lamentations · long passed…

Posted on Sunday 20 April 2014

Director’s Blog: NIMH
By Thomas Insel
April 11, 2014

… check out a new report  from the Treatment Advocacy Center on the treatment of people with serious mental illness. According to this report, there are now 10 times more people with serious mental illness in state prisons [207,000] and county jails [149,000] than there are in state mental hospitals [35,000]. The report includes a state-by-state assessment of treatment of people with mental illness in jails and prisons. In 44 of the 50 states, the largest single “mental institution” is a prison or jail…

How can this be possible? In the 1830’s Dorothea Dix revolutionized the care of people with mental illness by taking them out of jails and caring for them in asylums, later known as state hospitals. In the last 50 years, we have reversed this trend, resulting in a 90 percent reduction in public hospital beds for people with serious mental illness. While this reversal came about as the result of good intentions, it has resulted in unintended consequences. Many, but not all, people with serious mental illness can be treated effectively with the less restrictive care offered in outpatient settings. Sometimes patients with serious mental illness, just as with other serious medical illnesses, require hospitalization. In the absence of available public or private hospital beds, there are few options. Some patients are housed in emergency room holding areas; some return home, where family and friends struggle to provide care; and some—at considerable risk to themselves—become homeless. For those who do not realize they are ill and therefore resist treatment, or those whose behavior may be disruptive or aggressive, jails and prisons have become the de facto mental hospitals…

What should be done? Returning to the asylum system — which could be regarded as turning away from the goal of recovery — is not the answer. The new report suggests several remedies, including ensuring better treatment within the prison system, jail diversion programs, assisted outpatient treatment, and release planning. Surely our nation can do better than assigning the criminal justice system the responsibility for delivering care to the mentally ill. In an era of mental health parity and health care reform, how can we allow hundreds of thousands of people with a brain disorder to be treated in our justice system — if that can be called treatment — rather than our healthcare system? Abraham Lincoln, no stranger to serious mental illness, once lamented, “a tendency to melancholy… is a misfortune not a fault.” Our current system, if these new numbers are accurate, treats mental illness, for many, not as a misfortune but a crime, with little promise of recovery.
No, I’m not going to rale at Dr. Insel as I often have or chide him for finally getting around to noticing that our prisons are filled with chronic mental patients – or rant that this abysmal fact has been increasingly true since the deinstitutionalization reform movement in the second half of the last century. I’m not even going to point out that the criminalization of mental illness spans the Decade of the Brain or the age of Clinical Neuroscience.

And I’m not going let go with a primal scream that those 350,000 people are not Myths. Their commitment was as criminals. They are receiving medications whether they want them or not [or whether they need them or not]. And, by the way, the TAC doesn’t need any biomarkers to know who they are or to count them. The prison guards know. The other prisoners know. The judges that sent them there know. It’s just not that hard to tell.

And I’m not going to advocate more medications, or less, or pray for future medications, or long for old Asylums, or blame psychiatrists, or anyone else. But there is something worth saying here. The National Institute of Mental Health is our government Agency that is tasked with thinking about the mental health of the country, and this is a problem that actually belongs at the very top of that problem list. There are countries all over the world that do a much better job with this problem than we do. There are social scientists and psychiatrists and social workers and psychologists all over this country that specifically care passionately about this topic and these patients. So why doesn’t the National Institute of Mental Health have a Task Force to look at this problem rationally, to travel the world looking at solutions, to figure out a direction for us to be moving in.

This is more important than the RDoC, or Dr. Nemeroff’s neurobiology of trauma, or Dr. Gibbons CAT Screening tests, or Dr. Trivedi’s genetic tests to pick among light-weight antidepressants, or anything else on the NIMH agenda. I applaud Dr. Insel for reading that report and bringing up the problem, because he is perhaps uniquely positioned to assemble a cadre of people who could initiate doing something about it rather than just continuing to decry it. Let’s hope that it preys on his mind and spurs him into action. The time for lamentations has long passed…
    April 20, 2014 | 9:13 PM

    Even if his only concern was to have psychiatrists in control of and profiting from those who are now in the custody of our prisons, I suppose it’s good that he brings it to the attention of the NIHM. I do, however, find it hard to believe that they’ve been unaware of this— it’s pretty common knowledge.

