CONSEQUENCES OF NON-TREATMENT

The consequences of non-treatment for serious mental illness are devastating. Here are 2 articles on it

Homelessness People with untreated psychiatric illnesses comprise 250,000 people, of the total homeless population. The quality of life for these individuals is abysmal. Many are victimized regularly. A recent study has found that 28 percent of homeless people with previous psychiatric hospitalizations obtained some food from garbage cans and eight percent used garbage cans as a primary food source.
Incarcerationin 2011, there were about 240,000 seriously mentally ill in prisons and 125,000 in jails, or 365,000 adults with serious mental illness in jails or prisons.[i] An additional 770,000 seriously mentally ill are on probation or parole.[ii] There are now more than ten times more seriously mentally ill persons in jails and prisons than in state hospitals.[iii] The incarcerated mentally ill tend to have very severe disorders.[iv] If they are untreated, they often rack up new charges while on parole or in prison, and serve longer terms than the non–mentally ill.[v]These individuals are often incarcerated with misdemeanor charges, but sometimes with felony charges, caused by their psychotic thinking. People with untreated psychiatric illnesses spend twice as much time in jail than non-ill individuals and are more likely to commit suicide.
Episodes of ViolenceThere are approximately 1,000 homicides among the estimated 20,000 total homicides in the U.S. committed each year by people with untreated schizophrenia and manic-depressive illness. According to a 1994 Department of Justice, Bureau of Justice Statistics Special Report, “Murder in Families,” 4.3 percent of homicides committed in 1988 were by people with a history of untreated mental illness (study based on 20,860 murders nationwide).The Department of Justice report also found:
- of spouses killed by spouse 12.3 percent of defendants had a history of untreated mental illness;
- of children killed by parent 15.8 percent of defendants had a history of untreated mental illness;
- of parents killed by children 25.1 percent of defendants had a history of untreated mental illness; and
- of siblings killed by sibling 17.3 percent of defendants had a history of untreated mental illness.

A 1998 MacArthur Foundation study found that people with serious brain disorders committed twice as many acts of violence in the period immediately prior to their hospitalization, when they were not taking medication, compared with the post-hospitalization period when most of them were receiving assisted treatment. Important to note, the study showed a 50 percent reduction in rate of violence among those treated for their illness.

VictimizationMost crimes against individuals with severe psychiatric disorders are not reported; in those instances in which they are reported officials often ignore them. Purse snatchings and the stealing of disability checks are common, and even rape or murder are not rare.
SuicideSuicide is the number one cause of premature death among people with schizophrenia, with an estimated 10 percent to 13 percent killing themselves. Suicide is even more pervasive in individuals with bipolar disorder, with 15 percent to 17 percent taking their own lives. The extreme depression and psychoses that can result due to lack of treatment are the usual causes of death in these sad cases. These suicide rates can be compared to the general population, which is approximately one percent.
Clinical Outcomes More Severe Recovery UncertainThe longer individuals with serious brain disorders go untreated, the more uncertain their prospects for long-term recovery become. Recent studies have suggested that early treatment may lead to better clinical outcomes, while delaying treatment leads to worse outcomes. For example:
- A 1997 study from California (Wyatt et. al.) compared people with schizophrenia who received psychotherapy alone (89 patients) versus those who received antipsychotic medications (92 patients); those who received medications had much better outcomes three and seven years later.
- A 1998 study from England (Hopkins et. al.) revealed that delusions and hallucinations among patients suffering from psychosis increased in severity the longer treatment was withheld from the time of the initial psychotic break (51 patients were included in the study).
- A 1994 study from New York (Liebeman et. al.) showed that the longer a patient waited to receive treatment for a psychotic episode, the longer it took to get the illness into remission (70 patients were included in the study).
- A 1998 study from Italy (Tondo et. al.) demonstrated that the sooner patients were started on lithium for their manic-depressive illness, the greater their improvement became (317 patients participated in the study).

- Fiscal CostsSchizophrenia and manic-depressive illness are expensive diseases. A recent study found that the cost of schizophrenia alone was comparable to the cost of arthritis or coronary artery disease (D.J. Kupfer and F.E. Bloom, eds., Psychopharmacology: The Fourth Generation of Progress, 1995):
  - schizophrenia costs $33 billion per year;
  - arthritis costs $38 billion per year; and
  - coronary artery disease costs $43 billion per year.
  The costs included both direct costs of treatment as well as indirect costs such as lost productivity:
  
  Federal Benefits
  A significant percentage of government income benefits also go to people with severe mental illnesses. For example:
  - Fifteen percent of Medicaid recipients have a serious psychiatric disorder;
  - Thirty-one percent of Supplemental Security Income (SSI) recipients have a serious psychiatric disorder;
  - Twenty-six percent of Social Security Disability Insurance (SSDI) recipients have a serious psychiatric disorder;
  - Thirteen percent of those receiving VA disability benefits have a serious psychiatric disorder.
  Schizophrenia and manic-depressive illness are thus major contributors to the escalating costs of state and federal programs.
  
