Out of the Shadows: Confronting America's Mental Illness Crisis

Readers who have come to expect directness, controversy, and passion from E. Fuller Torrey will not be disappointed in his most recent book. Out of the Shadows provides all of that, as well as a hearty dose of compassionate concern for people who suffer from severe mental illnesses. The author, a research psychiatrist at the National Institute of Mental Health well known for his volunteer efforts on behalf of the National Alliance for the Mentally Ill, has once again provided a comprehensive and provocative volume revealing serious flaws in our approaches to the care of mentally ill persons.

Basically an analysis of the shortcomings of deinstitutionalization policy, Out of the Shadows is divided into ten chapters that summarize now-familiar problems: the disproportionate prevalence of homelessness and incarceration among mentally ill individuals, the devastating effects of mental illness on their relatives, the underestimation of the threat of violence among some mentally ill persons, the existence of funding mechanisms and legal concepts that limit access to needed care, and the failure to emphasize the biological basis of mental illness in research and service planning.

The central theme in this volume is that while deinstitutionalization has conferred notable advantages on some, possibly most, mentally ill persons, it has proven disastrous for "a substantial minority." Torrey provides extensive documentation for this contention, and, in this sense, the book serves as an up-do-date review of the research literature on deinstitutionalization.

Torrey offers several recommendations to counter current deficiencies in the system of care. They include placing severe mental illness within the rubric of neurological disease (he favors creating a National Brain Research Institute to replace both the National Institute of Mental Health and the National Institute of Neurological Disorders and Stroke); streamlining funding mechanisms for serving mentally ill persons in state-run service systems; limiting federal intervention largely to research and demonstration projects; and relaxing legal requirements for involuntary treatment of mentally ill persons.

Generally speaking, the book is a good read, despite a sometimes intrusive use of illustrative anecdotes. However, Torrey underplays some important sequelae of deinstitutionalization. For example, he does little to challenge a widely held notion that deinstitutionalization primarily affects the care of persons released from mental hospitals. In fact, many of today's most severe service delivery problems lie in our failure to take note of individuals who, because of prevalent admission-diversion policies that are also part of deinstitutionalization, never become hospitalized in the first place and receive absolutely no care. Torrey's arguments would be strengthened by a more focused examination of the unique service needs of this new generation of mentally ill individuals.

He also pays scant attention to geographical mobility, a perplexing problem that affects large numbers of severely mentally ill people who wander about both within and between catchment areas. Whether their apparent rootlessness represents a manifestation of personal pathology or a search for more responsive systems of care and support, these individuals' seemingly constant movement adds to their disfranchisement and severely limits their access to entitlements and needed services.

I would not characterize this book as a breakthrough; it is largely a restatement of what has been said, and said well, in several other books (1,2,3,4), including one by Torrey himself (5). Yet by its very provocativeness, the volume provides a needed incentive for change. As noted by Daniel Kevles (6) who reviewed this book for the New York Times Book Review, "Like all polemics Out of the Shadows should be read with caution, but its analyses deserve attention."

Dr. Bachrach is research professor of psychiatry at the Maryland Psychiatric Research Center of the University of Maryland School of Medicine.