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.
The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest to discuss a relevant Behavioral Health topic; after the speaker, we will discuss current issues with the Behavioral Health System attendees. This month, hear about Psynergy Healthcare from co-owner Arturo Uribe and Executive Director Lynda Kaufman. Psynergy Programs operates with the shared belief that recovery happens, especially when a cohesive set of supports and services are available to support and sustain it. Based in Morgan Hill, California, our organization has grown from one facility to four over the last four years, with a fifth now in development. Each campus offers clinical and residential services in a safe and supported residential area. This way, we can emphasize the best elements of a community-living experience for individuals facing various mental health challenges. We hope they expand to Arizona!
Arturo Uribe is the President & CEO at Psynergy Programs Inc. in Morgan Hill, California, United States. His vast experience includes assisting and Advocating for Individuals and Families who are navigating the California County Mental Health System•, Supervising Intensive Case Management Teams responsible for moving clients into less restrictive placement in Santa ClaraCounty• Managing clinical resources, Supporting community integration for clients previously residing in state hospitals, acute inpatient settings, and locked institutions• Individual Therapy, Couples Therapy, Family Therapy, and case management.
He has worked in various mental health systems, including:• Community Organizations•, Government Agencies• School Settings. At Psynergy Programs, I have been able to leverage my position as CEO to provide leadership with the philosophy that individuals have the power to do better when everyone works together. At Psynergy Programs, we have transformed communities and individuals by developing licensed adult residential facilities that provide a home-style setting coupled with both care and supervision and Mental Health treatment. At Psynergy Programs facilities, individuals can celebrate hope, promote personal growth, build social networks, and realize their full potential.
Experience Psynergy Programs Inc. President & Chief Executive Officer January 2006 – Present (17 years 9 months) Morgan Hill, California, United States
Santa Clara County Mental Health 24 Hour Care (Team Lead, LCSW) June 1999 – December 2005 (6 years 7 months)
Santa Clara County Narvaez Mental Health Clinic Psychiatric Social Worker I June 1998 – May 1999 (1 year) San Jose, California
Community Companions (Alliance for Community Care Clinical Case Manager (Team Lead) June 1990 – May 1998 (8 years) San Jose, California
Santa Cruz County Office of Education Teacher Assistant (CA Mini-Corps) January 1985 – May 1990 (5 years 5 months) Watsonville, California
Education San Jose State University Master’s degree, Social Work · (1995 – 1998) San Jose State University Bachelor’s degree, Clinical Psychology · (1989 – 1992)
Lynda Kaufmann is Director of Government and Public Affairs, managing Admission, Contracts, and Supported Housing w/ ACT + FSP San Francisco Bay Area. She is an Experienced Public Affairs Specialist with a demonstrated history of working with individuals with SPMI (Severe Persistent mental illness) in community settings. Skilled in contract management, coaching, government contracts, policies related to behavioral health, and MediCal practices. Strong community and social services professional.
Experience Treatment Advocacy Center Ambassador March 2023 – Present (7 months)
PSYNERGY PROGRAMS, INC Director of Government and Public Affairs April 2010 – Present (13 years 6 months) Morgan Hill, California
Topic: ACMI Stakeholder’s Meeting
Time: October 3rd, 2023, Psynergy Programs– CoOwner Arturo Uribe and ED Lynda Kaufman
November 7th, 2023, Greenbuurger’s Hope House, a secure treatment facility by ED Cheryl Roberts
December 5th, 2023, Secure Residential Treatment in San Mateo County by Terry Rittgers, Yessa Calderon, and Louise Rogers
January 2nd, 2024, TBD
February 6th, 2024, Terros Program and Offerings by COO Jennifer Nye and CEO Karen Hoffman Tepper
March 5th, 2024 Home Inc. by Charles Sullivan
Every month on the First Tuesday until December 25th, 2025
Please download and import the following iCalendar (.ics) files to your calendar system.
Reporters from the Washington Post came to Arizona to research the heightened risk for those living with Schizophrenia in our extreme desert summer heat.
Shannon Osaka and Erin Patrick O’Connor reported from Phoenix during its historic July 2023 heat wave to capture the impact on the city’s most vulnerable residents. John Muyskens, in Washington D.C., mapped Stephan Goodwin’s movements in his final hours.
The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest to discuss a relevant Behavioral Health topic; after the speaker, we will discuss current issues with the Behavioral Health System attendees. This month, hear about Joel R. Conger of Connections Health Solutions. He will be discussing the services they provide (psychiatric screening as well as the recent addition of Court-Ordered-Evaluations (COE),
Joel Conger is a highly experienced professional with a distinguished career spanning over 30 years in the behavioral health community in Arizona. He holds the esteemed position of Arizona Market President for Connections Health Solutions, a leading organization dedicated to serving the behavioral health needs of individuals in the state. Under his leadership, Connections Health Solutions successfully serves approximately 30,000 Arizonans each year who are facing behavioral health crises.
Before joining Connections Health Solutions, Joel served as the Associate Vice President of Behavioral Health for Molina Healthcare. During his tenure, he played a pivotal role in the procurement of integrated healthcare contracts across multiple states, including Iowa, Nebraska, Indiana, and California. His strategic contributions were instrumental in expanding the reach of behavioral health services and ensuring the seamless integration of care for diverse populations.
Joel’s expertise lies in the domain of public sector behavioral health service delivery, where he possesses acute knowledge from both the health plan perspective and as a network provider. This comprehensive understanding allows him to navigate the complexities of braided funding mechanisms, encompassing state, federal, and grant funding. His ability to navigate and optimize these funding streams has resulted in enhanced access to vital behavioral health services for countless individuals in need.
Throughout his career, Joel has demonstrated exceptional leadership and accountability, consistently driving positive change and improving the lives of those with behavioral health challenges. His extensive experience and in-depth understanding of the field make him a trusted authority in the behavioral health community in Arizona and beyond.
Joel Conger is committed to making a difference in the lives of individuals facing behavioral health crises, and his contributions continue to shape the landscape of behavioral healthcare delivery in Arizona.
Topic: ACMI Stakeholder’s Meeting
Time: September 12th, 2023, 04:00 PM Arizona, Connections Health Solutions by Joel R Conger,
October 3rd, 2023, Psynergy Programs– CoOwner Arturo Uribe and ED Lynda Kaufman
November 7th, 2023, Greenbuurger’s Hope House, a secure treatment facility by ED Cheryl Roberts
December 5th, 2023, Secure Residential Treatment in San Mateo County by Terry Rittgers, Yessa Calderon, and Louise Rogers
January 2nd, 2024, Home Inc by Charles Sullivan
February 6th, 2024, Terros Program and Offerings by COO Jennifer Nye and CEO Karen Hoffman Tepper
Every month on the First Tuesday until December 25th, 2025
Please download and import the following iCalendar (.ics) files to your calendar system.
Indeed, finding cures for serious mental illnesses is a complex and multifaceted challenge. Even the experts at the National Institute of Mental Health (NIMH) and other institutions globally often do not agree on various aspects of mental health treatment for several reasons: they cannot agree on the diverse manifestation, the biology is complicated, there are psychosocial factors, and there are philosophical differences in researcher and practitioners.
Given these challenges, it is not surprising that experts in the NIMH and other institutions often do not agree on the best approaches to treating serious mental illnesses. Some have focused on stigma reduction, and as the article below states, that seems to have been effective as more prominent people (athletes, actors, and politicians revealed personal struggles). If we could agree to focus on finding effective treatments and funding research on cures, we could achieve better outcomes. However, ongoing research and collaboration among experts are essential to improving our understanding and developing more effective treatments for mental illnesses.
As the COVID-19 pandemic eases, a mental-health crisis still has us in its grip. My fellow-psychiatrists and I continue to be flooded with referrals, desperate calls, emergencies, and relapses—likely the consequences of years of isolation and grinding anxiety, loss, school disruption, and who knows what kinds of viral assaults on the brain. Preliminary studies report elevated rates of suicide, anxiety and depression, addiction, developmental delay, and psychiatric E.R. visits. Socially marginal people, health-care workers, and the young all seem especially at risk.
COVID has left us destabilized, in the midst of what might be thought of as a psychiatric pandemic. How bad will this be? Who will escape harm, and who will suffer the most? With the virus, we eventually understood the answers to these questions and focussed our public-health efforts accordingly. But the psychiatric consequences of the pandemic will be intrinsically more complex, varied, and obscure. First, there are millions of mourners whose loved ones succumbed to covid, often in terrible, sudden ways. Then there are some who may be suffering from subtle neuropsychiatric effects of the infection. In addition, there are those stuck in chronic states of fight or flight, or helplessness—mental modes that affect our sense of time. Such people may be jumpy, irritable, violent, trigger-happy, drugged out, avoidant, defeated, morose, or self-harming, for reasons that no one can recall. Doug won’t acknowledge that he’s getting high so often because of the stress of the pandemic. Jen will be incensed if you imply that she’s cutting herself because of the difficulties of the past three years. As with traumas suffered by soldiers in war, the covid past will slip into the present, darkening the future.
