Narrator: When the state-run mental health facility opened in Independence in 1873, care largely meant isolating patients from the public, placing them on farms, far from anyone, so as not to cause harm to themselves or others. Through the years, treatment has advanced beyond electric shock therapy and the 200 lobotomies done in the early 50s, when Independence housed as many as 1800 patients.

Dave: Then with the help of the medications in the mid-1950s, the patients really began to improve. Their symptoms were much better controlled, and these patients were then correctly and appropriately discharged from the hospital. They went to the county homes. Some went home.

Narrator: Dr. Bhasker Dave is the superintendent of the Mental Health Institute in Independence. Dave says that while patient populations declined in the 3 decades after the 50s, the state institutions were still the primary care giver of mental health treatment. Two big state budget cuts in the 90s and a decade later slashed funding for the state's mental institutions, further reducing the population to its current level of 95 beds in all programs in Independence. Today the state has many layers of mental health care ranging from children's care, outpatient treatment, and therapy programs, to intense hospitalization, but they aren't all centered in the large institutions.

Dave: With a mental health center being available, which essentially is an outpatient program, patients that were discharged from hospital could stay at home or at a resident program, where they could go to the mental health center, be seen by a therapist or a psychiatrist as needed, and then medication could be continued and monitored in the mental health setting.

Pfeiffer: Unfortunately quite a few people fall through the cracks in our current system of mental health care. First and foremost, I think that people who fall through the cracks are people of few resources, people who don't have a lot of money, and don't have a lot of family support. They're prone to homelessness when they become ill, and they don't know really how to connect with the system that exists.

Narrator: Mary Beth Pfeiffer is an author from New York who studied Iowa's mental healthcare system for her book "Crazy In America: The Hidden Tragedy of Our Criminalized Mentally Ill." During her research Pfeiffer found many holes in Iowa's system and cited the need for improvements, especially in residential facilities.

Pfeiffer: We need more beds for people who are in psychiatric crisis. We need more programs in the community in particular to handle people with mental illness and to stabilize them, to keep them stable within communities. And that would mean job training programs. We need housing. Housing is a very serious shortage in terms of providing care for people with mental illness. We need programs that would provide counseling to people with mental illness. We need managers, people to be case managers of people with mental illness in the community to make sure that they have their medications, to make sure they're taking their medications, to make sure they are plugged into the programs that do exist, to make sure that they have housing.

Narrator: Some communities, Pfeiffer says, take the "not in my backyard" approach.

Pfeiffer: So communities need to understand that they need to be welcoming of people with mental illness. We need to recognize that people with mental illness are not some other group of foreign people. They're our brothers. They're our sisters. They're our relatives, our Children. They're people like us who desperately need care.

Narrator: The children Pfeiffer mentions make up the biggest patient population at the Independence facility.

Dave: If you protect the services that are offered to children, you intercept the illness process earlier and, thereby, hopefully there will be a better outcome.

Narrator: Independence also has male and female adult wards, which often have waiting lists. At times, this puts patients and caregivers in tough spots, trying to find a suitable and stable location during treatment to help balance a patient's symptoms and medications.

Dave: We in the MHI system are the safety net for these most vulnerable of all patients, the mentally ill, who just continues not to benefit from programs that are available in the community. We, as you know, are the providers of the last resort. If the person has any other options, insurance, other availability for treatment, they will be treated in the local community. It is only when the patient's care is such that the person can't afford that care in community or the symptoms are such that they cannot be managed in a psychiatric unit of a community general hospital that they will be referred here.