American Psychosis (29 page)

6.
Political interests to maintain the status quo
. Politically conservative state legislators and officials have gladly ceded fiscal responsibility for seriously mentally ill persons
to the federal government, thereby reducing costs to the states. Politically liberal legislators and officials, at both the federal and state levels, assume that the federal government should take responsibility for solving most social problems, including the care of persons with serious mental illness. This combination of politically conservative and liberal bedfellows is a major impediment to change.

7.
The federal government
. Given the fact that the present mental illness disaster is a direct product of federal programs implemented half a century ago, one might think that federal officials would attempt to take corrective actions. Such an assumption would be wrong. The federal government’s programs related to individuals with serious mental illnesses have continued to be a potpourri of completely uncoordinated programs, some of which counteract each other and many of which have made the problem worse. For example, in the late 1980s at the NIMH, research programs were attempting to find the causes of, and better treatments for, serious mental illnesses. Another NIMH program, the Protection and Advocacy program, was supporting public conferences at which invited speakers denied that mental illnesses exist and claimed that psychiatric medications destroy the brain.

NIMH subsequently righted itself with good leadership in the last decade, but the Protection and Advocacy program became part of another government agency, the Substance Abuse and Mental Health Services Administration (SAMHSA). In the
National Review
, I noted regarding this agency that “the health of its clients would improve if it went out of business.” Although the official mission of SAMHSA is to reduce “the impact of substance abuse and mental illness in America’s communities,” many of SAMHSA’s programs exacerbate the problem. For example, SAMHSA gives hundreds of thousands of dollars to groups in states such as California and Pennsylvania that attempt to block the implementation of laws that would make it easier to treat people with serious mental illnesses. SAMHSA also gives $330,000 a year to the National Empowerment Center in Massachusetts, whose director believes that “the covert mission of the mental health system . . . is social control.” Such federal programs are thus impediments to change, because once started, federal programs are extremely difficult to abolish. Thus, the federal government is a major impediment to improving the mental illness treatment system.
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8.
Lack of leadership
. Of all the impediments to change, this may be the most significant, as change will not occur without leadership. Disorders such as cancer and heart disease have large, effective organizations that lobby for research and improved services. Serious mental illnesses have nothing comparable. Mental Health America, formerly the Mental Health Association, advocates weakly for “mental health” but says virtually nothing about mental illness. NAMI, formerly the National Alliance
for the Mentally Ill, does a creditable job of providing education and support for mentally ill persons and their families at the local level but has had virtually no effect in most states or at the federal level. The Treatment Advocacy Center, which I helped organize in 1998, focuses exclusively on the problems described in this book but is a small organization with an annual budget of just $1 million.

Other possible sources for leadership are unpromising. Three decades ago, leadership still existed among state mental health directors, but now such positions are filled by administrators whose only task is to empty the hospitals and shift state costs to the federal government. The American Psychiatric Association, which was originally organized to focus attention on the care and treatment of individuals with serious mental illnesses, has long since abandoned that population and now functions mostly as a lobby to protect the economic interests of psychiatrists. Except for Dr. Thomas Insel, director of NIMH, Washington is devoid of leadership for the problems of individuals with serious mental illnesses. Congress at one time had leaders such as Senators Pete Domenici and Paul Wellstone who provided strong support, but since Domenici’s retirement and Wellstone’s death, nobody has stepped forward to take their place. In summary, it is not clear where the leadership for change will come from, but until it emerges, change is unlikely.

WHAT SHOULD WE DO?

The many impediments to change are the bad news. However, the fact that we know what to do to correct the existing mental illness disaster is the good news. There is a surprisingly broad consensus on what good services should look like, although there is less agreement on how they should be organized and funded. To illustrate the solutions, I will review the fundamental errors of deinstitutionalization—closing the hospitals, misunderstanding community treatment, and federal financing of mental health care. In doing so, I will highlight 10 lessons to be learned, lessons that should be incorporated into any future mental illness treatment system if it is to be successful.

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Closing the Hospitals

With the introduction of effective antipsychotic medication in the 1950s, it became possible, for the first time, to control the symptoms of many individuals hospitalized with severe mental illnesses—specifically schizophrenia, bipolar disorder, and major depression with psychotic features. These individuals constituted the majority of the patients who needed to be in state and county mental hospitals in 1955. By controlling the person’s delusions, hallucinations, and other psychotic symptoms, it was possible
to get many patients well enough to be moved to the community to live with their families, in nursing homes or board-and-care homes, or by themselves.

Given the fact that state mental hospitals had been the mainstay of public psychiatric care in the United States for more than a century, reversing this longstanding policy should have engendered careful planning. Many of the patients being moved to community settings had been hospitalized for 20 years or longer, so problems were predictable. Remarkably, almost no such planning took place. Rather, as noted by psychologist Franklyn Arnhoff, the emptying of the hospitals became an end in itself, “based upon the logical fallacy that since bad hospitals are bad for patients, any hospitalization is bad for patients and should be avoided entirely or made as short as possible.” The radical nature of this new policy appealed to many of the psychiatric leaders and their associates, such as Mike Gorman, who played a major role in the closing of state psychiatric hospitals. Gorman described “the truly revolutionary nature of what we have wrought in altering radically the profile of American psychiatry,” a change that appealed to Gorman’s politically radical interests. Such thinking was also reflected in President Kennedy’s historic 1963 speech to Congress, in which he said that the aim of the program “was to revolutionize the centuries-old mental health system.” At ground level, such thinking motivated the NIMH troops; psychiatrist Frank Ochberg, who was a director of the community mental health centers program in the 1970s, recalled: “What a privilege to participate in breaking the back of the asylums.”
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The emptying of state psychiatric hospitals as an end in itself became strongly reinforced by the availability of federal funds under Medicare, Medicaid, SSI, and SSDI for the patients once they had been discharged. States realized that they could save state funds by discharging patients, thereby closing state-funded hospital beds. The subsequent reduction in public psychiatric beds nationwide was indeed radical, from 340 beds to 14 beds per 100,000 population, as noted in
Chapter 7
. These psychiatric hospital bed closures are continuing, with many states having as a goal the closing of all public psychiatric hospitals and even the closing of the state department of mental health, which California achieved in 2012.

