Ideas Federal Government Should Consider to Help Seriously Mentally Ill (SMI) Adults

Support hospitals for seriously ill who need them

  • Eliminate IMD Exclusion (or at least chip away) to create hospital beds
  • Eliminate Medicare’s 190-day cap on hospitalization (or at least chip away)
  • Set minimum standard for stabilization under EMTALA.

Help parents provide care for seriously mentally ill

  • Free parent-caregivers from HIPAA handcuffs and FERPA restraints
  • Allow parents to supplement child’s SSI without putting benefits at risk (possibly limit this to food and transportation and housing which are necessary but SSI is inadequate for)
  • Create nationally administered pooled special needs trust parents can contribute to.

Decrease demand for housing for seriously mentally ill

  • Eliminate the one-third reduction in SSI benefits to consumers who live in housing provided by parents
  • Exempt homes left or given by parents of SMI to SMI from ‘means-testing’ (with certain restrictions) Perhaps tax the real estate transfer to create a fund for housing for others.
  • Let parents who can, supplement HUD vouchers.

Encourage the use Assisted Outpatient Treatment (AOT) for subset of seriously mentally ill

  • Make the court costs of Assisted Outpatient Treatment (AOT) (petitioning and hearings) reimbursable as case management under Medicaid
  • Create a robust blended Medicaid rate for individuals in AOT
  • Conduct provider and law enforcement education on benefits and usage

Improve services for seriously mentally ill

  • Create blended Medicaid rate for Clubhouse programs
  • Add diagnostic-specific or impairment-specific bump to Medicare/Medicaid reimbursement rates to account for higher cost of delivering care to SMI.
  • Incentivize states to create “DMV in a Van” services to accompany outreach workers visiting shelters, soup kitchens and homeless camps to provide instant IDs to homeless mentally ill where they are so they can access benefits
  • Until psychiatrist shortage is remedied, encourage pilot programs to train and license nurse practitioners and psychologists to write and monitor prescriptions.

Help Courts Help Seriously Mentally Ill

  • Incentivize mental health courts
  • Allocate X% of housing vouchers to be distributed by mental health courts
  • Create federal “Guilty And Mentally Ill (GAMI)” plea that would sentence people to ‘treatment’ for the maximum amount of time they could have been sentenced had they been found guilty. The treatment could be inpatient or out, and officers could move parties from one to other with no further hearings.

Reform SAMHSA/CMHS to Focus on Seriously Mentally Ill (as original legislation required)

  • Amend ADAMHA Reorg. Act to require CMHS director to be doctor.
  • Insert legislative language requiring federal mental health block grants to be spent on programs that have independent evidence they improve a meaningful metric in people with serious mental illness.
  • Eliminate CMHS direction in mental health block grant applications that encourage states to a) wrap social services in a mental health narrative and divert resources to them, b) divert them away from SMI, and c) divert them to non-evidenced based programs.
  • Require SAMHSA/CMHS to provide anosognosia education (ex Xavier Amador’s LEAP)
  • Purge NREPP of pop-psychology, programs without independent evidence, and those that don’t help SMI/SED. Move responsibility for NREPP to NIMH to improve quality of future evaluations.
  • End funding of antipsychiatry and pop-psychology learning modules.

Prohibit PAIMI/CRIPA from working to prevent seriously mentally ill from accessing care.

  • Transfer Protection and Advocacy for Individuals with Mental Illness (PAIMI) to Civil Rights of Institutionalized Persons Act (CRIPA) division of DOJ to align with federal priorities (CRIPA can be amended to allow individual representation).
  • Focus CRIPA on helping SMI access higher levels of care that prevent institutionalization rather than encouraging states to provide lower levels of care.

Focus NIMH on Seriously Mentally Ill

  • Increase funding for research focused on curing/treating SMI and on preventing violence.
  • Take specific steps to improve quality of research in light of fact that a much as 80% of the science from labs and journals cannot be replicated.
  • Take steps to reduce use of “P hacking.”

Help FDA better evaluate meds for seriously mentally ill.

  • Require pre-registration of study methodologies and the outcomes to be measured for all studies that will be used to approve medications. Require all the results of the pre-registered studies to be submitted to FDA as part of its review, even if results are negative or study was aborted.

