A History of Mental Institutions in the United States

This timeline was created by a capstone reporting class at the University of Maryland Philip Merrill College of Journalism, in conjunction with Kaiser Health News and Capital News Service, for a project on the deinstitutionalization of mental patients. Published Spring 2012. Edited by Chris Harvey. Photo courtesy of the Library of Congress

New Drugs Introduced

Before the development of psychiatric drug therapy, the most commonly used treatments for mental illness were electroconvulsive therapy, insulin coma therapy and lobotomies. These treatments often left patients severely damaged, so when new psychiatric drugs were developed in the 1950s, there was a new-found belief that people in mental institutions could be rehabilitated, according to Bernard Harcourt's research for the Ohio State Journal of Criminal Law. When the anti-psychotic Thorazine was introduced in 1954 as a way to calm patients with disorders such as schizophrenia and manic-depression, millions of people were prescribed the drug as a way to help hospital staff keep order in crowded facilities, Harcourt wrote. --By Kandyce Jackson

Half a Million in Institutions

In 1955 state mental institutions in the U.S. housed nearly 560,000 patients, according to William Gronfein, an associate professor at Indiana University-Purdue University.

Mental Institution Population Drops

By 1977, U.S. mental institutions had reduced the size of their collective population to about 160,000 patients, according to William Gronfein, an associate professor at Indiana University-Purdue University.

First Psychiatric Hospitals Open

The nation's first two psychiatric hospitals opened in the late-1700s. Eastern State Hospital in Williamsburg, Va., opened Oct. 12, 1773, and is still operational today. According to the hospital's website, it is the first national public facility built with the intention of solely treating patients with a mental illness. The building had 24 cells for male and female patients who were dangerous but had a chance of being treated. According to the Colonial Williamsburg website, treatments available at the hospital were "restraint, strong drugs, plunge baths and other "shock" water treatment, bleeding, and blistering salves," as well as an electro-static machine. According to the site, 20 percent of patients were "cured" and discharged between 1773 and 1790. The nation's second psychiatric hospital, Spring Grove Hospital, opened in Baltimore in 1798 just before the turn of the century. Spring Grove is still open, now located in Catonsville, Md. Spring Grove opened as the Public Hospital at Baltimore, according to the hospital's website, with the purpose of providing "for the relief of indigent sick persons, and for the reception and care of lunatics." --By Kirsty Groff

Justice Dept. Cracks Down

When President Obama took office in 2008, he reinvigorated the Justice Department’s efforts to crack down on states violating or failing to comply with the Supreme Court's Olmstead decision. Additionally, his administration fast-tracked a package of amendments to the Americans with Disabilities Act that broadened its scope, allowing more citizens to claim protections by loosening the requirements of what constitutes a disability. The amendments went into effect in January 2009. Since then, the department’s Civil Rights Division has been aggressively investigating the mental health care systems of states nationwide. Officials have looked into at least 20 states and have negotiated settlements with many of them, such as Kansas, Delaware and most recently, Virginia, according to DOJ reports. The agreements typically involve closing or significantly downsizing most or all of the state-run institutions in the jurisdiction in question and implementing a timeline by which to launch specific numbers and types of community programs and services. Even though Olmstead originated with plaintiffs in Georgia, the state’s system apparently had not implemented reforms satisfactory to the federal government until 2010, when state officials reached a settlement with the DOJ. At the time, federal officials called the agreement the “most comprehensive” to date, according to DOJ press releases, and said they planned to model other investigations off their success in Georgia. In other states, negotiations are still ongoing, such as in North Carolina, Oregon and New Hampshire, according to official reports. In March 2012, the Justice Department joined a lawsuit brought upon the New England state by private plaintiffs a month earlier, which was in response to DOJ findings from April 2011 that determined the mental health care system there was not up to par. The U.S. Department of Health and Human Services' Office of Civil Rights has also worked with many states to resolve complaints by private individuals or by advocacy groups on behalf of others. Between Aug. 1, 1999, and Sept. 30, 2010, the OCR resolved 850 cases related to Olmstead, according to the DHHS. Of these cases, 42 percent involved correcting the alleged civil rights violations through various measures; 26 percent found no violation of civil rights. Additionally, OCR conducted 581 investigations into Olmstead compliance, and 61 percent of those resulted in corrective measures being put in place. involved corrective action resolving civil rights issues and 26 percent found no civil rights violations, according to OCR. In Maryland, the State Department of Health and Mental Hygiene was involved with at least 15 such cases, according to the DHHS. Most of the cases cited were resolved in a similar manner; all involved expediting or facilitating transition into community settings where appropriate. Even before Obama stepped up enforcement of Olmstead, state and federal governments pursued community-based treatments in various capacities, such as offering financial incentives for programs to encourage states to move patients from institutions. --Compiled by Alissa Gulin

