More mentally ill prisoners, a burgeoning homeless population, and a high suicide rate indicate that a significant number of Americans deserve psychiatric attention, but fail to receive it, says the report's author, Timothy Kelly, Ph.D.
In "A Policymaker's Guide to Mental Illness," published by the conservative Heritage Foundation, Kelly contends that a national discussion about improving care for the mentally ill is sorely needed. He says policymakers should particularly emphasize improved care for individuals with serious mental illness, rather than for more benign psychiatric problems.
Serious mental illness, sometimes called SMI, includes chronic depression, bipolar disorder, schizophrenia, severe panic and obsessive-compulsive disorders, post-traumatic stress, severe attention deficit and hyperactivity disorder, and extreme anorexia nervosa.
Many of today's troubles are the result of the government's inadequate handling of de-institutionalization, Kelly says. De-institutionalization was the process during the
last 40 years in which psychiatric hospitals were downsized or phased out of existence. The improved effectiveness of antipsychotics and similar medications gave hope to physicians and families that individuals could function outside of sanatoriums.
Today the population of psychiatric hospitals is only 10 percent of the approximately one-half million patients during the mid 1950s, Kelly says.
The problem is that the government has not suitably handled the general disappearance of the nation's psychiatric institutions, he says.
"The initial hope was that antipsychotic medication would do for mental illness what penicillin did for infections--provide a cure for most cases," Kelly says. "Instead, the process of drug treatment and de-institutionalization brought about new problems. The medications themselves turned out to be problematic because they sometimes triggered severe side effects, and de-institutionalization gave rise to a critical need for treatment and support services in the home community."
Releasing patients was not a bad idea, he says, but Kelly believes that the effort to fill in the gaps in care left by the shuttered hospitals has been insufficient. In fact, the easily accessible community metal health services for the seriously mentally ill envisioned decades ago by the architects of de-institutionalization never materialized. Over the past 20 years, research has shown a direct relationship between de-institutionalization and increased numbers of the mentally ill homeless, and increased populations of mentally ill inmates in local and county jails.
To better serve Americans with SMI, Kelly advocates improved monitoring of treatment results, equal health insurance coverage for mental illness and physical care, and better commitment to the majority of mentally ill who receive their treatment through outpatient care.
Diane Rowland, executive vice president of the California-based Kaiser Family Foundation, says that the institutional mental health system is an antiquated notion, but its successor has not evolved to suit America's communities
"I think that de-institutionalization and large mental health institutions are now and should be a thing of the past," Rowland says. "People are better off in the community and they are better off if they can be maintained on prescription medications that they absolutely can get and be monitored for. But they need help with housing. They need help with job placement. [Patients] continue to have dependency needs that need to be supported and I think in many ways de-institutionalization became dumping instead of community-based care."
Mental patient rights activists are a major factor behind the failure of de-institutionalization, and have even hindered the implementation of community-based programs, according to Sally Satel, M.D., a fellow at the conservative American Enterprise Institute of Washington, D.C.
"This isn't cancer where we don't have a cure yet," Satel says. "We kind of know what to do, some of the systems just aren't built up enough and in some places you have anti-
psychiatry and civil liberties activists who really stand in the way of important policies that the severely mentally ill need--specifically outpatient commitment.
"How long can you justify people laying in the gutter getting frostbite, wallowing in their feces because they're right? That's absurd."
Americans are much more educated about mental illness than they used to be and there is less shame in talking about the subject, Rowland says. However, in spite of a greater knowledge of SMI, she says that existing supports are in decline, especially insurance coverage.
"The push to provide greater equity is an important one, but what I see on the current horizon is regression instead of progression," Rowland says. "I am specifically looking at some of the changes we are anticipating and seeing in employer-based coverage, as health insurance costs return and premiums rise. One of the first areas that becomes more restricted tends to be coverage for issues like mental health services."
The nature of mental illness makes measurements of severity and the tracking of cures extremely difficult, in spite of calls to do so, according to Merrill Matthews, senior fellow at The Heartland Institute, a Chicago-based libertarian think tank.
"The problem that you have with mental health care, one that makes it different from physical health care, is that it is easy to tell when a broken bone is healed, but it is difficult to tell when a broken mind is healed," Matthews says. "It is not entirely clear when a mind is broken. That has created all kinds of problems in a system in which the majority of health care costs are paid for by the third party."
The idea of equality for physical and mental health coverage is a non-issue, according to Satel.
"I don't think parity is relevant to the severely mentally ill. How many schizophrenics have private health insurance? It's not even a debate," she says. Satel favors Assertive Community Treatment or ACT services to treat schizophrenics who are unable to work and secure health insurance. ACT involves often publicly funded teams of multi-skilled professionals--a psychiatrist, a social worker, employment and housing specialists--who aggressively coordinate to fulfill the treatment and other needs of the mentally ill person.
She does favor parity of physical and mental health coverage for some SMI victims--those with severe depression and bipolar disorder, for example--who may eventually be able to work and secure private health insurance.
In response to criticism that HMOs and insurance companies do not proportionately cover mental illness, Matthews says that the public needs to realize the inherent difficulty in determining how to apportion coverage for those conditions.
"Because of the difficulties in knowing when a person is mentally ill, and how much care it takes to get that person stabilized, or whether stabilization is the goal or curing is
the goal, it becomes a real problem because in essence you create a blank check on the bank account of the insurance company," Matthews says.
"If you have a blank check on insurance companies you can justify an awful lot of mental health care. As a result, insurance companies have turned around and said: 'We have to put a stop on this, we can't give a blank check to our account, psychiatrists or psychologists, who oftentimes are providing very needed services but in many cases are holding people's hands.'"
A medical savings account is an appropriate balance between the needs of patients and the prudence of insurance companies, Matthews says. Medical savings accounts provide customers with high deductibles, but allow them to keep the surplus in their account if they fail to spend it over the course of a year, Matthews says.
Overall, Rowland says, if the movement to change the current mental health care system is going to gain ground, it will not be led from the top.
"I think the reformers are the people who have [mentally ill] family members and understand the dimensions of the mental health problems of this nation, and that together they need to exert the kind of leadership on the public policy leaders," she says. "I don't think that it comes from the policy community. It comes from the people."