Andy Whyman: The absence of mental health care in America
October 2, 2014
In 1963, Congress passed the Community Mental Health Act. The noble and generous idea driving this legislation was a simple one — if you had major mental health problems you could obtain care for those problems.
Typically, in the late 1960s and for some time afterward, if you were suicidal, homicidal or gravely disabled, i.e. unable to care for yourself by virtue of a mental disorder, you would be evaluated by a mental health provider in an emergency room of a hospital and, given that there were an adequate supply of psychiatric beds (some 340 psychiatric beds per 100,000 population), admitted to an acute care psychiatric facility.
If the police picked you up for similar reasons, they would bring you to the same emergency room for the same assessment.
This system worked passably well given that many of those afflicted were less than entirely cooperative with the process.
Consistent with the then prevailing philosophy of providing care in the least restrictive appropriate setting, after achieving acute stabilization, patients were referred to partial hospitalization services, day care, and individual and/or group treatment depending on the need.
There were abuses of the system. Patients were sometimes kept in hospital longer than necessary. Outpatient therapies were, at times, unnecessarily prolonged. Perhaps most important, from a civil liberties perspective, involuntary hospitalization sometimes occurred when it wasn't medically indicated.
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These abuses, coupled with competing demands for federal funds, the increasing power of civil libertarians, and the political establishments' dawning understanding that the mentally ill are less likely to vote, produced first an erosion of care, and than its evisceration.
Now we live in a world where the severely mentally ill are "free" to sleep on the streets, eat at soup kitchens or out of garbage cans, urinate in public places, be victimized by criminals or commit crimes, at times violent crimes, and end up in jail, prison or dead.
Presently there are 11 psychiatric beds per 100,000 population as contrasted with the aforementioned 340 beds. We have eliminated one million psychiatric beds in the past 40 years.
There are now some 3 and 1/2 million untreated severely mentally ill people. Hundreds of thousands of them are homeless. Hundred of thousands of them are warehoused or worse in jails and prisons. Said one research psychiatrist, "Public libraries have become the day care programs for the severely mentally ill."
What are some of the other institutional impacts of this situation? Emergency rooms may no longer have the staffing or resources to assess and stabilize those with severe mental illness.
Now when the severally mentally ill go to hospital emergency rooms, particularly in smaller, rural settings, there are frequently no trained mental health workers available. Now, mentally ill persons can languish in an emergency room for days or longer. Untreated they frequently get sicker.
Now, emergency psychiatric beds are usually not available. Now, if a bed can be found, ambulance services may refuse to provide a transfer because of insufficient reimbursement or the receiving facility may refuse to accept the patient for similar reasons.
As you might imagine, warehousing acutely distressed psychiatric patients in emergency rooms doesn't help either the patient or medical staff morale.
What's the impact on the criminal justice system? Not surprisingly, as funding for mental illness treatment has declined, funding for jails and prisons has increased dramatically. In fact, we now have an extraordinarily powerful criminal justice lobby coupled with the highest incarceration rates in the world.
Why? In no small measure because the mentally ill are more likely to commit minor crimes driven by their illness, which in turn clogs up the courts, increases the rate of incarceration and then the rate of re offending.
According to a 2006 Justice Department Study, more than half of all prisoners have mental health problems. Three quarters of female inmates have a mental disorder.
The largest mental health center in America is now the Cook County jail system in Chicago. Says Cook County Sheriff Thomas Dart, "It's criminalizing mental illness." Dart claims that the great majority of incarcerations flow from offenses related to mental illness.
Here are other depressing facts: According to a 2010 study by the National Sheriffs Association and the Treatment Advocacy Center, there are more than three times as many mentally ill people housed in jails and prisons than treated in hospitals. Moreover, the Justice Department reports that once incarcerated, the mentally ill are more likely to be injured in fights or disciplined because of trouble following jail rules.
Also, people with serious mental illness are more likely to be jailed: 40 percent of people with serious mental illness have been arrested at some point in their lives.
Sheriff Dart says, "We've systematically shut down all mental health facilities, so the mentally ill have nowhere else to go. We've become the de facto mental health hospital." Dart calls this "fiscally … stupid." He believes it would be far cheaper to manage the mentally ill with case workers out of jail rather than spend vast sums incarcerating them.
An absence of care is extremely costly in other ways. For example, while 11 percent of Medicaid beneficiaries have mental illness, they consume 30 percent of the cost of that system. Also, in the past 30 years the number of people receiving Social Security Disability(SSDI) Income has tripled and the fastest growing group, some 28 percent now have a psychiatric diagnosis.
There are now meaningful bills before Congress to address this fiscal and humanitarian crisis. Here's hoping that something comes of them.
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at email@example.com.