How should our psychiatric-health-care system respond? “We don’t have a psychiatric-health-care system,” the public-health expert Rosemary Stevens reminded me. She’s right. Americans suffering from mental illness routinely tumble through gaping cracks in our “system.” Homeless encampments, with many people in need of psychiatric help, sprawl along beaches near Los Angeles. Vast stretches of our heartland remain mental-health-care deserts. Chicago’s Cook County Jail has in recent years been our proud nation’s largest provider of psychiatric services. As for our struggling children, good luck finding help. The other day, I ran into a pediatrician who told me that she had just sent another suicidal teen to the emergency room; the kid was eleventh in line for a bed.
If by mental-health system we mean integrated parts working together, then it’s true that America doesn’t have one. Still, we do have an array of governmental agencies, nonprofits, biotech and pharmaceutical companies, hospitals, clinics, and medical colleges—in addition to an army of researchers, epidemiologists, psychiatrists, psychologists, social workers, and therapists—that could be called upon to meet whatever post-covid challenges we face. The National Institute of Mental Health sits at the center of this constellation. Founded in 1949, the N.I.M.H. was originally charged with leading America’s mental-health research, prevention, and treatment efforts after the Second World War, when startling numbers of veterans had “become mentally unbalanced in fighting for their country,” as the Post put it at the time. Since then, as the self-proclaimed largest funder of psychiatric research in the world, the N.I.M.H. has dominated the mental-health-and-illness ecosystem; its priorities nourish growth or extinguish it. One might imagine that comprehending and responding to the mental-health effects of the pandemic would skip to the front of that line.
Few of my clinical colleagues believe that will happen. Their pessimism reflects not just the current state of mental-health care in our country but decades-old trends that have reshaped how we think about mental illness—shifts that have blinded us to cataclysms like the one we have just endured. What should we do to correct our course?
Psychiatry has always been a “Rashomon”-like affair, with triumphalists and vilifiers, sincere testimonials from the saved and tragic ones from the lost. It is held by some to be humane and a force for progress, yet it has offended, at varying times, religious believers, libertarians, Marxists, Foucauldians, and “hard” scientists. Critics have never been in short supply.
So I should have been prepared to have my head spin when I interviewed clinicians, historians, and prominent leaders in the field about our capacity to respond to a post-COVID mental-health crisis. One day, I spoke to Allen Frances, the editor of the fourth Diagnostic and Statistical Manual of Mental Disorders, who was not optimistic and looked back in regret. “For me, the tragedy is that, on my watch—the last sixty years I’ve been involved in psychiatry—we have seen the care of patients deteriorate, not improve,” he said. The next day, Herbert Pardes, a former N.I.M.H. director, was more upbeat. Surveying the same time period, he noted that the stigma long attached to mental illness had diminished, and that new knowledge and treatments had blossomed.
Both, it turns out, are right. Psychiatry is composed of three intertwined enterprises: community care for sufferers; a medical specialty devoted to diagnosing and treating patients; and research programs focussed on mind/brain science. At their best, all three efforts aid and constructively challenge one another. But, in this country, during the past few decades, each has gone its own way. This fragmentation has been dramatic, tragic, and certain to compromise our capacity to respond to the post-covid crisis.
The availability of community care—essentially, food, shelter, and support for people with mental illness—is shaped by social values regarding those in need. Those ethical commitments have fluctuated over time. In the early nineteenth century, enlightened Western nations built asylums that were mostly justified in humanitarian terms, but those places of respite eventually became too-big-to-care institutions that warehoused and brutalized their occupants. In postwar America, as the welfare state came under increasing attack, and criticism of these so-called snake pits grew louder, state asylums closed. The sickest and poorest never made it to underfunded—or often unfunded—community mental-health centers. With the emergence of managed-care insurance, in the nineteen-eighties, shockingly short in-patient hospital stays led to still symptomatic patients’ being routinely discharged to the street or swept up into prison. There wasn’t funding for anything better. That is still the case. Should a mental-health epidemic strike us, there is no one to provide care at that scale.
This grim picture is made more painful by contrast with what the medical field of psychiatry, along with its allied disciplines, now can do. Médecine mentale, as it was once called, has long sought to stabilize itself with clear diagnoses and treatments; owing to the mysteries of the mind and brain, it didn’t get too far. Forty years ago, however, American psychiatry found its footing: the third edition of the Diagnostic and Statistical Manual cut free speculative claims about causation, sticking to diagnostic categories based on reliable and coherent clusters of symptoms and signs. Clinicians of all stripes now shared a common language. In reaction to orthodox Freudians and eager lobotomists, a “biopsychosocial” perspective took root, which encouraged practitioners to shun ideology and pragmatically address the biological, psychological, and social aspects of mental illness. Psychoanalysis grudgingly made room for an array of empirically validated psychotherapies. Medications such as Prozac, Effexor, and Risperdal emerged; they were mostly safe and, if not curative, often very helpful.
All these changes were accompanied by publicity campaigns attacking stigma. Mental disorders, we were reminded on billboards and in commercials, were no different from diabetes or any other illness. This work paid off. Today, princes, athletes, senators, and celebrities no longer hide their psychic struggles. And so, paradoxically, around three decades ago, as our commitment to care for the poor and uninsured evaporated, clinical psychiatry could boast of increased social acceptance and tools that were more effective than ever.
Many disorders remained far from cured; some were fully treatment resistant. But, for those patients, there was still hope. Psychiatry’s researchers were tasked with discovering the causes of these disorders. It was a gargantuan job, and a lot depended on its success. In the eighties, Senator Pete Domenici, a loyal supporter of mental-health efforts, told the Stanford neuroscientist Jack Barchas—a point person in the effort to stop cuts to mental-health spending by the Reagan Administration—that, although the country could not afford to care for all of its mentally ill, it could support finding cures for their diseases. During the nineties, which President George H. W. Bush declared the Decade of the Brain, hundreds of millions of dollars were directed to the N.I.M.H. in that effort.
Meanwhile, the institute shed some of its original congressional mandate for treatment and prevention, by giving the job of funding mental-health services to a new federal entity, the Substance Abuse and Mental Health Services Administration. From then on, as one former N.I.M.H. director told me, undertreatment and homelessness were samhsa’s responsibilities. As the Human Genome Project launched, and brain-scanning technology leapt forward thanks to functional MRI, pressure to find genetic and brain signatures for psychiatric illnesses grew. Yet, as the new millennium commenced, a specific scan for disorders such as schizophrenia remained elusive. Dreams of single genetic causes were dissipating. A crisis was brewing.
History holds a large, unmarked graveyard filled with the ideas of those who tried to pin down the ultimate causes of mind/brain illnesses. Critics and scholars have portrayed some of the memorable failures—a procession of phrenologists, degeneration theorists, germ enthusiasts, wild psychoanalysts, political revolutionaries, and sexual liberationists. All of them pushed for their cherished notion, only for it ultimately to be found misguided, wanting, or worse.
There’s an underlying reason for all this zigzagging. Picture an archer’s target; at the bull’s-eye, place the most basic of possible causes for mental illness—say, genes. Huntington’s chorea, a fatal disease that affects cognition and movement, is solely genetic: it sits wholly at the center of the target. But other, more common conditions, such as schizophrenia and bipolar disorder, can only partly be predicted in terms of genetic risk, and, in most other forms of mental illness, genetic determinism further diminishes. To fully understand those diseases, we have to start looking to the next ring in the target. What else might be at work? We may now take aim at neurons, then jump out to neural circuits and networks, then to the entire brain with its hundred billion neurons and trillions of synapses. At any of these different levels of biology, a pathogenic event might disrupt us.
As if that were not enough to overwhelm us, there is much more to consider. Next, our psychiatric archers must move their focus from the brain to the mind, bump up against the mind-brain problem, hurry past dozens of philosophers, and simply grant that minds, in part, can cause things to happen. After that, they must turn their attention to the other outer rings, such as the self, individual behavior, the social world, and the nonhuman environment. Each of those holds the possibility of specific kinds of trouble: negative thought patterns; chronic affects like fear or shame; relationships filled with abuse; deprivation, poverty, and our catchall term for many horrors, trauma; and then, in that very last circle, poisons, bacteria, and viruses.
By taking up all of the rings on that target as potentially interacting causes of illness, psychiatry captures a rich set of human possibilities, from errors in our molecules to forces like racism. Clinicians can take a shot at any of them, unleashing as many arrows as they need. Prozac, psychotherapy, leaving a brutal spouse? Yes, yes, and yes. But experimental science requires studies that reduce a vast field of variables to an independent one whose effect can be tested. Unlike a psychiatrist working with a patient, a scientist in search of a soluble problem must limit herself to only one spot. And so psychiatry has long been a scientifically unstable discipline; it has veered back and forth between different explanatory models because its object of study, the mind/brain, presents the most overwhelming array of epistemological problems in all of medicine. In our quest for valid and reliable answers, it’s easy to get lost.
