President Donald Trump’s call for mental hospitals as a way to fight mass shootings is alarming health professionals who consider the widespread use of the facilities outdated and the wrong tool for fighting gun violence.
In the days following shootings in El Paso, Texas and Dayton, Ohio this month, the president spoke about background checks as a way of preventing more violence. But he quickly turned his attention toward mental illness and mental hospitals, specifically.
“I remember, growing up, we had mental institutions,” Trump said Sunday. “A lot of them were closed. And all of those people were put out on the streets. And I said — even as a young guy, I said, ‘How does that work? That’s not a good thing.’ And it’s not a good thing. So I think the concept of mental institution has to be looked at.”
Mental health care is just one tool
Even if the Trump administration were to pursue legislation to institutionalize more mentally ill patients, medical professionals who work with these communities warned against looking only at mental health in order to prevent gun violence.
Dr. Marvin Swartz, a professor in Psychiatry and Behavioral Sciences at Duke University, referenced a widely quoted paper by his colleague at Duke University, Jeffrey Swanson, which found that even if even if mental illness were eliminated completely as a risk factor, violence would only go down by about 4 percent.
“Why you would connect [gun violence] to a decline in psychiatric beds…I think makes no sense.” said Dr. Swartz of Trump’s recent comments.
“Characterizing this as merely or primarily a mental health issue is misleading. The vast majority of people with mental illness would never be violent,” said Dr. Barron Lerner, a professor in the Department of Population Health at New York University’s Langone School of Health who works at a mental health clinic.
Dr. Jeff Lieberman, a professor and chair of the psychiatry department at Columbia University, added that while all countries deal with mentally ill populations, few of them have access to guns like those in the U.S. does. So while there are a number of things the administration could do in order to better the U.S. mental health care system, most experts say the issue shouldn’t be viewed in a silo.
“You’ve got to lower the ability of people who are potentially violent to get guns,” said Dr. Lerner. “All that is complementary to also dealing with the percentage of people where this is a mental health issue.”
Why did the U.S. move to close mental hospitals?
As the president noted, when he was younger, there were many more mental hospitals in the United States. In the early 20th century, before any drug treatment was available for the mentally ill, patients in the U.S. were largely committed to state institutions. But Columbia’s Dr. Lieberman said conditions in those hospitals were very poor. In the middle of the 20th century the system “had grown into largely warehousing patients in state mental institutions under appalling conditions where they didn’t receive good care,” he said.
By 1955, more than half a million Americans were housed in these state hospitals. But the introduction of psychiatric drugs around this time gave policymakers and medical providers hope that the U.S. mental health system could move away from institutions.
In 1963, President John F. Kennedy signed the Community Mental Health Act with the goal of moving treatment out of institutions into community-based centers. In the 1960s and 1970s, the number of patients in state mental institutions was dramatically reduced. By 1994, just over 70,000 people were committed.
“Institutions now basically serve as a backup when people on [the] outside deteriorate,” said Dr. Barron Lerner, a professor in the Department of Population Health at New York University’s Longone School of Health. “There are many fewer dedicated psychiatric hospitals now.”
Funding challenges and its effect on mental health care in the U.S.
Although the 1963 Community Mental Health Act was intended to bolster community-based health research and centers, federal funding cuts to mental health treatment in the years that followed left many patients who could benefit without adequate access to care.
Duke University’s Marvin Swartz said that many medical providers had overestimated the ability of antipsychotic drugs to treat patients in the 1960s and 1970s. Importantly, the medications didn’t help patients once they were released from these hospitals.
“We took these people out of hospital saying…if he’s got schizophrenia he’s gonna be hunky dory. But in truth it’s what’s going to help with the voices and the delusions, but not with the ability to take care of themselves in the community,” he said.
“Afterwards, you see a disaster,” said Dr. Lieberman of moving patients out of institutions. “People who had been released from state mental institutions or maybe would have been hospitalized in them, no longer were. And there were inadequate community based services. What resulted was homelessness, mental patients in nursing homes, and increasingly in jails.”
President Jimmy Carter tried to restructure the community mental health care system with the Mental Health Systems Act of 1980, but President Reagan repealed the legislation when he took office a year later. As governor of California, Reagan had signed the Lanterman-Petris-Short Act, which forbade institutionalizing mental patients against their will. Although the government still provided block grants for states, federal funding for mental health care was reduced during Reagan’s presidency.
But Dr. Lerner said that while funding cuts under Reagan didn’t help improve the mental health care system, the issue of funding for these programs runs deeper than just one president.
“Almost all of these state programs for mental health are chronically underfunded. There’s a period where advocacy works… but then at the next legislative cycle, you’ve got to fight for it again. It’s a chronic challenge to keep mental health in the spotlight.” he said.