Nearly all types of mental health establishments grew during this nearly 30 year period. The number of private psychiatric hospitals rose 132%, the number of non-federal hospitals with separate psychiatric services rose 114%. Residential centers for emotionally disturbed children rose 77%. The number of other types of organizations — psychiatric outpatient clinics, partial care organizations and multiservice mental health organizations — (data not shown in the panel) grew 141%. Only the number of state hospitals saw a decline, helped along by mergers, consolidations, and closings. The growth rates far exceed the growth rate in the general population, which was about 33%.
This growth took place as the number of beds in all hospitals and treatment centers were on the decline. Beds for residents fell 50% overall, from 524,878 to 261,903. But there were also fewer patients in them; the number of resident patients also fell during this period, from 471,451 to 215,798 (down 54%).
The move from state facilities to community care began much earlier. Mental hospitals had been the cornerstone of mental health policy in the years before World War II. There were significant changes taking place within the population of state mental hospitals just before 1950. Previously, they were home to schizophrenics who required life long care and seniors with dementia. (The aged sometimes had other afflictions that were not necessarily related to mental health. In the 19th century, senility was redefined as a mental illness, allowing local communities to ship the aged off to state facilities.) Post World War II, state hospitals were now seeing more patients with short and intermediate term care needs.
Shortly after the war, a push came to strengthen outpatient and community clinics, led by shifts in funding and psychiatric thinking (and, no doubt, the needs of returning servicemen). The effect of this thinking on these clinics — which pre-1940 had dealt primarily with children, not adults — was dramatic. Before 1948, more than half of all states had no clinics; a year later, all but five had one or more. By 1959, there were more than 1,400 clinics serving more than 500,000 people. Certainly, the clinics had value, but how adept was staff at spotting mental illness in the people it treated?
In 1948 came the film, The Snake Pit. In the midst of all these changes in the mental health field, it was one of the first films to treat mental illness and hospitalization in insightful, compassionate terms. But by the 1960s, some were openly challenging the entire concept of mental illness. In 1961, psychiatrist Thomas Szasz and sociologist Erving Goffman each argued that there is no such thing as mental illness. Goffman felt that people in mental hospitals exhibit psychotic behavior as a result of the hospitalization. In 1962, Ken Kesey wrote One Flew Over the Cuckoo's Nest, based on his experiences working in a psychiatric ward in a Veteran's Administration hospital. He makes the same arguments as Szasz and Goffman: the patients aren't mentally ill, they just behave in ways that aren't socially acceptable.
In the mid-1960s, many of the seriously mentally ill began to be removed from institutions to local mental health facilities. Antipsychotics such as Thorazine aided in this transition. Antipsychotics were first developed in the 1950s, and while they did not cure the mentally ill, they proved to be highly effective in reducing symptoms of psychosis in many patients. The Mental Retardation Facilities and Community Mental Health Centers Construction Act was passed in 1963. It provided federal funds to establish a network of mental health centers so the recently deinstitutionalized could seek out treatment. But many released patients did not do so. Without proper care, some mentally ill people end up homeless. Two decades later, roughly one-third of those living on the streets are thought to be mentally ill, with the vast majority of them suffering from schizophrenia.
There is perhaps a reason for the growth in hospitals with separate psychiatric wards — as shown in the panel. Some mentally ill people show up in general hospitals looking for help. They put such institutions under stress. Detroit Receiving Hospital in Michigan is one of the busiest in the nation, serving up to 12,000 psychiatric patients annually. "For people who have lost it all, this is their house," stated Dr. Alireza Amirsadri, the medical director of high intervention programs. Of the 1,000 patients evaluated monthly in the psychiatric ward, 250 are repeat patients.
Some mentally ill also end up somewhere else: in jail. A 1992 survey found that 7.2% of inmates (about 100,000 people) suffer from serious mental illness. Cook County Jail and Riker's Island, located in Illinois and New York respectively, have been described as the largest psychiatric facilities in their states.
Where do things now stand? The growth of local mental health facilities surely must speak to the need for such places. But state and county mental hospitals still remain the largest provider of psychiatric treatment in this country. Numbers have fallen, to be sure: in 1970, they treated 185.8 people per 100,000 and now treat about 21.2. Roughly half of the residents, argue some experts, would be better off somewhere else. A recent Supreme Court decision, Olmstead v. L.C., has opened the door for this. It was successfully argued before the Supreme Court that the mentally ill need better access to homes and small community centers.
What are likely to be future trends? In the West we appear to cycle between "holding" the mentally ill in institutions that are little better than prisons — and simply letting them roam free. "Mainstreaming," was a phrase used during deinstitutionalization. Money is an issue, always. For the foreseeable future, a combination of "mainstreaming" and use of drugs seems to be the precarious balance we have settled on. The mentally ill march on — these days the armies of the "homeless."
Sources: Chart statistics come from Chapter 14 of Mental Health in the United States, 2000 by the U.S. Department of Health and Human Services located at http://www.mentalhealth.org. Chamberlain, Claudine. "Out of the Cuckoos Nest." Retrieved August 7, 2002 from http://www.abcnews.go.com; Sarah Webster. "Mentally Ill Pouring into City Streets." Detroit News, August 29, 1999, P.1.Fred Kaplan. "For Mentally Ill, Jail Means Care." Boston Globe, July 26, 2000. "The Cost of Madness on the Streets, Chicago Tribune, June 7, 1999.
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