The United States has seen impressive advancements in both its economy and overall health. Life expectancy has increased by 20 years since 1930, and the poverty rate has decreased by over 10% since 1960. However, in mental health, the progress has been comparatively limited. One in five Americans has a mental illness, and less than half of them are getting treatment.
To understand the current state and how we got here, it is important to examine the historical context that has shaped our journey thus far. In this article, I will provide a high-level overview of this fluctuating progress, from the early days of asylums and superstition to the passing of mental health parity acts.
In the early days of American history, mental health care was rooted in superstition and religious beliefs. Those suffering from mental illness were often viewed as possessed by evil spirits, leading to rituals and exorcisms as treatment. Family members and religious institutions primarily provided care during this period.
The establishment of asylums marked a significant turning point in mental health care. The first American asylum, [Pennsylvania Hospital](https://www.uphs.upenn.edu/paharc/features/psych.html#:~:text=The Pennsylvania Hospital for the,mentally ill reached new heights.), emerged in 1751, followed by the establishment of other state-run institutions across the country. Unfortunately, the conditions within these asylums were often deplorable, with patients subjected to neglect and harsh treatments.
Despite these harsh conditions, the moral treatment movement was introduced in the United States in the early 1800s. It advocated for humane and compassionate treatment of individuals with mental illnesses, focusing on moral, psychological, and social interventions rather than harsh or punitive methods.
The 20th century witnessed a shift towards biological explanations for mental illness. Breakthrough discoveries, such as psychoactive drugs like chlorpromazine and lithium in the 1940s / 1950s, revolutionized psychiatric treatment. These drugs not only changed the way we treat mental illness, but also the way we talk about mental illness: it’s now considered a brain disease, not a behavioral problem.
This notion of curing mental illness encouraged research into the area: Harriet Truman passed the National Mental Health Act in 1946, which funded the National Institute of Mental Health to continue research efforts.
In the 1960s, the United States saw a period of significant reform and social change extending to various areas, including mental health. One month before his assassination, President John F. Kennedy passed the Community Mental Health Act (CMHA) of 1963, aiming to establish a network of community mental health centers throughout the country. The goal was to provide accessible and comprehensive care for individuals with mental illness, shifting the focus from institutionalization to community-based treatment.
This act was a part of a broader movement called deinstitutionalization, moving patients from large hospitals to local community centers. Unfortunately, we ultimately never built the systems of community care that were promised in this act and pushed patients out of institutions into oblivion.
When President Johnson assumed office following JFK's death, he introduced Medicare and Medicaid, but mental health was overlooked. The creation of institutions for mental disease (IMD) exclusion effectively restricted federal funds for mental health facilities. The objective was to encourage patients to leave mental health institutions, but the infrastructure for community mental health centers was not built due to insufficient funding and political oversight. As a result, numerous individuals with mental illness were left without proper care, contributing to a rise in homelessness and incarceration rates among the mentally ill.
Mental health continued to be a low priority through the Johnson, Nixon, and Ford administrations. There was a glimmer of hope when advocacy from Rosalind Carter created the [Mental Health Systems Act (1980)](https://en.wikipedia.org/wiki/Mental_Health_Systems_Act_of_1980#:~:text=The Mental Health Systems Act,to community mental health centers.) to help fund community mental health centers, but it was repealed in the Reagan Administration.
Traditionally, insurance companies have treated mental healthcare differently than other physical health conditions, using a number of methods to make mental healthcare less accessible. These methods include increased co-pays, caps on number of visits, and different prior authorization requirements.
In 1996, the initial [set of parity laws](https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet#:~:text=The Mental Health Parity Act,imposed on medical%2Fsurgical benefits.) was introduced, requiring health plans to impose identical annual dollar limits on mental healthcare coverage as they do on medical surgical coverage. Although this legislation represented a positive first step, it primarily carried symbolic significance and initially did not require insurance coverage for mental health services or effectively tackle other issues like visit limits and increased cost-sharing.
In 2008, The Mental Health Parity and Addiction Equity Act was passed by the aid of lead sponsor Patrick Kennedy, and nephew of JFK. This act introduced the next set of parity laws, which addressed gaps in the previous legislation and extended equal coverage to both mental health services and substance abuse treatment. Two years later, the Affordable Care Act (ACA) mandated coverage rather than requiring parity only if coverage is already provided.