Here are my thoughts about the IMS exclusion and appropriate treatment of people with serious mental illness.  We need all the levels of care available in the continuum of care. Today in-patient care is significantly limited due to this archaic Medicaid rule.

     In today’s blog from Pete Earley, he refers to a report by Steven Eida, a senior fellow at the Manhattan Institute and editor of City Journal, and Carolyn Gorman, a policy analyst on issues related to serious mental illness who has served as a board member of Mental Illness Policy Org., a nonprofit founded by the late DJ Jaffe.

     The Association for the Chronically Mentally Ill (ACMI) has championed the rights of the chronically mentally ill for more than three years.  Our focus has been on creating appropriate housing for people with chronic mental illness, in other words, those people with serious mental illness who are not adherent to the current treatments and policies available to them under our Arizona behavioral health system. This year, we made efforts to reform our state psychiatric hospital, the Arizona State Hospital (ASH). This article is directly on point and aligns perfectly with our goals in trying to make people realize that this group of non-adherent SMI, who we choose to call the chronically mentally ill, are not well served by relegating them to the usual treatments available in the community, but, instead, frequently need longer-term treatment in level 1 psychiatric hospitals.

    Also, after stability, when released to the community, they need more intensive supervision in order to treat their chronic psychiatric illness and have meaningful lives.

    In addition, an upcoming study by the Morrison Institute, sponsored by ACMI, found that there were significant savings to the behavioral health system because of the decreased costs that resulted when this notch group of seriously mentally ill, the chronically mentally ill, are treated appropriately, safely, and humanely.

Charles Goldstein, MD

Pete Earley’s original article

Will Eliminating Old Rule Return “Snake pit” Hospitals Or Help Seriously Mentally Ill Americans Get Much Needed Long Term Care?

Photo by Elina Krima from Pexels

(2-26-21) A conservative think tank has joined a growing national chorus calling for an end of a federal rule that discourages states from building psychiatric hospitals and providing long-term, in-patient care for the seriously mentally ill.

The Manhattan Institute argues in a new report released this week that the Medicaid’s IMD Exclusion rule has outlived its usefulness and should be repealed.

President Trump’s President’s Commission on Law Enforcement and Administration of Justice and the Interdepartmental Serious Mental Illness Coordinating Committee created by the Obama Administration also have called for dropping the rule.

What is the IMD Exclusion and why should you care?

It’s a rule that has been around since 1965 that discourages states from building and supporting large psychiatric hospitals and pushes them instead to provide community based treatment. The so-called “16 bed rule” accomplishes this by denying states Medicaid reimbursement for adults between the ages of 22-to-64 if they are treated in psychiatric hospitals and other facilities which have more than 16 beds. States must pay 100 percent of the cost of care for the seriously ill in most long-term psychiatric hospitals, compared to 50 percent for those treated in the community.

The new report’s authors, Stephen Eide and Carolyn D. Gorman, provide a thoughtful argument in favor of dumping the rule.

They document how difficult it is for parents and others to find hospital beds when someone is in the midst of a psychiatric crisis. It is not unusual for individuals to be turned away from emergency rooms or “boarded” in them for several days waiting for a hospital bed to become available. The lack of treatment beds also leads to individuals, who can’t get help, being arrested. The authors argue that Americans with serious mental illnesses simply can’t always get the long term help that they need in a community setting.

The 16 bed rule was enacted, in part, to put an end to warehousing patients in huge state hospitals, and those who support keeping it fear that state hospitals, once again, will become giant “snake pits” if the rule is repealed.

The authors of the Manhattan Institute report disagree.

They claim safeguards are in place now that weren’t years ago. Patients must be considered a danger to themselves or others before being held against their will in a state hospital. Many more treatment programs are available now than when state hospitals were the only choice. Federal laws, especially the Supreme Court’s Olmstead ruling, which requires individuals with mental illnesses be held in the least restrictive settings, will insure patients aren’t abused and forgotten in state hospitals. Plus, every state has a Protection and Advocacy Agency, specifically designed to investigate complaints about abuse in state hospitals and other long term facilities.

Modern psychiatric hospitals “are not designed as isolation wards” and “policies on seclusion and restraint are drastically changed” from the old days, the author’s wrote.

Opponents to dropping the rule warn that having Medicaid reimburse states for long term care in larger hospitals will blow up the Medicaid budget, costing as much as $1 trillion. They argue that states would reduce their spending on community care funding if given a choice between community programs and state hospitals.