Kennedy's Commitment

Less than a month before his death, President John F. Kennedy signed the Community Mental Health Centers Act of 1963, which provided $150 million for new mental health center programs. Enactment of the act culminated Kennedy’s pursuit of reform of the national mental health system, which he had a personal stake in. His sister, Rosemary, had received a prefrontal lobotomy at age 23. In 1955, when Kennedy was a senator, he sponsored the Mental Health Study Act, which assigned a joint commission to create detailed assessments of mental health care and the effect mental illness had on American society, according to an article by David Rochefort. The study advised a new role for state hospitals as intensive treatment sites that would be much smaller in size, the article said. As president in 1963, Kennedy presented a special message to Congress that detailed the need for new mental health legislation. Kennedy stated that 600,000 people in private and public mental institutions at the time were affected by the harsh conditions of the institutions and hospitals on a daily basis. Kennedy argued that because of the benefits of new psychotropic drugs, people with mental illness could live in more natural community settings. Kennedy suggested Congress allocate funds to train more mental health professionals, to build more programs and facilities and to continue research. His goal was to reduce by 50 percent the number of patients in state mental hospitals in 10 to 20 years, according to Rochefort. As a result of Kennedy's legislation, the number of patients in state mental hospitals declined by 62 percent by 1975. --Compiled by Kaitlin Bulavinetz; photo courtesy of the John F. Kennedy Presidential Library and Museum

Olmstead Case Decided by S.C.

The U.S. Supreme Court's 1999 Olmstead ruling gave institutionalized mental health patients more ammunition in seeking community-based care. The case was brought against the Georgia commissioner of human resources by two women with mental illness who were confined for treatment at the psychiatric unit of the Georgia Regional Hospital at Atlanta. Their treatment teams had concluded that the women could receive appropriate care in a community setting, but the women remained institutionalized, according to the case. Their lawyers argued that denial of this treatment was a violation of the Americans with Disabilities Act of 1990. Title II of the ADA states that programs and services offered by public entities must be provided in an integrated setting, unless separate or different measures are necessary to ensure equal opportunity. The U.S. Department of Justice defined an integrated setting as one “that enables individuals with disabilities to interact with non-disabled persons to the fullest extent possible.” The ruling of the case affirmed that under ADA unjustifiable institutionalization of a person with a disability is discrimination when the treating provider believes that community-based care would be better; when the affected person does not oppose the community-based option and when the placement can be reasonably accommodated. The court ruled that institutionalization limits a person’s ability to interact with other people, to work and to make a life for him or herself, according to the case document. The Olmstead case has brought progress for many individuals, successfully transitioning them from institutions to community settings, according to Diana Rovai in her "Review of Recent Department of Justice Olmstead Briefs." But waiting lists for community services have grown, and many who would like to receive community services aren’t able to obtain them. The Olmstead case came during a decade of milestones for deinstitutionalization. In the 1990s whole institutions began to close in significant numbers, and there was a greater emphasis on rights that secured community integration. In 1993 more state-controlled mental health dollars were given to community care than to the institutions, according to The Kaiser Commission on Medicaid and the Uninsured. --Compiled by Glynnesha Taylor

