Patients with severe mental illness (SMI) routinely have no access to adequate medication, psychological counseling, social support, and/or housing. The horrible result is that 600,000 patients are either prisoners or homeless—or rotate between the two. The past 50 years of neglect and criminalization have made the US one of the worst places in the world to have a mental illness.
Meanwhile, on the mild end of the psychiatric symptom spectrum, we have the opposite problem of massive over-treatment. About 20% of the general population regularly use psychotropic medications, most often prescribed unnecessarily and carelessly after brief visits with rushed primary care doctors eager to get the patient out of the office as quickly as possible.1 And, perhaps for too many of these patients, psychiatric medications may be no more than expensive placebos, wasteful and carrying the added burden of harmful adverse effects. With that in mind, I offer some advice to policymakers on how to solve the cruel paradox that haunts our mental health “nonsystem”—we are massively overtreating people who do not really need it, while callously neglecting those who desperately do.
The overall thrust of badly needed policy reform must be to correct this wasteful and inhumane misallocation of resources. We should be spending much less money on long-term medications for the worried well and for those with mild, transient problems. Watchful waiting and brief psychotherapy would be a much better (and cheaper) alternatives for them. And, we should also spend much less money on misallocated jail, prison, and police services. In contrast, we must spend much more money on psychiatric and addiction services to help patients avoid becoming prisoners or homeless. The following are my suggestions for policymakers in seven key areas.
1 The top and urgent priority must be to deinstitutionalize 350,000 mentally ill patients who are now inappropriately warehoused in jails and prisons and to rehouse 250,000 who are homeless. If we fail to correct this barbarity, nothing else we succeed in doing really matters.
2 Serious mental illness should be the focus of all publicly funded psychiatric treatment, social services, and housing—with a full push to provide universal and easy access to free services for the poor and the uninsured.
3 A high level and/or high priority mental illness (including addiction) task force composed of senior representatives from all pertinent federal agencies should be charged with developing a joint action plan to provide a nationwide system of community psychiatric, social, and housing services (along the lines of the Kennedy Community Mental Health Act of 1963). Legislation should receive urgent priority, speed through Congress with overwhelming bipartisan support, and be a feather in the cap of whichever president has the honor of signing it.
4 The funding mechanism should provide strong incentives for states and local jurisdictions to participate in the planning and implementation of the new programs and to provide matching funding over the long haul. Because there are so many stakeholders and moving parts, it is premature to speculate on precisely how funding would work and how it would be integrated with, or replace, current funding sources. It is essential that funding sources be bundled so that psychiatric, social, and housing services are integrated in seamless, wrap-around fashion. The chain of care is only as good as its weakest link.
Dr Frances is Professor Emeritus and former Chair, Department of Psychiatry, Duke University; Chair, DSM-IV Task Force. He is the author of Saving Normal and Essentials of Psychiatric Diagnosis. Twitter: @AllenFrancesMD. The views expressed in this article are those of the author and do not necessarily reflect the opinions of Psychiatric Times.
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