Clinical depression has never really had satisfactory treatment options. Recently some newer pharmaceutical medications are showing promise. More research is needed in the area of behavioral health treatments. Read the heart-wrenching Op-Ed from David Brooks, which was recently published in the New York Times, on how it impacts family and friends.

Laurie Goldstein, ACMI Vice President


David Brooks: How do you serve a friend in despair?

A friend’s job in these circumstances is not to cheer the person up.

(Photo illustration by Thomas Sauvin; photograph via the Marks family) At camp, David Brooks gave Peter Marks a lift. How do you serve a friend struggling with mental illness?

By David Brooks | The New York Times

  | Feb. 12, 2023, 5:00 a.m.| Updated: 12:37 p.m.

My friendship with Peter Marks was created around play. Starting at age 11, we played basketball, softball, capture the flag, rugby. We teased each other, pulled pranks, made fun of each other’s dance moves and pretty much everything else. We could turn eating a burger into a form of play, with elaborate smacking of lips and operatic exclamations about the excellence of the cheese. We kept it up for five decades.

My wife has a phrase that got Pete just right — a rare combo of normal and extraordinary: masculine in the way you’re supposed to be masculine, with great strength and great gentleness. A father in the way you’re supposed to be a father, with great devotion, fun and pride. A husband in the way you’re supposed to be a husband, going home at night grateful because the person in the whole world you want to talk with the most is going to be sitting right there across the dinner table.

Over the years, Pete and I often spoke about the stresses he was enduring over the management of his medical practice, but I didn’t see the depths of what he was going through, until we spent a weekend with him in the spring of 2019. My wife noticed a change immediately. A light had gone out; there was an uncharacteristic flatness in his voice and a stillness in his eyes. One bright June afternoon, he pulled us aside and told us he wasn’t himself. He was doing what he loved most — playing basketball, swimming in the lake — but he couldn’t enjoy anything. He was worried for his family and himself and asked for our continued friendship and support. It was the first time I had seen such pain in him — what turned out to be severe depression. I was confronted with a question for which I had no preparation: How do you serve a friend who is hit with this illness?

I tried the best I could, but Pete succumbed to suicide in April. This article flows from what I learned from those agonizing three years and that senseless tragedy. It reflects a hard education with no panaceas.

(Photo illustration by Thomas Sauvin; photograph via the Marks family) New York Times columnist David Brooks, left, with Peter Marks, a friend since childhood.

First, I need to tell you more about Pete. We met as kids at Incarnation Camp in Connecticut. We were campers and counselors together for a decade and remained close for life. At camp, Pete was handsome, strong, athletic and kind. There was an exuberant goofballism about him.

I remember once, in a fit of high silliness, he started skipping around the dining hall, singing, and leaping higher and higher with each skip. He tried to skip right out of the room, but there was a door frame, probably about 7 feet tall, and Pete slammed into the top of the frame and fell flat on his back. The rest of us, being 16-year-old junior counselors, found this utterly hilarious. Pete, also being 16, found this utterly hilarious, too. I remember him lying there in a fit of giggles, with a doorframe-shaped bruise forming on his brow.

One summer, Pete and I led a team of 12- and 13-year-olds in a softball game against a team of 14- and 15-year-olds. Our team miraculously won. In the celebration afterward, Pete, I and the boys piled on one another on the mound in a great wriggling heap of disproportionate ecstasy. We hugged and screamed and high-fived.

I think our celebration lasted longer than the game — a volcano-like pile of male self-approval that is lodged in my memory as one of life’s moments of pure joy.

As the years went by, Pete did well in college, joined the Navy, went to medical school and became an eye surgeon. On evenings before surgery, Pete took great care of himself, didn’t stay out, made sure he had enough sleep to do the job that he loved. On evenings after surgery, he’d call his patients to see how they were feeling. His wife, Jen, a dear friend who was also at camp with us, used to linger around just to hear the gentleness of his tone on those calls, the reassuring kindness of his manner.

He seemed, outwardly, like the person in my circle least likely to be afflicted by a devastating depression, with a cheerful disposition, a happy marriage, a rewarding career and two truly wonderful sons, Owen and James. But he was carrying more childhood trauma than I knew, and depression eventually overwhelmed him.

At first, I did not understand the seriousness of the situation. That’s partly temperamental. Some people catastrophize and imagine the worst. I tend to bright-icize and assume that everything will work out. But it’s also partly because I didn’t realize that depression had created another Pete. I had very definite ideas in my head about who Pete was, and depression was not part of how I understood my friend.

Over the next months, severe depression was revealed to me as an unimagined abyss. I learned that those of us lucky enough never to have experienced serious depression cannot understand what it is like just by extrapolating from our own periods of sadness. As philosophers Cecily Whiteley and Jonathan Birch have written, it is not just sorrow; it is a state of consciousness that distorts perceptions of time, space and self.

Journalist Sally Brampton called depression a landscape that “is cold and black and empty. It is more terrifying and more horrible than anywhere I have ever been, even in my nightmares.”

Novelist William Styron wrote brilliantly about his own depression in “Darkness Visible.” He wrote that “the madness of depression is, generally speaking, the antithesis of violence. It is a storm indeed, but a storm of murk. Soon evident are the slowed-down responses, near paralysis, psychic energy throttled back close to zero.” He continued: “I experienced a curious inner convulsion that I can describe only as despair beyond despair. It came out of the cold night; I did not think such anguish possible.”

During the COVID-19 pandemic, Pete and I spoke by phone. In the beginning, I made the mistake of trying to advise him about how he could lift his depression. He had earlier gone to Vietnam to perform eye surgeries for those who were too poor to afford them. I told him he should do that again, since he found it so tremendously rewarding. I did not realize it was energy and desire that he lacked, not ideas about things to do. It’s only later that I read that when you give a depressed person advice on how to get better, there’s a good chance all you are doing is telling the person that you just don’t get it.

