The history of mental health policy in the United States over the past sixty years is a story of a reform movement whose first half succeeded and whose second half failed. The first half was deinstitutionalization, the closure of the large state psychiatric hospitals that had warehoused hundreds of thousands of people in often brutal conditions, and the shift to a communitybased model of care. The conditions in many state hospitals were genuinely abhorrent, and the critique that led to their closure was wellfounded.
The second half, building the community mental health infrastructure that would serve the people leaving those institutions, was never adequately funded or implemented. The result was not communitybased care. It was no care, supplemented by emergency rooms, county jails, and homeless shelters that became the de facto mental health system for the most severely ill.
The current landscape
The United States has fewer than 40,000 inpatient psychiatric beds, a fraction of what it had at the peak of institutionalization, and far below what experts estimate is adequate to serve the population with severe mental illness. The shortage produces predictable consequences: people in acute psychiatric crisis who cannot be hospitalized, boarding in emergency departments for days or weeks, and ultimately, discharge into the same community environments that contributed to the crisis.
The policy failures are multiple and interactive. Inadequate funding is primary, behavioral health has been systematically underfunded relative to physical health, and parity laws, while legally significant, have been inconsistently enforced. Workforce shortages compound the funding problem; there are simply not enough psychiatrists, psychiatric nurses, and community mental health workers to serve the need. And the fragmentation of the system, across Medicaid, Medicare, private insurance, and statefunded services, creates navigation challenges that are particularly burdensome for the population with the most complex needs.
