Is This the Kind of Country We Want to Be?

November 2, 2015
Allen Frances, MD

Volume 32, Issue 11

There has probably never been a worse place and worse time to have a severe mental illness than now in the United States. How did we get into this mess?

[[{"type":"media","view_mode":"media_crop","fid":"43367","attributes":{"alt":"© Banauke/shutterstock.com","class":"media-image media-image-right","id":"media_crop_5802050218414","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4764","media_crop_rotate":"0","media_crop_scale_h":"197","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"width: 133px; height: 175px; float: right;","title":"© Banauke/shutterstock.com","typeof":"foaf:Image"}}]]Fraud, Theft, Waste and Private Profits: The Fate of Money Intended to Treat People With Serious Mental Illness is an important report by Torrey and colleagues1 at the Mental Illness Policy Org.

This recently released report offers depressing evidence that billions of dollars allocated by the states to provide mental health services have been wasted-some to outright fraud and some to support frivolous programs for the well and almost well, while the needs of the seriously ill have been shamefully neglected. The results of this misallocation and shortchanging are devastating.

There has probably never been a worse time and place to have a severe mental illness than now in the US. Because we have criminalized psychiatric disorders, 350,000 patients have inappropriately been made prisoners. Instead of receiving treatment, they are routinely jailed for minor nuisance crimes that could have been avoided if they had access to care. An additional 250,000 mentally ill persons are homeless because of our failure to provide them with anything approaching adequate housing.

Police officers who are forced to be first responders for the untreated mentally ill have learned that taking them to the emergency department is a waste of time because there are no treatment options. Imprisonment is a barbaric throwback, made doubly cruel by the high risk that the mentally ill will be placed in solitary confinement or be sexually abused. And untrained officers tend to be more frightened and trigger-happy when dealing with untreated patients-leading to the recent spate of tragic shootings.

How did we get into this mess? Deinstitutionalization of the mentally ill was a noble ideal badly tarnished by ignoble delivery. The number of psychiatric beds in the US has been reduced in the past 50 years from about 650,000 to about 65,000-nearly equivalent to the number of mentally ill who wound up on the streets or in prison. The mentally ill were abruptly kicked out of hospitals aptly called snake pits, only to be cruelly relegated to dungeons and back alleys.

It wasn’t supposed to be this way. The money saved by closing hospitals was to be reallocated for community treatment and housing. And for a while it seemed to be working reasonably well. But over time, the states gradually began to cut costs by privatizing the community mental health centers, which in turn began to cherry pick their case mix-neglecting the expensive and difficult-to-treat severely ill who desperately need help and instead developing more lucrative programs for the near well.

The profit motive doesn’t mix well with social responsibility. A civilized society is judged by the way it treats its most disadvantaged members. We flunk badly.

The question now is whether it is possible to reallocate the dollars that heretofore have been so badly misallocated. The timing makes this question essential. As a result of cost cutting, many prisons will soon close. It is crucial that the newly released mentally ill have accessible treatment and a decent place to sleep-or they too will wind up on the street.

The report by Torrey and colleagues is a valuable first step, providing a blueprint for reform. We cannot solve this problem without first identifying its causes. But it is no more than a first step and will have no impact unless it stimulates moral outrage and sustained pressure for change.

Those who benefit from the loopholes in the current non-system of mental health delivery will not give up their profits and perks without a fight. And no group in the US is as politically unrepresented, vulnerable, and powerless as the severely mentally ill.

Change will come only when our collective shame overcomes our current inertia. The report should stimulate the better angels of our national conscience. Most countries in the rest of the developed world take much better care of their severely mentally ill. We can do better and, if we are to avoid being ashamed of our country, we must.

This article was originally posted on 9/29/2015 and has since been updated.

References:

1. Torrey EF, Jaffe DJ, Geller JL, Lamb RL. Fraud, waste and excess profits: the fate of money intended to treat people with serious mental illness. Mental Illness Policy Org. September 28, 2015. http://mentalillnesspolicy.org/wastereport.pdf. Accessed September 29, 2015.