During the 1950s and 60s, many mental institutions were shut down due to concerns about the way the patients in those institutions were being treated. Those suffering from mental health issues were, to a large degree, just discharged into the larger community with few supports to help them re-integrate. Today, the concerns about severely mentally ill peoples’ actions may be pushing the system back toward some form of formal re-institutionalization, as Michael Shellenberger reports for Common Sense:

William Norris, shackled sitting upright on his bed at Bedlam, 1838.
Engraving by Ambroise Tardieu, Des maladies mentales Esquirol via Wikimedia Commons.

Though it is difficult to get an exact estimate, a large body of research makes clear that people like Zisopoulos, Mesa, and Simon are just three among hundreds of cases of people in New York alone — to say nothing of cities like Los Angeles, Seattle, San Francisco and others — in which mentally ill people off their medication have assaulted or killed people. And if you think the problem is getting worse, you are right.

In 2021, felony assaults in New York’s subway were almost 25 percent higher compared to 2019, despite a lower ridership because of the pandemic. The number of people pushed onto tracks rose from 9 in 2017 to 20 in 2019 to 30 in 2021. Psychiatrists and emergency department workers in San Francisco and Los Angeles tell me that they have seen a significant increase in homeless patients in psychotic states over the last few years.

How have we arrived at the point where we leave people with psychosis to their demons, and leave the public to take their chances? How have we allowed so many of our cities to have no decent plans or places for the burgeoning number of the violent mentally ill on the streets?

There are two major forces at work. The first is that the U.S. never created a functioning mental health care system. The second is that powerful groups have effectively prevented dangerously mentally ill people from getting treatment.

Starting in the late 19th century, the U.S. created large psychiatric hospitals, often in the countryside, known as asylums, for the mentally ill. Asylums were a major progressive achievement because they delivered, for many decades, significantly more humane, evidence-based care to people who, until then, had often been neglected, abused, or even killed.

But by the middle of the 20th century, the reputation of psychiatric hospitals was in tatters — and deservedly so. Conditions in many of them were appalling, even barbaric. People who were not severely mentally ill were sometimes subjected to years of involuntary hospitalization.

Many reformers just wanted better funding and oversight, but other reformers were more radical, and proposed shutting the hospitals down entirely and replacing them with community-based clinics. Some reformers claimed that serious mental illnesses were the result of poverty and inequality, not biology, and argued that they could be cured through radical social change.

The reformers largely won. State hospitals were shut down in droves before sufficient community centers could be built to treat the suffering. Over the next two decades, as state mental hospitals emptied out, many released patients ended up on the street, or incarcerated. Those community clinics that did start operating tended to treat “the worried well” — those suffering from comparatively low-level anxiety and depression, rather than psychosis.

Decades later, governments were still cutting funding for the treatment of the mentally ill. New York State in 2010 reduced Medicaid reimbursement for inpatient stays of the mentally ill in hospitals beyond 12 days. As a result, New York hospitals released the mentally ill earlier than they should have. From 2012 to 2019, the number of mentally ill adults in inpatient psychiatric care in hospitals and mental institutions in New York City declined from 4,100 to just 3,000. Meanwhile, the number of seriously mentally ill homeless people rose from 11,500 to 13,200.

The story is similar in California. Between 2012 and 2019, more than one-third of the group homes in San Francisco that served mentally ill and disabled people under the age of sixty closed their doors. Why? The measly Medi-Cal and Medicare reimbursement of $1,058 per person per month, and rising estate prices, made it more valuable for the private owners of group homes to sell than to keep operating them.

At the national level, the same dynamic was in play. The U.S. as a whole lost 15,000 board and care beds for the mentally ill and disabled between 2010 and 2016. Today, approximately 121,000 mentally ill people are conservatively estimated to be living on America’s streets.