into the street and write them a prescription. Soon, they aren't taking their meds, and it's their fault that they get smashed by society.

  •  On top of all the cuts (2+ / 0-)
    Recommended by:
    FarWestGirl, marina

    today's world, with its increased complexity and costs, combined with lowered wages for most, increases pressure on those with borderline mental health, making severe depression and various other problems more likely to crop up than they may have been for the prior generation.

    Republican threats amount to destroying the present if we don't allow them to destroy the future too. -MinistryOfTruth, 1/1/2013

    by sleipner on Fri May 03, 2013 at 09:56:24 AM PDT

  •  Thanks for this (6+ / 0-)

    As the parent of a mentally ill son who was also mentally ill as a child, I have seen first hand the inadequacies of the system. I also worked as a clinician in a state hospital for 8 years back in the Reagan years when deinstitutionalization was running rampant.

    We know what it takes to make a good community mental health system, and have chosen over and over again not to do it. And one of the things it needs is adequate beds for those times when a person needs one. My son has lived on the streets, and in jail, and spent nights in emergency rooms to stay out of the elements and away from those who would victimize him.

    This is such an important topic.

    Republicans want to make government small enough to fit in your vagina..

    by ramara on Fri May 03, 2013 at 10:57:25 AM PDT

  •  Reagan, as governor... (3+ / 0-)

    of CA, started the policy movement of de-institutionalization.  There were supposed to be community mental health facilities to take over care, but of course they weren't funded, and they were useless for the more seriously mentally ill.  

    Any discussion on this subject is not complete without a mention of E. Fuller Torrey, schizophrenia researcher, and past adviser to the Alliance on Mental Illness, who also worked at the NIMH and has been highly critical of  our "system."

    My interest in the subject stems from having several friends over the years who suffered from either schizophrenia or manic-depression, as well from as seeing the staggering numbers of homeless mentally ill in the Bay Area of CA.  

    The hospitals and sanitariums built in the late 19th and early 20th century were good public health policy, built with compassion and healing in mind, as their architecture and expansive grounds attest to.  

    There's a fascinating (and sad) photo compilation of the abandoned buildings, by Christopher Payne, with an introduction by Oliver Sacks:  Asylum: Inside the Closed World of State Mental Hospitals  ISBN: 0262013495

    Important works by Torrey:

    1988, Nowhere to Go: The Tragic Odyssey of the Homeless Mentally Ill, Harper Collins, ISBN 0-06-015993-6

    1996, Out of the Shadows: Confronting America's Mental Illness Crisis, John Wiley & Sons, Inc., ISBN 0-471-24532-1

    Torrey, E. Fuller; Stieber, Joan; Ezekiel, Jonathan; Wolfe, Sidney M; Sharfstein, Joshua; Noble, John H; Flynn, Laurie M (1992). Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals. A joint report of the National Alliance for the Mentally Ill and Public Citizen's Health Research Group. ISBN 0-7881-4279-8.

  •  This issue, unfortunately, was caused by (4+ / 0-)

    agreement between the left and right that "opening the doors" of mental hospitals was a good idea. The right of course does not generally did not believe in mental health/illness and also wanted to save money. The left at that time reacted to the terrible state of some hospitals and believed that patients would be better off in half-way houses or the community.

    Of course what happened was that the latter were never funded and the folks were put out on the street in the millions.

    If... the machine of government... is of such a nature that it requires you to be the agent of injustice to another, then, I say, break the law. ~Henry David Thoreau, On the Duty of Civil Disobediance, 1849

    by shigeru on Fri May 03, 2013 at 01:32:13 PM PDT

    •  In part, the Community Mental Health Act of 1963 (1+ / 0-)
      Recommended by:
      marina

      (wikipedia link) won the approval of the left in response to the horrible conditions in some mental health facilities of the day, but also in recognition of the fact that mental health patients who'd committed no crime and posed no danger to themselves or others had the right to be free if they wanted to be. Of course, it's a catch 22 as many mental patients lack the ability to recognize their need for help.

      Part of the Act provided funding to communities to construct community mental health facilities. With a combination of those funds and private philanthropy, the  community where I live constructed a very nice one that "worked" for decades. Over the years, the need has outpaced the capacity there, however, and several "patches" have been added, some better than others. Among these are some facilities funded by generous and compassionate donors and some privately owned facilities.

      It's a thorny issue. One of the troublesome aspects, IMO, it the steep increase in institutionalizing children as young as 6! We have a facility here expressly for children 6- to 8-years old.

  •  Mentally ill people are people too. (0+ / 0-)

    We can make our own choices, and who the heck are you to say those choices aren't rational?

    The impetus for the change from institutionalization to out-patient care came about with effective anti-psychotic medication. Once a person's psychoses could be effectively controlled with medication, permanent institutionalization was no longer necessary. As long as a person could be maintained on anti-psychotic medication and have a support system to help them become productive members of society, there would be no continuing purpose in keeping them locked up.

    A good part of this was driven by the mentally ill themselves, and continues to be driven by them. The goal of the mentally ill is rehabilitation. The goal of the mentally ill in rehabilitation is to become productive members of society despite their inherent disability.

    The number of available in-patient beds is irrelevant. Mentally ill people don't have to be housed away, but to be supported and encouraged and given the opportunities to be engaged in society. There are very few situations where a mentally ill person cannot be integrated into normal society.

    “Birds…scream at the top of their lungs in horrified hellish rage every morning at daybreak to warn us all of the truth. They know the truth. Screaming bloody murder all over the world in our ears, but sadly we don’t speak bird.” Kurt Cobain

    by RadicalParrot on Fri May 03, 2013 at 09:44:54 PM PDT

    •  When a schizophrenic (1+ / 0-)
      Recommended by:
      susanala

      is too delusional to recognize that he is eating raw hamburger crawling with maggots, he needs to be institutionalized.

      Now, that may violate his free will, but it will also save his life until his delusions simmer down.

      •  yes, and that is okay, but... (0+ / 0-)

        with the effectiveness of anti-psychotic medication, institutionalization is unnecessary. That I think is what people don't get. I will grant there are a subset of persons who will be non-compliant with their medication no matter what, but for the vast majority of the mentally ill, they can be medicated and given the support necessary to become completely productive members of society.

        It is not up to you to decide that mentally ill people should be locked up in hospitals. Functioning adults are more than able to decide their own fate.

        “Birds…scream at the top of their lungs in horrified hellish rage every morning at daybreak to warn us all of the truth. They know the truth. Screaming bloody murder all over the world in our ears, but sadly we don’t speak bird.” Kurt Cobain

        by RadicalParrot on Sat May 04, 2013 at 03:31:37 PM PDT

        [ Parent ]

        •  My personal experience says otherwise (0+ / 0-)

          It's not from a desire to "lock them up" but from a desire to protect the vulnerable who cannot function in society. They still exist, even with all the medical advances. They are people whose condition will not improve, but will get worse.

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