This study examines how housing and in-home supports affect public spending on individuals with chronic mental illness in Maricopa County, Arizona.
It does so through a comparative analysis of average costs per person per year across three housing settings: permanent supportive housing, housing with unknown in-home support, and chronic homelessness.
Specifically, it analyzes costs for housing, health care, and criminal justice during the period of 2014-2019. It also features a small-sample (small-N) case study of a housing setting that provides individualized, 24/7 in-home support to individuals with chronic mental illness (CMI) who have high support needs, examining average costs per person before and after moving into that setting (2016-2019).
Finally, the study outlines recommendations from interviews with dozens of experts who work with and care for individuals with CMI in Maricopa County about reducing costs and improving care.
Obviously frustrated with how long Arizona’s legislature was taking to pass a proposed State budget for 2022, Governor Ducey last week vetoed 22 bills that the legislature had passed and was sitting on his desk awaiting signature. In explaining his veto, the Governor remarked that the proposed bills “could wait” and that the budget was most important.
Unfortunately, the Governor’s veto means that these 22 bills are “dead” unless the legislature passes the bills a second time (which requires some changes in the legislative rules), and the governor then signs each bill. There is no guarantee that each of the 22 bills will make it back to the Governor’s desk.
Among the 22 vetoed bills were two bills that protect public health and safety bills. The first bill, SB1030, protects the public by strengthening the Psychiatric Review Security Board. The second bill, SB1716, lays the groundwork for how the Arizona State Hospital (ASH) can provide better care for patients and protect our communities in the future. These important bills were two years in the making; each passed the Senate and House unanimously! Sadly, the Governor’s veto came within weeks of a murder in a Gilbert “group home”… allegedly by a former patient at ASH whom the PSRB approved to live in the community just months ago.
The 2022 Budget obviously is critically important to our state, and it is the Legislature’s job to produce that budget. We all should advocate for our legislature to immediately pass a budget upon return on June 10. However, we also need the new laws that our elected representatives passed. Mental health and public safety are not simply “stuff” that can wait.
Be prepared to advocate for the Legislature to pass (again) SB1030 and SB1716 and, then to contact the Governor’s Office to ask the Governor to sign both bills. No further delays, please.
We have an underclass in Arizona – our chronically mentally ill, most of whom suffer from schizophrenia. Society treats this sliver of people with serious mental illness just as cruelly and inhumanely as the lepers of antiquity or the untouchables of India. Many of these persons have no shelter, no bed, no toilet, no shower or bathtub, no running water, no electricity, and no reliable access to food, clean water, or medical care unless they are in jail.
Our public mental health care system is organized for and provides exemplary care for the 90% of Seriously Mentally Ill (“SMI”) persons who have insight into their illness and are mostly compliant with treatment. But, some SMI persons are chronic, i.e., they are so ill they believe the voices in their heads and their delusions are real, they suffer anosognosia (inability to recognize one’s clinically evident mental illness). They are mostly non-compliant with treatment. So, they recycle, repeatedly, through treatment programs, emergency rooms, hospitals, the streets, and jails in a hellish existence. Their physical and mental health deteriorates as their families abandon them or become exhausted, struggling to get care for them, and are blocked at every turn.
This underclass results from myths about mental illness, which permeate much of our public mental health care system and block chronically mentally persons from desperately needed care. As the father of a chronically mentally ill adult, I personally have been told each of the comments paraphrased in quotes below:
Recovery myth: “All persons with SMI can recover and lead a normal life.” In reality, chronic mental illness is more like diabetes and can be managed but rarely, if ever, cured.
Compliance myth: “All persons with SMI can ‘recover’ by complying with treatment in short-term residential programs, community living programs or independent living with ‘wrap-around’ services, combined, as needed, with assertive community treatment (‘ACT’) and occasional involuntary treatment (i.e., injections and short-term hospitalizations), regardless of the severity of their illness.” “He fails to recover because he chooses not to comply with our treatment protocols and rules, so he cannot continue in our treatment program.” The most severely ill are denied treatment because of the severity of their illness.
Acuity myth: “SMI does not impair her ability to make good decisions and is no excuse for her inappropriate behavior.” In reality, schizophrenia is a physiological impairment of the brain which does affect judgment and behavior.
