American Psychosis (28 page)

The $45.7 billion in annual SSI and SSDI costs and the $60 billion in Medicare and Medicaid costs are the major contributors to public mental health costs. In addition, the federal government contributes
$5.7 billion
to mental health programs under the Department of Defense, the Veterans Administration, and a $386 million federal mental health block grant to the states. The costs of mentally ill individuals in jails and prisons must also be included. There are approximately 2 million individuals in jails and prisons; if an average of 20% of them are seriously mentally ill, then that would be 400,000 individuals. A conservative estimate of the cost of inmates in jails and prisons is $25,000 per year, although costs are higher for mentally ill inmates. Nevertheless, even at this cost, 400,000 inmates would add
$10 billion
a year to the nation’s mental health costs.
⁵⁸

In addition, the costs of law enforcement, courts, and public shelters used by mentally ill persons must be included. A 2002 estimate for persons with schizophrenia
cited law enforcement costs as
$2.6 billion
and public shelter costs as
$6.4 billion
. That survey also estimated the cost of family caregivers for individuals with schizophrenia at
$7.9 billion
.
⁵⁹

In total, it would appear that the direct costs of supporting and treating individuals with serious mental illnesses in the United States are presently at least
$140 billion
per year. This figure does not include indirect costs such as income lost by the mentally ill persons; in 2002 this was estimated to be $193 billion. Nor does it include the social costs of violent crimes committed by mentally ill persons, which have been estimated to be $925,000 per crime.
⁶⁰

One hundred and forty billion dollars per year is a lot of money. For purposes of comparison, it is three times the 2012 budgets of the National Institutes of Health, the National Science Foundation, and the Centers for Disease Control and Prevention
combined
. To obtain $140 billion dollars, each adult in the United States has to contribute approximately $650.

The fact that the $140 billion being spent on public mental health services in the United States is merely buying the grossly inadequate and disjointed services described in this book is mind-boggling. It suggests that something is profoundly wrong. One hundred and forty billion dollars should be more than sufficient to support excellent mental health services if the money was being used wisely. How this might be done will be the subject of the final chapter.

8
SOLUTIONS: WHAT HAVE WE LEARNED AND WHAT SHOULD WE DO?

For more than a century, the care of individuals with serious mental illnesses had been the responsibility of state governments. The transfer of this responsibility from states to the federal government began during 1962, with the deliberations of President Kennedy’s Interagency Task Force on Mental Health; this group planned the new, federally funded community mental health centers. Half a century has now passed since those meetings took place—what would members of the task force think of their plans in retrospect?

Boisfeuillet Jones, the lawyer who was the task force chairman, and Robert Manley, the Veterans Administration representative, both died without apparently publicly expressing an opinion regarding the task force’s work. Daniel Moynihan is now also deceased but in 1994 expressed clear reservations about what they had done. As chairman of the Senate Committee on Finance, Moynihan convened hearings on “Deinstitutionalization, Mental Illness and Medication.” In his opening statement, he criticized the failure to follow up patients after discharge from the state hospitals: “It was soon clear enough that in order for this [deinstitutionalization] to work you could not just discharge persons, they had to be looked after.” The result, he said, had been a sharp increase in the number of homeless people. “To make great changes casually and not pay rigorous attention to what follows,” he added, “is to invite large disturbances.”
¹

Both economist members of the Interagency Task Force—Robert Atwell and Rashi Fein—are alive. Atwell later served as president of Pitzer College and president of the American Council on Education. During the 1962 discussions, he was one of the strongest voices on the task force urging the closing of state hospitals and the federalization of mental health programs. Thinking back on the program during a 2011 interview, Atwell recalled: “I really wanted this thing to work. . . . I was a believer.” When asked why the program failed, he said: “Funding was always going to be a problem and was never forthcoming.” Rashi Fein has had an equally distinguished academic career and in a 2010 interview clearly recalled that members of the task force “were all troubled about the funding.” In retrospect, he added, “we should have more carefully examined and discussed what it would take in dollars and commitment at the local and state levels to make the model work.”
²

The other official member of the task force, Robert Felix, was the director of the National Institute of Mental Health (NIMH) and architect of the proposed plan. Even as he was retiring from NIMH in 1964, however, he expressed some doubts about the plan, calling “essential” the “follow-up and rehabilitative services for persons returned from inpatient psychiatric care, or under foster home or similar care.” Previously he had ignored such services and had not included them in the essential services for mental health centers. In 1984 Felix publicly acknowledged that “many of those patients who left the state hospitals never should have done so. . . . The result is not what we intended, and perhaps we didn’t ask the questions that should have been asked when developing a new concept but . . . we tried our damnedest.” Until his death in 1990, Felix continued to express serious doubts about the value of his legacy.
³

Stanley Yolles and Bertram Brown were the NIMH psychiatrists working closely with Felix at the time of the Interagency Task Force meetings. Yolles, who died in 2001, also expressed doubts about what they had created. He decried “the ‘dumping’ of mental hospital patients in inadequate community settings” and claimed that “the current situation results, in part, from an assumption made in 1963 that has not proved to be correct. At the time, many community psychiatrists believed that almost all mental patients could be treated in the community. This optimism was too euphoric. It now seems probable that there will always be some chronic patients—say, 15% of the total—who will require long-term, residential care.” Yolles added that “it is now obvious that . . . aftercare and rehabilitative services
must
be available within communities.”
⁴

