Research: Topics: Health Care

Overview of Mental Health in New York and the Nation

Colonial Period– Mid 1840s

Family care and custodial care provided by local poorhouses and almshouses predominated.  Caregivers were influenced by by Calvinist views that mental illness resulted from sin.

  • 1806 The State provided for the poor and indigent insane by enacting legislation for $12,000 for 50 years to go to the New York Hospital, the single corporate hospital designated to care of the institutional insane. Demand rapidly exceeded capacity.
  • 1809 The State allowed any town or municipality to contract directly with the governors of the New York Hospital for care of insane persons within its jurisdiction.
  • 1816 The State provided an additional fifty-year annuity of $10,000 annually to New York Hospital for additional construction. This facility built with these funds became the Bloomingdale Asylum.
  • 1821 Bloomingdale Asylum opened. It used moral treatment and was devoted exclusively to the care of the insane. At this time, most mentally ill people were still housed in poorhouses.
  • 1827 An "Act Concerning Lunatics" forbade confinement of insane persons   in prisons or houses of correction.

1840s-1890s:  Era of the Asylum

The number of penitentiaries and orphanages rose. The belief that mental illness was treatable grew in popularity. Causes and cures were seen as rooted in environmental and psychological factors. Moral treatment was the most popular form of therapy.  Moral treatment was influenced by  social norms, religious beliefs, medical expertise, scientific theory and demographic characteristics, and key components included:

  • Belief that insanity is curable-a disease of the brain
  • Patients must be totally isolated from family and stresses of society
  • An orderly environment and a gentle yet firm routine of light work, recreation, and rest will induce patients to develop self-discipline.
  • The causes of and solutions to insanity rest with society-not the laboratory.

However, asylums were prey to excessive overcrowding and, as the century progressed, biological theories of mental illness became increasingly popular.

  • 1843: Utica Asylum opened.  Only those deemed curable were admitted.
  • 1844: AMSAII organized: Association of Medical Superintendents of American Institutions of the Insane.
  • 1851: Asylum for Idiots in Albany established (not for mentally ill, but for mentally retarded and developmentally disabled indviduals).  The institution moved to Syracuse in 1854.
  • 1863-1882: State boards of charity were formed to act as central oversight committees and to develop policies for the humane treatment of the insane.
  • 1870s-1880s: Asylums were gradually placed under the authority of Boards of Charities.  Institutions housing criminals, the poor, orphans, and the handicapped were also placed under control of these boards.  All of these facilities provided   custodially oriented care.
  • 1873: The State appointed a State Commissioner in Lunacy. This was the first move toward creating a separate state policy for the mentally ill.
  • 1889: The position of Commissioner of Lunacy was abolished in lieu of a new 3-member State Commission in Lunacy. This move signaled the final separation of policy concerning insane persons from that focusing upon the indigent.  It also led to a reorganization of institutional mental health care.
  • 1878-1893: Several schools for "feeble minded" individuals and people with epilepsy were established: Neward, Oneida and Craig Colony for Epileptics..  Letchworth, another facility for epileptics, opened in 1909.
  • 1890s: New York State Care Act of 1890. For the first time the state assumed full responsibility of all mentally ill instate. Distinctions between acute and chronically mentally ill were eliminated. It was believed that hospitals could provide care that was more economical and individualized and facilitate more accurate classification of patients.  Other legislation formally changed the names of all state "lunatic asylums"--these facilities were now called "state hospitals."
  • 1896: Several significant institutions were absorbed by the state: Brooklyn State Hospital, Manhattan State Hospital, Central Islip State Hospital, Kings Park State Hospital.  Gowanda State Hospital opened in 1898, bringing the number of state hospitals to 13.

Early Twentieth Century:  Progressive Reform

Progressive Era reformers believed that mental illness was the product of environmental factors and that it was both preventable and progressively serious.  These beliefs gave rise to the Mental Hygiene Movement, which as characterized by the psychopathic hospital, child psychiatry and outpatient clinics.  All of these innovations were intended to prevent the emergence of mental illness or to provide early treatment designed to avert serious mental disorder.

