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Fixing Our Mental Health System

We can make a good start by spending money on the mentally ill more efficiently.

by
Clayton E. Cramer

Bio

February 21, 2013 - 12:14 am

The recent tragedy in Newtown has finally woken Americans up to the pitiful state of our mental health system.  We have had many dozens of these tragedies over the last three decades, and certainly, the pattern has been clear since at least 2000: people with recognized serious mental-illness problems are about half of these mass murderers, and it seems likely that much of the rest had unrecognized or perhaps merely undocumented problems.  (What sane person murders a bunch of complete strangers, then commits suicide?)

I have been banging the drum on this for several years, and each time, someone asks, “How are you going to pay for all this?” Mental hospitals are expensive to build, especially because so many states have either closed or demolished their state institutions.  Once built, operating costs are substantial.  In an era when many state governments are already in financial trouble, where is the money coming from to create a safer and more humane society?

We are already spending the money; we just aren’t spending it very efficiently, because we are spending it on cleanup.  Drawing chalk marks around bodies, having medical examiners do autopsies, assigning extra police to schools across the country after each disaster — these aren’t free.

Many of these mass murderers do not commit suicide, and trying them is expensive.  The public defender costs alone for capital murder trials in Clark County, Nevada, for 2009-2011 were $229,800; for non-capital murder cases, $60,100.  It seems quite believable that including prosecution costs, time spent operating the courts and investigating the crime, and the inevitable appeals a non-capital murder trial can easily cost the government $500,000, especially because mentally ill defendants are almost always indigent, and thus receive public defenders.  I almost forgot: because these are mentally ill murderers, the costs of experts to evaluate the defendant’s mental competency for trial almost certainly drives these costs up even higher.

Once convicted (even if found not guilty by reason of insanity), one can reasonably expect life in prison.  As an example, Colorado spends more than $32,000 per year per inmate; that’s almost a million dollars per inmate for 30 years.  The spending is just starting, however: mentally ill inmates cost almost twice as much as sane inmates, because of the costs of mental health care once they are in the slammer.  It seems a good bet that each mentally ill murderer costs the state $2.5 million over his lifetime.  If they get the death penalty for the murder (as sometimes happens), it will be much more expensive than that: at least ten years in prison waiting for the ACLU to lose the battle, but all the legal costs of the appeals.

There were 14,022 murders and non-negligent manslaughters in the U.S. in 2011.  Of these, 12,706 were cleared by arrest.  If we assume that 10% of these persons charged were mentally ill (based on studies of murderers and mental illness), that’s about 1270 murders by the mentally ill a year (minus a few suicides among the mass murder set).  We could easily be accruing more than $3 billion a year in current and long-term costs.  How much mental health care can you pay for with $3 billion?

Of course, this isn’t really fair.  If we successfully divert people into the mental health system before they commit crimes like murder, we will also make substantial inroads into other social costs that are somewhat harder to quantify: fewer homeless people begging on the streets; fewer requests to local governments to fund homeless shelters; fewer homeless people making a nuisance of themselves in public libraries. And I have not even considered the other major and minor crimes committed by mentally ill people who fall through the cracks.

I found myself wondering a little while back, how is it that I grew up in California at a time when community college tuition was free, the University of California’s costs were quite reasonable, and yet it was far less wealthy of a society than today? How did they manage to provide so many services, so effectively, with relatively little revenue? I am beginning to wonder if the problems of state or local government that have developed over the last forty years might be because we are spending money trying to clean up disasters, rather than prevent them.

Clayton E. Cramer teaches history at the College of Western Idaho. His most recent book is My Brother Ron: A Personal and Social History of the Deinstitutionalization of the Mentally Ill (2012). He is raising capital for a feature film about the Oberlin Rescue of 1858.

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All Comments   (44)
All Comments   (44)
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The Meds and the Machines are rapidly getting better and more reliable;
At what point in their effectiveness, and after what medical/judicial review,
will it become defensible to implant a mentally ill person with a 'Minder' ?
1 year ago
1 year ago Link To Comment
And no attempt to address the "offensive" side of this argument.
Considering "cost" of the debate, where you cannot even use most terms to describe a psychotic individual, the time and money for the debate phase will require a new debt ceiling bill before anything gets started.
"Terrorist"? No; Just a religious radical.
"Social deviate"? No; Just your average Democrat.
"Homicidal maniac"? No; Just your everyday hard core Democrat.

