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Mental illness in state and nation moved to forefront following watershed law in '63

Joan Baez and Bob Dylan at the March on Washington; The Rev. Dr. Martin Luther King Jr. on the same day, Aug. 28, 1963, delivers the "I Have a Dream Speech"; President John F. Kennedy addresses the nation on civil rights, June 11, 1963; Alabama Gov. Georg
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This article first appeared in the St. Louis Beacon, Oct. 28, 2013 - In the '60s, it often seemed OK to ridicule serious social issues, including mental illness. The book "One Flew Over the Cuckoo’s Nest" took aim at the administration of an institution in the Pacific Northwest. The real world of mental health policies began to change, however, in 1963, a year after the book was published, when a watershed federal law, the Community Mental Health Act, took effect.

Signed 50 years ago this month, that legislation has helped shape our still-evolving attitudes about how we regard, treat and care for people coping with psychological disorders.

Prior to that year, most mental patients were warehoused in overcrowded facilities in states, including Missouri, often forgotten victims of widespread abuse and neglect. They were remembered in brief snatches when an occasional newspaper exposé shined light on their scandalous conditions.

As attention increased, so did a public a call for more community-based services for the mentally ill, the goal of the 50-year-old law.

"The act set forth the vision that mental health was something that would be treated in the community,” said Dr. Joseph "Joe" Parks, chief clinical officer for the Missouri Department of Mental Health, and director of the Missouri Institute of Mental Health. "It wasn’t about locking people away in big places called hospitals, which were really detainment centers. It was a vision of people getting treatment locally where they lived instead of being shipped across the state to places away from families.”

Fifty years later, care for the mentally ill is far from perfect, but much has changed, including the mindset of those affected. Parks said both psychological and medical treatments are more effective than they used to be.

"And there is less stigma. People are less likely to see mental illness as a moral failure, a personal weakness, something they are ashamed to talk about.”

Blazing trails in Missouri

Anyone connecting the dots from 1963 will discover how much has changed, for better or worse, and how Missouri became a trailblazer for improving care. It was the first state to receive federal funds for building community treatment facilities and providing and treatment services under the act. By 1974, what had once been known as Missouri’s division of mental diseases had morphed into a full Department of Mental Health.

ASIDE

In place of warehousing 12,000 patients in five hospitals served by a dozen physicians trained in mental illness treatment, Missouri’s system has been decentralized. About 95 percent of the 170,000 patients the department now serves get their treatment in community settings, through more than 1,600 community services agencies. 

One of the big challenges continues to be finding the money to help all who seek care through funding from the department’s $1.4 billion budget. About half that money comes from federal sources and the rest from state and local dollars.

Funding Issues

Medicaid, the federal-state health insurance program for the needy, became the big game changer. The program made therapists willing to serve people who otherwise couldn’t have afforded treatment. All was not rosy, however.

Federal funding never matched the vision set forth in the act. No more than one-fourth to one-third of the facilities promised under the legislation were built. "It was like building a bridge a quarter of the way of what was needed,” Parks says. "Congress never funded the full package.”

The problem was complicated by the absence of additional federal money to offset rampant inflation during the late 1970s and 1980s, along with a shift toward block grants during the Reagan administration.

Until then, funding for mental health clinics came directly from the federal government. Under the new system, money previously used for direct funding was rolled into smaller block grants, with states controlling the purse strings and generally allocating fewer dollars for mental health services.

Federal waivers countered some of the problems. These allowed states and cities to cover services in a way not intended at the start of the Medicaid program. Initially used to pay for traditional medical services, such as seeing a doctor or being admitted to a hospital, Medicaid started to help mental health patients live independently — in apartments, for example, with part-time assistance from care providers.

The change actually helped to save money by allowing the people to live independently rather than be confined to a more costly nursing home or hospital care. Mental health centers that had been delivering psychiatric services were later allowed to provide support services, such as making sure patients kept doctor appointments and took their medications. Again, this was done to prevent patients from ending up needing expensive hospital care, which is one of the consequences of patients not taking their meds.

That has been part of a state model since 1988. It has been expanded to what’s known as a medical home approach, which not only focuses on a patent’s mental health needs but on health in general, Parks said. The goal here is to make sure patients are following the doctor’s orders to keep health problems such as diabetes and asthma from getting out of control and requiring more expensive care.

Drug Treatment Added

Since the 1990s, Parks said, an effort has been made to move toward better integration between treatment of substance abuse and mental health. "People with mental illness are more likely to have a substance abuse problem,” he says. "Their treatment (for mental health issues) isn’t as successful when you don’t treat the substance abuse problem also.”

Other notable changes have included:

• Legislation in 1998 authorizing civil commitment of sexual predators to control, care and treatment by the Department of Mental Health.

• Legislation in 2005 setting up a separate child mental health service system, needed, Parks said, because approaches for adults don’t always meet the needs of kids. They come into the system through a number of agencies, such as schools, foster care and child protective services. The goal, he said, is to use the new office to convene all different entities working with children "get their actions coordinated so that we wouldn’t be duplicative and we wouldn’t have gaps in services.”

• An Office of Autism Services was set up in 2008, Parks said, because autism was once under-diagnosed. "A lot more people are diagnosed with autism and, along with effective treatment and support, it’s important to have an office that makes sure that people are getting up-to-date treatment.

• A waiver to allow the department to intervene more quickly in a crisis to serve family members who might not be able to remain at home. Parks credits the Nixon administration with making resources available for early intervention before a family member ends up saying, "I can’t take it anymore. He (the mental patient) has got to move out of the house.” As a result of the program, Parks says thousands of people have been able get services early that have kept them in school, kept them in the community and with their families.”

Long-term Challenges

While medical and psychological treatment may be getting better, as Parks said, Missourians only have to go to the next corner in some urban and rural areas to find homeless people who appear to need mental health services. They are a sign that the hope of the law that began to change things 50 years ago hasn’t been fully realized.

"Community mental health centers have always had more requests for services than they could meet,” he says. "So they have to select the sicker people and prioritize the people they would see. They would give priority to someone dangerous to themselves and others. Those suffering with anxiety and depression weren’t dangerous and wouldn’t get care. That is a huge problem that has been going on since block grants in the 1980s.”

Matters haven’t been helped by the fact that, beginning in the ‘80s, the federal government reduced the amount spent to train new doctors, particularly those in graduate medical education program. "There are more of us retiring than young ones coming into the field,” Parks said. "At a time when more and more people are seeking treatment because they understand that they can get better, there are fewer psychiatrists around to do the treatment.”

In many ways, Missouri has fared better than many other states, from the time it jumped to the forefront to get federal funds under the Mental Health Act.

"We have had some visionary leaders who have worked hard on this,” he said, singling out George Ulett, the first director of the Department of Mental Health and Gov. Warren E. Hearnes. "The governor was behind mental health. He found visionary leaders and gave them the resources. We are pleased to have that kind of governor again with Gov. (Jay) Nixon. He’s a big supporter of giving us the tools needed to be at the front of the nation in terms of mental health."

What happens next, he says, will depend on whether Missouri expand its Medicaid program. Most people become mentally ill when they are in their 20s and 30s. "They are becoming mentally ill when they are not insured. So they can’t get treatment, are too sick to get that job, so they end up being disabled."

That could change if Missouri chooses to expand its Medicaid program to reach these individuals. So far, state lawmakers have opposed expansion, but the issue is expected to be revisited in the next legislative session.

"This is the next opportunity for us to reach and treat people when they begin to suffer and before they can’t hold a job and keep their housing. And certainly before they become dangerous."

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.