I tried to remind Pete of all the wonderful blessings he enjoyed, what psychologists call “positive reframing.” I’ve since read that this might make sufferers feel even worse about themselves for not being able to enjoy all the things that are palpably enjoyable.

I learned, very gradually, that a friend’s job in these circumstances is not to cheer the person up. It’s to acknowledge the reality of the situation; it’s to hear, respect and love the person; it’s to show that you haven’t given up on him or her, that you haven’t walked away.

Time and again Pete would talk about his great fear that he would someday lose his skill as a surgeon, that he would cease to be a healer, that he would lose his identity and self.

As Pete spoke of his illness, it sometimes seemed as if there were two of him. There was the one enveloped in pain and the other one who was observing himself and could not understand what was happening. That second self was the Pete I spoke to for those three years. He was analyzing the anguish. He was trying to figure it out. He was going to the best doctors. They were trying one approach after another. The cloud would not lift.

I am told that one of the brutalities of the illness is the impossibility of articulating exactly what the pain consists of. Pete would give me the general truth, “Depression sucks.” But he tried not to burden me with the full horrors of what he was going through. There was a lot he didn’t tell me, at least until the end, or not at all.

I never told him this, but there were moments during that hard plague year of 2020 that I feared that my own mind was slipping. Cheerfulness is my normal default state, but that year my moods could be dark and troubled. When your oldest friend is battling his demons, it’s natural to wonder about your own.

While I’ve devoted my life to words, I increasingly felt the futility of words to help Pete in any meaningful way. The feeling of impotence was existential.

After a while, I just tried to be normal. I just tried to be the easygoing friend who I always had been to him and he had been to me. I hoped this would slightly ease his sense of isolation. Intellectually, Pete knew that his wife and boys lavishly loved him, that his friends loved him, but he still felt locked inside the lacerating self-obsession that was part of the illness.

Perhaps the most useful thing I did was send him a video. My friend Mike Gerson, a Washington Post columnist, had been hospitalized with depression in early 2019. He had delivered a beautiful sermon at the Washington National Cathedral about his experience before he died of complications of cancer in November. Depression, he said, was a “malfunction of the instrument we use to determine reality.” Then he talked about the lying voices that had taken up residence in his mind, spewing out their vicious clichés: You are a burden to your friends, you have no future, no one would miss you.

That resonated with Pete and gave him a sense of validation. He, too, would describe the obsessive-compulsive voices that would attack him from inside his own head. Mike also talked about the fog eventually thinning, at the glimpse of beauty or of love, and reminded Pete that “there is something better on the far side of despair.”

Still the clouds refused to lift. Jen had some wise words when I asked her what she learned being around him during those years.

“I was very aware this was not the real Pete,” she said. “I tried not to take his periods of negativity and withdrawal personally.”

I wish I had bombarded Pete with more small touches. Just small emails to let him know how much he was on my mind. Writing about his own depression in The Atlantic last year, Jeffrey Ruoff mentioned that his brother sent him more than 700 postcards over the years, from all 50 states, Central America, Canada and Asia. Those kinds of touches say: I’m with you. No response necessary.

“There are moments in our lives,” Honore de Balzac wrote, “when the sense that our friend is near is all that we can bear. Our wounds smart under the consoling words that only reveal the depths of pain.”

The years went by and medications and treatment programs continued to fail. Pete and Jen began to realize how little the medical community knows about what will work. They also began to realize that mental health care is shockingly siloed. Pete saw outstanding doctors who devoted themselves to him, but they work only within their specific treatment silo. When one treatment didn’t work, Pete would get shuttled off to some other silo to begin again. Jen recently emailed me that when she had a cancer recurrence, in the middle of Pete’s depression, she had a “tumor board” — three different cancer experts (a surgeon, an oncologist and a radiation oncologist) — who coordinated her care.

“In our experience, there is none of this in mental health,” she wrote me. In many places, there is no one looking at the whole picture and the whole patient. “If one more mental health professional tells me ‘Everyone did their best,’ I will scream,” Jen wrote. “If this is our best, it is not nearly good enough.”

Pete developed theories to explain why this had happened to him. He pointed to a series of traumas and neglect he had suffered at home as a child — events he had vaguely referred to during our friendship but had never gone into in detail with me until his final years.

He thought part of his illness was just straight biology. Think of it like brain cancer, he’d say. A random physical disease. I agree with some of that, but I’m also haunted by the large number of medications doctors put him on. He always seemed to be getting on one or getting off another as he ran through various treatment regimens. His path through the mental health care system was filled with a scattershot array of treatments and crushing disappointments.

Pete and his family joined us for Thanksgiving in 2021. By this point I was just trying to be as I always had been toward him, in hopes that he might be able to be as he always had been toward me. We all played basketball and board games and enjoyed the weekend. I felt some hope. But Pete appears in one of the photos that were taken that weekend, sitting on the couch, still-faced, enveloped in shadow. One afternoon, he asked my wife to pray over him in the kitchen, plaintively, grasping for hope.

The experts say if you know someone who is depressed, it’s OK to ask explicitly about suicide. The experts emphasize that you’re not going to be putting the thought into the person’s head. Very often it’s already on her or his mind. And if it is, the person should be getting professional help.

When Pete and I gestured toward the subject of suicide, we just talked about what a magnificent family he had, how much they all loved one another. Like Jen, I tried to tell him that this darkness would lift, though as the years went by and the therapies failed, his faith in this deliverance waned.

Pete was always the braver of the two of us. He was the one who would go cliff diving or jump over bonfires without fear. And he was never more courageous than over his last three years. He fought this malady with astonishing courage and steadfastness against a foe that would bring anybody to his knees. He fought it minute by minute, day by day — over a thousand days. He was driven by his selfless love for his family, which he cherished most in the world.

We had dinner a few days before he died. Jen and I tried to keep the conversation bouncing along. But, apparently, their car ride home was heart-rending. “How can I not be able to talk to my oldest friend?” Pete asked. “Brooksie can talk to people. I can’t.”

