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3 Ways the American Mental Health System Has Fallen Apart

Ever since Dorthea Dix’s clarion call for more attention to patients with mental illness, the United States has struggled to find the best way to serve a growing segment of our population – about 26.2% of individuals over the age of 18 have a diagnosable mental disorder in a given year.

There have been great successes, like Truman’s 1946 National Mental Health Act or the Americans with Disabilities Act, which finally put mental and physical illness on the same legal footing.

Three trends — de-institutionalization, budget cuts, and the unique state of mental health in the military — consistently plague our national mental health system.

1. De-institutionalization

Beginning in the mid-1900s, there was a move away from the “institutions” of the Dorthea Dix era (asylums, mental hospitals) towards community-based care. Researchers and advocates felt that patients were much more likely to experience a satisfactory quality of life if they were in smaller, community-care settings or even with their own family. The increased attention to detail and familiarity of the surroundings, it was thought, was infinitely preferable to cold, aseptic, unstimulating institutional care.

The debate over de-institutionalization continues to this day. While many argue that it is the better philosophical approach to treating mental illness, the reality is that many community-care centers and families lack the resources to adequately care for the mentally ill.

Some studies have reported positive outcomes from community-based mental health care programs, (including improvements in adaptive behaviors, friendships, and patient satisfaction,) while other studies have found that these individuals experience significant deficits in important aspects of health care, including vaccinations, cancer screenings, and routine medical checks, as well as “loneliness, poverty, bad living conditions, and poor physical health.” The right balance between institutions and community-based care is elusive.

2. Budget cuts

When it comes to paying for care, let’s face it: Money problems are everywhere, and the mental health system has suffered from severe budget cuts across the country.

Lack of public advocacy, however, means that mental health systems are often first cut or most drastically affected, especially at the state level. Sandy Pasch, a state representative from Wisconsin, notes that “Mental health is often one of the first things to cut ... it’s not one of the heavily lobbied groups."

Over $4.3 billion has been cut from state mental health budgets in the past three years, and private practices are shrinking. Many providers no longer take insurance because it does not cover their costs.

3. Ignoring mental health in the military

The attitude towards mental health in the military has been a subject of concern for many years. In addition to the fact that many military personnel are put in situations where mental illnesses and trauma are developed or exacerbated (post-traumatic stress disorder being the primary example), the military culture of stoicism and silence discourages reporting and treatment. Less than 40% of individuals diagnosed with PTSD will get proper and complete treatment.

Military officials face a catch-22 of duty vs. health: A diagnosis of serious mental illness often signals the end of an individual’s military career, so doctors and military personnel do their best to treat soldiers while keeping them in the fight. This exacerbates the stigma associated with getting treatment for mental illness.

Each of these trends will require creative, innovative solutions to show real progress in moving our mental health system forwards.

Better education, especially in schools, may help the problem. Mental health is not always included in school curricula regarding health and safety, and even if a community has extensive resources available for treatment, often individuals do not know how to recognize indicators of mental illness and do not know where to go for help. Educating students will allow them to grow up to be active members of the community in promoting mental health.

Governments, both state and federal, should fund more and fund what works. California’s Proposition 63 offers a model for restructuring state level funding for mental illnesses to ensure that effective programs are being adequately funded, and that research continues in developing best practices in mental health care.

The military should conduct mental health screenings. A study conducted with Army soldiers shows that those screened for mental health issues before deployment, allowing for preemptive treatment and early detection, experience 78% less psychiatric and behavioral problems than their non-screened colleagues.  

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