Ignoring serious mental illness

By Henry Tomes, PhD
APA Executive Director for Public Interest

The more things change, the more they remain the same. This statement applies in many areas, but the one that I'll focus on is the treatment or--perhaps a better word--maltreatment of people with serious mental illnesses such as schizophrenia, bipolar disorder and major depression.

In the revolutions that have occurred in the name of better, more humane care of the mentally ill, the names of Clarence Beers, Dorothea Dix and others come to mind. They championed the cause of people with mental illnesses by seeking humane treatment, developing better mental health facilities and introducing more effective treatments.

Also seen as advocates for this group are those who, more recently, called for the abolition of large state-operated psychiatric facilities. As a result of their efforts, hundreds of facilities were closed and thousands of people with mental illnesses were discharged to community care in the 1960s and 1970s.

Deinstitutionalization held out the hope that people with mental illnesses would be treated on an outpatient basis near home by caring professionals. The story has been told often enough over the last 20 or so years of the dual failure of deinstitutionalization and inadequate care in communities, so it need not be repeated here. There are probably few readers of the Monitor who could not recite tales of how the mentally ill have been mistreated, ignored and abused by a nation whose leadership is failing to designate a portion of its trillions of surplus federal tax dollars to care for the mentally ill. State leaders, who still have primary responsibility for treating this population, are also spending or designating hundreds of millions of "extra" dollars elsewhere.

Where are the mentally ill?

The answer to that question is varied. Some are in hospital inpatient units, others in outpatient treatment, others are on the nation's streets and others are in homeless shelters. Many are cared for by families and friends.

However, the nation's prisons and jails have become places that hold increasing numbers of them. Several years ago it became known that the Los Angeles County jail had more than 4,000 inmates with mental illnesses, making it de facto the largest facility for the care and treatment of the mentally ill in the country.

Other large urban areas--among them New York City and Cook County--were not far behind in the incarceration of mentally ill people. A report, released in July by the U.S. Department of Justice's Bureau of Justice Statistics, estimated that 283,800 mentally ill offenders are incarcerated in the nation's prisons and jails. Another 547,800 were reported to be on probation after "serving time."

So, as state mental health systems are gradually reduced, state correctional systems spend sums that rival what they spend on the care and treatment of the mentally ill. Seriously mentally ill people who struggle to access treatment in their communities are often able to receive court-mandated treatment once they're arrested and jailed. Certainly, the arresting and jailing of mentally ill people is proceeding speedily and deliberately. By plan or default, jails and prisons are becoming the nation's mental health facilities.

What does the future hold?

For the pessimist, or perhaps for the realist, the future for mentally ill people who need public care has to be seen as more of the same--less care in places designed expressly for people with mental illness, more mentally ill on the streets and in homeless shelters, more incarceration and care in places designed by authorities within the criminal justice system.

For the optimist, the future holds brighter prospects for the mentally ill: The nation will become appalled at its mistreatment of this group and will once again reform its mental health systems. State and local mental health systems will redevelop community-based care. Rehabilitation will become an important outcome of the system. And the only mentally ill people considered for prison will be those who have committed a crime.

Whether the optimistic or pessimistic views of the future will prevail, of course, depends on national policy. The question is whether the nation is willing to dedicate resources to rejuvenate mental health systems or whether, as is the current strategy, it plans to continue expanding correctional systems that house many but rehabilitate none.



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