Budget Cuts Change Care

The 1980s marked a period in which sweeping budget cuts led to a decline in services for the mentally ill. President Ronald Reagan helped institute a variety of cuts to social programs that affected a number of groups throughout the country. His administration supervised cuts throughout the decade that hampered support for the poor and mentally ill, among other groups. Prior to Reagan’s presidency, President Jimmy Carter helped establish the Mental Health Systems Act of 1980, which restructured federal community health center programs by increasing and strengthening links between local, state and federal governments, according to a history of mental health in the United States by the Minnesota Psychiatric Society. The act mandated the Community Mental Health Centers to increase a number of grant programs for the mentally ill, such as services for the severely mentally ill, the severely emotionally disturbed and increasing education and consulting needs. At the time he signed the act, Carter said the act was “the most important piece of federal mental health legislation” since President John F. Kennedy's Community Mental Health and Mental Retardation Facilities Act in 1963. It was designed to reestablish many of the community programs from the Kennedy years and President Lyndon B. Johnson’s Great Society that had been cut or diminished during the Nixon presidency. However, Reagan repealed the act soon after taking office in 1981, because the federal support of Community Mental Health Centers ran counter to his goals to reduce spending and social programs, according to Alexandar R. Thomas, a sociology professor at Northeastern. In its stead, Reagan enacted the Alcohol, Drug Abuse and Mental Health Block Grant, which decreased funding by 30 percent in 1982, leading to major service reductions. Under this system, the federal government simply redistributed money to the states, but in smaller amounts, which increased the burden placed upon local and state governments, according to a 1994 journal article by Gerald Grob of Rutgers University. By 1985 the federal funds provided to the ADMS Block Grant covered only 11 percent of agency budgets, while states’ responsibility grew to 42 percent. --Compiled by Matt Birchenough; photo courtesy the Ronald Reagan Library

Dix and the Growth of Institutions

The maltreatment of people with mental illnesses in prisons in the 19th century inspired the increased creation of institutions to treat them. In Massachusetts, the Rev. Louis Dwight created the Boston Prison Discipline Society in 1825, which advocated for better prison and jail conditions and hospitals for the mentally ill. The society's focus led to the creation of a state legislative committee in 1827 to look into jail conditions. The committee recommended moving the mentally ill to the Massachusetts General Hospital. The general court later approved the construction of a 120-bed hospital for the mentally ill, the Worcester Lunatic Asylum, which opened in 1833 as the first of its kind in the state, according to the Massachusetts Department of Mental Health. To increase the momentum of the asylum-movement, school teacher Dorothea Dix (pictured) began her advocacy work in 1841. Beginning in Massachusetts, she traveled down the East Coast, visiting prisons and almshouses --housing for the poor. She visited an estimated 18 prisons, 300 jails and 500 almshouses by 1847, six years after taking up her crusade as a 39-year-old, according to E. Fuller Torrey's book, "Out of the Shadows: Confronting America's Mental Illness Crisis." She argued that people "who have diseases of the brain" should be treated "much more compassionately,” said Ron Honberg, director of policy and legal affairs for the National Alliance on Mental Illness. “Prisons are not constructed in view of being converted into County Hospitals, and Alms-Houses are not founded as receptacles for the Insane,” Dix said in an address to the Massachusetts Legislature in 1842. “And yet, in the face of justice and common sense, Wardens are by law compelled to receive, and Masters of Alms-House not to refuse, Insane and Idiotic subjects in all stages of mental disease and privation.” Dix's work is believed to have directly influenced the creation of 32 state psychiatric hospitals, according to Encyclopaedia Britannica. By 1880, there were 75 public psychiatric hospitals in the United States, according to Torrey. “They were, at the time, very nice buildings. They were supposed to be very peaceful locations where people could go to recover or at least have a chance to recover and not be subjected to those terrible conditions” in the prisons, Honberg said. --Compiled by Kirsty Groff; photo courtesy of the Library of Congress

Prisons See Surge in Mentally Ill

The number of mentally ill Marylanders jailed in state prisons has steadily increased in recent years, as the state has shrunk the number of patients in its psychiatric hospitals, officials say. Of the roughly 26,000 inmates in Maryland penitentiaries, about 4,200, or 16 percent, have been diagnosed with a mental illness, said Dr. James Holwager, director of Mental Health Services for the Maryland Department of Public Safety and Correctional Services. That represents about a 5 percent jump from two years earlier, he said. The increase of the mentally ill in Maryland prisons mirrors a national trend and coincides with a decades-long push to move patients out of mental hospitals and into community-based care. Nationally, the percentage of mentally ill in prisons has grown from about 5 percent about 25 years ago to closer to 20 percent today, Holwager said. As psychiatric hospitals closed, advocates say, insufficient funds were provided for community care and residential programs, leaving some mentally ill without proper treatment and with nowhere to go. “Where are [the mentally ill] going to get their services?” asked Dan Martin, director of public policy of the Mental Health Association of Maryland. “It’s more likely to be in jail.” -- By Katilin Bulavinetz and Glynnesha Taylor

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