The authors of the Manhattan Institute report argue the costs would be $5.4 billion spread over a ten year period and there would be no incentive for states to reduce spending on community programs.

Republicans attempted to eliminate the IMD Exclusion when former Rep. Tim Murphy (R-Pa) drafted the Helping Families In Mental Health Crisis Act. (Murphy was credited as an adviser to the Manhattan Institute Report.) But consumer groups, such as Mental Health America, and Disability Rights advocates strongly opposed ending the rule and Democrats successfully blocked Murphy’s language when his bill was incorporated into the 21st Century Cures Act in 2016.

Channeling the late D. J. Jaffe, who was a contributor at the Manhattan Institute, the authors argue that community based mental health services simply fail to help the seriously mentally ill who need long-term care to recover. Community services are failing this group, they argue, partly because of where they are directing their resources and efforts.

“As the number of diagnoses has expanded – and the number of Americans diagnosed at some point in their lifetimes with a mental disorder has increased – the number of claimants on public mental health resources has increased.”

In other words, what Dr. E. Fuller Torrey warned decades ago remains true.

We prefer to spend limited tax dollars and devote time to helping the “worried well” rather than those who need treatment the most.

You can read the full Manhattan Institute report here.

(Do you believe the IMD Exclusion should be dropped? Have you had trouble securing a hospital bed for someone in crisis? Would ending it hurt community services and turn back the clock to “snake pit” hospitals? Let me know your thoughts on my Facebook page.)

About the report’s authors:

Stephen Eide is a senior fellow at the Manhattan Institute and contributing editor of City Journal. He researches state and local finance and social policy questions such as homelessness and mental illness. He has written for many publications, including National Review, New York Daily News, New York Post, New York Times, Politico, and Wall Street Journal. He was previously a senior research associate at the Worcester Regional Research Bureau. Eide holds a B.A. from St. John’s College in Santa Fe, New Mexico, and a Ph.D. in political philosophy from Boston College.

Carolyn D. Gorman is a policy analyst on issues related to serious mental illness and has served as a board member of Mental Illness Policy Org., a nonprofit founded by the late DJ Jaffe. She was a senior project manager at the Manhattan Institute for mental illness policy and education policy. Gorman served on the U.S. Senate Committee on Health, Education, Labor and Pensions. Her writing has appeared in the Wall Street Journal, New York Daily News, New York Post, City Journal, National Review, and The Hill. Gorman holds a B.A. in psychology from Binghamton University and will graduate with an M.S. in public policy from the Robert F. Wagner Graduate School of Public Service at New York University in 2021. Twitter: @CarolynGorm

From the report:

Medicaid’s IMD Exclusion was crafted for an entirely different era. During the last half-century, America built a system of community-based mental health services that did not exist in 1965. Income-support programs for the disabled, assertive community treatment, clubhouse programs, supportive housing, assisted outpatient treatment, supported employment, peer support services—these either did not exist in the 1950s, or they operated on a much smaller scale than now. Nevertheless, a small subset of severely mentally ill individuals still needs inpatient treatment on a short-term, intermediate-term, and long-term basis. The IMD Exclusion inhibits those individuals’ access to medically appropriate care. ..

ACMI upcoming webinar:

Come learn from Dr. Carol Olson M.D., DFAPA, Chair, Psychiatry Department, Valleywise Health System

Date: February 24th, 6-7 PM MST

Time: 18:00-19:00

Register in advance for this meeting:

https://us02web.zoom.us/meeting/register/tZYvce-vpzMrHNKGqmIK-Hdoe5WHOEwi9wDW

After registering, you will receive a confirmation email containing information about joining the meeting.

Certificate of attendance by Copa Health available.

Crisis Evaluation
Psychiatric evaluation and diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Arizona State Hospital

 

 

 

 

 

 

 

The Association of the Chronically Mentally Ill is focused on the sickest group within the SMI population. This group is non-compliant with treatment and often afflicted with anosognosia or the lack of ability to perceive the realities of one’s own condition. There are a number of systemic issues within our public systems that impact this target group. One such issue is the 55 bed limit at the Arizona State Hospital, which was created to incentivize the state to create community-based programs. Long past the usefulness of that policy, Josh Mozell’s November 30th, 2020 article in the Capitol Times help to explain some of the fallout of this policy, and the reasons the 55-bed limit should be eliminated.