I don’t know what he was thinking on his final day, but I have read that depression makes it hard to imagine a time when things will ever be better. I have no evidence for this, but knowing Pete as I did, I strongly believe that he erroneously convinced himself that he was doing this to help his family and ease the hardship his illness had caused them. Living now in the wreckage, I can tell you that if you ever find yourself having that thought, it is completely wrong.

Depression can be bitterly ridiculous. Pete died a few weeks before his younger son’s college graduation, enmeshed by loving relationships and friendships.

It’s ridiculous that we still know so little about the illness and how to treat it. I find it unfathomable that it’s been well over a century since Sigmund Freud started writing about psychology. We’ve had generations of scholars and scientists working in this field, and yet suicide rates in 2020 were 30% higher than they were in 2000 and 1 in 5 American adults experience mental illness each year. We need much more research funding to figure this out.

If I’m ever in a similar situation again, I’ll know that you don’t have to try to coax somebody out of depression. It’s enough to show that you are trying to understand what this troubled soul is enduring. It’s enough to create an atmosphere in which the sufferer can share her experience. It’s enough to offer him or her the comfort of being seen.

My friend Nat Eddy, who also accompanied Pete through those final years, wrote to me recently: “Do whatever it is you do to give the wives and children a break — an hour or two when they don’t have to worry that the worst will happen (and pray that it doesn’t happen on your watch, because that isn’t a given). Do whatever it is you do so you can look at yourself in the mirror. True friendship offers deep satisfactions, but it also imposes vulnerabilities and obligations, and to pretend it doesn’t is to devalue friendship.”

I feel sorrow that I didn’t know enough to do this more effectively with Pete. I might have kept him company more soothingly. I might have made him better understand what he meant to me. But I do not feel guilt.

Pete had teams of experts walking with him through this. He had his wonderful wife and kids, who accompanied him lovingly and steadfastly every day.

I’ve talked to Jen about this. Pete used to say he found talking to Jen more helpful than talking to any of the experts. So there is no reason for any of us to feel like failures because we could not alter what happened. Every case of depression is unique, and every case is to be fought with as much love and endurance and knowledge as can be mustered. But in this particular case, the beast was bigger than Pete; it was bigger than us.

I feel like I’ve read a lot about the grieving process for family members but not so much about what grieving is like when your friends die. Death and I were too well acquainted last year. I lost three good friends — Pete, Mike Gerson and my longtime “NewsHour” partner, Mark Shields. I’ve been surprised by how profound and lasting the inner aches have been.

Pete’s death has been a cause of great disorientation. He’d been a presence for practically my whole life, and now the steady friendship I took for granted is gone. It’s as if I went to Montana and suddenly the mountains had disappeared.

One great source of comfort has been the chance to glimpse, from time to time, how heroically Pete’s boys, Owen and James, have handled this loss. In their own grief, they have rallied forcefully and lovingly around their mother. Two months after Pete’s passing, my eldest son married. To my great astonishment and gratitude, Jen and the boys were able to make the trip to attend. At the reception, the boys gently coaxed their mother to join us on the dance floor. It felt appropriate since this is what we did at camp; dancing skeined through the decades of our lives. I have a sharp memory of those two fine young men dancing that evening, and a million memories of the parents who raised them so well.

If you are having thoughts of suicide, call or text 988 to reach the National Suicide Prevention Lifeline or go to for a list of additional resources.

(Nam Y. Huh | AP photo) New York Times columnist David Brooks at the University of Chicago, Jan. 19, 2012.

David Brooks is a columnist for The New York Times.

By David Brooks | The New York Times

Dr. Christopher J. Smith is an experimental psychologist with expertise in diagnosing autism spectrum disorder and measuring associated traits. Dr. Smith oversees all diagnostic evaluations and assessments for our clients while also directing all internal and external research projects. Prior to joining us at SARRC, he worked as an assistant professor in the Department of Psychiatry at the Mount Sinai School of Medicine, where he still maintains a faculty position. Originally drawn to study autism because of the complexity of the disorder, here at SARRC, Dr. Smith values the ability to work with clients across all age groups and engage in out-of-the-box research endeavors.

  • B.S. Psychology
    East Stroudsburg University
  • M.A. Experimental Psychology
    CUNY, Graduate School: Brooklyn College
  • Ph.D. Experimental Psychology
    CUNY, Graduate School: Brooklyn College

Here are the links to the slides and the webinar. You need to sign up for an account to access the restricted content. Accounts are free.

Autism in Adults Dr Christopher Smith

Autism defined by Dr Christopher Smith

Please read the latest report on Reimage Schizophrenia: transforming how we are treated function and thrive.

Published from the Schizophrenia & Psychosis Alliance, the summary of findings published Feb 2023.

BREAKING! Click here to read our new Voice of the Patient Report (, which captures the powerful stories of people living with schizophrenia and those who care for them. The report summarizes the compelling testimony provided during our Externally-Led Patient-Focused Drug Development meeting on Nov. 2, and was submitted today to the U.S. Food and Drug Administration.

The meeting gave our community a voice – and it was heard. FDA’s Dr. Bernard Fischer told us during the meeting that “the FDA recognizes that there is more work to be done to get better treatments for schizophrenia.”

We thank our meeting co-hosts, who joined us to provide a united front in the fight for treatment equity for people living with schizophrenia: American Foundation for Suicide Prevention, Mental Health America, National Council for Mental Wellbeing and NAMI. And we are indebted to the people living with schizophrenia and their caregivers who participated in this effort and made their voices heard.

People with schizophrenia have the right to effective medicines – just like anyone else with a serious disease. We are working every day to make that happen.

Executive summary

Schizophrenia is a serious, disabling brain disease. While medical treatment for schizophrenia has existed for many years, these treatments are often ineffective and can cause debilitating side effects. The result: countless people with this severe brain disease are subjected to a trial-and-error approach, switching from one medicine to another in hopes of finding something that will curb what can be disabling and life-disrupting symptoms.

