Deinstitutionalization in the United States

The public's awareness of conditions in mental institutions began to increase during World War II. Conscientious objectors (COs) of the war were assigned to alternative positions which suffered from manpower shortages. In 1973, a federal district court ruled in Souder v. Brennan that patients in mental health institutions must be considered employees and paid the minimum wage required by the Fair Labor Standards Act of 1938 whenever they performed any activity that conferred an economic benefit on an institution. Following this ruling, institutional peonage was outlawed, as evidenced in Pennsylvania's Institutional Peonage Abolishment Act of 1973. Rosenhan's experiment in 1973 "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible." ==Alternatives==

Pharmacotherapy During the 1950s, new drugs became available and were incorporated into treatment for the mentally ill. The new drugs effectively reduced severe symptoms, allowing the mentally ill to live in environments less stringent than institutions, such as halfway houses, nursing homes, or their own homes. Drug therapy also allowed many mentally ill to obtain employment. Patients in partial hospitalization programs show the same or greater levels of improvement as their inpatient counterparts, and unlike inpatient hospitalization, these individuals are able to maintain their familial and social roles during treatment. Partial hospitalization allows for a smoother and less expensive transition between inpatient hospitalization and community life. These programs combine psychotherapy with pharmacotherapy, group therapy, substance abuse counseling, and related services in a very structured and time-intensive format, typically three hours a day, three days a week, but up to five days a week. They are a less time-intensive step down from partial hospitalization, but they can provide greater support than weekly therapy appointments alone. IOPs can serve as a transition between inpatient hospitalization and less intensive weekly therapy when a patient requires a greater level of care. ==President Kennedy==

In 1955, the Joint Commission on Mental Health and Health was authorized to investigate problems related to the mentally ill. President John F. Kennedy had a special interest in the issue of mental health because his sister, Rosemary, had been lobotomized at the age of 23 at the request of her father. Shortly after his inauguration, Kennedy appointed a special President's Panel of Mental Retardation. The panel included professionals and leaders of the organization. In 1962, the panel published a report with 112 recommendations to better serve the mentally ill. In conjunction with the Joint Commission on Mental Health and Health, the Presidential Panel of Mental Retardation, and Kennedy's influence, two important pieces of legislation were passed in 1963: the Maternal and Child Health and Mental Retardation Planning Amendments, which increased funding for research on the prevention of retardation, and the Community Mental Health Act, which provided funding for community facilities that served people with mental disabilities. Both acts furthered the process of deinstitutionalization. However, less than a month after signing the new legislation, JFK was assassinated and could not see the plan through. The community mental health centers never received stable funding, and even 15 years later less than half the promised centers were built. ==Changing public opinion==

While public opinion of the mentally ill has improved somewhat, it is still often stigmatized. Advocacy movements in support of mental health have emerged. These movements focus on reducing stigma and discrimination and increasing support groups and awareness. The consumer or ex-patient movement, began as protests in the 1970s, forming groups such as Liberation of Mental Patients, Project Release, Insane Liberation Front, and the National Alliance on Mental Illness (NAMI). Many of the participants consisted of ex-patients of mental institutions who felt the need to challenge the system's treatment of the mentally ill. Initially, this movement targeted issues surrounding involuntary commitment, use of electroconvulsive therapy, anti-psychotic medication, and coercive psychiatry. Many of these advocacy groups were successful in the judiciary system. In 1975, the United States Court of Appeals for the First Circuit ruled in favor of the Mental Patient's Liberation Front of Rogers v. Okin, establishing the right of a patient to refuse treatment. A 1975 award-winning film, ''One Flew Over the Cuckoo's Nest'', sent a message regarding the rights of those committed involuntarily. That same year, the U.S. Supreme Court restricted the rights of states to incarcerate someone who was not violent. This was followed up with a 1978 ruling further restricting states from confining anyone involuntarily for mental illness. NAMI successfully lobbied to improve mental health services and gain equality of insurance coverage for mental illnesses. In 1996, the Mental Health Parity Act was enacted into law, realizing the mental health movement's goal of equal insurance coverage. In 1955, there were 340 psychiatric hospital beds for every 100,000 US citizens. In 2005, that number had diminished to 17 per 100,000. ==Reducing costs==

As hospitalization costs increased, both the federal and state governments were motivated to find less expensive alternatives to hospitalization. Specifically, a provision of Medicaid largely prohibited reimbursement to states for mental illness treatment in facilities that had more than sixteen beds. This clause incentivized states to close their larger mental hospitals and offer treatment in a community out-patient setting, which was 50% reimbursable under Medicaid. In 1955, there were 558,239 severely mentally ill patients in the nation's public psychiatric hospitals. By 1965, the number had declined to approximately 500,000, after which it dropped rapidly, reaching approximately 100,000 by the early 1980's. The rate of decrease slowed thereafter, reaching 71,619 in 1994 and 62,532 by 2014. Studies from the late 1980s indicated that one-third to one-half of homeless people had severe psychiatric disorders, often co-occurring with substance abuse. A process of indirect cost-shifting may have led to a form of "re-institutionalization" through the increased use of jail detention for those with mental disorders deemed unmanageable and noncompliant. When laws were enacted requiring communities to take more responsibility for mental health care, necessary funding was often absent, and jail became the default option, being cheaper than psychiatric care. ==See also==