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By The Editorial Board
The editorial board is a group of opinion journalists whose views are informed by expertise, research, debate and certain longstanding values. It is separate from the newsroom.
Across the country hundreds of thousands of Americans with serious mental illnesses, such as schizophrenia and bipolar disorder, have been consigned to lives of profound instability. Instead of therapists to help them manage their illnesses or doctors to oversee their medication regimens or evidence-based treatment for their substance use disorders, they cycle through homeless shelters and the jails and prisons that have become the nation’s largest mental health providers. Or they make their homes on the streets. They are victims of a mental health system that is not designed to meet their needs — and of a society that has proved mostly indifferent to their plight.
Few Americans are receiving adequate psychiatric care or psychological support these days — either because their health insurance doesn’t cover it, or because they don’t have insurance to begin with, or because wait lists run far too long. But even amid such pervasive insufficiency, society’s neglect of the most severely mentally ill stands out. Of the 14 million or so people who experience the most debilitating mental health conditions, roughly one-third don’t receive treatment. The reasons are manifold — some forego that treatment by choice — but far too many simply cannot access the services they want and need.
The most obvious reason is money. Community-based mental health clinics serve the vast majority of Americans with serious mental illnesses. These patients tend to be low-income, disabled and to rely on Medicaid, whose reimbursement rates are so abysmal that clinics lose money on nearly every service their doctors provide. “They get 60 to 70 cents on the dollar,” says Chuck Ingoglia, president of the National Council for Mental Wellbeing, a nonprofit representing thousands of U.S. community mental health centers. “I don’t know any other part of health care where your physician is your loss leader.” As a result, staff vacancies can run upward of 30 percent in public mental health clinics and waiting lists can stretch for months, even for people in crisis.
In many ways, the criminal justice system has become the only reprieve: Because court-ordered patients are granted priority, pressing charges against loved ones is a common way to get them psychiatric attention in a crisis. Jails and prisons also serve as final landings for those who fall through the cracks: They make up the three largest psychiatric facilities in the country, and more than 40 percent of the nation’s inmates have been diagnosed with mental disorders.
Americans have long accepted that, tragic though it may be, there are no other options. That apathy is easy to understand. When it comes to caring for the mentally ill, the arc of American history has nearly always bent toward failure. But the policies and programs that could undo this crisis have existed for decades.
In 1963, in what would turn out to be the last bill he signed into law, President Kennedy laid out his vision for “a wholly new emphasis and approach to care for the mentally ill.” It involved closing the nation’s state psychiatric hospitals — which had become dens of neglect and abuse — and replacing them with a national network of community mental health centers. The centers, unlike the hospitals, would support and treat the formerly institutionalized so that they could live freely in their communities, with as much dignity as possible.
Lawmakers and health officials executed the first half of that vision with alacrity. Thanks to a roster of forces — Kennedy’s bill, new and effective antipsychotic drugs and a rising tide of activism for patients’ rights — the number of people housed in large psychiatric hospitals fell by 95 percent between the 1950s and 1990s. But nearly 60 years after Kennedy’s bill became law, health officials and lawmakers have yet to realize the second half: There is still no community mental health system in America, but it is possible to start building one now.
Steven Sharfstein remembers the Boston State Hospital in Mattapan, a creaking 19th-century building where he and his fellow psychiatry residents were forced to send their most intractable patients.
“It was a terrible place,” says Dr. Sharfstein, who served as president of the American Psychiatric Association. “The lights didn’t always work, the patients wandered around like zombies. Nobody got better.”
Eventually, he and his fellow residents banded together and refused to go. Move the patients back to central Boston, they insisted, and treat them at the community mental health center. Their small protest was part of a growing movement to close state psychiatric hospitals across the nation and replace them with community-based care.
Those hospitals had also arisen from a movement: In the mid-1800s, after visiting hundreds of almshouses, jails and hospitals and seeing the horrid conditions that most people with mental illnesses lived in, the reformer Dorothea Dix begged health officials to create asylums where those patients could be treated more humanely. The first such facilities were small, designed for short-term, therapeutic care, and functioned more or less as Dix had hoped they would. But as local officials began foisting more of their indigent populations onto the states, they morphed into human warehouses. By the time Dr. Sharfstein started his career, most of them held upward of 3,000 patients, often for years at a time.
Advocates of a community-based approach argued that even the sickest psychiatric patients deserved to live in or near their own communities, that they should be cared for in the least restrictive settings possible, and that with the right treatment (humane, respectful, evidence-based) the vast majority of them could recover and even thrive.
Kennedy’s bill was meant to enshrine these principles. The plan was to build some 1,500 community mental health centers across the country, each of which would provide five essential services: community education, inpatient and outpatient facilities, emergency response and partial hospitalization programs. Ultimately, the centers would serve as a single point of contact for patients in a given catchment area who needed not just access to psychiatric care but help navigating the outside world.
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