The State of Serious Mental Illness in the U.S. Has Always Been a Dangerous Crisis

The novel coronavirus has unleashed a wave of concern about the mental health of Americans. Disaster hotlines are seeing unprecedented spikes in calls by distressed individuals seeking help. Mental health professionals cite concerns about the dangers of a looming crisis in the wake of Americans’ extreme stress and anxiety. But perhaps the most urgent aspect of this crisis is the one receiving comparatively little attention: the needs of the 8.3 million Americans with severe mental illnesses (SMIs), like schizophrenia and bipolar disorder.  

The frightening reality is that systems put in place to assist people living with severe mental illness (SMI) have long been broken. People with SMI die 10 to 25 years earlier than the general population. Up to half of those with SMI receive no treatment in a given year, despite living with paranoid thinking, an altered reality, or extreme episodes of mania or depression. More than 350,000 people with SMI are currently unhoused.

The causes are myriad, but all can be traced to one fundamental fact: over the past seven decades, our nation has demolished desperately needed psychiatric treatment facilities. Today, the United States has just 20 public or private beds per 100,000 population. As a consequence, care for people in mental health crises has fallen to the “safety net” systems that can’t turn people away: emergency departments, homeless shelters, and even our jails and prisons. 

But what happens when the COVID-19 pandemic closes even those doors? 

The federal government has issued waivers allowing general hospitals to convert the few existing psychiatric unit beds to acute-care beds for COVID-19 patients. This step is understandable, given the scope of the pandemic. What’s missing from the Feds’ announcement is guidance about where people in the midst of a psychotic episode are supposed to go for care. 

Before COVID-19, our emergency departments (EDs) were often called on to pick up the slack, providing makeshift mental health care amidst the Sturm und Drang of car crashes and heart attacks. But EDs also struggle with systematic mental health failures, often resorting to leaving psychiatric patients waiting in hallways until an appropriate bed opens. Almost 80 percent of ED physicians reported psychiatric patients “boarding” or waiting for a bed in their EDs every week — well before beds were taken up with COVID-19 patients — with 55 percent reporting patient boarding for multiple days. That situation is unthinkable as EDs attempt to triage and isolate contagious COVID-19 patients. 

In America, a large majority of people with SMI ultimately end up in our two universal catchalls: jails and the streets. Incarceration is generally a dangerous proposition for people with SMI — not to mention a terrible place to provide psychiatric care. But in the midst of a pandemic already seeing outbreaks at correctional facilities never designed to meet social distancing requirements, relying on jails as a substitute for mental health treatment is unconscionable.

Releasing people into homelessness will only exacerbate the crisis. We are already seeing the rapid spread of illness in these communities threaten to overwhelm hospitals; California state models predict 12,000 hospital beds could be necessary to treat people experiencing homelessness.

We are under no illusion that the federal and state governments will be able to solve decades of mental health neglect in the midst of this pandemic. But there are steps that can help lessen the impact of untreated severe mental illness on our response efforts.

First, we urgently need more psychiatric beds. Prior to the onset of the pandemic, the federal government had already begun efforts to restore bed capacity through initiatives such as overriding the discriminatory Institutions of Mental Disease (IMD) exclusion (a holdover of deinstitutionalization) that prohibits federal payments to hospitals containing more than 16 psychiatric beds. Jails have no similar limits on bed capacity. The law is strikingly anachronistic in an age when cities like Los Angeles had approved plans to build a jail with upwards of 3,800 beds for people with mental illness.

The federal coronavirus relief bill did make investments in mental health, including $425 million to provide a comprehensive range of mental health and substance-use-disorder services to communities. But a crisis of this scope and magnitude requires sustained prioritization of people with severe mental illness — those in facilities and in our communities. These efforts are crucial to staving off disaster.  

In this moment of crisis, the federal government should finally abandon the discriminatory IMD exclusion to allow freestanding psychiatric hospitals to address the mental health treatment needs of those displaced from general hospitals. Hospitals need to be able to treat more than 16 psychiatric patients at a time. Additionally, the unjustifiable 190-day Medicare payment limit on inpatient psychiatric care, which prevents insurance coverage long before most psychiatric disorders are under control, must also be removed so that patients transferred from general hospitals aren’t threatened with loss of coverage. 

Congress must also ensure there is a distribution pipeline of PPE to mental health professionals and further funding to mental health agencies and providers suffering financial hardships due to the pandemic. It must also fund further expansion of certified community behavioral health clinics whose efforts to treat and support people with SMI are essential — a movement launched in 1962 that was never fully realized. 

Our nation has a history of failing people with SMI, to all of our detriment. Few families — and no communities — are immune to its impact. Now more than ever, we must finally accept our responsibility to protect our most vulnerable citizens.


John Snook is the executive director of the Treatment Advocacy Center, a nonprofit that works to eliminate barriers to treatment for people with severe mental illness.

Dr. Kenneth Paul Rosenberg is the director of the PBS film “Bedlam.” Dr. Rosenberg is also the author of the Penguin Random House book “Bedlam,” and a psychiatrist at Weill Cornell Medical Center. 

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