Decriminalizing Mental Illness — The Miami Model

John K. Iglehart
N Engl J Med 2016; 374:1701-1703

Here is an excerpt:

Miami-Dade’s initiative was launched in 2000, when Judge Leifman, frustrated by the fact that people with mental disorders were cycling through his court repeatedly, created the Eleventh Judicial Circuit Criminal Mental Health Project (CMHP). As Leifman explained, “When I became a judge . . . I had no idea I would become the gatekeeper to the largest psychiatric facility in the State of Florida. . . . Of the roughly 100,000 bookings into the [county] jail every year, nearly 20,000 involve people with serious mental illnesses requiring intensive psychiatric treatment while incarcerated. . . . Because community-based delivery systems are often fragmented, difficult to navigate, and slow to respond to critical needs, many individuals with the most severe and disabling forms of mental illnesses . . . fall through the cracks and land in the criminal justice or state hospital systems” that emphasize crisis resolution rather than “promoting ongoing stable recovery and community integration.”

The article is here.

Stopping the revolving prison door for the mentally ill

by Courtenay Harris Bond
Phillie.com
Originally posted May 10, 2016

Here is an excerpt:

But the unfortunate reality right now is that many people with serious mental illness who commit even minor infractions are locked up, making over-crowded prisons and jails responsible for mental health services they are ill equipped to deal with.

“The police are called on to do too much, and the health care system is not doing enough,” Sisti said. “The whole idea that the police are now front-line mental health workers shows that we’ve abdicated our responsibilities as health care professionals.”

“The police in their best efforts aren’t equipped with the tools”—psychiatric medications, for example, that only physicians and nurses can administer­—“to de-escalate some of these situations,” added Cyndi Rickards, an assistant professor in the Department of Criminology and Justice Studies at Drexel.

Dr. Philip Candilis, director of the forensic psychiatry fellowship at St. Elizabeth’s Hospital in Washington, described a jail diversion program in Arlington, Va., where courts work with social service agencies to aid people struggling with mental illness who find themselves in trouble with the law. Mental health courts in Philadelphia and Washington function in a similar way.

The article is here.

Pentagon perpetuates stigma of mental health counseling, study says

Gregg Zoroya
USA Today
Originally published May 5, 2016

Even as troop suicides remain at record levels, the Pentagon has failed to persuade servicemembers to seek counseling without fears that they'll damage their careers, a stinging government review concludes.

Despite six major Pentagon or independent studies from 2007 through 2014 that urged action to end the persistent stigma linked to mental health counseling, little has changed, analysts said in the April report by the Government Accountability Office.

The article is here.

Tennessee Lawmakers Pass Bill Permitting Mental Health Professionals to Discriminate

By Eric Levitz
New York Magazine
Originally posted April 6, 2016

Tennessee's House of Representatives just passed a bill that would allow therapists who believe homosexuality is the mark of Satan to refuse to treat gay clients. More precisely, the bill allows mental-health counselors to deny treatment to anyone who seeks help with "goals, outcomes, or behaviors that conflict with the sincerely held principles of the counselors or therapist." If the bill makes it into law, Tennessee would be the first state to allow therapists to pick what kind of clients they're willing to serve.

From a certain angle, the law may appear more significant on a symbolic level than a practical one: If you're a gay teenager looking for someone to counsel you through your first same-sex relationship, it's probably in your interest to see someone who doesn't think that relationship will bring you eternal hellfire. But what's really at stake in the legislation is what the ethical code for licensed mental-health professionals in the United States will entail. The bill was drafted in reaction to the American Counseling Association's 2014 code of ethics, which warned counselors not to impose their personal values onto their clients. Tennessee's bill would allow the state's mental-health professionals to reject clients — for failing to conform to their beliefs — without losing their licenses.

The article is here.

Doctors Often Fail To Treat Depression Like A Chronic Illness

Shfali Luthra
NPR.org
Originally published March 7, 2016

Depression prompts people to make about 8 million doctors' appointments a year, and more than half are with primary care physicians. A study suggests those doctors often fall short in treating depression because of insurance issues, time constraints and other factors.

More often than not, primary care doctors fail to teach patients how to manage their care and don't follow up to see how they're doing, according to the study, which was published Monday in Health Affairs. Those are considered effective tactics for treating chronic illnesses.

"The approach to depression should be like that of other chronic diseases," said Dr. Harold Pincus, vice chair of psychiatry at Columbia University's College of Physicians and Surgeons and one of the study's co-authors. But "by and large, primary care practices don't have the infrastructure or haven't chosen to implement those practices for depression."