  • 1900s-1920s: Psychiatrists sought to reestablish their medical credentials and adopted an aggressive therapeutic stance.
  • 1909: The National Committee for Mental Hygiene (NMCH) was founded and its headquarters established in Manhattan. The NCMH spearheaded the mental hygiene movement, which was pessimistic about curing mental illness but convinced that it could be prevented.
  • 1910: Patient numbers had doubled from 13,434 in 1890 to 31,280. New York State now had the largest number of institutionalized people with mental illness in the nation.
  • 1912: The State Lunacy Commission became the State Hospital Commission.
  • 1912: Creedmoor State Hospital opened. It was initially a farm colony of the Brooklyn State Hospital.
  • 1917: State Hospital Development Commission was established.
  • 1918: State Board of Charities relinquished control of state schools for the retarded and the State Commission for the Meebleminded was assigned responsibility for operating them.  This commission was renamed the State Commission for Mental Defectives in 1919
  • 1920s-1930s: Over-crowded institutions. The Great Depression plunged state hospitals further into the custodial mode. Great numbers of indigent and aged people entered state hospitals.
  • 1920's-1940's: The mental hygiene movement's preventative activities focused upon schools.
  • 1920's: Fever therapy was introduced in mental hospitals.
  • 1921: Harlem Valley State Hospital opened.
  • 1926: The New York State Department of Mental Hygiene (DMH) was created in the wake of the 1925 constitutional reorganization of state government.
  • 1927: The New York State Mental Hygiene Law is enacted. The DMH is given almost all responsibility for the care and treatment of the mentally ill, the developmentally disabled, and epileptics.
  • 1930's: Insulin shock and metrazol shock therapies and surgical technique of prefrontal lobotomy were developed. As was the case with fever therapy, many psychiatrists were hesitant to embrace them.
  • 1930's- 1945: Conditions in state mental institutions deteriorated as a result of Depression-era financial hardships and the resource and personnel demands of the war. Decaying physicial plants and extreme overcrowding were common.
  • Late 1930's-Early 1940's: Electroconvulsive therapy, which replaces insulin and metrazol shock therapies, was introduced into the United States.
  • 1941-1945: The experience of treating military personnel suffering from combat-related mental illness leads many psychiatrists to emphasize the social dimensions of mental disorder and hypothesize that mentally ill civilians might best be treated outside of traditional mental institutions.

1945 – 1960: Policy Revolution

  • Mid-1940's: Fountain House, a Manhattan-based support group, was started by a group of former patients of the Rockland State Hospital.
  • 1946: The federal Hill-Burton Act, which allocated monies for state hospital renovation and construction, was enacted.
  • 1946: Mental Health Act of 1946. Provided funding for research into causes, prevention and treatment of mental illness. It also led to establishment in 1949 of the National Institute of Mental Health and provided for Federal investigation of mental hospitals.  Investigators found apathy, neglect, and custodial care.
  • Late 1940's--Early 1950's: Expos�s of hospital conditions produced a widespread public and professional demand first for reform and then for dismantling of state hospitals.
  • 1949: The National Institute of Mental Health (NIMH), a new component of the Public Health Service's National Institute of Health, came into existence.
  • 1949: The New York State Mental Health Commission was formed.
  • 1949: The State mental health system included 27 facilities, and the state's inpatient census was the largest in the nation.
  • WWII - 1950s Hospital construction during the War halted in New York State, and a significant number of state hospital staff entered the armed forces.
  • 1950’s: "Social Milieu Therapy" became increasingly popular.   It represented a move away from surgeries. The institution onceagain became the focal point of therapy.  Milieu therapy called for developing a permissive and rich social environment for the chronically mentally ill. It emphasized personal hygiene, attractive surroundings, bright colors, light, attractive meals, group activities (poetry, music, singing, and discussions). Music therapy preceded ECT. Superficially, milieu therapy resembled nineteenth-century moral treatment; however, it lacked its predecessor's emphasis upon self-discipline.
  • 1954: The New York State Community Mental Health Services Act was passed. The act encouraged localities to establish community-based mental health programs and to apply for state reimbursement of up to fifty percent of the cost of these programs.
  • 1955: New York’s inpatient population peaked at 93,600
  • 1955: The Federal Mental Health Study Act funded the activities of the Joint Commission on Mental Illness and Health, a study group established by the American Medical Association and the American Psychiatric Association.
  • 1956: The DMH created the Association of Community Mental Health Boards in order to foster communication between and innovation among community mental health boards (CMHB's), the local authorities responsible for creation and administration of community-based mental health programs.
  • 1957: The DMH commissioner sent seven state hospital administrators to Britain to study the open-hospital movement. All seven returned adherents of the principle of allowing patients the greatest freedom of movement.
  • 1959: The DMH created ten Regional Mental Health Advisory Committees in an effort to assist CMHB efforts to devise suitable programs.
  • Mid-1950's: The development of psychiatric drugs such as Thorazine and new tranquilizers reinforce psychiatric confidence in the effectiveness of outpatient treatment and their ability to cure mental illness. Less need for shock treatment, restraints and seclusion rooms. Able to begin to develop and sustain intensive individualized treatment programs. Nation’s mental health inpatient population was reduced by the drugs.

