(July 24, 2014) When Medicaid tries to save money by restricting access to the most effective antipsychotics for people with severe mental illness, more mentally ill people end up in jail, according to new research from the American Journal of Managed Care (“AJMC Study Finds Medicaid Barriers to the Right Drugs May Cause More with Schizophrenia to Land Behind Bars,” July 22).

The antipsychotics, called “atypical antipsychotics,” have been associated with lower rates of relapse in people with schizophrenia. Using data from 16,844 prison inmates, researchers found that restricting access to atypical antipsychotics – Medicaid must review the prescription before covering it – was associated with a 22 percent increase in the likelihood that a person with severe mental illness would end up behind bars.

“The United States spends $8.5 billion each year on persons with severe psychiatric disorders in jails and prisons,” the authors said in a statement. “The prison system is an expensive way to deal with mental illness, especially when many of those incarcerated are nonviolent.”

This study comes at a time when jails and prisons are facing increased scrutiny for their treatment of mentally ill prisoners and states are under pressure to enact policies that keep people with serious mental illness out of the criminal justice system.

This scrutiny makes sense. Criminalizing people with severe mental illness is a human rights violation and costs taxpayers money. An investigation by USA Today found that a 94-day incarceration cost $30,258, whereas a full year of housing, disability income, and treatment for a person with a serious mental illness was just $31,200.

“Limiting access to effective therapy may save states some Medicaid money in the short run,” said lead author Dana Goldman, director of the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California. “But the downstream consequences -- including more people in prisons and more criminal activity -- could be a bad deal for society."

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(July 23, 2014) Police encounters with people with severe mental illness are the subject of USA Today’s latest article in a series on the human and financial costs of abandoning the seriously ill (“Mental illness cases swamp criminal justice system,” July 21). Excerpted below:

Inside a cluttered downtown apartment that she shares with a cat, the 57-year-old woman is in the midst of a near-meltdown.

“There's three of them,” she tells two police officers, referring to “these predators who won't leave me alone. Those sons of bitches won't let me go.“

The police have been here before — 61 times, in fact, in the past 17 months — and the only intruders to be found are the ones apparently stalking the woman's troubled psyche.

During these episodes, she always summons the police because they are the closest thing she has to family. And no matter what, they always come.

"I didn't have any choice but to go to Jimmy,'' she said, waving the glowing end of her lighted cigarette in the direction of Officer Jimmy Winters. “I'm sorry I'm such a pain in the ass.''

In the shadow of enormous wealth, where tourists flock to view the iconic mansions along Bellevue Avenue, about 40% of all calls to police involve people who are mentally ill or have behavioral problems. It is, as Newport Chief Gary Silva described it, an "alarming'' number. Yet it only begins to assess how an overwhelmed criminal justice system has become the de facto caretaker of Americans who are mentally ill and emotionally disturbed.

From police departments and prisons to courthouses and jails, the care of those who are mentally ill weighs heaviest on law enforcement authorities, many of whom readily acknowledge that they lack both resources and expertise to deal with the crushing responsibility.

Read the entire article in USA Today.

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(July 22, 2014) Marlene Murillo’s 31-year-old son with schizophrenia has been jailed as a result of his mental illness more often than he has been hospitalized to receive treatment, according to the Durango Herald.

Murillo's story illustrates the level of failure in our mental health system but also highlights why some minorities are overrepresented in all stages of the criminal justice system.

One reason for this is the disparity that exists in the use of mental health services - even though African Americans and Hispanics living in poverty are almost three times more likely to suffer from psychological distress. In fact, African American and Hispanic youth receive 60 - 50 percent less attention to their mental health care, according to data reviewed by Benjamin Le' Cook Ph.D., senior scientist at the Center for Multicultural Mental Health research at Cambridge Health Alliance.

Even more tragic than the lack of access to mental health care is what happens as a result.

We all know that stereotypes of African Americans as criminal are deeply embedded in American society. But these stereotypes are most likely used by decision makers in the criminal sentencing process. Research from Melissa Thompson, a sociologist at Portland State University, shows that African Americans who commit crimes are less likely to be given a psychiatric evaluation to determine their mental capacity at the time of the offense. They are also disproportionately arrested and given longer sentences than whites.