Most people with depression seek help from their primary care doctors, the study notes. That can be because patients often face shortages and limitations of access to specialty mental health care, including lack of insurance coverage, the authors write. Plus there's stigma: Patients sometimes feel nervous or ashamed to see a mental health specialist, according to the authors.

The article is here.

How America's criminal justice system became the country's mental health system

By German Lopez
Vox.com
Originally published March 1, 2016

Here are two excerpts:

It's a terrifying statistic: Someone with an untreated mental illness is 16 times more likely to be killed by police than other civilians approached or stopped by law enforcement, according to a 2015 report by the Treatment Advocacy Center.

(cut)


If people were getting comprehensive care and support, police most likely would not need to get involved in many of the circumstances that end up in horrible tragedies. But very often in the US, that's not happening.

Before Kevin broke into a neighbor's house and was arrested by police, Pete tried to take steps that would have prevented the whole encounter. Kevin had just suffered a psychotic episode in 2002, and Pete raced Kevin to emergency care to hopefully get Kevin into some form of long-term care, potentially against Kevin's will if necessary.

But doctors said they couldn't do anything because Kevin, an adult, didn't appear to pose a threat to himself or others in the four hours they sat in an emergency room. So he was let free, and within 48 hours, he went through the episode in which he broke into the neighbor's house.

The article is here.

Mental health care 'is ruining lives'

By Nick Triggle
Health correspondent - BBC
Originally posted February 15, 2016

Inadequate and underfunded mental health care in England is leading to thousands of "tragic and unnecessary deaths" a review has found.

The report - by a taskforce set up by NHS England - said around three-quarters of people with mental health problems received no help at all.

It said more needs to be done to tackle rising suicide rates.

Ministers agreed with the findings, committing a £1bn extra a year by 2020 to treat a million more people.

This is to come out of the £8.4bn the government has promised to the health service during this Parliament and comes on top of extra money already announced for children's services.

Prime Minister David Cameron said the plan would help put "mental and physical healthcare on an equal footing".

The article is here.

Editorial Note: In spite of federal legislation in the United States insuring mental health parity, there are frequent reports of insurance companies not following the law.  Additionally, the mental health system in the US is chronically underfunded through insurance companies as well as local, state, and federal systems.

Mental health on college campuses: A look at the numbers

By Sarah Sabatke
USA Today
Originally published January 30, 2016

Approximately 42,773 Americans commit suicide every year, according to the American Foundation for Suicide Prevention, many of whom are college students.

The University of Pennsylvania, Tulane University, Appalachian State University and Yale University, among others, made national headlines in recent years after student suicides rocked their campus communities, highlighting a growing need for comprehensive mental healthcare on college campuses.

The page of statistics and infographics is here.

Under Gun Rules, FBI Will Receive Health Data

By Robert Pear
The New York Times
Originally posted January 6, 2016

Here is an excerpt:

Virtually every push for new gun sale restrictions in recent years has been greeted by opponents countering with proposals to address mental health as a factor in gun violence.

“For those in Congress who so often rush to blame mental illness for mass shootings as a way of avoiding action on guns, here’s your chance to support these efforts,” Mr. Obama said at the White House on Tuesday.

But that challenge moved the administration into a thicket of difficult health questions. Under a rule published Wednesday in the Federal Register, the background check system run by the Federal Bureau of Investigation will receive the names of people who are forbidden to buy or own firearms because they have been involuntarily committed to a mental institution or found to pose a danger to themselves or others.

The article is here.

Mental Health Reform Will Not Reduce US Gun Violence, Experts Say

Rita Rubin
JAMA.
Published online December 16, 2015. doi:10.1001/jama.2015.16421

Here is an excerpt:

But while few people would disagree with the need for mental health reform, scientists who study gun violence say it won’t make much of a dent in the number of homicides and attempted homicides committed with firearms. That’s because although mass shooters are likely to be mentally ill (but not necessarily diagnosed), high-profile mass shootings represent only a small fraction of US gun violence, the vast majority of which is committed by people who are not mentally ill. In addition, most people with mental illness are not violent; they are far more likely to be the victims than the perpetrators of shootings.

People should realize that “even though it feels that mass shootings happen all the time, they’re still extremely rare,” said Jeffrey Swanson, PhD, a professor of psychiatry and behavioral sciences at Duke University.

Through early December 2015, about 450 individuals died in mass shootings in the United States last year, according to Mass Shooting Tracker, a crowd-sourced website that defines a mass shooting as one in which at least 4 people have been shot but not necessarily killed (http://bit.ly/1MuHpVL). Compare that with 11 208, the number of people killed in homicides committed with firearms in 2013, the most recent year for which the Centers for Disease Control and Prevention (CDC) has US data (http://1.usa.gov/1GEJ0TN).