Fairness myth: “All adults with SMI should be allowed to make their own medical decisions, to refuse treatment, to choose homelessness and never should be subjected to long-term involuntary care, regardless of the severity of their illness.” “Removing such liberty is unfair discrimination against the mentally ill.”
Substance use myth: “It’s just illicit drugs.” ”We cannot treat his mental illness until he overcomes his substance use problem.” In reality, 75% of SMI persons who are chronically afflicted self-medicate with illicit substances for temporary relief from painful symptoms at some point in their life, which exacerbates their illness.
These myths coalesce into an unconscious, sometimes deliberate, and often-denied culture of blocking chronically-afflicted persons from care because “he won’t comply”; “he uses drugs”; or, “he’s an adult and makes his own choices.” In reality, she thinks the voices and delusions are real, and hence she cannot participate consistently in the treatment offered to the other 90% of SMI persons who have insight. She needs a caring system free of these myths, more flexible, more attuned to her individual needs, and more accountable to the public. And, she might even need long-term involuntary treatment, opponents of which sincerely believe and use these myths to block expansion of such treatment, unwittingly keeping this underclass in our streets and jails.
Dick Dunseath, father of a chronically mentally ill adult son / Carefree, Arizona
The recent murder of one mentally ill patient by another mentally patient in a Gilbert, Arizona Behavioral Health Residential Facility brings into sharp focus the importance of careful placement and diligent supervision of individuals living with chronic mental illness. Of course, the complete facts surrounding the tragic death of 49-year-old Steven Howells, apparently at the hands of Christopher Lambeth, are not yet known. What is known is that Lambeth “stepped down” to a facility with only hours of staffing daily, and the alleged murder occurred when no staff was present.
A critical unknown known fact is whether Lambeth was medication and treatment adherent. Also, whether his behaviors began deteriorating in the prior days or weeks without an intervention by his treatment team or whether this deterioration (if any happened) was even noticed by staff during the mere 8-hours daily they were present in the home (assuming staff was, indeed, present). The critical known fact is that Arizona’s Psychiatric Security Board did not hear from a psychiatrist or psychologist and acted without a Risk Assessment, a formal report on the risk of violence by someone in a new environment, for example, a residence with minimal staffing.
Thankfully, Senator Nancy Barto is trying to make the community safer for all patients with her PSRB reform bill.
The profound tragedy of the Tilda Manor murder is that it is two-fold:
One patient is dead, and the accused patient faces horrific criminal charges.
The behavioral health system failed each of these men.
SB1030 — The PSRB Bill. With agreed-upon floor amendments, this bill will not have a budget impact. It reforms the Psychiatric Security Review Board and will have a significant impact on Public Safety. You can read more about this important work in a recent Op-Ed published in the Arizona Capitol Times.
Please take a moment to email or call your State Representatives and senators and ask them to support this bill! Every email or phone call matters and makes a huge difference!! Thank You!
Here is a link to find your AZ Representative’s and Senator’s email. You can also quickly email all House and Senate members through this site:
Sen. Nancy Barto is spearheading an effort to abolish the state board that decides whether those who commit serious crimes but were found guilty except insane are fit to return to the community.
The effort gained urgency after a man allegedly beat another resident of his Gilbert group home to death last month – 15 years after he killed his own grandparents and less than a year after the Arizona Psychiatric Security Review Board decided after a brief hearing that he needed less supervision.
Legislative efforts to reform the board fell short last year, but have picked up steam this session. SB1029 looks to reform the board, and SB1030 would sunset it and move the board’s duties back to the courts in 2023.
Barto, R-Phoenix, said the two bills – which are waiting for a floor vote in the House – are being rolled into one. SB1030 will have the reforms outlined in SB1029 while still dissolving the board in a couple years.
Barto said she’d been hearing concerns about the board for years. When she attended a board meeting to see for herself how it operated, she described it as “haphazard” and unusual.
“It’s hard to overestimate how lack of rules, really has potentially and actually harmed the public in this instance; we need to rectify it,” she said.
