True or False: Three out of four patients with schizophrenia report substance use.
A review of electronic medical records of patients with schizophrenia spectrum disorders in a community teaching hospital’s psychiatric unit found that more than three-quarters used substances such as tobacco and cannabis. Researchers presented their findings in a poster at the virtual 2021 American Psychiatric Association Annual Meeting.
Among patients with schizophrenia, 62.3% used tobacco, 41.5% used cannabis, 40.2% used alcohol, and 27.4% used cocaine. In patients who reported using tobacco, unadjusted odds ratios were 7.24 for comorbid alcohol use, 5.00 for cocaine use, 4.62 for synthetic cannabis use, and 2.80 for cannabis use, according to the study. Multivariate analysis results supported the findings.
With that information, one would hope that the behavioral health providers would do a better job at treating dual diagnosis individuals. Often families of loved ones that have serious mental illness and substance use disorders hear that the person needs to get sober before mental health treatment can be effective. However, they are also then told that the person is too ill to be in the substance use treatment because of their serious mental illness. Kind of a Catch 22 situation. Treatment needs to address both illnesses.
I was speaking with a mother in crisis suffering through yet another psychiatric emergency with her adult son. His serious mental illness symptoms were frightening and possibly dangerous; he likely needed a medication adjustment. Easier said than done. His psychiatrist had been contacted, and an appointment was set. Before the appointment, there was an exacerbation of symptoms which resulted in a scuffle with a housemate and an assault. Nothing that required medical attention, not this time.
The house staff was inclined to call the police, but his mother begged them to call his ACT (Assertive Community Team) instead. Keep in mind he was already in a 24hr residential treatment center due to his serious mental illness. The ACT team concurred that her son needed to go back to a psychiatric screening agency for re-assessment. After going to the psychiatric evaluation center, they determined that he needed an in-patient psychiatric bed. After waiting in a recliner bed overnight, he went to one of the community psychiatric hospitals. The nurse practitioner from the community hospital did talk to the mother. If instead, he had ended up in jail and had been found guilty of assault, he would have lost his benefits. When a person with serious mental illness is sent to jail, often their medications are changed or missed for a while, so they come out requiring more extended hospital stays for stabilization.
Once he was admitted, the mother tried to talk to someone and provide them with his history. Her son has been ill for over 25 years. No one would talk to her even though she is his guardian. She called repeatedly. The phone is often not even answered. She finally reached the CEO as she often has had to do in the past; the staff ignore her requests for information. After that discussion with the CEO, communication improved marginally. But that did not stop a healthcare worker from refusing to send her son’s new medication regimen. The worker told her to call the CEO again; such blatant disrespect of guardians and families should not be tolerated.
Now contrast that with her recent experience with her husband, who had a medical emergency. He was quickly rushed to the hospital by paramedics. But unlike emergencies having to do with psychiatric crises, the police were not called. Had this emergency been due to a psychiatric problem, the police would have been called. Her son would have been cuffed and taken either to jail or perhaps a psychiatric evaluation center if he was lucky. Once at the hospital, everyone talked to her and included her in the decision-making process. There were many follow-up calls, and she did not have to escalate the issue to force people to communicate.
The treatment is of people with SMI in a psychiatric crisis is criminal. While we have parity laws, the reality is that we DO NOT have parity.
This would be a troubling predictor if accurate. Childhood obesity is growing at an alarming rate in the United States. According to the CDC, Pediatric obesity is now of epidemic proportions in the United States. Pediatric overweight and obesity now affects more than 30 percent of children, making it the most common chronic disease of childhood. We may face a tsunami of mental illness with psychiatric disorders in the future.
Physical conditions such as insulin resistance and weight gain, which are known to commonly co-occur with psychiatric disorders like psychosis and depression, could be detectable years before the onset of the psychiatric disorder, researchers recently reported in JAMA Psychiatry. Below, researcher Benjamin Perry, MRCPsych, of the University of Cambridge, England, explains the reasons for the study, clinical implications of the findings, and directions of future research.
Q: What led you and your colleagues to study the link between childhood insulin levels and later mental health problems?
A: We chose to conduct this study for a few reasons. There is good evidence from meta-analyses and other observational studies that early signs of developing physical health problems, such as insulin resistance and weight gain, can be detected right at the onset of psychiatric disorders such as psychosis and depression in young adults. Left unchecked, this can lead to type 2 diabetes, obesity, cardiovascular diseases and ultimately an early death. Sadly, people with psychosis and depression live on average 10-15 years less than the general population, mostly because of physical comorbidity.
