In addition, according to the President's Commission, the list of mental health problems should be extended beyond identifiable psychiatric conditions to include the damage to mental health associated with unrelenting poverty, unemployment, and discrimination on the basis of race, sex, class, age, and mental or physical handicaps.
Public health authorities customarily distinguish among three forms of prevention. Primary prevention refers to attempts to prevent the occurrence of mental disorder, as well as to promote positive mental health. Secondary prevention is the early detection and treatment of a disorder, and tertiary prevention refers to rehabilitative efforts that are directed at preventing complications.
Two avenues of approach to the prevention of mental illness in adults were suggested by the President's Commission. One was to reduce the stressful effects of such crises as unemployment, retirement, bereavement, and marital disruption; the second was to create environments in which people can achieve their full potential. Thecommission placed its heaviest emphasis, however, on helping children. It recommended the following steps:
1) good care during pregnancy and childbirth, so that early treatment can be instituted as needed;
2) early detection and correction of problems of physical, emotional, and intellectual development;
3) developmental day-care programs focusing on emotional and intellectual development;
4) support services for families, directed at preventing unnecessary and inappropriate foster care or other out-of-home placements for children.
Care of the mentally ill has changed dramatically in recent decades. Drugs introduced in the mid-1950s, along with other improved treatment methods, enabled many patients who would once have spent years in mental institutions to be treated as outpatients in community facilities instead. (A series of judicial decisions and legislative acts has promoted community care by requiring that patients be treated in the least restrictive setting available.) Between 1955 and 1980 the number of people in state mental hospitals declined from more than 550,000 to fewer than 125,000. This trend was due partly to improved community care and partly to the cost of operating hospitals; in an effort to save public money, some large state mental hospitals have been closed, forcing alternatives to be found for patients. This is generally considered a progressive trend because when patients spend extended periods in hospitals they tend to become overly dependent and lose interest in taking care of themselves. In addition, because the hospitals are often located long distances from the patients' homes, families and friends can visit only infrequently, and the patients' roles at home and at work are likely to be taken over by others.
The psychiatric wards of community general hospitals have assumed some of the responsibility for caring for the mentally ill during the acute phases of illness. Some of these hospitals function as the inpatient service for community mental health centers. Typically, patients remain for a few days or weeks until their symptoms have subsided, and they usually are given some form of psychotropic drug to help relieve their symptoms. Following the lead of Great Britain, American mental hospitals now also give some patients complete freedom of buildings and grounds and, in some instances, freedom to visit nearby communities. This move is based on the conclusion that disturbed behavior is often the result of restraint rather than of illness.
Treatment of patients with less severe mental disorders has also changed markedly in recent decades. Previously, patients with mild depression, anxiety disorders, and other neurotic conditions were treated individually with psychotherapy. Although this form of treatment is still widely used, alternative approaches are now available. In some instances, a group of patients meets to work through problems with the assistance of a therapist; in other cases, families are treated as a unit. Another form of treatment that has proven especially effective in alleviating phobic disorders is behavior therapy, which focuses on changing overt behavior rather than the underlying causes of a disorder. As in the serious mental illnesses, the treatment of milder forms of anxiety and depression has been furthered by the introduction of new drugs that help alleviate symptoms.
The release of large numbers of patients from state mental hospitals, however, has caused significant problems both for the patients and for the communities that become their new homes. Adequate community services often are unavailable to former mental patients, a large percentage of whom live in nursing homes and other facilities that are not equipped to meet their needs. Most of these patients have been diagnosed as having schizophrenia, and only 15 to 40 percent of schizophrenics who live in the community achieve an average level of adjustment. Those who do receive care typically visit a clinic at periodic intervals for brief counseling and drug monitoring.
In addition to such outpatient clinics, rehabilitation services include sheltered workshops, day-treatment programs, and social clubs. Sheltered workshops provide vocational guidance and an opportunity to brush up on an old skill or learn a new one. In day-treatment programs, patients return home at night and on weekends; during weekdays, the programs offer a range of rehabilitative services, such as vocational training, group activities, and help in the practical problems of living. Ex-patient social clubs provide social contacts, group activities, and an opportunity for patients to develop self-confidence in normal situations.
Another important rehabilitative facility is the halfway house for patients whose families are not willing or able to accept them after discharge. It serves as a temporary residence for ex-patients who are ready to form outside community ties. A variant is the use of subsidized apartments for recently discharged psychiatric patients.