Treating Mental Illness

by D. J. Jaffe
There is a known way of saving patients from being a danger to themselves and others.

Two new studies should lead to a radical change in how we treat some persons with serious mental illness. The first study, conducted in Australia, found that individuals with schizophrenia — even those who do not have substance-abuse problems — are significantly more likely to be violent than the general population. 

Using a sample of 4,168 schizophrenia patients and a randomly selected control group who had never been diagnosed with schizophrenia, it found that 25 percent of the individuals with schizophrenia were charged with a criminal offense during their lifetime, compared to 10 percent of the control group. Just 2.4 percent of the control group were found guilty of a violent offense, compared to 6.4 percent of those with schizophrenia. That number soars to 22.8 percent for those who add substance abuse to schizophrenia.

This study is consistent with almost all recent studies on this issue and not a surprise to the general public. Unfortunately, as National Review reported 15 years ago, the non-profit mental-health industry vigorously denies a relationship between violence and untreated serious mental illness for fear of causing stigma. This head-in-the-sand approach has prevented widespread implementation of programs that can reduce the violence.

The second study, from Duke University, suggests what to do about increased violence among people with serious mental illness. Researchers studied the cost of Assisted Outpatient Treatment (AOT) in New York City and in several other parts of New York State. Under Kendra’s Law in New York and Laura’s Law in California, a court may order an individual who has a serious mental illness to stay in treatment as a condition of living in the community. AOT is only for those who have the most serious mental illnesses and who have a history of failure to comply with treatment even though it is necessary to prevent them from becoming violent, incarcerated, homeless, and/or hospitalized. Previous research had proved that AOT was highly effective at preventing these tragedies. But critics argued that it was too expensive and diverted resources from higher-functioning individuals. The new study lays those claims to rest.

Researchers found that AOT does increase costs for community-based mental-health care, but they also found that the increase is dramatically offset by reduced hospitalization and incarceration costs. In the New York City sample, net costs declined 50 percent in the first year after AOT began and an additional 13 percent in the second year. Savings were even greater outside the city. When researchers compared the group that was ordered to receive care against a group that was not, savings for the court-ordered group were about twice as large as those for voluntary recipients of similar care. 

The conclusion from these two studies is that we should be making much wider use of Assisted Outpatient Treatment. It allows individuals with serious mental illness to live safely in the community, rather than behind bars or in locked inpatient wards. It keeps the public, the police, and the patients themselves safer, and it saves money.

Unfortunately, the mental-health industry stands in the way, and President Obama seems to be enabling it. He did call for a high-profile “national dialogue” after recent mental-illness-related tragedies, but he tapped the non-profit mental-health industry and the Substance Abuse and Mental Health Services Administration (SAMHSA) to conduct it. Both refuse to admit the association between violence and untreated serious mental illness. The president should have invited the Department of Justice to take part. It certified AOT as an effective crime-prevention program, something SAMHSA has failed to do.

The brightest light on the federal level seems to be coming from leaders like Representative Tim Murphy (R., Pa.), a former child psychologist and co-chairman of the House Mental-Health Caucus. He recently used his position on the House Energy and Commerce Committee’s Subcommittee on Oversight and Investigations to bring attention to the failures at SAMHSA and the need to expand our use of Assisted Outpatient Treatment.

We may hope that legislation will come out of the subcommittee that will make AOT more widely available to the individuals who so desperately need it.

— D. J. Jaffe is the executive director of Mental Illness Policy Org.

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