Mental health policies in the United States

In 1843, Dorothea Dix submitted a Memorial to the Legislature of Massachusetts, describing the abusive treatment and horrible conditions received by the mentally ill patients in jails, cages, and almshouses. She revealed in her Memorial: "I proceed, gentlemen, briefly to call your attention to the present state of insane persons confined within this Commonwealth, in cages, closets, cellars, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience. . . ."^[35] Many asylums were built in that period, with high fences or walls separating the patients from other community members and strict rules regarding the entrance and exit. In those asylums, traditional treatments were well implemented: drugs were not used as a cure for a disease, but a way to reset equilibrium in a person's body, along with other essential elements such as healthy diets, fresh air, middle class culture, and the visits by their neighboring residents. In 1866, a recommendation came to the New York State Legislature to establish a separate asylum for chronic mentally ill patients. Some hospitals placed the chronic patients into separate wings or wards, or different buildings.^[36]

In A Mind That Found Itself (1908) Clifford Whittingham Beers described the humiliating treatment he received and the deplorable conditions in the mental hospital.^[37] One year later, the National Committee for Mental Hygiene (NCMH) was founded by a small group of reform-minded scholars and scientists – including Beer himself – which marked the beginning of the "mental hygiene" movement. The movement emphasized the importance of childhood prevention. World War I catalyzed this idea with an additional emphasis on the impact of maladjustment, which convinced the hygienists that prevention was the only practical approach to handle mental health issues.^[38] However, prevention was not successful, especially for chronic illness; the condemnable conditions in the hospitals were even more prevalent, especially under the pressure of the increasing number of chronically ill and the influence of the Depression.^[34]

In 1961, the Joint Commission on Mental Health published a report called Action for Mental Health, whose goal was for community clinic care to take on the burden of prevention and early intervention of the mental illness, therefore to leave space in the hospitals for severe and chronic patients. The court started to rule in favor of the patients' will on whether they should be forced to treatment. By 1977, 650 community mental health centers were built to cover 43 percent of the population and serve 1.9 million individuals a year, and the lengths of treatment decreased from 6 months to only 23 days.^[39] However, issues still existed. Due to inflation, especially in the 1970s, the community nursing homes received less money to support the care and treatment provided. Fewer than half of the planned centers were created, and new methods did not fully replace the old approaches to carry out its full capacity of treating power.^[39] Besides, the community helping system was not fully established to support the patients' housing, vocational opportunities, income supports, and other benefits.^[34] Many patients returned to welfare and criminal justice institutions, and more became homeless. The movement of deinstitutionalization was facing great challenges.

After realizing that simply changing the location of mental health care from the state hospitals to nursing houses was insufficient to implement the idea of deinstitutionalization, the National Institute of Mental Health in 1975 created the Community Support Program (CSP) to provide funds for communities to set up a comprehensive mental health service and supports to help the mentally ill patients integrate successfully in the society. The program stressed the importance of other supports in addition to medical care, including housing, living expenses, employment, transportation, and education; and set up new national priority for people with serious mental disorders. In addition, the Congress enacted the Mental Health Systems Act to prioritize the service to the mentally ill and emphasize the expansion of services beyond just clinical care alone.^[40] Later in the 1980s, under the influence from the Congress and the Supreme Court, many programs started to help the patients regain their benefits. A new Medicaid service was also established to serve people who were suffering from a "chronic mental illness." People who were temporally hospitalized were also provided aid and care and a pre-release program was created to enable people to apply for reinstatement prior to discharge.^[39] Not until 1990, around 35 years after the start of the deinstitutionalization, did the first state hospital begin to close. The number of hospitals dropped from around 300 by over 40 in the 1990s, and finally a Report on Mental Health showed the efficacy of mental health treatment, giving a range of treatments available for patients to choose.^[40]

The 2011 National Prevention Strategy included mental and emotional well-being, with recommendations including better parenting and early intervention programs, which increase the likelihood of prevention programs being included in future US mental health policies.^[41][42] The NIMH is researching only suicide and HIV/AIDS prevention, but the National Prevention Strategy could lead to it focusing more broadly on longitudinal prevention studies.^[43]