Last month I wrote about the Mental Health Parity law that requires insurers to provide equal coverage for both medical and mental health services. When health reform rolls out fully in 2013, many Americans with expanded access to private health insurance will have more equitable coverage for treatment of depression, attention disorders, addiction problems and other serious mental health ills. But parity laws that apply to private insurance will do little to advance the plight of the growing portion of our population that is seriously—and chronically—mentally ill, often homeless and increasingly showing up in the criminal justice system.
According to the Department of Justice, 14.5% of men and 31% of women recently admitted to jail have a serious mental illness. Applied to the 13 million jail admissions reported in 2007 (the most recent figure), the findings suggest that more than 2 million individuals with a serious mental illness may be locked-up annually. In many cases they cycle in and out of the criminal justice system; with a stop on the way to the emergency room or for hospitalization. It’s an expensive and futile exercise.
With all the emphasis on health reform and discussion centering on a vast overhaul of how we deliver, pay for and mandate medical care, the plight of the seriously mentally ill gets short-shrift. But that doesn’t mean there isn’t a real crisis in funding (especially at the state level) and treatment–or that there isn’t a wave of reform coursing through the mental health field. It’s just that without the loud voices of lobbyists from doctor, pharmaceutical and hospital organizations and powerful patient advocates, the mental health field is reform’s poor step-sister—beyond insurance parity, very few provisions in the Patient Protection and Affordability Act address chronic, serious, mental illness.
It is, in fact, the Justice Department (as well as courts at the state and county level), not Congress and not the Department of Health and Human Services that has taken initiative in dealing with these seriously mentally ill individuals. Born out of judges’ frustration with the lack of help available for the growing cadre of mentally ill defendants showing up at the bench, the first “mental health court (MHC)” was established in Broward County, Florida in 1997. The idea behind this and the subsequent MHCs that sprang up over the next dozen years or so is to move people with serious mental illness out of the criminal justice system and into monitored community treatment, without sacrificing public safety. There are now more than 250 mental health courts around the country—the majority limiting their cases to those accused of misdemeanors or non-violent crimes.
How well are these alternative court systems doing? There have been individual case studies, like this one by the RAND Corporation in 2007 that found that a Pennsylvania mental health court saved taxpayers $3.5 million over a two-year period.
But the mental health courts have been dogged by what Henry (Hank) Steadman, President of Policy Research Associates (PRA), a firm that conducts research on mental health services, calls “notorious idiosyncrasies.” These court programs differ in whether they accept those convicted of felons or just misdemeanors; the length of the mandated treatment; the inclusion of housing and vocational services and whether or not a participant’s criminal record is expunged after completing the program. According to a report from the National Center for State Courts, “There are as many mental health court models as there are mental health courts, and, aptly describing these differences practitioners proclaim, ‘when you have seen one MHC, you’ve seen one MHC.’”
In October, Steadman and other researchers from PRA published the first study to look at multiple disparate courts (two in California, one in Minnesota and another in Indiana) and to measure how successful they were at keeping the mentally ill out of the criminal justice system and steering them toward mental health services. The study, which appeared in the Archives of General Psychiatry, included one group of offenders that was referred to MHC programs while the other was given “treatment as usual;” jail time and probation without psychological counseling or mandated treatment programs.
Results were not staggering, but they did show a positive effect. Some 49% of mental health court patients were re-arrested in the 18 months after starting the mandated programs, compared with 58% of those in the traditional system. The average number of jail days increased for both groups, but for those who went through the MHCs the rise was just 12 % (from 73 days in the 18 months before to 82 in the 18 months after entering the alternative court system.) For the group who received “treatment as usual” (mainly jail time), there was a 105% increase in number of incarceration days.
Interestingly, graduates of the Minnesota MHC showed no lowering of rates of re-arrest or days in jail when compared to those who were not referred to the program. But in a separate study of just that site, researchers found that mentally ill participants who spent a longer time in the treatment phase and received housing as part of the program actually did show significant improvement.
To Ira Birnum, legal director of the Bazelon Center for Mental Health Law this is an important finding. He, like many mental health advocates, believes that mental health courts—although well-intentioned—shouldn’t be taking the place of an effective mental health system. He notes that mental health courts criminalize mental illness by using the court system—and a conviction—as the best conduit to comprehensive services. “Most misdemeanors don’t actually lead to prison sentences” says Birnum, noting that he’s seen some people who've been sent to MHCs and basically coerced into pleading guilty to minor crimes like loitering. The result is that they no longer can get work or government housing because of their police record.