Help DOJ send SMI back to Mental Health Systems

  • Screen all NGRI acquitees and mentally ill federal prisoners who are about to be released and connect them to services
  • Expand the use of forensic parole and forensic probation
  • Train the leadership of national, state and local sheriffs and police, DAs, chief judges on how to engage politically to end the practice of the mental health system off-loading the difficult patients to criminal justice.
  • Educate law enforcement on AOT and open criminal justice funding streams for it
  • Pilot the creation of Secure Congregate Therapeutic House Arrest Facilities (bonded group home with on-site services) similar to Hope House Greenburger Center is establishing. (Perhaps focus on those Incompetent to Stand Trial (IST) since they will likely have charges dropped or be sentenced to time-served).

Lower Costs of treating seriously mentally ill

  • Eliminate provisions in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 that prevent consumers from importing medicines from other countries and prevent the government from negotiating prices with pharmaceutical companies.
  • Refuse to fund programs that have no impact. These include MHFA, suicide education, many trauma (vs. PTSD) initiatives, many NREPP programs, stigma initiatives, public health approaches, programs that claim to predict or prevent serious mental illness, advertising/awareness campaigns that are designed to mislead about serious mental illness.
  • Cut programs that don’t meet a federal definition of ‘evidence-based.’ To be evidence based, a program must have independent evidence it improves a meaningful metric in people with serious mental illness. Meaningful metrics should include rates of homelessness, arrest, incarceration, violence, hospitalization and suicide. Other programs can be researched.
  • Transfer worthy social service programs that masquerade as mental health programs off mental health budgets and to the appropriate federal departments where they can compete with similar social service programs for funds.

Important Truths to Remember

  • While MI and SMI are not more violent than others, SMI who go untreated are more violent than others. 30% of SMI do go untreated per NSDUH. Denial will not reduce the violence. Reducing violence will reduce stigma.
  • Trauma is not a mental illness. PTSD is, and even that can run from mild to severe.
  • We don’t know how to prevent schizophrenia and bipolar. A Noble Prize will go to the person who discovers how. So don’t fund programs that claim they can prevent them. Fund research into prevention.
  • We don’t know how to predict who will develop SMI. Most mild illness does not become SMI. So don’t fund programs that claim to predict SMI. (FEP is after MI occurs, so is good.)
  • Stigma is not a major barrier to care for SMI. It is far behind lack of services, lack of doctors, lack of programs willing to accept SMI, cost, transportation, insurance, etc. Focus on those before stigma.
  • Suicide campaigns have not reduced suicide. Clozaril, lithium, and perhaps ECT have. So has means-removal.
  • Respite centers may be good for drying out, but are not alternative to hospitals for SMI. Most limit admissions to voluntary patients with no medical issues who are not homeless, can manage their own medications and health needs and can be stabilized quickly thereby excluding most SMI when in crisis
  • SAMHSA’s expert panel correctly noted the research on peer support is anecdotal and lacks experimental rigor. (Bottom of page 8) No peer support research has been specifically on SMI. No quality research has shown significant improvement in the meaningful metrics of homelessness, arrest, and incarceration. The only research that has compared peer support with non-peer support to determine if peers are better or worse than say, professional social workers at providing the same services found no difference.
  • AOT is only a six-month intervention and only for a very small subset of the most seriously ill. It is the only program extensively researched and proven to reduce homelessness, arrest, incarceration and hospitalization in the 70% or better range. It is less restrictive than alternatives: jailing and involuntary inpatient commitment. 80% of those in it (as opposed to CMHS funded groups that purport to talk for them) say it helped them get well and stay well.
  • Only having a single parent, getting bad grades, being unemployed, going through divorce, losing a loved-one, living in a bad neighborhood, having concerns about sexual identity are all part of life that most experience at some time. They are not mental illnesses, nor serious mental illnesses. They are not causes of serious mental illness (with the possible occasional exception of depression). Be wary of wrapping worthy social service programs  in a mental health narrative (“at-risk,” “trauma”) and then diverting mental health funds to them.

Research on all the above can be found in Insane Consequences: How the Mental Health Industry Fails the Mentally Ill.

Prepared 9/14/17 by Mental Illness Policy Org.

DJ Jaffe is Executive Director of the non-partisan Mental Illness Policy Org., and author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. He is a critic of the mental health industry for ignoring the seriously ill, and has been advocating for better treatment for individuals with serious mental illness for over 30 years. He has written op-eds on the intersection of mental health and criminal justice policy for the New York Times, Wall St. Journal and the Washington Post. New York Magazine has credited him with being the driving force behind the passage of New York’s Kendra’s Law and Congress incorporated ideas proposed by DJ in the Helping Families in Mental Health Crisis Act.