    I doubt that he would recommend that these prisoners be treated much differently as far as drug therapy is concerned (psychiatrists in the prisons are doing the prescribing, no?), and psychiatrists and judges can effectively deprive them of their civil rights and force treatment outside of prison.

    Though it is no doubt a profound difference between being an outpatient and being a prisoner— not least is not being housed with sociopaths and violent criminals who commit violent acts with a clear mind and considered intent— I don’t trust that the patients themselves would have any more freedom in choosing their treatments under Dr. Insel’s guidelines than in prison. A chemical straight-jacket that causes horrific side-effects and does not prevent psychosis is not less debilitating in its effects outside of prison walls than it is on the inside.

    When the antipsychotics and other top choices in polypharmacy are given to counter a diagnosis made in respect to a “mental” illness “unmasked” by an antidepressant, then there is more to be questioned than whether or not the person labeled with “mental illness” is benefiting from his/her cocktail and the option of discontinuing carefully and consciously should be an option rather than using judicial power to force more medications and utilizing interventions that don’t require drugs. Also, the possibility that a person behaving violently while on psychoactive drugs may be doing so because of the drug should always be a consideration, especially when that person has no history of violent or criminal behavior.

    If there is evidence to the contrary it would surely cheer me up to see it.

    Bernard Carroll
    April 20, 2014 | 9:34 PM

    Indeed, Dr. Mickey and Dr. Insel, the road to hell is paved with good intentions. There is more than enough blame to go around. I see many contributing factors. Hubris in the early days was one. Wishful thinking back then was another. Then, in many centers there was a loss of focus – the nice walking wounded were more pleasant to engage than difficult patients with what I call the A-list disorders. Add in the false economies of planners and politicians. Managed care did its bit to re-shape practice away from clinical need towards cost containment. Along the way, patients took on the quality of objects to be managed, as Dr. Mickey has discussed – that is when they weren’t frankly commodified. By the time they reach jails they are treated outright as objects by the system. Professional organizations like the American Psychiatric Association did not effectively push back on these trends, while they capitulated abjectly to managed care with its carveouts and controls. Over the same period, academic departments of psychiatry lost much of their funding base from inpatient services and resorted to all manner of expediencies just to survive.

    It is indeed a damning national tragedy, as Allen Frances also has been saying early and often. It puts into perspective the insignificant debates raging around DSM-5. I agree that we need a task force to address these systemic issues. But I would prefer to see a Presidential Commission that can pull rank on all the players, rather than leave it up to NIMH. We had such a Presidential Commission in the late 1970s and there is a current Presidential Commission for the Study of Bioethical Issues. That’s the level at which I think this nettle needs to be grasped. None of the individual stakeholders, including NIMH, has the standing to take it on alone.

    April 20, 2014 | 9:34 PM

    I wasn’t going to make any comments on Easter, yet your post prompted me to change my mind. If I could rate your article, I’d give it 10,000 upvotes.

    Our society has lost it’s way and it’s the least among us that bear the brunt of it. However, it wouldn’t take all of society to address this, only a few good men. Let society follow.

    Thanks for keeping things in perspective.

    April 20, 2014 | 10:56 PM

    Interesting proposal, Dr. Carrol. A Presidential Commission would also leave out Congresspersons who are convinced that the answer to stopping mass murder which appears to be an American (U.S.) pastime, is forcing more medication on more people who are considered “dangerous” by virtue of having been given a label that is perceived to be “dangerous” (when not medicated)— although they have no history of being dangerous— and putting them on a rotating schedule of polypharmacy to keep them in a stupor.

    While it’s considered to be an “accident” when an adult leaves a loaded gun where a two year-old can pick it up and kill him/herself or someone else with it, because—?

    There is a lot more crazy and mentally incompetent sh*t happening in our society than the mentally ill or “mentally ill” could accomplish on their own.

    April 20, 2014 | 11:22 PM

    I don’t know why anyone would need to convene a Task Force. I can imagine how that would be bloated by captains of industry. We already have one federal agency that is basically part of the managed care industry. Why didn’t they identify this problem that has been known for years?

    The solutions are already known and the first step involves getting rid of most people who would end up on the Task Force.

    Bernard Carroll
    April 20, 2014 | 11:56 PM

    Good for you, Dr. Dawson. That’s as fine a summary as I have seen, and I was not aware of the SAMHSA issues. The conditions on my A-list are not just “severe emotional distress” or “a spiritual experience” or “a coping mechanism and not a disease.” The issue for now is how to get momentum underway? I have no better idea than a Presidential Commission but I am a rookie in politics.

