The new asylums frontline summary

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Lesson 7: Adult Mental Health Services
Readings:

Department of Health and Human Services (1999). Surgeon General’s Report on Mental Health, Chapter 4 http://mentalhealth.about.com/cs/comprehensivesites/l/blsgc4s1.htm

Greenberg, G.A. & Rosenheck, R.A. (2008). Jail Incarceration, homelessness, and mental health: A National Study. Psychiatric Services 59(2), 170-177

Watson, A., Hanrahan, P., Luchins, D., & Lurigio, A. (2001). Mental health courts and the complex issues of mentally ill offenders. Psychiatric Services, 52, 477-481

Frontline (May 14, 2005). The New Asylums. http://www.pbs.org/wgbh/pages/frontline/shows/asylums/view/

New York Times (July 30, 2015). A psychologist as warden? Jail and mental illness intersection in Chicago. http://www.nytimes.com/2015/07/31/us/a-psychologist-as-warden-jail-and-mental-illness-intersect-in-chicago.html?_r=0 .

Watch “The Released" (PBS) http://video.pbs.org/video/1114528522/

Scan:

President’s New Freedom Commission on Mental Health Executive Summary. http://store.samhsa.gov/shin/content//SMA03-3831/SMA03-3831.pdf

SAMHSA: Leading Change 2.0: Advancing the Behavioral Health of the Nation, 2015-2018. http://store.samhsa.gov/product/Leading-Change-2-0-Advancing-the-Behavioral-Health-of-the-Nation-2015-2018/PEP14-LEADCHANGE2

Introduction

This week the topic is adult mental health care. Although many attempts have been made over the years to create a coherent policy and a system of care for adults, these outcomes have been elusive. Although community programs were designed to address the abuses found in large institutions, deinstitutionalization did not live up to the promises for better treatment and services.

Deinstitutionalization

The issue of deinstitutionalization was briefly addressed in Lesson 2. A short refresher of historical developments leading up to deinstitutionalization, however, may be helpful.

Treatment options for persons with mental illness grew in the twentieth century as we began to apply new knowledge and treatments. In addition to somatic treatments such as electroshock therapy and psychosurgery developed during the 1930’s and 1940’s, the use of psychodynamic methods became better known after World War II. At the same time that psychodynamic orientation became more widely used, there was increasing interest in the impact of environment on mental disorders. The pioneer in this area was psychiatrist Harry Stack Sullivan. In fact, Grob (1991) credits Sullivan as the primary person who “paved the way for the collaboration of psychiatry and social science, and thus facilitated the emergence of socially oriented therapies . . .” after the war (p.140).

While Grob states that psychopharmacology was “virtually nonexistent” immediately following the war, this science made tremendous advances in a very short period during the late 1940’s and early 1950’s. During this time, clinical trials were conducted showing the results of the use of chlorpromazine, the first drug with antipsychotic properties. These studies were first published in 1952 by French authors working at St. Anne’s Hospital in Paris. Testing in the United States was begun shortly thereafter and the drug was marketed as Thorazine. Development of the drug, reserpine, quickly followed. Grob (1991) notes that now not only were there improvements in patients confined to hospitals, but, at least, initially, there did not seem to be the drawbacks of either the somatic treatments or psychotherapy. These drugs could be used on a large number of patients, they required minimal staff time, they were relatively inexpensive and they worked (ibid, p. 155).

When these advances are seen in light of previous readings about the large numbers of patients, including the elderly, confined to mental hospitals, it is not surprising that policies would change toward treatment of persons with mental disorders. Grob states that the data show that discharge rates improved during this time for those patients who were nonelderly, athough Koyangi (2007) notes that initially only those patients who responded well to medication were discharged. Because so many geriatric patients remained in psychiatric facilities, hospital censuses remained very high. And while efforts were made at the state level to rebuild the mental health hospital systems, there was also a move toward expanding community treatment and services because of these advances in pharmacology and psychotherapy.

Continuing treatment in the community, however, was often necessary for those discharged. Examples of outpatient and community clinics existed dating to 1914 in Massachusetts, where a program was established to bring psychiatric services to the community at large. Most of those clinics that existed, however, served children, and only very few dealt with persons with serious mental illness (Grob, p. 167).