However, most of the existing research in the field has been cross-sectional, and/or has included people who already have a diagnosis of psychosis or depression. Therefore, it’s been difficult to disentangle the direction of association (ie, the chicken and egg. What comes first – the physical or the mental health problems?). Also, previous research has mostly included single-point measures of cardiometabolic markers, yet repeat measures of these markers provide much greater resolution into potential underlying biological pathways. In our study, we aimed to address those limitations.
Q: Please briefly describe your study method and the most significant findings.
A: We were fortunate enough to be able to access data from the Avon Longitudinal Study of Parents and Children (ALSPAC), which is a United Kingdom (UK) population-representative cohort study of around 15,000 participants who have been followed since birth. ALSPAC is a really rich resource, so we were able to include a number of repeat measurements of body mass index (BMI) and insulin levels from early childhood through early adulthood. We used a statistical technique called growth mixture modeling to delineate distinct trends of BMI and insulin levels through childhood and adolescence. Then, we examined whether any specific cardiometabolic developmental trajectory was associated with psychosis and depression in adulthood, after taking into account a number of other possible explanations (confounders).
We found that a trend of persistently high insulin levels from as far back as age 9 years was associated with a higher risk of psychosis in adulthood. We also found that BMI increases around the age of puberty onset were strongly associated with a higher risk of depression in adulthood. These associations remained after taking a number of potential alternative explanations into account, including sex, ethnicity, social class, physical activity, smoking, alcohol and substance use, sleep problems, calorie intake, and childhood behavioral and emotional problems.
Taken together, the findings from our study suggest that the cardiometabolic comorbidity so often attached to adult depression and psychosis may have early-life beginnings, and may be detectable long before the onset of depression or psychosis, at least in some individuals.
Q: Were any of the outcomes surprising or different than expected?
A: Perhaps the main thing that stood out for us was that there appeared to be distinct associations between childhood/adolescent trends of BMI and insulin levels with depression and psychosis respectively. Disruptions to glucose-insulin homeostasis and obesity often go hand-in-hand since they predispose to each other; this may explain why people with depression and psychosis have similarly higher rates of both obesity and type 2 diabetes mellitus than the general population, particularly in chronic illness. Our results however suggest the biological mechanisms underlying this comorbidity may be different in people suffering from psychosis compared with depression.
Q: Do you feel there are any near-term applications of these findings in clinical practice?
A: Our findings underscore the crucial importance that all young people presenting with symptoms of depression and psychosis receive a full and comprehensive work-up of their physical health. Intervening early is the best way to improve long-term health outcomes, both physical and psychiatric, and is the best way to reduce the mortality gap sadly faced by people with depression and psychosis.
Q: Are you doing any more research on this topic, and are there any other studies you feel are needed?
A: We do have a number of other studies at various stages of completion which we are really excited about, and the present study really is only the beginning. For example, we don’t know how/why insulin levels might be raised from childhood and how this might increase the risk of psychosis in adulthood.
We also don’t know exactly why BMI increases around the age of puberty onset might predispose to depression in adulthood—particularly when the evidence for this was much stronger than for an association of persistently high BMI levels throughout childhood and depression in adulthood.
We are also motivated to conduct research that can benefit patients directly, for example with studies that might help clinicians more easily recognize the cardiometabolic risk of young people with depression and psychosis. Early intervention is the best way to improve longer term outcomes, both physical and psychiatric, and help to close the mortality gap sadly faced by people who have depression and psychosis.
Benjamin Perry, MRCPsych, is an academic clinical psychiatrist based at the University of Cambridge, England. He is funded by a fellowship from the UK National Institute for Health Research. Dr. Perry is passionate about improving our understanding of why people with mental disorders such as psychosis and depression suffer from a higher prevalence of physical health problems than the general population, and in finding the best ways to reduce this health inequality.
Photo from Harvard children’s health blog By Nandini Mani, MD,
Here is the executive summary, taken from their full report (Eide & Gorman, 2021):
Inpatient psychiatric care forms a crucial part of America’s mental health system. Though most mental health services are provided on an outpatient basis, treating some serious mental illnesses requires a hospital setting. Inpatient treatment may be provided in a general hospital unit or a specialized psychiatric hospital. Within the context of Medicaid, specialized psychiatric hospitals are known as “Institutions for Mental Diseases,” or IMDs.