The entire article is here.

Survey: 8 in 10 US doctors feel unprepared to treat mentally ill

By Sarah Ferris
The Hill
Originally published December 7, 2015

More than eight in 10 family doctors in the U.S. say they are not adequately prepared to care for severely mentally ill patients, according to a survey released Monday by the Commonwealth Fund.

Just 16 percent of U.S. doctors said their offices had the capacity to care for those with serious mental illnesses, the lowest of any other developed country besides Sweden, according to the annual international study.

Diagnosing and treating mental illnesses has come increasingly into focus this year as the number of mass shootings committed by mentally unstable individuals continues to rise. GOP leaders in Congress have repeatedly pointed to mental health reform as their best response to the nation's epidemic of shootings.

The entire article is here.

Common Violations

Parity Track
A website dedicated to inform about mental health parity.

Here are some of the most common ways your parity rights could be violated. Please keep in mind that not every possible parity violation is on this page.

1. I have a separate deductible for behavioral health services that is not part of my overall deductible.

2. My co-pay for behavioral health services is higher than it is for other health services.

3. I have limits on how many time I can see a behavioral health provider.

The website is here.

When Students Become Patients, Privacy Suffers

By Charles Ornstein
ProPublica
Originally published October 23, 2015

Here is an excerpt:

Yale Health’s website informs parents that they cannot access their child’s health information without a signed written consent form. Andrea said she does not recall signing that document. When she recently asked to see any such form, she said, she was told by the counseling center’s chief that there was none. “Most of what happened while I was in the hospital happened without my knowing it,” she said. “I got an update every day or two about where my life was going.”

Andrea’s case is a vivid demonstration of how weaknesses in state and federal laws — and the often-conflicting motives of students, parents, and college officials — have left patient privacy vulnerable when students receive medical treatment on campus.

Universities walk a fine line when providing that treatment or mental-health services to students. If campus officials don’t know what’s going on or disclose too little, they risk being blamed if a student harms himself, herself, or others. If they pry too deeply, they may be accused of invading privacy, thereby discouraging students from seeking treatment.

The entire article is here.

Is mental health 'parity' law fulfilling its promise?

By Jenny Gold
Kaiser Health News/CNN
Originally posted on September 20, 2015

Here is an excerpt:

The so-called parity law, which was intended to equalize coverage of mental and other medical conditions, has gone a long way toward eliminating obvious discrepancies in insurance coverage. Research shows, for instance, that most insurers have dropped annual limits on the therapy visits that they will cover. Higher copayments and separate mental health deductibles have become less of a problem.

But many insurers have continued to limit treatment through other strategies that are harder to track, according to researchers, attorneys and other critics. Among the more murky areas is "medical necessity" review -- in which insurers decide whether a patient requires a certain treatment and at what frequency.

Kamins is among a small group of people around the country to file lawsuits alleging federal or state parity laws were violated when patients with mental illness were held to a stricter "medical necessity" standard than those with other medical conditions.

The entire article is here.

Guns, suicide prevention, and backwoods lifestyles

By Massad Ayoob
Backwoods Home Magazine
Originally published June 2015

Things to look for

Don't expect the warning signal to be as obvious as "Hey, I need a gun ... and one cartridge." When someone known to you as a non-gun owner asks to borrow a gun, quiz them as to why. Don't make it an accusing "Whaddaya want a deadly weapon for?" Instead, say something like, "Well, guns are tools. If you asked to borrow one of my tools, I'd ask you if you're going to cut boards or pound nails, because that would help me to decide whether to lend you a saw or a hammer. Different guns are for shooting different things. What do you need to shoot?" And take it from there.

An answer like, "I just need a gun!" is a red flag. More questioning — and analysis of answers — is indicated. In the NHFSC program, gun dealers are taught to ask, "Do you have a cleaning kit?" A "yes" answer is fairly copacetic. The cryptic "I won't be needing that" may be another red flag.

If a neighbor asked to borrow a chainsaw or your backhoe or something in between, one of your first questions would be, "How experienced are you with that equipment?" If the answer was anything from "It doesn't matter" to "None of your business," I doubt you'd be lending them that gear. The same must be true with a firearm! If the person requesting is someone you know or suspect has little or no knowledge of firearms operation and safety, invite them to a firearms safety session. If the answer is anything like "I don't need it" or "I don't have time for that," another red warning flag is flying.

You, the friend/relative/neighbor, have an advantage the person behind the gun shop counter does not: You know this person. Apply that knowledge to their request for a gun.

