Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Chronic Mental Illness. Show all posts
Showing posts with label Chronic Mental Illness. Show all posts

Friday, October 7, 2022

Have American jails become the inferior replacement for mental hospitals?

Matthew Rozsa
Salon.com
Originally posted 5 SEPT 22

Here is an excerpt:

"We've known for some time that this country's chief response to serious mental illness is incarceration, a fact that stands out because prisons are so clearly unsuited to treating mental illness," Wanda Bertram, Communications Strategist at Prison Policy Initiative, told Salon by email. "Our organization recently found that even though 43% of people in state prisons have been diagnosed with a mental disorder, only 26% have received some form of mental health treatment, and only 6% are currently receiving treatment."

Bertram added, "The readiness with which our justice system fast-tracks people with mental illnesses into prison, despite knowing that jail and prison settings won't make that person any better, speaks volumes about the system's ability to deliver justice."

Dr. Craig Haney, a psychologist who has studied the psychological effects of incarceration for decades and a psychology professor at the University of California, Santa Cruz, offered some insight into why America tends to incarcerate rather than help people with mental illnesses.

"The structural origins start with the history of two simultaneous trends that began in the early 1970s," Haney wrote to Salon. The first was the widespread closing of publicly-funded mental hospitals "in part on the promise that they would be replaced by more humane community-based treatment, a promise that was never kept" and the second was "the beginning of a decades-long 'tough-on-crime' era in which politicians competed with each other on who could criminalize the most things and impose the longest sentences. So we shrunk our mental health system and increased the size of our prison system."

Bertram also attributed the trend to imprison people who are mentally ill to ideological choices.

"I think the major problem is an ideology that says that if you have some kind of illness, including mental illness, you ought to be the primary person responsible for your own care," Bertram explained. "That's the ideology that props up our healthcare system, where sick people bear extraordinary costs and crushing debts. And it keeps us from asking why mental health services like therapy, psychiatry, and long-term care are not only expensive, but difficult to access." Pointing out that their report revealed roughly half of people in state prisons lacked any kind of health insurance prior to their arrest, Bertram concluded that "we continue to send people with mental disorders to prison, because there seems to be nowhere else for them to go."

Monday, September 5, 2022

Advance directives for mental illness raise deep ethical questions

Tania Gergel
psyche.co
Originally posted 3 AUG 2022

Here is an excerpt:

What about the potential drawbacks? 

Medical ethicists worry that self-binding directives might allow involuntary treatment to be imposed on someone at an early stage of illness, while they are still capable of making an informed decision about treatment. How can we be sure that someone lacks what is known, in medical law, as ‘decision-making capacity’ and that we should be turning to the instructions in a document rather than what they are saying right now? Human rights advocates, such as the United Nations Committee on the Rights of Persons with Disabilities, go so far as to state that all involuntary treatment is a violation of an individual’s fundamental human rights.

The debate over self-binding directives has been working through these issues since the 1980s. However, one voice that was largely missing was the voice of ‘lived experience’. The arguments have gone backwards and forwards without asking the opinions of those who have the most intimate knowledge of what it is like to be unwell, and the likely consequences of illness; the very people who have found themselves hospitalised for mental illness and who may well have received involuntary treatment.

As part of ongoing research into mental health advance directives, our team at King’s College London conducted an internet survey in partnership with the charity Bipolar UK. We asked people who have lived with bipolar lots of questions about their views and any experiences of any forms of advance decision-making in relation to their condition. One of the questions we asked participants was whether they thought self-binding directives were a good idea and why they thought this. We found that 82 per cent of participants endorsed the self-binding directive idea, with the vast majority explaining this endorsement in terms of experiencing a determinate shift to distorted thinking and decision-making when they are unwell.

While ethicists might feel that the risk that someone retains decision-making capacity is a barrier to self-binding directives, many participants were adamant that their decision-making is impaired when they are unwell, and often mentioned ‘capacity’ in their responses, even though it was not alluded to within the questions themselves. A good example was this response:
You are unwell and lack capacity. I [recognise this now] looking back at when I was last sectioned, but my views were very different at the time due to my illness. It is my well views and opinions that should be acted upon.
Some people described this transition in terms of a shift of ‘self’, suggesting that illness makes them an entirely different person from their well self. As a philosopher working on medical ethics and law, I am particularly interested in questions about personal identity and illness, so it was fascinating to see answers such as this:
When psychotic or manic or depressed you can become another person and irrational. It is easy to make bad decisions when ill that may not be in my best interest.
When participants referred to the practical consequences and risks of illness, they were often related to suicide. People talked about how their ill self impelled them towards death in a way that was utterly inconsistent with their wishes when well.