Many people with schizophrenia have yet to find a medicine that works for them — creating an entire population of people who cannot
work or live independently and can suffer devastating symptoms of psychosis that can lead to incarceration or homelessness. Just as with
heart disease, diabetes or any other serious illness, if schizophrenia isn’t treated properly, it can get progressively worse. With the goal of turning the tide and improving drug-treatment options for schizophrenia, people with the brain disease and their caregivers gathered virtually on November 2, 2022, to describe what it’s like to live with this serious disease and share their experiences with available drug treatments.
Participants not only pressed drug developers to intensify efforts to develop more effective drug treatments with fewer side effects— they also urged the U.S. Food and Drug Administration (FDA) to allow broader access to the “last resort” drug clozapine, which many patients credited with restoring their ability to attend school, work and live healthy and productive lives.

The meeting, “Reimagine Schizophrenia: Transforming How We Are Treated, Function and Thrive,” was co-hosted by the Schizophrenia & Psychosis Action Alliance, the American Foundation for Suicide Prevention, Mental Health America, the National Alliance on Mental Illness and the National Council for Mental Wellbeing as part of the FDA’s Externally-Led Patient-Focused Drug Development (PFDD) initiative. The FDA launched this initiative in 2012 to collect information about patient and caregiver perspectives on drug development — in particular, what people living with a disease consider to be meaningful treatment benefits and how they want to be involved in the drug development process.

Many people with schizophrenia have yet to find a medicine that works for them — creating an entire population of people who cannot work or live independently and can suffer devastating symptoms of psychosis.

A class action suit—Arnold v. Sarn—was filed in 1981 against the State of Arizona, alleging that the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS) and Maricopa County did not provide a comprehensive community mental health system as required by statute. The case proceeded through the court system (slowly), and an agreement was reached between the parties in 2014, which resulted in a Stipulation for Providing Community Services and Terminating Litigation. There were other decision points made during this case, one of which was that the number of long-term psychiatric care beds available at Arizona State Hospital (the only hospital in Arizona which offers long-term psychiatric care) for Maricopa County would be 55 (for those committed under Title 36, i.e., civil commitment). This number, seemingly plucked out of thin air, is absurd considering the size of the population it serves (about 4,500,000 people in Maricopa County, so this equates to 1.2 beds per 100,000 available for long-term psychiatric care).

As you can see from the article by Research weekly, a publication of the Treatment Advocacy Center, the optimal number of long-term psychiatric beds available in any population should be around 60, with 30 beds acceptable as a bare minimum.

As an organization devoted to the care of people with SMI, ACMI is intent on removing this absurd artificial limit to bed capacity at ASH for those unfortunates who happen to live in Maricopa County, Arizona, one of the largest counties in the US, with the smallest capacity to serve people with this terrible disease.

Charles Goldstein, M.D. ACMI Treasurer

    RESEARCH WEEKLY: Two New Studies on Psychiatric Bed Number Targets – Treatment Advocacy Center

    RESEARCH WEEKLY: Two New Studies on Psychiatric Bed Number Targets

    By Elizabeth Sinclair Hancq 

    (March 2, 2022) Two research reports on the optimum number of psychiatric beds have been published in the past few months, both of which validate the Treatment Advocacy Center’s recommendation for 40 to 60 beds per 100,000 population. 

    In this week’s Research Weekly blog, I will first review the Treatment Advocacy Center recommendations and then summarize the two new studies that support those numbers. 

    Treatment Advocacy Center bed recommendations

    Treatment Advocacy Center published a study in 2008 that included a safe minimum number of psychiatric beds, concluding that there is “a need for 50 (range 40 to 60) public psychiatric beds per 100,000 population for hospitalization for individuals with serious psychiatric disorders.” This is considered a minimum number because it assumes the availability of good outpatient programs, including assisted outpatient treatment. 

    This recommendation was developed utilizing the Delphi method, a structured technique to develop a consensus from a variety of experts. Treatment Advocacy Center collected input from 15 experts on psychiatric care in the United States to inform the estimates. The experts were instructed to take into consideration a variety of factors that impact the need for psychiatric beds, including the number of people with serious mental illness who may need hospital care, the adequacy of community outpatient services, how long individuals usually remain in hospitals, short stay versus long stay beds, and how the psychiatric beds are financed. 

    RAND Corporation bed recommendations for California

    The RAND Corporation is a nonprofit and nonpartisan research organization that conducts research to inform public policy challenges. RAND was contracted by the California Mental Health Services Authority to conduct a research analysis to estimate psychiatric bed need in California for the next five years, including variations for types of beds and regional needs throughout the state. The results of the study were published in January. 

    The study authors first determined the current psychiatric bed capacity in California, breaking down the beds to acute and subacute type beds. Acute beds were described as those for higher acuity patients and shorter lengths of stay (days to weeks), typically utilized to stabilize patients. Subacute beds were defined as those used for individuals with moderate to high acuity needs but for a longer duration (multiple months). 

    They estimated the bed needs in the state using multiple methods. In one method, they convened a panel of technical experts, of which I was a member, to discuss estimates of bed need and the various factors that impact psychiatric bed capacity numbers, including how they are utilized and what types of patients they serve. Secondly, they utilized regional variation in rates of serious psychological distress to estimate how bed need may differ by region of the state. Thirdly, they computed the number of beds required by using a formula that includes how many beds currently exist and current bed occupancy rates, wait list volumes, average length of stay and transfers needed to higher or lower levels of care.

    The RAND report authors found that California requires 50.5 inpatient psychiatric hospital beds per 100,000 adults, which is consistent with the Treatment Advocacy Center findings. The authors further break these numbers down by type of bed, suggesting that these bed targets include 26 acute beds per 100,000 adult population and 24.6 subacute beds per 100,000 population. Taking into account how many beds California currently has, the results suggest that California is short 1,971 acute beds and 2,796 subacute beds. In addition, the authors conclude that the shortage of psychiatric beds will only worsen over time, predicting a 1.7% increase in psychiatric bed need by 2026. 

