Better but Not Well: Mental Health Policy in the United States Since 1950

As illustrated by Jeffrey Geller's ( 1 ) overview of 50 years of discussions regarding psychiatric services, the last half of the 20th century was a time of major upheaval in the delivery of mental health services. From the late 1970s to the early 1990s a number of volumes by historians, sociologists, policy analysts, and psychiatrists provided narrative for these events ( 2, 3, 4, 5 ). The 1990s—which saw the introduction of managed care, privatization, redoubled efforts to close state hospitals, and the ascendancy of Medicaid as a major driving force in mental health service delivery—were in many ways the culmination of the events of the preceding 40 years. But just as things got really interesting, the pace of narrative production in the form of books diminished. Someone needed to succinctly tie together the policy, organization, financing, clinical, and philosophical threads that constitute the fabric of current mental health policy in a succinct overview that could be read and understood by a wide audience. In Better but Not Well Richard Frank and Sherry Glied address that need admirably.

Better but Not Well, a title recycled from a paper written in the 1970s by the late Gerald Klerman ( 5 ), begins with an overview of what is known about the prevalence of mental illness from current epidemiological studies. The book then proceeds to describe research regarding the status of contemporary treatment approaches for psychiatric disorders. The next two chapters deal with how that treatment is funded and the changing landscape of systems for delivering that treatment. The sixth chapter succinctly outlines the status of mental health policy and briefly describes the historical processes that created the current policy environment. Chapter 7 summarizes current data on the well-being of persons with mental illness—a discussion that fits particularly well in the context of the chapters leading up to it. In some ways, this chapter answers the question "What has been the product of the last half century's efforts?"

As the book's title suggests, the authors argue that the status of persons with psychiatric disabilities has improved significantly in the past 50 years in a host of different dimensions but still is not where it could or should be. In the final chapter the authors suggest reforms for further improving the lives of persons with psychiatric disorders. Their observations are responsive to those of Rosalynn Carter, who, in her foreword to the book, argues that progress has been attempted but in some cases thwarted politically and that much reform remains to be accomplished.

The subtitle of this book led me to expect a dense, massive tome. It is anything but. It provides a wealth of information but contextualizes that information extremely well. As such, it will serve for many years as a useful reference for persons working in this field. The book is also an amazingly good read for one providing so much information and could easily be assigned to advanced undergraduates and graduate students. But Better but Not Well should be assigned to every practitioner, mental health clinician, administrator, and advocate—as well as every legislator and policy maker—concerned with the status of Americans with serious mental illness and what might be done to improve it.