Severe Mentall Illness
Background
52 million people in the US suffer from a mental illness such as anxiety or depression and just over 13 million are severely mentally ill.
Severe mental illness includes schizophrenia, severe bipolar disorder, mood and thought disorders, and serious depression.
Serious mental illness is disabling, preventing people from engaging in normal work or family life.
Many with severe bipolar disorder or schizophrenia do not know that they are ill, which is called lacking “insight.”
Adults with serious mental illness are more likely to suffer from substance use disorder as well as numerous general health conditions such as heart disease, diabetes, and respiratory conditions, which complicates their care needs.
In 2012, an estimated 35,000 people were in state hospitals, while an estimated 356,000 with serious mental illness were in jails and state prisons at any given time.
According to the World Health Organization, serious mental illness reduces life expectancy by ten to twenty-five years, primarily due to chronic health conditions and suicide.
There is frequent violence within psychiatric emergency departments by the severely mentally ill who are admitted.
California has more than one million individuals with a serious mental illness, and, on any given day in 2019, as many as half were untreated. They cycle in between the streets, jails, hospitals, and halfway houses.
Neither San Francisco nor California has enough psychiatric beds. The California Hospital Association recommends having a minimum of 50 beds per 100,000 people, yet the state has less than half that. The European Union has 73 beds per 100,000 people. As of 2020, the San Francisco Bay Area as a whole needed over 2,500 more psychiatric beds to meet the California Hospital Association’s goal of 50 inpatient beds for every 100,000 residents. San Francisco General saw its acute inpatient psychiatric beds decline from 88 in 2011 to 19 in 2013. They have not risen since. Across California, the number of psychiatric beds per 100,000 people fell from 30 in 1995 to 17 in 2017.
California has a 30 percent higher rate of mentally ill people in jails, and a 91 percent higher rate of mentally ill people on the streets or in homeless shelters, than the nation as a whole, despite spending $7,300 per patient on mental health services, which is 50 percent more than the national average.
Fewer than 1 person per 10,000 San Francisco residents is under conservatorship, while 4 to 5.5 out of every 10,000 people are under conservatorship in neighboring counties are. The number of people in San Francisco referred to conservatorships actually declined by 143 between 2012 and 2018.
History
In the late 1800s mental health advocate Dorothea Dix successfully led a movement to transfer the severely mentally ill out of abusive and degrading conditions in jails, homes, and poorhouses, and put them in hospitals.
An 1880 survey found that about the same number of severely mentally ill people were living at home (41,083) as lived in hospitals (40,942) while 9,023 were in almshouses, which are charitable housing that sometimes included basic services. Only 397 were in jail, making the mentally ill just 0.7 percent of the total jail population.
Hospitals like the Napa State Asylum in California treated the mentally ill with dignity through disciplined staff and activities like raising poultry and growing crops.
While the mental hospitals were a major improvement over previous conditions, over time state mental hospitals abused their power to involuntarily hospitalize people and became overcrowded.
The Great Depression and World War II dramatically worsened the conditions in the mental hospitals. The institutions became underfunded and understaffed while increasing their patient counts. The population of state mental hospitals increased from 150,151 to 423,445 between 1903 and 1940. Meanwhile, around half of the hospitals’ professional staff worked on the war effort.
To rectify the inhumane treatment of the mentally ill, President Truman signed the National Mental Health Act in 1946, which established the National Institution of Mental Health (NIMH). The big idea was to replace public mental hospitals with 1,500 privately owned, community-based mental health centers. But fewer than half were ever built.
Around this time many advocates for the mentally ill wanted more funding for state mental hospitals, not the closing down of these institutions.
Progressives successfully started shutting down California mental hospitals in the 1950s. Many progressives blame Ronald Reagan for emptying state hospitals in California, yet the Lanterman-Petris Act, which closed many of California’s mental hospitals, passed with veto-proof majorities during Reagan’s governorship, meaning he could not have kept the hospitals open. Plus, Governor Reagan served between 1966 and 1974, long after progressives started closing the hospitals.
President Kennedy passed legislation in 1963 that further directed federal funds away from state mental hospitals and towards community-based treatment centers. These centers mostly failed to treat the severely mentally ill or didn’t materialize at all.
The Severely Mentally Ill and Homelessness
The San Francisco Department of Health estimates that 4,000 of San Francisco’s homeless have a history of both serious mental illness and substance abuse disorder. Of these individuals, 41 percent frequently use urgent and emergency psychiatric services. 95 percent of those folks suffer from alcohol use disorder, and 35 percent are African American despite the fact African Americans only make up six percent of San Francisco’s population. People with serious mental illness are more likely to be homeless, interact with drug dealers, and be raped, beaten, or otherwise victimized than the general public.