The closing of so many beds was a major mistake. It has become clear during the years of deinstitutionalization that a minimum number of public psychiatric beds continue to be needed. One reason they are needed is to treat patients with serious mental illnesses who are acutely ill and need to be stabilized on medication. Many such patients, if manic or otherwise acutely psychotic, must be hospitalized involuntarily and cannot be adequately treated in the psychiatric units of most general hospitals. Public psychiatric beds are also needed for a small group of seriously mentally ill patients who do not respond well to existing medications or do not take their medications. Some are repeatedly victimized in community settings and are thus a danger to themselves, whereas others are a danger to themselves because of repeated self-injury or suicide attempts.
Others are repeatedly violent and thus a danger to others. Both types of patients often shuttle between jail and the streets, because beds are not available. A 2011 study, in fact, reported that states that have fewer public psychiatric beds have higher homicide rates. As early as 1974, Aaron Rosenblatt, a psychiatric social worker, recognized the need for long-term psychiatric beds for the small number of treatment failures, calling such individuals “weary sojourner[s] in a hostile world.” More recently, psychiatrist Dinesh Bhugra suggested that we revive the concept of the asylum as a place of refuge and safety: “The move of services to the community was the right thing,” said Bhugra, “but we must not forget that there are always people who will need asylum.”
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How many such psychiatric beds are needed? There has been remarkably little research on this question. In 2008, 15 psychiatric experts answered the question with a surprising consensus that about 50 (range 40–60) public psychiatric beds per 100,000 population was the minimum number needed, assuming at least adequate outpatient psychiatric services. This is approximately four times more beds than presently exist. The number will vary, of course, depending on the quality of outpatient services. What is clear, however, is that all public psychiatric hospitals cannot be completely abolished; a minimum number of beds, perhaps 40–60 per 100,000 population, are needed.
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1. Public psychiatric hospitals cannot be completely abolished. A minimum number of beds, perhaps 40 to 60 per 100,000 population, will be needed. This is approximately four times more beds than we have available today.

As seriously mentally ill patients were being discharged from public mental hospitals to live in communities, another major mistake was made. For most patients, anti-psychotic medication had improved their symptoms. Thus, at the time these patients left the hospital, most were clinically much improved. However, antipsychotic medications help to control psychotic symptoms but do not cure the disease. Such medications are therefore similar to insulin, which controls the symptoms of diabetes but does not cure it. When the antipsychotic medications are stopped, the symptoms usually recur, and this is what happened to many discharged patients.

Why did patients stop taking their medications? Side effects of the medication are one reason. Lack of insurance coverage, lack of funds, cognitive confusion, and uncoordinated treatment are additional reasons. The most important reason, however, is that illnesses such as schizophrenia, bipolar disorder, and severe depression with psychotic features often affect the parts of the brain we use to think about ourselves, as previously discussed. Individuals with damage to these parts of the brain lose their awareness of illness and
insight into their own needs. This is not a form of denial, which we all use, but rather the result of disease-related anatomical damage to specific brain areas. It is also seen in neurological patients who have strokes involving these particular brain areas and is prominent in patients with moderate or severe Alzheimer’s disease, who usually have no awareness that anything is wrong. In neurology, this condition is referred to as anosognosia.
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As patients were being discharged from public mental hospitals, no allowance was made for the possibility that some of them would stop their medication. It was simply assumed that most patients would continue taking the medications that had improved their symptoms if they needed to do so. While in the hospital, the patients had no choice—medications were administered to them whether they wished to take them or not. Once out of the hospitals, however, the patients had a choice, and many chose not to take their medications. Why should they take them, they asked, as nothing was wrong with them? The mental health professionals who were the architects of deinstitutionalization made no allowance for this possibility.

The results have been completely predictable. At any given time, approximately half of all seriously mentally ill individuals in the United States are receiving no treatment. These are the individuals who end up living on the streets or in jails and prisons, being victimized, or perpetrating acts of violence related to their delusions, hallucinations, mania, and other untreated symptoms. Therefore, lack of awareness of illness (anosognosia) must be considered when planning any mental illness treatment system and provision made for some form of involuntary treatment, such as assisted outpatient treatment (AOT) or conditional release, for selected patients.

Studies of AOT and conditional release have reported that these approaches are very effective in maintaining seriously mentally ill individuals on medication. AOT does so by a court order that says the person must take medication as a condition for living outside the hospital. Conditional release is similar with the exception that the judicial authority is vested in the director of the psychiatric hospital. Multiple studies of AOT show that patients on AOT have a dramatic decrease in rehospitalization, victimization, and incarceration in jails and prisons. For example, one study of individuals before and after being placed on AOT reported that “the risk of any arrest was 2.66 times greater . . . and the risk of an arrest for a violent offense was 8.61 times greater . . . before AOT than it was while receiving AOT.” A study in a small county in California reported that AOT reduced hospitalizations by 61% and incarcerations by 97% for those individuals on AOT; the savings to the county were $1.81 for every $1.00 spent on the program. Other studies have reported that AOT reduced homelessness from 19% to 5% and victimization from 42% to 24%.
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