Christopher Lambeth, 37, last appeared in front of the board in August 2020. Previously committed to the Arizona State Hospital after being found guilty except insane in his grandparents’ murder, Lambeth had been living in a transitional facility in Tucson. At the August hearing, which lasted 20 minutes, his request to move to the Phoenix area was unanimously approved and he was placed in a home with only eight hours of supervision a day.
Advocates say the subsequent tragedy was preventable, but predictable, and that it speaks to a litany of problems with the board and how it’s run. They say the board handles cases inconsistently, provides inadequate time for clients and attorneys to prepare for hearings and has insufficient written guidelines and procedures.
Holly Gieszl, a founding member of the Association for the Chronically Mentally Ill, said Lambeth’s case was a prime example of the board’s dysfunction. Gieszl often attends board meetings to represent her own clients, and she remembers Lambeth’s August hearing setting off alarm bells at the time.
“Chris comes in, they don’t have a risk assessment; they don’t hear from a physician or psychologist, and they let him go to an eight-hour house,” Gieszl said. “Seven months later, he murdered someone.”
Board members are appointed by the governor. The board is headed by a retired psychiatrist and has a psychiatrist, psychologist, parole officer and a public member. The board is responsible for deciding whether those who committed serious crimes but were found guilty except insane are fit to be discharged from the state hospital. It is also tasked with monitoring the progress of those on conditional release from the hospital. The board deals with roughly 100 cases a year.
Some of the issues flagged by Gieszl and others were also noted in a 2018 auditor general report. The report stated that the board needed to develop rules and policies to guide its work, issue orders and notices as statutorily required and make sure it was getting consistent information on the patients’ mental health before making decisions.
It alsostated that some mental health reportswere much more detailed than others, with some offering only “general conclusion statements with little or no support.”
“The lack of sufficient information jeopardizes the Board’s ability to make timely and consistent decisions regarding GEI (guilty except insane) persons,” the report stated.
While board chairman Dr. James Clark has said that the board completed the recommendations outlined by the audit, advocates disagree and also want more changes.
“What the PSRB has not changed at all is the way that it has gone about assessing risk before it releases somebody,” Gieszl said, adding that her organization is backing the legislation to address those inadequacies.
Among the changes proposed in the legislation are placing a retired judge as the chair of the board, giving a 45-day notice to patients before hearings and having the board explain its decisions on each patient. After the board sunsets in 2023, the cases would be transferred to the Superior Court where the person was sentenced as guilty except insane.
Barto said that in stakeholder meetings, board members were resistant to any sort of change.
“I think they just really think that the status quo is working,” Barto said. “When you look at what just happened, unfortunately, we’ve known this is coming, something like the tragedy that happened with Mr. Lambeth and who he killed. It’s unfortunate that we have such a prime example of the board’s inability to make a better determination of this man’s future.”
Clark declined an interview, instead referring to his presentations to the Senate Judiciary Committee and House Criminal Justice Reform Committee. He declined to comment on whether the board handled Lambeth’s case appropriately.
“(D)oing away with the PSRB and having Superior Courts assume jurisdiction and monitoring/oversight/supervision of individuals adjudicated Guilty Except Insane, as SB1030 proposes, would be a major policy change, a step backwards and would add an extra burden on the Superior Courts that is unnecessary,” Clark said in his written statement.
As Tim Murphy points out, while most people with serious mental illness are not violent (but, instead, are more likely to be victimized), there is an association between violence and serious mental illness. People with untreated or undertreated psychosis can be dangerous. Families and friends need to understand the risk. Risk assessments, appropriately done by experts, would help recognize and mitigate potential bad outcomes to societies when people with SMI are re-introduced to communal living. More attention needs to focus on serious mental illness, the causes, the treatment, and optimal disease management. Serious mental illness should be managed in the same manner as cardiovascular disease or diabetes, understanding that this is likely a lifelong condition that waxes and wanes in severity and must be managed continually. We need to recognize mental illness as a disease and not a character flaw.
Charles Goldstein, M.D.
Serious Mental Illnesses Are More Deadly Than Covid, Tim Murphy Argues. So Why Aren’t We Doing More?
(5-14-21) Former Rep. Tim Murphy (R.-Pa.) wrote and pushed the most significant federal mental health legislation in decades through Congress during the final days of the Obama Administration. In this OP Ed first published in the Pittsburgh Post Gazette, he argues that serious mental illnesses are claiming more lives than COVID and calls for reforms, many of which, were stripped from his original bill. As with all guest blogs, the views expressed are the author’s. I welcome comments on my Facebook page.