In a 2006 report, Bazelon looked into the growing number of MHCs and found that; “Mental health courts may provide immediate relief to criminal justice institutions, but alone they cannot solve the underlying systemic problems that cause people with mental illnesses to be arrested and incarcerated in disproportionate numbers.” The report likens these programs to “outpatient commitment,” compelling an individual to participate in treatment under threat of going back to jail. “However, the services available to the individual may be only those offered by a system that has already failed to help,” the report continues; “Too many public mental health systems offer little more than medication and very occasional therapy.”
A study in the journal Psychology, Public Policy and Law in November found that criminal offenders with a serious mental illness get first arrested early in life—often in adolescence—and persist over time. The factors that are most related to multiple arrests; “homelessness, a co-occurring substance abuse diagnosis, fewer mental health outpatient service contacts and more mental health emergency room/inpatient contacts.”
The answer, says Birnum, is to direct more resources toward creating a robust mental health system that provides intensive community-based services including housing, vocational training and direct outreach early on; before an individual is arrested. Currently, the police in many places are attuned to the fact that the only way to get many of these folks access to these types of services is to arrest them, he adds.
To start, advocates recommend that mental health courts only accept felons, with mentally-ill individuals who commit misdemeanors being sent to “pre-booking diversion programs” that get them access to services before arrest. One such successful program for felons operates in New York City. Begun in 2000, the Nathaniel Project was the city’s first alternative-to-incarceration program for felony offenders with serious and persistent mental illness. In 2003, the project formed an Assertive Community Treatment team (ACT team) made up of clinicians who have training and experience in psychiatry, mental health, nursing, social work, substance abuse treatment, peer support, employment and criminal justice. The program provides supportive housing too. The ACT concept—which is available to clients 24-7—is now considered the most promising intervention for those who are seriously mentally ill and veering toward crime.
The Nathaniel ACT has produced measurable results with a recalcitrant population: 72% of participants receiving service at any time between 2003 and 2006 had no subsequent re-arrests, and 82% had no further criminal convictions, during a study period that averaged 19 months following release to the program. Many of these people had been in prison or hospitalized numerous times before being arrested and starting the program. But it doesn’t come cheap—a program that includes housing and an ACT team can cost $40,000/participant (less than the cost of incarceration for a year or hospitalization, but about $10,000 more than some of the more comprehensive MHC programs.)
Funding for mental health services has, in real dollar terms, been actually dropping in the several decades since insane asylums and other long-term care institutions were emptied of their patients. And that remains the biggest barrier to good intentions. Take the case of Kansas. A recent article in the Kansas City Star detailed a 19-month study that found that 17 percent of those booked into the Johnson County (a fast-growing metropolitan area in the northeastern part of the state) jail were mentally ill. A review of all Johnson County jail bookings in the last five years found that about 30 percent of 7,400 inmates had at some point been served by the county’s Mental Health Department. The report included three dozen recommendations for keeping mentally ill people out of jail, and noted that treating the mentally ill is far preferable and cheaper than incarceration. But the article also added that most of the recommendations are unlikely to receive funding; Kansas cut $1.7 million from the Johnson County mental health budget in the last two years, and a new proposed budget would cut it $1.5 million more.
In the face of declining budgets, the long-term solution to the problem of the chronically mentally ill—as it is for “medical” health reform—will require a fundamental shift in how the system is designed. For those patients suffering chronic ills like diabetes, asthma and heart disease, for example, health reform emphasizes moving away from urgent care and fee-for-service and towards creating medical homes and accountable care organizations that promote prevention and well-coordinated care. The goal is to avoid more expensive—and traumatic—alternatives like visits to the emergency room and frequent hospitalizations.
In mental health, reform is also taking place—albeit at a slower pace and with far less fanfare. The goal here, says Birnbum, is to realize a “radical view of community integration.” This is not very different from the idea of creating medical homes and ACO’s—but in this case evidence is showing strong benefits in providing supportive community housing and teams of professionals (psychiatrists, vocational specialists, social workers, nurses, etc.) who interact directly with patients on a weekly or monthly basis. The goal; keep the mentally ill out of more expensive—and catastrophic—alternatives like prisons, emergency rooms and hospitals.
The parallels between the mental health care system and the “body-oriented” health care system go further. A strong argument from reformers of both systems is that we don’t need to spend more money on care; we need to spend it in ways that are less wasteful, more cost-effective and ultimately, offer better outcomes. For the seriously mentally ill a lot of funding still goes toward long-term hospital care, out-patient “daycare” programs that offer very expensive babysitting, some talk therapy and activities like finger-painting. Advocates insist that these funds would be far better spent on extensive mobile outreach, housing, and rehabilitative services like vocational training and drug counseling; ideally before the mentally ill become marked as criminals. For those in the mental health trenches, there's a long fight ahead.