   Solving the problems of our broken mental health system often seems so overwhelming that work does not begin. However, there are narrow solutions with broad implications that can be implemented. One such solution is ending Arizona’s long-standing bed limitation placed upon our state hospital.

   It may surprise many to learn that Arizona still has an operational mental asylum. Opened in 1887, it is now known as the Arizona State Hospital. The purpose of the State Hospital is and has always been to provide care for the most mentally ill in our community. For many in that group, months, if not years, of long-term programming is necessary for real recovery. That being the case, the State Hospital becomes the only place in Arizona where they have a chance for meaningful improvement.

   However, the hospital is nearly inaccessible for Maricopa County’s residents due to an arbitrary 55-bed limitation. To provide perspective, health policy experts estimate that a community needs between 40 and 60 beds per 100,000 to meet the demand for state hospital beds. In Maricopa County, however, for those who are civilly committed, we have one bed per 100,000.

   Why? In 1981, a path-breaking class-action lawsuit, Arnold v Sarn, was filed on behalf of Maricopa County’s mentally ill. The litigation lasted over 30 years, finally settling in 2014. During that time, the case revolutionized Arizona’s mental health system. But in 1995, the parties entered into a plan to resolve the litigation. In that stipulation, the parties agreed there would be a cap of 55-beds at the Arizona State Hospital for civilly committed patients from Maricopa County. Due to this limitation, the only pathway to gaining admission is to fail repeatedly, in spectacular fashion, and do it for years.

   The failure looks like this: Because this group of chronically mentally ill does not receive the long-term treatment needed, they transition from one crisis to the next, experiencing more serious decompensation. This results in a constant recycling through the various public systems at an enormous cost to the taxpayers. Year by year the person is increasingly overcome by the disease. There are persistent police and fire interactions, multiple visits to emergency rooms, long medical hospital stays, arrests for petty crimes, and, unfortunately too often for serious crimes. Then there is the involvement of the judicial system, homeless shelters, and the penal system. Rinse and repeat – the cycle continues for years. For this group of people, the system is not just broken, but inhumane.

   The bed limitation also has many downstream effects. For instance, those who need access to Arizona State Hospital do not disappear simply because there is not an available bed. Instead, they consume scarce mental health resources, which otherwise could be provided to others in need. The most serious manifestation is in our civil commitment system. To be hospitalized through civil commitment, a patient receives a bed at Valleywise Health, the one hospital system licensed to carry out the process in Maricopa County. The average length of stay during the process is 22 days, and, during those 22 days, the patient receives very good psychiatric care. But, we have just 343 beds in Maricopa County, which is far less than what is needed to serve the population. Due to that bed shortage, our system is already limited in its ability to treat those who need help.

  The Arizona State Hospital 55-bed limit pours gasoline on a fire. To keep the patient and the public safe, Valleywise is often forced to keep the patient for months until the patient stabilizes, without the infrastructure for true long-term treatment. Therefore, despite maximizing the stabilization possible at a short-term hospital, it is not enough. The patient is often back at Valleywise within weeks after release. This routine can continue for years until the patient finally fails enough for State Hospital consideration.

   Commonly, the amount of failing will total 1,000 days or more at Valleywise – in addition to visits to the ER, jail, crisis centers, etc. Therefore, on just one patient who would be most appropriately treated at Arizona State Hospital, 45 patients could receive a 22-day hospital stay at Valleywise. Consequently, the bed shortage is made worse, individuals do not receive care, and scarce state resources are exhausted. This extends the system to the point of breaking, which cannot be sustained.

  Our system is broken in many ways. But again, there are many narrow fixes with broad positive implications which start the process of improvement. This is one of those narrow fixes. The 55-bed cap is a monumental failure – it should be eliminated.

Josh Mozell is a lawyer with Frazer, Ryan, Goldberg & Arnold, L.L.P.

Josh Mozell

ACMI President

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Photo by Louis Reed on Unsplash

    I was pleasantly surprised to read this article stating the FDA approval for a new drug trial for schizophrenia. Research into the treatment of schizophrenia is long overdue, as it can be a devastating disease process.