Brown, the youngest of the psychiatric triumvirate that led NIMH down the community mental health path, is alive and was willing to recount these events during extensive discussions. He said that he and his colleagues “were carrying out a public mandate to abolish the abominable conditions of insane asylums,” but in doing so “the doctors were overpromising for the politicians. The doctors did not believe that community care would cure schizophrenia, and we did allow ourselves to be somewhat misrepresented.” He acknowledged a “failure of appreciation of the care needed by seriously mentally ill patients.” “For Yolles and me, individuals with serious mental illnesses were not a primary concern. . . . We should have done something to cover them, but it was not a priority. . . . We wanted to do something to help people using public health.” Asked what he should have done differently, Brown said he should have hired “five good mental health superintendents as consultants.” Looking back on it all, Brown characterized it as “a grand experiment” but added: “I just feel saddened by it.”
⁵

Fifty years after the initiation of this grand experiment, we also look with sadness upon the detritus of mental health dreams and lees of lost lives. As sociologist Andrew Scull observed, too often “the new programs remained castles in the air, figments of their planners’ imaginations. . . . The term ‘community care’ . . . merely an inflated catch phrase which concealed morbidity in the patients and distress in the relatives.”
⁶

As noted previously, these failed mental health programs were not conceived with malevolent intent. Their architects truly believed that closing state mental hospitals and moving patients into the community would improve everyone’s lives. In a 1972 interview, Felix said that his primary motivation was to make psychiatric services available to more people, and this wish was also expressed by Yolles and Brown. As noted by columnist and psychiatrist Charles Krauthammer, the “disaster” of deinstitutionalization was not “the result of society’s mean-spiritedness . . . [or] of mysterious determining forces, but of a failed though well-intentioned social policy. And social policy can be changed.”
⁷

IMPEDIMENTS TO CHANGE

Social policy
can
indeed be changed, but change does not come easily. Psychologist Franklyn Arnhoff, writing about mental health policy in 1975, observed that “it is extremely difficult to change its course even if there is mounting evidence that its costs or its harmful effects far exceed its benefits.” If we hope to change mental health policies, we must first understand the forces that impede change. These include the following
⁸
:

1.
Lack of understanding of serious mental illnesses
. There is a lack of public understanding, including among public officials, of the nature of serious mental illnesses. In recent decades, it has become clear that schizophrenia, bipolar disorder, and severe depression are brain diseases, just as multiple sclerosis and Alzheimer’s disease are brain diseases. However, public understanding lags behind the scientific understanding. Because of the inordinate influence of Sigmund Freud’s ideas on American thought in the last century, many Americans still believe that serious mental illnesses are psychological, not biological, in origin. This lack of understanding is especially acute regarding mentally ill individuals whose brain dysfunction involves the parts of the brain we use to think about ourselves—what we call anosognosia. Despite being overtly mentally ill, such individuals have no awareness of their own illness or need for medication; most such individuals will thus refuse to take medication because they honestly believe that nothing is wrong with them. It is very difficult for most people to understand this.

2.
Lack of understanding of the magnitude of the mental illness problem
. There is a lack of public understanding, including among public officials, of the magnitude of the mental illness problem as described in the preceding chapters. The deterioration of public mental illness services has been a gradually evolving disaster, like slowly rising water without any major flood to call attention to itself. The mental illness
disaster also has many manifestations, which at initial glance do not appear to be related. For example, an average American family may be aware that their county taxes are being raised to pay for the new addition to the overcrowded county jail; that they no longer allow their children to go to the public library alone because of all the strange men there talking to themselves; that people are reported by the news as sometimes doing bizarre things, like the man in Buffalo who cut down utility poles with a chainsaw; and that rampage killings, such as those carried out by Jared Loughner and James Holmes, seem to be happening more frequently. All these are consequences of a single problem—the failure to appropriately treat individuals with severe psychiatric disorders—but almost nobody makes the connection.

3.
Lack of understanding of the civil rights of people with severe mental illnesses
. Americans highly value our civil rights to live as we please and not have the government tell us what to do. Many people thus defend the rights of homeless mentally ill persons to be “free” to live on the sidewalk, under a bridge, or in jail. What they don’t realize is that most such people are not “free”; rather, their actions are dictated by their delusions and auditory hallucinations, however irrational those may be. The freedom to live in the community while psychotic may also interfere with the rights of other members of the community. As psychiatrist Gary Maier phrased it, “When the personal freedom of the mentally ill is given priority over all other considerations, the tyranny of some will jeopardize the autonomy of all.”
⁹

4.
Public mistrust of psychiatry
. The history of psychiatry includes multiple examples of gross abuse, including the killing of mental patients in Nazi Germany, the forced psychiatric hospitalization of political dissidents in the Soviet Union, and the unconsented sterilization of patients in psychiatric hospitals under the eugenics movement in the United States. Groups opposed to psychiatry, such as the Scientologists and the “psychiatric survivors” described in the last chapter, exploit this public mistrust to block any legislation associated with involuntary treatment.

5.
Economic interests to maintain the status quo
. The nursing home industry and the board-and-care home industry have greatly profited from the discharge of hundreds of thousands of psychiatric patients, whose community care is then paid for with federal funds. Two-thirds of nursing homes and almost all board-and-care homes are for-profit operations. As the owner of seven nursing homes in Illinois inelegantly phrased it: “It’s almost impossible not to make money—unless you’re a total and complete idiot.” In many states, the nursing home and board-and-care home industries have close financial ties to state legislators and governors, making change problematic. For-profit managed care companies have also benefited significantly by managing the care of the deinstitutionalized patients.
¹⁰