Approximately 121,000 mentally ill people are conservatively estimated to be living on the streets.
There are over 11,000 people with serious mental illness living unsheltered on the streets in Los Angeles.
San Francisco General Hospital evaluates 6,100 annually for psychiatric holds, one-third of whom are homeless, but only admits 20 percent of them. While some of them just need to get sober, many of them would benefit from being hospitalized, even if briefly, say experts.
The Severely Mentally Ill and the Criminal Justice System
In California, just under one-third of those in prisons and jails have mental illness. In the Los Angeles County Jail, about 25 percent of the men and 40 percent of the women need mental health care. 89 percent of the remaining 12,000 patients in California’s state mental hospitals in 2018 were there for criminal cases.
78 percent of homeless inmates of the San Francisco County Jail system who suffered serious mental illness also suffered from addiction to alcohol or drugs, according to a study in 2000. Inmates who suffered both mental illness and addiction were more likely to be homeless and to be charged with violent crimes.
The Los Angeles County Jail has more mentally ill people than every hospital in the country and nearly more than any other institution.
Prisoners with a serious mental illness are two to three times more likely to be reincarcerated as other prisoners. The high rate of recidivism creates the cycling of people between the streets, hospitals, and jails or prisons.
One study estimates that around one-quarter of the people shot and killed by police in any given year in the US have an untreated severe mental illness. Those with an untreated severe mental illness are thus sixteen times more likely to be killed in an encounter with the police than those without one. California had 162 such incidents in 2017.
A 2016 San Francisco Chronicle analysis found that 60 percent of all fatal shootings by police in the city since 2010 had involved people who had a mental illness or were acting erratically. And at least 37 people with mental illness died in California jails between 2011 and 2017 because staff left them languishing.
Current Policy
California voters in 2004 passed historic legislation, the Mental Health Services Act, Proposition 63, which raises and disburses to the state’s fifty-eight counties over $2 billion per year for the treatment and prevention of serious mental illness. The initiative was promoted to voters as a way to address untreated mental illness among the homeless. The initiative placed a 1 percent tax on incomes over $1 million, affecting roughly 30,000 taxpayers. It increased the state’s spending on mental illness by nearly one-third.
Yet in 2015, the Little Hoover Commission, an independent oversight body, reported that the “state still cannot definitively quantify who has been helped by Proposition 63 spending and how.” The result is that the most difficult mentally ill and addicted homeless people end up becoming the responsibility of the police and criminal justice system.
California insurance providers pay a lower-than-average reimbursement rate to psychiatrists, which contributes to the state’s lack of psychiatric beds.
Some board and care group homes provide housing and treatment to individuals with severe mental illness, an arrangement that is an improvement over homelessness and incarceration. Yet between 2012 and 2019, more than one-third of the board and care group homes in San Francisco that served people under the age of sixty closed their doors. It was more valuable to sell the homes than to be reimbursed by Medi-Cal and Medicare, which was only $1,058 per person per month. The same is occurring nationally. The United States lost 15,000 board and care beds between 2010 and 2016.
San Francisco in 2019 spent record amounts on mental illness and substance abuse, $370 million, of which about two-thirds was spent on the homeless, and half on homeless individuals who suffer both mental illness and substance addiction. In December 2019, the Board of Supervisors passed a measure aimed at extending mental health care to all uninsured or homeless San Franciscans, and in 2020, voters approved a bond measure that earmarked another $207 million for mental health care, substance abuse treatment, and homelessness services.
There are two main ways to require long-term psychiatric care in California: conservatorship and assisted outpatient treatment. Under conservatorship, which is called guardianship in other states, a judge appoints a relative or other qualified person to make financial, legal, and other key decisions on behalf of a person deemed “gravely disabled” by a qualified physician.
But California courts have been reluctant to apply conservatorships, and so in 2002 the California legislature passed “Laura’s Law,” named after a college student who was killed by a mentally ill man who had refused psychiatric treatment, to allow for assisted outpatient treatment. Under assisted outpatient treatment, courts can require mentally ill people who do not comply with their treatment plans to be held for up to seventy-two hours to determine if they meet the standard for involuntary hospitalization.
There is good evidence from California and other states that assisted outpatient treatment reduces homelessness and incarceration. Nine of the ten assisted outpatient treatment programs studied in California reduced criminal justice involvement. Six out of seven programs significantly reduced homelessness. Research finds that similar assisted outpatient treatment laws in other states reduced homelessness by up to 74 percent and arrests of the mentally ill by up to 83 percent.
