Deinstitutionalization was a government policy that moved mental health patients out of state-run "insane aslyums" into federally-funded community mental health centers. It began in the 1960s as a way to improve treatment of the mentally ill, while also cutting government budgets.
Causes of Deinstitutionalization
Three societal and scientific changes occurred that caused deinstitutionalization. First, the development of psychiatric drugs, such as Thorazine and later Clozapine, effectively treated the symptoms of mental illness. Second, society accepted that the mentally ill needed to be treated, instead of locked away. Third, federal funding, such as Medicaid and Medicare, went towards community mental health centers as opposed to mental hospitals. (Source: Ohio State Journal of Criminal Law, Reducing Mass Incarceration: Lessons from the Deinstitutionalization of Mental Hospitals in the 1960s, 2011)
1954 - The FDA approved Thorazine (chlorpromazine) to treat psychotic episodes.
1955 - With the Mental Health Study Act of 1955, Congress called for "an objective, thorough, nationwide analysis and reevaluation of the human and economic problems of mental health."
1962 - Ken Kesey published One Flew Over the Cuckoo's Nest, a fictional story about abuses in a mental hospital. It dramatized conditions. and helped turn public opinion against electro-shock therapy, commonly used at the time.
1963 - President John F. Kennedy signed the Mental Retardation Facilities and Community Mental Health Centers Construction Act to create community-based mental health facilities. The National Institute of Mental Health (NIMH) created them to provide prevention, early treatment, and ongoing care, with one per every 125,000-250,000 people. The centers allowed patients to be closer to their families, and integrated in society. (Source: MindDisorders.com, Community Mental Health Centers)
1965 - Medicaid was passed. It doesn't pay for patients in mental hospitals, so states moved them into nursing homes and hospitals to transfer the costs to the Federal government.
1967 - California's Governor Ronald Reagan signed the Lanterman-Petris-Short Act, which limits the ability of families to commit their mentally ill relatives without the right to due process. It also sought to reduce the state's institutional expense. The number of mentally ill people in California's criminal-justice system doubled the next year, while the number treated by hospital emergency rooms also increased. Other states followed with similar involuntary commitment laws.
1977 - There were only 650 community health centers, less than half what was needed, serving 1.9 million patients. At first, they helped those with less chronic disorders. However, as states closed hospitals, the centers were overwhelmed patients with more serious challenges.
1980 - President Jimmy Carter signed the Mental Health Systems Act, to fund more direct care and rehabilitation.
1981 - President Reagan repealed the Act through the Omnibus Budget Reconciliation Act, shifting the funding to the state through block grants. This grant process meant that community mental health centers competed with other needs, like housing, food banks and economic development, for Federal funding.
1985 - Federal funding dropped to 11% of community mental-health agency budgets.
1990 - The FDA approves Clozapine to treat the symptoms of schizophrenia.
2004 - Studies suggest approximately 16 percent of prison and jail inmates are seriously mentally ill, roughly 320,000 people. This year, there are about 100,000 psychiatric beds in public and private hospitals. That means there are more three times as many seriously mentally ill people in jails and prisons than in hospitals.
2009 - The Great Recession forced states to cut $4.35 billion in mental-health spending over three years.
2010 - The Affordable Care Act mandates that insurance companies must cover mental health care as one of the ten essential benefits. Specifically, it states that Mental and Behavioral Health Treatment - This includes treatment for alcohol, drug and other substance abuse and addiction. Patient co-pays could be as high as $40 a session, and the number of therapist visits could be limited. (Source: Mother Jones, Timeline: Deinstitutionalization and Its Consequences, April 29, 2013)
Deinstitutionalization Pros and Cons
Deinstitutionalization was successful in giving more rights to the mentally challenged. It changed the culture of treatment from "send them away" to integrate them into society where possible. It was especially advantageous for those with Down's Syndrome and other high-functioning people with mild mental challenges.
Many of those who were deinstitutionalized were severely mentally ill, living on the back wards of the hospitals for decades. They received varying levels of care, and were not considered treatable. This is the situation that deinstitutionalization tried to solve.
Despite these living conditions, many of them were not really good candidates for community centers due to the nature of their illnesses:
- 50-60% were schizophrenic.
- 10-15% were manic-depressive or severely depressed, or both.
- 10-15% had organic brain diseases, such as epilepsy, strokes, Alzheimer's, and brain damage secondary from trauma.
- The suffered from mental retardation with psychosis, autism, or brain damage from drug addiction.
Today, 2.2 million of these severely mentally ill people do not receive any psychiatric treatment at all. About 200,000 of those who suffer from schizophrenia or bipolar disorder are homeless (about 1/3 of the total homeless population).
More than 300,000 are in jails and prisons. This means 16% of all inmates are severely mentally ill. This year, there are about 100,000 psychiatric beds in both public and private hospitals. That means there are more than three times as many seriously mentally ill people in jails and prisons than in hospitals. (Source: Treatment Advocacy Center, Deinstitutionalization: A Failed History; Frontline, Deinstitutionalization: A Psyciatric Titanic, May 10, 2005)'
Effects of Deinstitutionalization
Between 1955 and 1994, roughly 487,000 mentally ill patients were discharged from state hospitals. This reduced the number from 558,000 patients, or .03% of the population, to only 72,000 patients. As a result, more than 750,000 mentally ill people are now living in the community -- whereas before they would have been in a mental hospital. That's more than the population of Baltimore or San Francisco. (Source: Mother Jones, Timeline: Deinstitutionalization and Its Consequences, April 29, 2013)
As a result, many states closed their hospitals, permanently reducing the availability of long-term, in-patient care facilities. By 2010, there were 43,000 psychiatric beds available. This equated to about 14 beds per 100,000 people, the same ratio as in 1850.
Was Deinstitutionalization a Failure?
The goals of the movement were laudable -- to provide better care for the nation's mentally ill and allow those that could to take a place in society. However, it didn't really achieve its goals for three major reasons.
- Federal funding for the mental health centers was not enough. In addition, was difficult to coordinate it with state and local funding to create any comprehensive programs.
- Long-term, in-patient care provides better treatment for many with severe mental illnesses. Mental health professionals underestimated how difficult it was to coordinate community resources for those with disorders scattered throughout a city.
- The courts made it almost impossible to commit anyone against their will, even if it was for their own safety and welfare.
As a result, many of those the movement was meant to help aren't receiving the treatment they need. Instead, some are homeless, living in prisons or being cared for by overwhelmed family members. A few represent a danger to themselves and society, creating a bigger economic cost than before.
Lessons From Deinstitutionalization
After two decades of deinstitutionalization it's clear that two things are needed. First, is funding and coordination for a vast expansion of community housing and other services. Second, the realization that community services don't meet the needs of the severe and chronically mentally ill. There needs to be a better treatment for those that are institutionalized in prisons. The laws need to be changed to allow the severely mentally ill, who cannot always make rational decisions for themselves, to be placed in an institution that protects them as well as society. (Source: Hospital Community Psychiatry. Deinstitutionalization and the homeless mentally ill.1984 Sep;35(9):899-907) Article updated November 12, 2013