    International Delphi Method 

    The other new research report on psychiatric bed supply need per capita was an international effort conducted by a group of researchers from around the world and published in Molecular Psychiatry in January. These researchers again utilized the Delphi method to reach a global consensus on the minimum and optimum number of psychiatric beds per population. The Delphia panel included 65 experts, including me, from 40 different countries. These included individuals from all six World Health Organization regions and those from high- and low- income countries. 

    The results of the Delphi process concluded that 60 beds per 100,000 population is the optimal number, and 30 beds per 100,000 population is the absolute minimum. A psychiatric bed supply range of 25-30 was considered a mild shortage, 15-25 as a moderate shortage, and less than 15 per 100,000 population as a severe shortage of psychiatric beds. The results from this international panel of experts are again consistent with Treatment Advocacy Center’s psychiatric bed recommendations. 

    These two new psychiatric bed capacity target research studies further validate Treatment Advocacy Center’s previous report on the subject, suggesting a given jurisdiction should have at least 40-60 inpatient psychiatric beds per 100,000 population to meet the needs of their community. 


    Elizabeth Sinclair Hancq is the director of research at Treatment Advocacy Center.

    To receive Research Weekly directly in your email inbox on a weekly basis, click here

    Research Weekly is a summary published as a public service of the Treatment Advocacy Center and does not necessarily reflect the findings or positions of the organization or its staff. Full access to research summarized may require a fee or paid subscription to the publications.

    What will it take for the Centers for Medicare & Medicaid Services (CMS) to realize that an amendment is needed? The cost to society of not providing care and treatment results in the use of emergency rooms, fire and police resources, and public community environments. It comes with a high price tag and dismal results. Refer to the report “Housing is Healthcare

    People with serious mental illness live in squalor and end up dead or in jail or prison, often for crimes of street survival. Mental illness is the only “medical” condition that is criminalized (e.g., while psychotic, destroying property while failing, or not complying with officers, vocalizing against perceived threats, and creating a public disturbance ).

    Laurie Goldstein- ACMI Vice President

     Matt H. Wade via | CC BY 3.0


    Why One State Is Pushing Back Against Medicaid’s IMD Exclusion

    By Chris Larson | January 20, 2023

    Why One State Is Pushing Back Against Medicaid’s IMD Exclusion – Behavioral Health Business (

    New York state hopes to strengthen and remake state-managed behavioral health care by getting around the so-called IMD exclusion.

    It’s doing so by securing federal Medicaid funds typically forbidden from covering facility-based behavioral health through its latest 1115 waiver amendment.

    On Jan. 5, the Centers for Medicare & Medicaid Services (CMS) announced New York applied for a waiver to Medicaid’s now-antiquated institution for mental disease (IMD) exclusion. New York has asked for federal matching funds for Medicaid to be allowed to cover IMD services to address serious mental illness (SMI), substance use disorder (SUD) and serious emotional disturbance (SED) for adults and children.

    New York specifically is seeking matching funds to reimburse short-term inpatient, residential and other services for SMI and SUD by IMDs. The state is also applying for matching funds to help transition patients in state psychiatric facilities back to the community up to 30 days before their discharge.

    “The objective of the demonstration is to transform the role of some state psychiatric inpatient facilities and [SUD] residential treatment facilities, improve care transitions and access to community-based treatment and support services, and improve health and behavioral health outcomes in individuals with chronic and/or [SMIs] by transforming selected (pilot site) state-run psychiatric hospitals, facilities, and campuses from long-term care institutions to community-based enhanced service delivery systems,” the 1115 waiver amendment proposal states.

    Since the beginning of Medicaid in 1965, the Social Security Act forbade federal funds for Medicaid from covering treatment provided by facilities where 16 or more beds are dedicated to treating behavioral health issues of people aged 21 to 64.

    This move was intended to prevent states from offloading state psychiatric hospital costs on the federal government through the jointly funded and managed Medicaid program. It was also part of a political and regulatory retreat from treating behavioral health issues in large hospital-like settings, with champions of that movement including President John F. Kennedy.

    The movement is sometimes referred to as deinstitutionalization.

    However, some see the start of the deinstitutionalization movement as the start of the present psychiatric bed shortage, even within the federal government.

    “There’s been an understanding in the past several years that this lack of federal funding contributes to high levels of unmet need,” Madeline Guth, senior policy analyst for Kaiser Family Foundation (KFF), told Behavioral Health Business. “The federal government has been providing some new mechanisms in the past few years for states to get an exception to this exclusion and get some federal financing for IMD services for non-elderly adults.”

    The mechanisms, including the Medicaid 1115 waiver, allow states to secure some federal funding for certain IMD-related services.

    Medicaid 1115 waivers, if approved by the federal government, allow states to experiment with different ways of implementing the Medicaid program.

    There are three specific 1115 waiver benefit expansions that are related to behavioral health.

    KFF, which tracks these waivers, found that 34 states have received approvals for an IMD exclusion payment exemption for SUDs. Additionally, 10 states have an exemption for mental health treatment, with 23 states having other exemptions for community-based health and behavioral health. 

    Recent presidential administrations have enabled ways around the IMD exclusion through the 1115 waiver.

    In July 2015, the Obama administration allowed for 1115 waivers to “develop a full continuum of care for individuals with SUD, including coverage for short-term residential treatment services not otherwise covered by Medicaid,” which included the IMD exclusion. 

    The Trump administration announced in November 2019 that it approved the first-ever 1115 waiver related to IMD exclusion for SMIs and SEDs for adults and children.

