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Monday, April 20, 2009

Report card on U.S. mental healthcare: We have nothing to be proud of (Part I)

Editor's Note: This is part one of a two part series that examines the lack of support we provide to Americans who suffer from mental illness, especially those who lack insurance or other funding to pay for treatment.

Part I discusses the issues in broad terms, while Part II will discuss possible solutions, some of which have already been tried.

We often pride ourselves on being a caring, inclusive society, looking after those among us who are especially vulnerable. Some of our most vulnerable are easily recognizable: the very elderly and the very young are two examples.

But there are also those who are extremely vulnerable but are frequently ignored: adults with a serious mental illness.

On what do I base this last statement? I base it on a report card on America's mental healthcare system. It is called Grading the States 2009: A Report on America's Health Care System for Adults with Serious Mental Illness, and it is published by the National Alliance on Mental Illness, or NAMI.

The results are appalling. Collectively, America grades out with a 1.25 GPA, or approximately a D+. This grade is based on a series of criteria spread over four general categories, with our nation's grades in parenthesis:
  1. Health Promotion and Measurement (D
  2. Financing & Core Treatment/Recovery Services (C)
  3. Consumer & Family Empowerment (D)
  4. Community Integration & Social Inclusion (D)
And what of the states by themselves?

By far, the most common grade was a "D": twenty two states received that ignoble distinction. Even worse, six states received an "F". Not a single state in the union, nor the District of Columbia, received an "A".

And only six states received a "B".

In case you are wondering how the Pacific Northwest did, Oregon and Washington led the way with C's. Alaska, Idaho, and Montana all came in with D's.

I don't know about you, but I cannot accept a 1.25 grade point average when the stakes are human lives. If this country were on an academic scholarship in a "humanities" program, it would get kicked out of school. The current state of affairs is an unacceptable lack of response to a population that is vulnerable, often misunderstood, more often overlooked, and even more often stigmatized.

How did we get here?

In the "old days", which I define as the period prior to the early 1960s, people were institutionalized in state psychiatric hospitals.

Conditions in some hospitals were abysmal at best. Bryce Hospital, the state hospital in Alabama, serves as a perfect example:
It failed to provide: (1) a humane psychological and physical environment, (2) qualified staff in numbers sufficient to administer adequate treatment and (3) individualized treatment plans. More specifically, the Court found that many conditions, such as nontherapeutic, uncompensated work assignments, and the absence of any semblance of privacy, constituted dehumanizing factors contributing to the degeneration of the patients' self-esteem. The physical facilities at Bryce were overcrowded and plagued by fire and other emergency hazards. The Court found also that most staff members were poorly trained and that staffing ratios were so inadequate as to render the administration of effective treatment impossible. The Court concluded, therefore, that whatever treatment was provided at Bryce was grossly deficient and failed to satisfy minimum medical and constitutional standards.
The hospital was the subject of a class action suit by family members of several patients at the hospital. The Federal Court ordered Alabama to rectify the situation. The hospital did not comply, at which point the Federal Court took over the task, appointing a "special master" to oversee the changes.

(For more, see Wyatt v. Stickney, 344 F.Supp. 373 (D.C.Ala., 1972).

The changes implemented seem like the most obvious basic building blocks of human dignity, yet it took a federal lawsuit to put those blocks in place. We take for granted that patients at a psychiatric hospital will have privacy, even if limited, personal space, and available mental health treatment, to say the least.

The state argued that it lacked money to hire staff to provide the basic necessities of human dignity. The Federal Court rejected that argument, explaining that lack of money does not excuse a lack proper facilities.

What has changed since those days?

Based in no small part on the abysmal conditions at state psychiatric hospitals, the government began "de-institutionalizing" mental health treatment locations in the community. That worked quite well until the government began cutting funding for mental health outpatient facilities.

The result is what we have now: persons with mental illness with nowhere to go on the streets, and nowhere to go for treatment.

It doesn't have to be this way.

In a follow-up post, I'll explore potential solutions that would fix our broken system and put us on the path to building a true safety net for the mentally ill that doesn't let anyone fall through the cracks.


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