Throughout the 18th Century and up to the mid 1900’s, individuals with mental illness, particularly those with severe mental problems, were often institutionalized in state mental hospitals also referred to as insane asylums. Hospitals were grossly overcrowded and understaffed, with often appalling living conditions. The Joint Commission on Mental Illness and Health was formed in the mid-1950’s from a call to action by the American Psychiatric Association. Their role was to study conditions and develop a national mental health program.
In an effort to change treatment and provide better care, sweeping federal legislation was passed in 1963 that was designed to replace the shabby treatment of the millions of mentally disabled in custodial institutions to treatment in community health centers. The program model was to transfer responsibility of the mentally ill from the federal government to the state. Although well intentioned, the end result was underfunded programs, neglect and higher rates of community violence. The emergence of Community Health Centers to both treat existing mental illness and prevent future cases, did little to improve mental health programs.
There are several lessons gleaned from reviewing the deinstitutionalization of mental health treatment. Continuity of caregivers is very important. Constantly shifting venues and caregivers are extremely difficult for those whose brains are not functioning normally and usually lead to treatment failure. Just as jails and prisons have become America’s new psychiatric inpatient system, sheriffs, police and courts have become the new psychiatric outpatient system.
Even with proven models of success, most patients do not fit the funding requirements and continued to receive uncoordinated and disjointed mental illness services. The reasons are many as follows:
- Lack of public understanding of serious mental illness
- Lack of understanding of the magnitude of mental illness, including among public officials
- Lack of understanding of the civil rights of people with severe mental illness
- Public mistrust of psychiatry
- Economic and political interests to maintain the status quo
- The federal government
- Lack of leadership (unlike major diseases as heart or cancer)
What can be Done To Improve the Mental Health System?
Research has shown the ACT (Assertive Community Treatment Teams) Model, also known as PACT, is the most promising for patients being discharged from inpatient mental health care. ACT teams consists of 100 to 120 participants assigned to a team of approximately 10 mental health workers, usually including a psychiatrist, psychologist, psychiatric nurses, social workers and others. The team take responsibility for the patients, visiting them, making sure they are taking their medications and responding to crises before they lead to re hospitalizations or worse.
Source: American Psychosis, E. Fuller Torrey, M.D.
Legal Issues and Assisted Outpatient Treatment (AOT)
AOT is court-ordered treatment (including medication) for individuals who have a history of medication noncompliance, as a condition of their remaining in the community. Studies of AOT and conditional release have reported that those approaches are very effective in maintaining seriously mentally ill individuals on medication. Forty-five states permit the use of AOT. Studies and data from states using AOT prove that it is effective in reducing the incidence and duration of hospitalization, homelessness, arrests and incarcerations, victimization and violent episodes. In addition, AOT also increases treatment compliance and reduces caregiver stress.
Source: Treatment Advocacy Center
Mandatory Outpatient Treatment (MOT) Laws in Virginia
Virginia has civil commitment laws that establish criteria for determining when involuntary treatment is appropriate for individuals with severe mental illness who cannot seek care voluntarily. Virginia’s laws allow for the use of court-ordered treatment in the community (MOT).
For inpatient treatment, a person must meet the following criteria:
- Be an imminent danger to self/others
- Be so seriously mentally ill as to be substantially unable to care for self
- Be substantially likely to “suffer serious harm due to substantial deterioration of his capacity to protect himself from harm or to provide for his basic needs as evidenced by current circumstances”
For outpatient treatment, a person must meet the following criteria:
- Meet the inpatient criteria
- Be competent to understand the stipulations of treatment
- Want to live in community
- Agree to abide by treatment plan
- Reside where ordered treatment can be delivered on outpatient basis
- Can be monitored by community services board or designated providers
As with many other states, the problem with MOT is the duration of detainment, lack of timely treatment and the lack of public psychiatric beds.
Source: Treatment Advocacy Center
Legislative Updates
The Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646), is designed to reduce the barriers to treatment for those that need it most. Congressman Tim Murphy, PhD, a psychologist by training, introduced the comprehensive legislation to help individuals and families living with severe mental illness. The bill has received support from the American Psychiatric Association (APA) and the National Association for the Mentally Ill (NAMI).