Tuesday, September 25, 2018

Horrific deaths, brutal treatment: Mental illness in America’s jails

Gary A. Harki
The Virginian-Pilot
Originally published August 23, 2018

Here is an excerpt:

“We are arresting people who have no idea what the laws are or the rules are because they're off their medications,” said Nashville Sheriff Daron Hall, a vice president of the National Sheriffs’ Association. “You'd never arrest someone for a heart attack, but you're comfortable arresting someone who is diagnosed mentally ill. No other country in the world is doing it this way.”

In addition to causing pain and suffering for people with mental illness, the practice is costing municipalities millions.

At least 53 percent of the deaths examined have resulted in a lawsuit. Combined, the cases have cost municipalities at least $145 million. The true cost is much higher – in many cases, lawsuits are still pending and in others the settlement amount is secret. The figures also do not take into account lawyers’ fees.

The article is here.

There are a series of articles related to mental health issues in prison.

Saturday, May 19, 2018

County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care

Andrea G. Segal, Rosemary Frasso, Dominic A. Sisti
Qualitative Health Research
First published March 21, 2018

Abstract

Approximately 20% of the roughly 2.5 million individuals incarcerated in the United States have a serious mental illness (SMI). As a result of their illnesses, these individuals are often more likely to commit a crime, end up incarcerated, and languish in correctional settings without appropriate treatment. The objective of the present study was to investigate how correctional facility personnel reconcile the ethical challenges that arise when housing and treating individuals with SMI. Four focus groups and one group interview were conducted with employees (n = 24) including nurses, clinicians, correctional officers, administrators, and sergeants at a county jail in Pennsylvania. Results show that jail employees felt there are too many inmates with SMI in jail who would benefit from more comprehensive treatment elsewhere; however, given limited resources, employees felt they were doing the best they can. These findings can inform mental health management and policy in a correctional setting.

The information is here.

Wednesday, November 15, 2017

Catholic Hospital Group Grants Euthanasia to Mentally Ill, Defying Vatican

Francis X. Rocca
The Wall Street Journal
Originally posted October 27, 2017

A chain of Catholic psychiatric hospitals in Belgium is granting euthanasia to non-terminal patients, defying the Vatican and deepening a challenge to the church’s commitment to a constant moral code.

The board of the Brothers of Charity, Belgium’s largest single provider of psychiatric care, said the decision no longer belongs to Rome.

Truly Christian values, the board argued in September, should privilege a “person’s choice of conscience” over a “strict ethic of rules.”

The policy change is highly symbolic, said Didier Pollefeyt, a theologian and vice rector of the Catholic University of Leuven.

“The Brothers of Charity have been seen as a beacon of hope and resistance” to euthanasia, he said. “Now that the most Catholic institution gives up resistance, it looks like the most normal thing in the world.”

Belgium legalized euthanasia in 2002, the first country with a majority Catholic population to do so. Belgian bishops opposed the legislation, in line with the church’s catechism, which states that causing the death of the handicapped, sick or dying to eliminate their suffering is murder.

The article is here.

Monday, September 11, 2017

Nonvoluntary Psychiatric Treatment Is Distinct From Involuntary Psychiatric Treatment

Dominic A. Sisti
JAMA. Published online August 24, 2017

Some of the most ethically challenging cases in mental health care involve providing treatment to individuals who refuse that treatment. Sometimes when persons with mental illness become unsafe to themselves or others, they must be taken, despite their outward and often vigorous refusal, to an emergency department or psychiatric hospital to receive treatment, such as stabilizing psychotropic medication. On occasion, to provide medical care over objection, a patient must be physically restrained.

The modifier “involuntary” is generally used to describe these cases. For example, it is said that a patient has been involuntarily hospitalized or is receiving involuntary medication ostensibly because the patient did not consent and was forced or strongly coerced into treatment. Importantly, a person may be involuntarily hospitalized but retain the right to refuse treatment. “Involuntary” is also used to describe instances when an individual is committed to outpatient treatment by a court. The fact that a person is being treated involuntarily raises numerous challenges; it raises concerns about protecting individual liberty, respect for patient autonomy, and the specter of past abuses of patients in psychiatric institutions.

