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Better But Not Well

Mental Health Policy in the United States since 1950

Richard G. Frank and Sherry A. Glied foreword by Rosalynn Carter

Publication Year: 2006

The past half-century has been marked by major changes in the treatment of mental illness: important advances in understanding mental illnesses, increases in spending on mental health care and support of people with mental illnesses, and the availability of new medications that are easier for the patient to tolerate. Although these changes have made things better for those who have mental illness, they are not quite enough. In Better But Not Well, Richard G. Frank and Sherry A. Glied examine the well-being of people with mental illness in the United States over the past fifty years, addressing issues such as economics, treatment, standards of living, rights, and stigma. Marshaling a range of new empirical evidence, they first argue that people with mental illness—severe and persistent disorders as well as less serious mental health conditions—are faring better today than in the past. Improvements have come about for unheralded and unexpected reasons. Rather than being a result of more effective mental health treatments, progress has come from the growth of private health insurance and of mainstream social programs—such as Medicaid, Supplemental Security Income, housing vouchers, and food stamps—and the development of new treatments that are easier for patients to tolerate and for physicians to manage. The authors remind us that, despite the progress that has been made, this disadvantaged group remains worse off than most others in society. The "mainstreaming" of persons with mental illness has left a policy void, where governmental institutions responsible for meeting the needs of mental health patients lack resources and programmatic authority. To fill this void, Frank and Glied suggest that institutional resources be applied systematically and routinely to examine and address how federal and state programs affect the well-being of people with mental illness.

Published by: The Johns Hopkins University Press


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pp. vii

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pp. ix-x

America has always struggled to care for and support people who have mental illnesses. The challenges of addressing these disabling health conditions demand that we both show our compassion and use our ingenuity. When Jimmy was president during the 1970s, I served as honorary chairperson for a presidential commission to assess the mental heath needs of the nation and to develop...

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pp. xi-xv

In the past ten years, discussions of mental health policy have routinely taken a dour view of the recent history of mental health care in the United States. President Bush’s 2003 New Freedom Commission report begins by calling mental health care in America “a system that had fallen into a state of disarray.” The...

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1 Introduction

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pp. 1-7

The mental health system today bears scant resemblance to that of the first half of the twentieth century. Albert Deutsch, after a decade of investigation, indicted mental health care in 1948 in The Shame of the States. Deutsch described how people with severe mental illness languished on the filthy back wards of public mental hospitals...

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2 The Population with Mental Illness

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pp. 8-25

Mental illness is far more visible today than it was fifty years ago. People with severe mental illness, once housed in state institutions often located far from population centers, now live in the community. People who were once thought to have personality quirks or to be victims of harsh social circumstances are now described...

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3 The Evolving Technology of Mental Health Care

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pp. 26-47

The past fifty years have been filled with technological innovations in health care. From the polio vaccine to water fluoridation, from new pharmaceuticals to joint replacement, the benefits of new technologies over the past half century have been staggering. The economist William Nordhaus estimates that during these...

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4 Health Care Financing and Income Support

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pp. 48-69

Between 1950 and 2000 the financing and delivery of mental health care underwent structural changes as dramatic as those in the Eastern European nations after the Soviet Union’s disintegration. In a matter of twenty years, starting in the mid-1960s, mental health care moved largely from a centrally planned...

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5 The Supply of Mental Health Services

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pp. 70-90

Public and private spending on mental health services and social services that improve the well-being of people with mental illness have expanded tremendously since 1950. An infusion of new funding, coupled with the renewed professional optimism about the potential of mental health treatment that, in part, prompted...

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6 Policy Making in Mental Health: Integration, Mainstreaming, and Shifting Institutions

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pp. 91-103

In the 1950s and 1960s mental health policy making was the domain of governors and their state mental health program directors. Organized psychiatry wielded great influence and was deeply involved in consequential debates about the future of mental health care in the United States. Today, by contrast, state Medicaid directors, the...

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7 Assessing the Well-being of People with Mental Illness

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pp. 104-139

Over the past five decades, Americans have witnessed vast improvements in living standards. Incomes have more than tripled (adjusting for inflation). The share of U.S. families living in poverty has fallen by half. The life expectancy of adults has increased seven years since 1950. Most Americans have benefited...

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8 Looking Forward: Improving the Well-being of People with Mental Illness

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pp. 140-149

In 1963 President Kennedy set out a “to-do list” for improving the quality of mental health care in the United States and the lives of people with mental disorders: We must act to bestow the full benefits of our society to those who suffer from mental disabilities; to prevent occurrence of mental illness . . . wherever and whenever...


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pp. 151-156


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pp. 157-176


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pp. 177-183

E-ISBN-13: 9780801889103
E-ISBN-10: 0801889103
Print-ISBN-13: 9780801884436
Print-ISBN-10: 0801884438

Page Count: 208
Illustrations: 13 line illustrations
Publication Year: 2006