(Repeats story moved Dec 29 without changes to headline or
text)
* State mental health budgets slashed since 2009
* 11 mln mentally ill report ‘unmet need’ for care
* ‘Cycling through the system’
By Sharon Begley
NEW YORK, Dec 29 (Reuters) – Lori, a 39-year-old mother in
New Jersey, would like to save for the usual things: college,
retirement, vacations. But those goals are far down her wish
list. For now, she and her husband are putting aside money for a
home alarm system. They’re not worried about keeping burglars
out. They need to keep their son in.
Mike, 7, began seeing a psychiatrist in 2009, after one
pre-school kicked him out for being “difficult” and teachers at
the public school he later attended were worried about his
obsessive thoughts and extreme anxiety. He was eventually
diagnosed with bipolar disorder.
As she keeps trying to get help for him, “I am learning
firsthand how broken the system is when dealing with mental
illness,” said Lori. (Surnames of patients and their families
have been withheld to protect their privacy.)
“We fight with doctors, our insurance company, educators,
each other; the list goes on and on … It isn’t even a system.
It’s not like there’s a call center to help you figure out what
to do and how to get help.”
Last week, the National Rifle Association blamed mass
shootings such as that at Sandy Hook Elementary School in
Newtown, Connecticut, on the lack of a “national database of the
mentally ill,” who, it claimed, are especially prone to
violence.
Dr. Paul Appelbaum, professor of psychiatry, medicine and
law at Columbia University, disagrees, however. “Gun violence is
overwhelmingly not about mental illness,” he said. “The best
estimate is that about 95 percent of gun violence is committed
by people who do not have a diagnosis of mental illness.”
But experts on mental illness agree with one implication of
the NRA’s argument: families trying to get help for a loved one
with mental illness confront a confusing, dysfunctional system
that lacks the capacity to help everyone who needs it – and that
shunts many of the mentally ill into the criminal justice system
instead of the healthcare system.
“Public mental health services have eroded everywhere, and
in some places don’t exist at all,” said Richard Bonnie,
professor of law and medicine at the University of Virginia.
“Improving access to mental health services would reduce the
distress and social costs of serious mental illness, including
violent behavior.”
Because mental health care is in such short supply,
emergency cases receive priority. If a young man has a psychotic
break and threatens his mother with a knife, “you can call the
police and initiate an emergency evaluation,” said Bonnie.
A psychiatrist called to the local emergency room may agree
that the man is an imminent threat to himself or others, or
cannot provide for his basic needs – the criteria for
involuntary commitment in most states. Anything short of that
and even someone with a diagnosis of severe mental illness
cannot be involuntarily committed.
Critics argue that this emphasis on civil liberties lets
dangerous people roam the streets, and cite numerous cases where
it has been fatal. In October, for instance, a Tacoma,
Washington, man who had been diagnosed with paranoid
schizophrenia and was in and out of mental hospitals for years
confessed to killing his father with a hatchet.
One lesson of such tragedies, experts say, is that
psychiatrists’ ability to predict who will be violent “is better
than chance, but not much better,” said Dr. Marvin Swartz,
professor of psychiatry at Duke University.
Another is that the shortage of in-patient treatment has led
everyone from judges to mental health professionals to look for
any excuse to avoid committing someone involuntarily. There is
often no place to put them, and admitting one patient means
discharging another who might be equally ill.
“Getting people into hospitals is extremely difficult
because of the shortage of beds,” said Columbia University’s
Appelbaum.
The shortage extends to out-patient services, too, largely
as a result of continuing budget cuts. Since 2009, states have
cut more than $1.6 billion from such spending, found a 2011
report by the National Alliance on Mental Illness (NAMI), a
nonprofit education and advocacy group. The result is
“significant reductions in both hospital and community
services,” it said.
Connecticut, where Newtown is, is an exception. Its mental
health budget rose from $676 million in 2009 to $715 million in
2012.
‘THEY’RE ALL PSYCHOTIC’
More typical are Illinois (a reduction in spending on mental
health of $187 million in that period), Ohio (down $26 million)
and Massachusetts (down $55.6 million). “There’s a waiting list
for our program (in Boston) and it’s hard to get in,” said
psychiatrist and NAMI medical director Ken Duckworth, who treats
mentally ill patients.
There is room in his program for 60 people. The waiting list
has 20, he said, “and they’re all psychotic.”
It wasn’t supposed to be this way. The Community Mental
Health Center Act, passed in 1963, called for federal funding of
outpatient psychiatric facilities in towns and cities “so people
would at least know where to start” when they or a family member
needed a mental health evaluation or treatment, said Appelbaum.
