E. FULLER TORREY: FAILING THE MENTALLY ILL ****
JFK’s dream of replacing state mental hospitals with community mental-health centers is now a hugely expensive nightmare.
On Feb. 5, 1963, 50 years ago this week, President John F. Kennedy addressed Congress on “Mental Illness and Mental Retardation.” He proposed a new program under which the federal government would fund community mental-health centers, or CMHCs, to take the place of state mental hospitals. As Kennedy envisioned it, “reliance on the cold mercy of custodial isolations will be supplanted by the open warmth of community concern and capability.”
President Kennedy’s proposal was historic because the public care of mentally ill individuals had been exclusively a state responsibility for more than a century. The federal initiative encouraged the closing of state hospitals and aborted the development of state-funded outpatient clinics in process at that time.
Over the following 17 years, the feds funded 789 CMHCs with a total of $2.7 billion ($20.3 billion in today’s dollars). During those same years, the number of patients in state mental hospitals fell by three quarters—to 132,164 from 504,604—and those beds were closed down.
From the beginning, it was clear that CMHCs were not interested in taking care of the patients being discharged from the state hospitals. Instead, they focused on individuals with less severe problems sometimes called “the worried well.” Federal studies reported individuals discharged from state hospitals initially made up between 4% and 7% of the CMHCs patient load, and the longer the CMHC was in existence the lower this percentage became.
It has now become politically correct to claim that this federal program failed because not enough centers were funded and not enough money was spent. In fact, it failed because it did not provide care for the sickest patients released from the state hospitals. When President Ronald Reagan finally block-granted federal CMHC funds to the states in 1981, he was not killing the program. He was disposing of the corpse.
Meantime, during the years CMHCs were funded, Medicaid and Medicare were created and modifications were made to the Supplemental Security Income and Social Security Disability Insurance programs. None of these programs was originally intended to become a major federal support for the mentally ill, but all now fill that role. The federal takeover of the mental-illness treatment system was complete.
Fifty years later, we can see the results of “the open warmth of community concern and capability.” Approximately half of the mentally ill individuals discharged from state mental hospitals, many of whom had family support, sought outpatient treatment and have done well. The other half, many of whom lack family support and suffer from the most severe illnesses such as schizophrenia and bipolar disorder, have done poorly.
According to multiple studies summarized by the Treatment Advocacy Center, these untreated mentally ill are responsible for 10% of all homicides (and a higher percentage of the mass killings), constitute 20% of jail and prison inmates and at least 30% of the homeless. Severely mentally ill individuals now inundate hospital emergency rooms and have colonized libraries, parks, train stations and other public spaces. The quality of the lives of these individuals mocks the lofty intentions of the founders of the CMHC program.
Perhaps the most remarkable aspect of this 50-year federal experiment is its inordinate cost. In 2009, 4.7 million Americans received SSI or SSDI because of mental illnesses, not including mental retardation, a tenfold increase since 1977. The total cost was $46 billion. The total Medicaid and Medicare costs for mentally ill individuals in 2005 was more than $60 billion.
Altogether, the annual total public funds for the support and treatment of mentally ill individuals is now more than $140 billion. The equivalent expenditure in 1963 when Kennedy proposed the CMHC program was $1 billion, or about $10 billion in today’s dollars. Even allowing for the increase in U.S. population, what we are getting for this 14-fold increase in spending is a disgrace.
Including President Kennedy, five Democratic and five Republican presidents have presided over the 50-year federal experiment. Jimmy Carter and George H.W. Bush appointed presidential commissions to examine the failed programs, but nothing useful came from either.
Nor is President Obama likely to do anything, since his lead agency, the Substance Abuse and Mental Health Services Administration, has essentially denied that a problem exists. Its contribution to the president’s response to the Dec. 14 Newtown tragedy focused only on school children and insurance coverage. And its current plan of action for 2011-14, a 41,000-word document, includes no mention of schizophrenia, bipolar disorder or outpatient commitment, all essential elements in an effective plan for corrective action.
The evidence is overwhelming that this federal experiment has failed, as seen most recently in the mass shootings by mentally ill individuals in Newtown, Conn., Aurora, Colo., and Tucson, Ariz. It is time for the federal government to get out of this business and return the responsibility, and funds, to the states.
The federal government, perhaps through the Institute of Medicine, would be responsible only for evaluating and rating state programs, much as it now does for education. The ultimate responsibility would rest with state legislatures and governors. Then, for the first time in 50 years, somebody could be held accountable for what has become an ongoing disaster.
Dr. Torrey is founder of the Treatment Advocacy Center and author of “American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System,” forthcoming from Oxford University Press.
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