Remember never to offend anybody!
1 year ago
1 year ago Link To Comment
"It seems a good bet that each mentally ill murderer costs the state $2.5 million over his lifetime."

Clayton, why do you think this would bother anyone? We all sit idly by knowing that the majority of public service employees costs the state (read: taxpayers) more than $2.5 million for their retirement years alone. At least we get entertained by the murderers trial.
1 year ago
1 year ago Link To Comment
It isn't a matter of bothering anyone -- it is that the money spent on criminal prosecution and imprisonment is money that could be spent more productively on mental illness treatment.
1 year ago
1 year ago Link To Comment
I get your point. I was just being sarcastic. And and also suggesting that there is a lot of money that could be better spent (or not spent at all) in big government.
1 year ago
1 year ago Link To Comment
I recently read where, lacking state mental hospitals, some communities are seding dangerous mentally ill people that cannot be allowed to run loose to live in rest homes ordinarily used to take care of elderly people.

You can imagine what happens next. The mentally ill prey upon the elderly. And that cannot be cheap, either in terms of the cost to place such mentally ill people in the rest homes or the additional medical care required for their elderly victims.

1 year ago
1 year ago Link To Comment
As tradgic as mental health can be/is in almost any state, it is one that must be addressed by the states and NOT the federal government. The mentally ill fit nicely into the same package as convicted felons, convicted sooninmates and the homeless -- keep them mostly out of sight so we can keep them mostly out of mind. Thats the social mentality of todays society!

I wouldn't be looking for much interest muchless, any resolve to this problem anytime soon with todays generations. The states and thier people want nothing to do with anything that the federal government won't pay for at the same time they complain to the high heaven that government is to big, costs too much and has to much power over the states.
1 year ago
1 year ago Link To Comment
Agreed. This is almost entirely a state level problem.
1 year ago
1 year ago Link To Comment
A person's criminal tendencies are not caused by mental illness. A person with criminal tendencies can have mental illness get them into horrendous crimes and ruin their ability to flee. Mass murderers are criminals with mental illness or criminals carrying out criminal cultural behavior from a harsh foreign culture (e.g., killing all the witnesses as a usual procedure). Criminal tendencies have been identified and they appear in early age. Working with those with criminal tendencies is the issue, not the vast number of non-criminal mentally ill along with the criminals who are mentaly ill.
1 year ago
1 year ago Link To Comment
Sorry, but the claim that mental illness is not was caused criminal behavior is demonstrably false. One example: a Chinese immigrant in Manitoba in 2008 beheaded the passenger next to him on a Greyhound bus, and then started to eat him. The bus emptied out in a hurry, as you might expect. It turns out that schizophrenia meant that the killer thought the Earth was being invaded by aliens, and one was sitting next to him on the bus. He feels very sorry for what he did, now that he has been medicated long enough to realize that the hallucinations were just that.

You really think that this wasn't the cause of what he did?
1 year ago
1 year ago Link To Comment
It is not wise to approach all murderers as being one and the same. Just because the man in your example was mentally ill does not mean all of them are.

I'm afraid I have to agree with Wishkah39 here. Criminal tendencies are identifiable from an early age, largely in peoples with harsh tempers, self-centered personalities, and lacking in self-control. These sorts of people are everywhere in our society, but most are able to control themselves. Yes, genetics plays a role, but from what I have witnessed over the years, it is also poor upbringing.

I would argue that the erosion of American society, particularly in the homeplace, is largely to blame.

In regard to the article itself, I must state that I've had personal experience with institutionalized mentally ill, and their legal rights border on ridiculous. Violent pedophiles and hallucinogenic schizophrenics wander our streets because they cannot be held if they do not wish to be. I agree there must be reform, but like most of the comments here, I believe it should be on the state level. In regard to the costs of sheltering known murderers, some legal reform to increase criminal executions would go far - particularly as a deterrent.
1 year ago
1 year ago Link To Comment
I thought that I had made it quite clear in the article that most murderers are not mentally ill.