1960s-90s: Community Mental Health

The community mental health movement was buoyed by successes of drug treatments. Noting the failure of hospitals to integrate patients into the community, proponents of community mental health called for the dismantling of the state hospital system.

  • 1961: The Joint Commission on Mental Illness and Health issued its final report, Action for Mental Health. The lack of consensus and focus within the commission, which was dominated by social and behavioral psychiatrists, was evident, and the APA was divided about its recommendations.
  • 1963: The Federal Community Mental Health Centers Construction Act made available federal funds for construction of community centers.
  • 1963: The New York State Mental Hygiene Facilities Improvement Corporation was established and made responsible for disbursing all local, state, and federal funds targeted for facility construction.
  • 1965: Medicare and Medicaid were established. Both contained provisions for mental health treatment, but care furnished in state hospitals was explicitly not covered and mentally ill people under the age of sixty-five were ineligible for Medicaid benefits. These provisions resulted in the transfer of large numbers of the elderly mentally ill from state hospitals to nursing homes.
  • 1967: The NIMH was given full bureau status.
  • Mid 1960's-1970's: Academic attacks on mental health and psychiatry proliferated. Laing, Szasz, Scheff, and others were critical of psychiatry and mental institutions. Their view gained wide acceptance and shaped popular perceptions of the mental health system.
  • Late 1960's-1970's: State and federal courts ruled that the mentally ill had the legal right to refuse treatment and could be involuntarily committed to mental institutions unless they posed a clear and present danger to themselves or others. Other court rulings forced New York State and other states to improve the quality of care in the institutions they operated.
  • Late 1960's-1970's: The definition of mental illness expanded to include minor mental disorders and difficulty in coping with life crises. This expansion reflected increasing involvement of psychologists, social workers and other non-psychiatric personnel in treating mental illness.
  • Late 1960's-1970's: The mass political movements of the era were often hostile to the concept of mental health.
  • Late 1960's-1970's: The problems associated with the policy of mass discharges (deinstitutionalization) from state hospitals became increasingly evident: lack of continuity of care and failure to meet the needs of the seriously mentally ill.
  • 1970's: Economic difficulties affected the DMH and hamper its ability to maintain and expand programs.
  • 1972: Two new federal Social Security programs, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), dramatically altered care for the mentally ill allowing them to live independently.
  • 1973: The New York State Unified Services Act was passed.  It was designed to improve coordination between state and local agencies.  However, only five counties put forth acceptable unified services plans.
  • 1973: The NIMH was made part of the Department of Health and Human Services' newly created Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). Its research functions were transferred to the National Institute of Health.
  • 1974: The New York State Legislature enacted laws mandating that the state furnish appropriate care for those discharged from state hospitals.
  • 1975: The Creedmoor and Pilgrim Psychiatric Centers were stripped of their accreditation. Although deeply embarrassed, the DMH continued to channel resources away from the state's psychiatric centers.
  • 1975: The Federal Mental Health compelled federally funded community mental health centers to care for the seriously mentally ill.
  • 1977: Jimmy Carter formed the President's Commission on Mental Health.
  • 1977: The New York State Mental Hygiene Law was recodified and the DMH's responsibilities were broken down and assigned to three autonomous offices: the Office of Alcohol and Substance Abuse, the Office of Mental Retardation and Developmental Disability, and the Office of Mental Health (OMH).
