The Ethics of Mental Hospitals

Overcrowding and deteriorating conditions in state-run mental hospitals was exacerbated by the economic depression of the 1930’s followed by the widespread reallocation of medical personnel caused by World War II.  In partial response to these problems, the Mental Hygiene Movement arose during the early 20^th century ^iv that proposed creating more outpatient clinics (like the MHMRs mentioned above) to provide mental health treatment away from the traditional confines of mental hospitals.  Also, during the 1930s and 1940s, psychiatrists began experimenting with new types of therapies (some of which were later criticized and discontinued) including insulin and electric shock, psychosurgery, and different medications.

Despite these problems and worsening conditions, the United States reached its peak number of mental hospital beds in 1955, almost all of which were in state-run facilities.  At that time, there were over 500,000 available psychiatric beds (compared with just over 50,000 as of 2014 — a ninety percent reduction during this six-decade period).^v

The 1950’s brought major pharmacological changes to the field of psychiatry with development of chlorpromazine and other anti-psychotic medicines, which offered the hope of treating some of the most severe and debilitating psychiatric problems like psychosis and schizophrenia (i.e., the serious or severe mental illnesses or SMI).  Though some members of the SMI population responded positively to these new medicines, many continued to need long term custodial care.

Serious mental illness (SMI) is defined by the NIMH as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI.

One of the researchers into these new drug treatments was Dr. Nathan S. Kline,^vi  a professional colleague of my late father Dr. Melvin Goodman.  In 1952, Dr. Kline created a research unit at Rockland State Hospital in New York, where he investigated the use of reserpine as a possible treatment for schizophrenia.  He also promoted the use of iproniazid, an anti-depressant for the treatment of severe depression.  (As a child, I accompanied my family on a vacation to Haiti where we visited the Mars and Kline Psychiatric Institute, which was co-founded by Dr. Kline.)

All these changes led to the deinstitutionalization movement that started in the 1960s.  Within the judiciary, courts responded to real civil rights concerns by creating increasingly stringent rules for making commitments into mental hospitals starting with the case of Lake v. Cameron,^vii which introduced the concept of “least restrictive setting.”  In 1975, the U.S. Supreme Court found in O’Connor v. Donaldson^viii that a person had to be a danger to him- or herself or to others for confinement in a mental hospital to be constitutional.  Finally, in 1999 the U.S. Supreme Court in Olmstead v. L.C.^ix determined that mental illness was a disability under the Americans with Disabilities Act,^x and as such “reasonable accommodations” had to be made to move people from mental hospitals into community-based treatment facilities.

As noted by Dr. Daniel Yohanna, Chair of the Department of Psychiatry at the University of Chicago Pritzker School of Medicine, in his 2013 comprehensive review of these events in the AMA Journal of Ethics,^xi these judicial constraints on the commitment process were instituted at about the same time that Congress passed the “Community Mental Health Construction Act,” in 1963, which made federal grants available to states for establishing local community health centers in anticipation of closing the state-run mental hospitals.

But the most significant change in federal law was the introduction of Medicaid, which shifted funding for people with SMI from a state-run program into a shared partnership with the federal government.  This created a perverse incentive for states to close the facilities that they funded on their own (i.e., the state mental hospitals) and move those patients into community mental health facilities and nursing homes partially paid for by the federal government through Medicaid.

The deinstitutionalization process continued in 1981 with the “Omnibus Budget Reconciliation Act,”^xii which ended federal funding for community-based nursing homes that primarily treated patients with mental health problems and required states to return to funding non-nursing homes (many of which were private and for-profit) for the long-term care of people with SMI within the community.

The resulting confusion and disruption caused by these well intentioned judicial and legislative initiatives, and their unintended consequences, are apparent in every city around the United States.  The resulting plague of unhoused and unsheltered individuals living on our city streets suffering from SMI and, even more distressingly, the use of jails and prisons as default long-term residential facilities for some individuals with SMI are outrageous.  And yet, as Dorothea Dix observed so many years ago, we have the power to alleviate this suffering.

A reviewer of this article commented, and I agree, that society must begin to move the needle away from the moral/eugenics model for mental health (which we still apply, yet which is most often absent from general physical medical care) – creating a double standard between mental and medical ethics in the USA that we can no longer afford given the known negative public health outcomes.