What’s more, once they arrive in their cells, mentally ill African-American inmates are less likely to receive treatment than mentally ill white prisoners.

Even without the racial disparities, mentally-ill-minority inmates have little hope of receiving adequate treatment while in jail. With some jails reporting only 1 psychiatrist for nearly 1,000 inmates, chances are slim that inmates with mental illness will receive the help they need to keep their symptoms from worsening while in jail.

CHARLES BROOKS
CHIEF LEGAL COUNSEL
SOUTHERN CHRISTIAN LEADERSHIP CONFERENCE

(July 21, 2014) It’s no secret that giving to others feels good. Now, Amazon is making it even easier to give to the Treatment Advocacy Center and help eliminate barriers to treatment for the most severely ill.

When you shop at amazon.com, every purchase you make can help the Treatment Advocacy Center make treatment possible for more people with severe mental illness – at no extra cost to you. That’s because the Treatment Advocacy Center is a participant in the AmazonSmile program. Every time you buy something through the AmazonSmile portal, 0.5% of your dollar goes to the Treatment Advocacy Center.

Here’s how AmazonSmile works:

To shop at AmazonSmile simply go to smile.amazon.com from the web browser on your computer or mobile device. You may also want to add a bookmark to AmazonSmile to make it even easier to return and start shopping. Select the Treatment Advocacy Center from the dropdown menu as the charity you wish to support. Once you do this, every time you shop at smile.amazon.com, a portion of your purchases will aid our organization.

The Treatment Advocacy Center is the only national nonprofit dedicated exclusively to expanding treatment access for people with the most severe mental illness. Designating us to receive your AmazonSmile dollars will help eliminate barriers to treatment for the people who need help the most.

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(July 17, 2014) Antipsychotics like clozapine and mood stabilizers like lithium are a critical tool for reducing violent crime in people with severe mental illness, according to a study published in the Lancet (“Antipsychotics, mood stabilizers and risk of violent crime,” May 8).

Based on data collected by Swedish national health registries from 2006 to 2009, researchers observed the effects of antipsychotics and mood stabilizers on a sample of over 80,000 patients.

The researchers found that people who take antipsychotic medication are approximately 50% less likely to commit a violent crime than those with bipolar disorder who do not take medication.

 "Patients with psychiatric disorders are at risk of perpetrating violent acts, as well as being victims,” said Dr. Seena Fazel, lead researcher on the study.

“Until now, we have not known whether antipsychotics and mood stabilizers reduce risks of violence,” she continued. “By comparing the same people when they are on medication compared to when they are not, our study provides evidence of potentially substantial reductions in risk of violence, and suggests that violence is to a large extent preventable in patients with psychiatric disorders."
 
The results of this study show that many people with serious mental illness who commit violent acts have done so as a result of untreated psychosis or other symptoms of the illness rather than malicious intent.

The authors highlight the importance of effective medication management in treating serious mental illness, specifically the use of mood stabilizers and antipsychotics to reduce violent crime among patients suffering from psychosis.

It is important to remember that most people with mental illness are not violent and are almost 4x more likely to be the victim of a crime than to perpetrate a crime. In either case, better assisted outpatient treatment (AOT) laws would facilitate effective medication management for the most severely ill.

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(July 16, 2014) Seventy-seven percent of inmates injured in attacks at Rikers had a diagnosed mental illness, report journalists Michael Winerip and Michael Schwirtz for the New York Times (“Rikers, where mental illness meets brutality in jail,” July 14).

The growing number of mentally ill inmates is a major contributing factor to the escalating levels of violence at Rikers, Winerip and Schwirtz say. But Rikers is also not equipped to handle this surge of mentally ill inmates. Supervision is provided by officials who are not trained mental health professionals and “instead rely on pepper spray, take-down holds and fists to subdue them.”

Inmates with mental illness are also especially vulnerable in the harsh environment of incarceration. They are “often the weakest in a kind of war of all against all, preyed upon by correction officers and other inmates.”

“There’s lots of brutality,” said Daniel Selling, the former director of the jail’s mental health services. “Horrible brutality.”

This horrific brutality should hardly come as a surprise. With 12,200 inmates, Rikers Island Jail in New York City is the largest de facto “mental institution” in New York and prison workers “complain that they do not have the tools to properly care for inmates with mental health problems.”