Although it has become both a clinical colloquialism and legal touchstone, the concept of involuntary treatment is used imprecisely to describe all instances in which a patient has refused the treatment he or she subsequently receives. In some cases, a patient outwardly refuses treatment but may have previously expressed a desire to be treated in crisis or, according to a reasonable evaluator, he or she would have agreed to accept stabilizing treatment, such as antipsychotic medication. A similar scenario occurs in the treatment of individuals who experience a first episode of psychosis and who outwardly refuse treatment. With no prior experience of what it is like to have psychosis, these patients are unable to develop informed preferences about treatment in advance of their first crisis. In these cases, some believe it is reasonable to provide treatment despite the opposition of the patient, although this could be debated.

The article is here.

Monday, August 7, 2017

Study suggests why more skin in the game won't fix Medicaid

Don Sapatkin
Philly.com
Originally posted July 19, 2017

Here is an excerpt:

Previous studies have found that increasing cost-sharing causes consumers to skip medical care somewhat indiscriminately. The Dutch research was the first to examine the impact of cost-sharing changes on specialty mental health-care, the authors wrote.

Jalpa A. Doshi, a researcher at the University of Pennsylvania’s Leonard Davis Institute of Health Economics, has examined how Americans with commercial insurance respond to cost-sharing for antidepressants.

“Because Medicaid is the largest insurer of low-income individuals with serious mental illnesses such as schizophrenia and bipolar disorder in the United States, lawmakers should be cautious on whether an increase in cost sharing for such a vulnerable group may be a penny-wise, pound-foolish policy,” Doshi said in an email after reading the new study.

Michael Brody, president and CEO of Mental Health Partnerships, formerly the Mental Health Association of Southeastern Pennsylvania, had an even stronger reaction about the possible implications for Medicaid patients.

The article is here.

Wednesday, April 19, 2017

Should Mental Disorders Be a Basis for Physician-Assisted Death?

Paul S. Appelbaum
Psychiatric Services
Volume 68, Issue 4, April 01, 2017, pp. 315-317

Abstract

Laws permitting physician-assisted death in the United States currently are limited to terminal conditions. Canada is considering whether to extend the practice to encompass intractable suffering caused by mental disorders, and the question inevitably will arise in the United States. Among the problems seen in countries that have legalized assisted death for mental disorders are difficulties in assessing the disorder’s intractability and the patient’s decisional competence, and the disproportionate involvement of patients with social isolation and personality disorders. Legitimate concern exists that assisted death could serve as a substitute for creating adequate systems of mental health treatment and social support.

The article is here.

Thursday, March 2, 2017

Jail cells await mentally ill in Rapid City

Mike Anderson
Rapid City Journal
Originally published February 7, 2017

Mentally ill people in Rapid City who have committed no crimes will probably end up in jail because of a major policy change recently announced by Rapid City Regional Hospital.

The hospital is no longer taking in certain types of mentally ill patients and will instead contact the Pennington County Sheriff’s Office to take them into custody.

The move has prompted criticism from local law enforcement officials, who say the decision was made suddenly and without their input.

“In my view, this is the biggest step backward our community has experienced in terms of health care for mental health patients,” said Rapid City police Chief Karl Jegeris. “And though it’s legally permissible by statute to put someone in an incarceration setting, it doesn’t mean that it’s the right thing to do.”

This is the second major policy change to come out of Regional in recent days that places limits on the type of mental health care the hospital will provide.

The article is here.

Thursday, December 22, 2016

Hard Time or Hospital Treatment? Mental Illness and the Criminal Justice System

Christine Montross
The New England Journal of Medicine
2016; 375:1407-1409

Here is an excerpt:

When law enforcement is involved, the trajectory of my patients’ lives veers sharply. The consequences are unpredictable and range from stability and safety to unmitigated disaster. When patients are ill or afraid enough to be potentially assaultive, the earliest decision as to whether they belong in jail or in the hospital may shape the course of the next many years of their lives.

It’s now well understood that the closing of state hospitals in the 1970s and 1980s led to the containment of mentally ill people in correctional facilities. Today our jails and state prisons contain an estimated 356,000 inmates with serious mental illness, while only about 35,000 people with serious mental illness are being treated in state hospitals — stark evidence of the decimation of the public mental health system.

