The North Texas State Hospital

Caring for people with mental illnesses has always primarily been a state responsibility, not the federal government's. In Texas, state hospitals are at capacity and local mental health and mental retardation centers are underfunded, understaffed and under-serving.

According to the Mental Health Association in Texas more than half a million people were considered at risk of a mental disorder and eligible to receive state care last year. However, only 30 percent of them got it.

Lynn Lasky, with the MHA in Texas, said the state mental health care system, as it is today, is not reaching thousands of Texans.

"We're just not doing what we need to do as a state to care for our sickest of the sick and our poorest of the poor," she said. "There are a number of people that end up in the criminal justice system both children and adults, homeless shelters and suicides."

About 385,000 Texans did not get the services they needed last year. With looming budget cuts that number could be even higher this year.

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	Care through the years Many say care of the mentally ill has dwindled over the years.

"Anytime you have a complex system of care, like we have, there are going to be people that don't get the kind of care that they need and that may be because of their choice or other circumstances," Carl Schock, CEO and superintendent of the Austin State Hospital, said.

Currently, 10 state hospitals in Texas like ASH treat people in crisis situations at risk to themselves or others. Once stabilized, patients are released into the care of one of 42 local mental health and mental retardation centers around the state.

Since the Kennedy administration, stays in state hospitals have become shorter over the years -- 10 to 12 days now -- compared to years and even lifetimes decades ago.

That is known as deinstitutionalization.

Though far from perfect, today's system is working better than the previous system of institutionalization, according to King Davis, executive director of the Hogg Foundation for Mental Health at the University of Texas: The idea and implementation of institutions began in the late 1700s in Williamsburg, Va. and continued through President John F. Kennedy's term.

"People died within the institutions from neglect. They found that people didn't get much better and, for the most part, the U.S. reflected what was reflected back in the 1800s -- that people were ashamed of the quality of care.

"One of the most significant aspects of all this business of community programs is how are people going to be housed. That's the one thing state hospitals did fairly well. They provided a place for people to stay 24-hours a day, meals, healthcare and the like. So yeah, community programs are working in some places very effectively, but probably not nearly as well as they could if they had more staff, better resources, better ideas about some of the ways they could help their clients," Davis said.

That will take more money and with the state's budget crisis many people will remain underserved or not served at all – leaving them alone, forced to fend for themselves.

"Untreated mental illness can result in the loss of family relationships, employment, loss of stable housing and can result in homelessness. Here in Austin we have about 4,000 individuals that are currently identified as being homeless and between a third and a half of those individuals can either have a condition of mental illness or mental illness coupled with substance abuse history," David Evans, executive director with the Austin Travis County Mental Health Mental Retardation Center, said.

Mental health advocates said the future looks bleak, too. That's why they've spent months at the state Capitol urging lawmakers not to cut from the mental health and mental retardation services budget.

"I think that it's important that our community understand that mental illness needs to be addressed as any other health care issue. If other organs of the body -- the heart or the liver – weren't working or functioning, we have compassion, a real interest in an available and accessible set of health care treatments. We need to view the brain in the same way," Evans said.

Community-based care allows mentally ill individuals to live outside the walls of an institution. However, without the proper care, the same individuals may deteriorate and find themselves either in a hospital or jail.

	Chronology of Mental Health Policies
1700 – A series of local mental health acts that created local responsibility for the mentally ill. 1800 -- State policies began an era of rapid development of state hospitals, with 84 percent of the states following this trend. Between 1800-1850 over 300 state hospitals were constructed. 1853 -- President Franklin Pierce vetoed a bill that would have involved the federal government in the provision of mental health care at the state level. 1930 – Federal statute creating a division of mental health within the Public Health Service. This division was the forerunner of the National Institute of Mental Health (NIMH). 1946 – Congress passed legislation (PL 79-487) creating NIMH and asked each state to designate a single state agency to be responsible for mental health care. This law was in response to the high proportion of males found mentally unfit to serve in WWII and to the number of psychiatric causalities. 1947 – The Supreme Court ruled that national health insurance was constitutional. 1955 – Congress passed legislation (PL 84-142) creating the President’s Commission on Mental Illness. The Commission identified 600,000 individuals in state hospitals in the United States in poor conditions in state hospitals. The report of the Commission (Action for Mental Health) became the basis for the eventual development of the community mental health movement and law. 1963 – Congress passed and President John F. Kennedy signed (PL 88-164), the community mental health centers construction act, providing federal money to construct mental health centers that provided the five essential services. The Act bypassed the states and gave money directly to non-profit groups to provide alternative services to the state mental hospitals. 1964 – Congress passed amendments to the Social Security Act creating Medicaid and Medicare that provided graduated federal payment to the states to provide medical and inpatient psychiatric care outside state hospitals for the poor and aged. This Act enabled private psychiatric hospitals and general hospitals with psychiatric units, but not community mental health centers, to be paid for the inpatient care that they provided to the mentally ill. 1973 – Congress passed legislation (PL 93-45) extending the 1963 legislation for an additional year. Community mental health legislation and funding were strongly opposed by President Nixon and efforts were made by his administration to eliminate this legislation. 1980 – Congress proposed new legislation (PL 96-398) called the community mental health systems act (crafted by Ted Kennedy), but the program was ended by newly-elected President Ronald Reagan. This action ended the federal community mental health centers program and its funding. 1980 – Congress passed legislation (PL 96-416) tile Civil Rights of Institutionalized Persons Act (CRIPA) allowing the Justice Department to sue state governments if they violate the civil rights of the mentally ill or mentally retarded in their state hospitals (the Act was focused originally on prisons). 1981 – Congress passed legislation (PL 97-35) sought by Reagan, titled the Omnibus Reconciliation Act of 1981 that shifted funds to the states vial block grants. States had the option of using their funds to continue to support mental health centers. 1987 – Congress passed new legislation (PL 99-319) developing rules for the protection and advocacy for the mentally ill and offered dollars to the states to set up human rights agencies and regulations to insure rights of the mentally disabled. 1987 – Congress passed new legislation (PL 99-660) requiring that for states to receive block grant monies for mental health and substance abuse, the states had to develop plans for how they would care for the mentally ill who were released from state hospitals and the staff who needed to be retrained. 1987 – Congress passed new legislation (PL 100-77) called the Stewart B. McKinney Homeless Assistance Act, to assist the states in providing housing for the homeless who are mentally ill. 1989 – Congress passed legislation (PL 100-336) titled the Americans with Disabilities Act, designed to prohibit discrimination against individuals with physical or mental disabilities. 1990 – Newly elected President Clinton proposes a national health reform act that will provide mental health and substance abuse services in the coverage (Hillary Rodham-Clinton was chairperson). 1992 – A newly elected Republican congress endorses managed care as the policy for controlling costs and services in health care in the United States. -- Courtesy of the Hogg Foundation