    Addressing the IMD exclusion did come up during the legislative work in 2022 that culminated in a sweeping behavioral health bill included in the omnibus funding bill passed just before Christmas. However, it was not included in the final bill that was signed into law on Dec. 29

    While New York’s latest 1115 waiver application is not unprecedented, it does reflect a two-for-one application for two IMD exclusion exemptions — including both SMI and SUD funding.

    Further, the New York waiver and the other waivers tracked by KFF show that states of all political leanings seek to address mental health via innovations to Medicaid.

    Medicaid is the single largest payer of mental health services in the U.S. 

    Advocates across the country are fighting against barriers to healthcare for people seeking mental health treatment. The IMD exclusion (explanation in the OP-ED) continues to eliminate the stability period that is necessary for many people with serious mental illness. Let’s continue to ask for reforms to the IMD exclusion rule; waivers are not enough.

    Laurie Goldstein- ACMI Vice President

    Congress must stop blocking mental health clinics from needed money

    By Cheryl Roberts

    New York Daily News

    Jan 24, 2023 at 5:00 am

    Newly elected Congressman Dan Goldman’s announcement about reintroducing the Michelle Alyssa Go Act is welcomed news. The Act, named after Michelle Go, the young woman pushed to her death in front of a subway train by Martial Simon, a homeless man with serious mental illness, would amend the decades old federal rule at the root of our broken mental health system.

    The Institutions of Mental Disease or “IMD Rule” was enacted in 1965 as part of the Social Security Act and denies Medicaid to patients admitted to psycho-therapeutic facilities with more than 16 beds including hospitals, nursing homes and community or so-called congregate care facilities. By restricting federal Medicaid dollars to small residential institutions, Congress rightly figured that service providers would never achieve “scale,” making it impossible for IMD providers to break even, let alone make a responsible profit.

    Instead, Congress hoped that by funding community services and eliminating large asylums, poor people with serious mental illness would be served elsewhere, and they have been — in prisons, jails and at the undertakers.

    Michelle Go (left) and Martial Simon
    Michelle Go (left) and Martial Simon

    The need for more psychiatric beds whether in-patient or congregate care, is an uncomfortable fact that some would rather ignore, a luxury not possible for parents like Teresa and Dan Pasquini, sisters like Hilary de Vries, or members of Michelle Go’s family.

    Like it or not, some people living with serious mental illness would do better having access to financially viable, reasonably sized congregate care residential facilities located close to family and loved ones. Yet for many people, this community-based option has been off the table for nearly 60 years because of the IMD Rule. Without this option and others, including in-patient hospitalization and residential facilities where residents are not completely at liberty to come and go, the much heralded “continuum of care” is not achievable, at least not for everyone.

    There is no better proof of this reality and the need for a range of such facilities, than the fact that over the same time period, many of these options have been available to those who can afford private pay residential and in-patient facilities. This reality demonstrates that IMDs above 16 beds are not inherently bad, we just don’t want to pay for good ones, at least not for poor people. Instead, we have stood by and watched as our prisons and jails filled up with poor people living with mental illness, especially Black and Brown people, who landed in the criminal justice system after the mental health system failed them, their loved ones and the innocent victims and their families.

    Ironically, in the end, the IMD fundamentally undercut the gold standard of our mental health care system: ensuring access to community-based mental health services as part of a broad continuum of care. By drawing a crude line in the sand at 16 beds for all IMDs, Congress over-simplified both the problem and the solution needed to address the very real concerns associated with the large, underfunded snake-pit mental health asylums of old.

    As Goldman reintroduces legislation to amend the IMD Rule, rather than seeking a wholesale repeal of the rule, the amendments should be drawn with more precision. Otherwise, not only will complete repeal of the IMD be dead on arrival due to its high cost, it will also unnecessarily raise real concerns about the government’s ability to control very large scale asylums and prevent some of the abuses of the past.

    Rather, instead of once again taking a crude, one size fits all approach to Medicaid funding for mental health treatment, Congress should create different bed limitations for different kinds of facilities. For example, members might find that 36-bed congregate care facilities would be both humane for clients and financially viable for service providers. Similarly, raising the legal bed capacity for in-patient psychiatric hospitals to 100 or 150 might enable New York City’s public Health + Hospitals to offer high quality, safe, therapeutic and humane options for New Yorkers in need of that level of care.

    Not only would extending the continuum of care be the humane option for those living with serious mental illness and their families, but it would also improve public safety and save money by preventing people with serious mental illness from entering into the criminal justice system in the first place.

    It’s time for Congress to get this one right. To be thoughtful but to delay no longer. Michelle Go and Martial Simon deserved better, so did their loved ones.

    Roberts is a part-time City Court judge in Hudson, N.Y., where she presides over the Mental Health Court and is the executive director of the Greenburger Center for Social and Criminal Justice.

    This report was released in Psych News Alert on Monday, January 23, 2023

    When it comes to the risk of metabolic side effects, not all antipsychotics are equal, suggests a meta-analysis published in World Psychiatry. The analysis revealed that patients with schizophrenia who took chlorpromazine or clozapine for more than 13 weeks experienced the most weight gain on average compared with those taking placebo.

    Angelika Burschinski, M.D., of the Technical University of Munich and colleagues compiled data from 137 clinical trials that compared outcomes of patients who had schizophrenia, schizophreniform disorder, or schizoaffective disorder and took antipsychotics or placebo for more than 13 weeks. The combined sample included 35,007 participants who had taken 31 different antipsychotics (both oral and injectable) that are available in the United States and/or Europe. The researchers compared the effects of these medications on body weight as well as fasting glucose, cholesterol, and triglyceride levels.

    The median age of the participants in the analysis was 39 years, and the median length of follow-up was 45 weeks. The researchers found that five antipsychotics contributed to significant average weight gain relative to placebo:

    • chlorpromazine (5.13 kg, or over 11.3 lbs)
    • clozapine (4.21 kg, or over 9.3 lbs)
    • zotepine (3.87 kg, or 8.5 lbs)
    • oral olanzapine (3.82 kg, or 8.4 lbs)
    • long-acting injectable olanzapine (3.60 kg, or 7.9 lbs)

    Seven other antipsychotics, including risperidone and quetiapine, were associated with average weight gains of 1 to 2 kg (2 to 4.5 lbs) over the study period.