Complicating the problem is that many of the inmates who need treatment the most are left untreated, according to a Treatment Advocacy Center study which found that New York is one of the most difficult places for prisoners with severe mental illness to receive involuntary treatment. Without proper treatment, systems are likely to worsen.

Until we maintain a functional public mental health treatment system, people with mental illness will continue to languish in jails and prisons with staff that are ill prepared to handle mental illness.

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(July 15, 2014) The Los Angeles County Board of Supervisors voted unanimously to implement Laura’s Law countywide today, making it the third major California county – and the largest – to embrace court-ordered treatment as a tool for making treatment possible to individuals with severe mental illness who are too ill to seek help for themselves.

A year ago, Los Angeles was running a small but successful pilot assisted outpatient treatment (AOT) program and only Nevada County was operating a countywide program.

What a difference a year makes.

In the last two months, San Francisco and Orange counties have voted to implement Laura’s Law. In June, Yolo County implemented its use.

With the Los Angeles supervisors’ vote, more than half of California’s population now will live where assisted outpatient treatment is available to individuals who qualify under the state’s strict criteria, which include a history of non-compliance, hospitalization and/or violence to self or others.

“The scales have finally tipped in favor of providing treatment before tragedy,” said Doris A. Fuller, executive director of the Treatment Advocacy Center. “The calls of families rendered optionless and the mentally ill abandoned to our streets, jails and prisons are finally compelling legislators to implement laws that provide timely and effective treatment.”

California was unique in the United States when it included in Laura’s Law a requirement that each county opt in with a vote by its Board of Supervisors. With the Los Angeles vote, five California counties have fully implemented the law, but families in the state’s other 53 counties are still without access to this proven method of supporting recovery from the most severe mental illness and saving taxpayer dollars.

Nevada County, which implemented Laura’s Law in 2008, estimates it saves $1.81 for every $1 invested. A recent study in New York, where every county has implemented its version of Laura’s Law, found that mental health services could be expanded beyond AOT participants with the savings from these high utilizers of public systems staying in treatment.

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(July 11, 2014) Our mental health system is in shambles and many of the most severely ill are being excluded from the treatment system. For the most severely ill, many of whom are destitute or homeless, private health insurance is not an option – leaving Medicaid the only way that many low-income people can afford to get healthcare.

However, the Institutions for Mental Diseases (IMD) Exclusion prohibits Medicaid from paying for care received in mental health institutions if the hospital has more than 16 psychiatric beds. Not only is this a barricade to treatment for those who need it most, the IMD Exclusion is very costly to state and federal governments when untreated patients are stowed away in correctional facilities or living on the street.

Seventy years ago, there were 550,000 inpatient psychiatric beds for a country half the size it is now. Today, there are fewer than 40,000 inpatient psychiatric beds. The IMD Exclusion has accelerated the shortage of psychiatric beds during the “deinstitutionalization” process several because it gives states an economic incentive to close hospitals.

This provision of Medicaid has inadvertently caused our jails and prisons to become warehouses for the mentally ill and for our homeless population to grow exponentially.

People with untreated psychiatric illness now make up one-third of our estimated 600,000 homeless population.  Studies from Massachusetts and Ohio show that between 27 and 36 percent of discharged patients from state mental health hospitals had become homeless within six months.
 
We must recognize the price that we pay when untreated individuals with mental illness find themselves imprisoned. In 2012, there were an estimated 356,268 inmates with severe mental illness in prisons and jails across the nation. In the vast majority of states, prisons or jails in each state hold more individuals with SMI than the largest remaining state hospital. In Texas, there are 35,000 prisoners with a severe mental illness but just 4,500 psychiatric units in all Texas general hospitals combined.

Prison is also one of the most destructive environments for individuals with mental illness.

Mentally ill prisoners often become much sicker in prison because they are likely not being treated. By no fault of their own, people with severe mental illness often refuse treatment because they do not believe they are mentally ill, also known as “anosognosia.” Though this occurs inside and outside of prisons, mentally ill prisoners who “misbehave” and refuse medication spend additional time behind bars and are more likely to spend time in solitary confinement, which only worsens symptoms.

On top of all of this, the IMD Exclusion creates even more barriers to treatment for minority communities since many individuals in these communities rely on Medicare and Medicaid for health insurance. According to recent studies, African American and Hispanics living in poverty are three times more likely to have psychological distress.

