As the U.S. economy remains mired in the worst funk since the 1930s, public services for the country’s most vulnerable populations—children, the elderly, the mentally ill—are being cut or disappearing at a time when the need for them is greater than ever. Faced with gaping deficits, states have slashed $1.6 billion from mental health programs over the past four years, according to a report by the National Alliance on Mental Illness. Cuts to the Medicaid program, now being debated in Washington, may well worsen the situation.

In Detroit, the county mental health program has lost $30 million in state funding over the past three years, forcing numerous cuts to the agencies it supports. Detroit Central City Community Mental Health, which provides outpatient treatment and reentry programs for people leaving jails and psychiatric hospitals, lost a quarter of its funding and cut its staff by a third. Charlotte House, a transitional housing program for people with psychiatric disorders discharged from the county hospital, closed its doors.

California has cut mental health funding by $765 million, or 21 percent, since 2009. On December 1 of this year, 38,000 elderly residents—a quarter of them with dementia and almost half with mental health diagnoses—were slated to lose access to the health centers they depend on for daytime meals, therapy, and healthcare. This cut, being challenged in court, may force the closure of 300 centers that are intended to keep fragile seniors out of nursing homes. Illinois has slashed $187 million from its mental health budget and plans to close three of nine psychiatric hospitals. A budget passed in November by the Chicago City Council will close half the city’s 12 mental health clinics.

Meanwhile, homelessness, domestic violence, and child abuse are rising. Nationally, nearly 1 million schoolchildren were homeless in the 2009–2010 school year, up 38 percent in four years, according to the U.S. Department of Education. Researchers reviewing hospital records from parts of Washington, Pennsylvania, Ohio, and Kentucky found that the rate of children younger than 5 brought to emergency rooms with abusive head trauma—brain injuries from being shaken or struck—was 65 percent higher during the 19 months of official economic recession that began in December 2007 than in the previous four years. Sixteen percent of the children died. Over the past three years, therapists from Valley Community Counseling in San Joaquin County, California, treated 60 percent more children who’d been exposed to domestic violence and 50 percent more whose parents were substance abusers.

In some of these places, individuals and communities are taking things into their own hands. In late 2009, as the unemployment rate in San Joaquin County reached 18 percent and 1 in 12 homes were being foreclosed—the twelfth highest rate in the nation—two high school students in the town of Ripon, population 15,000, committed suicide within two months of each other. More suicides occurred every few weeks in neighboring school districts, and by the time the following school year had ended, a total of at least 18 schoolchildren in the county had taken their own lives—a pattern that public health researchers call “suicide contagion.”

Years of declining budgets had cut the number of counselors, nurses, and psychologists in county schools, impairing the ability of individual districts to handle the needs of grieving students, parents, and communities on their own. To bridge the gap, school officials in the cities of Ripon, Stockton, Lodi, and Linden turned to each other for help—a grassroots response seen more and more across the country as communities look to their own resources to address pressing needs.

The school districts made use of a mutual aid pact, like those employed by firefighters and police. On the morning after each death, school nurses and counselors trained in suicide response, along with a team of therapists from Valley Community Counseling, converged on the school the student had attended. They met with pupils and parents, focusing on kids who knew the victims or seemed to be at particular risk.

In each affected community, charities, church groups, parents, and friends pitched in to help out. The mother of 17-year-old Marissa McLeod, the second of the Ripon students to commit suicide, opened a store, Marissa’s Closet, where girls can get free dresses for proms and formal occasions, fulfilling one of her daughter’s dreams. The spirit of cooperation helped the team fashion an effective crisis response and ease the pain of some survivors, says David Love, executive director of Valley Community Counseling. But, by definition, it came too late, he adds.

“We’re doing everything we can to partner, so if something happens, I can call up six different school districts and ask for a couple of counselors at 7 a.m. tomorrow,” Love says. “But we’re still band-aiding. When you’re doing crisis work, you’re at the back end. The tragedy is we don’t have the resources early in the process.”

Today, the 900 students at Ripon High, where the suicides started, have just two guidance counselors to help them. That’s better than the statewide student–counselor ratio of one counselor for every 810 students, the second worst of any state. The neighboring city of Manteca has no elementary school counselors and has gone from four to two at each of its seven high schools, says Caroline Thibodeau, the district’s director of health services.

Meanwhile, students’ needs keep increasing. The number of homeless children in Manteca has doubled in the past five years, Thibodeau notes. Rates of alcoholism, drug abuse, and child abuse are climbing, putting families under enormous stress, says Love.

“It’s a big circle,” he states. “Family stress, community stress, student stress equals higher levels of depression and related issues among caretakers and children. With school cuts, counselor cuts, and classroom sizes going up, the schools are seeing more mental health issues and have fewer resources. We’re getting more kids sent to us with clinical depression, PTSD, or behavioral issues. And all this increases the possibility of suicide.”