  Incarceration and Related Costs
  It is a mistake to think that money is saved overall by not treating individuals with severe psychiatric disorders. Individuals who are untreated for their illness cost money by being incarcerated. For example, the total annual cost for these illnesses in jails and prisons is estimated by the Department of Justice Source Book on Criminal Justice Statistics (1996) to be $15 billion (based on an estimated cost of $50,000 per ill inmate per year, and 300,000 individuals with serious psychiatric disorders being incarcerated.)
  
  Adding to this expense are court costs, police costs, social services costs, and ambulance and emergency room costs. A study of schizophrenia costs in England reported that “97 percent of direct costs are incurred by less than half the patients” and concluded that “treatments which reduce the dependence and disability of those most severely affected by schizophrenia are likely to have a large effect on the total cost of the disease to society and may, therefore, be cost-effective, even though they appear expensive initially.” (Davies and Drummond, British Journal of Psychiatry, 165 (Suppl. 25): 18-21, 1994).
  
  When calculating the fiscal costs of untreated severe psychiatric disorders, intangible costs must also be included: the deterioration of public transportation facilities, loss of use of public parks, disruption of public libraries, and losses due to suicide. The largest intangible cost, of course, is the effect on the family.
- In sum, severe psychiatric disorders such as schizophrenia and manic-depressive illness are costly three times over: Society must raise and educate the individual destined to become afflicted; people with the illnesses are often unable to contribute economically to society; and many require costly services from society for the rest of their lives.

HOMELESSNESS, INCARCERATION, EPISODES OF VIOLENCE:
WAY OF LIFE FOR ALMOST HALF OF AMERICANS WITH UNTREATED SCHIZOOPHREMIA AND BIPOLAR

National Disgrace:
Millions of Americans with Serious Brain Disorders Go Untreated

An estimated 4.5 million Americans today suffer from two of the severest forms of brain disorders, schizophrenia and manic-depressive illness (2.2 million people suffer from schizophrenia and 2.3 million suffer from bipolar disorder). According to the National Advisory Mental Health Council, an estimated 40 percent of these individuals, or 1.8 million people, are not receiving treatment on any given day, resulting in homelessness, incarceration, and violence. The reasons for this are many, including economic factors, the failure of deinstitutionalization, civil liberty issues as well as the effects of the illnesses themselves.

Economic factors and the failure of deinstitutionalization are the two leading causes of todays crisis situation. A greedy game of musical chairs, or cost shifting by state and local governments to the federal government, especially to Medicaid, has played a pivotal role. As a result, individuals with serious brain disorders have been dumped out of psychiatric hospitals and shoved into nursing homes and general hospitals (many of which offer worse care than the psychiatric hospitals from which they were discharged), and forced onto the streets and into jails.

Since its beginnings in 1955, deinstitutionalization has been more about political correctness than scientific knowledge. When deinstitutionalization began there had been no scientifically sound studies conducted on how to best reintroduce individuals with the severest brain diseases back in to the community. In addition, there have been very few services available to these individuals when they are released into the community.

Battles in the nations courtrooms over individual civil rights also have helped to further jeopardize Americas most vulnerable citizens. Civil liberty advocates have changed state laws to such an extent that it is now virtually impossible to assist in the treatment of psychotic individuals unless they first pose extreme and imminent danger to themselves or society.

Adding to this crisis are the illnesses themselves. Schizophrenia and manic-depressive illness greatly impair self-awareness for many people so they do not realize they are sick and in need of treatment. Unfortunately, todays state mental health systems and treatment laws that oversee the care and treatment these individuals receive play right into the vulnerability of these devastating diseases with the effect that far too many people remain imprisoned by their illness.

