The mental-health mess.

Serious, incapacitating mental illness is often treatable. Our federal and state governments--sometimes with the best of motives, sometimes not--have conspired not to treat it.

PROVIDING care for people with serious mental illnesses has been seen as a legitimate function of state government since before there was a United States. In 1766 Governor Francis Fauquier went before the Virginia House of Burgesses and asked for funds to open the first public psychiatric hospital. Fauquier was concerned about the increasing number of the seriously mentally ill--people we would diagnose today as having schizophrenia and manic-depressive psychosis--who were accumulating on the streets and in the jails of Williamsburg and other Virginia towns. Fauquier's efforts led to the opening of what would become Eastern State Hospital. For the next two hundred years state governments accepted full responsibility for these people, housing them in state-operated asylums because there was no effective treatment for their illnesses.

In the past thirty years this situation has changed dramatically. First, medications became available to control many of the psychiatric symptoms--medications such as Prolixin, Haldol, and Navane, which control the voices and delusional thinking of schizophrenia, and lithium, which controls the mania of manic-depressive psychosis.

Next, we began emptying the state psychiatric hospitals, reducing their overall population from 559,000 in 1955 to just over 100,000 today. Most of the people thus released could live in the community if they continued to receive medication and other aftercare. But we have not provided this aftercare, for reasons that will be explained below. The consequence has been the largest social disaster in late-twentieth-century America.

The dimensions of the disaster are obvious to anyone who has been downtown in any American city in the past ten years. The seriously mentally ill, who make up one-third of the total homeless population, can be seen on streetcorners chatting amiably with or responding angrily to voices in their heads. These individuals are suffering from schizophrenia and manic-depressive illness. At the time they were discharged from state psychiatric hospitals almost all of them were taking their medication and were clinically in reasonable condition. But that was months or years ago; they failed to receive aftercare, and so they became sick again and eventually homeless.

A study in Massachusetts showed that 27 per cent of those discharged from state psychiatric hospitals became homeless within six months; a similar study in Ohio found the figure to be 36 per cent. These people joined other mentally ill homeless people in cities like New York and San Francisco.

Another measure of the mental-health mess is the increasing number of mentally ill people in jails and prisons. A recent survey found that, on any given day, there are approximately 30,700 persons with schizophrenia or manic-depressive illness among the 426,000 inmates in the nation's local jails. Many of these mentally ill inmates have no charges whatsoever against them but are merely being held in jail awaiting transportation to, or the availability of a bed in, a state psychiatric hospital. In 17 states it is still legal to hold such mentally ill people in jail without any charges. Another large segment of the mentally ill in jails are there on minor charges, such as "dine-and-dash" (ordering a restaurant meal they cannot pay for). Sometimes police charge the mentally ill with minor crimes just to get them off the streets, a practice commonly known as "mercy bookings." In the jail survey 69 per cent of the respondents said that the number of seriously mentally ill inmates has increased in the past ten years.

Studies in state prisons corroborate these findings. A recent summary of these studies by Dr. Ron Jemelka and his colleagues at the University of Washington concluded that 10 to 15 per cent of the 771,000 inmates in state prisons are seriously mentally ill. This would be approximately 100,000 inmates. When this number is combined with the 30,700 seriously mentally ill in local jails and the 116,000 in the homeless population, it becomes evident that, on any given day, approximately 250,000 seriously mentally ill people--a quarter of a million--are living on the streets, in public shelters, in jails, and in prisons.

Another measure of the mental-health mess is the increasing episodes of public violence by the untreated mentally ill. (It is important to emphasize the word "untreated," because studies have shown that treated individuals with serious mental illness are not more dangerous than the general population.) Such cases include Juan Gonzalez, who killed two people with a sword on New York's Staten Island ferry; Sylvia Seegrist, who shot ten people in a shopping center near Philadelphia; Laurie Dann, who shot six children in an elementary school near Chicago; Herbert Mullin, who randomly killed thirteen people near San Francisco; and James Brady, who shot five people in a shopping mall in Atlanta. All of these people had been identified as seriously mentally ill and were in need of treatment but were not receiving it. A recent study of people who push strangers in front of subway trains in New York City showed that more than half of them had a diagnosis of schizophrenia but apparently were receiving no treatment.

