427
EDITORIAL
Putting the "Public" Back in Mental Health, the "Mental" Back in Public Health
It is ! 1 years since the President's Commission on M e n u Health recommended a comprehensive national program. Some of its recommendations w e n incorporated into Mental Health Systems Act (MHSA) designed to extend the gains of the landmark Community Mental Health Centers Act of 1963. Among other provisions, i~ key features ere to introduce greater flexibility in the p r o ~ s of ~ e community mental health centers, with particular emphasis on including the most vulnerable groups, such as h~ose with chronic mental illness, severely mentally d i s t ~ d chil~en and adolescems, and the elderly. It was also designed to strengthen the federal, state and local roles. Greater emphasis was to be placed on closer linkages between mental health and general health care settings and on preventive m e n ~ health progreans (Foley and Sharfstein 1983). In the aftermath of the 1980 presidential election, L~,e MHSA was repealed in 198 i. With its repeal a public health emphasis on mental health languished. During the same period, the infrastructure of the public health system underwent erosion as well (Institute of Medicine 1988); it was in no position to provide offse~ng support for mental heal~ efforts. If there is the slightest silver lining to tiffs dark cloud it is the emergence of the field of mental health services research; a field, however, that suffers from too narrow a focus on cost issues. These developments have taken place at a time when the states' capacities to deal with public health and mental health have been allowed to atrophy in response to what is widely perceived as an intractable fiscal crisis, one which p ~ l e l s the decline in the federal commitment for human services. Welfare and social services, housing, recreation, day care, preschool and school programs on which public mentaJ~ heMth depends, all are in serious disarray. This state of affairs has been "rationalized" by conservatives as the "inevitable" result of the federal budget deficit. Yet that deficit itself resulted from a deliberate commitment to extravagant military spending matched by an adamant refusal to raise taxes. We who wimess the suffering of the disadvantaged in our d ~ y c l ~ c a t work have a moral obligation to become their advocates for national priorities in public health and mental health. In 1963, Helen Wortis and her colleagues (WoRis et al 1963) repor,ed a study of 250 consecutively born prem~.ture infants in BrooHyn. They concluded with these , , , , , , . a o . v v li.Pil ~ . a ~ .
The inadequate incomes, crowded homes, lack of consistent family ties, the mother's depression and helplessness in her own situation were as important as her chRd rearing practices m influencing the child's development and preparing him for an adult role. It was for us a sobering experience to watch a large group of newborn infants, #asfic h ~ beings of unknown potential, and observe over a 5 year period their social preparation to enter the class of the least skilled, least educated and most rejected in our society. Thirty years later, will we tolerate the perpetuation of these i m m o ~ conditions? © 1991 Society of Biological Psychiatry
0006-3~3/91/$0350
428
BIOL PSYCHIATRY 1991;~:427-429
Editorial
Our nation is not now acting on the knowledge base it has, Advances in the neurosciences have brought a much richer knowledge of the pathophysiology and treatment of schizophrenia and depression. Research on the developmentof infants and young chi!dren has enhanced our understanding of the effects of early experience on later development and cognitive ability. Growing capacity to detect disorders earlier and to intervene more effectively suggest many public health approaches (Shaffer et al 1989). The civil rights revolution led to the Head Start Program. Despite widespread acknowledgment of its many positive effects in stimulating development, it still reaches only 30% of the children in need. Despite the limits of our knowledge of substance abuse, treatment programs do influence outcomes positively; yet every drug abuse program has long waiting lists because of insufficient funds. Too lime is being done to make use of pilot studies showing that inte~entions to prevent substance abuse can work in school settings. A further example of failure to put what we know into practice is in the treatment of depressive illnesses. Depression is ubiquitous in primary care medical practice (Wells et al 1989, Broadhead et al 1990). Because of inadequate medical education, practitioners