We must act to ensure that we do not warehouse our most vulnerable people with serious mental illness in prisons or leave them untreated and living on the streets. We must work to eliminate barriers to better mental health treatment for our underserved minority communities.

Repealing the IMD Exclusion can help those with mental illness regain access to the treatment they deserve. It could also save taxpayers the burden of costly emergency room visits for patients with severe mental illness and the expense of incarcerating prisoners with severe mental illness. It can help us decrease our homeless population and instead help people gain access to treatment and stable housing by making it more economically viable for hospitals and other residential psychiatric facilities treat them when they are in crisis or recovering from crisis. We must make treatment available for low-income people with mental illness and, to do that, we must do our best to   repeal the IMD Exclusion.

While many individuals with mental illness can be treated successfully in the community, there is a small population of people with serious mental illness who cannot. I strongly believe and advocate that this population of people deserve and have a right to be treated. Transferring them from mental health facilities to cells and the streets – or worse – is inhumane, immoral and hurts all of us.

Congresswoman Eddie Bernice Johnson (TX-30)

(July 9, 2014) San Francisco supervisors voted to implement Laura’s Law Tuesday¹, making it the second large California county in three months to authorize court-ordered outpatient treatment for at-risk individuals with serious mental illness who meet the state’s strict criteria.

Doris A. Fuller, executive director of the Treatment Advocacy Center, called the vote a “watershed.”

“San Francisco is famously one of California’s most liberal counties, just as Orange County is historically one of the most conservative,” she said. “The fact that both counties have adopted Laura’s Law in the span of three months speaks volumes about the desperate need – and nonpartisan support – for expanded access to treatment for California’s most vulnerable population.”

The law is named after Laura Wilcox, a university student who was shot to death while she was volunteering in a mental health clinic by a man with untreated schizophrenia. The law was passed to provide a pathway to recovery for the individuals most at risk for violence, incarceration, homelessness and other ills because they struggle to stay in treatment.

“Laura’s Law will give San Francisco a critical lifeline for patients who refuse treatment and end up on the streets, a risk to themselves or others, in jail or worse,” Fuller said.

San Francisco voters overwhelmingly supported implementation of Laura’s Law, with polls finding more than 70% of the population in support. NAMI California and numerous public leaders – San Francisco Mayor Ed Lee, District Attorney George Gascón, City Attorney Dennis Herrera, Public Health Department Chief Barbara Garcia, Police Chief Greg Suhr, Fire Chief Joanne Hayes-White and the police and firefighters' unions – also endorsed implementation.

Even though San Francisco will make five counties using the law, families in the state’s other 53 counties that have not yet implemented the law remain virtually powerless to help their loved ones and communities escape the consequences of untreated severe mental illness.

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(July 9, 2014) Charles has pleaded with state legislators and health officials to help his son with untreated severe mental illness get into the treatment he desperately needs, but to no avail, writes Stephanie McCrummen in the Washington Post about a family abandoned by the mental health treatment system (“Behind the yellow door, a man’s mental illness worsens,” the Washington Post, June 28).

This week, the Treatment Advocacy Center has shared brief excerpts from McCrummen’s narrative. Today, we share Charles’ perspective.

Charles’ perspective:

“He is worried like everyone else, and as he pulls into his son’s neighborhood at noon on a Thursday, he is surprised to see him out of the house and in his car, parked by the neighborhood entrance.

“Charles honks his horn, parks and walks over. He taps on the window, and as it rolls down, he sees his son for the first time in so many months of trying, months of sitting outside the house, waiting for him to come outside.

“When news broke that a man shot and killed 12 people at the Washington Navy Yard, he wondered, is that my son? When he reads a story about a body pulled from the harbor, he worries, is that going to be him? If his son can’t get help, how will things end?

“For two years, he has written his governor, his US senator, the US Department of Health and Human Services, whoever he can think of to plead for help.

“’We are lost in how to help our son who lives alone and we can’t do anything because of existing mental health laws,’ he wrote in one letter. ‘In light of all the recent tragic issues with mentally ill involved in tragic events, we want to help prevent this situation from occurring with our son,’ he wrote in another.

“’Please help us!!!!!’ was how he ended them all.”

Read the entire story by Stephanie McCrummen.

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