Addressing the link between violence, serious mental illness
Mass murders have already exceeded several dozen in 2021. The act is so abhorrent to us that we continually seek explanations in hope of finding a cause and cure.
Some blame the weapon (primarily firearms) and some the characteristics of the perpetrator such as the presence of serious mental illness (SMI), including schizophrenia and bipolar disorder. Global studies of mass violence report that perpetrator SMI is present in less than 10% of the cases, leading some advocates to suggest preventive efforts be directed away from mental illness.
Nearly 30% of family homicides involve someone with a SMI
SMI is present in about 10% of all law enforcement responses and 20% of the prison population (where most do not receive proper treatment and are twice as likely to be victims of inmate violence). Those with SMI are 11 times more likely to be the victims of crime, are almost half of the victims in fatal police encounters, and the untreated SMI are 16 times more likely to die in a police encounter.
Perpetrator SMI is reported in 29% of family homicides and 20% of law enforcement officer fatalities. Half of those with SMI attempt suicide, and 75% have at least one chronic illness such as cardiovascular disease or diabetes contributing to their 10–15-year shorter lifespan.
Dr. Tom Insel, former head of the National Institute of Mental Health, estimated SMI has an annual death toll of a few hundred thousand lives in the U.S. and 8 million lives globally. By comparison, 3.2 million total deaths worldwide have been attributed to COVID-19 to date. Yet, for COVID, we shut down the planet.
SMI Kills More Than COVID – Why Are We Failing?
So where and why are we failing people living with SMI? Simply put, we still make it very difficult to get proper care.
Many with SMI do not seek care because of a common symptom called “anosognosia,” whereby the illness itself causes the person to be unable to understand they have an illness, and therefore will not voluntarily seek help. They are unable to recognize their hallucinations and delusions are not real, and like other deteriorating brain diseases such as Alzheimer’s, they are even unaware they are unaware they are ill.
As with dementia they can become paranoid, distrustful, combative and resist treatment. However, unlike SMI, coordinated treatment and care is widely available for dementia. Tragically, federal and state policies create insurmountable barriers to care for the SMI, even for those who voluntarily seek treatment.
Key Provisions Of His Bill Were Dropped
When Congress passed my Helping Families in Mental Health Crisis Act in 2016, several major reforms were created to better treat mental illness. However, key provisions were left out, mostly for budgetary reasons. Passage of them now would provide major tools for prevention of more tragedies.
• Increase Psychiatric Bed Capacity. There are 10 times more people with SMI in jails than in psychiatric hospitals. An antiquated regulation known as the Institute for Mental Diseases (IMD) Exclusion was designed to close overcrowded psychiatric hospitals like Mayview and Dixmont by barring federal Medicaid funds in psychiatric facilities with more than 16 beds. In 2016, a new federal IMD rule loosened restrictions but still limits psychiatric inpatient hospital care to 15 days per month. This is a ludicrous policy and anti-science since it is based on budgetary and not medical standards of care. Just medication stabilization alone often requires more time.
• More providers. Early symptoms of SMI appear by age 14 in half the cases and in three-fourths by age 24. Early treatment makes a huge difference in prognosis. However, most counties have no child/adolescent psychiatrists, psychiatrists, psychologists or psychiatric nurse practitioners and even among those who do, most do not specialize in treating SMI. Low insurance reimbursement rates and high provider burnout causes many to leave these careers early. Medical and graduate school scholarships and loan forgiveness should be granted to any doctoral level psychiatric provider specializing in the care of SMI.
• Stop treating SMI as a crime. Many state courts order treatment or allow access to state-funded care only if the person commits a crime. A better alternative is Assisted Outpatient Treatment (AOT) based on a standard that recognizes “psychiatric deterioration” before “dangerousness to self/others” or “grave disability” as criteria for those who need treatment.
In AOT, a court orders a person to remain in outpatient treatment with medication, social services and supportive housing. AOT reduces crime, arrests, homelessness, incarceration and improves adherence to treatment often by over 70%. Fund and promote AOT.
