xxAACP Newsletter, Volume 14, Number 3, Summer 2000
Guest Column
The State of Mental Health Care in The 21st Century: What do the Tea Leaves Say?
That issue very nicely told of 200 years of the history of mental health care in America. At the end of it was an article which I have never forgotten (Resnick, E . 1976) about the future of mental health care in America . What would mental health be like 12, or 22, or 55 or even 100 years hence. In his paper Dr. Resnick described his visit to Madame Futura, a seer who lived in Orange county and who could see into the future and tell exactly what was to happen. For example when she looked into her crystal ball she saw that in 1988 (remember this was written in 1976) Donald Degan and his American Patriotic Party had been elected and
"decided that mental illness was a luxury the country could no longer afford. Tax money was needed for essential services such as national defense against foreign ideologies, so all appropriations for psychiatric facilities, training, and research were eliminated. It was quite clear that by the elimination of all mental health workers, the closing of all clinics and the anticipated closure of all state psychiatric hospitals (by 1998) mental illness would be eliminated. A law was passed making phobias, obsessions, and depression criminal offenses."A chilling but disturbingly accurate (although unintended) prediction for 1976 (four years before Reagan was elected) wouldn't you say? It seemed quite amusing at the time.
Since I don't really go in for mysticism and I am hoping that the nightmare of locking up the mentally ill in jails and prisons will go away, I decided to take a brief sabbatical (more like a vacation) and travel around some of the western world talking not to Madame Futura, but to old and trusted colleagues in some of the more advanced and civilized countries about how mental health systems work there. Perhaps I will be able to predict the future not by magic but just by looking into a different present?
I have long been aware that good ideas travel fast around the world and now with the internet they go at the speed of light. Maybe here in the current world there is evidence or answers to my questions as to the successes and failures of community mental health. And so I began my "Gulliver's travels" to find out if the world I live in is real or surreal and if there is another more civilized, humanitarian one somewhere.
In Europe everything is very old (including the Queen Mum now 100) and what really seems to matter most is what happened in the past. For example, evidence of miracles is everywhere. In the Belgian town of Gheel there will be a mental health meeting in August 2000 celebrating the millennium in a town with a thousand plus year history of tending to the needs of mentally ill individuals.
The Belgians and the Dutch have continued to house mentally ill people in long stay facilities out in the country where they can live a less stressful life. At Gheel, the home of St. Dymphna, there are still foster homes on surrounding farms where patients become quasi - family members and participate in the work of the family farm (a practice which no doubt continues to have economic advantages for the farmers).
The mental health system in Holland has changed little since the last time I visited. They still have ample long stay hospital beds and short stay as well. There are some reduced services due to organizational changes but there is also a small reduced availability of funds. The riaggs (CMHC's) are merging with the regional mental hospitals. They are now called mental health centers or organizations. They are no longer independent free standing CMHC's. They were distributed throughout the country 20 years ago and they are now being swallowed up by or merged with the hospitals. In this fusion process the CMHC director could be in charge of the whole thing but mostly the hospitals have the authority over the group of regional facilities. The old state hospitals are gone and these categorical small hospitals have 200 - 500 beds and usually each hospital has 1 - 3 associated CMHC's. All of this is paid for by the central government insurance system's (Algemene Wet Bijzondere Ziektekosten) AWBZ ) Fund for Severe Medical Risks.
There are a few differences with hospital bed availability. In Rotterdam 80% of inpatients are voluntary whereas in Amsterdam 95% are involuntary. Average stay in both cities is 2 months. That gives them time to stop all meds for the first three days and see what works according to their practice guidelines, all 100% paid for by insurance. There is also a problem with the high threshold for involuntary care which results in people winding up homeless in the streets but not in jail. There are also problems getting jobs and rehab for severely mentally ill persons.
Despite problems with power struggles associated with the reorganization, essentially what they have is a single payor system in place and functional. There are some mentally ill in prison but there is no plan to build more capacity. In fact the effort is to find a way to move them to the mental health system. In subsequent installments I will describe what I learned in France and England. Stay tuned.
(Resnick, E V, Mental Health Care in America: 2076.
Hospital and
Community Psychiatry Vol 27 # 7 July 1976 519 - 521.)
David L Cutler
MD
Editor, Community Mental
Health Journal
Department of Psychiatry - OP02
Oregon Health Sciences University
3181 SW Sam Jackson Park Blvd.
Portland, OR 97201-3011
Office: (503) 494-8147
Fax: (503) 494-6578
cutlerda@ohsu.edu
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