In 2002, at a moment when the clinical promise of the Decade of the Brain remained unfulfilled, it came time to choose a new N.I.M.H. director. Thomas Insel, a leader in the quest to find biological explanations for complex behaviors, got the job. Insel was brilliantly successful, famous for illuminating the role of the hormone oxytocin in eliciting bonding behavior in voles—an important finding in the emerging field of social neuroscience. Frustrated by the weaknesses in the nation’s mental-health-research program, he concluded that they stemmed from one of the foundations of clinical work: DSM-III was serving practitioners and patients well enough, but its categories were sometimes too muddy for researchers in search of well-defined scientific targets. How many specific kinds of depression lurked in “D.S.M. 296.31, Major Depressive Disorder, Recurrent, Mild”? Most experts would guess that there were many. And, if one did not tease apart those variants, how could anyone figure out what caused Jim’s depression but not Jane’s, why Zoloft worked on Amelie but not Eli?
In 2010, Insel and his team unveiled the Research Domain Criteria, or rdoc, a new framework for the study of mental disorders that introduced its own nomenclature and benchmarks. The move seemed to separate scientific research from the language and culture of patient treatment—a divorce made more bitter when Insel suggested that DSM categories were mere constructs “based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.”
rdoc’s influence was felt across the institute’s research portfolio. It aspired to be objective. It also prompted scientists to ask questions about disorders in a very specific way. You could study problems like hyperactivity in kids, post-traumatic stress disorder in rape victims, or self-harm in adolescents—but, to maximize your chances of being funded, your study had to incorporate a measurable characteristic, such as a gene or neural circuit, that reflected an underlying biological process. In a 2013 ted talk, Insel, standing before mesmerizing brain scans and images of neurons, assured his audience that new knowledge based on this approach—he had previously called it “clinical neuroscience”—would soon sweep away two centuries of psychiatry.
Since then, this new paradigm has powerfully altered what psychiatric scientists look for—and what they look past. For example, researchers have discovered hundreds of genetic loci associated with schizophrenia and with major depression, and more than fifty for bipolar disorder and autism. Each time a new correlation is found, geneticists celebrate. But, as E. Fuller Torrey, an advocate for the severely mentally ill, told me, so much success has added up to failure. “They have identified a lot of risk genes, not any that cause a disease,” he said. “That’s very embarrassing to them.”
Insel left the N.I.M.H. in 2015, and later confessed that one of the reasons he did so was this same dispiriting realization. In a 2017 interview, he elaborated on his departure. “I spent thirteen years at N.I.M.H. really pushing on the neuroscience and genetics of mental disorders,” he said. “And when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness. I hold myself accountable for that.” When I spoke to Insel recently, he said, of rdoc, “I think it became an academic exercise. . . . You want to pick up measures that actually are of value to patients, families, and providers. And rdoc got way too complicated. It wasn’t really tied to clinical outcomes in a way that would matter.”
Meanwhile, a decade spent in search of so-called biomarkers crushed clinical investigators who had been trained to use descriptive DSM categories and who aimed their studies at symptom relief and therapeutic impact. By 2015, only around ten per cent of the N.I.M.H. budget was directed toward clinical research. Psychotherapy researchers, who had made much progress before rdoc, saw their funding dry up. Barbara Milrod, of Albert Einstein College of Medicine, told me, “I am angry, as a psychiatrist and as a clinical researcher, because we are doing nothing for our patients and losing generations of researchers and methods.”
Imagine a lighthouse keeper whose beam and horn guide ships in storms. Imagine that this operator, in an epiphany, realizes that all the difficulties he encounters come from water and air. He determines to study the chemistry of H2O and O2. This steward is no eccentric but rather a prestigious and powerful voice in his field; thanks to his financial largesse, many others follow his lead. They all stop worrying about their beacons and foghorns, and no longer bother with weather reports, tides, or distress signals from vessels. When called to task, they assure those whose loved ones have drowned that, though it might take fifty or a hundred years, the riddle of water and air will eventually be solved.
Sound ludicrous? But where were our psychiatric sentinels as opioids, alcoholism, and suicide ripped through the struggling towns of middle America? It took two economists, Anne Case and Angus Deaton, vacationing in Montana, to notice the early mortality of white males around them, and, in 2015, alert us to the shocking numbers of what they called “deaths of despair.” Why did the mental-health-research community fail to notice this? One reason, perhaps, is that there is no gene for social collapse.
The covid pandemic, with its complex biopsychosocial effects, was a cataclysm that emerged from our environment, and its psychiatric consequences have only begun to be understood. Much of its impact, I fear, might simply be ignored, because many of our lookouts remain intently focussed on threats from the opposite end of the causal spectrum. While we concentrated on things like neural circuits, a viral menace attacked. The fear, helplessness, and isolation that it created roiled our communities and families, put great pressure on our emotional and psychic lives, and deeply affected our children. We need to pivot so as to better comprehend those realms, for the pandemic has thrown overly reductive assumptions about neuroscience into contradiction. Yes, malfunctioning brains can make us ill, but three years of death, uncertainty, and angst have demonstrated a homespun truth: the world can really mess you up.
The United States has the most funding for psychiatric research in the world, arguably the greatest array of professional talent, and significant private and public capacities. And yet the rising tide of mental illness after covid will only highlight how our social contract with those patients has long been broken. The idea that shelter and humane care are human rights has dedicated advocates but little political power. In addition, although clinicians are armed with medications and therapies, they have long been pleading for new and better tools. Guidance about what this once-in-a-century pandemic might bring their way should come from our scientific and public-health leaders in Washington, but they are divided, with separate fiefdoms for psychiatric research, alcohol abuse, drug abuse, epidemiology, and the delivery of services. We suffer from systemic failures that seem to be no one’s responsibility.
A notable exception, Vivek Murthy, the Surgeon General, has called attention to the post-pandemic psychiatric crisis, citing burnout among frontline health workers, a spike in teen suicide, and an “epidemic of loneliness and isolation.” But who will take up his call? The National Institutes of Health has created the recover initiative, which will support studies of the medical aftereffects of covid, and Congress has allocated a small amount of money directly to the N.I.M.H. for covid-targeted research. It’s not obvious what will happen when those funds run out.
To be clear, no one I spoke with advocated for calling off the Mars mission to understand the brain; exciting work is being done in optogenetics, in circuit dynamics, and in mapping the brain’s structural network (the “connectome”), to name just a few domains. It is critical that the U.S. invest in such basic research. Similarly, it would be unconscionable not to pursue solid, clinically relevant neuroscience. But there needs to be an adjustment. When I spoke to the present N.I.M.H. director, Joshua Gordon, he admitted that the introduction of rdoc had come at a cost. “It wasn’t communicated to the scientific community in a way that they understood. They took it as a kind of severing of the N.I.M.H. from diagnostic frameworks,” he said. “In my opinion, what should have been said was that it’s clear that there’s heterogeneity within our disorders, and there’s overlap across our disorders. The diagnostic labels are useful. But they have not proven tremendously useful in terms of uncovering biology.” Since Gordon’s appointment, in 2016, the N.I.M.H. has somewhat relaxed its focus on rdoc methodology. When I queried him about its value, he said, “Certainly I emphasize it less than my predecessor did.” Yet rdoc’s adoption reflected decades of at times quite strident belief that the causes of all “real” psychiatric illness could be captured by clinical neuroscience. These may not be commitments that can be easily undone.
Surrounded by this jarring disjunction between high-minded science, clinical urgency, and human suffering, I was reminded of my year as a medical intern, when a different terrifying infection was sweeping the country. On New Year’s Eve, 1987, I held a young man’s feverish hand as he fought to breathe. By then, scientists had isolated H.I.V., and the National Institute of Allergy and Infectious Diseases, led by Anthony Fauci, had begun research on a vaccine. Access to possible drugs was stalled, while gay men perished. A community rose up in protest. Fauci now recalls meetings that he had with act up and one of its leaders, Larry Kramer, as critical to the realignment of his priorities. Thankfully so. If the government had bet the house on an H.I.V. vaccine, we would still be waiting. Instead, accelerated and liberalized clinical protocols, “short-term” fixes, and deeper collaboration saved countless lives.