• Train police. Crisis intervention training is effective to de-escalate a potentially volatile situation, saving the lives of citizens and police. Require it. Fund it.
• Let families help. Current confidentiality laws are supposed to serve the patient’s best interest; however, they create barriers when doctors are blocked from important communication with families regarding history of treatment, medication, violence and ability for self-care. Informed decisions about treatment should permit compassionate communication between providers and families under defined circumstances. Reform the Health Insurance Portability and Accountability Act privacy rule.
• Increase SMI research. NIMH decreased research on bipolar disorder by 25% and on schizophrenia by 17.5% between 2016 and 2019 and cut research trials for medication by 90% between 2003 and 2019.
• It costs less to care. A report to be released in a few weeks from Schizophrenia and Psychosis Action Alliance (on which I serve as a board member) will detail that the total costs of our misguided approach to schizophrenia and bipolar disease in the U.S. is several hundred billion dollars per year. The annual per person costs for schizophrenia alone exceed $100,000 per year. Treatment is one-sixth the cost of incarceration, and greatly reduces the risk for violence.
There is plenty of research indicating effective treatment can greatly reduce the risk for violence among those with SMI. Common decency, compassion and economics all underscore the value of changing our approach. We risk repeating the same tragic course if we again fail to act properly. And if we fail, the fault lies not in our guns, but in ourselves. Now that is a mass tragedy.
ABOUT THE AUTHOR: Tim Murphy is a psychologist and a former Pennsylvania state senator and U.S. congressman from Western Pennsylvania. He works as a psychologist in the Pittsburgh area, especially with veterans struggling with PTSD.
ACMI Action Alert: Arizona’s 2021 Budget, Please Include These Items for SMI
SB1142 a modest (up to $1 million) tax incentive bill for employers who hire one of Arizona’s 40,000 individuals diagnosed as Seriously Mentally Ill. It serves 2 purposes: offset initial training costs and gives purpose and meaning to individuals ready to take the next step towards recovery and independence.
SB1786 a prisoner transition program designed specifically for individuals with the most serious mental diseases. Transition programs work for those with a serious mental illness and who are most at risk for harming themselves or others without effective transitioning (cost $1.3 million).
On their own, these bills do not solve every gap in Arizona’s continuum of care for individuals with chronic mental illness. However, they are vital parts of that continuum and important steps forward. People with serious mental illness can find support transitioning out of prison and others can find meaning and purpose through employment and inclusion in the community.
SB1030 — The PSRB Bill. With agreed upon floor amendments, this bill will not have a budget impact. It reforms the Psychiatric Security Review Board and will have a significant impact on Public Safety. You can read more about this important work in a recent Op-Ed published in the Arizona Capitol Times.
SB1716. The Arizona State Hospital (ASH) Bill. The Bill does not have an impact on the budget this year as well. We are confident that this is the beginning of reforming the bottleneck that leaves so many in Maricopa County languishing in inappropriate hospital settings or worse. This legislation also seeks to bring more accountability to ASH for the services it provides and improve patient safety.
But we need YOUR help NOW!
Please take a moment to email or call your State Representatives and Senator and ask them to support the two budget items! Every email or phone call matters and makes a huge difference!! Thank You!
Here is a link to find your AZ Representative’s and Senator’s email. You can also quickly email all House and Senate members through this site:
SCR1018 — The Concurrent Resolution. This expresses support for community-based efforts to provide clinically appropriate care to individuals with chronic serious mental illness; Passed unanimously in both the Senate and House! Please take some time to read this Resolution and thank our legislators on social media and through emails.
This Resolution acknowledges the needs of individuals and families living with chronic serious mental illness in Arizona and our legislators unanimously agreed that we must work toward providing a full continuum of care, including access to the Arizona State Hospital, for this group of people.
SENATOR BARTO— We continue to be grateful for Senator Nancy Barto’s tireless work on addressing these gaps in the continuum of care on behalf of the Chronically Mentally Ill in Arizona down at our State Capitol every week! Please express your appreciation when you have a moment as well to other legislators who support these important bills.
Please join us to learn about the “Mapping the Costs of Serious Mental Illness” which was a two-year study commissioned by ACMI to determine various costs associated with serious mental illness. There will be a presentation followed by a Q & A session.