While there is much destructive erosion of American society that has taken place over the last 30 years, the overall murder rate is now where it was in the early 1960s.
1 year ago
1 year ago Link To Comment
Prior to government involvement in the mental hospital business, there were private mental institutions. Aside from the fact that you had the issues of cost (and because of them), the private hospitals were smaller, less crowded and generally had better conditions for their patients than the later generation of government-run mental institutions that were shut down in the '70s because of deplorable conditions. Again, another example of the private sector better able to do what the government later attempted for everyone.

Perhaps the answer here isn't to have the government step in and run mental instutions, but for the private sector to stand up and start opening mental hospitals. All the government really needs to do is allow for relatives to hospitalize their own again.
1 year ago
1 year ago Link To Comment
Uh, no. The first mental hospitals in America were governmental institutions. Private mental hospitals develop slightly later, but remained a small part of the total care system. Nor is it clear that the private hospitals were better than the public mental hospitals.

The reasons for the closure of government-run mental hospitals are multifactorial; your attempt to fit everything into your simple libertarian model does not work.
1 year ago
1 year ago Link To Comment
Likewise, fitting everything into a government-run model also will not work. And for the same reasons that government run health care will not work. The treatments will be substandard and they will not get to those who truly need them in time in many cases. At the same time, there will be those who will learn how to abuse the system at the other end to gain benefits that are un-needed.
1 year ago
1 year ago Link To Comment
Actually, since this truly is a public safety issue at its heart, there should absolutely be public funding available. I'm sure the Newtown families are not worried that someone will be abusing the system and getting mental health services they don't deserve.
1 year ago
1 year ago Link To Comment
Part of why state mental hospitals came into existence when they did was that there was no real solution to the most severe problems at the time. (Even today, for psychotic disorders, the medications are not cures so much as methods of maintaining some level of sanity.)

Private mental hospitals are a wonderful thing, and I have seen enough of how they work to agree that they should be part of any solution -- but the reason that the states need to remain players is that private mental hospitals mean that a mentally ill person has insurance that covers this. While most Americans have health insurance that provides mental health care, many of those with the most serious problems have already declined enough that they have lost their jobs, and thus their health insurance.
1 year ago
1 year ago Link To Comment
Elimination of all or large parts of the Dept of Education, Dept. of Energy, HUD, Homeland Security, Dept. of Transportation, without changing the tax structure as it now exists and reallocating federal taxes, I mean revenue, would free up billions for the treatment of mental illness and make a large cut in the annual deficit to boot.

Just saying...
1 year ago
1 year ago Link To Comment
I agree with peepers that parents do 'know' when there's a problem. They need support and yes, that may include civil commitment options. Right now, you can only get 'committed' once you have committed a crime, and for many mass shooters, their first crime is horrific. All these mass shooters had red flags waving all around them yet their friends and family could do nothing to help. The largest psychiatric hospitals in this country are in prisons. This is a shame.

The other issue many parents face is the ease with which psychiatrists prescribe anti-psychotic drugs. They hand them out like candy, especially to teens who are mildly depressed. There needs to be a national database of withdrawal effects and other side effects, and parents need to start saying NO to doctors and schools who insist their kids get put on drugs (speaking of banging drums...). Unfortunately, the FDA is funded with big Pharma lobbying money that rewards doctors who prescribe them.

I think a rather small percentage of the population is dangerously mentally ill, and I agree that we as a country would do well to treat them as such.
The idea that civil liberties are at stake is valid, but it's a slippery slope that has to be navigated. Ignoring the dangerously mentally ill until they are criminals is a mistake.
1 year ago
1 year ago Link To Comment
I absolutely agree!

Something else that a lot of people don't realize in this conversation is that the federal and state governments tend to hand more funding over to handle teaching "special needs" students.

Basically, the more kids a school district has who are on medication - the more funding they get.

There is a built-in positive feedback for that diagnosis that rewards the school district, and I do think this plays a role at some level on the pressure parents get from teachers sometimes.

Many teachers are perfectly fine with this, as it means a more pliable and controllable child.

As with asbestos and smoking, I'm afraid society has not recognized the dangers of something and allowed it to become commonplace and accepted practice - but at some point you can't overlook the cancer that is spreading.

