The Political Development of Disease: Mental Health and the American State

Abstract

American mental health practices have changed significantly since the middle of the 20th century. Private actors are often deemed to be the primary causal agents in these shifts, with political actors playing little to no role. This dissertation argues that political institutions and policy developments played causally necessary and substantively significant roles in the transformation and expansion of the diagnosis and treatment of mental health issues in the second half of the twentieth century. Disease development, I argue, is shaped by political development.

Through a series of historically rich, in-depth case studies, I demonstrate that the political development of disease was divided, differentially affecting diagnosis and treatment. The evolution of the National Institute of Mental Health since its postwar founding and its interactions with Congress and the White House caused expansionary modifications to the measurement and modeling of illness, contributing to the growth of diagnosis. Meanwhile, constraints on pharmaceutical regulation in the Food and Drug Administration and Congress precluded strong regulation of drug-based treatments, and constraints on community mental health centers precluded the public provision of other forms of therapy. Those affected by these policy changes, Americans with lower psychological well-being, are, based on a statistical analysis of data on political participation, less likely to be politically active and advocate for their own preferred policies.

Though mental health is seldom considered in leading accounts of health policy development, or is addressed primarily through discussions of custodial institutions, insurance laws, or single policies, this dissertation argues that looking across multiple policy areas and institutions can demonstrate the underappreciated mechanisms by which political development significantly affects health policy and practice. This account thus broadens our understanding of the mechanisms of health policy change. A diverse set of policies and contingent political developments collectively contributed to a result – expanded diagnosis and expanded pharmaceutical treatment – that was neither intended nor foreseen, but was nonetheless enormously consequential for American health practices.