Studies into the dangerous long-term effects of repeated psychosis should underscore the need for early and continued treatment for persons with psychotic disorders. We do understand that long-acting injectable anti-psychotic medications (LAIs) are expensive; however, one episode of psychosis necessitating an inpatient stay will far exceed the cost of LAI treatment. And, yet, despite this knowledge, insurers insist on step therapy. Let us share our experience with our insurer’s denial for our son’s long-acting injectable medication after he had failed at oral medication for a decade and subsequently been stable on an LAI.
Schizophrenia is a complicated chronic disease affecting approximately 3.5 million people in the United States, its annual healthcare costs exceed $155 billion. People living with schizophrenia often experience a reduced quality of life (QOL) and are likely to be homeless, unemployed, or living in poverty. Life expectancy for patients with schizophrenia is 25 years below the average lifespan. Furthermore, patients with schizophrenia experience numerous comorbidities; weight gain, increased cardiovascular risk, and mood and cognition deterioration. Treatment nonadherence can increase the risk of relapse, rehospitalization, and self-harm, leading to reduced Quality of Life (QOL) and increased economic burden.
Here is an Op-Ed from the Arizona Republic on April 23rd on our experience:
The following bills that seek to enhance the well-being of individuals and families with chronic mental illness in Arizona continue to move forward. Here’s where they stand and how you can help:
SB1059 – Clarifies current law requires that a person with mental illness and substance use diagnosis must be evaluated and not summarily dismissed due to the presence of drugs. The intention is to make treatment consistent.
Status: Passed in the Senate. Passed out of House Committees, currently waiting to go to House floor for a vote. Email all House members.
SB1142 – A tax incentive bill for employers who hire people with serious mental illness. Sets the credit amount at $2 for each hour worked by an SMI employee during the calendar year, not to exceed $20,000, tax-paying business owner. Government agencies excluded.
Status: Passed in the Senate. To be heard in the House Appropriations Committee this Tuesday, 3/30, for a vote.
SB1716 – Currently, only 55 patients from Maricopa County can be at the Arizona State Hospital (ASH) — even when there are empty beds. ASH will no longer limit the number of patients who can be admitted based on the county where the patient lives. Admission should be based on clinical needs.
Reforms the existing ASH Governing Body (Governing Body) to operate without conflicts of interest: Most members will NO LONGER be employees of the Department of Health Services, which oversees ASH. Requires that the Chair of the Independent Oversight Committee (IOC) be invited to Board meetings and provided quarterly reports about human rights violations with patients. Improves transparency — requires Governing Body file annual reports with the Legislature that describe the treatment provides and what is working.
Patient safety improvement: ASH has an outmoded video surveillance system that puts patient safety at risk. We need a better surveillance system. The bill requires ASH to maintain a surveillance system with video and audio and appropriates $500,000 to do so. ASH administration has requested a new system last year and is currently in a Request for Proposal.
Status: Passed in the Senate. To be heard in the House Appropriations Committee this Tuesday, 3/30, for a vote.
SB1029 & SB1030 – Psychiatric security review board (PSRB) bill, SB1029, requires more information and reports for the Board to ensure that it treats patients fairly and protects the public. The Board now operates without enough information on patients when it makes decisions. The bill has a retired judge become the Chair, so the Board operates by fair rules.
Because the PSRB Board opposes any changes and claims that it operates perfectly, SB1030 ends the PSRB and sends the functions that the PSRB performs to the Superior Court in each county. This saves the state money and will ensure that patients get a fair hearing in front of a judge who follows the law.
Status: Passed in the Senate. Passed in the House Committees, waiting to go to the House floor for a vote.
ACMI would like to thank Senator Nancy Barto, the sponsor of these bills, for her tireless and heroic work on behalf of individuals and families living with chronic mental illness in Arizona! When you have an opportunity, please thank her as well.
We realize that everyone’s life is full; if you are unable to call or email but still want to help the chronically mentally ill, you can partner with us financially. ACMI is a group of dedicated volunteers; no one receives a salary. Your gift will go directly toward improving the well-being of people living with chronic mental illness.
Please contact your legislators by this Monday morning.