Better But Not Well: Mental Health Policy in the United States since 1950 (review)

This book's title, "Better But Not Well," aptly summarizes its basic message. Richard Frank and Sherry Glied, both prominent health economists, document the radical transformation of the mental health system over the past half-century, arguing that care for persons with serious mental illness, although far from ideal, is much improved. They focus on the social policy changes that have revolutionized this system through altering incentives for mental health services on both the supply and the demand sides. These changes have transformed the system from one based on services provided within large, state-financed, inpatient mental institutions to a community-based, heterogeneous, and decentralized collection of services funded through federal dollars. "The result," the authors summarize, "is that the lives of most people with mental illnesses are better today than they were fifty years ago" (p. 2). Paradoxically, none of the major policies that shaped the major changes in the mental health system—including Medicaid, Medicare, and Supplemental Security Income (SSI)—was specifically developed to affect this system, but instead arose to fund health care in general and was then adapted to mental health.

Frank and Glied's major theme is that the central issues in the contemporary mental health system arise from the tension between the mainstreaming of mental health care into the general health system that the reliance on Medicaid, Medicare, and SSI has created, and the need for mental health exceptionalism that grows out of the special dilemmas that serious mental illness poses. On the one hand, mainstream health programs have provided persons with serious mental illness, and the programs that serve them, an unprecedented stream of funding that has vastly increased consumer choice and raised standards of living. On the other hand, these programs do not take into account the special needs of persons with serious mental illness, which necessitate intensive psychosocial services including the provision of housing, job training, and stable, long-term employment. They also have led to a vacuum of responsibility and leadership in policy issues involving mental illness because the most influential policymakers lie outside the mental health system.

Although Frank and Glied recognize and dissect many flaws in the current mental health system, their view might still be overoptimistic. They ignore conflicts among competing groups within the system, such as those that arise between advocacy groups that consist of family members and those representing mental health consumers. They tend to slight the negative influence of pharmaceutical companies on the medical and psychiatric professions, advocacy groups, and research. Their distinction between mental health technologies that reduce symptoms, are harmful, or are easier to use is innovative and useful—however, their unmitigated view of the benefits of current psychotropic medications seems overly sanguine. Their chief policy recommendation, creating a new federal agency for mental illness that would report directly to the president, seems unrealistic and could become a questionable precedent for innumerable agencies focusing on specific illnesses.

These flaws, however, pale in comparison to the great achievements of the book. In fewer than 150 pages of text, the authors present a clear, systematic, and surprisingly complete analysis of the major forces driving changes in the mental health system, as well as valuable overviews of psychiatric epidemiology, the mental health professions, and the effectiveness of mental health treatments. They marshal a wide range of data that clearly document the policies and the resulting changes the system has undergone in the past fifty years, and that provide a firm grounding for their masterful and nuanced analysis of major social policies with their often unintended effects on the mental health system. They write in an accessible style that makes their book useful not only for professionals interested in a short, readable summary of policy changes in mental health, but also for upper-level undergraduate and graduate students.

Especially when read...