The National Mental Health Act of 1946 provided grants to states that supported existing outpatient facilities and programs or the development of new such services, with a goal of an outpatient facility per each 100,000 population. So while less than half the states had clinics prior to this legislation before 1948, the next year, all but five states had one or more outpatient facilities. Grob states that during the 1950’s, rhetoric was so pervasive surrounding the belief that community care was superior that it “. . . not only shaped policy, but actually impeded evaluation research.” (p. 177)

Community Mental Health Act of 1963 and beyond

The Community Mental Health Centers Construction Act was passed in 1963. Its provisions included a three year authorization to give states grants to build mental health centers if they met certain eligibility criteria. This included developing and submitting a comprehensive plan, designating an agency with an advisory council with broad representation to manage the plan, and instituting a construction program that took into account existing resources and that was federally approved. Subsequent legislation added other provisions, including such things as 24 hour emergency services and, two years later, funding was authorized for staffing the Community Mental Health Centers (CMHC).

There was great enthusiasm about these changes in programs and services, and the discharge of patients into the community accelerated as CMHC’s were built. Barton (1966) noted some of the differences of treating patients during this time including how interventions were evolving now that psychiatrists could see a patient in the context of the community and family. He also noted the new interest in prevention of mental disorders. Most prescient, however, he described the difficulties in coordinating the new, but fragmented programs.

Young & Magnabosco (2004) quote Lerman who postulated that, by 1980, the CMHC system that was anticipated by the 1963 Act had reached only 40% of its goal. Several other attempts to improve community services were tried. These include the Community Support Program (CSP) guidelines set by the National Institute of Mental Health in 1977. The program was designed to aid states and communities to improve services and programs for persons with serious mental illness by assisting mental health consumers in their recovery, rehabilitation and integration into the community. Additional laws were passed, such as P.L. 99-660, which was the first legislation to provide for planning the creation of a community-based system of care for persons with chronic mental disorders. The intent was to build a more comprehensive system of care that included all aspects of a person’s life—mental health, physical health, employment, housing, education, and the like.

Despite all these efforts at community-based care, Young & Magnabosco (2004) note that access to services has remained a problem, resulting in a variety of societal problems such as homelessness, the revolving door syndrome wherein mental health consumers have frequent and brief hospital stays, poor housing situations, and contact with the criminal justice system (p. 182). Furthermore, persons with serious mental illness (SMI) must be able to acknowledge the need for assistance and seek it out when it is necessary.

While access to services is a problem, new advances in treatment are available, but not necessarily in wide usage. The authors note that there are many treatments existing with good research showing their effectiveness. A mental health system needs a wide variety of these evidence-based treatment options to deliver high quality care to persons with serious mental illness. Evidence-based treatments, using a comprehensive care approach, can do much to assist persons to better function in the community. Evidence based practices and programs include Assertive Community Treatment (ACT), medications, and psychotherapies such as cognitive therapy, to name a few.

Finally, the authors state there is a need to include other rehabilitative supports such as supported housing, supported employment, caregiver services, peer support and consumer operated support services. All these services either are evidence-based or are being studied to show their effectiveness. Family psycho-education, for example, has been shown to reduce relapse rates and aid in the recovery of persons with mental illness (Dixon, McFarland, Lefley, Lucksted, Cohen, Falloon, Mueser, Miklowitz, Solomon, & Sondheimer, 2001).

Young and Magnabosco (2004) end their chapter by stating that we are just now studying how best to improve care and disseminate effective mental health care interventions. In addition, they believe that a multidimensional approach may be necessary to bring about good outcomes. This approach requires the field to adopt learnings from physical health care including those related to information systems. Still, access remains a significant problem for many persons with mental illness.

A brief word about mental illness and incarceration

As mentioned above, societal problems remain. As Greenberg & Rosenheck (2008) found, two of these problems, homelessness and jail incarceration, appeared to be linked and can perpetuate each other. The issue of involvement with the justice system has become increasingly publicized as abuses to mentally ill inmates become known. Recent press reports particularly from Rikers Island in New York City, Cook County jail, and other large metropolitan jails have been prominent in the news.

In a recent report from the Treatment Advocacy Center, Torrey et al. (2014) state that “Prisons and jails have become America’s ‘new asylums’: The number of individuals with serious mental illness in prisons and jails now exceeds the number in state psychiatric hospitals tenfold . . . .” (p. 4). They further note that “. . .by shifting the venue . . . from hospitals to prisons and jails, we have succeeded in replicating the abysmal conditions of the past but in a nonclinical setting . . . “ (p. 8). In fact, some writers use the term “trans-institutionalization” to describe the problem created when persons were released into the community without needed supports for their mental illness (see, for example, Aufderheide, 2014).

