"All I could think to myself was, 'At least he is safe and will receive treatment in prison—something the community failed to provide him.'"
Every day, I wake up and go to work in a community-based, short-term care facility, where I provide psychiatric care to the most vulnerable members of our society. These are individuals with serious mental illnesses—most with unstable housing situations and a general lack of basic resources that most take for granted.
They cycle through homeless shelters, jails, and short-term care facilities, often multiple times within the same month. The prison system in the United States may be the largest provider of mental health treatment, but this was not by choice.
Although the mental health system lacks the necessary resources to support these patients’ needs, these patients are more so victims of a society that does not value proper humane treatment of those with serious mental illness.
The reason so few patients with serious mental illness in the United States are receiving adequate mental health care is complex and multifactorial. Insurance is an obvious reason, and so is access to care. What is not talked about nearly enough is the impact of unstable housing and food insecurity.
It is hard to focus on mental health treatment when you have no idea where you will sleep at night or how you will get your next meal. Having a great psychotherapy session or starting a medication will not solve these problems. There are real limitations to what psychotherapy and medication management can offer.
This is hard to understand if you are not working on the front lines, treating patients with serious mental illness. Many patients brought to the inpatient unit for mental health treatment are there involuntarily for being a danger either to themselves or to others. A good portion of these individuals lack the insight and judgment to engage in proper mental health treatment and are therefore not agreeable to starting evidence-based treatments. Those who do start treatment are often lost to follow-up shortly after discharge, or they discontinue medication once discharged.
Although money may be the obvious reason that community-based mental health care clinics are not meeting the needs of the patients, it is also about appropriate allocation of the funds that are available. It is a given that these clinics are going to operate at a deficit; providing care to vulnerable populations should not be for profit. With such poor reimbursement rates and poor patient outcomes, many well-meaning physicians will avoid working in community mental health.
This is also true for other members of the treatment team, including nurses and social workers, resulting in poor staffing and less access to services. We want to feel like we are making a difference and helping people—but the current practice can make you feel inadequate and useless to meet patients’ needs.
Although the criminal justice system is now the largest supplier of mental health treatment, this was not by choice.1 When community mental health care was introduced, the number of state psychiatric hospital beds decreased substantially and continues to do so. This relationship is known as Penrose’s law, which states that as the number of mental health hospital beds decreases, the number of incarcerated individuals with serious mental illness increases.2
I had a case in which a patient waited 60 days for a state hospital bed and eventually no longer met commitment criteria. He was discharged to a homeless shelter and subsequently incarcerated with serious charges within weeks of discharge. All I could think to myself was, “At least he is safe and will receive treatment in prison—something the community failed to provide him.” Although the policies and programs to avoid these circumstances theoretically exist, they are poorly executed and operate on limited budgets.
I do not believe this is what former President of the United States John F. Kennedy had in mind in 1963, when he envisioned a new approach to caring for our nation’s mentally ill.3 The vision of a network of well-organized community mental health centers to keep individuals out of state hospitals sadly never came to fruition. Now we are left with nothing to help these individuals.
What Kennedy did not understand, because he never worked with individuals with serious mental illness, is that not all these patients can live independently in the community. The level of support they require to live independently is far more than the community can supply, and now the safety net of the state hospital is gone.
There are real limits to what psychopharmacology can do for patients with serious mental illness. The idea that a person with decades of damage from untreated serious mental illness will start taking antipsychotic medication and suddenly be capable of meeting all their needs is ridiculous. These patients can recover and go on to live productive lives, but it will take a lot more than 3 to 5 days of short-term inpatient care followed by community mental health treatment that is not designed to meet their needs.
You will only know this if you are treating and working with these individuals daily. In theory, it is possible to treat individuals with serious mental illness in the community, but we must get serious about the true level of support and funding that is required to do so.
Although the dream of community mental health centers across the country can still be achieved, long-term funding to sustain these projects remains a barrier. The money that was saved by the reduction in state hospital beds was not allocated to mental health treatment and went on to fund things that had nothing to do with mental health. Individuals with serious mental illness are now relegated to a revolving door of short-term hospitalizations with no meaningful safety net or way out. It is not a surprise that many of these individuals find themselves in homeless shelters and prisons across the country.
A comprehensive community mental health treatment plan will require the coordination of hospitals, police departments, homeless shelters, and community mental health centers. We will need to educate the community about how to work with individuals with serious mental illness. We must continue to work on reducing the stigma that is associated with serious mental illness and the treatment of these disorders. Individuals should want to receive treatment at community mental health centers.
We need outpatient services, short-term inpatient facilities, and even long-term care facilities that all communicate effectively, allowing for soft transitions to each level of care. We need to track the data and outcomes so science can guide which parts are working effectively and which parts need revision. All this takes is the proper investment in the individuals of our population who have been neglected for far too long.
Dr Rossi is an inpatient and consultation liaison psychiatrist who also performs electroconvulsive therapy services at AtlantiCare Regional Medical Center in Pomona, New Jersey. He currently serves on the board of the New Jersey Psychiatric Association, where he worked on advocacy projects, including enhancing access to collaborative care in New Jersey.
1. Roth A. Insane: America’s Criminal Treatment of Mental Illness. Basic Books; 2018.
2. Hartvig P, Kjelsberg E. Penrose’s law revisited: the relationship between mental institution beds, prison population and crime rate. Nord J Psychiatry. 2009; 63(1):51-56.
3. Sharfstein SS. Whatever happened to community mental health? Psychiatr Serv. 2000;51(5):616-620.