Such cases are merely the visible tip of an iceberg of violence. A recent study of families of the seriously mentally ill, carried out by the National Alliance for the Mentally Ill, reported that in 11 per cent of these families the person who was mentally ill had physically attacked a family member or someone else within the past year. In most instances the mentally ill person was not receiving treatment at the time.

Six Mistakes

THE mental-health mess is all the sadder because we know how to organize good services for those with serious mental illnesses. Furthermore, approximately $25 billion is being spent each year by federal, state, and local governments on public mental-health services, a remarkably large amount of money, given the mediocre product being delivered. It is neither lack of knowledge nor lack of funds, then, that has produced the mental-health mess. Rather it is the consequences of six mistakes that have been made over the years. Three of these mistakes were made by the Federal Government, one by both federal and state government, and one by state government alone; the sixth mistake was made by everyone.

1. Federal funds were misdirected. In the early 1960s, when the discharge of hundreds of thousands of the seriously mentally ill from state psychiatric hospitals was just getting under way, President John F. Kennedy proposed using federal funds as seed money to help start Community Mental-Health Centers (CMHCs) to treat the mentally ill closer to home. In congressional hearings it was explicitly stated that the proposed CMHCs would provide care for patients discharged from state hospitals.

From day one the CMHC program was an abysmal failure. Federal officials by-passed state mental-health authorities in funding local programs, thereby earning the permanent enmity of the states. The National Institute of Mental Health (NIMH) provided vague guide-lines and virtually no oversight, so that some CMHCs used federal funds to build swimming pools and tennis courts, even hiring swimming instructors on federal staffing grants. A total of 789 CMHCs were eventually given more than $3 billion in federal funds. Follow-up studies of the CMHCs suggest that about 5 per cent of them have provided reasonably good services for the people targeted by the original legislation. The other 95 per cent have simply ignored those people.

2. Costs were shifted from states to the Federal Government. Up until the early 1960s, the Federal Government provided only 2 per cent of the total cost of care for those with serious mental illnesses. When the Federal Government began funding CMHCs, however, it also decided to make the seriously mentally ill eligible for emerging federal programs such as Medicare, Medicaid, Supplemental Security Income (SSI), Social Security Disability Income (SSDI), food stamps, and federal housing subsidies.

As a result, states have tried to empty their psychiatric hospitals, for which they pay virtually all the costs, and let the patients become eligible for the various federal subsidies instead. Once the patients have been discharged, the states close down those beds. If the patients need re-admission, the states direct them to the psychiatric wards of general hospitals, where federal Medicaid funds will cover much of the cost.

Furthermore, the states, having discharged patients, have no incentive to provide aftercare. The discharged patients can end up homeless or in jail and often do; from a purely fiscal point of view, this costs state mental-health authorities nothing, since shelters and jails are mostly run with local (county and city) funds. The single most important function of state mental-health authorities today is to find additional ways to shift costs to other levels of government.

3. The Federal Government failed to support research. Research on diseases is a function of government that has been most effectively funded at the federal level. The primary purpose of the National Institute of Mental Health, created in 1946 as a part of the National Institutes of Health, was to do research on "the cause, diagnosis, and treatment of psychiatric disorders." Allowance was also made for "training personnel in matters relating to mental health" and for "developing and assisting states" with treatment programs, but research was to be the cornerstone of the Institute.

