Treating Mental Illness Seriously

by D. J. Jaffe

Before Miriam Carey drove her car into a White House gate, led police on a car chase to the Capitol, and was shot dead to protect public safety, her boyfriend tried to prevent it from ever happening.

According to CNN, he “contacted police in December saying he feared for the safety of their child, who was 4 months old at the time. The boyfriend said the woman was acting delusional, claiming the president had placed Stamford under lockdown and that her house was under electronic surveillance.” He thought she had post-partum depression, but police found medications for schizophrenia, bipolar disorder, and depression in her home.

The most likely scenario is that Miriam was not taking the medications or they weren’t working. Either way, someone who was dangerous was on the streets.

We know how to stop this. What we need is mandatory and monitored community treatment for those known to have serious mental illness and a history of dangerousness, incarceration, or needless repeated hospitalizations.

Assisted Outpatient Treatment (AOT) is a court order to stay in treatment as a condition of living in the community. To be eligible, individuals must have serious mental illness and a past history of dangerousness, incarceration, or needless hospitalizations caused by going off effective treatments. The decision is made by a judge, and only after consulting with the patient, their lawyer and observing full due process. Other protections ensure it is rarely used, is time limited, and is not abused.

According to media reports, Miriam Carey had a prior psychiatric hospitalization and acted dangerously toward her four-month-old child. While not enough is known yet, she may have been eligible for AOT. But Connecticut, where she lived, does not have an AOT law.

New York State has the largest and most studied program, called Kendra’s Law. Studies found those enrolled in Kendra’s Law are four times less likely to engage in future violence than those in a control group. Other New York studies found it reduced homelessness by 74 percent; suicide attempts, 55 percent; substance abuse, 48 percent; physical harm to others, 47 percent; property destruction, 43 percent; hospitalization, 77 percent; arrests, 83 percent; and incarceration, 87 percent. These results are consistent with those in other localities that use it.  

By reducing the use of jails and locked psych wards as treatment settings, AOT saves a lot of money even accounting for the increased costs for court proceedings, case management, and prescriptions. A major study “The Cost of Assisted Outpatient Treatment: Can It Save States Money?” by Jeffrey W. Swanson, Ph.D. et al., compared the costs incurred by New York for patients in AOT during the twelve months prior to receiving AOT and two subsequent twelve-month periods. They found net average costs declined at least 50 percent in the first year and an additional 13 percent in the second. The first-year savings were approximately $50,000 per patient and were achieved primarily through reducing arrest, incarceration, and hospitalization. This too is consistent with findings in California and elsewhere.

How many persons with serious mental illness and a history of dangerous behavior or needless hospitalizations could be subject to a court order to stay in treatment? It’s not millions as the straw-man brigade would have us believe. In his new book, American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System, Dr. E. Fuller Torrey estimates that “approximately 10% of seriously mentally ill individuals are the most problematic (e.g., have repeated incarcerations, homelessness, repeated hospitalizations, etc.) and that 10 percent of those who are problematic, or 1 percent of the total, are a definite danger to themselves or to others.” Using National Institute of Mental Health estimates of illness prevalence, Dr. Torrey estimates there are 123,000 seriously mentally ill adults who should be on some form of assisted treatment at any given time. At $50,000 each, over $6 billion dollars could be saved. 

Why isn’t it used more? Ideology and hubris. No one is comfortable requiring anyone to do anything. It goes against our American grain. But requiring seriously mentally ill people who have a history of dangerous behavior, like Miriam Carey is alleged to have had, to stay in treatment while in the community is less restrictive than it’s alternatives: incarceration, involuntary inpatient commitment, or in her case, death.

Another impediment are state and county mental-health directors. By failing to implement AOT, they successfully move people off their own budgets and onto that of the criminal justice system. The mental-health directors look like heroes to their bosses who fail to see the impact on criminal justice.

Like Miriam Carey’s brother, I’ve had to call police to get help for my loved one with serious mental illness. If AOT were more widely used, fewer families of the mentally ill would have to resort to that option, and fewer members of the public bear the consequences when it doesn’t work.

— D. J. Jaffe has a seriously mentally ill relative and is executive director of Mental Illness Policy Org., a non-partisan think tank addressing serious mental illness (not ‘mental health’).



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