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Concern for the mentally ill has waxed and waned through the centuries, but the development of modern-day approaches to the subject dates from the mid-
18th century, when reformers such as the French physician Philippe Pinel and the American physician Benjamin Rush introduced humane “moral treatment” to replace the often cruel treatment that then prevailed.
Despite these reforms, most of the mentally ill continued to live in jails and poorhouses—a situation that continued until 1841, when the American reformer Dorothea Dix campaigned to place the mentally ill in hospitals for special treatment.

The modern mental health movement can be traced to the publication in 1908 of A Mind That Found Itself, an account of the experience of its author,
Clifford Whittingham Beers, as a mental patient. The book aroused a storm of public concern for the mentally ill. In 1909 Beers founded the National
Committee for Mental Hygiene.

Public awareness of the need for greater governmental attention to mental health services led to passage of the National Mental Health Act in 1946.
This legislation authorized the establishment of the National Institute of
Mental Health to be operated as a part of the U.S. Public Health Service.
In 1950 the National Committee for Mental Hygiene was reorganized as the
National Association for Mental Health, better known as the Mental Health
Association.

In 1955 Congress established a Joint Commission on Mental Illness and
Health to survey the mental health needs of the nation and to recommend new approaches. Based on the commission’s recommendations, legislation was passed in 1963 authorizing funds for construction of facilities for community-based treatment centers. A similar group, the President’s
Commission on Mental Health, reported its findings in 1978, citing estimates of the cost of mental illness in the U.S. alone as being about
$17 billion a year.

Scope of the Problem

According to a common estimate, at any one time 10 percent of the American population has mental health problems sufficiently serious to warrant care; recent evidence suggests that this figure may be closer to 15 percent. Not all the people who need help receive it, however; in 1975 only 3 percent of the American population received mental health service. One major reason for this is that people still fear the stigma attached to mental illness and hence often fail to report it or to seek help.

Analysis of the figures on mental illness shows that schizophrenia afflicts an estimated 2 million Americans, another 2 million suffer from profound depressive disorders, and 1 million have organic psychoses or other permanently disabling mental conditions. As much as 25 percent of the population is estimated to suffer from mild or moderate depression, anxiety, and other types of emotional problems. Some 10 million Americans have problems related to alcohol abuse, and millions more are thought to abuse drugs. Some 5 to 15 percent of children between the ages of 3 and 15 are the victims of persistent mental health problems, and at least 2 million are thought to have severe learning disabilities that can seriously impair their mental health.

In addition, according to the President’s Commission, the list of mental health problems should be extended beyond identifiable psychiatric conditions to include the damage to mental health associated with unrelenting poverty, unemployment, and discrimination on the basis of race, sex, class, age, and mental or physical handicaps.

Prevention

Public health authorities customarily distinguish among three forms of prevention. Primary prevention refers to attempts to prevent the occurrence of mental disorder, as well as to promote positive mental health. Secondary prevention is the early detection and treatment of a disorder, and tertiary prevention refers to rehabilitative efforts that are directed at preventing complications.

Two avenues of approach to the prevention of mental illness in adults were suggested by the President’s Commission. One was to reduce the stressful effects of such crises as unemployment, retirement, bereavement, and marital disruption; the second was to create environments in which people can achieve their full potential. The commission placed its heaviest emphasis, however, on helping children. It recommended the following steps:

1) good care during pregnancy and childbirth, so that early treatment can be instituted as needed;

2) early detection and correction of problems of physical, emotional, and intellectual development;

3) developmental day-care programs focusing on emotional and intellectual development;

4) support services for families, directed at preventing unnecessary and inappropriate foster care or other out-of-home placements for children.

Treatment

Care of the mentally ill has changed dramatically in recent decades. Drugs introduced in the mid-1950s, along with other improved treatment methods, enabled many patients who would once have spent years in mental institutions to be treated as outpatients in community facilities instead.
(A series of judicial decisions and legislative acts has promoted community care by requiring that patients be treated in the least restrictive setting available.) Between 1955 and 1980 the number of people in state mental hospitals declined from more than 550,000 to fewer than 125,000. This trend was due partly to improved community care and partly to the cost of operating hospitals; in an effort to save public money, some large state mental hospitals have been closed, forcing alternatives to be found for patients. This is generally considered a progressive trend because when patients spend extended periods in hospitals they tend to become overly dependent and lose interest in taking care of themselves. In addition, because the hospitals are often located long distances from the patients’ homes, families and friends can visit only infrequently, and the patients’ roles at home and at work are likely to be taken over by others.

The psychiatric wards of community general hospitals have assumed some of the responsibility for caring for the mentally ill during the acute phases of illness. Some of these hospitals function as the inpatient service for community mental health centers. Typically, patients remain for a few days or weeks until their symptoms have subsided, and they usually are given some form of psychotropic drug to help relieve their symptoms. Following the lead of Great Britain, American mental hospitals now also give some patients complete freedom of buildings and grounds and, in some instances, freedom to visit nearby communities. This move is based on the conclusion that disturbed behavior is often the result of restraint rather than of illness.

Treatment of patients with less severe mental disorders has also changed markedly in recent decades. Previously, patients with mild depression, anxiety disorders, and other neurotic conditions were treated individually with psychotherapy. Although this form of treatment is still widely used, alternative approaches are now available. In some instances, a group of patients meets to work through problems with the assistance of a therapist; in other cases, families are treated as a unit. Another form of treatment that has proven especially effective in alleviating phobic disorders is behavior therapy, which focuses on changing overt behavior rather than the underlying causes of a disorder. As in the serious mental illnesses, the treatment of milder forms of anxiety and depression has been furthered by the introduction of new drugs that help alleviate symptoms.

Rehabilitation

The release of large numbers of patients from state mental hospitals, however, has caused significant problems both for the patients and for the communities that become their new homes. Adequate community services often are unavailable to former mental patients, a large percentage of whom live in nursing homes and other facilities that are not equipped to meet their needs. Most of these patients have been diagnosed as having schizophrenia, and only 15 to 40 percent of schizophrenics who live in the community achieve an average level of adjustment. Those who do receive care typically visit a clinic at periodic intervals for brief counseling and drug monitoring.

In addition to such outpatient clinics, rehabilitation services include sheltered workshops, day-treatment programs, and social clubs. Sheltered workshops provide vocational guidance and an opportunity to brush up on an old skill or learn a new one. In day-treatment programs, patients return home at night and on weekends; during weekdays, the programs offer a range of rehabilitative services, such as vocational training, group activities, and help in the practical problems of living. Ex-patient social clubs provide social contacts, group activities, and an opportunity for patients to develop self-confidence in normal situations.

Another important rehabilitative facility is the halfway house for patients whose families are not willing or able to accept them after discharge. It serves as a temporary residence for ex-patients who are ready to form outside community ties. A variant is the use of subsidized apartments for recently discharged psychiatric patients.

Research

Many different sciences contribute to knowledge about mental health and illness. In recent decades these sciences have begun to clarify basic biological, psychological, and social processes, and they have refined the application of such knowledge to mental health problems.

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