In 17th and 18th-century America, the problems posed by mental illnesses were relatively minor and of little public concern. Population was sparse, with most individuals living in scattered rural and agricultural communities. Hence, the number of people with mental illness was limited, and they were generally cared for by their families or local officials who assumed responsibility for their welfare.
People with mental illness became a public concern only if they were unable to care for themselves or lacked family connections. They were treated in accordance with the English Poor Law system whose foundations predated the famous Elizabethan Poor Law legislation written between 1595 and 1601. This system was based on the principle that society had a corporate obligation for poor and dependent people. Virtually every American colony enacted laws that replicated the English system.
Under this arrangement, local communities, rather than the colony or mother country, had to assume fiscal and supervisory responsibility for those citizens incapable of surviving without some form of assistance. As a result, before 1800, confinement of people with mental illness was a rare exception rather than the rule. People who were mentally ill and had no family or private resources received the same treatment as sane paupers: they were either boarded with families or kept in public almshouses.
After 1800, new circumstances ultimately led to reliance on some form of institutional care. First, demographic changes, including population growth, geographic mobility, urbanization and a rise in immigration altered the structure of society. Second, a growing awareness of social and medical problems transformed attitudes and perceptions in terms of mental illness. Third, Americans became aware of innovations in France and England as Philippe Pinel’s treatise on insanity appeared in 1806 with wide circulation in the United States.
The transformation of mental illness into a social problem requiring state intervention in contrast to familial and community responsibility was not a unique phenomenon. The 19th century was noted for its widespread use of institutional solutions to social problems and for the transfer of functions from families to public or quasi-public structures. In 1820, only one state hospital for people with mental illness existed in the United States. By the Civil War, virtually every state had established one or more public institutions for that purpose.1
According to the History of Cincinnati, “The movement for the erection of a commercial hospital in Cincinnati was inaugurated by Dr. Daniel Drake, and the plan of an insane department was added at his sole suggestion.”
On January 22, 1821, Ohio’s legislature appropriated $10,000 to assist in the construction of the Commercial Hospital and Lunatic Asylum for the State of Ohio at Cincinnati. Construction was completed on January 27, 1824. It was primarily a county institution, and the state regularly contributed to its maintenance. In 1860, it became Longview State Hospital.
On March 5, 1835, the General Assembly passed an act to establish The Lunatic Asylum of Ohio and appointed three directors. A 30-acre tract of land north of Broad Street and about one mile east of where the Statehouse would be located was purchased. Construction of the asylum cost $61,000 and the first patient was admitted on November 30, 1838.3
Dorothea Dix, the most famous and successful psychiatric reformer in American history, began her quest to improve the plight of people with mental illness in 1841. She visited dozens of almshouses and jails in Massachusetts and then presented a report to the state legislature. By 1847, she had taken her crusade to many eastern states and had visited 500 almshouses, 300 county jails and 18 prisons. Her success in persuading state legislatures and securing funding to build psychiatric hospitals was a major impetus to providing more humane care to people with mental illness.4
In Ohio’s Constitution of 1851, there is a section stating, Institutions for the benefit of the insane, blind, deaf and dumb shall always be fostered and supported by the state.
In 1852, the legislature approved the expansion of the Columbus Asylum. State hospitals were established in Cleveland and Dayton in 1855 and in Athens in 1874.
Many psychiatric hospitals built during this period in Ohio and other states followed the Kirkbride architectural style. Thomas S. Kirkbride, one of the founders of the American Psychiatric Association, was an authority on construction, organization and general arrangement of psychiatric hospitals. He felt that the most economical type of construction involved a center hall for offices, employee living areas, a church and recreation facilities.
Off both sides of the center were a series of wings that stepped back progressively. New patients were placed on wards farthest from the center. As their conditions improved, patients were moved closer to the center hall. Hence, the term, back ward, which referred to areas where patients with the most intractable illnesses lived.
On the evening of November 18, 1868, the Columbus Asylum was almost wholly destroyed by fire. Six patients died in the fire, and the remaining 308 were transferred to the state’s asylums in Cleveland, Dayton and Cincinnati. The following year, the legislature authorized rebuilding the asylum on the same site but later decided to build on the hilltop west of downtown where 300 acres were purchased from William S. Sullivant for $250 per acre. The hospital was completed on July 4, 1877 at a cost just more than $1.5 million.2 State hospitals were established in Toledo in 1888 and in Massillon in 1898.
Prior to 1911, the state’s psychiatric hospitals were operated by separate boards of trustees. In 1921, all state institutions were placed under the State Department of Public Welfare.5
Lima State Hospital, which opened in 1915, served dangerous and homicidal patients from other state hospitals and mentally ill inmates from Ohio’s prisons. Lima staff also examined certain offenders for the courts to determine whether their crimes could have been caused by mental illness, mental deficiency or psychopathic personality.
Hawthornden State Hospital, later known as Western Reserve Psychiatric Habilitation Center, operated as a farm for Cleveland State Hospital from 1922 until 1938. It was established as a separate facility in 1941.