    Steve Lucas
    April 21, 2014 | 7:54 AM

    Has the system possibly created the problem that we are now expecting the system to correct, due in part to a lack of drug trial transparency?

    Remember, that the bulk of those in prison or jail are young and have long troubled histories that can be traced to psychological problems and developmental issues.

    Steve Lucas

    April 21, 2014 | 8:38 AM

    I think we need to be careful in reading reports like this. While I am certainly not an advocate of placing psychotic individuals who commit crime because they were influenced by delusional thoughts into jails, I also think that the numbers of the mentally ill in jail are high in part because of our broad definition of what constitutes a mental illness. I could probably write a report applauding the fact that we have far more people diagnosed with a mental illness in universities than in state hospitals given the rate at which we are diagnosing and medicating today’s youth. Yes, we have largely shuttered out state hospitals. I agree with Dr. Dawson that we need to continue to fund our community mental health centers and that they tend to get short shrift but the linkage of violence and serious mental illness is present it is a shaky construct. From everything I have read, Adam Lanza would not have been in a state hospital nor would forcing him on drugs have reduced his risk of acting violently. I am not sure any of us have a solution so let’s be humble about having answers for these horrific events. As for SAMHSA and Disability Rights – when did it become so bad to include the voices of those we are trying to help? That is what Treatment Advocacy is railing against.
    Sorry to rain on this parade. Maybe I am wrong. I certainly have been before.

    Bernard Carroll
    April 21, 2014 | 10:35 AM

    From under my umbrella: Sandra, I think you have picked up the wrong end of the stick here. Dr. Mickey’s post was not about Adam Lanza and it was not about overly broad definitions of mental illness. And Dr. Dawson’s post was not about denying a voice to those we are trying to help. It was about recognizing serious mental illness for the showstopper that it is.

    April 21, 2014 | 11:15 AM

    Maybe I misread. I am just reacting – and perhaps incorrectly – to the leap in these discussions to involuntary interventions (common on TAC) when in fact there are many things that can be done that can improve care and the quality of people’s lives. This has to do with the kinds of programs that SAMHSA tries to promote (and TAC is extremely critical of SAMHSA). I admit I am skeptical of big government top down approaches. Perhaps I am misguided because I live in a state that tries to be helpful to the disenfranchised. We have many of the programs Insel mentions. It is interesting though; despite all we do, our pressure on jails seems to increase and it is not primarily with psychotic individuals – it has to do with drugs and poverty. Anyway, I apologize to all if I misunderstood. I know I do not have the answers. I get mental whiplash in my attempts to read perspectives form all sides.

    April 21, 2014 | 12:32 PM

    What if a criminal is not mentally ill, but manages to convince a jury he/she is?

    How many people should be unnecessarily forced treatment for mental illness they may or may not actually have to possibly prevent one person with mental illness or “mental illness” from killing someone?

    Overall, schizophrenics have low base rates of violence, with an estimated prevalence of between 10 and 15 percent. As I’ve discussed here in the context of sex offenders, the rarer a behavior is, the harder it is to successfully predict, leading to erroneous predictions of high risk in people who are not truly dangerous. The authors quote another research finding that in order to prevent one stranger homicide by a schizophrenic, governments would need to detain a whopping 35,000 patients.

    Since there are no reliable ways of predicting who will and will not become homicidal or suicidal and people not suffering from mental illness are violent and fully capable of killing before they do or do not kill someone, then how is forcing treatment, as a rule, of those labeled with mental illness justified? Most murders are committed by people who are legally sane.

    How many people should be deprived their civil rights in the name of a moral panic being exploited by politicians?

    What if conditions in prisons are creating reactive psychoses that are then labeled and treated as endogenous brain disorders?

    It’s a well-known fact that solitary confinement alone can make a person psychotic.

    Whether you think my response is within the invisible guidelines here, Dr. Carrol; I think whether or not a prisoner considered to be mentally ill is actually mentally ill should be considered when discussing whether or not they should be in prison and whether or not we should have more accommodations for people who are mentally ill and dangerous or potentially dangerous.

    Have psychiatrists found a reliable way to distinguish between sociopaths and the mentally ill? Can someone be both?

    Bernard Carroll
    April 21, 2014 | 12:39 PM

    It looks to me like you picked up the wrong end of the stick too, Wiley.