Today, the covid pandemic may be over, but our psychiatric crisis continues. It should serve as an alarm that shakes us out of our slumber and reframes our thinking. We need to balance our mental-health efforts to include funding more clinical trials, actively researching sociological and psychological determinants of mental health and illness, revitalizing and refining public-health efforts for early treatment and prevention, and looking for innovative ways both to care for the underserved and to provide humane asylum. Will we? Indifference, bureaucratic rigidity, and ideological opposition will likely resist such changes. Back in 1987, months before I sat up with my dying patient, act up formed. What will it take this time, I wonder, to remake our future? ♦
Medicaid is our social safety-net program in the United States that provides health coverage for some of the country’s most vulnerable citizens. It is essential for people with serious mental illnesses. Sadly, Medicaid law contains the IMD exclusion provision, which excludes payment for services for those unfortunate people needing long-term in-patient care. The IMD exclusion is a significant barrier to meaningful treatment for people with serious mental illness (SMI).
In addition, failing to recognize that involuntary treatment is required for many people with SMI has led to many individuals living lives without dignity on the streets or being punished in our jails and prisons.
There are many reasons why more Medicaid services are needed for the seriously mentally ill:
Rising Prevalence: The number of people diagnosed with serious mental illnesses is rising. As the population increases and the stigma around mental health starts to fade, more individuals seek help. This calls for a proportional increase in services. We have not seen this happening in AZ.
Complex Needs: Individuals with serious mental illnesses often require comprehensive, long-term, individualized care that can include therapy, medications, crisis services, and sometimes even inpatient care. The current inpatient stays are relatively short, almost always under the 15-day IMD cap. There is no artificial capitation for other medical conditions.
Coexisting Conditions: Many people with serious mental illnesses have co-occurring physical health issues or substance use disorders. They need integrated care services that can address all their health needs simultaneously. There is an attempt at integrated care, but there are no shining examples I am aware of.
Societal Benefits: Comprehensive services can reduce societal costs, such as homelessness, incarceration, and emergency medical care. Individuals with untreated mental illness often end up in emergency rooms, the criminal justice system, or living homeless, which are more costly interventions than preventive and therapeutic services.
Economic Considerations: Early and consistent treatment can help individuals with serious mental illnesses maintain employment and contribute to the economy. Without adequate services, these individuals are at a higher risk of unemployment and homelessness, increasing the economic burden on society.
Crisis Prevention: Regular access to treatment can help prevent mental health crises. Crises not only endanger the individual but also place a strain on emergency services, hospitals, and the broader community. Unfortunately, there are many police encounters with individuals in crisis who end up injured, incarcerated, or dead due to the symptoms of their disease.
Housing Stability: Stable housing is crucial for recovery. Sadly Medicaid does not pay for housing, only treatment when medically necessary. Refer to the ASU Morrison Institute Housing is healthcare to understand that it is not only the right thing to do for the patient but also saves society about 30% over the cost of treating unhoused people with serious mental illness.
Better Outcomes: Continuous access to mental health services has led to better health outcomes and quality of life. Medicaid can fill the gap, ensuring the most vulnerable have consistent access to these essential services. Providing the entire continuum of care is available.
Stigma Reduction: By increasing the availability of services and prioritizing mental health, society takes a step toward reducing the stigma surrounding mental illness. This can encourage more individuals to seek help when they need it. Receiving care early is essential to stopping episodes of psychosis and protecting the brain.
Future Savings: Investing in mental health now can lead to savings in the future. Providing comprehensive mental health services through Medicaid makes individuals less likely to require more intensive and costly interventions later on. Again refer to the ASU Morrison Institute study.
New York and California have seen the results of not enforcing treatment. Each is now taking small steps to reverse the substantial number of homeless people with serious mental illness. In summary, expanding Medicaid services for the seriously mentally ill is not only a moral imperative, considering the vulnerable nature of this population, but it’s also a wise investment. It can lead to better health outcomes for individuals, reduce societal costs in other sectors like criminal justice, and result in a healthier, more productive, and safer society.
The bill was introduced by Sen. Kirsten Gillibrand and Rep. Dan Goldman. (Spectrum News NY1)
N.Y. bill aims to bolster services for people with serious mental illnesses
BY PATRICK ADCROFT NEW YORK CITY
PUBLISHED 3:30 PM ET AUG. 01, 2023
Sen. Kirsten Gillibrand, Rep. Dan Goldman and Rep. Jerry Nadler on Tuesday touted legislation aimed at strengthening access to medical care for people living with serious mental illnesses.
The “Strengthening Medicaid for Serious Mental Illness Act,” if passed, would generate new services under Medicaid designed specifically for people living with mental illnesses like schizophrenia, bipolar disorder and major depressive disorder, the lawmakers said during a news conference at Manhattan’s Fountain House.
What You Need To Know
· A bill introduced by Sen. Kirsten Gillibrand and Rep. Dan Goldman in June, the “Strengthening Medicaid for Serious Mental Illness Act,” aims to strengthen access to medical care for people living with serious mental illness
· Gillibrand, Goldman and other New York elected officials touted the legislation during a news conference at Manhattan’s Fountain House on Tuesday
· The legislation, if passed, would generate new services under Medicaid designed specifically for people living with mental illnesses like schizophrenia, bipolar disorder and major depressive disorder
The legislation would also set a national standard for care for people with serious mental illness and incentivize states to provide services to treat them.
“Those with serious mental illness have often found themselves in a devastating cycle: going from hospitals to jails to the streets, and back around again,” said Gillibrand, who first introduced the legislation along with Goldman in June.
“Frankly, it’s unacceptable and it’s inhumane,” she added. “It’s a major issue for public safety and it’s a major issue for caring for our families.”
The legislation would provide states with the ability to offer services that would help people with severe mental illness get and keep jobs. It would also allow states to provide access to support services and mobile crisis intervention teams.
States would also be required to abide by certain standards of care, such as tracking disparities in treatment, according to a news release from Gillibrand.
“We are still struggling in the aftermath of COVID, which interrupted mental health treatment for so many, especially the low-income and underprivileged individuals in our community who rely on government services, the community services that were halted,” Goldman said.
“And that’s why this bill is so important,” he added. “It’s important that we get people the treatment they need in a way that works.”
The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest to discuss a relevant Behavioral Health topic; after the speaker, we will discuss current issues with the Behavioral Health System attendees. This month, hear about Brighter Way Dentistry, a clinic model that offers free or discounted dentistry through an innovative model. We have Dr. Kris Volcheck discussing his program and services. He will discuss the importance of dental health to better health outcomes.
EDUCATION MBA, Arizona State University, 1991, Magna cum Laude, Beta Gamma Sigma DDS, Emory University, 1985 BS, Biology, University of Pittsburgh, 1981 EXPERIENCE Upon graduating from Dental School in 1985, Dr. Volcheck opened a private dental practice in Globe, AZ. His patients ranged from birth to 80+ years, and he provided comprehensive dentistry. Dr. Volcheck began working on a Master’s in Business Administration at ASU, where he became acquainted with Mary Orton, the founder and then director of Central Arizona Shelter Services (CASS). Ms. Orton persuaded Dr. Volcheck to volunteer at CASS’ single adult shelter, and he volunteered there for two years while still in his private practice. After completing his MBA, Dr. Volcheck closed his dental practice and became a full-time case manager for CASS. As a case manager, Dr. Volcheck worked in a trailer, on the streets, and in fields and riverbeds. This experience quickly immersed him in the complex issues surrounding homelessness. Over his seven years as a case manager, Dr. Volcheck witnessed first-hand the devastating effects of homelessness on an individual’s oral health. In late 1999, Dr. Volcheck began preparations for the state’s only dental clinic for the homeless. Working in collaboration with the Arizona State Office of Oral Health and the Maricopa County Healthcare for the Homeless Clinic, the CASS Dental Clinic opened to its first patient on Jan 1, 2001. In the first year, 20 volunteer dentists, 15 hygienists, and 20 dental labs provided service in the two-chair dental trailer. Four years later, Dr. Volcheck completed the design, secured funding, and oversaw the relocation of the clinic to an eight-chair facility located on the Human Services Campus in downtown Phoenix. It became one of the largest volunteer-driven dental clinics in the nation, providing comprehensive dental care to homeless veterans, adults, and children. Many hundreds of volunteers and dental students are now working at the clinic to serve the oral health needs of the homeless community. In addition to serving as Dental Director, Dr. Volcheck frequently provides technical assistance to agencies wishing to establish similar dental programs. He has also presented at the Annual National Healthcare for the Homeless Conference. March 1, 2007 – Dr. Volcheck opened the CASS Dental Program for Homeless Children on the Human Services Campus. The Children’s program utilizes the same successful model of dental volunteers and students treating homeless children. June 2010 – With funding from the Diane & Bruce Halle Foundation, Dr. Volcheck launched the Murphy Kids Dental Clinic. This clinic served 2,200 impoverished children in this elementary school district. Also, in partnership with the Halle Foundation, in 2012, Dr. Volcheck opened an accredited Dental Assisting School to assist in rehabilitating domestic violence victims. July 1, 2014 – The Bob & Renee Parsons Foundation funded the opening of the Parsons Center for Pediatric Dentistry and Orthodontics at the site of the Murphy Kids Dental Clinic. This Foundation has continued supporting efforts to treat these uninsured, impoverished children. The Center provides comprehensive care to over 15,000 impoverished, predominantly Hispanic children annually. March 4, 2016 – In collaboration with Canyon State Academy, BWI formed the Canyon State Academy Dental Center for Foster Children. This center now operates under the auspices of Canyon State. July 01, 2016 – Brighter Way Institute (BWI) was incorporated as a nonprofit 501 (c)(3). With Dr. Volcheck as the CEO, this new organization took the three clinics that formerly belonged to CASS and formed an organization that would continue to focus on treating the oral health needs of our underserved communities. 