    The medications associated with the highest weight gain in participants were also associated with greater changes in glucose, cholesterol, and triglyceride levels. Olanzapine was associated with the greatest effects on glucose, total cholesterol, and LDL cholesterol; amisulpride (which led to an average weight gain of 1.43 kg, or over 3 lbs), was associated with the greatest effects on HDL cholesterol and triglycerides.

    “[M]etabolic side effects of antipsychotics are likely to contribute to the average 14.5 years reduced lifespan of individuals with schizophrenia. Furthermore, weight gain is associated with decreased quality of life and treatment nonadherence, the latter resulting in poor treatment outcome and psychotic relapses,” Burschinski and colleagues wrote. “As antipsychotic drugs are often taken for long periods of time, our results represent more valuable clinical information on these health consequences than previous analyses based on short-term studies, which on average only lasted 6 weeks.”

    The first Tuesday of each month from 4-6 pm Arizona time, except for holiday weekends, ACMI will have a featured guest that will discuss a relevant Behavioral Health topic; after the speaker, we will have discussions with attendees on current issues with the Behavioral Health System.

    “Autism in Adults: What does that look like, and what to do about it” by Dr. Christopher Smith

    Dr. Christopher J. Smith is an experimental psychologist with expertise in diagnosing autism spectrum disorder and measuring associated traits. Dr. Smith oversees all diagnostic evaluations and assessments for our clients while also directing all internal and external research projects. Prior to joining us at SARRC, he worked as an assistant professor in the Department of Psychiatry at the Mount Sinai School of Medicine, where he still maintains a faculty position. Originally drawn to study autism because of the complexity of the disorder, here at SARRC, Dr. Smith values the ability to work with clients across all age groups and engage in out-of-the-box research endeavors.

    Topic: ACMI Stakeholder’s Meeting

    Time: February 7th,, 2023 04:00 PM Arizona

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    As we celebrate these holidays, let’s resolve to help the less fortunate.  The article below, by Steve Twist and Seth Leibsohn, vividly describes the misery of homeless persons in our community.  The most tragic are those who suffer from Serious Mental Illness (a pathological brain disorder) and co-occurring addiction and homelessness, living in our streets and jails.  Approximately 30% of homeless persons and 30% of incarcerated persons are Seriously Mentally Ill.   

    Some are so mentally ill they believe their internal voices and delusions are real and, hence, they are pathologically unable to participate in their own treatment.  Some seek relief with illicit substances, which exacerbates their illness and misery.  To help these Chronically Mentally Ill persons, we need (a) more group homes with staff inside the homes 24 hours per day and 7 days per week, (b) well-regulated and secure residential treatment facilities from which residents cannot leave without authorization, to allow enough time for their treatment to become effective and (c) more beds and more accountability for care at the Arizona State Hospital, including removing the 55-bed limit on persons who reside in Maricopa County.

    These three steps would provide better clinical outcomes at less cost than we now spend on recycling these persons through our emergency rooms, hospitals, short-term treatment programs, the streets, and jails, as their mental and physical health deteriorates.

    We at the Association for the Chronically Mentally Ill (“ACMI”) welcome the attention Mr. Twist and Mr. Leibsohn bring to the problems described in their article.  And we believe the three steps indicated above would be significantly helpful as to the persons who are homeless due to their Chronic Mental Illness.

    Dick Dunseath, Board Secretary of the Association for the Chronically Mentally Ill, and father of an adult suffering with Chronic Mental Illness


    Phoenix neglects homeless, ignores rampant crime in ‘the Zone’ ( published Nov 17th 2022

    Phoenix neglects the homeless, ignores rampant crime in drug-riddled ‘Zone’

    A homeless person, who was included in the annual Point-in-Time homeless street count, sleeps on the [edestrian bridge, Jan 25th, 2022, at Seventh and Lopp 202 in Phoenix (Mark Hemie/The Republic

    Opinion: Nearly 1,000 homeless folks exist in disease, filth and crime. Phoenix is guilty of not only neglecting them but setting a policy to not enforce laws.

    Steve Twist and Seth Leibsohn

    Within an area of central Phoenix, bounded roughly between Seventh and 15th avenues and Jefferson and Harrison streets, there is an ongoing dystopia. Euphemistically and casually, it’s referred to as “the Zone.”

    This past week, an unborn child, at 20-24 weeks of gestation, was found dead in the middle of the street – burned to death.

    There, nearly a thousand of our fellow citizens exist in disease, filth and crime. They are “living” on the streets, in makeshift tents and under tattered tarps, amid scattered garbage, human waste, chronic illness, drug paraphernalia, fire and fear.

    These are the unseen, forgotten and abandoned. They are the mentally ill, walking the streets, talking to the air, battling unseen demons. They are the drug and alcohol addicted, so desperate for another fix or drink they will do anything except seek treatment. They are routinely victims of both crime and neglect.

    No decent society abandons its fellow citizens to live this way; Darfur or Beirut is not our human or scenic aspiration. Not only is Phoenix guilty of shocking neglect of these most needy among us, it seems to be the policy of the city not to use the tools at its disposal to intervene as a force for help and repair.

    Drug crimes, assaults define life in ‘the Zone’

    Nicky Stevens (left, with MAG) interviews a homeless person during Maricopa County's annual Point-in-Time count, Jan. 25, 2022, near Seventh Avenue and Roosevelt Street in Phoenix.
    Nicky Stevens (left, with MAG) interviews a homeless person during Maricopa County’s Point-in-time count Jan 25, 2022, near Seventh Avenue and Roosevelt Street in Phoenix. Mark Henie/The Republic

    Take the cases of crimes being committed against those in the Zone. Those living there are both routine and regular perpetrators and victims of serious crime. Not only are drug crimes the basis for regular escape and anesthesia, but sexual and aggravated assaults, robberies, arsons and thefts regularly define the contours of daily subsistence in the Zone.