    Schizophrenia is a complicated chronic disease affecting approximately 3.5 million people in the United States, and its annual healthcare costs exceed $155 billion. People living with schizophrenia often experience a reduced quality of life (QOL) and are more likely to be homeless, unemployed, or living in poverty than the general population. Life expectancy for patients with schizophrenia is 15 to 20 years below the average. It is complicated by numerous comorbidities, such as weight gain, increased cardiovascular risk, and mood and cognition changes. Treatment nonadherence can increase the risk of relapse, rehospitalization, and self-harm, leading to a reduced QOL and increased economic burden.

    Schizophrenia is a complex chronic illness with multiple comorbidities and high mortality rates. The development of Long-Acting Injectables and generic medication options has significantly improved patient adherence and reduced care costs in patients with schizophrenia. Despite these advances, schizophrenia has a high economic burden for patients and society. Providers caring for patients with schizophrenia are charged with a complicated task of ensuring individualized care while managing numerous adverse effects that may occur with recommended therapy (Wander, 2020).

Wander, C. (2020).  Schizophrenia: Opportunities to Improve Outcomes and Reduce Economic Burden Through Managed Carehttps://www.ajmc.com/view/schizophrenia-opportunities-to-improve-outcomes-and-reduce-economic-burden-through-managed-care

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FDA Advisory Board In Favor of ALKS 3831 for Schizophrenia

October 9, 2020

Kenny Walter

Relevant Topics

The schizophrenia drug currently has a PDUFA date set for November 15.

    A US Food and Drug Administration’s (FDA) advisory committee has given a recommendation for the ultimate approval of a combination of olanzapine and samidorphan (ALKS 3831) in schizophrenia patients.

    During the joint meeting of the Psychopharmacologic Drugs Advisory Committee and the Drug Safety and Risk Management Advisory Committee, the group voted 16-1 to approve the treatment, developed by Alkermes.

    ALKS 3831 is an investigational, novel atypical antipsychotic earmarked for once-daily oral application for the 2 psychiatric disorders composed of samidorphan, a novel, new molecular entity, co-formulated with olanzapine, an established antipsychotic agent in a single bilayer tablet.

    Recently, researchers presented data from the ENLIGHTEN-2 trial, a six-month study evaluating the weight gain profile of ALKS 3831 compared to olanzapine in 561 patients with stable schizophrenia.

    “The favorable outcome of today’s joint advisory committee meeting represents an important milestone for the patients, clinicians and families who may benefit from new medicines for the treatment of schizophrenia and bipolar I disorder,” Craig Hopkinson, MD, chief medical officer and executive vice president of R&D at Alkermes, said in a statement. The personal testimonies shared during today’s open public hearing reinforced the need for treatment approaches that consider patients’ overall mental and physical health. The ALKS 3831 development program is part of our ongoing commitment to develop new therapeutic options for adults living with serious mental illness.”

    There is currently a Prescription Drug User Fee Act (PDUFA) target action date of Nov. 15.

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James Lee Carr, Photo courtesy of Maricopa County Sherriff’s office

Last Tuesday my husband called as I dropped our son off at his group home after spending the morning shopping and enjoying coffee together. He wanted to know where we were, and I could hear the unease in his voice. An officer had just been shot outside of a Federal court building in downtown Phoenix and given the recent escalation in violence, I could understand his concern.

We now know that this incident had nothing to do with our current political climate, but it had everything to do with another person with under-treated mental illness that resulted in a violent outcome and a ruined life. James Carr will likely be forgotten and spend the rest of his life in prison. A Federal court officer’s life has been significantly altered.

What can be done to decrease the number of heartbreaking tragedies? We need a laser-like focus on policy and resource efforts toward the gaps in care for those with more chronic forms of mental illness and who are most at risk. This is why ACMI is committed to the following solutions:

  • a person-centered culture (instead of a program-centered),
  • financial & other incentives, based on performance & outcomes, for providers to better serve this population;
  • more Lighthouse- like homes, i.e. community living properties with 24-hours per day and 7-days per week supportive staff inside these properties,
  • humane, well-regulated facilities for a secure residential treatment, involuntary as medically appropriate, for those who need more intensive care for a longer period of time to gain insight and continue their recovery in a less restrictive setting; and,
  • other possible solutions that include increasing capacity and oversight at the Arizona State Hospital.

I will continue to spend every Tuesday with my son who has a chronic mental illness because he is one of the fortunate few whose family has been able to obtain these appropriate and humane levels of treatment and support. Sadly, James Carr’s family will only be able to visit him in prison along with so many other people in this same situation. We must do better in order to prevent these needless tragedies and keep the general public safe.