Unfortunately, by that time it takes generations for the full extent of the damage to become known.
1 year ago
1 year ago Link To Comment
Not all of the mass shooters had red flags: the Clackamas Mall shooter apparently had no history. But generally, yes, these are people who family, friends, police, and mental health workers knew had serious problems and were likely dangerous to self or others.
1 year ago
1 year ago Link To Comment
There is tremendous resistance in many families to acknowledging that there are dire problems with their children. Everyone on the political spectrum is capable of idealizing the perfectly happy family, or looking to religion to cure mental illness. I wrote a bit about this problem here: http://clarespark.com/2013/01/17/bondage-and-the-family/.
1 year ago
1 year ago Link To Comment
Oddly enough, nearly everyone that I know with a seriously mentally ill family member has no problem acknowledging that there is a serious problem. There are a lot of less serious problems, such as depression, that may indeed be ignored or overlooked, but when you have a family member attacking complete strangers on the street, that's hard to ignore or gloss over.
1 year ago
1 year ago Link To Comment
Part of the resistance may be that they have no solutions available.
1 year ago
1 year ago Link To Comment
There is a real problem with overprescription of medications, especially for kids whose problems involve bad parenting. Side effects are real and sometimes severe. But don't confuse psychoses with ADHD (often diagnosed when a kid is simply a very active little boy).
1 year ago
1 year ago Link To Comment
Agreed, my point is that overuse and withdrawal from these might create more problems than the original prescription was given to treat.
1 year ago
1 year ago Link To Comment
Agreed. There are people who have very negative reactions to psychoactive drugs-anything that messes with your brain chemistry for any reason. I've had a bad reaction to one myself when taking it for migraine prevention. It destabilized my moods and made me prone to intense feelings of almost uncontrollable anger. Needless to say, I got taken off of it right away and my neurologist has ruled out that entire category of medications with a note in my chart.

It was the oddest thing. I'd just get unreasonably angry for no real reason. Part of me knew I was mad for no reason, but I had no control over it.

Those drugs are dangerous because they can provoke that kind of reaction, and if you aren't aware of what could happen, it could be too late.
1 year ago
1 year ago Link To Comment
Dangerous but not necessarily useless: as with many prescription drugs, they require medical supervision, and sometimes a lot more than a general practitioner is qualified to provide. One great hazard of the SSRI antidepressants is that if a GP only sees someone with bipolar disorder when they are depressed, it is tempting to assume that they are simply depressed. The use of SSRI antidepressants without a mood stabilizer in those situations can greatly aggravate the mood swings.
1 year ago
1 year ago Link To Comment
The average patient with bipolar illness has 5 depressive episodes before they have their first manic episode. Usually they are younger and don't respond as well to SSRI's as people with unipolar depression, but they usually do respond. There is also a significant spectum with bipolar illness with the recognition of Bipolar II disorder representing an 'milder' form of the disease. Mood stabilizers are used with treatment of resistant depression with a fair degree of success. The key to treating these patients is followup with the patient and their family and establishing a long term relationship with them. 3/4 of all medications for the mentally ill are prescribed by primary care providers.
1 year ago
1 year ago Link To Comment
For once, I almost agree with Bonesteel about something. Yes, we threw the baby out with the bathwater in the '70s in "reforming" mental health. It definitely needed reforming; One Flew Over the Cuckoo's Nest was altogether too real, but we shouldn't have all but abolished our public mental health system and create a population that instead of shuffling along the halls of a mental institution was shuffling along the sidewalks of every city in America. That said, I'm simply not willing to let the government use mental illness as a reason to involuntarily incarcerate people with not even a right of habeas corpus. A judicial committment for an evaluation to see if one was sane enough to stand trial was essentially a life sentence with no right of habeas corpus. So, yeah, I really want somebody who works for one of the Coumos or Browns of this Country having the power to decide that my political views make me insane.
1 year ago
1 year ago Link To Comment
Even in 1960, most states had a better due process arrangement for civil commitment than you are describing. There was certainly room for improvement (in Maine, for example, an emergency commitment could lead to life inside a hospital), but we went way too far the other way.
1 year ago
1 year ago Link To Comment
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