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p r e fa c e 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 Bazelon Center for Mental Health Law’s 2001 call to action argues that “for decades mental health systems have been burdened with ineffective service delivery programs and stagnant state bureaucracies” (Bazelon Center, 2001). These views of the past sometimes generate policy proposals that treat existing policies and institutions simply as hopeless impediments to progress. At other times, advocates cling to familiar institutions that have long served people with mental illnesses as “ports in a storm.” Yet if their views of the past are distorted, policy makers and advocates may be mistaken in the institutions and policies they choose in an effort to make a better future. In 1999 the MacArthur Foundation’s Network on Mental Health Policy began a series of discussions about how to improve the care of people with mental illness in the United States. It quickly became clear that the discussions were heavily influenced by perceptions of the recent past. We realized that we needed an empirical scorecard that assessed how the well-being of people with mental illness had changed since the policy ferment of the late 1950s and 1960s and what forces had caused the evolution of care. Thus, the Network encouraged us to engage in a data-driven assessment of the recent history of mental health care, and we recognized that we would view the evidence and the events in the delivery of mental health care through the lens of the discipline of economics. This book is the result of that reexamination. Our purpose is to explore the changes occurring over the last fifty years in the lives of people with mental illnesses and to assess the factors that generated these changes. Discerning if people with mental illnesses are better off turns out to be far from simple. This book xii Preface strives to collect and analyze the indicators that may be useful to glean a fair and accurate picture of how lives have improved and then to infer why. Emphasizing only the deficiencies of the present—without an understanding of how these relate to the past—can lead to a replay of earlier unproductive efforts. By taking a longer-term view of the subject, we aim to put some of today’s problems into perspective. Understanding the forces that have promoted and impeded gains in the lives of people with mental illness can help to guide the development of policies likely to prove useful in the future. This book places special emphasis on how increasing decentralization and declining mental health exceptionalism have contributed to these changes in well-being. Chapter 1 provides an overview of the major developments affecting the well-being of people with mental illness since 1950. In chapter 2 we evaluate estimates of the size and character of the population with mental illness over time. Our analysis suggests that the size of the population with mental illness—or with severe mental illness—has remained relatively constant as a share of the U.S. population. Furthermore, the characteristics of the population with mental illness have not changed substantially over time. Together, these two findings imply that whatever improvement or deterioration we observe in the condition of people with mental illness cannot be attributed mainly to changes in the underlying population. Chapter 3 turns to a second possible explanation of changes in the well-being of the population with mental illness—changes in the ability to treat illness effectively . The early part of this fifty-year period—the 1950s and 1960s—saw the development of several therapies for the treatment of mental illness that were clearly improvements over the treatments preceding them. Since then, there has been a great deal of innovation. In terms of symptom reduction alone, however, the treatment arsenal available today is not really much better than that available twenty-five years ago. The new technologies are, however, much easier to use in practice. We argue that practice-simplifying innovations of this kind are particularly important in an era of decentralized practice. We also document the treatment improvements that have come about through the withdrawal from practice of ineffective and harmful treatments. Finally, we note that...


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