Magazine article Issues in Science and Technology

Better Data for Better Mental Health Services: Evidence-Based Policies for Improving Care and Treatment of Those with Serious Mental Illness Are Urgently Needed-But Good Evidence Is Hard to Find

Magazine article Issues in Science and Technology

Better Data for Better Mental Health Services: Evidence-Based Policies for Improving Care and Treatment of Those with Serious Mental Illness Are Urgently Needed-But Good Evidence Is Hard to Find

Article excerpt

In 1948, Mary Jane Ward's best-selling semi-autobiographical novel, The Snake Pit, brought widespread attention to the deplorable conditions in state psychiatric hospitals. Subsequently made into an Academy Award-winning movie, the novel's vivid descriptions of understaffing, overcrowding, and inhumane treatment profoundly affected the general perception of treatment for individuals with serious mental illness (SMI) and prompted many states to begin making significant reforms. Widespread recognition of the need to improve the care of this vulnerable population, which had been so shockingly neglected, served as a major impetus to the development of a policy known as "deinstitutionalization."

Deinstitutionalization shifted much of mental health care for individuals with SMI (schizophrenia, bipolar disorder, major depression, and other disorders that can result in significant functional impairments) from inpatient state psychiatric hospitals to outpatient community settings. The guiding principle of deinstitutionalization was that individuals with SMI should receive treatment in the "least restrictive setting." This view emerged from the confluence of many factors, including the history of abuses in state hospitals, the development and widespread availability of new psychotropic medications, and an increasing societal concern for civil liberties. In particular, the advent of new antipsychotic medications in the 1950s and 1960s allowed, for the first time, limited control of delusions and hallucinations, and therefore made life in the community a possibility for persons with serious and chronic mental disorders.

The dramatic changes in the mental health system that have taken place over the past 50 years had their origins in the Community Mental Health Systems Act, signed in October 1963 by President John F. Kennedy and conceived with the noblest of intentions. But in policy makers' haste to correct the abuses revealed in state hospitals, deinstitutionalization was carried out, in the words of psychiatrists H. Richard Lamb and John Talbott, writing in the Journal of the American Medical Association (JAMA) in 1986, with "much naivete and many simplistic notions." In his recent book, American Psychosis, E. Fuller Torrey, a former National Institutes of Mental Health psychiatrist, traced such notions to the Interagency Committee on Mental Health, whose 1962 report influenced the subsequent law: "Because no committee member really understood what the hospitals were doing, there was nobody who could explain to the committee that large numbers of the patients in these hospitals had no families to go to if they were released; that large numbers of the patients had a brain impairment that precluded their understanding of their illness and need for medication; and that a small number of the patients had a history of dangerousness and required confinement and treatment."

Torrey, founder of the Treatment Advocacy Center, a national nonprofit organization dedicated to eliminating barriers to the treatment of severe mental illness, argues that the 1963 law was fatally flawed because it encouraged the closing of state mental hospitals without any realistic plan as to what would happen to the discharged patients, especially those who refused to take medication they needed to remain well. It did not include a plan for the future funding of mental health centers, and it focused on prevention when no one understood enough about mental illnesses to know how to prevent them.

Discharging long-term patients from institutions was a way for states to cut their expenses, since outpatient therapy and drug treatment were less expensive than inpatient care. Increasing attention to the civil liberties of those involuntarily hospitalized also brought the enactment of laws in many states that made it much more difficult to hospitalize the mentally ill against their will.

However, although the number of patients discharged from state hospitals increased and the number of inpatient psychiatric beds declined precipitously after 1960, the planned network of 1,500 community mental health centers, which was intended to assume responsibility for the care of those with SMI, failed to fully materialize because of a chronic lack of funding and shifts in political priorities. …

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