Proposed legislation could finally fix mental-health care

Bloomberg NewsDecember 26, 2013 

In the wake of gun violence such as occurred at Sandy Hook Elementary School and Virginia Tech, commissions are organized and institutional reviews are conducted. Rarely, however, are meaningful reforms proposed.

The legislation recently introduced in the House of Representatives by Tim Murphy, R-Pa., is a refreshing change. The Helping Families in Mental Health Crisis Act of 2013 addresses a long list of inadequacies in services for people who suffer from schizophrenia, bipolar illness, major depression and other severe conditions – problems that Murphy uncovered in his yearlong investigation of the U.S. mental-health system.

These flaws begin with the dubious “recovery model” of treatment, extolled by the Substance Abuse and Mental Health Services Administration, the federal agency charged with administering $440 million in state block grants to fund community mental-health facilities. The recovery model is based, in SAMHSA’s wording, on “change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.”

This may work for certain high-functioning patients. But for those languishing in back bedrooms and flophouses because they are too paranoid, oblivious or lost in psychosis to “self- direct” their lives, it amounts to malpractice.

By focusing on “recovery,” SAMHSA promotes only a handful of treatment programs aimed at the sickest patients.

Meanwhile, the agency fails to recommend “assisted outpatient therapy,” a form of civil-court-ordered community treatment for patients who are known to be self-destructive or dangerous when off their medication. Much research has shown this therapy to be extraordinarily effective for people with severe mental illness.

The Murphy bill would set things straight by taking away SAMHSA’s authority to administer the mental-health block grants and turning it over to a new assistant secretary for mental-health and substance-use disorders. It would also fund assisted outpatient therapy programs and require that each state have a law on the books to administer them as a prerequisite for receiving block grants.

A second big weakness in the system is a shortfall of hospital beds – estimated to be 100,000 nationwide. This came into the spotlight last month when Gus Deeds, the son of Virginia state Sen. R. Creigh Deeds, stabbed his father and then shot himself, fatally. A day earlier, Gus had undergone a psychiatric evaluation under an emergency custody order, but because no local bed was available, he wasn’t admitted to a hospital.

The Murphy bill would increase access to acute-care beds for the most critical patients by lifting Medicaid rules that prohibit reimbursement for patients over age 21 and under 65.

The bill would also curb excessive secrecy surrounding patient information under the scope of the Health Insurance Portability and Accountability Act. Respectful confidentiality regarding psychiatric treatment is one thing, but too often frantic family members are not even told that their loved ones have been hospitalized. Murphy’s legislation would allow parents (psychotic illness often begins in late teenage years) and other “personal representatives” to communicate with patients’ doctors and caretakers.

Finally, there is the need to help disturbed people who never get to a hospital – for example, Aaron Alexis, who killed 12 people at the Washington Navy Yard in September. Several weeks earlier, Alexis, paranoid and delusional, had called police from a hotel room, but the responding officers were unequipped to handle the situation.

The Murphy bill would provide training to law enforcement and correctional officers on how to recognize mental illness and intervene to help people get treatment.

The bill includes other innovations – for example, funding for a National Mental Health Policy Laboratory to identify more effective treatments. It also directs the Justice Department to monitor crimes committed by people with serious mental illness and develop strategies to prevent them. And it requires states to refine commitment statutes to encompass involuntary care for people who are unable to seek the psychiatric care they need to prevent further physical or psychiatric deterioration.

It is the most ambitious mental-health legislation since the Community Mental Health Act of 1963, which funded federal community clinics as a way to accelerate the emptying of big state asylums. Unfortunately, the outpatient clinics set up 50 years ago weren’t prepared to treat the most gravely ill, many of whom were abandoned to streets and jails.

Greater funding remains a critical need, but if Murphy’s bill can be passed in the year ahead, the federal government will have begun major repairs to our flawed mental-health system.

Sally Satel is a psychiatrist and a resident scholar at the American Enterprise Institute. She wrote this for Bloomberg News.

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