Federal law generally prohibits IMDs from billing Medicaid for care given to adults between the ages of 21 and 64 at a facility with more than 16 beds. This “IMD Exclusion” has been in place, in some fashion, since Medicaid was enacted in 1965. The intent was to prevent states from transferring their mental health costs to the federal government and to encourage investments in community services. The IMD Exclusion achieved its desired effect by contributing heavily to what’s popularly called “deinstitutionalization,” the transformation of public mental health care from an inpatient-oriented to an outpatient-oriented system.
This report argues that the IMD Exclusion has outlived its usefulness and should be repealed. It discourages states from investing in inpatient care, hampering access to a necessary form of treatment for some seriously mentally ill individuals. As a result, these individuals end up repeatedly in the emergency departments of general hospitals, “boarded” for lack of access to available beds, and overrepresented among the homeless and incarcerated populations. More broadly, the exclusion discriminates, through fiscal policy, against the seriously mentally ill.
Concerns that repealing the IMD Exclusion would lead to a mass re-institutionalization of the mentally ill are overblown. The population of public psychiatric hospitals today stands at about 5% of what it was before deinstitutionalization. Individuals in need of mental health care have access to a much greater diversity of programs and public services than existed before the 1960s, when institutional care was often the sole option. Strong legal regulations also now exist that did not exist when Medicaid was first passed—most notably, the “integration mandate” of the Supreme Court’s Olmstead ruling, which requires mentally ill individuals to be provided services in the community when those services are appropriate, are not of objection to patients, and can be reasonably
Interest in repealing the IMD Exclusion has increased recently in response to a concern over bed shortages for the seriously mentally ill and persistent challenges with mental illness-related homelessness and incarceration. There have also been signs of bipartisan interest in a full and clear repeal. Under the Biden administration, mental health-care reform, beginning with the repeal of the IMD Exclusion, may present an opportunity for substantive bipartisan policy reform.
Eide, S., & Gorman, C. D. (2021). (rep.). Medicaid’s IMD Exclusion: The Case for Repeal (pp. 4–10). New York, NY.
Worth reading: Attorneys, and ACMI Board members, Josh Mozell and Holly Gieszl wrote an in-depth piece about Arizona’s mental illness treatment system in this award-winning magazine. They focus on the 55 bed limit for Maricopa County at the Arizona State Hospital (ASH). They discuss the community treatment and the true interpretation of Olmstead. *Begins page 40. #mentalhealth#mentalillness#Arizona
On page 80 is an interview with the infamous Chic Arnold. Well done!
ACMI would like to encourage those who have interacted with Arizona’s crisis line to provide feedback on their experience.
AHCCCS, the state Medicaid agency, seeks feedback from Arizonans who have called a crisis line to get help for themselves or others. Please take this short survey. We want to know—what worked well and what could go better?
Most folks reading our blog know the long disturbing history of how we have gotten to such a sad place in the US in our treatment of people with serious mental illnesses. You may find it interesting, as I did, to learn that President Reagan made a major change (see below), which resulted in diminished community resources.
“That began to change shortly after Ronald Regan was elected president in 1980. He ended earmarking of federal funds for this system of community mental health centers and instead substituted block grants to the states that they could use at their discretion. Almost all the states acted badly, cutting taxes rather than using the federal funding as before for community mental health.”
We need a federal plan that also involves the removal of the IMD exclusion. This mental health treatment exclusion is a parity violation. There is no such restriction on the length of stay or the number of medical beds in hospitals for medical conditions. Learn more about parity laws.
We need to focus on the people with SMI and not just general mental health!!
Original article published by StatNews on July 9th by Allen Frances
President Biden’s ambitious infrastructure plan has a glaring omission: It makes no effort to redress the awful reality that the United States has the worst mental health infrastructure of any country in the developed world.
People with mental illness, their families, and society at large are suffering the tragic consequences of four decades of mental health defunding and privatization: 90% of psychiatric beds have been closed; the once-wonderful system of publicly funded community mental health centers has been gutted; crisis response teams are almost nonexistent; and the available pool of affordable housing meets only a fraction of what’s needed.
In the Middle Ages, people with severe mental illness were often chained in prisons, begged on the street, or languished in poor houses. In modern America, 350,000 people with mental illness are in jails or prisons (often for nuisance crimes that could easily have been avoided had treatment been available); 250,000 of them are homeless; and the average life span of those with severe mental illness is 20 years less than that of the general population. The rate of dying from Covid-19 was three time higher among people with schizophrenia than in the general community — the second biggest risk factor after age.