Federal Dollars Fuel Disjointed, Uncoordinated Care

- - Deinstitutionalization A Rocky Road To Nowhere
    Deinstitutionalization, the name given to the policy of moving people with serious brain disorders out of large state institutions and then permanently closing part or all of those institutions, has been a major contributing factor to increased homelessness, incarceration and acts of violence.Beginning in 1955 with the widespread introduction of the first, effective antipsychotic medication chlorpromazine, or Thorazine, the stage was set for moving patients out of hospital settings. The pace of deinstitutionalization accelerated significantly following the enactment of Medicaid and Medicare a decade later. While in state hospitals, patients were the fiscal responsibility of the states, but by discharging them, the states effectively shifted the majority of that responsibility to the federal government.In 1965, the federal government specifically excluded Medicaid payments for patients in state psychiatric hospitals and other “institutions for the treatment of mental diseases,” or IMDs, to accomplish two goals: 1) to foster deinstitutionalization; and 2) to shift the costs back to the states which were viewed by the federal government as traditionally responsible for such care. States proceeded to transfer massive numbers of patients from state hospitals to nursing homes and the community where Medicaid reimbursement was available. (Note: IMDs were defined by the federal government as “institutions or residences in which more than 16 individuals reside, at least half of who have a primary psychiatric diagnosis.”)
    - Since 1960, more than 90 percent of state psychiatric hospital beds have been eliminated. In 1955, there were 559,000 individuals with serious brain disorders in state psychiatric hospitals. Today, there are less than 70,000. Based on the nations population increase between 1955 and 1996 from 166 million to 265 million, if there were the same number of patients per capita in the hospitals today as there were in 1955, their total number today would be 893,000.
    - The pace of psychiatric hospital closures has accelerated. In the 1990s, 44 state psychiatric hospitals closed their doors, more closings than in the previous two decades combined. Nearly half of state psychiatric hospital beds closed between 1990 and 2000.
    Because of incentives created by federal programs, hundreds of thousands of patients who technically have been deinstitutionalized have in reality been transinstitutionalized to nursing homes and other similar institutions where federal funds pay most of the costs. These alternative institutions, however, lack the full range of services needed to adequately care for persons with severe brain disorders.
  - Psychiatric Patients Dumped into Nursing Homes and General Hospitals
    As state psychiatric hospitals improved in quality in the 1970s and 1980s, it became increasingly common to discharge patients from relatively good hospitals with active rehabilitation programs and transinstitutionalize them to nursing homes, general hospitals or similar institutions with markedly inferior psychiatric care and no rehabilitation at all. States save state funds, but transinstitutionalized patients pay a substantial price for the substandard care.
    - By the mid-1980s 23 percent of nursing home residents, or 348,313 out of 1,491,400 residents, had a mental disorder.
    - Costs in general hospitals are often $200 per day or more than the costs in public psychiatric hospitals. These additional costs are of little consequence to the states since federal Medicaid dollars are paying the majority of the bill; the states costs are lower and that is the limit of their concern. Unfortunately, evidence shows that general hospitals admit psychiatric patients with less severe illnesses, but turn away those who are more seriously ill. Inpatient stays for people with serious brain disorders are typically shorter in general hospitals, which compromises the persons ability to stabilize on medication.
  - Jails and Shelters Serve as Surrogate Hospitals
    The woeful failure to provide appropriate treatment and ongoing follow-up care for patients discharged from hospitals has sent many individuals with the severest forms of brain disease spinning through an endless revolving door of hospital admissions and readmissions, jails, and public shelters.At any given time there are more individuals with schizophrenia who are homeless and living on the streets or incarcerated in jails and prisons than there are in hospitals:
    - Approximately 200,000 individuals with schizophrenia or manic-depressive illness are homeless, constituting one-third of the estimated 600,000 homeless population. Many eat from garbage cans and are victimized regularly.
    - Nearly 300,000 individuals with schizophrenia or manic-depressive illness, or 16 percent of the total inmate population, are in jails and prisons, primarily charged with misdemeanors, but some charged with felonies, that were caused by their psychotic thinking.
    - Less than 70,000 individuals with schizophrenia or manic-depressive illness are in state psychiatric hospitals receiving treatment for their disease.

Violence Real Issue for Untreated Severe Brain Disorders

- - A 1990 study of families with a seriously ill family member reported that 11 percent of the ill individuals had physically assaulted another person in the previous year.
  - In 1992, sociologist Henry Steadman studied individuals discharged from psychiatric hospitals. He found that 27 percent of released patients reported at least one violent act within four months of discharge.
  - Another 1992 study, by Bruce Link of Columbia University School of Public Health, reported that seriously ill individuals living in the community were three times as likely to use weapons or to “hurt someone badly” as the general population.
  - A 1998 MacArthur Foundation study found that people with serious brain disorders committed twice as many acts of violence in the period immediately prior to their hospitalization, when they were not taking medication, compared with the post-hospitalization period when most of them were receiving assisted treatment. (The study showed a 50 percent reduction in rate of violence among those treated for their illness. Roughly 15.8 percent of individuals with a severe brain disorder committed an act of violence prior to hospitalized treatment, compared with only 7.9 percent of these same individuals post-treatment.)
  - There are three primary predictors of violence, including:
    - History of past violence, whether or not a person has a serious brain disorder;
    - Drug and alcohol abuse, whether or not a person has a serious brain disorder; and
    - Serious brain disorder combined with a failure to take medication.*
  - Other indicators of potential violence include:
    - Neurological impairment;
    - Type of delusions (i.e., paranoid delusions feeling that others are out to harm the individual and a feeling that their mind is dominated by forces beyond their control or that thoughts are being put in their head); and
    - Type of hallucinations (i.e., command hallucinations).