Have they been depressed lately? Gravely ill? Suffered the loss of a loved one, or a crushing economic reverse? Have they been recently dumped by a lover or spouse? I put the latter in italics for two reasons: It seems to be a particular trigger for the departure-from-life impulse, and it's associated with not just intent to commit suicide, but sometimes, intent to commit murder as well. All of these can be red flags.

When someone you know asks to borrow a lethal weapon, and it seems out of character for them to do so, be particularly alert for signs of "departure ritual." The person who has committed herself to leaving life behind will often put her affairs in order. The person who has been chronically tardy in paying bills suddenly brings all accounts up to date, for example. Conversely, in one case I worked, the individual burned all his bills in a ritual bonfire the night before he committed "suicide by cop," attacking police with a weapon and forcing a sergeant to shoot him to death.

The entire blog post is here.

Massad participated in an Ethics and Psychology podcast that can be found here.

A shocking number of mentally ill Americans end up in prison instead of treatment

By Ana Swanson
The Washington Post
Originally published April 30, 2015

Here is an excerpt:

For various reasons, these community treatment plans proved inadequate, leaving many of the mentally ill homeless or in jail. According to the Department of Justice, about 15 percent of state prisoners and 24 percent of jail inmates report symptoms meet the criteria for a psychotic disorder.

In its survey of individual states, the Treatment Advocacy Center found that in 44 of the 50 states and the District of Columbia, the largest prison or jail held more people with serious mental illness than the largest state psychiatric hospital (see map below). The only exceptions were Kansas, New Jersey, North Dakota, South Dakota, Washington and Wyoming. "Indeed, the Polk County Jail in Iowa, the Cook County Jail in Illinois, and the Shelby County Jail in Tennessee each have more seriously mentally ill inmates than all the remaining state psychiatric hospitals in that state combined," the report says.

The entire article is here.

Mental-Health Crunch on Campus

By Melissa Korn and  Angela Chen
The Wall Street Journal
Originally published April 28, 2015

Universities are hiring more social workers, psychologists and psychiatrists as demand for campus mental-health services rises. But persistent budget gaps mean that students in some cases foot much of the cost of the positions.

Students at George Washington University will be charged an additional $1,667 in tuition next year, a jump of 3.4%. More than $830,000 of the resulting new revenue will pay for mental-health services.

(cut)

“The demand [by students] so outpaces the supply of appointments that it’s very hard to get a weekly appointment, even for students having pretty serious symptoms that interfere with their academic function,” said Elizabeth Gong-Guy, executive director of counseling and psychological services at UCLA and president of the Association for University and College Counseling Center Directors.

The entire article is here.

Most Prisoners Are Mentally Ill

By Olga Khazan
The Atlantic
Originally posted April 7, 2015

Here is an excerpt:

The numbers are even more stark when parsed by gender: 55 percent of male inmates in state prisons are mentally ill, but 73 percent of female inmates are. Meanwhile, the think-tank writes, "only one in three state prisoners and one in six jail inmates who suffer from mental-health problems report having received mental-health treatment since admission."

An increasingly popular program might help thin the ranks of these sick, untreated inmates. What are known as "mental-health courts" have sprung up in a number of states as an alternative to incarceration. A shoplifter who has, say, schizophrenia might be screened and found eligible for mental-health court, and then be sentenced to judicially supervised treatment. These types of courts have expanded rapidly since 2000, and there are now hundreds around the country.

The entire article is here.

Mental health coverage unequal in many Obamacare plans

By Laura Ungar and Jayne O'Donnell
USA Today
Originally posted March 9, 2015

Insurance coverage for mental and physical illness remains unequal despite promises that Obamacare would help level the playing field, mental health advocates and researchers say.

A new study by the Johns Hopkins Bloomberg School of Public Health found that consumer information on a quarter of the Obamacare plans that researchers examined appeared to go against a federal "parity" law designed to stop discrimination in coverage for people with mental health or addiction problems.

This makes it nearly impossible for consumers to find the best plan to cover their mental health needs, the research suggests.

The entire article is here.

The Growing Risk of Suicide in Rural America

Young people in the countryside have more guns, fewer doctors, and are more isolated than their urban counterparts—and a new study says they're killing themselves in greater numbers.

By Julie Beck
The Atlantic
Originally published March 10, 2015

In rural America, where there are more guns, fewer people, and fewer doctors than in the urban U.S., young people are at particular risk of suicide.

A study published Monday in JAMA Pediatrics analyzed suicides among people aged 10 to 24 between 1996 and 2010, and found that rates were nearly doubled in rural areas, compared to urban areas. While this gap existed in 1996 at the beginning of the data set, it widened over the course of this time period, according to Cynthia Fontanella, the lead author on the study, and a clinical associate professor of psychiatry at Ohio State University’s Wexner Medical Center.

The entire article is here.