are ill equipped to recognize and treat depression. Yet, brief training courses can much improve the diagnostic and counseling skills of general practitioners (Gask et al 1988). Little is being done to implement such training and to make reimbursement schedules compatible with the time needed to use the new skills in practice. Perhaps the greatest crisis in the m e n u health system lies in the care of the chronically mentally ill. The population of patients in our public mental hospitals has declined steadily over the past 3 decades. The capacity of mental health centers to provide care in the community did not k ~ p pace; almost nothing was done to improve the supply :~" public housing. Thus, the problem of chronic mental illness is compounded by hc~!essness; social programs for :.he homeless are complicated by the issues of chronic mental illness. One physician describes it more graphically (Weisman 1985): In the nineteen-fifties, the mad people were warehoused in heated public hospitals with occasiena! access to trained professionals. In the sixties and seventies they were released into the community and permitted to wander the streets witho~.t access to psy :b~atric care. In the eighties, we have made progress, however. When the mentally ill become too cold to wanclei~the streets, we can warehouse them in heated church basements without supervision. Some decades ,-go, the cntlque of care in public mental hospitals was termed the "Shame of the States;" what we face now is the "Shame of Society." As professionals, we are no less responsible than our fellow citizens; it is unthinkable that our affluent society cannot do better. Public mental hospitals continue to carry the greatest part of the burden of care for the more severely ill. In a recent study (Dorwart et al 1991), 44% of the patients in public facilities were diagnosed as schizophrenic whereas that diagnosis applied to only 18% of patients in private for-profit facilities. Yet public mental hospitals are not only undeffunded and understaffed, they are being closed out without any assurance that services will be provided in the private sector. The disarray in our public health and mental health systems in the face of high expenditures for health care has reached crisis proportions. These developments reflect distorted priorities. Our challenge is to generate the political will to include an adequately financed, comprehensive program to provide high quality services that include the full
Editorial
B~
PSYCH|A~Y
4~ ¢)
range of mental health services in the emerging propo~|s for a national ~ prog~xn. We cannot wait for the public health system to |e~d ~ e way. I ~ . mental heal~ may lead the way for the public health community. It ~s a sad and omirmus fact that o ~ y oce school of public health in the United Slates has a department of m e n ~ ~ a l ~ . Research to generate new knowledge is essential. At the same time we know e r ~ g h to act in many areas. We have more and better warned professior~als ~han ~ y other country in the world; we have the knowledge base. It is free for a na~onal strategy. The frontal health community must lead the way! Julius B. Richmond Leon Eisenberg Harvard Medical School Department of Social Medicine 641 Huntington Ave. Boston, MA 02115
References Bmadhead WE, Blazer DG. George LK, et al (~990): Depressi~, d~sabi|i~ ~ys, and ~ y s tost from work in a prospective epidenuologic su~vey. J A~er Med Assoc 2~:2524-~28. Dorwart RA. Schlesinger M. Davidson H. et ~ (|99i): A national study of psyc~a~c ~ s p i ~ care. Amer J Psychiatry 148:204-210. Foley HA, Sharfstein SS (1983): Madness and Government: Who Cares for the ?dentally 111? Washington, D.C.: American Psychiatric Press. Gask L, Goldberg D, Lesser AT, et al (1988): I~proving the psyc~amc s~11s of established gene~ practitioners: ev~uafion of group teaching. ,~led Educ 22:132-138. Institvte of Medicine ~1988): The Future of Public Health. Was~gton, D.C.: National Academy Press. Shaffer D, Phi|ips I, Enzer NB ~1989): Prevention of Mental Disorders, A&ohol ~ Other Drug Use in Children and Adolescents. DHHS ~ablica6on No. (ADM) 89-1646. Rockville, MD: Office for Substance Abuse Prevention. Weisman G (1985): The Woods Hole Cantata Ess~,s on Science and Society. New Yore: ~ , Mead. Wells KB, Stewart A, Hays RD, et al (1989): Hae functioning and welt-being of depressed patients: results from the M~Jdic~ Outco~ Study YAmer Med Azsoc 262:914-919. Wo~Js H, n a ~ e h JL, f',t|er R et :~ (!.~63): f~iFd rearing praetiee_,~ in a !ow ~acioecanomic groups: mothers of premature infan,~. Fed~.~ics 32:298-307.