When a mentally ill person comes into contact with the criminal justice system, the decision about whether that person belongs in jail or in the hospital is rarely a clinical one. Instead, it’s made by the gatekeepers of the legal system: police officers, prosecutors, and judges. The poor, members of minority groups, and people with a history of law-enforcement involvement are shuttled into the correctional system in disproportionate numbers; they are more likely to be arrested and less likely than their more privileged counterparts to be adequately treated for their psychiatric illnesses.

The article is here.

Wednesday, November 2, 2016

Hard Time or Hospital Treatment? Mental Illness and the Criminal Justice System

Christine Montross
N Engl J Med 2016; 375:1407-1409
October 13, 2016

Here is an excerpt:

When law enforcement is involved, the trajectory of my patients’ lives veers sharply. The consequences are unpredictable and range from stability and safety to unmitigated disaster. When patients are ill or afraid enough to be potentially assaultive, the earliest decision as to whether they belong in jail or in the hospital may shape the course of the next many years of their lives.

It’s now well understood that the closing of state hospitals in the 1970s and 1980s led to the containment of mentally ill people in correctional facilities. Today our jails and state prisons contain an estimated 356,000 inmates with serious mental illness, while only about 35,000 people with serious mental illness are being treated in state hospitals — stark evidence of the decimation of the public mental health system.

When a mentally ill person comes into contact with the criminal justice system, the decision about whether that person belongs in jail or in the hospital is rarely a clinical one. Instead, it’s made by the gatekeepers of the legal system: police officers, prosecutors, and judges. The poor, members of minority groups, and people with a history of law-enforcement involvement are shuttled into the correctional system in disproportionate numbers; they are more likely to be arrested and less likely than their more privileged counterparts to be adequately treated for their psychiatric illnesses.

The article is here.

Wednesday, September 28, 2016

The Ethics of Behavioral Health Information Technology

Michelle Joy, Timothy Clement, and Dominic Sisti
JAMA. Published online September 08, 2016.
doi:10.1001/jama.2016.12534

Here is an excerpt:

Individuals with mental illness and addiction experience negative stereotyping, prejudice, discrimination, distancing, and marginalization—social dynamics commonly called stigma. These dynamics are also often internalized and accepted by individuals with mental health conditions, amplifying their negative effect. Somewhat counterintuitively, stigmatizing beliefs about these patients are common among health care workers and often more common among mental health care professionals. Given these facts, the reinforcement of any stigmatizing concept within the medical record system or health information infrastructure is ethically problematic.

Stigmatizing iconography presents the potential for problematic clinical consequences. Patients with dual psychiatric and medical conditions often receive low-quality medical care and experience worse outcomes. One factor in this disparity is the phenomenon of diagnostic overshadowing. For example, diagnostic overshadowing can occur in patients with co-occurring mental illness and conditions such as cardiovascular disease or diabetes. These patients are less likely to receive appropriate medical care than patients without a mental health condition—their psychiatric conditions overshadow their other conditions, potentially biasing the clinician’s judgment about diagnosis and treatment such that the clinician may misattribute physical symptoms to mental health problems.

The article is here.

Wednesday, August 24, 2016

The Controversial Issue of Euthanasia in Patients With Psychiatric Illness

Emilie Olie & Philippe Courtet
JAMA. 2016;316(6):656-657

A main objective of legalization of euthanasia or physician-assisted suicide (EAS) is to ease suffering (ie, physical pain and loss of autonomy elicited by an irreversible serious disease), when a terminally ill patient's pain is overwhelming despite palliative care. It implies that there is no reasonable alternative in the patient's situation, with no prospect of improvement of a painful condition or global functioning. Because mental disorders are among the most disabling illnesses, requests for EAS based on unbearable mental suffering caused by severe psychiatric disease may possibly increase. EAS may be differentiated from suicide because EAS results in death without self-inflicted behavior, yet both are driven by a desire to end life. This raises the question: Should the management of patients with psychiatric disorders requesting EAS be considered for suicide prevention?