Law enforcement officers, sheriffs, and judges have become the most vocal critics of the brutal criminalization of mental illness and are now among the strongest advocates for improved community treatment and housing. Forcing scared and untrained police officers to be first responders for people with untreated mental illness puts them in untenable positions and is partly responsible for police brutality and shootings. People with untreated mental illness are 16 times more likely to die during a police encounter than other civilians.
And once in jail, people with mental health issues are difficult to manage, deteriorate further, spend disproportionate time in solitary confinement, and have prolonged stays (especially since they have no place to go and no treatment if released).
How did the U.S. get into this mess? Massive and rapid deinstitutionalization of people with mental health issues began in the late 1950s for several reasons: partly because effective antipsychotics had been discovered; partly as a humanitarian response to the horrors of the overcrowded “snake pit” state psychiatric hospitals; partly as a cost-cutting method (since mental health was often the biggest and most tempting item in state budgets).
The “new approach to mental illness” that President John F. Kennedy called for in a 1963 speech, which resulted in his signing into law the Community Mental Health Centers Act later that year, was a response to the great disruption caused by the rapid closure of the huge state hospitals. Community services were meant to provide a better life for people with mental illness at less cost to the states.
My first job working in a community mental health center in 1973 in New York City was thrilling. Patients who had languished for decades in state hospitals were able to enjoy much more normal lives with the benefits of medication and inclusion in the community. The U.S. became the world leader in community psychiatry and I was proud to be a psychiatrist.
That began to change shortly after Ronald Regan was elected president in 1980. He ended earmarking of federal funds for this system of community mental health centers and instead substituted block grants to the states that they could use at their discretion. Almost all the states acted badly, cutting taxes rather than using the federal funding as before for community mental health.
And the money saved by closing the expensive state psychiatric hospitals rarely followed patients into their communities to provide badly needed treatment and housing. Community mental services either closed or were privatized, and the newly private services routinely refused care to people with severe mental illness because they were usually uninsured and always very expensive to treat.
Eventually, deinstitutionalization turned into reinstitutionalization as prisons replaced hospitals as the biggest line item in state budgets. Under Reagan, the U.S. quickly went from having the best system of community psychiatric care in the world to the worst, and things have further deteriorated ever since.
It is not clear how much of Biden’s extensive physical and human infrastructure rebuilding plan will eventually be enacted into law. But it is crystal clear that rebuilding our country’s shamefully lacking mental health system is not part of the plan.
It is also clear why. Powerful lobbying forces in Washington are fiercely jostling to capture the money allocated to the infrastructure program. Whatever emerges will reflect how much political and economic muscle each industry can exert on the politicians doing the horse trading. In this battle of the titans, people with mental illness are voiceless and their advocacy groups lack political and economic muscle.
The care of people with severe mental illness is necessarily a public responsibility that has been neglected in our primarily for-profit private health care system. The United States has shirked this public responsibility more than any other developed nation on earth. The Biden plan is a sad lost opportunity to play catch-up on desperately needed mental health services and its exclusion of mental health means there is no hope in sight.
Mahatma Gandhi once said that a nation’s greatness is judged by how it treats its weakest members. By this standard, the United States is morally bankrupt and the very opposite of great.
Allen Frances is a psychiatrist, professor and chair emeritus of the Duke University Department of Psychiatry, and was chair of the DSM-IV Task Force from 1987 to 1994.
ACMI would like families and members to submit feedback on their experiences with Court Ordered Evaluation / Court Ordered Treatment (COE/COT). Arizona has some very smart laws in this area. There is ample protection for individuals’ liberty, safety, and long-term recovery. All individuals undergoing COT are provided attorneys, all COT orders are subject to review, and the individual on COT can ask the court to review a COT order to either modify or terminate the order if appropriate. Our current COT process protects the individual while assuring them of treatment. It saves lives.
Provide feedback to help AHCCCS strengthen the process to ensure our loved ones experiencing a psychiatric episode get timely and appropriate care.
In response to the Committee’s recommendations, AHCCCS has created a Court Ordered Evaluation / Court Ordered Treatment (COE/COT) committee. The goal of this committee is to develop an effective and standardized statewide training on Court Ordered Evaluation and Treatment. This training will include individual county processes, resources, and peer and family member perspectives.
OIFA’s statewide are collaborating to gather the peer and family member voice and experience with the COE/COT process. Please help us by completing this survey.
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.