    April 21, 2014 | 12:50 PM

    what else is new in this field dr carroll?

    a bunch of incompetent idiots running around with a prescription pad, each of them eager to earn their ‘specialist’ salary, have really destroyed the direction of the field over the past 30-40 years. i expect nothing less than misguided attempts at “helping” others.

    some patients are afraid of proper diagnoses, as if it means they’re “bad apples”. they don’t even understand that in order to TREAT, one must know the CAUSE.


    Galen give me strength.

    April 21, 2014 | 7:03 PM

    What is the “right end of the stick”, Dr. Carrol? And what makes it “right”?

    April 21, 2014 | 7:12 PM

    Antisocial personality disorder and substance abuse/dependency are in the DSM, and so many of those in correctional facilities have either or both of those “Diagnoses” and thus the large number of mentally ill in prison.

    I’ve done correctional work, briefly and now 12 years ago, but, I did NOT see so many people who were incarcerated who were also profoundly psychiatrically ill. Oh, and those who became anxious or depressed once in jail, that is to count as mood and anxiety disorders too?

    Face it, histrionic and factitious disorders are certainly a quantifiable number in the correctional system, but, look at all the above per Axis 2, drugs, and acting out, and ask yourselves, who is in need of real treatment, and who is looking for excuses to get out, or at least get drugs?

    I will agree the homeless are horrendously mistreated by the law, case in point the man shot to death in Arizona last month as the most recent example. But, you start rationalizing there are “so many patients incarcerated”, you are just going to dump these people on the Community Mental Health System and, yes, I will not be thanking all those forensic psychiatrists who just jump to conclusion after the 15 min evals done in the correctional facilities.

    The story about mentally ill being incarcerated is as much an agenda to satisfy the prison system as could be a legitimate principle being mishandled. But, that makes the issue gray, and so many can’t handle blurred boundaries, eh?

    April 21, 2014 | 8:42 PM

    as an addendum to the above comment, in the most recent issue of was an article by Aaron Levin tltled “Defendants with Mental Illness diverted to Social Security System”. I tried to link the article but the Net is acting peculiar with anything at tonight, so you folks link it as able. In there was this:

    ” Nationally, only 29 percent of first time applicants are granted SSDI or SSi, but 65% of SOAR (SSI/SSDI Outreach Access and Recovery program) initial applications nationwide are approved within 100 days, …[followed in next paragraph by this] …The Miami SOAR program does even better, however racking up a 94% record of approvals in an average of 27 days in part because it is integrated with the 11th Judicial Circuit Mental Health Project in Miami-Dad County.”

    Gee, you thing word of this doesn’t get out to people in corrections?

    Oh, and to show there is motivation for the docs to pad the diagnoses for this program, later in there was this:
    “Once the patient is approved for benefits by the SSA, the evaluating doctor can bill for services rendered as much as three months prior to the application date.” Which at Miami Dade seems to get done in 1 month.

    Isn’t anyone else besides me sick of the pervasive dependency and entitlement growing at logarithmic levels these past 5-10 years?! Oh, and don’t forget correctional guests get to apply for Obamacare too, so maybe there is a silver lining to be jailed, hmm?

    It’s a shame so many doctors are so quick to side with Liberal/Left/Democrat agendas without looking at the big picture. But, that is exactly what the Left and Democrats want, you folks to leap first and ask questions as you hit the rocks! Not that I advise listening to the Right/Republicans either, but, again, one has to wade through the gray haze of life to figure out what makes sense.

    Lemmings please follow the crowd up the hill to the cliff…

    Bernard Carroll
    April 22, 2014 | 1:25 AM

    Wiley, you can surely recognize a metaphor when you see one. Please don’t play obtuse or concrete.

    Just look at your lead-off comment: “Even if his only concern was to have psychiatrists in control of and profiting from those who are now in the custody of our prisons, I suppose it’s good that he brings it to the attention of the NIHM” (sic). This is what I call tendentious reframing of the issue and changing the subject to suit your dystopian “attitude.” What the hell makes you think this gratuitous smear is a smart idea? You don’t seem to understand that when you lob hand grenades like this into a dialogue you just give aid and comfort to the likes of Lieberman and the APA leadership. Time for you to wise up, I think.

    April 22, 2014 | 9:22 AM

    Dr Carroll, good luck with this “dialogue”.

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