Generally, around 20% of those in jails and prisons are thought to be seriously mentally ill, although some estimates can be found that show between 20 to 60 percent of inmates may have symptoms of mental illness (Steadman, Osher, Robbins, et al., 2009; Aufderhide, 2014; Kim, Coen, & Serakos, 2015). Further, close to 75% of state prisoners have co-occurring disorders [James & Glaze (2006) quoted in Kim et al.]. Many of those in jail have been detained for minor offenses such as trespassing, minor retail theft, disorderly conduct, and illicit drug use (Ollove, 2015). They are vulnerable to a variety of problems such as homelessness, recidivism, suicide, victimization, etc.

The Treatment Advocacy Center’s (TAC) survey of state jail and prison treatment practices found, among other things, that the estimate of inmates with severe mental illness in these institutions was estimated at 356,268 and about 35,000 such patients in state psychiatric hospitals. Further, a prison or jail in 44 states has more persons with serious mental illness than does a state’s largest remaining psychiatric facility. Although required to house persons with serious mental illness, in many cases jails and prisons are ill-equipped to provide the types of treatment necessary to alleviate psychiatric problems and prisoners often experience a worsening of their symptoms. They cite several horrific stories about the lack of treatment, such as the case of a man with schizophrenia in which 13 of his 15 years of prison were spent in solitary confinement.

For prison inmates with serious mental illness, the TAC study showed that 31 states including Missouri have authorized a procedure (sanctioned by a legal case, Washington v. Harper, which began in Washington state and was upheld by the U.S. Supreme Court) where involuntary treatment can occur if certain state-specific criteria are met and a treatment review committee composed of prison officials and a medical professional review the case.

In county jails, on the other hand, persons with mental illness receive little to no treatment. The TAC cites that a majority of counties require that persons with mental illness be transferred to a state facility before involuntary treatment can occur. This very recent editorial from the Washington Post, however, shows the difficulty of achieving a transfer and the deterioration of an inmate with mental illness who does not receive necessary treatment: https://www.washingtonpost.com/opinions/jamycheal-mitchells-ghastly-death/2015/10/03/fbdf862c-67b9-11e5-9ef3-fde182507eac_story.html

Until a permanent solution fixing the treatment of persons with serious mental illness is found the TAC report has six interim recommendations to help alleviate the current situation. They are:

1. Provide appropriate treatment for those in prison and jail

2. Implement and promote jail diversion programs (including crisis intervention teams)

3. Promote the use of assisted outpatient treatment

4. Encourage cost studies to determine true expenses of incarcerating inmates with mental illness.

5. Establish careful intake screening

6. Mandate release planning (p. 13).

Additional efforts to address the problem are underway. For example Ollove (2015) notes that in early May 2015, a coalition of organizations (Council of State Governments Justice Center, the American Psychiatric Foundation and the National Association of Counties) has started a national campaign to collect data on persons in jails with mental illness and to find strategies that prevent incarceration. The MacArthur Fund has provided monies to support jurisdictions that are looking for ways to decrease needless incarceration of individuals including those with mental illness. Steadman et al. (2009) also notes programs such as mental health courts, jail diversion projects, and trauma-recovery programs to veterans, all of which have been supported through various state and federal grants.

Additional Recent Developments for Adult Mental Health Systems

In 2006, Missouri was one of nine states to receive a Mental Health Transformation State Incentive Grant. These grants were designed to provide funding to states to improve and build additional infrastructure so that a more comprehensive public health approach could be planned and implemented. To help facilitate this, the grants were awarded to the Governor’s Office and managed by the Department of Mental Health. These grants were operational from 2007-2012.

An outgrowth of the six goals of the President’s New Freedom Commission, each Transformation State Incentive Grant funded state produced both a mental health needs assessment/resource inventory and a comprehensive plan to address the needs of those individuals with mental illness. Through the efforts of the grant in Missouri, the infrastructure was strengthened by expanding the use of evidence-based programs and practices, training mental health consumers as peer support specialists, creating a plan for implementing supported housing and employment, strengthening consumer operated services, using data to inform practices, and addressing many other of the types of treatment and services that have been mentioned above.

