E. Fuller Torrey, M.D., Details Mistakes That Led to Today’s Public Mental Health Crisis

American psychiatry and the public mental health system must work to correct policy mistakes of the past that have led to today’s public health travesty: criminalization of people with mental illness by placing them in jails and prisons and the failure to treat homeless individuals with serious mental illness (SMI).

So said E. Fuller Torrey, M.D. (pictured above), the keynote speaker at yesterday’s Opening Session of APA’s IPS: The Mental Health Services Conference in New York. Torrey, the founder of the Treatment Advocacy Center and associate director for research at the Stanley Medical Research Institute, has been a fierce advocate for people with SMI for five decades.

During his address, he detailed a history of tragic public policy blunders that led to the current crisis: the emptying of state psychiatric hospitals, passage of the Community Mental Health Act (CMHA) with no mandated provisions for care after people with SMI were discharged from state hospitals, and federal financial incentives that encouraged states to abdicate responsibility for this population.

“In summary, we emptied the state hospitals and provided federal fiscal incentives to make sure it happened,” Torrey said. “We began a new program of community mental health centers that was targeted to prevent mental illness but ignored patients being discharged from the state hospitals. And we partially federalized what had been a state and county responsibility with no provisions for the most seriously mentally ill.”

Torrey drew attention to a grim irony: The founders of APA 175 years ago were concerned about and discussed the practice of locking up people with mental illness in jails and prisons. These discussions were instigated by Dorothea Dix, who had been outraged by what she saw when she toured the prisons of Massachusetts. This year, Torrey said, a detention center in Georgia became the first jail to be accredited as a mental health facility by the National Commission on Correctional Health Care.

Torrey wondered, “What would Dorothea Dix say of us today?”

He emphasized that the motives that led to deinstitutionalization were good. And he noted that the process of emptying the state hospitals did not begin with the CMHA but with the introduction of chlorpromazine (Thorazine). However, he said, the vast majority of community mental health centers created by the CMHA, having no mandates to treat discharged patients, operated as private psychiatric clinics focused on prevention rather than treatment.

Torrey said IPS is a crucial venue for addressing the problems created by the past and looked to young psychiatrists in the audience for solutions. “Rarely have so many well-meaning people been so wrong,” Torrey said. “My generation made major mistakes in emptying the state hospitals without thinking about how to treat the seriously mentally ill in the community. It is up to the next generation to solve those problems.”

For related information, see the Psychiatric News articles “Mental Illness in America’s Jails Also Made Headlines 50 Years Ago” and “Signs of Problems With Access: Homelessness and Incarceration.”

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Ten Times More People With Serious Mental Illness in Jails Than Hospitals

Ten times more individuals with serious mental illness are residing in state prisons and county jails today than in the nation’s state psychiatric hospitals, according to a new study released today by the Treatment Advocacy Center (TAC). “The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey” found that in 44 states the largest institution housing people with severe psychiatric disease is a prison or jail. Nationwide, the study reports that there are an estimated 356,000 mentally ill inmates compared with 35,000 public-hospital patients.

The survey provides state-by-state illustrations of how protocols for treating mentally ill inmates who are deteriorating or acutely ill create obstacles that leave inmates without treatment for extended periods or indefinitely, especially in county jails. The report also contains several recommendations, including use of court-ordered outpatient treatment—deemed by the Department of Justice to be an evidence-based practice for reducing crime and violence—to help at-risk individuals live more safely and successfully in the community.

“The lack of treatment for seriously ill inmates is inhumane and should not be allowed in a civilized society,” said psychiatrist E. Fuller Torrey, M.D., founder of TAC and lead author of the study. “This is especially true for individuals who – because of their mental illness – are not aware they are sick and therefore refuse medication.”

In comments to Psychiatric News, Torrey said, “it is remarkable that we have let this situation deteriorate to this point.” He added, “Jails and prisons are not built to be mental hospitals, and corrections personnel are neither hired nor trained to be mental health workers. We have returned to the situation that existed in the 1830s when Dorothea Dix began the reform movement to get mentally ill persons removed from jails and prisons and put into hospitals. The fact that we are where we were almost 200 years ago should give us all pause.”


To read more on this subject, including strategies to reverse the trend, see the Psychiatric News article, "Judges, Psychiatrists Confer on Handling Mental Illness in Justice System." Also see "Prevalence of Mental Illnesses in U.S. State Prisons: A Systematic Review" in Psychiatric Services in Advance.

 

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