This past week, Mother Jones‘ Deanna Pan posted a great, although brief, timeline of deinstitutionalization in the United States’ mental health systemi, running from the 1st mental patient admitted to an asylum in the 18th century(1) to the present day. Much of the information presented in the timeline is relevant to a discussion of the decline of the state mental health system in America, but one particular stat jumped out at me: In 2010, there were a mere 43,000 available psychiatric beds in the US, a number which stretches out to about 14 beds per 100,000 citizens. And, while that 14 for every 100,000 number may look bad on the surface, it gets even worse when put into historical context. The current ratio of inpatient psychiatric beds to the general population is the same as existed in 1850, before a sizable movement to take care of the mentally ill had even formed. Keep in mind it was less than 60 years ago that America had in excess of 560,000 occupied mental hospital beds, and that was for a population that was about half of the size it is today. If our inpatient psychiatric capacity had just managed to keep up with population growth, we’d have over 1 million available beds for mentally ill Americans. Instead we don’t even have enough inpatient psychiatric patients to fill a decent sized NFL stadium.
Given the fact that our country now has the same inpatient psychiatric capacity that it did the year that California was admitted to the union as a state, the $64,000 question becomes, where did all of those beds go? It isn’t as if mental health issues have become less prevalent or less culturally accepted over the past 60 years. You can’t watch TV for more than half an hour without seeing that miraculously happy Zoloft egg bouncing across the screen or watching an ad for Hoarders or Intervention or any of the 1,001 shows dedicated to documenting the “reality” of mental illness in all of its glossy, made-for-TV splendor. In the 21st century, it’s become culturally accepted (with varying amounts of salt) that 1 in 4 people will suffer from some sort of mental illness in their lifetime, so how is it that our psychiatric inpatient facilities have cleared out like Disney World in January?
Well, to paraphrase George Orwell, all mental illnesses are equal, but some mental illnesses are more equal than others. As a society, we have come to accept and even embrace the more palatable mental health issues like depression and anxiety because they’re not too far from our own experience and because they generally occur in folks who are functioning members of society. All of us get sad and nervous from time to time, so it’s not too hard to place ourselves in the shoes of a friend or neighbor who suffers from clinically significant depression or anxiety. Plus, these people generally have a fairly easy time articulating what they’re feeling and are able to develop a good rapport with a therapist or psychiatrist. Put another way, these are middle class mental illnesses.Higher-income countries have much higher rates of depression than low or middle-income countries, in part because these countries generally have time, money and infrastructure to deal with such problems. According to a recent World Health Organization survey, the United States can boast a lifetime depression rate of 19.2%, while China’s was only 6.5%. You can call me crazy, but I have a hard time believing that there are 3 times as many depressed people in the US as there are in China. And, while I’m sure there are myriad factors that go into the creation of a disparity like that, I believe that a good chunk of that depression gap comes from the fact that Americans have been acculturated to look for depression within themselves and others, while the Chinese have not. It’s kind of hard to self-report being depressed if you don’t know what feeling depressed is supposed to look like.
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Now, while there has been a great deal more acceptance of disorders like depression and anxiety, the same cannot be said of severe and persistent mental illnesses like schizophrenia, bipolar and various personality disorders. Essentially, the crazier you are, the less people are going to embrace you as you deal with your disorder. An employer who might be sympathetic to an employee suffering from panic attacks that effected his productivity will likely lose most of that sympathy if that same person has a manic episode during a conference and takes the company’s rental car out on a 2 week joyride without telling anyone. Deinstitutionalization was tailor-made for the person suffering from severe anxiety or generalized depression. Any service that a person suffering from either of those disorders could ever need can be found within the context of the community-based clinic. In the majority of cases, placing someone with chronic depression in an inpatient facility constitutes an inappropriate level of care and a waste of resources.
What deinstitutionalization has ignored to a criminal degree are those folks suffering form severe and persistent illness who truly need long term inpatient care and, if they are to live in the community, need to have a much more intensive array of services at their disposal. 60 years of mental health policy from Kennedy to Reagan to Clinton has emptied our psychiatric hospitals and kept deferred prospective patients to alternative systems of care without ever taking care to build these alternative systems to anything approaching the capacity needed to deal with the length and breadth of the problem. In the absence of such services, those most affected by mental illness have been forced into other institutions that are unsuited to deal with their needs or are simply cast out on the street. In 1955, there were 560,000 occupied inpatient psychiatric beds in America compared to around 250,000 prison and jail beds. Today, America sports 43,000 psychiatric beds and 2,239,800 prison and jail beds, with an estimated 320,000 of those being occupied by people suffering from severe mental illness. After 60 years of “progress”, America now has more severely mentally ill prisoners in 2013 than it did total prisoners in 1955.
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1As an aside, the people with the ignominious distinction of being the first two mental hospital patient in our nation’s history are Zachariah Mallory, a 42-year old man from Hanover County, VA and Catherine Harvey of New Kent County, VA, who were described by the first court of directors responsible for the reception of patients to mental hospitals in October of 1772 as being, “persons of insane and disordered minds.” Mallory, for his part, would be dead within a year of being committed to the asylum, while Harvey’s ultimate fate is unknown.