Mental illness increases suicidal risk and requires treatment. Nevertheless, evidence-based medical and psychosocial treatments currently are not provided to the majority of patients with psychiatric diseases who would benefit. Even if these therapies were prescribed, about 30% of depressed patients are treatment resistant. Patients may have undergone treatments destined to fail or they may have refused potential effective therapeutics. Nevertheless, the probability of disease remission increases with number of different treatments attempted. Given these uncertainties and that there are no valid indicators to predict the response to treatment, there is no reliable mechanism to define incurable disease and determine medical futility for psychiatric care. Considering euthanasia for psychiatric patients may reinforce poor expectations of the medical community for mental illness treatment and contribute to a relative lack of progress in developing more effective therapeutic strategies.

The article is here.

Thursday, June 23, 2016

How to Fix a Broken Mental-Health System

by Norm Ornstein
The Atlantic
Originally published June 8, 2016

Here is an excerpt:

And, for people with the most serious diseases, who cannot recognize they are ill or who have deep psychoses that leave them detached from much of reality, we need to recalibrate the balance between civil liberties and the need to provide real treatment—the kind of wraparound, assisted outpatient treatment (AOT) that Leifman has pioneered in Florida—while making it easier, with appropriate safeguards, for family members to intervene to help their loved ones.

In Washington, the good news is that reforming the system to deal with mental illness is one of the few areas where there is serious bipartisan cooperation and action—including, in the Senate, Democrats like Debbie Stabenow, Chris Murphy, and Al Franken, and Republicans like Roy Blunt, Bill Cassidy, and John Cornyn. In the House, there’s a major bill cosponsored by Republican Tim Murphy, the body’s only psychologist, and Democrat Eddie Bernice Johnson, a former psychiatric nurse.

Of course, there is bad news—this is American politics in 2016. The highly dysfunctional Congress is stymied from action so far even in areas that have broad and deep bipartisan support, like  Puerto Rico’s debt crisis, the opioid crisis, and criminal-justice reform.

The article is here.

Friday, June 10, 2016

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.

Monday, June 6, 2016

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.

Monday, May 2, 2016

Mental illness: Families cut out of care

Liz Szabo
USA TODAY
Originally posted April 14, 2016

Here is an excerpt:

The federal law, called the Health Insurance Portability and Accountability Act, or HIPAA, forbids health providers from disclosing a patient’s medical information without consent.

Unlike patients with physical conditions, people with serious mental illness often need help making decisions and taking care of themselves, because their illness impairs their judgement, says Jeffrey Lieberman,chairman of psychiatry at the Columbia University College of Physicians and Surgeons and director of the New York State Psychiatric Institute. In some cases, patients may not even realize they’re sick.

Excluding families can have a devastating impact on patients like these, Lieberman says.

Many health providers don’t understand what HIPAA actually allows them to say. As a result, they often shut families out, even in circumstances in which they’re legally allowed to share information, says Ron Manderscheid, executive director of the National Association of County Behavioral Health and Developmental Disability Directors.

The article is here.

Friday, April 1, 2016

Assisted Outpatient Treatment: APA’s Position Statement

Renée Binder
Psychiatric News
Originally posted February 29, 2016

Here is an excerpt:

  • Is AOT ethical? Some opponents of AOT feel that it is unethical to force patients into treatment except for emergency treatment, that is, when a patient is a danger to self, a danger to others, or unable to care for basic needs. They argue that AOT goes against the principles of autonomy and right to self-determination.

Opponents contend that even if someone has a chronic mental illness and has a history of hospitalization or incarceration, they still have the right to decide if they want to comply with treatment, barring an emergency. AOT supporters argue that AOT is consistent with the principle of beneficence and tries to intervene before someone meets the criteria for involuntary hospitalization to prevent deterioration based on past history. After reviewing the arguments on both sides, the APA position statement supports the use of AOT and opines that it is ethical when used appropriately.

The article is here.

Monday, January 25, 2016

Texas allows guns into state mental health hospitals

By Rick Jervis
USA TODAY
Originally published January 8, 2016

Here is an excerpt:

Visitors to one of Texas' 10 state mental health hospitals will be allowed to openly carry weapons into the facilities, according to the Texas Department of State Health Services. Employees and patients will still be barred from bringing in weapons. The hospitals this week pulled down signs banning guns at its facilities and posted new ones asking people to leave their firearms in their cars or conceal them from patients, said Carrie Williams, a state health department spokeswoman.

“While licensed visitors are legally permitted to carry on our hospital campuses, our patients are being actively treated for psychiatric conditions and generally it’s best not to expose them to weapons of any kind.,” Williams said in statement.

The article is here.

Sunday, December 27, 2015

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.