Bipartisan Mental Illness Plan
The abysmal conditions in state mental hospitals in the 1940s were caused by 3 factors, none of which are now true. Let’s explore.
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COMMENTARY
According to his campaign website, Donald Trump is planning to reopen some state mental hospitals if he regains the White House. Referring to individuals who are “severely mentally ill and deeply disturbed,” Trump said, “we will bring them back to mental institutions, where they belong, with the goal of re-integrating them back into society once they are well enough to manage.”1 Many will dismiss Trump’s plan out of hand, saying that it has already been established that state mental hospitals are bad.
But wait, where did that idea come from? It came from the post-war 1940s journalistic exposés of conditions in the hospitals at that time. In his book Oklahoma Attacks its Snake Pits, condensed for a 1948 Reader’s Digest, Mike Gorman described a state mental hospital dining room that made “Dante’s Inferno seem like a country club.”2 Albert Deutsch, in his 1948 book The Shame of the States, similarly described some state mental hospital wards as “scenes that rival the horrors of the Nazi concentration camps.”3 In 1958, the president of the American Psychiatric Association called for the abolition of all state mental hospitals. This theme was carried forward into the 1960s in Ken Kesey’s One Flew Over the Cuckoo’s Nest and Thomas Szasz, MD’s The Myth of Mental Illness.4,5
The abysmal conditions in state mental hospitals in the 1940s were caused by 3 factors, none of which are now true. The hospitals were grossly overcrowded—the number of state hospital patients increased from 255,000 in 1923 to 423,000 in 1940, a 66% increase during years when the general population increased only 18%. The hospitals were also markedly understaffed. Lucy Ozarin, MD, MPH, described working during the war as a psychiatrist in New York’s Gowanda State Hospital. Initially she was given responsibility for 500 patients, but when another psychiatrist was drafted into the Army, she became responsible for another 500 as well. Most important, there were no effective pharmaceutical treatments available at that time: antipsychotics and antidepressants did not become available until the 1950s.
Today, the situation at state mental hospitals is very different. We have a variety of effective treatments and enough mental health professionals to adequately staff the hospitals. What we do not have is a sufficient number of beds. In 1955, the number of state mental hospital beds peaked at 559,000. Deinstitutionalization reduced that number today to 40,000, a reduction of 93 percent. Sixty-two state hospitals have been closed altogether and those that are still open have a fraction of their previous beds. A professional consensus suggests that approximately 50 public psychiatric beds per 100,000 population is needed to provide adequate care; that translates into 160,000 beds, 4 times the number currently available. The beds are needed to stabilize and effectively treat those with the most serious mental illnesses, especially those who are homeless or incarcerated in jails and prisons. Such individuals may require several weeks of hospitalization, sufficient time for trials of clozapine, the most effective antipsychotic, as well as long-acting injectable antipsychotics. Stabilization ultimately requires more than just medication; Assertive Community Treatment (ACT) teams and Assisted Outpatient Treatment (AOT) for those who are unaware of their own illness are also needed, as well as attention to housing and rehabilitation, such as is available in the clubhouse (Fountain House) model. But stabilization in a hospital is the first requirement.
But perhaps the most important reason for taking Trump’s plan seriously is that it is not just a Republican idea. The Democratic mayor Eric Adams in New York and Democratic governor Gavin Newsom in California are both implementing plans to get homeless mentally ill individuals off the streets. In both cases, opening additional public psychiatric beds is part of the plan. Thus, Trump’s plan could represent a bipartisan beginning of a solution to the nation’s mental illness crisis.
Dr Torrey is the founder of the Treatment Advocacy Center and the author of American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System.
References
1. Owens C. Trump's plan to bring back mental institutions. Axios. October 31, 2023. Accessed January 5, 2024. https://www.axios.com/2023/10/31/trump-homelessness-mental-institutions
2. Gorman M. Mental illness: legislative and economic considerations. Am J Public Health Nations Health. 1963;53(3):403-408.
3. Deutsch A. The Shame of the States. Harcourt, Brace and Company; 1948.
4. Kesey K. One Flew Over the Cuckoo's Nest. Berkley; 1963.
5. Szasz T. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. Secker & Warburg; 1961.
