Ignoring psychological well being infrastructure can be a expensive mistake

P.Resident Biden’s ambitious infrastructure plan has a glaring loophole: it makes no effort to offset the dire reality that the United States has the worst mental health infrastructure of any country in the developed world.

People with mental illness, their families and society as a whole suffer from the tragic consequences of four decades of mental health defunding and privatization: 90% of psychiatric beds have been closed; the once wonderful system of publicly funded community-owned psychiatric centers has been gutted; There are almost no crisis response teams; and the available pool of affordable housing only covers a fraction of the need.

In the Middle Ages, people with severe mental illnesses were often chained up in prisons, begged on the street or slaughtered in poor houses. In modern America, 350,000 people are in jail or jail with mental illness (often for harassment crimes that could easily have been avoided if treatment had been possible); 250,000 of them are homeless; and the average life expectancy of people with severe mental illness is 20 years shorter than that of the general population. The death rate from Covid-19 was three times higher in people with schizophrenia than in the general population – the second largest risk factor after age.


Police officers, sheriffs and judges have become some of the most vocal critics of the brutal criminalization of mental illness and are now among the strongest advocates of improved community treatment and housing. Forcing frightened and untrained police officers to be first responders for people with untreated mental illness puts them in untenable positions and is partly responsible for police brutality and shootings. People with untreated mental illnesses are 16 times more likely to die in police operations than other civilians.

And once in prison, people with mental health problems are difficult to deal with, continue to deteriorate, spend disproportionate amounts of time in solitary confinement, and stay longer (especially since they have no place to go and no treatment in the event of one) Release).


How did the US get into this mess? The massive and rapid deinstitutionalization of people with mental health problems began in the late 1950s for several reasons: partly because effective antipsychotics had been discovered; in part as a humanitarian response to the horrors of overcrowded state psychiatric “snake pits” hospitals; partly as a cost-cutting method (since mental health has often been the largest and most enticing item in government budgets).

The “new approach to mental illness” called for by President John F. Kennedy in a 1963 speech that led to his signing of the Community Mental Health Centers Act later that year was in response to the major disruptions caused by the rapid closure caused by the large state hospitals. Community services should enable people with mental illnesses to live better lives at a lower cost to states.

My first job at a mental health community center in 1973 in New York City was exciting. Patients languishing in government hospitals for decades have been able to lead much more normal lives with the benefits of the medication and community inclusion. The US became the world leader in community psychiatry, and I was proud to be a psychiatrist.

That began to change shortly after Ronald Regan was elected president in 1980. He ended federal funding for this system of community mental health centers and instead replaced block grants to the states that they could use at their own discretion. Almost all states have acted badly and cut taxes rather than using federal funds on community mental health as they did before.

And the money saved by closing expensive government psychiatric hospitals rarely followed patients to their communities to provide much-needed treatment and shelter. Community psychiatric services were either closed or privatized, and the new private services routinely refused to care for people with severe mental illness because they were usually uninsured and treatment was always very expensive.

In the end, deinstitutionalization turned into restitutionalization, as prisons replaced hospitals as the largest item in state budgets. Under Reagan, the United States quickly went from the best community mental health system in the world to the worst, and things have only got worse since then.

It is not clear how much of Biden’s extensive plan to rebuild the physical and human infrastructure will eventually be put into law. But it is crystal clear that rebuilding our country’s shamefully lacking mental health system is not part of the plan.

It is also clear why. Powerful lobby forces in Washington are rushing to get the money for the infrastructure program. Whatever the outcome will reflect how much political and economic power each industry can exert on the politicians who run the horse trade. In this clash of the titans, people with mental illness are voiceless and their interest groups lack political and economic strength.

Caring for people with severe mental illness is inevitably a public task that has been neglected in our primarily for-profit private health system. The United States has shirked this public responsibility more than any other developed nation on earth. The Biden plan is a sadly missed opportunity to catch up on much-needed mental health services, and mental health exclusion means there is no hope in sight.

Mahatma Gandhi once said that a nation’s greatness is measured by how it treats its weakest members. By this standard, the United States is morally bankrupt and the exact opposite of great.

Allen Frances is a psychiatrist, professor, and chairman emeritus of the Duke University Department of Psychiatry and was chairman of the DSM-IV Task Force from 1987 to 1994.

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