By Deborah Geesling

ACMI Board

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Courtesy of Healing Minds NOLA September 16th, 2020.

 

     Hello all, on Friday, September 18th, 2020 I watched a presentation by Healing Minds NOLA on the IMD exclusion with Tim Murphy and Teresa Pasquini, moderated by Janey Hays and Eric Smith. This segment focused on the IMD exclusion;  a part of the original 1965 Medicaid law. I encourage each of you to watch this presentation.

    The Institutions for Mental Disease (IMD) exclusion is an outdated, discriminatory federal rule that creates significant barriers to treatment for adults with severe mental illness. Under this rule, Medicaid restricts payments to states for non-geriatric adults (the exclusion applies to individuals aged 21 through 64) from receiving psychiatric care in a treatment facility with more than 16 beds. This limits the ability of states to provide an adequate number of treatment beds for psychiatric illnesses, especially those individuals with severe mental illness.

    Tim Murphy, Ph.D. a psychologist, and former Pennsylvania State Senator and U. S. Congressman, was the primary author of “HELPING FAMILIES IN MENTAL HEALTH CRISIS ACT 2015 HR 2646” (“HFMHCA”).  The HFMHCA requires the Assistant Secretary of Mental Health to focus on improving the most important metrics associated with mental illness and particularly severe mental illness, including rates of suicide and attempts, emergency psychiatric hospitalizations, emergency room boarding, arrests, incarcerations, victimization, and homelessness. The bill dramatically adjusts the threshold to be used in determining the efficacy of programs. It establishes a coordinating committee to advise the Secretary that includes significant representation from criminal justice, a needed addition of an important stakeholder to the national conversation.
Read more at: https://mentalillnesspolicy.org/federalmentalillnesslegislation/hr2646/hr2646narrative.html

   Representative Tim Murphy worked with many families on the HFMHCA legislation.  Unfortunately, the final version of the legislation HFMHCA included measures to repeal the IMD exclusion, but these provisions never made it into the final law. Also left on the cutting room floor was a more precise and transparent definition of “grave disability”.  These are important items for consideration going forward.

 

This webinar is about the IMD exclusion, but it goes much further explaining the history of mental illness, severe mental illness, and many of our behavioral health system’s shortcomings. This video is a straightforward exposition of how our behavioral health system fails people with serious mental illness. I urge everybody to watch it. In addition, Representative Tim Murphy makes a very impassioned plea for advocacy.

 

For this and several more informative webinars, I urge you to visit Janet Hays, Director (Healing Minds NOLA) & Eric Smith (Mental Health Advocate and Graduate Student). They are co-hosting an 8-part series on Implementing a Full Continuum of Coordinated Psychiatric Treatment and Care.

 

   Learn about the IMD exclusion; which is Medicaid Institutions for Mental Disease (IMD) exclusion is an outdated, discriminatory federal rule that creates significant barriers to treatment for adults with severe mental illness. Under this rule, Medicaid payments to states are prohibited for non-geriatric adults receiving psychiatric care in a treatment facility with more than 16 beds.

By Dr. Charles Goldstein

What Is the IMD Exclusion?

   The IMD exclusion is a long-standing policy under Medicaid that prohibits the federal government from providing federal Medicaid funds to states for services rendered to certain Medicaid-eligible individuals who are patients in IMDs (§1905(a)(30)(B) of the Social Security Act [SSA]). When a Medicaid-eligible individual is a patient in an IMD, he or she cannot receive Medicaid coverage for services provided inside or outside the IMD. Due to the exceptions explained in the “Legislative History” section, the IMD exclusion applies to individuals aged 21 through 64. Determination of whether a facility is an IMD depends on whether its overall character is that of a facility established and maintained primarily to care for and treat individuals with mental diseases. Examples include a facility that is licensed or accredited as a psychiatric facility or one in which mental disease is the current reason for institutionalization for more than 50% of the patients. For the definition of IMDs, the term mental disease includes diseases listed as mental disorders in the International Classification of Diseases, with a few exceptions (e.g., mental retardation). (See Centers for Medicare & Medicaid Services [CMS], State Medicaid Manual, Part 4, §4390.) Under this definition, substance use disorders (SUDs) are included as mental diseases. If the substance abuse treatment follows a psychiatric model and is performed by medical personnel, it is considered the medical treatment of mental disease.