The legislation would, for the first time in decades, bring system wide reforms and improvements to care for current patients and those lacking access to needed treatment. The legislation is supported in Virginia by Senator Creigh Deeds, who personally testified on behalf of his family’s personal experience in dealing with the failure of the mental health system and the loss of his son.
The specific action of H.R. 2646 are as follows:
- Requires states to authorize assisted outpatient treatment (AOT) in order to receive Community Mental Health Service Block Grant funds
- Clarifies HIPAA to permit a “caregiver” to receive protected health information when a mental health care provider reasonably believes disclosure to the caregiver is necessary to protect the health, safety or welfare of the patient or the safety of another (The definition of a “caregiver” includes immediate family members).
- Establishes a new National Mental Health Policy Laboratory in the Department of Health and Human Services
- Prevents federally funded Protection and Advocacy organizations from engaging in lobbying activities and counseling individuals on “refusing medical treatment or acting against wishes of a caregiver.”
- Requires the U.S. controller general to submit a report to Congress detailing the costs to the federal and state government of imprisoning people with severe mental illness
- Increases congressional oversight of SAMHSA programs and seeks improvements to the program it supports
Legislative Contacts
Federal: US Senate
Federal: US House of Representatives
State: whosmy.virginiageneralassembly.gov
Brain Research and Recent Findings
Although there are many challenges in the mental health system and laws governing treatment delivery or lack thereof, there has been progress in mental illness research. Since effective treatment for mental illness emerged only during the 20th century, it is not surprising that scientifically based mental illness prevention is only recently coming of age.
There has been a huge explosion of work in mental illness prevention in the last decade. Roughly 20-30 clinical trials indicate that the onset of common mental disorders like depression and anxiety can be delayed and in some cases prevented. One study found a 50 percent reduction in the incidence of major depression among mildly depressed patients who received stepped-care intervention. Scientific evidence for the prevention of other disorders such as schizophrenia and bipolar disorder is more challenging. Evidence points to more robust scientific evidence for preventing recurrent episodes versus primary prevention (Source: “Future Looks Promising for Mental Illness Prevention, Psychiatric News, APA, January, 2013)
Findings from research projects of patients diagnosed with a serious mental disorder reveal they die 25 years earlier than the general population. Mental disorders were one of five most costly conditions in the United States. However, progress has been demonstrated in the use of telepsychiatry and new medications that extend the reach and type of treatment available. Telepsychiatry has been found to be especially beneficial to those living in more rural areas with less access to mental health providers.
Another area of interest in mental health prevention that is evolving is a mental health application (app) that can be downloaded onto doctors’ iPhones, called the Electronic Preventive Services Selector (EPSS). The doctor types in a patient’s demographic information and the EPSS gives you evidence-based screening tools to use with the patient, including tools to help detect early warning signs of a mental disorder. There are also apps in development designed for the patients themselves to remind them to take their medications.
Source: Agency for Healthcare Research and Quality
The development of computerized screening tools to be used in hospital emergency departments across the country has been developed by a team of scientists. The goal is to avert youth suicides, the second leading cause of death among teens aged 12 to 17 in the United States. The team aims to refine algorithms that can predict which youth are most likely to attempt suicide.
Source: Brain and Behavior Research Foundation, Fall Quarterly 2014
Treatment Advocacy Center (TAC)
TAC is a national nonprofit organization dedicated to eliminating barriers to the timely and effective treatment of severe mental illness. The organization promotes laws, policies and practices for the delivery of psychiatric care and supports the development of innovative treatments for and research into the causes of severe and persistent psychiatric illnesses, such as schizophrenia and bipolar disorder. Together, TAC and the Chas Foundation have met with local and state legislators in an effort to educate them and advocate for more effective mental illness laws. John Snook, Brian Stettin and their staff are working to advocate improvements in the broken mental health systems in all 50 states including Virginia as well as the federal level. Their work to implement Mandatory Outpatient Treatment (MOT) laws and Assisted Outpatient Treatment (AOT) laws is providing a continuum of care in states where hospitals for the mentally ill and long-term treatment no longer exists.