EDITORIAL
Putting the "Public" Back in Mental Health, the "Mental" Back in Public Health
It is ! 1 years since the President's Commission on M e n u Health recommended a comprehensive national program. Some of its recommendations w e n incorporated into Mental Health Systems Act (MHSA) designed to extend the gains of the landmark Community Mental Health Centers Act of 1963. Among other provisions, i~ key features ere to introduce greater flexibility in the p r o ~ s of ~ e community mental health centers, with particular emphasis on including the most vulnerable groups, such as h~ose with chronic mental illness, severely mentally d i s t ~ d chil~en and adolescems, and the elderly. It was also designed to strengthen the federal, state and local roles. Greater emphasis was to be placed on closer linkages between mental health and general health care settings and on preventive m e n ~ health progreans (Foley and Sharfstein 1983). In the aftermath of the 1980 presidential election, L~,e MHSA was repealed in 198 i. With its repeal a public health emphasis on mental health languished. During the same period, the infrastructure of the public health system underwent erosion as well (Institute of Medicine 1988); it was in no position to provide offse~ng support for mental heal~ efforts. If there is the slightest silver lining to tiffs dark cloud it is the emergence of the field of mental health services research; a field, however, that suffers from too narrow a focus on cost issues. These developments have taken place at a time when the states' capacities to deal with public health and mental health have been allowed to atrophy in response to what is widely perceived as an intractable fiscal crisis, one which p ~ l e l s the decline in the federal commitment for human services. Welfare and social services, housing, recreation, day care, preschool and school programs on which public mentaJ~ heMth depends, all are in serious disarray. This state of affairs has been "rationalized" by conservatives as the "inevitable" result of the federal budget deficit. Yet that deficit itself resulted from a deliberate commitment to extravagant military spending matched by an adamant refusal to raise taxes. We who wimess the suffering of the disadvantaged in our d ~ y c l ~ c a t work have a moral obligation to become their advocates for national priorities in public health and mental health. In 1963, Helen Wortis and her colleagues (WoRis et al 1963) repor,ed a study of 250 consecutively born prem~.ture infants in BrooHyn. They concluded with these , , , , , , . a o . v v li.Pil ~ . a ~ .
The inadequate incomes, crowded homes, lack of consistent family ties, the mother's depression and helplessness in her own situation were as important as her chRd rearing practices m influencing the child's development and preparing him for an adult role. It was for us a sobering experience to watch a large group of newborn infants, #asfic h ~ beings of unknown potential, and observe over a 5 year period their social preparation to enter the class of the least skilled, least educated and most rejected in our society. Thirty years later, will we tolerate the perpetuation of these i m m o ~ conditions? © 1991 Society of Biological Psychiatry
0006-3~3/91/$0350
428
BIOL PSYCHIATRY 1991;~:427-429
Editorial
Our nation is not now acting on the knowledge base it has, Advances in the neurosciences have brought a much richer knowledge of the pathophysiology and treatment of schizophrenia and depression. Research on the developmentof infants and young chi!dren has enhanced our understanding of the effects of early experience on later development and cognitive ability. Growing capacity to detect disorders earlier and to intervene more effectively suggest many public health approaches (Shaffer et al 1989). The civil rights revolution led to the Head Start Program. Despite widespread acknowledgment of its many positive effects in stimulating development, it still reaches only 30% of the children in need. Despite the limits of our knowledge of substance abuse, treatment programs do influence outcomes positively; yet every drug abuse program has long waiting lists because of insufficient funds. Too lime is being done to make use of pilot studies showing that inte~entions to prevent substance abuse can work in school settings. A further example of failure to put what we know into practice is in the treatment of depressive illnesses. Depression is ubiquitous in primary care medical practice (Wells et al 1989, Broadhead et al 1990). Because of inadequate medical education, practitioners