“It was supposed to be a single point of entry.” But only about
650 of the 1,500 centers were built, and federal funding for
staffing tailed off after four years when Congress did not
appropriate more.
As a result, of the estimated 45.9 million U.S. adults 18 or
older who had mental illness in 2010, some 11 million had “an
unmet need for mental health care,” estimates the Alliance for
Health Reform, a nonprofit advocacy group.
One of those 11 million is Joseph. Even though he became
violent, tried to jump out of a moving car, hit his wife and
threatened to burn down their house, it was not enough to keep
him in the psychiatric unit of their local New Jersey hospital.
He “cycled through the system,” said his daughter. He went
to the local emergency room five times, was arrested four times,
went to the psychiatric unit three times, and spent 25
nonconsecutive days in a psychiatric hospital – all in three
months in 2010.
Joseph’s psychiatrist and family believed he should be in a
state mental hospital, but his doctor did not show up to testify
at a commitment hearing and the main evidence presented was a
threatening letter Joseph had written to his wife. He was not
deemed a danger to himself or others, and was released.
He did, however, cycle between jail and the psychiatric
ward, making him one of many cases that “wind up in the criminal
justice system instead of the healthcare system,” said the
University of Virginia’s Bonnie. “Families watch their loved one
unravel and can’t get assistance, and then they get ensnared in
the criminal justice system and can’t get them out.”
The difficulty getting outpatient care for the mentally ill
is particularly widespread because most psychiatric hospitals
were closed during the “de-institutionalization” of the 1960s
and 1970s, an effort to provide more humane care than in the
sometimes nightmarish wards.
One facility that closed was Fairfield Hills State Hospital,
which opened in 1933, housed just over 4,000 mentally ill,
long-term patients at its peak in the 1960s, and closed in 1995.
It was located in Newtown.
“It’s a metaphor for what we’ve done about mental health
treatment in this country,” said Duckworth. “A town that had a
major treatment facility for 60 years has a mass shooting by
someone who was mentally ill. We don’t have a coordinated system
of screening for, let alone treating, mental illness.”
Even a diagnosis of mental illness with a possibility of
harming oneself or others is no guarantee of help, even for
young people.
“We estimate that fewer than one-quarter of the children,
teenagers and young adults who have a mental health problem
receive any treatment whatsoever,” said Bernadette Melnyk,
professor of psychiatry and pediatrics at Ohio State University
College of Medicine. “And of those who do get treated, a
substantial amount of the treatment is not the best,
evidence-based kind.”
For instance, a combination of cognitive-behavior therapy
and medication is most effective at treating depression. “But
very few patients receive the psychotherapy because we have such
a severe shortage of mental health providers,” said Melnyk.
Trying to get that help can drain a family emotionally.
‘SOME SORT OF MONSTER’
“There are no professionals to help us with the tantrums or
hysteria at the dentist or getting a haircut,” said Lori, the
New Jersey mother. “When Mike has a fit or screams obscenities
in public, strangers assume he’s a spoiled brat or some sort of
monster.”
“I worry that if he does not take good care of himself . . .
well, let’s just say that I can empathize with Adam Lanza’s (the
Newtown shooter’s) family, too,” she said.
To be sure, protecting the public from crime spurred by
mental illness is only one argument for better psychiatric care.
Every person who needs such care and doesn’t get it is one more
individual whose dreams of a full and productive life are
shattered.
Virginia’s Bonnie saw that firsthand when, after the 2007
Virginia Tech shooting rampage by Seung-Hui Cho, scores of
families told him of their struggles to get help for loved ones
with mental illness.
One young man, a brilliant college student and athlete,
suffered his first psychotic break as an 18-year-old freshman
and was diagnosed with paranoid schizophrenia. Robert was
hospitalized nine times over 12 years, but when he attempted
suicide after one stay his parents could not get him admitted
again: he did not meet the “imminent danger” standard.
Feeling threatened by his “increasing psychotic behaviors,”
the parents told Bonnie, they called the police, who arrested
and jailed Robert for breaking and entering the family home.
Without treatment, his psychosis only became worse.
It is all too common for the mentally ill to wind up in the
criminal justice system, not the health system, said Bonnie.
“Families are suffering the consequences of the lack of mental
health treatment all the time,” he said. “Every once in a while
they explode into public view” with a national tragedy like
Newtown.
(Reporting by Sharon Begley; Editing by Jilian Mincer and Steve
Orlofsky)
