Mental health care in America has a long, complex history.
More than one billion people worldwide live with a mental health condition, yet only about half of individuals actually receive the care they need (The Lancet Public Health, 2025; National Institute of Mental Health, 2023).
Persistent mental health care provider shortages, lack of access to therapy and medications due to the unaffordability of health insurance, inequitable distribution of providers and healthcare access in rural areas of the nation, and continuing stigma against mental illness are just a few of the contributing factors to today’s problems in mental health care.
Historically, until the mid-1900s, people struggling with their mental health were cared for in the privacy of the family’s home or ended up in almshouses or jails. With the advent of mental institutions, once referred to as “insane asylums,” these overcrowded and understaffed state hospitals quickly became centers for inhumane treatment and poor conditions (National Library of Medicine, n.d.).
The 1963 Community Mental Health Act was pivotal in dismantling institutionalized care in favor of community mental health centers; however, funding for these initiatives was often lacking. Today, we are still in the midst of an ever-evolving model of mental health care in America, one that is far from perfect. Many people still face significant barriers to treatment, and the criminal justice system continues to be a place where people facing mental illness eventually land in the absence of other systems of care (Mental Health America, 2025).
Author Hannah Thurman explores the story of a lingering psychiatric hospital reaching its final days in the late 1990s, examining the complexities of this slice of mental health history in America in her novel, Mercy Hill.
Q: Share a bit about your background and what inspired you to write Mercy Hill.
Hannah Thurman (HT): I grew up in Raleigh, NC, a few miles away from Dorothea Dix Hospital, which was often in the news while I was growing up. It was in this long process of shuttering—it had gone from being the first psychiatric hospital in the state, this enormous facility that housed thousands of patients and staff, to a very small operation in the ’90s/’00s. Amidst the current mental health crises facing this country, I thought it would be interesting to look back at this type of institution as the people within it struggled to come to terms with its final chapter.
Q: In your novel, the Cross sisters grow up at Mercy Hill, a mental hospital run by their psychiatrist mother. Together, the family works to prevent Mercy Hill from being closed, following the closure of many other psychiatric hospitals around the country. Where does Mercy Hill take place in the history of mental health care in America?
HT: Mercy Hill takes place in a kind of inflection point for mental health care in the country. The hospital itself is weathering the storm of deinstitutionalization, of defunding of central mental health facilities that began in the ’60s but was continuing well into the ’90s when it is set.
It’s also coming about 50 years after the introduction of the first prescription antipsychotics (e.g., Thorazine) and the later waves of better-tolerated and more widely prescribed psychiatric medication (atypical antipsychotics, different waves of SSRIs that were approved in the 1990s).
Both deinstitutionalization and the introduction of these drugs changed the size and type of patient population of these sorts of facilities. It has become in the novel a place of last resort for some patients, and the characters in the novel struggle with the idea that Mercy Hill may not be the best place for its residents—but there’s nowhere else for them to go.
Q: What aspects of Mercy Hill are criticized by the public, and what about the hospital does the family believe in and wish to protect?
HT: In various points in the book, members of the public accuse Mercy Hill of being underfunded, understaffed, and generally antiquated—it was, after all, an institution built before the Civil War. Other times, it’s clear that due to these staffing and budgetary woes, patients are receiving substandard care—missed doses of medications, lack of appropriate monitoring, etc. The family at the heart of the novel sees these sides to the institution, but they also see patients getting care who would otherwise potentially end up on the streets or in the prison system.
Q: Where do you most see yourself in this story? What did you take away from the process of writing it?
HT: One of the central themes of the story is how hard we should fight for the things we believe in vs. when we should let them go—I think that’s something I took away from the various drafts putting this book together. You want a finished novel to be as good as it can be, but there are ideas/characters/scenes that you have to gracefully set aside when you realize they’re not as strong as the rest of the manuscript.
Q: What does Mercy Hill offer readers in terms of a commentary on mental health care in the United States? Where do you see opportunities for continued growth in the quality and accessibility of mental health care provided to people in our country?
HT: Unfortunately, there are many, many opportunities for continued growth in accessibility of mental health care in this country. Right now, mental healthcare is expensive, hard to access quickly, and hard to maintain for many people. Many mental healthcare workers are overworked and underpaid. And tying healthcare in general to peoples’ employment, which is often on shaky ground in this rocky economy, leads to huge gaps in care. Single-payer healthcare that is not tied to employers would be a significant start.
Q: What do you hope readers take away from spending time with Mercy Hill?
HT: I hope that people learn a bit about what was happening with state-run mental hospitals at the end of their tenure in the United States, and how all the residents of “The Hill” would have lived their lives.
