Drawing on an analysis of the French mental health system, this essay examines four presumptions about mental health care dominant in the United States. Claims about 1) the required abolition of the hospital for psychiatric deinstitutionalization, 2) the substitutability of public and private financing, 3) the importance of a “dangerousness” criterion for involuntary commitment procedures, and 4) the need for an ever-expanding scope of care hold little weight when subjected to comparative scrutiny. We close by discussing the implications of these revelations for U.S. mental health care policy and ethics.

Shortages of equipment, medication, and staff under coronavirus disease 2019 may force hospitals to make wrenching decisions. Although bioethical guidance is available, published procedures for decision-making processes to resolve the time-sensitive conflicts are rare. Failure to establish decision-making procedures before scarcities arise exposes clinicians to moral distress and potential legal liability, entrenches existing systemic biases, and leaves hospitals without processes to guarantee transparency and consistency in the application of ethical guidelines. Formal institutional processes can reduce the panic, inequity, and irresolution that arise from confronting ethical conflicts under duress. Drawing on expertise in critical care medicine, bioethics, and political science, we propose a decision-making protocol to ensure fairness in the resolution of conflict, timely decision-making, and accountability to improve system response.

As the presidential race heats up, candidates are weighing in on how they would reform the nation’s broken mental health system. Pundits have linked its flaws to a range of headline issues. Behavioral health care shortages purportedly exacerbate the increased frequency of mass gun violence, the negative effects of social media, and even the anxieties produced by the economic, environmental, and immigration landscape. The mental health system is far from the cause of those problems, but politicians (on both sides of the aisle) are rightly concerned about how to end the policy chaos that leaves millions of Americans untreated, and often homeless or incarcerated instead.

Many of these policy proposals, however, contain unexamined assumptions about our current system and how it operates. In previously published research in the Lancet Psychiatry and Psychiatric Services, I used cross-national data from the World Health Organization (WHO) and the Organization for Economic Cooperation and Development (OECD) to examine the economic assumptions that guide mental health policy making and found reason to doubt two common beliefs: one, about the importance of private payers, and the other, about the relationship between inpatient and outpatient care.

Community-based psychiatric services are essential to mental health. For decades, researchers, advocates, and policy makers have presumed that expanding the supply of these services hinges on reducing the supply of hospital-based care. Cross-national data from the World Health Organization call this presumption into question. Community and hospital psychiatry appear to be complements, not substitutes.

Institutional fragmentation and a lack of national solidarity have derailed the pandemic response.

The Australasian College for Emergency Medicine (ACEM) has released a major report on Australia’s mental health system: Nowhere to go: Why Australia’s health system results in people with mental illness getting ‘stuck’ in emergency departments. The report is significant for several reasons. First, ACEM joins the Royal Australian and New Zealand College of Psychiatrists (RANZCP) in national advocacy for improved mental healthcare (Jenkins, 2019; Judkins et al., 2019). Second, the report presents a clear case for an emergency department (ED) focus in national mental health policymaking, along with well-defined outcome measures including ED length of stay (LOS). Finally, the report takes a balanced approach to community and hospital services: ‘ACEM will also continue to advocate for governments to increase the amount of inpatient mental health services and community mental health services to ensure that people with mental health needs have sufficient and equable access to appropriate services’ (ACEM Report, p. iii).

Is deinstitutionalization to blame for the regularity of mass shootings in America? Deinstitutionalization occurred not only here but also across other high-income democracies. Major international organizations, such as the World Health Organization, have supported the reduction of hospital psychiatry. Comparing cross-national data of mass shootings—typically defined as four or more fatalities—with the decline of inpatient psychiatric capacity offers little evidence to support this association.

Compared with the general health system, the mental health system faces distinct challenges. Perennial flashpoints include issues of stigma, coercive treatment, and nosology, which generate heated ethical and policy debates. Often overlooked, however, is another characteristic of the mental health sector: its financial dependence on the public purse

The time has come for repealing Medicaid’s Institutions for Mental Diseases Exclusion rule.

Some of the most immediate health effects of the 2008 economic crisis concerned the mind, not the body. Rates of generalized anxiety, chronic depression, and even suicide spiked in many European societies. This viewpoint highlights the role of mental health professionals in responding to this emergency, and argues that their sustained mobilization is necessary to its long-term resolution.