The NIMH's cornerstone was more like a pebble. Research occupied an increasingly small share of its annual budget, and, within that budget, an increasingly large share of funds was devoted to research on social problems such as violence, racism, and sexism. In 2969 the NIMH left the National Institutes of Health altogether, no longer wishing to be viewed as a research institute. One consequence was neglect of research on schizophrenia and manic-depressive illness. By 1985 the Federal Government was spending the same amount of research money on schizophrenia as it was on tooth decay. Per-patient total research expenditures were 8 times higher for multiple sclerosis than for schizophrenia, 15 times higher for cancer, and 50 times higher for muscular dystrophy.

4. Federal and state governments failed to ensure adequate manpower in public-sector psychiatric jobs. In 1940 there were approximately 9,000 psychiatrists, psychologists, and psychiatric social workers in the United States. In 1990 there were over 200,000, a 22-fold increase during a period when the population did not quite double. The training of such professionals had traditionally been a function of state government until the 1950s; over the following thirty years more than 2.1 billion federal dollars were spent on training.

The problem was that neither the federal nor state governments made any effort to ensure that the professionals, once trained, would be available for public-sector jobs. During the 1945 congressional hearings creating the NIMH, Representative Clarence J. Brown of Ohio explicitly asked Department of Health, Education, and Welfare officials whether they planned to include some arrangement "whereby a man who gets a subsidy from the Federal Government must pay back or in some way compensate the government" with a period of public service. Dr. Robert Felix, representing HEW, replied that there was such a plan: "I would think that a reasonable requirement of these men would be that they would spend at least one year in public service for every year they spent in training at public [federal] or state expense." Despite such assurances, a payback was never implemented rederally until 1981, by which time training funds had been markedly reduced because of the program's failure.

The consequence is that many state mental hospitals and mental-health centers find it virtually impossible to recruit competent staff. In 1985 Wyoming State Hospital went almost a year with no psychiatrist whatsoever on its staff; five mental-health centers in South Dakota must share a single psychiatrist (each gets him one day a week); and many centers in rural areas have no psychiatric professionals whatsoever.

Where did all the mental-health professionals go? Most of them went directly into private practice in wealthy neighborhoods. For example, affluent Princeton, New Jersey, has one psychiatrist for every 250 residents, while poorer Jersey City has one for every 13,000. Psychologists and psychiatric social workers are similarly distributed.

5. States changed their laws to make involuntary hospitalization and treatment more difficult to impose. A major contributor to the mental-health mess has been lawyers--especially those connected with the American Civil Liberties Union and the Mental Health Law Project who, with more idealism than common sense, persuaded the majority of state legislatures to change these laws. It would be a great thing if all individuals with schizophrenia and manic-depressive illness could think clearly and understand their need for treatment. Unfortunately the organ they use for thinking, the brain, is the one that is affected by these diseases. Hence approximately half of all those with serious mental illnesses have little or no insight into their own condition or need for treatment.

6. Until recently, many people misunderstood the nature of serious mental illnesses. Of all the mistakes that were made, this was the most understandable. In the 1960s, when the foundation for the current problems was being laid, much less was known about the causes of serious mental illnesses. Followers of Freud said the illnesses were caused by bad mothering; Dr. Ronald Laing called them a sane response to an insane world; novelist Ken Kesey described the hospitalized mentally ill as being politically oppressed; Dr. Thomas Szasz claimed that the illnesses did not really exist at all. Looking back, such opinions now seem more thought-disordered than the opinions of the mentally ill.

It is now known that schizophrenia and manicdepressive illness are brain diseases, with structural and functional brain changes, just as multiple sclerosis, Parkinson's disease, and Alzheimer's disease are. As with these other diseases we do not yet know the precise neurochemical, neuropathological, and genetic sequence of causal events, but it is clear that these events are biological in nature. Thus, whereas thirty years ago well-meaning advocates might open the gates of mental hospitals and hope the released inmates would, by themselves, live happily ever after, as in the movie King of Hearts, today we should fully realize that, in order to do so, such individuals will need medication, aftercare, housing, and rehabilitation.

A Way Out

GETTING out of the mental-health mess will depend upon correcting the mistakes that got us into it. The following steps must take place.