    In its 2020 report, Strategies to Address Homelessness, the city of Phoenix acknowledged, because of “Gaps,” “(t)he result is a fluctuating level of encampments along the streets, defecation in public – sometimes on private property, litter and debris, public drug use, lewd acts, theft and other property and violent crimes.”

    It’s only become worse.

    According to a recent complaint that area business operators filed in Maricopa County Superior Court, the city “refuses to enforce in and around the Zone quality-of-life ordinances prohibiting loitering, disturbing the peace, drunken and disorderly conduct, drug use, domestic violence, and obstructing streets, sidewalks, or other public grounds.”

    So, the victims are abandoned.

    People call for help thousands of times

    Article 2 of our state constitution recognizes victims of crimes have the rights to “justice” and “to be treated with fairness, respect, and dignity.” These constitutional rights are promises made by the people of Arizona to every victim of crime, rights that city officials from the mayor on down have sworn to uphold.

    Yet they have become a mockery as city officials refuse to enforce the very laws that have been written to protect victims from harm.

    A model for others? Tempe parking lot will become affordable apartments

    In this limited area of a few city blocks, in just the first nine months of this year, people have called the police for help more than 2,800 times. On average, in just a few square blocks, more than 10 people need help from the police every day.

    Enforcing our criminal laws when a homeless person commits a crime against another homeless person does not stigmatize homelessness: it respects the rule of law and the rights of the victim essential to natural order. It recognizes a humanity that inheres in certain populations too many of us would, evidently, rather ignore. And these prosecutions can result in services being mandated for the homeless perpetrator.

    Actively police this area. Enforce the law

    But Phoenix is so wrapped in the dogma that pushes the failed policy of “housing first” and appeasement rather than treatment that it leaves the victims with neither justice nor respect. It leaves the homeless abandoned to the vicious cycle of desperation and misery.

    The city has been justifying its shameless inaction because of a misreading of a recent 9th Circuit Court of Appeals case. But that case, Robert Martin v. City of Boise, noted, “Nor do we suggest that a jurisdiction with insufficient shelter can never criminalize the act of sleeping outside.

    “Even where shelter is unavailable, an ordinance prohibiting sitting, lying, or sleeping outside at particular times or in particular locations might well be constitutionally permissible. So, too, might an ordinance barring the obstruction of public rights of way or the erection of certain structures.”

    Start policing the Zone. Enforce the rule of law.

    Start arresting those who break the law. Work with prosecutors and courts to screen for services and treatment. Start with a policy not of “housing first” but “protecting victims first.”

    That is what a sane and civil community would do – before it spreads, and before more lives are brutalized and lost.

    Steve Twist, a former chief assistant attorney general for Arizona, is the founder of the Arizona Voice for Crime Victims. Seth Leibsohn is a radio host at KKNT/960am and a senior fellow of the Claremont Institute, which advocates for limited government. Reach them at and

    Not all unsheltered populations require the same solution. Each population is unique. Project Haven for seniors is suited for the older population. The rate at which CASS was able to find permanent supportive housing (PSH) for the senior population during the pilot is impressive.

    We need specialized solutions for people with serious mental illnesses, including supportive services. Without supportive services, most people will not be successful.

    St. Vincent de Paul’s Washington Model is another smaller shelter in Phoenix that accommodates persons with pets and has onsite services.


    Phoenix leaders push for more shelters after 700+ unhoused people died in 2022

    Phoenix leaders push for more shelters after 700+ unhoused people died in 2022 – Axios Phoenix posted 12/20/2022 by Jessica Boedm.

    A rendering of The Haven after renovations. Courtesy of CASS

    Homeless service providers in Phoenix are trying to quickly open new shelters across the Valley to address the growing number of people living on the streets.

    Why it matters: Tuesday marks Homeless Persons’ Memorial Day, which is recognized on the winter solstice, the longest night of the year.

    By the numbers: Homelessness in Maricopa County increased 22% over the past two years and more than 700 people experiencing homelessness have died this year. That’s up from about 550 last year.

    Of note: Investigators reported an additional 450 deaths this year of people whose housing status could not be determined.

    What’s happening: Government agencies and nonprofits are using federal pandemic-relief funds to provide new shelter options, especially for seniors and people with mental illnesses.

    • For years, the 600-bed Central Arizona Shelter Services (CASS) location was virtually the only option for emergency housing.
    • Now, local leaders are looking to create smaller facilities that address specific needs for different populations.

    The latest: CASS is getting ready to renovate the old Phoenix Inn on Interstate 17 near Northern Avenue. When finished this summer, it will provide 170 beds for people 55 and older.

    • The Haven will have onsite medical care and other resources tailored to senior citizens.
    • CASS tested the model by renting out part of a hotel for seniors experiencing homelessness during the pandemic. Almost 70% of the people who stayed there got permanent housing, CEO Lisa Glow told us.
    • The group purchased the hotel outright with pandemic funding from the state housing department. The Phoenix City Council approved $4 million of their federal dollars for the renovation.

    What she’s saying: “It’s a more dignified, safer space for [senior citizens] than having to navigate 600 beds,” Glow said.

    Flashback: Earlier this year, St. Vincent de Paul opened a new 200-bed shelter in south Phoenix.

    • The Human Services Campus opened a 100-bed structure next to the CASS shelter and is prioritizing people with significant barriers to housing, including individuals discharged from hospitals.

    What’s next: CASS is partnering with Copa Health to open a 54-bed transitional housing facility for people with a Severe Mental Illness in 2024 on the state hospital grounds.

    • Community Bridges, Inc., is looking to open a 100-bed behavioral health wellness center in Sunnyslope.