Another area that Missouri’s Transformation grant addressed was providing staff training and developing the infrastructure to assist individuals who have both mental and substance abuse disorders. The importance of addressing co-occurring problems cannot be overstated. Osher (2004) notes that there are an estimated 10 million people in the United States who meet the criteria for having both addictive and mental disorders. Though there is evidence-based treatment for these co-occurring disorders, the availability and access to comprehensive and integrated services is lacking. The author credits this to “. . . the fragmentation of existing service systems for people with numerous and complex clinical, social, and legal problems.” (p. 339). He further notes that the lack of coordination for co-occurring services and treatment is at both the clinical and administrative level.

Additionally, the linking of physical and mental health through co-location of services has been an important emphasis for Missouri. Through the Federally Qualified Health Center/Community Mental Health Center initiative, clients of the Department of Mental health can be provided a more holistic approach to health and wellness management. This is particularly important in that persons with mental illness are at increased risk for physical illness. In fact, there is evidence that they die 25 years, on average, earlier than other individuals, mostly due to treatable medical conditions (Manderscheid, Druss, & Freeman, 2007). Colton & Manderscheid (2006) in a study of clients in the public mental health system in eight states found that client deaths were from 4.9 to 1.2 times higher than what would be expected in the states and that they lost an average of between 13 to more than 30 years of life depending on the state and year.

Finally, Missouri is one of the nation’s leaders in the implementation of health homes. Health homes are another attempt to address the health needs of persons with mental illness in a more holistic way. We will be talking more in depth about health homes later in the semester.

As has been implied, the primary agency for addressing mental health and substance abuse prevention and treatment is the Substance Abuse and Mental Health Administration (SAMHSA). Created in 1992, it is part of the Department of Health and Human Services. Its vision is “ . . . to facilitate a life in the community for everyone by providing resources for individuals with mental health and/or substance use disorders and for their families.” (Retrieved on 10/2/2011 from http://www.edrugrehab.com/samhsa.html ). SAMHSA continues to provide funding to states for a variety of initiatives beyond transformation.

A SAMHSA document entitled Leading Change: A Call to Roles and Actions 2011-2014 released in 2011reflected a more public health approach to addressing the issue of behavioral health at the federal level. An update of that document entitled Leading Change 2.0: Advancing the Behavioral Health of the Nation 2015-2018 was released last year. This document outlines new strategic goals for mental health. Continuing the public health approach, there are six strategic initiatives. These include prevention of substance abuse and mental illness, health care and health systems integration, trauma and justice, recovery support, health information technology, and workforce development. This list of initiatives reflects the importance of mental health to the PPACA and builds on the Mental Health Parity and Addictions Equity Act of 2008.

In later lectures, among other things, we will be talking about the importance of recovery movement to persons with mental illness. We will also discuss health homes and the integration of health and mental health. Both of these are relatively new ideas and have great significance for consumers of mental health services.

Update

There have been a number of recent stories in the New York Times, Washington Post, and other newspapers about persons with mental illness. Many of them revolve around criminal justice. For example, the New York Times has had several stories about the continuing problems at the infamous jail at Rikers Island. The Washington Post had an editorial recently, based on the TAC report, http://www.washingtonpost.com/news/wonkblog/wp/2015/04/30/a-shocking-number-of-mentally-ill-americans-end-up-in-prisons-instead-of-psychiatric-hospitals/

We’ve noted others of them in the reading for this lesson. You can find many others that might be of interest to you. Some of these appear below.

You can find some interesting information on current, but controversial community treatment, particularly compulsory outpatient treatment at: http://www.nytimes.com/2013/07/30/us/program-compelling-outpatient-treatment-for-mental-illness-is-working-study-says.html?pagewanted=all&_r=0

Mary Buser, a social worker who worked on the mental health ward at Rikers Island, has just published a book (September 29, 2015) entitled: Lockdown on Rikers: Shocking Stories of Abuse and Injustice at New York’s Notorious Jail. You can find an early excerpt from the book at: http://solitarywatch.com/2014/02/28/bing-time-memories-mental-health-worker-rikers-islands-solitary-confinement-unit/

Also interesting reading is an account of the experience of a legislator and his quest to find treatment for his son with mental illness. You can find this at: http://content.healthaffairs.org/content/31/9/2138.full.pdf+html

