The Start of America’s Mental Health Crisis

Mental hospital

Heritage Explains

The Start of America’s Mental Health Crisis

The consequences of deinstutionalizing the severely mentally ill.


MICHELLE CORDERO: Right now our nation is in the middle of a serious debate about gun violence and mass shootings. A year has passed since a former student killed 17 people at Marjory Stoneman Douglas High School in Parkland, Florida.

: What made the shooting at Stoneman Douglas so different than other mass shootings was how quickly students and parents turned their pain into action.

CORDERO: Some are pushing for broader restrictions on Second Amendment rights. With new legislation like the recently voted on HR-8 that would impose significant burdens on law abiding citizens by mandating universal background checks.

REP. NANCY PELOSI: This will be a priority for us in the next Congress. Common sense background checks to prevent guns going into the wrong hands.

CORDERO: But we've still heard little on a number of other issues that weigh into gun violence and mass shootings. Like mental health, family breakdown, culture, media and more.

CORDERO: Heritage recently released a series of papers that address these issues. One of them tries to help us understand why the United States is suffering from a crisis of untreated serious mental illness.

CORDERO: During the 1960s and '70s, there was a mass removal of the seriously mental ill from inpatient facilities. It officially began in 1963 when the Kennedy administration implemented the Community Mental Health Act. This gave official credence to a movement that had been slowly developing and that kept developing afterward. The process has an official name and it's referred to as de-institutionalization. And between 1955 and 2016, the number of available public psychiatric beds in the United States dropped by 95%.

CORDERO: So what led to this movement? Where did all those who truly needed inpatient care go? And what have been some of the consequences?


CORDERO: Amy Swearer, a legal policy analyst in Heritage's Meese Center for Legal and Judicial Studies and one of the authors of the report that inspired today's episode, explains.

AMY SWEARER: It is really a combination of about four things. There was kind of this growing public consciousness of some really bad conditions in certain mental health facilities that just left a bad taste in a lot of people's mouths. But then also along with that, started in the 1950s, you had changes in medicine and in psychiatry in particular. That was not just a general trend of liberalization toward trying to get people out of inpatient facilities, but also the development of new medications that made a lot of doctors rethink their ability to adequately treat people in an outpatient setting.


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SWEARER: And so then along with that, you had changes from a fiscal standpoint with Medicaid. So when Medicaid gets introduced in 1965, it defacto encouraged a lot of states to close down inpatient facilities because what Medicaid did was reward states for having outpatient facilities by increasing money for every outpatient commitment that you had. But then saying, "Okay, and if you have inpatient commitments, we're not going to cover that with Medicaid." So, of course, when federal dollars are involved, states start acting accordingly and it was all of a sudden financially beneficial for states to have fewer inpatient beds to fill up so that they could have more outpatient beds and get more money.

SWEARER: And then on top of that, kind of on the further, into the 1970s, or kind of as this is already in full development, you have a series of court opinions from the United States Supreme Courts that on top of all of this, then made it harder for states to commit people to inpatient mental health treatment. It used to be that states could simply prove that someone had a mental illness and could benefit from treatment. But now they had to prove that the person was a risk of danger to themselves or others. And it also, some of these opinions made it easier for these people even if they were mentally ill and in inpatient facilities, it made it easier for them to reject treatment.

SWEARER: And so all of this kind of combined into this grand scheme of deinstitutionalization, just all of it together.

CORDERO: And I want to make sure that we highlight this number, in your research you found that as a result of these social, medical, and legal changes, that the number of available psychiatric beds in the United States dropped by 95% at this time. That's a lot.

SWEARER: Yeah, it is. It's de-institutionalization as a movement was extremely successful. When you put those four factors together, you had states shutting down inpatient mental health facilities. It wasn't financially beneficial, it was hard to do from a legal standpoint, and it just ... I mean, there's no other way to put it except that that movement, as a movement, was extremely successful.


CORDERO: So what do mental health budgets actually look like in states right now?

SWEARER: State budgets, especially since the downturn in 2008, 2009, states have been cutting their budgets across the board. But one of the places in particular that a lot of states have tried to cut their budgets is in mental health spending. So not only have you seen over the last couple of decades that dramatic decrease in inpatient infrastructure, but then on top of that, just between 2009 and 2012, states cumulatively cut about 4.3 billion dollars from their mental health budgets.

SWEARER: Some states more than others, but generally just across the board you saw states slashing mental health budgets. Not just for inpatient commitments, but also for outpatient commitments which were supposed to pick up the burden of all of those individuals who no longer had inpatient beds.

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CORDERO: Are there studies that show what we should actually have?

SWEARER: Yeah, so most policy experts, when they talk about a minimum number of inpatient beds that a population needs, they generally recommend between 40 to 60 inpatient beds per 100,000 people. And in most European OECD countries, it's well above that. In the United States, unfortunately, as of 2016, the average state provided only 11.7 beds per 100,000 people.

SWEARER: I think the national average is a bit higher than that when you include federal beds, but it's still well below the minimum that's recommended by policy experts.

CORDERO: So it's sad, actually. What started out with the best intentions actually still hurt our society because the alternatives weren't adequate. And we sort of created a vacuum and our mentally ill are either on the streets or in jails. And that leads me to my next question, which is in your report you mentioned that having fewer inpatient services has been associated with higher crime. Can you tell me about that?