1. Clarify responsibility and funding. The effort to shift fiscal responsibility from one level of government to another is the single biggest cause of the problem.

One can make a theoretical argument that complete fiscal responsibility for these services should be assigned to the Federal Government. Personally I would disagree, because that fixes responsibility at a level too remote from where the services must be delivered.

State government is a more logical level. Some states, especially larger states, may wish to pass this responsibility down one more level to counties, as California and Wisconsin now do, or to local service boards, as Ohio does. The main point is that fiscal authority must accompany responsibility or the system will not work.

The most logical way to end the current division of both responsibility and fiscal authority is to block-grant to the states all federal funds for the mentally ill. This will be easier to do for programs like Medicaid and Medicare and more difficult for entitlement programs such as SSI and SSDI, but it must be done.

Fixing responsibility and fiscal authority at the level of state government would make single-source funding possible. This means that decisions regarding how many hospital beds are needed, how to reduce rehospitalization rates, how to develop better housing for the mentally ill, how to develop jobs programs for them, etc., could be made depending on clinical needs, not on what will be reimbursed by federal programs. Single-source funding is the main reason why a Canadian province such as British Columbia offers better services for people with serious mental illnesses than any U.S. state, although British Columbia spends less money on these services than do most states.

2. Establish priorities. Mental-health centers in most states try to be all things to all people. They function as counseling centers for marital problems, existential crises, adolescent turmoil, and general unhappiness. Many mental-health centers spend so much staff time on these problems that little time remains for people with serious mental illnesses. Since states are funding these centers, the states can establish priorities any time they wish simply by reimbursing for some conditions (e.g., schizophrenia) but not others (e.g., marital strife).

3. Encourage innovation. Present attempts at innovation are severely restricted by the reimbursement formulas of the various federal funding sources. Privatization is one avenue to explore, although the few efforts at privatization so far have resulted in widely varying outcomes. Some ventures (e.g., Northwest Mental Health Services in Seattle) have been highly praised; others (e.g., Brooklyn Psychosocial Rehabilitation Institute in New York) have been accused of offering poor services and of corruption.

4. Ensure professional manpower for public-sector jobs. This problem can be solved simply by having an automatic one-year-for-one-year payback obligation attached to all state-funded training programs. Another way to alleviate the shortage of psychiatrists, especially in rural areas, is to provide a special training program for psychologists, physician assistants, and nurse practitioners and then give them the jobs the psychiatrists refuse to take.

5. Change state laws. Any state that wishes to do so can change its laws back again, to make it easier to involuntarily hospitalize and treat the seriously mentally ill. A few (e.g., Washington) have already begun.

6. Ensure adequate research funds. Within the past five years there has been a marked increase in federal research funds. Much of the leadership on this issue has come from Senator Pete Domenici (R., N.M.). Recent legislation also returned the NIMH to the National Institutes of Health. Finally, private foundations have begun supporting such research; a noteworthy example is the Theodore and Vada Stanley Foundation, which in 1992 alone donated almost $2 million to research on schizophrenia and manic-depressive illness. Such public and private investments of research funds may well pay as rich dividends as they did in the prevention of polio.

In summary, solutions to the mental-health mess are possible if government has the will to implement them. The leadership issue is further complicated by the fact that mental-health issues have traditionally been politicized. Advocates for the mentally ill have been strongly identified with liberal causes and Democratic politics, whereas opponents of mental-health causes have been identified with right-wing organizations (and particularly with the John Birch Society in the 1950s and 1960s). It is time to move beyond this traditional dichotomy. The mess has now been presided over by three Democratic and four Republican Presidents. Serious mental illnesses are not respecters of political boundaries. The mental-health mess is truly bipartisan in origin and must be bipartisan in solution.

Dr. Torrey is a research psychiatrist and writer in Washington, D.C. His most recent book is Freudian Fraud: The Malignant Effect of Freud's Theory on American Thought and Culture (HarperCollins, 1992).