A Crisis Ignored
October 28, 2003
by E. Fuller Torrey
THE report of President Bush's Commission on Mental Health, appointed to take stock of the nation's broken mental-health system and recommend improvements, is a tremendous disappointment. All that saves it from being a total waste is a hint that suggests a better way forward.
Two brand-new studies underscore the degree to which our jails have become our de facto mental-health care system: One in five of the 2.1 million Americans in jail and prison is seriously mentally ill, a report from Human Rights Watch says - outnumbering by far the mentally ill in mental hospitals. The other study, from the Correctional Association of New York, notes that one in four New York state prisoners in solitary confinement is mentally ill.
Yes, the commission report, among other acknowledgments of the systems failings, notes that the nation's prisons and jails teem with inmates suffering from serious mental illnesses. But President Carter's mental-health commission made similar points 25 years ago. Most of the report's recommendations are mere platitudes (e.g.: We must "promote the mental health of young children"). Others are marvels of evasion.
For example, the commission calls for a national campaign to "reduce the stigma" of mental illness, without addressing what multiple studies (and common sense) show to be the main cause of that stigma: untreated mentally ill individuals committing acts of violence - from pushing subway commuters into the path of oncoming trains, as has happened time and again in New York in recent years, to shooting the president, as John Hinckley did in 1981.
The psychiatrically disabled (less than 1 percent of the U.S. population) commit 1,000 murders a year in America, 4 to 5 percent of the nation's total yearly homicides.
The commission says nothing about such incidents; it is politically incorrect in the psychiatric community to link violence with mental illness. But the typical citizen is well aware that untreated mentally ill individuals can be dangerous, whether professionals want to speak about it or not. All he need do is open his morning paper.
Perhaps the commission's most glaring weakness, however, is its failure to confront directly the irrational and counterproductive way the nation funds the mental-health system.
Nobody can plausibly claim that the system lacks money. When the first President's Commission on Mental Health issued its report in 1961, the nation spent about $1 billion a year on mental-health care. Adjusted for inflation and population growth, that's roughly $8 billion in 2003. Yet in 1997 alone, the United States spent $71 billion on "treating mental illness."
Given the "often inadequate" treatment of the mentally ill that the commission mentions, though, it's clear that this largesse hasn't done much good.
Part of the reason is the outdated ideas of the psychiatric community. But government bureaucracy bears much of the blame too. Federal officials at the Baltimore headquarters of the Centers for Medicare and Medicaid Services dole out two-thirds of that $71 billion and decide what services to fund. These bureaucrats lack adequate knowledge of local conditions and resources, which vary widely from place to place, and they have had no reliable way of determining whether a program actually helps patients or is cost-effective - a recipe for inefficiency and waste.
It wasn't always this way. Back in the early '60s, state governments paid 98 percent of the total cost of the mental-health system. Then they discovered that, by closing down beds in state psychiatric hospitals, they could shift the burden of paying for psychiatric patients to four federal programs - Medicaid, Medicare, Supplemental Security Income, and Social Security Disability Income. (From the 1960s on, these offered benefits to mentally ill individuals, but only if they were not receiving care in a state mental hospital. )
No longer did mental-health officials ask, "What is best for patients?" The question now became, "What will the federal government pay for?"
The consequences have been grim. State mental institutions released scores of patients who should have remained hospitalized. Many fell through the cracks of the system, landing in jail or on the streets.
The President's Commission on Mental Health says little about this perverse funding arrangement, but its report does have a hidden signpost pointing toward a better system: The commission says Washington should grant states "increased flexibility" in spending federal money on the mentally ill, "in exchange for greater accountability and improved outcomes."
Here, truly, is ground for hope. Nothing would improve mental-health care more swiftly than giving states not just greater flexibility - the commission is far too cautious - but as much control as is politically feasible in spending mental health-care dollars, and then holding them accountable by measuring various outcomes. (These could include quality-of-life ratings by patients and their families, the number of homeless and incarcerated mentally ill, the employment rate of mentally ill people, quality of housing, and so on.)
The federal government would need to collect accurate data from the states in all these areas, woefully lacking at present. The feds would then reward states that did a good job by giving them more funding; states that let homeless mentally ill individuals use government funds to stay drunk and live on the streets would lose money. As a first step, federal officials could set up an experimental program in half a dozen states and analyze the results.
Local innovation, as the commission recognizes, has already created most of the nation's best mental-health programs. A prime example: the so-called clubhouse model, which originated with New York's Fountain House.
In these community facilities, mentally ill people can come together in a low-key, friendly atmosphere and receive vocational and social help. Clubhouse staff don't prescribe medicine or provide therapy, but they do remind clients to take their medicine and are on hand to give guidance and encouragement. These inexpensive programs are a big success, as their clients' high employment and low re-hospitalization rates prove.
Turning responsibility for mental health over to the states, while holding them accountable, would unleash many more such policy experiments, just as states that received waivers from the federal government to pursue welfare initiatives during the late 1980s and '90s came up with effective welfare innovations that set the stage for federal welfare reform.
For a president committed to "compassionate conservatism," there could be no better demonstration project than transforming the mental-health system along these lines, which would go far toward rescuing the most desperate of our homeless population. Too bad his commission, for the most part anyway, didn't see the opportunity.
E. Fuller Torrey is an M.D. and president of the Treatment Advocacy Center in Arlington, Virginia. The article is adapted from the new City Journal.
©2003 New York Post