The history of mental illness coincides with the civil rights movement although to this day, the courts have not recognized a right to mental health treatment. Up until the turn of the nineteenth century, people with mental illness were confined indefinitely. Then, in the 1970s, the extensive use of psychotropic drugs made involuntary hospitalizations less necessary and the states began closing their state mental hospitals. For the first time, people with mental illness who preferred to live in their homes and were not a danger to themselves or others were free to do so. In 1975, the U.S. Supreme Court opened the doors to deinstitutionalization when it held that mental illness alone could not justify confining people indefinitely in state mental hospitals (O'Connor v. Donaldson, Addington422 U.S. 563 (U.S. Supreme Court 1975)). Up until this time, people could be committed to state mental hospitals, without treatment programs, even if they were not dangerous to themselves or others. Four years later the Court held that the due process rights of the mentally ill require a higher standard than a regular civil proceeding if it might result in indefinite commitments (Addington v. Texas, 441 U.S. 418 (U.S. Supreme Court 1979)). In 1982, the Court held that mentally ill people have a constitutionally protected right to refuse drug therapy (Mills v. Rogers, 457 U.S. 291, 299 (1982)). The Court explained that involuntary commitment provides no basis to infer someone is incompetent without a further judicial finding. Today, people with mental illness now have rights, but if they cannot afford treatment, they are now often either homeless or imprisoned. The prevailing view is that the nation’s entrenched mental health system does not adequately provide for the mentally ill; a cumbersome process has struck a balance too far toward preserving due process rights with inadequate attention being directed to the need for treatment (Rich, 2009)

Questions

1) Discuss why the operation of the nation’s mental health system might be primarily based on principles of economics rather than evidence-based medicine. While it was very expensive to keep mentally ill people institutionalized, by closing most of the mental hospitals, was the expense of institutionalization simply transferred to other social systems like the criminal justice system and homeless programs?

2) How should the U.S. health care system finance effective out-patient care for the mentally ill?