2016 – Dr. Volcheck launched the BWI Implant Training Center. Dentists throughout the U.S. travel to Phoenix to volunteer and provide patients, primarily veterans, with no-cost implants and no-cost implant-supported dentures. 2018 – Dr. Volcheck partnered with United Healthcare to form BWI’s first mobile dental unit serving Title I schools, Boys and Girls Clubs, and gay homeless youth and young adults at One-N-Ten. 2019 – At the request of Marica Mintz, CEO of Phoenix Metro Boys and Girls Clubs, BWI entered into a new partnership that took advantage of our expertise in nonprofit dentistry to help another nonprofit and its patients. BWI moved into a new area by now becoming a practice management group for the Boys and Girls Club Dental Clinic. 2020 – Brighter Way celebrates its 20th Anniversary at Legacy Place, where the BWI Board honors Dr. Volcheck for 30 years working with the homeless and establishes the Brighter Way Endowment. 2022 – Brighter Way Dental Center at the Human Services Campus is renamed the Diane and Bruce Halle Brighter Way Dental Center which then becomes an inaugural site for the first Jacksonville University Comprehensive Oral Implantology Residency program. 2023 – Brighter Way Institute comprises the Diane & Bruce Halle Brighter Way Dental Center, Parsons Center for Pediatric Dentistry & Orthodontics, and Brighter Way United Healthcare Mobile Dental Center, donated by United Healthcare in 2018. AWARDS 2001 Direct Service Provider of the Year from the Arizona Coalition to End Homelessness 2002 Inducted into Golden Key Society at Arizona State University 2004 CASS Dental Clinic ‘Nonprofit Excellence in Collaboration Award’ from SRP 2006 Dentist of the Year, Arizona Dental Association 2006 HealthCare Hero in the Dental Industry, Arizona Business Journal 2008 Mary Haywood Award for 15 years of service to the homeless community 2010 Robert Wood Johnson National Award as Community Health Leader 2013 Volunteer Service Award-American Academy of Cosmetic Dentistry Charitable Foundation 2017 Arizona Medical Association David O. Landrith Humanitarian Award 2017 Eide Bailly Industry Resourcefulness Award 2019 Ed Stihls National Award for Innovation in Dentistry
Advocates for specialized institutions (sometimes referred to as “asylums”) for those with severe mental illness, particularly those who have not benefitted from community treatment, emphasize the following points:
Specialized Care and Treatment: Traditional asylums in the past were often criticized for inhumane conditions and poor treatment. However, a modern, well-regulated institution can provide specialized, 24/7 care tailored to the needs of those with severe mental illnesses. Such a facility would be equipped with trained professionals and evidence-based therapeutic techniques to assist in recovery.
Safety and Security: For individuals with severe mental illness who might be a danger to themselves or others, an institution can provide a safe environment. This includes preventing self-harm, ensuring patients receive their medications, and protecting the broader community from potential harm.
Comprehensive Services Under One Roof: An institutional setting can bring together various services—medical, therapeutic, occupational, and recreational—all in one place. This can ensure a holistic approach to care that might be hard to coordinate in a community setting.
Stabilization and Structure: Some individuals with severe mental illness benefit from a structured environment where routines are established, and there are clear expectations and supports in place. An institution can offer this consistent environment, which can be therapeutic in and of itself.
Potential to Alleviate Homelessness and Incarceration: Many individuals with untreated severe mental illnesses end up homeless or in the criminal justice system. Specialized institutions could serve as an alternative to these outcomes, providing care and shelter to those who might otherwise be left to the streets or incarcerated.
Family and Community Support: Having a loved one with severe mental illness can be overwhelming for families, especially when community resources are lacking or ineffective. Institutions can provide respite for families, ensuring their loved ones are cared for while they also receive support and education about the illness.
Research and Training Opportunities: Specialized institutions can become centers of excellence for research into severe mental illnesses, promoting the development of innovative treatments and therapies. They can also serve as training grounds for professionals in the field.
However, it’s crucial to consider such institutions’ potential pitfalls and criticisms. It’s essential that they don’t revert to past abuses, respect patient rights, and don’t become a default option at the expense of community-based resources and support. Advocates for these institutions stress the importance of a well-regulated, humane, and patient-centered approach.
The ongoing saga of the severely mentally ill in America is stirring attention again in a sadly familiar way. In Los Angeles in early 2022, a 70-year-old nurse was murdered while waiting for a bus, and two days later a young graduate student was stabbed to death in an upscale furniture store where she worked. That same week in New York City, a 40-year-old financial analyst was pushed onto the subway tracks as a train was arriving, killing her instantly.
All three assaults, random and unprovoked, were committed by unsheltered homeless men with violent pasts and long histories of mental illness. In New York, the perpetrator had warned a psychiatrist during one of his many hospitalizations of his intention to commit that very crime.
“The death of Jordan Neely speaks volumes about the public’s fear of aggressive and sometimes violent behavior of the mentally ill.”
Then came the chance encounter this May that led to the death of Jordan Neely on a Manhattan-bound subway car. Homeless and schizophrenic, Neely had spent most of his adult life in and out of emergency rooms, psychiatric wards and prison. He had 42 prior arrests, mostly for nuisance crimes, but also for assault. He’d recently pleaded guilty to punching an elderly woman in the face, fracturing her eye socket.
What happened in the moments leading up to his death is still in dispute. While a jury will decide whether another passenger’s chokehold on Neely was second-degree manslaughter or an act of self-defense, the attention the incident received speaks volumes about the public’s fear of the aggressive and sometimes violent behavior of the mentally ill. Most of all, Neely’s death highlights the failures of a mental health system that allows profoundly disturbed people to slip through the cracks.
On an average night, according to the U.S. Department of Housing and Urban Development, close to 600,000 people in the country will be homeless—a figure seen by many as an undercount. More than 40% will be “unsheltered,” or “living in places not suitable for human habitation,” and about 20% will be dealing with severe mental illness.
Experts sharply disagree about the contribution of homelessness to rising crime rates. Some emphasize that the most of these crimes are low-level victimless offenses, such as loitering or public urination. But others note the disproportionately high level of all crimes, including assaults and homicides, committed by those battling homelessness and mental issues simultaneously.
Had Jordan Neely and the others been born a generation or two earlier, they probably would not have wound up on the streets. There was an alternative back then: state psychiatric hospitals, popularly known as asylums. Massive, architecturally imposing, and set on bucolic acreage, they housed close to 600,000 patients by the 1950s, totaling half the nation’s hospital population. Today, that number is 45,000 and falling.
The term “asylum” implies refuge for those in distress.
Asylums were created for humane ends. The very term implies refuge for those in distress. The idea was to separate the insane, who were innocently afflicted, from the criminals and prostitutes who were then commonly referred to as the “unworthy poor.” Asylums were popular because they provided treatment in isolated settings, far from temptation, while relieving families of their most burdensome members.
But “insanity” in these years cast a very wide net. A typical asylum included patients who were suffering from alcoholism, dementia, depression and epilepsy, as well as such now defunct diagnoses as “lunacy” and “melancholia.” The usual stay was marked in years, not months, as evidenced by the rows of crosses in asylum graveyards.
Over time, the number of institutionalized patients far outpaced the state’s willingness to support them. Funding and oversight disappeared. And this, in turn, produced a flood of exposés—some embellished, others sadly true—portraying these institutions as torture chambers where icepick lobotomies, electric shock, sterilization and solitary confinement turned humans into zombies.
A seemingly revolutionary solution soon appeared—a new drug with the potential to treat psychotic disorders such as schizophrenia and bipolar disorder. First marketed in 1955 under the brand name Thorazine, it became the psychiatric equivalent of antibiotics and the polio vaccine. Why keep patients locked away in sadistic institutions when they could be successfully medicated close to home?
The promise of Thorazine coincided with a dramatic assault upon traditional psychiatry led by radical critics such as Michel Foucault and Thomas Szasz. Asylums existed to enslave those who ignored society’s norms, they believed. Who could say with assurance that the people locked away in these places were any more or less insane than the authorities who put them there? It seemed a perfect fit for the 1960s, appealing to emerging rights groups and a counterculture scornful of elites. “If you talk to God, you are praying,” Szasz declared. “If God talks to you, you are schizophrenic.”
