This is one in a mini-series of posts exploring the state of mental health care in America, and how to fix it.
In the January issue of the
University of Pennsylvania bioethicists argued that “prisons have become the nation’s largest mental health care facilities” — replacing the old asylums of the past, phased out since the ’60s in the process known as “deinstitutionalization.” The authors' controversial commentary recommends a “return to the asylum,” rebuilding large psychiatric facilities.
The JAMA authors' call to rebuild costly "asylums" reflects our nation's misguided spending priorities. The United States ranks first in health care spending but 25th in spending on social services among nations in the Organization for Economic Cooperation and Development. This reflects a bad set of decisions with equally poor results. Despite our high health-care spending, we have dismal health outcomes compared with similarly wealthy nations.
Instead, we should be funding community-based services that support recovery and rehabilitation. Research shows that spending on the "social determinants" of health such as permanent, affordable housing and vocational and educational services have far more impact on overall health than medical services alone.
When we fail to invest "upstream" in the social determinants of health, including supportive housing, we pay for it later: in "downstream" spending on mass incarceration, as well as in high-cost increased emergency and inpatient medical care.
Simiriglia feels that what is needed in Philadelphia is to better integrate existing jail diversion programs with Housing First programs. "Currently the system is fragmented," she said. "We can only serve returning prisoners if they are on the streets long enough to be considered 'chronically homeless' and if they are sick enough to be considered to be 'seriously mentally ill.'" She added, "there are a whole lot of people going in and out of prison who are committing low-level crimes. It is costing the city a fortune to keep them stuck in this cycle."
While current jail diversion programs in Philadelphia generally connect people with transitional housing, Simiriglia notes that "people do better with permanent, supportive housing."
The University of Pennsylvania biothecists who recommended a return to asylums were correct in their diagnosis: The status quo is unacceptable, and unjust incarceration of people with psychiatric disabilities must end. But their prescription was wrong. It's not more asylums we need, but more housing.