  • 1978: The Civil Service Employees Association’s advertising campaign resulted in an executive-office policy directive instructing the OMH to increase staffing levels in state psychiatric centers.
  • 1978: The OMH created the Community Support System, a program designed to furnish treatment and support services to the seriously mentally ill.
  • 1979: The National Alliance for the Mentally Ill (NAMI), a new advocacy group for people with serious mental illness and their families, was formed.
  • 1980: The National Mental Health Systems Act, which asserted that the federal government would continue to shape mental health policy but assume less of the burden of paying for treatment, is passed.
  • 1980: The New York State Insanity Defense Reform Act increased the OMH's responsibility for caring for and evaluating criminals deemed not responsible by reason of insanity.
  • 1980's: The OMH created new initiatives designed to meet the specific needs of mentally ill African-Americans and Latinos, develops outpatient programs for the elderly/Alzheimer patients, mentally ill criminals, and people with AIDS.
  • Early 1980's: Seeking to cut federal expenditures, the Reagan administration directed the Social Security Administration to pare the SSI and SSDI rolls. Social Security administrators responded by developing definitions of mental illness that diverged from those used in the past and those employed by mental health professionals. The resulting dislocations ultimately produced a public outcry that compelled the administration and Social Security to back down.
  • 1981: The 1981 Omnibus Budget Reconciliation Act repealed the provisions of the National Mental Health Systems Act, cut federal mental health and substance abuse allocations by twenty-five percent, and converted them to block grants disbursed with few strings attached. New York State, which used block-grant monies to fund community-based programs, and other states have to cut mental health programs.
  • 1981: The President's Commission on Mental Health issues its final report, albeit without fanfare.
  • 1984 New York’s inpatient population was 32,000
  • Mid-1980's: Federal support for mental health treatment increased as advocacy groups protest against funding cuts and Democrats in Congress buried funding allocations in omnibus budget bills.
  • 1986: The federal State Comprehensive Mental Health Plan Act compelled states to devise detailed service plans that emphasized the needs of the seriously mentally ill in order to remain eligible for federal block grant funds. In its emphasis upon planning, it closely resembled New York State's efforts to insure that seriously ill people receive adequate care.
  • 1986: New York State served 500,000 people via the deinstitutionalized approach. New York State has 33 mental health facilities: 23 psychiatric centers for adults; 6 psychiatric centers for children; 2 forensic psychiatric centers, and 2 research facilities
  • 1992: The federal Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act abolished the ADAMHA and replaced it with the Substance Abuse and Mental Health Services Administration (SAMHSA). During the Bush and Clinton administrations, the SAMHSA emphasized information provision and administration of block grants, which had more restrictions than they had in the past.
  • 1993: The Clinton administration's efforts to create a national health insurance program were  notable for their relatively generous provisions for mental health care. However, Republicans and many Democrats in Congress rejected the plan and the administration shied away from advancing any other bold policy initiatives.
  • 1993: The New York State Community Mental Health Reinvestment Act mandated that all savings realized from the closure of unneeded state psychiatric centers be funneled to community mental health programs. The act was propelled in part by the OMH's intention to close several facilities.
  • 1996: The federal Mental Health Parity Act compelled companies that offer mental health insurance benefits to their employees to insure that coverage of mental and physical illness was reasonably equitable.