President John F. Kennedy signs the Community Mental Health Act, October 1963. The law aimed to shift treatment of the mentally ill from asylums to local clinics, but the results were likened by one critic to ‘a psychiatric Titanic.’ PHOTO: BILL ALLEN/ASSOCIATED PRESS
In October 1963, President John F. Kennedy put his signature to the last bill he would ever sign—the Community Mental Health Act. It aimed to demolish the walled-off world of the asylum in favor of 1,500 local clinics where patients could receive the drugs and therapies they needed. Kennedy had a personal stake in the legislation: His sister, Rosemary, had undergone an experimental lobotomy that left her severely disabled. On paper, at least, deinstitutionalization seemed both more humane and more likely to succeed. Then reality set in.
Closing the asylums was the easy part. Getting people to accept a mental health clinic next to their local church or elementary school proved a much tougher sell. Asylum inmates returned home to find their former neighbors unprepared and often unwilling to help. Most of the clinics never materialized. And the promise of Thorazine was blunted, in part, by its nasty side effects. Surveys of those released from state asylums found that close to 30% were either homeless or had “no known address” within six months of their discharge. One critic likened it to “a psychiatric Titanic.”
A few voices had predicted as much. In 1973, a Wisconsin psychiatrist named Darold Treffert wrote an essay about the dangerous direction in which his profession was headed. His colleagues had become so fixated on guarding the patient’s civil liberties, he noted, that they had lost sight of the patient’s illness. What worried him was the full-throated endorsement of recent laws and court decisions that severely restricted involuntary commitments. What purpose was served by giving people who couldn’t take care of themselves the freedom to live as they wished? He titled his piece, “Dying With Their Rights On.”
Treffert was referring to cases like Lessard v. Schmidt (1972), where a federal court ruled that involuntary commitment must be limited to cases involving the “extreme likelihood” that someone “will do immediate harm to himself or others”—a very strict standard. Three years later, the Supreme Court tightened things further by asserting that authorities had been too cavalier in locking away the “harmless mentally ill.” In O’Connor v. Donaldson, it declared: “Mere public intolerance or animosity cannot constitutionally justify the deprivation of a person’s physical liberty.”
Enter Joyce Brown, a 40-year-old woman who went by the street name “Billie Boggs.” The year was 1987, and Brown was living atop a heating vent on New York’s tony Upper East Side. It was a tense time for the nation’s largest cities, with exploding crime rates, rampant crack addiction, the AIDS crisis and thousands of homeless people camping in parks, bus stations, subway tunnels and doorways. Under extreme pressure, New York’s Mayor Edward Koch authorized the involuntary commitment of those living unsheltered on the streets. Brown was the first to be confined.
Little was known about her beyond her struggles with heroin and a diagnosis of schizophrenia following her eviction from a New Jersey shelter. Brown was more of a nuisance than a threat to the neighborhood—stopping traffic, screaming at pedestrians, using the sidewalk as her toilet. Social workers who periodically visited her worried that she ate poorly, never bathed and lacked the clothing to handle New York’s brutal weather. Some viewed her as self-negligent to the point of being suicidal.
Taken to Bellevue Hospital, Brown was bathed, deloused and given antipsychotic drugs. Four psychiatrists confirmed the diagnosis of chronic schizophrenia. Bellevue contained a courtroom where patients could challenge their confinement before a state-appointed judge. Most were represented by a public defender, but the American Civil Liberties Union took on Brown’s case, claiming that her confinement violated federal court guidelines.
Ironically, Brown turned out to be her own best witness. Carefully medicated, she testified thoughtfully enough to convince the judge that the evidence before him was too ambiguous to merit the loss of her liberty. But he surely was conflicted, writing: “There must be some civilized alternatives other than involuntary hospitalization or the street.”
Joyce Brown, whose involuntary commitment to New York’s Bellevue Hospital sparked a civil-rights lawsuit, speaks at Harvard Law School in 1988. PHOTO: CAROL FRANCAVILLA/ASSOCIATED PRESS
Unfortunately, there weren’t. An appeals court reversed the decision to free Brown, leading her to refuse all medication. Another trial was held to determine whether antipsychotic drugs could be forced upon her, and this time she prevailed. The city, weary of lawsuits, chose to discharge her rather than to appeal.
Brown became an instant celebrity. She traveled the TV talk show circuit as “the most famous homeless person in America” and even gave a lecture of sorts at Harvard Law School. “I like the streets, and I am entitled to live the way I want to live,” she explained. Offered a room at a “residential hotel,” she quickly returned to the life that she knew best, panhandling for drug money at the Port Authority Bus Terminal before fading from public view. She died in 2005 at age 58.
The questions her case raised, however, are more relevant than ever. How does a civilized society deal with severely mentally ill people who refuse assistance? What constitutes the sort of behavior that requires forced hospitalization? Is it time to bring back the asylum?
These issues are intertwined with a fundamental change brought about by deinstitutionalization. Put simply, civil libertarians and disability rights advocates have largely replaced psychiatrists as the arbiters of care for the severely mentally ill. And a fair number of them, with the best of intentions, seem to view the choices of those they represent as an alternative lifestyle rather than the expression of a sickness requiring aggressive medical care.
The enormous vacuum created by deinstitutionalization has been a calamity for both the mentally ill and society at large.
The role once occupied by the asylum has been transferred to the institutions perhaps least able to deal with mental health issues—prisons and jails. The number of inmates in the U.S. in 1955 was 185,000; today, that figure is 1,900,000.
Unsurprisingly, the nation’s three largest mental health facilities are the Los Angeles County Jail, the Cook County Jail in Chicago, and Rikers Island in New York City. Approximately one quarter of their inmates have been diagnosed with a serious mental disorder.
In this massive system, the mentally ill are less likely to make bail, more likely to be repeat offenders and far more likely to be victimized by other inmates. Given the sheer numbers, maintaining order in these prisons and jails depends heavily on antipsychotic medication. It’s hard to imagine a worse environment for the safety, much less the treatment, of the mentally ill.
Meanwhile, state mental hospitals continue to shrink. Gone is the laundry list of afflictions that marked asylum life in the 1950s. The majority of the current patients are there “involuntarily”—people who have been judged a danger to themselves or to others, who have been found not guilty of a crime by reason of insanity, or who are being evaluated for their competency to stand trial. Because so many psychiatric beds have disappeared, the waiting period for admission can take months, which means that inmates languish in jail without having been convicted of a crime.
In the past decade, a growing number of scholars from across the ideological spectrum have suggested a return to asylums. Among them is Ezekiel Emanuel, a leading medical ethicist, who joined with two colleagues in 2015 to recommend the building of “safe, modern and humane” state institutions to end the revolving door of homelessness-hospitalization-prison that passes for policy today.
Actress Louise Fletcher as the sadistic Nurse Ratched in the 1975 film ‘One Flew Over The Cuckoo’s Nest,’ starring Jack Nicholson (right). PHOTO: UNITED ARTISTS/GETTY IMAGES
The model they suggested is the Worcester Recovery Center in Massachusetts, a facility for 320 long-term patients with private rooms and “a recovery-inspired residential design.” Opened in 2012 on the grounds of a long-abandoned state asylum, it cost $300 million to complete, making it one of the most expensive non-road construction projects in the state’s history.
There is little doubt of the need for it, and the early signs, including surveys of recovery outcomes, are encouraging. Since the goal is to serve patients, rather than to warehouse them, the price can be steep. In 2015 Massachusetts spent $55,000 per prison inmate, with some additional costs for those with serious mental health issues. Meanwhile, the Worcester Recovery Center, with an annual budget of $60 million, spent close to four times that sum per patient. How this will play out in the long run, and how many other states will follow, remains to be seen.
The very word “asylum” brings shivers to those old enough to remember its abuses. It has a disturbing cultural legacy to confront in the sadistic Nurse Ratched of “One Flew Over the Cuckoo’s Nest.” Bringing it back in any form will face the twin obstacles of cost and image. But for the most vulnerable among us, who exist in a world of peril to themselves and to others, it is a far better option than the alternatives of homelessness and incarceration.
David Oshinsky directs the Division of Medical Humanities at NYU Langone Health. His books include “Bellevue: Three Centuries of Medicine and Mayhem at America’s Most Storied Hospital” and “Polio: An American Story,” which won the 2006 Pulitzer Prize for history.
Photo illustration caption: Clockwise from top left: A patient record from a state mental hospital in Massachusetts; Bellevue Hospital in 1962; a sign at a protest following the death of Jordan Neely, May 5; a New York subway train; a doctor examines a patient at a state mental hospital in New York, 1937; a bottle of Thorazine, the antipsychotic drug introduced in 1955; the Twin Towers jail in Los Angeles; nurses restrain a patient at an asylum in Ohio, ca. 1946.