SWEARER: Sure. I mean, as you said, it's important to recognize that the movement of deinstitutionalization started with the best of intentions. The problem was that there weren't adequate numbers of outpatient facilities and community facilities in place. And so all of a sudden you had large numbers of various mentally ill people without any sort of infrastructure for treatment and all of a sudden communities are dealing with this influx. And the burden on communities has been horrific. It's been a very large burden, not just from homelessness. Which homelessness as a concept did not really exist in the 50s, 60s, and 70s.

SWEARER: But when you look at studies that have really looked at the results of deinstitutionalization, there have been studies that show strong indications that the dramatic rise in violent crime that we saw as a nation during the 1980s and 1990s was in large part an effect of deinstitutionalization. So you had this massive influx of individuals with serious mental health needs, who became violent when they were untreated. And who were committing other crimes as a result of homelessness or not having their needs being adequately met.

SWEARER: Then when you start seeing this decline again in violent crime during the 1990s and early 2000s, a lot of that is actually attributable and unfortunately to these mentally ill individuals being essentially re-institutionalized, just back into jails and prisons. So there's this direct correlation between the number of severely mentally ill people out on the streets and some of these rises in violent crime.

CORDERO: So, in short, the burden of dealing with the individuals has fallen on law enforcement as opposed to mental healthcare professionals.

SWEARER: Yeah, that's unfortunately exactly right. There has been a tremendous increase in the amount of dealings with law enforcement with mentally ill individuals, to the point where many law enforcement agencies are bringing on board full-time psychiatrists and case managers because they're just seeing the same individuals. Most of the time for nuisance crimes, just over and over and over.

SWEARER: It's bad for people who are mentally ill, dealing primarily with officers who are well intentioned, but not trained in psychiatric needs. It's also dangerous for officers. So studies that have looked at violent confrontations, whether it's assaults on officers or officer involved shootings, a significant percentage of these incidents are related to untreated mental illness.

CORDERO: We'll be right back after this short break.


CORDERO: Amy, tell me more about your research and what you found when it comes to individuals in our jails who are mentally ill.

SWEARER: So recent studies that have looked at the proportion of mentally ill inmates in the United States have found absolutely stunning results that anywhere between 37% and 44%, so about 1/3 of our nation's state and federal inmates have been told by a mental health practitioner at some point in the past that they suffered from a mental illness. So not just, "Oh, they might be exhibiting signs or they're self-diagnosing," but have had a mental health practitioner tell them that they suffer from a mental illness that needs to be treated.

SWEARER: And that's vastly more significant than what you would see in the average population, which is about 1 to 2% of individuals who are dealing with serious mental illness on a given day.

CORDERO: Yeah, that's alarming.


CORDERO: So what can we do?

SWEARER: Well, there's a number of things that we can do. I think one thing we have to keep in mind is no one wants to say, "Well, we need to swing the pendulum back to the 1940s and 1950s where anyone with any sign of mental illness needs to be locked up in an inpatient facility for the rest of their lives." But we do need to start admitting that there is a place in society for inpatient mental health treatment. Especially as psychiatric beds of last resort, for when people are in the midst of a mental health crises and they need that emergency treatment, they need a place to stabilize.


SWEARER: And unfortunately right now we simply as a nation do not have an adequate number of beds. And so you're seeing essentially log jams of wait lists for people who go in and out of ERs with mental health crises, kind of get emergency stabilization treatment, but then there's nowhere for them to go. And so they're just kind of left on their own on wait lists or kind of given inadequate outpatient treatments, but they don't follow up or they don't understand their illness and there really isn't any sort of way of keeping them from deteriorating again.

SWEARER: And so one of the things that states can do to combat some of the effects of deinstitutionalization is to ensure that they are funding enough public psychiatric beds for these types of individuals. So that you're not seeing these long wait lists, you're not seeing this spiral down crisis.

SWEARER: And then another thing that states can do is enforce their existing mental health commitment procedures. So as I mentioned, in the 1970s there was a series of cases that made it harder for states. But even within that, there's some leeway with what states can do and the language that they can use to facilitate mental health commitments. And so one of the things that we talk about is how states can work within the existing framework to change that language and ensure that they're not making it harder than necessary on themselves to ensure that their citizens who are in desperate need of mental health treatment can have courts order them to that treatment.

SWEARER: And lastly, we need to make sure, 'cause as conservatives a lot of times when we're talking about throwing around money and funding things, we are for limited government. But it's important that when we're talking about states investing in public health initiatives such as investing in public psychiatric facilities, ensuring a sufficient number of beds, these are up front costs, yes. But they may seem daunting, but when you look at it in terms of the long term cost of shifting the burden of housing and treatment of severely mentally ill people to the criminal justice system, to the emergency medical systems, not to mention the human and economic costs associated with untreated serious mental illness, homelessness, petty crimes, things of that nature, it really is something that states should consider investing in and not slashing these budgets. Because these are some of the problems that are the underlying causes of so much social angst and ailments that we see in society right now.

CORDERO: Thank you so much, Amy.

SWEARER: Thank you.