This tragic story about a Virginia legislator and his son with mental illness shows the difficulty of obtaining much needed help. This article can be found at: http://www.washingtonpost.com/local/crime/virginia-state-senator-injured-in-home-another-person-found-dead-inside/2013/11/19/3e419ac4-512c-11e3-9fe0-fd2ca728e67c_story.html

Finally, a success story recently published in the Washington Post: https://www.washingtonpost.com/posteverything/wp/2015/09/23/jails-are-no-place-for-the-mentally-ill-i-was-lucky-to-get-out/

Assignment and Group Discussion

Briefly respond to the following two questions. Your responses and your participation in the group discussion will be worth 8 points.

1. In your opinion, how can we ensure that persons with mental illness get appropriate treatment in the community? What suggestions do you have to improve the mental health system. For example, should psychiatric hospitalization be more readily available?

2. Think about the issue of whether jails should be used as mental health treatment facilities. Should treatment be available in jails? If so, who should provide it and what kinds of treatment should be available. Are there better ways than jail time to treat persons with mental illness who commit low level crimes?

As usual, provide a citation or two to back up your arguments. Citations can be media (popular press, magazines, etc.) or scientific journal articles.

Please have your initial answers to the question on the Discussion Board by Friday so that you can respond to others in the class by Sunday night.

References

Aufderheide, D. (April 2014). Mental illness in America’s jails and prisons: Toward a public safety/public health model. Health Affairs Blog. Retrieved 10/2/2015 from: http://healthaffairs.org/blog

Barton, W.E. [1966 (2000)]. Trends in community mental health programs. Psychiatric Services, 51, 611-615. Reprinted from the original article in Hospital and Community Psychiatry, September 1966.

Colton, C.W., & Manderscheid, R.W. (April, 2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease: public Health Research, Practice, and Policy, 1-14. Retrieved on 9/25/2011 from: http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm

Dixon, L., McFarlane, W.R., Lefley, H., Lucksted, A., Cohen, M., Falloon, I., Mueser, K., Miklowitz, D., Solomon, P. & Sondheimer, D. (2001). Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatric Services, 52(7), 903-910.

Grob, G.N. (1991). From asylum to community: Mental health policy in modern America. Princeton, N.J.: Princeton University Press.

Kim, K., Becker-Cohen, M.B., Serakos, M. (March 2015). Processing and treatment of mentally ill persons in the criminal justice system: A scan of practice and background analysis. Urban Institute Research Report.

Koyangi, C. (2007). Learning From History: Deinstitutionalization of people with mental illness as precursor to long-term care reform. Kaiser Commission on Medicaid and the Uninsured. Retrieved on 9/26/2013 from: http://www.nami.org/Template.cfm?Section=About_the_Issue&Template=/ContentManagement/ContentDisplay.cfm&ContentID=137545

Manderscheid, R., Druss, B., & Freeman, E . (2007, August 15). Data to manage the mortality crisis: Recommendations to the Substance Abuse and Mental Health Services Administration. Washington, D.C.

Ollove, M. (May, 2015). New efforts to keep the mentally ill out of jail. Stateline, The Pew Charitable Trusts. Retrieved on 9/29/2015 from: http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/5/19/new-efforts-to-keep-the-mentally-ill-out-of-jail

Osher, F.C., (2004). The public health implications of co-occurring addictive and mental disorders. In Levin, B.L., Petrila, J., & Hennessy, K.D., Eds., Mental Health Services: A Public Health Perspective. Oxford: Oxford University Press, pp. 330-343.

Steadman, H.J., Osher, F.C., Robbins, P.C., Case, B., & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60, 761-765.

Torrey, E.F., Zdanowicz, M.T., Kennard, A.D., Lamb, H.R., Eslinger, D.F., Biasotti, M.C., & Fullder, D.A. (2014). The treatment of persons with mental illness in prisons and jails: A state survey. Treatment Advocacy Center. Retrieved on 10/1/2015 from: http://www.tacreports.org/treatment-behind-bars

Young, A.S., & Magnabosco, J.L. (2004). Services for adults with mental illness. In Levin, B.L., Petrila, J., & Hennessy, K.D., Eds., Mental Health Services: A Public Health Perspective. Oxford: Oxford University Press, pp. 177-208.