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. (AP Photo/Bill Allen, File)
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."
