By Osefame Ewaleifoh, PhD/MPH Candidate
“The pattern of psychotherapeutic practice in America is seriously imbalanced in that too many of the ablest, most experienced psychiatrists spend most of their time with patients who need them the least.” – Jerome Frank (1961)
Recent news events, from the current non-stop gun violence to celebrity suicides, have made mental health more visible today than they have ever been in the past. Beyond race, gender or sexual orientation, the mentally ill remain the most widely marginalized group in society by almost every criterion. In Better But Not Well, authors Richard Frank (Harvard) and Sherry Glied (Columbia) provide an exceptionally engaging and comprehensive retrospective on the evolution of contemporary mental health care in the United States since the 1950’s. Better But Not Well is an intellectual treasure trove for any reader – from the casual health consumer to the avid health care scholar – as it attempts to answer the question of both how and why the current mental health landscape in the United States evolved.
In its rich and very thoughtful first seven chapters, Better But Not Well contemplates both policy and practice changes that have influenced how mental health is perceived and treated in the U.S. The authors begin by establishing a very broad overview of the major trends and factors that have led to improvement in mental health care. Next they consider the composition, characteristics and proportion of the mentally ill in society from 1950 until today, asking if this population has changed or remained relatively constant through the years.
To attempt to better understand the specific factors that have driven improvement in care, the authors explore changes and innovations in our treatment capacity for the mentally ill, noting that while there have been incredible advancements in treatment capacity, these improvements are not widely accessible or disseminated. Moving beyond treatment capacity, Better But Not Well provides overwhelming data that the true driver of the current advancements in mental health has been the evolution of mental health care financing and government policies.
Changes in mental health financing have altered everything from the structure of care (a shift from institutionalized centralized care to decentralized mostly outpatient care) to the supply of care providers (more social workers, psychiatrist and mental health workers) and the funding and affordability of care (more federal dollars are spent on health care today than ever before). The authors carefully explore how each of these factors has affected the quality and delivery of mental health care, arguing that while the financial revolution has led to increased care accessibility by decentralizing care delivery it has created a system where no single agency is exclusively responsible for the care of patients – which could be very detrimental for severely ill mental health patients who must utilize multiple levels and agencies for their care.
Figure 3. Trends in the institutionalization of the mentally ill.
The authors conclude with specific examination of how the current evolution of mental health care has affected various populations, from veterans to the homeless. They argue that while substantial progress has been made since the early 1900s, where the mentally ill where corralled and locked up in insane asylums, much work remains to be done.
Unlike every other disease-related group (DRG), the mentally ill are the only group that that is often blamed for their condition. Thus while no one ever accused a cancer or dementia patient of “weak will” most mental health conditions are still erroneously perceived to result from “weak will” and “bad character”.
Clearly much work remains to be done. In Better But Not Well Frank and Sheryl excellently argue that we have to do better for people with mental health issues, and perhaps the way to do this is by expanding general social welfare programs and making insurance programs for the mentally ill more mainstream. To some degree this is precisely what the mental health provisions of the Affordable Care Act attempt to do – only time will tell the true impact of the ACA on mental health care.
Figure 1 :Timeline on mental Health Financing. Better But Not Well. Richard Frank and Sherry Glied.
Figure 2: Trends in mental health care spending. Better but not well. Richard and Sherry Glied.
Figure 3:Trends in state and county mental hospitals in the U.S. from 1970 to 1992. Ronald W. Manderscheld, Ph.D. et al.
Figure 4: Public conceptions of mental illness: Labels, causes, dangerousness, and social distance. B G Link, J C Phelan, M Bresnahan, A Stueve, and B A Pescosolido