Source photographs for illustration: Max Denisov/Unsplash; Vlad Hilitanu/Unsplash; Renan Kamikoga/Unsplash; Tim Gouw/Unsplash; Diego Jimenez/Unsplash; Jerry Cooke/Getty Images; John Tlumacki/The Boston Globe/Getty Images; ROBYN BECK/AFP/Getty Images; Spencer Platt/Getty Images; Jack Harris/Associated Press; School of Pharmacy, University of Wisconsin, Madison, Wisconsin/Smithsonian Institution; Alfred Eisenstaedt/The LIFE Picture Collection/Shutterstock
The Institutions for Mental Diseases (IMD) exclusion is a policy that restricts Medicaid funding for certain residential facilities with more than 16 beds, primarily focusing on those providing mental health and substance abuse treatment. While the policy aims to regulate and improve the quality of care, it inadvertently creates discrimination and prejudice against individuals with serious mental illness (SMI). This case highlights the adverse effects of the IMD exclusion policy on vulnerable individuals and the need for reforms to ensure equitable access to mental healthcare.
Case Summary: John, a 32-year-old man diagnosed with schizophrenia, resides in a state that strictly enforces the IMD exclusion policy. Due to the limited availability of community-based mental health services, John has been repeatedly denied admission to residential treatment facilities due to their size exceeding the exclusion threshold. This policy restriction exacerbates John’s condition, denying him access to appropriate care and causing a detrimental impact on his overall well-being.
Limited Access to Intensive Treatment: John requires intensive psychiatric care and monitoring due to the severity of his symptoms. However, as a result of the IMD exclusion, the only available options for him are outpatient clinics or smaller residential facilities that lack the resources and staff to provide the level of care he needs. This restricted access prevents him from receiving adequate treatment and support to manage his condition effectively.
Increased Risk of Homelessness and Incarceration: Without access to appropriate residential treatment, John’s mental health deteriorates rapidly, leading to frequent hospitalizations or encounters with law enforcement. The lack of suitable options under the IMD exclusion policy forces individuals like John into a cycle of homelessness or incarceration, where their mental health worsens, perpetuating the stigmatization of mental illness.
Disproportionate Impact on Low-Income Individuals: The IMD exclusion disproportionately affects low-income individuals who rely on Medicaid for their healthcare needs. Private residential facilities, not subject to the exclusion, often charge exorbitant fees, making them unaffordable for those with limited financial resources. Consequently, the policy further entrenches socioeconomic disparities and denies individuals from lower-income backgrounds equal access to critical mental health services.
Inequity in the Healthcare System: The IMD exclusion policy perpetuates a two-tiered healthcare system, with individuals with SMI receiving suboptimal care compared to those with physical health conditions. While patients with chronic medical conditions can access specialized facilities without similar restrictions, individuals with mental illnesses face discrimination due to the arbitrary limitations imposed by the exclusion policy, denying them their right to equitable healthcare.
Conclusion: The IMD exclusion policy, though well-intentioned, inadvertently perpetuates discrimination and prejudice against individuals with serious mental illness. The policy’s impact on individuals like John highlights the urgent need for reforms to ensure equitable access to comprehensive mental healthcare. Revisiting the IMD exclusion and advocating for increased funding, expanding community-based treatment options, and encouraging parity between mental and physical health services are essential steps towards dismantling the systemic barriers faced by those with SMI.
California psychiatric hospitals began closing their doors in the 1960s, starting a nationwide movement known as “deinstitutionalization.” Today, most inpatient treatment for severe mental illness occurs behind bars. Two changes could help rectify this tragic reality.
GUEST COMMENTARY WRITTEN BY
Alice Feller is a psychiatrist and writer based in Berkeley. Her work has appeared in the Journal of the American Psychoanalytic Association, East Bay Express, Laney Tower and the opinion pages of the San Francisco Chronicle and New York Times.
Robbie, our young patient at the county hospital in San Mateo, believed his parents were trying to poison him.
He refused to come into the house and foraged in the neighbors’ garbage cans for all his meals. Nevertheless, since he was able to survive on garbage, he was judged no longer in need of treatment.
I was shocked. It was so callous – such a breach of our usual standard of care. But then I spent a year working as a staff psychiatrist at the county hospital in Oakland. I learned that Robbie’s experience was not out of the ordinary; it was the usual state of care in California.
In the 1960s, American psychiatric hospitals began to close their doors. The movement began in California, first with the large state hospitals and then the small community hospitals as well.
By 1994 nearly half a million former patients had been sent back to live with their families, who were often unable to care for them. A quarter million newly discharged patients ended up on thestreets or behind bars.
“Deinstitutionalization,” as the movement to close these hospitals is known, began as a cost-saving measure. In 1965 the federal government abruptly withdrew its financial support for the state hospitals, as well as the small community hospitals providing psychiatric care.
This was accomplished through a little-known law, the Medicaid IMD exclusion, passed by Congress in 1965 along with the creation of Medicaid. The provision forbids the use of Medicaid dollars to pay for care in a mental hospital. Any psychiatric hospital with more than 16 beds is forbidden to take Medicaid.
Hospital treatment for severe mental illness can mean the difference between life and death, but because of this law such treatment is specifically denied to the people who need it most. No other severe illness is subject to such discrimination.
We have come full circle from the early 19th century, when Dorothea Dix campaigned to rescue the mentally ill from the prisons where they languished, often under shockingly inhumane conditions. Due to her work, people with mental illness were rescued from prisons and cared for in hospitals.
But today that trend has been reversed. Once again, Americans with serious mental illness are being warehoused out of sight in our prisons. And many more are living unsheltered on our streets. A third of our homeless population today suffer from untreated severe mental illness, most commonly schizophrenia.
Schizophrenia is a brain disorder. It affects 1 out of every 100 human beings on Earth. Good parenting doesn’t prevent it, and bad parenting doesn’t cause it. It begins in adolescence or early adulthood, and without treatment it will be permanently disabling. It leaves the afflicted person living in a psychotic world, unable to tell reality from delusion.
Lives are derailed. Suicide is common.
Treatment requires early intervention by a specialized team of clinicians who collaborate on patient care. Unfortunately these dedicated programs are rare. Despite mountains of evidence showing their effectiveness, insurers refuse to cover early intervention programs.
California can rectify this situation by obtaining a waiver of the IMD exclusion. We need to restore hospital care to stabilize our patients and enable them to use outpatient treatment. We need to mandate early intervention programs and require insurance coverage for this vital treatment.
These two interventions would do more than anything else to help our mentally ill homeless citizens. It is not a simple lack of housing that leaves so many homeless. Like Robbie, our patient who ate out of garbage cans, they are unable to use available housing due to their mental illness.
Caring for people with serious mental illnesses, such as schizophrenia, bipolar disorder, or major depressive disorder, who also have anosognosia (a lack of awareness of their illness) is crucial for numerous reasons, and not providing necessary care can have detrimental effects.
Preservation of Human Rights: All individuals, regardless of their mental health status, have a right to health and well-being. This right includes access to healthcare and social support. Ignoring or denying care to someone because they lack insight into their condition due to anosognosia infringes upon these rights.
Health Consequences: Without proper care, individuals with serious mental illnesses and anosognosia are at risk of worsening symptoms. This can lead to significant health consequences, including higher rates of hospitalization, physical health problems, homelessness, and suicide.
Social Consequences: Failure to provide care for individuals with serious mental illness and anosognosia has broader societal impacts. It can lead to increased homelessness, as individuals may be unable to maintain stable housing. Furthermore, untreated mental illness can also contribute to an increased burden on the criminal justice system, as these individuals may engage in behaviors that get them into legal trouble, often because they aren’t receiving the care they need. They typically are crimes related to their illness, such as trespassing, public disturbance, or petty crime, but they can sometimes be violent crimes.
Economic Burden: Treating individuals with mental illnesses early and effectively is cost-effective. Hospitalizations, incarcerations, homelessness, and emergency services are all costly societal burdens. Providing continuous, comprehensive care reduces these costs in the long term.
Family Impact: The family and loved ones of those with serious mental illness often bear a substantial burden when adequate care is not provided. This can strain relationships and cause emotional, physical, and financial hardship for the family members involved.
Potential for Recovery: Many individuals with serious mental illness, once appropriately treated, can lead meaningful, productive lives. By providing necessary care, even when anosognosia is present, we increase the chances of these individuals gaining insight into their conditions, adhering to treatment, and experiencing recovery.
Ethical Responsibility: As a society, we have an ethical responsibility to care for those who are most vulnerable, including individuals with serious mental illness. Anosognosia, as a symptom of these illnesses, should not exempt these individuals from receiving the care they need.
In conclusion, while anosognosia presents unique challenges in the care of individuals with serious mental illness, it is imperative that we continue to advocate for and provide necessary support and treatment. The human, societal, and economic costs of not doing so are simply too great.
