Using Laws to Help Solve the Public Health Crisis of Mental Illness

May is Mental Health Month, a good time to remember the ten million adult Americans who suffer from a serious mental illness such as depression, bipolar disorder, or schizophrenia.  Without proper treatment, psychiatric disorders put an enormous strain on affected individuals, family members and on society at large.

In the mid-1950s, state mental hospitals housed about a half a million people with mental illness. Many held patients against their will for decades in understaffed and deteriorating wards.

Today, most of those hospitals have been shuttered; the ones remaining hold fewer than 50,000 patients.

Taking people out of psychiatric institutions would have marked an extraordinary leap in social progress, if only it had been accompanied by a proportionate and continuing public investment in community-based mental health care. Instead, we now have a public system of mental health care that is fragmented and grossly underfunded.

In fact, only 12% of people with diagnosable psychiatric disorders receive minimally adequate treatment.

If left untreated, chronic brain disorders that seriously impair thought and behavior can lead to unemployment, homelessness, and involvement with the criminal justice system.

As a society we now spend limited resources to confine nearly a half-million people with serious psychiatric disorders in jails and prisons. The majority of them get picked up by the police for minor offenses, not violent crimes.

A penal institution is no place for someone whose only crime, it could be argued, is getting sick and not receiving the treatment they need to prevent a downward spiral.

The mental health landscape has shifted dramatically over the last fifty years.  Legal reforms, new approaches to treatment in the community, and changes in the way we manage and pay for behavioral health services have led to some improvements in mental health care in America.  Yet we have a long way to go, as noted in our recently published analysis, “Mental Illness, Law, and a Public Health Law Research Agenda.”

That analysis, funded by the Robert Wood Johnson Foundation’s Public Health Law Research program,  makes it clear that people suffering from schizophrenia, bipolar disorder and other serious mental illnesses can recover and go on to lead productive lives—if they receive access to treatment and supportive services.

But how do we get there?

Public health laws and policies have an important role to play in keeping people safe and healthy; indeed, innovative laws may be the best approach to the daunting challenge of ensuring access to community-based mental health care for those who need it the most.

For example, New York State passed and implemented a law that provides court-ordered treatment and services—including housing—to people with serious mental illness who meet certain criteria.  Equally important, as a consequence of the law, the state set aside funding to pay for these critical services.   Evidence from an independent, comprehensive evaluation of the law suggests that it works.

Virginia amended its health care decisions law to allow people with mental illness to sign an advance directive when they are healthy. That directive allows people to avoid involuntary treatment during an incapacitating mental health crisis, because doctors can follow the person’s own legally-documented instructions for treatment.

At a time when economic pressures threaten individual and public resources, we need to try new approaches supported by rigorous research to find out which public health laws and policies work best to improve mental health, and for what specific populations.  We also need evidence on better ways to implement cost-effective legal interventions in the “real world.”

For example, should more states do what New York did and provide court-ordered mental health treatment? Or do such laws backfire unless they also increase funding for services?  What are the most effective ways to assist re-entering prisoners with mental illness, so that they become reintegrated in the community? What are the best ways to ensure that people who wish to complete a mental health advance directive are able to do so?

We need answers to these questions and others in order to inform the public debate and extend a hand to an estimated 1 in 5 Americans currently struggling with some form of mental illness.

Jeffrey Swanson, Ph.D., professor of psychiatry and behavioral sciences at Duke University School of Medicine and John Petrila, J.D., L.L.M., professor of mental health law and policy at the University of South Florida are coauthors of the recent monograph, “Mental Illness, Law and a Public Health Law Research Agenda.” The monograph was funded by Public Health Law Research, a national program of the Robert Wood Johnson Foundation. To find out more about the Public Health Law Research program go to: http://publichealthlawresearch.org

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