One social worker whose resilience has been tested by the economic downturn is Deidra Thomas-Murray, director of homeless services for the St. Louis schools, where the number of homeless children has almost doubled in the past three years, to 3,000. Thomas-Murray spent many years in her native New Orleans working in schools and with juvenile offenders, and then became a refugee after Hurricane Katrina destroyed her home. She and her five daughters and foster daughters spent two weeks sleeping on the floor of a friend’s house in Baton Rouge, and then went to Missouri, drawn by a relative’s offer of help. For a while, she says, five families were crowded into a two-bedroom apartment while she collected food stamps and hunted for work.

She found a job as a drug counselor, then as a family therapist, and in 2006, was hired as a school social worker. Since 2009, she’s coordinated the program for homeless students, networking constantly to solicit donations of clothing and sleeping bags for families. Her main focus is getting teachers and principals to know their kids so they can identify those who are homeless and make sure they get the services they’re entitled to by law.

“A lot of times we’ll see stuff happening with kids, but never ask what’s going on,” she says. “We just assume they’re some BAKs (bad-ass kids)—which in many instances, isn’t the case. We, the educators, play a major role in how we embrace this population.”

Thomas-Murray is painfully aware of the damage that homelessness inflicts on kids. “They worry about where they’re going to sleep at night,” she says. “They have difficulty separating from parents. If there’s been violence in the family, they’re preoccupied with whether the parent is safe. They have difficulty focusing. They stare off into space. They can be invisible in a crowd of kids. Or they can be the most disruptive in the class.”

The stress of economic uncertainty isn’t confined to the jobless, or to people who’ve lost homes or services. Therapists working in government-funded agencies themselves are under intense pressure as they absorb the distress of their clients, handle heavier caseloads, and fret about their own flat salaries and job security.

“It’s not a good feeling that there are 50 kids on a waiting list and you can’t hire more clinicians,” remarks Stacey Katz, director of the West Coast Children’s Center in Oakland, California. “How do we decide who needs services the most without violating our mission that kids should have mental health services when they need it?”

In April, Places for People, a St. Louis agency serving the city’s mentally ill, opened a drop-in center that offers assistance to anyone in need. The number of help-seekers climbed from 248 in May to 509 in August. “It’s off the charts,’’ admits executive director Joe Yancey. The spike in demand has been so intense that the agency is grappling with whether it has the capacity to continue helping all comers.

The ability to meet the needs of the poor and distressed depends increasingly on the dedication of service providers. Social worker Megan Heeney, 26, is an outreach specialist with Places for People by day, helping individuals who are being released from psychiatric hospitals. At night, she’s part of a Catholic Worker community that provides housing for homeless women and children. She helps organize volunteers to bring homeless people off the streets when the temperature dips below 20 degrees, and she’s recruited local churches to provide shelter.

“We try as hard as we can to help people manage their crises,” she says. “We want to aid people in moving toward recovery, yet because of economic conditions, we’re constantly doing crisis management.” In a system so out of joint and lacking in resources, dedicated social workers can only do so much.

The Timing of Trauma Treatment

In this year alone, hundreds of terrorist attacks have been attempted or completed. Most were in Iraq, Afghanistan, and Pakistan, but some occurred in China, Russia, Northern Ireland, and Norway, where a right-wing extremist set off bombs and shot teenagers and legislators at a summer camp, killing 77. Attacks, counterattacks, and retaliatory air strikes raged between Israel and the Palestinian territories. In total, terrorist incidents killed more than 2,100 people around the world in 2011. Thousands more were injured or witnessed the maiming or killing of others—an experience that can leave survivors with devastating psychological effects.

Clinical researchers have long debated when and how to give services after disasters. Now researchers at Hadassah University Hospital, the principal urgent-care center treating traumatic injuries in Jerusalem, have provided some answers from their study of patients who received emergency treatment between 2003 and 2007. The results appeared in the October issue of Archives of General Psychiatry.

To assemble the study participants, researchers called more than 5,000 patients who’d experienced a potentially traumatic event about 10 days after the occurrence to inquire whether they needed assistance and wanted to join the study. Most chose not to or didn’t meet study criteria. Eventually, 242 patients were enrolled; among them were 201 who’d been in auto accidents and 26 who’d been hurt in a terrorist attack. All were judged to have symptoms of acute stress disorder, such as difficulty sleeping, heightened anxiety, trouble concentrating, and intrusive flashbacks of the event. The purpose of the study was to determine the best ways to keep short-term, acute stress symptoms from developing into full-blown post-traumatic stress disorder (PTSD), characterized by symptoms that last at least a month and sometimes for years.