   However, even with the IMD exclusion, states can receive federal Medicaid funding for inpatient mental health services for individuals aged 21 through 64 outside of an IMD. States can provide Medicaid coverage for services rendered in facilities that do not meet the definition of an IMD, such as facilities with 16 or fewer beds and facilities that are not primarily engaged in providing care to individuals with mental diseases. https://fas.org/sgp/crs/misc/IF10222.pdf

 

 

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Photograph by Laurie Goldstein on streets of San Diego August 23rd, 2020

It seems to be tragic that individuals suffering from the symptoms of serious mental illness must try and fail oral medication therapies before qualifying for long-acting injectables. Besides being much more effective and efficient in medicine delivery, adherence increases significantly. Physicians are well aware that people do not take medications as directed. Lack of compliance in taking medicines as prescribed holds for physical health and mental health treatments. A person suffering from bronchitis may stop taking their antibiotics after five days of a 10-day course once they are feeling better. So, it is not surprising that many people struggle with adherence to daily or twice daily oral medications.

The issue of non-adherence has dire consequences if the condition involves the brain and psychosis. Repeated psychotic events can result in a change in the baseline. According to McKnight (2017) “Researchers now stage schizophrenia. Just like cancer, the more advanced the stage, the worse the outcome,” said Dr. Nasrallah, the Sydney W. Souers Endowed Chair and professor of psychiatry and behavioral neuroscience at Saint Louis University, told his audience. “The additional damaging effects of the second episode is what leads to clinical deterioration and can start the process of treatment resistance. But if no psychotic episodes are allowed to recur after the first episode, many patients can return to their baseline functioning, such as school or work.”

As data mount confirming the neurodegenerative effects of psychotic episodes in schizophrenia, one expert urges psychiatrists to think of psychosis as a “brain attack” which, like heart attacks, must be prevented from recurring. McKnight (2017)

According to McKnight (2017) “Schizophrenia doesn’t have to be progressive neurodegenerative unless patients relapse again and again, but that happens all the time because we give our patients pills they don’t take as prescribed. There are many reasons for poor adherence,” Henry A. Nasrallah, MD, said at the meeting held by Global Academy for Medical Education.

 By Laurie Goldstein 

ACMI

 

See more surprising schizophrenia statistics, including:

  • Rise in cost related to relapse
  • Number of hospital beds available for patients
  • Connection between adherence and relapse

https://www.medscape.com/infosites/285165.1/isarticle-1?src=0_nl_sm_0&uac=371324FZ

McKnight, W. (2017, July). First-episode psychosis is a ‘brain attack,’ and LAIs can prevent recurrence, expert says. Clinical Psychiatry News2017(1), 1.

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Photo by Michael Jin & Photo by Camilo Jimenez on Unsplash

Recently, when we were still permitted to congregate socially, I was at a Friday night service in my synagogue when a young woman in the back row emitted a frightening scream, fell, and began convulsing. During her seizure, she hurt herself by falling and hitting her head (danger to self) and broke a chair nearby when she fell on it (property damage). Of course, paramedics were called who attended to her and eventually transported her to a hospital, whereupon I lost contact with this particular young woman and her continued treatment. At no point were the police involved with this manifestation of symptoms of an otherwise presumably well-controlled person with epilepsy. Being an emergency physician myself, I can only tell you that my experience with people with seizure disorders being brought to the emergency room is that they are never subsequently taken to jail.  The options are either hospitalization or, more frequently, discharged home on appropriate medications with appropriate follow up.

 

In another hypothetical scenario, a “brittle diabetic,” usually well-controlled on his insulin, passes out while driving and knocks over a Postal box when he runs into it with his car (a federal crime!).  Police and paramedics show up; the patient is taken to an emergency room where it is ascertained that he indeed has diabetes and had become hypoglycemic. The patient is either admitted to the hospital or sent home on appropriate medications with appropriate follow-up.

 

In neither of these cases detailed above, were the patients assumed to be criminals.  People exhibiting symptoms from a chronic disease are treated appropriately for their symptoms. Their underlying illness and hospitalization, if needed, are not a problem; there are plenty of inpatient beds for them.

