Should Involuntary Mental Health Treatment be Expanded to Increase Care and Lower Crime?

WASHINGTON – Rep. Tim Murphy (R-Pa.) has introduced an ambitious proposal to overhaul federal mental-health policies and eliminate the ineffective ways in which the federal government spends money to tackle mental illness.

The Helping Families in Mental Health Crisis Act, which has 60 bipartisan cosponsors, is a wide-ranging reform proposal that looks at everything from mental-health research to the shortage of mental health professionals.

The bill, which was unveiled in December, is the product of a year-long examination of the nation’s mental healthcare system by Murphy and the House Energy and Commerce subcommittee on Oversight and Investigation.

The subcommittee found that the federal agencies in charge of mental health programs often fail to use the best available medical treatment and practices, rarely coordinate their actions, and barely engage in data collection to track treatment outcomes.

Murphy had promised the parents of Sandy Hook Elementary that he would introduce the bill before the anniversary of the shooting in which Adam Lanza, who suffered from mental illness, killed 20 elementary school students and six adults before killing himself in December 2012.

Speaking at the American Enterprise Institute recently, Murphy explained that while not all mentally ill individuals are violent, it is an issue of serious concern due to the number of recent tragedies that have been committed by someone with an untreated mental illness.

“Our nation has been rocked by several of these tragedies, and although those with mental illness are not of the vast majority likely to be violent, it is an area of great concern that some of these tragedies have been committed by someone who suffered from severe untreated mental illness,” Murphy said.

Murphy, a psychologist, said that individuals diagnosed with a severe and persistent mental illness are more likely to end up in jail or on the streets because they are not getting the necessary treatment.

“There are about 60 million Americans that have some degree of mental illness -- from the mild, transient, acute, mental illness to severe mental illness,” he said.

More than 9 million Americans suffer from severe mental illness, and over 3 million are without treatment. Between 20 and 50 percent of all U.S. inmates have a mental illness.

The federal government spends about $125 billion on mental health illnesses, most of which goes to payment for disability and Medicaid, and very little goes to programs focused on treating the most serious illnesses – schizophrenia, bipolar disorder or severe depression.

During the 1950s and 1960s, there was a powerful movement to deinstitutionalize psychiatric patients. This was primarily a product of the overcrowding and deterioration of hospitals, and the advent of new medications that would allow people suffering from mental illness to lead relatively normal lives.

In the 1950s, there were over 500,000 inpatient psychiatric beds in the U.S., which translated to 340 beds per 100,000 Americans. Today, there are fewer than 40,000, or 17 beds per 100,000 individuals. A 2010 survey by the Treatment Advocacy Center and the National Sheriffs’ Association estimated there were three times more individuals with serious mental illness in jails than in hospitals.

“It’s not that crime is so vast and expanding in our nation. It’s that we have traded the hospital bed for the prison cell,” Murphy said. “We have also traded the hospital bed for a mattress in a flophouse and homeless shelter, or blanket over some subway grate in our cities.”

“It’s inhumane and immoral,” he added.

Not only can those with mental illness cause pain for others, but they are also more likely to be the victim. For instance, someone with a mental illness is three to four times as likely to be a victim of violence or sexual assault.

“It’s extremely important to understand what happens when someone is without treatment,” he said. “When someone is without treatment, they can exhibit some violent or aggressive tendencies.”

In contrast, there is a 15-fold decrease in the likelihood of violence when someone is in treatment, Murphy said.

Last year, Virginia State Sen. Creigh Deeds was stabbed multiple times in the head and chest by his 24-year old son. His son, Gus, then committed suicide outside the family’s home. Less than 24 hours before the stabbing, Gus had undergone an evaluation by mental health professionals while he was under emergency custody order. Officials reportedly had to release Gus because no psychiatric bed was available and an individual could only be held under emergency custody for up to six hours.

The Murphy bill would work to fix the shortage of inpatient beds by changing the “16-bed rule.” Medicaid currently will not reimburse for psychiatric care in any hospital that has more than 16 psychiatric beds.

A similar shortage of psychiatric professionals – especially for children – has meant the average time between a first episode of psychosis and initial treatment can be 110 weeks. Currently, there is only one child psychiatrist for every 7,000 children with a mental illness or behavioral disorder.

The bill addresses this by advancing tele-psychiatry to link pediatricians and primary care physicians with mental health professionals in areas where patients do not have access to these services.

Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) provisions have become another barrier for parents trying to help their loved ones. As these laws currently stand, families and caregivers are often unable to share information with a physician about a patient’s medical history.

“You can’t get permission from someone who doesn’t even know where they are, someone who is so severely involved in paranoia and psychosis,” Murphy said. “That’s wrong and it’s a misinterpretation of the law. If you’re in an auto accident and are in a coma, they don’t wait until you’re out of the coma to treat you. Why is it that way for mental illness?”

The bill would clarify the HIPAA and FERPA laws, allowing parents to share and receive information about a mentally ill loved one.

Murphy identified some key areas that needed significant change, including addressing the shortage in inpatient treatment, finding alternatives to institutionalization, and proactively providing quick and appropriate treatment to all mental health patients.

“The plight that these patients face, and the turmoil that their families feel about handling this has got to change,” Murphy said. “Our system is far away from helping people get better to recover, to get jobs again, and to get independent housing."

Mental health advocacy groups are among the bill's supporters and detractors.

Mental Health America said in a statement the group "rejects the expanded use of involuntary treatment—ignoring the rights of persons with mental health conditions to make decisions concerning their treatment or minimizing the dignity, autonomy and self-determination of persons affected by mental health conditions."

"We believe that involuntary treatment should only occur as a last resort and should be limited to instances where persons pose a serious risk of physical harm to themselves or others."