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| FILE - In this Oct. 31, 1963 file photo, President John F. Kennedy signs a bill authorizing $329 million for mental health programs at the White House in Washington. The Community Mental Health Act, the last legislation that Kennedy signed, aimed to build 1,500 mental health centers so those with mental illnesses could be treated while living at home, rather than being kept in state institutions. It brought positive changes, but was never fully funded. Former U.S. Rep. Patrick Kennedy will host a conference on Oct. 24, 2013 in Boston, to mark the 50th anniversary of the act, and formulate an agenda to continue improving mental health care. |
PROVIDENCE, R.I.
(AP) -- The last piece of legislation President John F. Kennedy
signed turns 50 this month: the Community Mental Health Act, which
helped transform the way people with mental illness are treated and
cared for in the United States.
Signed on Oct.
31, 1963, weeks before Kennedy was assassinated, the legislation aimed
to build mental health centers accessible to all Americans so that those
with mental illnesses could be treated while working and living at
home, rather than being kept in neglectful and often abusive state
institutions, sometimes for years on end.
Kennedy
said when he signed the bill that the legislation to build 1,500
centers would mean the population of those living in state mental
hospitals - at that time more than 500,000 people - could be cut in
half. In a special message to Congress earlier that year, he said the
idea was to successfully and quickly treat patients in their own
communities and then return them to "a useful place in society."
Recent
deadly mass shootings, including at the Washington Navy Yard and a
Colorado movie theater, have been perpetrated by men who were apparently
not being adequately treated for serious mental illnesses. Those
tragedies have focused public attention on the mental health system and
made clear that Kennedy's vision was never fully realized.
The
legislation did help to usher in positive life-altering changes for
people with serious illnesses such as schizophrenia, many of whom now
live normal, productive lives with jobs and families. In 1963, the
average stay in a state institution for someone with schizophrenia was
11 years. But only half of the proposed centers were ever built, and
those were never fully funded.
Meanwhile,
about 90 percent of beds have been cut at state hospitals, according to
Paul Appelbaum, a Columbia University psychiatry professor and expert in
how the law affects the practice of medicine. In many cases, several
mental health experts said, that has left nowhere for the sickest people
to turn, so they end up homeless, abusing substances or in prison. The
three largest mental health providers in the nation today are jails:
Cook County in Illinois, Los Angeles County and Rikers Island in New
York.
"The rhetoric was very highfalutin. The
reality was a little more complicated, and the funds that were provided
were not adequate to the task," said Steven Sharfstein, president and
CEO of Sheppard Pratt Health System, a nonprofit behavioral health
organization in Baltimore.
"The goals of
deinstitutionalization were perverted. People who did need institutional
care got thrown out, and there weren't the programs in place to keep
them supported," said former U.S. Rep. Patrick Kennedy, the president's
nephew. "We don't have an alternate policy to address the needs of the
severely mentally ill."
He is gathering
advocates in Boston this week for the Kennedy Forum, a meeting to mark
the 50th anniversary of his uncle's legislation and an attempt to come
up with an agenda for improving mental health care.
The
1963 legislation came amid other changes in treatments for the mentally
ill and health care policy in general, Appelbaum said. Chlorpromazine
or Thorazine, the first effective antipsychotic medicine, was released
in the 1950s. That allowed many people who were mentally ill to leave
institutions and live at home.
In 1965, with
the adoption of Medicaid, deinstitutionalization accelerated, experts
said, because states now had an incentive to move patients out of state
hospitals, where they shouldered the entire cost of their care, and into
communities where the federal government would pick up part of the tab.
Later,
a movement grew to guarantee rights to people with mental illness. Laws
were changed in every state to limit involuntary hospitalization so
people can't be committed without their consent, unless there is a
danger of hurting themselves or others.
Kennedy's
legislation provided for $329 million to build mental health centers
that were supposed to provide services to people who had formerly been
in institutions, as well as to reach into communities to try to prevent
the occurrence of new mental disorders. Had the act been fully
implemented, there would have been a single place in every community for
people to go for mental health services.
But one problem with the legislation was that it didn't provide money to operate the centers long-term.
"Having
gotten them off the ground, the federal government left it to states
and localities to support," Appelbaum said. "That support by and large
never came through."
Later, during the Reagan
administration, the remaining funding for the act was converted into a
mental health block grant for states, allowing them to spend it however
they chose. Appelbaum called it a death knell because it left the
community health centers that did exist on their own for funding.
Robert
Drake, a professor of psychiatry and community and family medicine at
Dartmouth College, said some states have tried to provide good community
mental health care.
"But it's been very hard
for them to sustain that because when state budget crunches come, it's
always easiest to defund mental health programs because the state
legislature gets relatively little pushback," he said.
"Services are at a
very low level right now. It's really kind of a disaster situation in
most states."
Sharfstein points out that most
mentally ill people are at a very low risk of becoming violent. He said
it's unthinkable we would go back to the era when people were housed in
"nightmare" conditions at overcrowded, understaffed and sometimes
dangerous state hospitals.
"The opportunity to recover is much greater now than it was in 1963," he said.
But
for those who do not take their medication, don't recover from their
first episode of illness and don't seek treatment and support from
professionals, they are vulnerable to homelessness, incarceration and
death, he said.
Linda Rosenberg, president and
CEO of the National Council for Behavioral Health, counts among its
2,100 member organizations many of the original community mental health
centers that were built under the 1963 legislation.
"Whenever
you pass a piece of legislation, people would like to think that you've
solved the problem," she said. "It did some very important things. It
laid some ground work. It's up to us now to move forward."