Opposition to involuntary hospitalization is also behind the failure of California’s Mental Health Services Act, Proposition 63, passed in 2004. None of the $2.4 billion raised through Proposition 63’s tax on millionaires can be used for involuntary treatment. Twenty percent of MHSA money is allocated by the state to spend to “prevent mental illness from becoming severe and disabling.” But much of this money has been spent on ostensibly therapeutic activities for people with milder mental illness, including exercise classes, gardening, and “creative learning circles,” rather than on preventative psychiatric treatment of the seriously mentally ill.
Opposition by the ACLU and progressives is also behind California’s failure to apply for, and receive, federal funding to pay for more psychiatric beds. An obscure provision, the “Institutions for Mental Disease (IMD) Exclusion,” prohibits Medicaid from reimbursing states for adults with mental illness who receive long-term care in a psychiatric hospital with more than sixteen beds. The provision requires states to pay 100 percent of the cost of care for the seriously ill who need long-term hospital care, as compared to 50 percent for those treated in the community.
But since San Francisco, Los Angeles, and other progressive cities have largely stopped enforcing the laws against public defecation and open-air drug use, the police do not make those arrests and often do not investigate violations of the law by potentially mentally ill homeless people.
Policy Solutions
California should institute universal psychiatric care so that all Californians have access to mental health care. Let’s call this new program “Cal-Psych.” Cal-Psych would be a new statewide agency responsible for procuring treatment beds and care facilities, providing case workers, and implementing evidence-based solutions, with a focus on severe mental illness.
Cal-Psych would be built around empowered caseworkers who would have evidence-based solutions to support their clients with. Caseworkers would know if their clients were abstinent, following treatment plans, homeless, or in jail. They would provide “tough love” by challenging their clients to improve their lives and would have the tools for tough love to work.
At the most basic level California needs more psychiatric beds so that the ill can receive emergency or urgent care when they need it and for as long as they need it. Hospitals offer patients a chance to stabilize and begin a treatment program.
California should expand “Laura’s Law,” California’s assisted outpatient treatment law, and conservatorship so that no one remains untreated due to a lack of insight. While some policymakers hesitate to use mandated care, it must be an option since some of the mentally ill, not knowing they are ill, refuse care they desperately need. Sometimes mandated care is the only chance an individual has for a dignified and healthy life.
Contingency management is a treatment program based on giving clients rewards in exchange for making progress towards their goals, like abstinence, accepting treatment, or job seeking. Some rewards that have been implemented in contingency management programs include cash, gifts cards, and housing.
The efficacy of contingency is well-supported by academic studies. Contingency management can reduce psychiatric hospitalizations, improve financial management, and raise the quality of life for the mentally ill suffering substance abuse disorder.
A large, randomized controlled trial among the seriously mentally ill, two-thirds of whom were homeless, found that the participants who received the contingency management intervention were 2.4 times more likely to be abstinent than the control group. Contingency management had a very low cost compared to other forms of drug treatment, just over $100 per week per participant. Those receiving contingency management were one-fifth as likely to be hospitalized for psychiatric reasons. And “abstinence persisted after treatment was discontinued,” researchers found, which has been replicated by many subsequent studies.
Contingency management harnesses well-established psychological principles, which is likely why it works for such a wide number of people the mentally ill and addicted. Contingency management is based on the psychological theory of operant conditioning. It emphasizes the need for concrete and immediate reinforcements. Contingency management swaps one set of rewards, such as meth and heroin, for another set of rewards, such as gift cards and apartment units.
Despite the evidence in favor of contingency management, it remains rarely used in the United States. Part of the reason is that it has been unpopular with some policy makers and practitioners, who are skeptical that it makes a difference over the long term. But contingency management has been included in the National Registry of Evidence-Based Programs and Practices, adopted and implemented by the Department of Veterans Affairs, as well as by the governments and medical establishments of the United Kingdom, Brazil, and China. Hundreds of studies, meta-analyses, and reviews published in the world’s leading scientific journals conclude that contingency management works as well as, and often better than, any other drug treatment.
Cal-Psych would be responsible for making shelter available to all homeless individuals who need it. The mentally ill would benefit from access to shelter because sheltered homeless individuals are healthier than the unsheltered. Over 29,000 Californians with severe mental illness are unsheltered.
Given how many mentally ill individuals are shot by police each year, it is critical that police are trained to interact with these individuals. Arizona and Texas have police officers trained to handle mental health calls. They track down people who have violated court orders for treatment. They check in on people. They often have social workers with them. Crucially, their status allows them to handle people who might be in a violent, psychotic state, which social workers are usually not equipped to handle.