In 1945, an act of the legislature established a statewide system of receiving hospitals for the treatment of people in the early stages of mental illness who might respond to early and intensive treatment. Woodside Receiving Hospital in Youngstown opened that year, while facilities in Cleveland and Cuyahoga Falls opened a year later. During the next few years, all state hospitals were authorized to perform the receiving function, and an Army hospital in Cambridge was transferred to the state for use as a psychiatric facility.5
Because its continued growth had turned the Department of Public Welfare into the largest and most complex of state departments with more than 45,000 employees, the General Assembly established a separate Department of Mental Hygiene and Correction in 1954.
Populations in Ohio’s state-operated psychiatric hospitals peaked in 1955 at 28,663 resident patients.
After World War II, mental health reform began moving at a dizzying pace. New, effective treatments made community life a realistic prospect for virtually every person with a mentally illness. The 1963 Community Mental Health Centers Act fostered by President John F. Kennedy initiated a period of more dramatic change. Expansion of insurance coverage (both private insurance and Medicare and Medicaid programs) and the resultant growth of private facilities were enormous.
In 1968, Ohio House Bill 648 created a community-based system of county and multi-county boards to plan and coordinate care. By the mid-1970s, general hospitals were admitting more psychiatric patients than were state hospitals. Even though their populations continued to decrease, state hospitals remained the last resort for care for poor people with a serious mental illness.
During the 1980s, change continued. House Bill 900 created separate Departments of Mental Health, and Mental Retardation and Developmental Disabilities in 1980.6 Community support strategies like intensive case management, day hospital treatment and residential care programs could meet the needs of most hospitalized individuals. By 1985, more than 350 community agencies were serving 170,000 clients. State hospitals were becoming more focused on intensive care.
In 1988, Ohio moved to the national forefront of mental health reform with the passage of the Mental Health Act. This landmark legislation had two primary goals: to move toward community treatment rather than institutionalization and to emphasize local direction rather than state control.
Successful implementation of this legislation has made Ohio a nationally recognized leader in mental health reform and has given us the strongest community system of any large state. Ranked 26th among the states in a 1986 survey, Ohio moved into seventh place in 1988 and by 1990 was rated fourth best in the country.
Appointed director of the Ohio Department of Mental Health in 1991 by then Governor George Voinovich, and re-appointed by Governor Bob Taft in 1999, Michael Hogan, Ph.D., guided Ohio’s public mental health system through several cycles of change, becoming the longest-serving state mental health director in the country before his departure in 2007.
In 1992, Hogan convened the Inpatient Futures Working Group to examine the status and future prospects for the publicly funded mental health system. Through this locally based process, Ohio’s mental health constituencies developed a long-range plan to expand community supports and reduce hospital costs while preserving an essential and substantial hospital role.
Initial hospital re-engineering efforts achieved efficiencies in business functions, pharmacy, medical records, dietary and telecommunications. Subsequent efforts concentrated on improving clinical services through use of a best practices approach. The hospitals also expanded their mission to provide outpatient care through community support networks that serve children and adults throughout the state.
President George W. Bush tapped Hogan in 2002 to chair The President’s New Freedom Commission on Mental Health, a one-year examination of the mental health service delivery system. The final report, Achieving the Promise: Transforming Mental Health Care in America, was issued in July 2003. The commission‘s six recommendations focused on improving awareness, prevention and access to treatment for all consumers and families. “The benefits will be felt across America in families, communities, schools and workplaces,” Hogan wrote in the report.
A Transformation State Incentive Grant (TSIG) was awarded to Ohio in October 2005 by the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services. The five-year grant was intended to support the research, planning and initial implementation of improvements to Ohio’s system that are necessary to achieve the recommendations of the New Freedom report.
Since 1990, as local systems have increased the number and types of services they provide, the inpatient population of state hospitals has decreased from 4,000 to fewer than 1,100 patients. These local systems of care, managed by 50 community mental health and alcohol, drug addiction and mental health boards, currently contract with approximately 400 local agencies to provide services to more than a quarter million Ohioans every year.
During the past two decades, Ohio's public mental health system has been engaged in reform efforts to improve the quality of and access to care so that individuals with severe illnesses can recover and contribute.
1. The Chronically Mentally Ill In America: the Historical Context, Gerald N. Grob, Ph.D.; Mental Health Services in the United States and England, Struggling for Change, The Robert Wood Johnson Foundation, Princeton, NJ, 1990
2. Biographical Annals of Ohio, Vol. 1, 1902-03
3. Institutional Care of the Insane in the United States and Canada, Vol. III, Henry M. Hurd et al., ed., Johns Hopkins Press, 1916
4. Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals, National Alliance for the Mentally Ill and Public Citizen’s Health Research Group, 1992
5. Citizen’s Advisory Board Handbook, Ohio Department of Mental Health, 1982
6. Community Care and Inpatient Treatment: Solutions for the Next Century, Ohio Department of Mental Health, Michael F. Hogan, Ph.D., September 1994
Special thanks to retired Communications Director Sam Hibbs, who compiled much of this history during 2003, and to Dee Roth, Chief, Office of Program Evaluation and Research, for loan of the antique postcards used throughout this presentation.