are ill equipped to recognize and treat depression. Yet, brief training courses can much improve the diagnostic and counseling skills of general practitioners (Gask et al 1988). Little is being done to implement such training and to make reimbursement schedules compatible with the time needed to use the new skills in practice. Perhaps the greatest crisis in the m e n u health system lies in the care of the chronically mentally ill. The population of patients in our public mental hospitals has declined steadily over the past 3 decades. The capacity of mental health centers to provide care in the community did not k ~ p pace; almost nothing was done to improve the supply :~" public housing. Thus, the problem of chronic mental illness is compounded by hc~!essness; social programs for :.he homeless are complicated by the issues of chronic mental illness. One physician describes it more graphically (Weisman 1985): In the nineteen-fifties, the mad people were warehoused in heated public hospitals with occasiena! access to trained professionals. In the sixties and seventies they were released into the community and permitted to wander the streets witho~.t access to psy :b~atric care. In the eighties, we have made progress, however. When the mentally ill become too cold to wanclei~the streets, we can warehouse them in heated church basements without supervision. Some decades ,-go, the cntlque of care in public mental hospitals was termed the "Shame of the States;" what we face now is the "Shame of Society." As professionals, we are no less responsible than our fellow citizens; it is unthinkable that our affluent society cannot do better. Public mental hospitals continue to carry the greatest part of the burden of care for the more severely ill. In a recent study (Dorwart et al 1991), 44% of the patients in public facilities were diagnosed as schizophrenic whereas that diagnosis applied to only 18% of patients in private for-profit facilities. Yet public mental hospitals are not only undeffunded and understaffed, they are being closed out without any assurance that services will be provided in the private sector. The disarray in our public health and mental health systems in the face of high expenditures for health care has reached crisis proportions. These developments reflect distorted priorities. Our challenge is to generate the political will to include an adequately financed, comprehensive program to provide high quality services that include the full
Editorial
B~
PSYCH|A~Y
4~ ¢)
range of mental health services in the emerging propo~|s for a national ~ prog~xn. We cannot wait for the public health system to |e~d ~ e way. I ~ . mental heal~ may lead the way for the public health community. It ~s a sad and omirmus fact that o ~ y oce school of public health in the United Slates has a department of m e n ~ ~ a l ~ . Research to generate new knowledge is essential. At the same time we know e r ~ g h to act in many areas. We have more and better warned professior~als ~han ~ y other country in the world; we have the knowledge base. It is free for a na~onal strategy. The frontal health community must lead the way! Julius B. Richmond Leon Eisenberg Harvard Medical School Department of Social Medicine 641 Huntington Ave. Boston, MA 02115
References Bmadhead WE, Blazer DG. George LK, et al (~990): Depressi~, d~sabi|i~ ~ys, and ~ y s tost from work in a prospective epidenuologic su~vey. J A~er Med Assoc 2~:2524-~28. Dorwart RA. Schlesinger M. Davidson H. et ~ (|99i): A national study of psyc~a~c ~ s p i ~ care. Amer J Psychiatry 148:204-210. Foley HA, Sharfstein SS (1983): Madness and Government: Who Cares for the ?dentally 111? Washington, D.C.: American Psychiatric Press. Gask L, Goldberg D, Lesser AT, et al (1988): I~proving the psyc~amc s~11s of established gene~ practitioners: ev~uafion of group teaching. ,~led Educ 22:132-138. Institvte of Medicine ~1988): The Future of Public Health. Was~gton, D.C.: National Academy Press. Shaffer D, Phi|ips I, Enzer NB ~1989): Prevention of Mental Disorders, A&ohol ~ Other Drug Use in Children and Adolescents. DHHS ~ablica6on No. (ADM) 89-1646. Rockville, MD: Office for Substance Abuse Prevention. Weisman G (1985): The Woods Hole Cantata Ess~,s on Science and Society. New Yore: ~ , Mead. Wells KB, Stewart A, Hays RD, et al (1989): Hae functioning and welt-being of depressed patients: results from the M~Jdic~ Outco~ Study YAmer Med Azsoc 262:914-919. Wo~Js H, n a ~ e h JL, f',t|er R et :~ (!.~63): f~iFd rearing praetiee_,~ in a !ow ~acioecanomic groups: mothers of premature infan,~. Fed~.~ics 32:298-307.