Posted by Twisted Sisters Advocacy & Activism for Serious Brain Disorders July 9th, 2023.
Anosognosia affects between 50% and 98% of people with schizophrenia, about 40% of people with bipolar disorder, and more than 80% of people with Alzheimer’s disease.
For a disease that demands treatment above all else, leaving someone with anosognosia alone on the streets until they die is a cruel and unusual punishment for a disease. Why do civil rights activists and disability activists keep harming our family members? What’s the point of letting them deteriorate and preventing them from getting basic medical care? In pursuit of an ideal? Does it matter? In my experience as a family member of someone who died as a result of severe mental illness and anosognosia symptoms, I am offended to my core by those who wish to maintain the status quo.
Civil and disability rights activism has a human cost here. It is of the utmost importance to recognize the suffering and struggles of those affected. It is also important to ensure that those who need medical care receive it. We do not let our Alzheimer’s patients with anosognosia roam the streets. We speak for them. We care for them. We need to demand more humane treatment for people with anosognosia from severe mental illnesses.
Activists for civil rights and disability are strangers to our loved ones. They do not understand the pain and suffering we have been through. There’s no personal connection between them and our loved ones. No professional connection exists between them. They are not privy to the suffering of my loved one or have intimate knowledge of it. Because #FamiliesLikeMine don’t have a right to treatment before tragedy strikes, the activists for civil rights can sleep soundly at night despite the pain they cause those whose loved ones die a slow, agonizing death. What do citizens of this magnificent nation do when tragedy strikes beyond the individual suffering from a brain disorder? They scream, “Why didn’t the family act? But, what can a family do if the law does not recognize their right to treatment?
As defined, anosognosia is not denial. Anosognosia is a mental illness in which the sufferer is unaware of their condition. A denial of anosognosia’s legitimate importance in the medical community and in our laws and policies is to ignore it. That is a denial.
It is not a denial of the experience of those with anosognosia, but rather a denial of the reality of anosognosia as a medical condition. We need to recognize anosognosia as a legitimate medical condition and ensure that our laws and policies reflect this understanding. This will ensure that individuals with anosognosia can access the care and treatment they need.
Untreated psychosis can have severe and long-term effects on an individual with serious mental illness. Here are some potential dangers:
Symptom Progression: Without treatment, symptoms of psychosis, which include delusions, hallucinations, and disorganized thinking, can become more severe and frequent. This exacerbation can interfere significantly with a person’s ability to function daily and may lead to an increased risk of hospitalization.
Physical Health Deterioration: People with untreated psychosis are often unable to take care of their physical health, neglecting things like nutrition, exercise, and sleep. This neglect can result in physical illnesses, from general malaise to chronic conditions like heart disease and diabetes.
Suicidality: Individuals with untreated psychosis may have a higher risk of suicide due to a combination of depressive symptoms, feelings of hopelessness, and difficulty distinguishing between reality and their delusions or hallucinations.
Substance Abuse: Some people may use drugs or alcohol to cope with their symptoms, leading to substance abuse problems. This can exacerbate psychotic symptoms and make treatment more challenging.
Impaired Social and Occupational Functioning: Psychotic symptoms can make it difficult to maintain relationships or hold down a job, leading to social isolation and financial instability. This situation can further worsen mental health and hinder recovery.
Chronic Condition: When left untreated, psychotic disorders can become chronic, meaning that they persist over a long period. This situation can result in a continuous cycle of illness and recovery, leading to a lower overall quality of life.
Cognitive Impairment: Long-term untreated psychosis can lead to cognitive impairments affecting memory, attention, and problem-solving abilities. Over time, these cognitive deficits can make it harder for a person to engage effectively in their treatment and can limit their ability to live independently.
In conclusion, timely treatment of psychosis is vital for better recovery outcomes. This can involve medication (like antipsychotics), psychotherapy, social skills training, and supported employment programs, all of which can significantly improve the prognosis for people with psychotic disorders. Untreated psychosis has far-reaching implications that extend beyond mental health to all aspects of a person’s life. Early intervention is essential to prevent the progression of the disease and maintain the highest possible quality of life. This can often involve involuntary treatment.
Being an American Canadian Mother of a Daughter With Schizophrenia
This mother shares her experience of having a loved one with schizophrenia and the difference location can make in treatment.
My younger daughter has lived with schizophrenia for 23 years. During that time, I have connected with families in similar situations in both Canada and the United States. My daughter’s life has been positively and negatively impacted by mental illness policies in both countries.
My education in the United States left me ill-informed about illnesses like schizophrenia.1 I knew much more about Freud and RD Laing than I did about the growing knowledge base in contemporary psychiatry. This problematic education in many social sciences and humanities also continues to exert a powerful influence in Canada. Both countries share a lack of appropriate public mental illness literacy campaigns. But what differentiates them?
Canada vs the United States
Ignorance led my husband and me to make serious mistakes in selecting a therapist when our daughter began floundering as a teenager. After I wrote a memoir2 about these poor choices, I heard from many families in both countries who made the same mistakes. Our daughter’s therapist’s lack of appropriate science-based training led to an unnecessarily longer duration of untreated psychosis.
Fortunately, we live in British Columbia and when my daughter became fully psychotic, she received the medically based treatment she needed. British Columbia continues to have a strong mental health act that enables individuals with psychosis to receive the involuntary treatment they often need. This access is limited in Canada, as in the United States, by a shortage of acute psychiatric beds.
Additionally, the 23 years of treatment our daughter has received in British Columbia, which have included some lengthy hospitalizations, have not cost us anything. Early on in our daughter’s illness, when I began to attend the national conferences of the US National Alliance on Mental Illnesses, I was horrified to meet too many families who had been bankrupted by their family member’s illnesses. These financial catastrophes were caused either by medical bills or by lawyers’ fees when untreated illnesses led to involvement in the criminal justice system.
Expenses for lawyers have grown among the Canadian families I have met in recent years because the same trends that negatively impacted the United States have spread in Canada. For instance, the powerful peer movement has successfully lobbied to have their training programs exclude any education about illnesses like schizophrenia while they expand their role in service delivery. It is a movement that teaches its practitioners that individuals must always choose their treatments while simultaneously not allowing individuals to learn about the brain-based illnesses that can make real choice impossible.
This is an alarming time in British Columbia. The laws that have allowed individuals like my daughter to lead a satisfying life are in jeopardy. Some provinces have adopted mental health legislation that makes it much more difficult for individuals with psychotic disorders to receive the involuntary treatment they often need to become stabilized and the follow-up involuntary treatment that they may need as outpatients. The Council of Canadians with Disabilities has launched a Charter of Rights and Freedoms challenge against British Columbia’s Mental Health Act. If successful, British Columbia will follow the dangerous direction that Ontario took; those who are a danger to themselves or others can be admitted to the hospital involuntarily, but they or a substitute decision maker must agree to treatment.
Individuals with schizophrenia and their families have suffered in both the United States and Canada because of persuasive but misguided ideas emanating from human rights lawyers and disability rights movements.3 These groups refuse to acknowledge the existence of anosognosia and the widespread lack of medically based treatment for psychotic disorders, which leads individuals with psychotic disorders in both countries to become homeless, addicted, and incarcerated.
I am inspired by the positive changes I see in the United States as a growing number of governors and mayors push back against the narrative that homeless individuals with severe mental illnesses must be allowed to choose whether they want treatment. My community in Canada is not seeing much of this well-informed political leadership, even though the growing homeless encampments in our cities and towns are full of the suffering of individuals abandoned to their psychotic delusions.
My community is also inspired and guided by the families in the United States who have developed a much stronger voice. I was able to tap into this kind of powerful advocacy last summer when Democrats Abroad and their Global Disability Caucus invited me to organize a webinar on mental illnesses for their annual celebration of the passage of the Americans with Disabilities Act.4 Using helpful resources available from the US Treatment Advocacy Center, American mother and advocate Leslie Carpenter helped an eager audience understand the origins of the current crisis and the further steps that need to be taken. American Canadian psychiatrist Randall White, MD, provided the much-needed, medically based information this group wanted. I helped others understand why the psychiatric survivor movement, which shapes the positions of most disability rights groups, should not be seen as the legitimate voice of individuals with illnesses like schizophrenia.
As I see it, the bold initiatives in the United States acknowledge the reality of severe mental illnesses and respond in genuinely helpful ways. These efforts can provide the guidance we increasingly need in Canada.
The opinions expressed are those of the author and do not necessarily reflect the opinions of Psychiatric Times®.
Ms Inman is the author of After Her Brain Broke: Helping My Daughter Recover Her Sanity.
1. Inman S. Personal accounts: becoming the mother of a child with schizophrenia. Psychiatr Serv. 2016;67(12):1290-1291.
2. Inman S. After Her Brain Broke: Helping My Daughter Recover Her Sanity. Bridgeross Communications; 2010.