 

Let’s contrast this with what might have happened if this was a person with serious mental illness attending the same Sabbath service and became symptomatic, started flailing around, and did some property damage as this woman did. Police and/or paramedics would have been called. The patient may or may not have been taken to an emergency room and may or may not have gone to jail because society draws a fine line (not so fine) between apparent “medical” conditions and “psychiatric” conditions. Unfortunately, in a behavioral health crisis, when people become symptomatic because of their underlying disease, the behaviors related to their disease can suddenly be considered a crime. Also, if it was adjudged that this patient needed further treatment on an inpatient basis, they would have found this to be nearly impossible as there is an extremely limited number of inpatient psychiatric beds in the state of Arizona.

 

Currently, experts recommend approximately one psychiatric inpatient bed for every 250,000 people. In Maricopa County alone, there are about 4 1/2 million people; this equates to an inpatient psychiatric capacity that should exist of around 1,800 inpatient beds. At present, in Maricopa County, there are just 55 beds available in the public system for long-term psychiatric treatment. The inadequate number of limited long-term inpatient psychiatric beds is a figure so egregiously deficient that the reader might well be shocked that this is the truth; shamefully, it is.

 

We need to correct this appalling lack of inpatient psychiatric therapy currently available for the Seriously Mentally Ill.

Charles Goldstein, MD

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Photo courtesy of Isaac Geesling Photography 2018

With DJ Jaffe’s passing on August 23, 2020, individuals living with serious mental illness (and their loved ones) lost a highly effective advocate.  Some of us at ACMI, notably Deborah Geesling, lost a friend as well.  So, what do we do next?   How do we build on DJ’s work?

 

DJ knew first-hand what life is like for those living with serious mental illness and their families.   He took up advocacy to make those lives easier, safer, better. And his work instructed and inspired a generation of mental health advocates.   DJ’s messages — always delivered in clear, simple English — are notable for the absence of policy lingo and the gloss of politically correct phrases.  He spoke authentically, unassumingly, and he spoke truth.  With unparalleled, laser-like precision, DJ exposed shortcomings, and failures within the current “behavioral health” industry, a trendy nomenclature that DJ would remind us is a misnomer for what the seriously mentally ill need.  DJ was clever, quiet, studious, relentless.  And, of course, pony-tailed!   He never shied away from a powerful adversary.  No Goliath was too big for DJ.  And so, he left big footprints for those of us engaged in advocacy for the seriously mentally ill.  Perhaps DJ’s greatest attribute was his unparalleled ability to identify and “call out” practical policy failures that created and sustain our behemoth public mental health system.  And while DJ is now gone, we remain blessed by his writings and speeches — his practical, informed, insightful words of wisdom.

 

During DJ’s visit to Phoenix a few years back, he spoke at a church in the East Valley and at an ACMI salon.  The salon was held on a chilly evening beneath a spectacular Arizona sky.   Chuck and Laurie Goldstein’s patio, overlooking the Paradise Valley Desert and facing the spectacular mountains east of the Valley, is both beautiful and inspiring.  Add fireplaces, thoughtfully placed heaters, and blankets, and about 50 of us had a perfect setting for conversation and reflection.  Before DJ began his remarks, we chatted privately; I thanked him for his work, which was so needed.  His typically cogent response: “Well sadly it’s needed, but it really shouldn’t be.” Those words stay with me and remind me of the value of DJ’s concrete focus.

Photo courtesy of Isaac Geesling Photography 2018

Before meeting DJ, I had read the speech that he delivered to the 2012 NAMI New York State convention.  I keep it on my computer “desktop”.  My favorite part is this:

I am not a mental health advocate.   

Like most of you, I am a mental illness advocate.  I think we need less mental health spending and more mental illness spending.  It is the most seriously ill not the worried-well, who disproportionately become homeless, commit crime, become violent, get arrested incarcerated or hospitalized. 360,000 are behind bars and 200,000 homeless because we are now focused on improving mental health, rather than treating serious mental illness.

DJ Jaffe

NAMI/NYS convention 2012

As a tribute to DJ Jaffe, each week for the next year, ACMI’s website will feature a quote from DJ Jaffe. We are calling this, simply, “52 Weeks of Truth Telling From DJ Jaffe”.  By the anniversary of this remarkable’ s man’s passing, we’ll have quite a collection of words to live by .. a path of footprints, so to speak, to guide our advocacy and to honor this wonderful man.  RIP, DJ JAFFE.

Holly R. Gieszl, JD

Founding Member, Board of Directors, the Association for the Chronically Mentally Ill.

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