In earlier centuries, mental illness was often considered a sign of possession by the devil or, at best, moral weakness. A change in these attitudes began in the late eighteenth century, when mental illness began to be perceived as a treatable condition. It was then that the concept of "asylums" was developed, not simply to lock the mentally ill away, but also to provide them with "relief" from the conditions they found troubling.
Who Are the Mentally Ill?
Providers of mental health care distinguish between people who are severely mentally ill (defined by diagnosis), those who are mentally disabled (defined by level of disability), and those who are chronic mental patients (defined by duration of hospitalization). These three dimensions—diagnosis, disability, and duration—are the models used to describe the mentally ill population in the United States.
Mental Health: A Report of the Surgeon General, 1999 defines mental disorders as "health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning." The report distinguishes mental disorders from mental problems, describing the signs and symptoms of mental health problems as less intense and of shorter duration than those of mental health disorders; it acknowledges, however, that both mental health disorders and problems may be distressing and disabling.
The U.S. Public Health Service uses this definition:
The chronically mentally ill population includes persons who suffer from emotional disorders that interfere with their functional capacities in relation to such primary aspects of daily life as self-care, interpersonal relationships, and work or schooling, and that may often necessitate prolonged mental health care.
The U.S. Surgeon General's Report asserts that at the close of the twentieth century, the nation's ability to prevent, identify, and treat mental disorders had outpaced the system for delivering mental health care to all those in need of it. The report estimated that one in five Americans suffers from a mental disorder in any given year and 15% of adults make use of mental health services during the year—8% seek care for a mental disorder and 7% have mental health problems.
Where Are the Mentally Ill?
The chronically mentally ill reside either in mental hospitals or in community settings, such as with families, in boarding homes and shelters, in single-room-occupancy hotels (usually cheap hotels or boardinghouses), in jail, or even on the streets as part of the homeless population. The institutionalized mentally ill are those persons with psychiatric diagnoses who have lived in mental hospitals for more than one year or those with diagnosed mental conditions who are living in nursing homes.
Between 1986 and 1998 the number of patients housed in county mental health institutions declined, although the number of mental health organizations rose by almost 975 during this time. The total number of beds dropped from 267,613 to 266,729, and from 111.7 beds to 99.1 beds per one hundred thousand persons. State and county mental hospital beds were reduced most dramatically, by more than one-half, from fifty to twenty-four beds per one hundred thousand persons. (See Table 3.8.) This is not necessarily a result of better treatment for the mentally ill, but rather a consequence of reduced funding for those institutions and individuals. Unfortunately, many of the patients who were once housed in mental institutions (including some who had been lifelong residents in these facilities) now fend for themselves on the streets or in prisons.
Declining mental health expenditures have resulted in fewer available services for specific populations of the mentally ill, particularly those who could benefit from inpatient or residential care. Even for persons without conditions requiring institutional care there are barriers to access. The Surgeon General's Report describes the U.S. mental health service system as largely uncoordinated and fragmented, in part because it involves so many different sectors—health and social welfare agencies, public and private hospitals, housing, criminal justice, education—and it is funded through many different sources. Finally, inequalities in insurance coverage for mental health, coupled with the stigma associated with mental illness and treatment, have also limited access to services.