The participants were divided into five groups. One group was treated weekly with exposure therapy. They were taught breathing techniques, educated about trauma, and guided to reexperience the event that triggered their distress as a means of overcoming it. The second group received Cognitive-Behavioral Therapy (CBT), which taught them to examine and modify their negative and distorted thoughts related to the event without reliving the experience. The third group was given the antidepressant Lexapro, while the fourth received a placebo. A fifth group was placed on a waiting list and not treated at all for five months.

After the initial five months of therapy, medication, placebo, or waiting, PTSD symptoms were seen in 20 percent of those who received CBT, 22 percent of patients who received exposure therapy, 56 percent of those given placebos, 59 percent of those on the waiting list, and 62 percent of those who took Lexapro. The waiting-list patients with PTSD were then offered exposure therapy.

When the groups were reassessed at nine months, the number of patients treated with medication or placebo who had PTSD had dropped but was still nearly twice as large as in the groups who’d been treated with therapy. For those who’d been on the waiting list for the first five months and started treatment later, therapy still had a substantial benefit, cutting the number with PTSD to 23 percent, about the same percentage as those who’d started therapy five months earlier.

The study results indicate that both forms of therapy—CBT and exposure therapy—were the most successful in helping prevent PTSD. Furthermore, it appears that therapists can help patients without asking them to reengage in an intensive way with the memories of the event itself, says Arieh Shalev, the Hadassah psychiatrist who led the research. Skilled therapists and patients can therefore choose whichever type of therapy they’re most comfortable with and get good results, he adds.

There’s also some leeway in how quickly treatment needs to be provided, as it seems that people who receive therapy later ultimately have the same benefit from therapy as those who start earlier. In the aftermath of the 9/11 attacks in New York, many therapists were criticized for racing to provide assistance while survivors were still coping with more pressing issues. Shalev thinks that such speed was probably unnecessary. “The problem with providing therapy as early as possible is that often there’s no ability to offer comprehensive services,” he notes. Assisting with food, housing, and basic survival should be the priority after a disaster, Shalev says—and, as the study results show, there’s no magic time frame within which therapy must begin.

The Revolt Against DSM-5

As the long-awaited next revision of the book known as the bible of mental health treatment lurches closer to publication, an undercurrent of criticism has exploded into a revolt by members of U.S. and British psychological and counseling organizations. The chief complaint is that the revision lowers diagnostic criteria, creates “subthreshold” disorders, and generally makes it easier to find a diagnosis that allows for the medication of patients.

The Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM, is published by the American Psychiatric Association, and it’s used by virtually every U.S. mental health professional who wants reimbursement for services. It has a worldwide influence. The fifth edition is slated for publication in May 2013.

The latest reaction against the DSM-5 began with a salvo from across the Atlantic. A special committee of the British Psychological Society sent a letter in June complaining that “clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences.” The committee criticized the proposed creation of an “attenuated psychosis syndrome”—essentially a subthreshold form of psychosis that aims to identify young people who may develop schizophrenia—“as an opportunity to stigmatize eccentric people.” The committee objected to a proposed reduction in the number of symptoms needed to diagnose adolescents with attention deficit/hyperactivity disorder because it might increase diagnoses and the use of medication.

Then David Elkins, professor emeritus at Pepperdine University and president of the Society for Humanistic Psychology, division 32 of the American Psychological Association (APA), formed a committee to discuss similar objections, drafted a petition listing them, and posted the petition online. “I figured we’d get a couple hundred signatures,” Elkins remarks.

The response stunned him and his colleagues. Within three weeks of going online on 22 October, the petition had attracted more than 6,000 signatures and had been endorsed by 12 other divisions of the APA. On 8 November, American Counseling Association President Don Locke jumped in with a letter to the American Psychiatric Association objecting to the “incomplete or insufficient empirical evidence” underlying the proposed revisions and expressing “uncertainty about the quality and credibility” of the DSM-5.

“This has become a grassroots movement among mental health professionals, who are saying we already have a national problem with overmedication of children and the elderly, and we don’t want to exacerbate that,” notes Elkins.

David Kupfer, the University of Pittsburgh psychiatrist who chairs the task force overseeing the revision, says he welcomes the criticism, as nothing is final. “There’s a myth that all the decisions have been made, when in fact, all the decisions haven’t been made,” he says. “Just because [things have] been proposed doesn’t necessarily mean they’ll end up in the DSM-5.” He explains that the task force has been testing proposed new diagnoses in 2,300 patients at 11 field sites. “If they don’t achieve a level of reliability, clinician acceptability, and utility, it’s unlikely they’ll go forward,” he adds. Stay tuned. This battle isn’t going away.

Rob Waters

Rob Waters is the former editor of the men’s health channel at WebMD and a former contributing editor to the Psychotherapy Networker.