(*Note: While failure to take medication is one of the top three predictors of violence, civil rights lawyers have continuously expanded the rights of those with a lack of insight into their illness to refuse to take medication. Past history of violence is another major predictor of violent behavior, yet in many states these same civil rights attorneys have restricted testimony regarding past episodes of violence in determining the present need for hospitalization and assisted treatment.)

[i]. Jails are generally run by counties for those serving short sentences or awaiting trials. Prisons are for those serving longer sentences and can be run by the state or federal government. There were 1,504,150 people in prisons and 735,601 in jail or 2,239,751 total. Lauren E. Glaze and Erika Parks, “Correctional Populations in the United States, 2011” (Washington, DC: bulletin, Bureau of Justice Statistics, DOJ, November 2012), http://bjs.gov/content/pub/pdf/cpus11.pdf (accessed July 9, 2016). More than 50% of those (1,119,875) have a mental health problem. Doris J. James and Lauren E. Glaze, “Mental Health Problems of Prison and Jail Inmates,” (Washington, DC: special report, Bureau of Justice Statistics, DOJ, September 2006), http://bjs.gov/content/pub/pdf/mhppji.pdf (accessed July 9, 2016). However only about 16 or 17% of individuals in federal prisons (240,664) and 17% of those in jails (125,052) have “serious” mental illness. Fred Osher, David A. D’Amora, and Martha Plotkin et al., “Adults with Behavioral Health Needs under Correctional Supervision” (paper, Council of State Governments Justice Center, National Institute of Corrections, and Bureau of Justice Assistance, DOJ, 2012), https://www.bja.gov/Publications/CSG_Behavioral_Framework.pdf (accessed July 9, 2016).

[ii]. There are 4,814,200 individuals under probation or parole. Glaze and Parks, “Correctional Populations.” If the proportion of the mentally ill on probation and parole is the same as the proportion incarcerated, 50% (2,406,100) have any mental illness and 16% (770,000) have serious mental illness.

[iii]. E. Fuller Torrey, Mary T. Zdanowicz, Sheriff Aaron D. Kennard (ret.) et al., “The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey” (Arlington, VA: report, Treatment Advocacy Center, April 8, 2014). http://tacreports.org/storage/documents/treatment-behind-bars/treatment-behind-bars.pdf (accessed July 9, 2016).

[iv]. A recent study of a Correctional Center in Oklahoma found, that of “the 10 psychiatric medications the Department of Corrections spent the most on in 2013, seven were antipsychotics and three were anti-depressants.” Clifton Adcock and Shaun Hittle, “Prison Drug Data Reveals Disorders are Severe for Many Mentally Ill Inmates,” Miami News-Record, February 15, 2014. Version at http://oklahomawatch.org/2014/02/01/prison-meds-reveal-disorders-severe-for-mentally-ill-inmates (accessed July 9, 2016). In Muskegon, MI, “at least 10 to 20% of people charged or convicted of crimes can clearly be classified as having significant mental illness. Common diagnoses are schizophrenia, bipolar disorder . . . or post-traumatic stress disorder” and the cost is 50% higher than for other inmates. John S. Hausman, “Mental Illness and Criminal Justice: Law Enforcement Copes with Issues Hospitals Once Handled,” Muskegon (MI) Chronicle, December 16, 2013, http://www.mlive.com/news/muskegon/index.ssf/2013/12/mental_health-criminal_justice.html (accessed July 9, 2016). In 2010, people with mental illness were only 29% of the New York City jail population. By 2014 they represented 38%. Approximately one third of this 38% had serious mental illness. Bill De Blasio, Mayor’s Task Force on Behavioral Health and the Criminal Justice System (New York: 2014),http://www1.nyc.gov/assets/criminaljustice/downloads/pdfs/annual-report-complete.pdf (accessed July 26, 2016).

[v]. James and Glaze, “Mental Health Problems.”