The concept of mental health treatment in the U.S. has an interesting history. We have to look no further than the social connotations or cultural definitions used to describe someone with a mental illness. Over time, we’ve used terminology to describe someone with mental health issues as mad, insane, crazy and loco. The systems used to care for the mentally ill reflect our understanding of the disease. People suffering from a mental illness are most likely to receive care from a family member. Mental health treatment facilities have been called lunatic houses (looney bends), psych hospitals (psych wards), the crazy farm and community mental health centers.
Mental health care in the U.S. isn’t a unified system it’s a patchwork of different systems private, voluntary and public. These systems include acute and chronic mental health treatment, medical health care, long term care (dementia and Alzheimer), substance abuse (addictions) and a network of aging services. People suffering from a mental illness may interact with multiple systems simultaneously.
In order to appreciate the multi network system of care practices in the U.S., we must examine the history of care in this country. These systems have continually evolved because of economic and political pressure. By understanding how our current system of care came to be, we much first comprehend how we arrive at this point. There have been a number major movements dating back to the 19th century which help to shape the multiple systems we currently experience.
Dorothea Dix applied political pressure, in the late 19th century to move mentally ill patients from overcrowded almshouses and prisons. The pressure moved patients into state operated psychiatric hospitals for care. These were mostly inpatient facilities, which remained in existence until the 1950s.
After the 2nd World War, congress passed the National Mental Act creating the National Institute of Mental Health. In 1955, the passage of the Mental Health Study Act provided federal money to investigate the human and economic concerns associated with mental health.
In 1963, the Kennedy Administration passed the Community Mental Health Centers Act (CMHCA), due to concerns of overcrowded state institutions, the cost of building new hospitals and advances in pharmaceutical treatments. This legislation deinstitutionalized mentally ill patients.
CMHC provided services for inpatients, outpatients, partial hospitalization, emergency services, consultation and education. CMHC failed to meet its goals because of funding shortfalls, lack of staffing and an underestimation of its need.
Medicare and Medicaid was enacted in 1965, providing funds for long term care. Medicare and Medicaid provided sustainable long term living conditions for older adults, who were kicked out of state run hospitals for the mentally ill.
In the late 1970, Community Support Program (CSP) were implemented to address the gap in service and treatment for patients with serious mental illness (SMI). CSP provided community support services, outreach and coordinated care for individuals with mental illness. CSP crafted training programs for social and employment opportunities needed for individuals to live in the community.
The challenge of CSP was in defining what programs provided consistent community support. Many of the programs were a challenge to scale nationally. The programs did yield positive outcomes under the right conditions.
The Carter administration prioritized mental health by enacting two pieces of legislations; the Presidential Commission on Mental Health Act and the Mental Health Systems Act. These Acts prioritized the need for community based services, by providing grant programs to fulfill resource demands. The Nixon administration reallocated resources away from direct support of CMHC toward managed care.
The Reagan administration continue the efforts of the Nixon administration reducing the federal response to mental health. Responsibility for the care of mentally ill individuals were shifted to the states. Raegan’s Omnibus Budget Reconciliation Act (OBRA) eliminated the Mental Health Systems Act, created under the Carter administration. Each State could now allocate funds for mental illness, addiction and rehab as they saw fit.
OBRA cut funding for mental health programs by 25% in the first year, with subsequent cuts continuing each year thereafter. The reduction in funding took treatment of mental health back 100 years, where people were cared for by family members or locked up in prison. Today prisons occupy the largest number of mentally ill individuals in this country.
The Reagan administration did pass a Nursing Home Reform Act, requiring facilities to perform an initial psych exam to determine the mental health needs of its constituents. The psych exam requirement has produced some conflicting outcomes in nursing home practices. Some studies reveal that over half of nursing home constituents receive some psychiatric treatment on a weekly basis. While others reports show no significant benefit of the Act. A concerning problem with nursing homes is that they appear to suffer from a lack of quality care, based on consistent independent reports.
Mental health policies are expected to affect the baby boom generation more than any other generation. The baby boom generation represent approximately 65 million adults. The need and requirements for services are expected to continue to rise as life expectancies increase. The presence of depression, anxiety, addictions and dementia are just a few of the mental disorder services that will require treatment.
OBRA ushered in manage care and privatization of mental care treatment, from inpatient to outpatient. Payment to private providers are reimbursed by Medicare, destroying the system of public Community Mental Health Centers. Medicare reimbursements expanded mental provider’s coverage. The Obama administration reduced the copayments for mental health services.
There have been two major movements involved in the treatment of mental health in this country. The Consumer/Survivor Movement and the Recovery Movement.
Consumer/Survivor Movement responded to the scarcity of resources, implementation problems and authoritarian services dominating the treatment of individuals with mental illnesses. Providing alternative self-help, peer support and education was the impetus behind this movement. The movement was plagued with conflicts like; consumers believed reforms should come from within the mental health system, psychiatric survivors who opposed the psychiatric system and family advocacy organization who believed that mental illness required a medical intervention.
The Recovery movement began in the 1980’s as a grassroots reform believing that recovery should be defined as an individual’s pursuit of a preferred future dealing with their mental illness not the elimination of the illness. The recovery movement concept gained widespread recognition, by the Surgeon General and the President. The movement emphasized evidence based treatment and highlighted the need for collaborative decision making between the consumer and provider.
The more we’ve learned about mental disorders, we understand that the treatment of mental illness does not occur in a vacuum. Today we’re beginning to see more of a collaborative effort in the treatment of mental disorders. Collaborations between primary care providers and mental health practitioners. We will exam these collaborations more next week.
Gumber, S. & Stein, C. H. (2013). Consumer perspectives and mental health reform movements in the United States: 30 years of first person accounts. American Psychological Association 36(3) 187-194 doi: 10.1037/prj0000003
Knight, B. G. & Sayech, P. (2011). Mental health and aging in the 21st century Journal of Aging & Social Policy 23 228-243 doi: 10.1080/08959420.2011.579494