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Redeeming a Promise to the Mentally Ill

<i> E. Fuller Torrey, a research psychiatrist in Washington, is the author of "Surviving Schizophrenia" and co-author with Sidney M. Wolfe of "Care of the Seriously Mental Ill: a Rating of State Programs," published by the Public Citizen Health Research Group, Washington. </i>

Has deinstitutionalization been a failure? Take a walk through the parks of the city--any city--and decide for yourself. Count the number of clearly disturbed individuals chatting amiably to the air, gesticulating wildly to the clouds or just standing mute in the shadows of decaying buildings like 20th-Century gargoyles. These mentally ill individuals were not part of our landscape 25 years ago when we started emptying state mental hospitals.

Several studies suggest that seriously mentally ill individuals make up about 40% of the homeless. Therefore, by the most conservative estimates, there are at least 150,000 people with schizophrenia living on the streets.

Schizophrenia is a brain disease like multiple sclerosis, Parkinson’s and Alzheimer’s. Unlike these other diseases, however, schizophrenia can be successfully controlled with medications in the majority of cases. Yet almost none of the afflicted who live on the streets and in public shelters are receiving treatment for their disease.

Who is to blame? Since 1766, when the governor of Virginia went before the House of Burgesses requesting funds to build a hospital for “a poor unhappy set of People who are deprived of their Senses, and wander about the Country terrifying the rest of their Fellow Creatures,” states have had the primary responsibility of providing care for the seriously mentally ill. The federal government has been involved through Social Security disability payments and the funding of community mental-health centers, but mostly it has been the states that have provided care.

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It is becoming increasingly difficult to avoid the conclusion that most states have done an abysmal job. Apologists for one or another government agency or professional self-interest group committed to the status quo try to persuade us that state mental hospitals really are not that bad, that board-and-care homes really do quite a nice job, and that most of the homeless mentally ill prefer to live on the streets. The people described in the media’s horror stories, they assure us, are exceptions. But the exceptions keep appearing in our line of vision, more and more of them, growing in numbers until they no longer appear to be exceptions. We wish that they would go away, but they will not.

So what is to be done? Long-term re-hospitalization of the seriously mentally ill is not the answer. We know that most such individuals can be restored to function with hospital stays of only a few weeks. Nor is more money the answer. In a recent study by the Health Research Group in Washington, three states--Wisconsin, Rhode Island and Colorado--were the most highly rated in programs for the seriously mentally ill. They are spending $20.32, $31.54 and $24.88 (respectively) per capita per year on their mental-health programs. The average for all states is $30.27. California spends $28.88 and New York $74.06, yet their programs are rated far down the list.

How do the highly rated states achieve better services without spending more money? Colorado designates the seriously mentally ill as its first priority for the use of state mental-health dollars; if state funds are used to pay salaries for psychotherapists to treat “the worried well,” as happens in California and many other states, there are few funds left over for the seriously mentally ill. Rhode Island does it by providing decent community housing for the mentally ill disabled, the voters having approved 11 such bond issues in the last 18 years. Wisconsin does it by fixing fiscal responsibility at the county level and having “the dollar follow the patient” into the hospital and back out to the community. These and other highly rated states do it through effective leadership in their state mental-health agencies, supportive governors and legislatures, strong Alliance for the Mentally Ill consumer groups, and reliance on outpatient commitment (if the patient stops taking medicine, he or she can be returned to the hospital).

There really is no mystery about what needs to be done to provide high-quality yet economical services for the seriously mentally ill. Apart from the examples in other states, look at the better public programs in California’s San Mateo, Marin and Napa counties; go to the Eden Express in Hayward, where seriously mentally ill people are being rehabilitated and trained in restaurant work, or stop by Project Return in Santa Monica, which functions as a clubhouse for such individuals.

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We do not need more consultants, commissions or task forces to tell us what needs to be done. We simply need the will to do it.


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