Every year 38,000 people in the United States kill themselves. In America, we have more people who are victims of suicide than are victims of homicide. Or car accidents. Or prostate cancer. Yet mental health care in the United States: how and whether it works, how it is funded, and  the challenges it faces, is rarely discussed. It isn’t something that we like to talk about.

In his book “A Common Struggle,” Patrick Kennedy goes into intimate detail about the alcoholism, drug addiction, and mental illness that he and his family have struggled with. As the title suggests it is a problem that is dealt with by millions of Americans–as patients, caregivers and loved ones. The book, in addition to trying to de-stigmatize mental illness, chronicles the passage of the Mental Health Parity and Addiction Equity Act of 2008. If you have no idea what that is you are not alone. According to a survey by the American Psychological Association, 96 percent of Americans have no idea that this law exists or that it requires insurance providers to treat a mental illness in the same way it would treat a physical one.

Mental Health and Mental Health Parity

Mental health care in the United States is faced with a two unique challenges: access and attitudes. The United States spends $113 billion a year on mental health care. Despite the significant investment, it is more difficult to get access to a provider for mental health services than it is to get access to a physical health provider. Nearly 90 million Americans live in a “shortage area” for mental health care providers–compared to 55.3 million Americans who live in a shortage area for primary care physicians. But an even greater barrier to treatment are the attitudes about mental health. When researchers looked into why people were refusing treatment, 71 percent said that they wanted to solve the problem on their own.

A response like that would be considered ridiculous if it was given after a cancer diagnosis. Yet, because mental illness is considered to be different from a physical illness, we don’t find this response as shocking in that context. Some people do deal with mental illness and addiction on their own, some people even do so successfully. But for individuals who want or need treatment, an attitudinal change that allows patients to believe they are entitled to receive it, and the ability to actually access it, is critical.

Take a look at this explanation of the situation given by Representative Jim Ramstad. This video was his commentary in favor of the Mental Health Parity and Addiction Equity Act of 2008. Essentially, this law requires that insurance providers treat a mental health issue the same way that they would treat a physical health issue, with the same co-pays, deductibles, and access to treatment, including treatment for substance abuse. Ramstad argues in favor of passing the law, citing himself as a success story for treatment.

The arguments dividing supporters and opponents on this issue are the same reasons that people don’t seek treatment: cost and attitude. The human cost of living with mental illness is very high but treatments for mental illness can also be extremely expensive. Treatment often includes therapy, which involves repeatedly engaging the services of a professional for hours each month. That’s a hefty price tag. When treatment involves medication, as it often does for serious mental illnesses like bipolar disorder and schizophrenia, the cost of the medications themselves can be staggering. This is often because the dosages need to be carefully calibrated, frequently adjusted, and generics are not always readily available. All of this involves more physicians and psychiatrists. Hospitalization and in-patient treatment can cost thousands of dollars for just a few days. Insurance companies are understandably reluctant to be responsible for providing these services.

The Costs of Mental Illness

It’s difficult to calculate society’s financial costs for the nearly 42 thousand deaths that were attributed to suicide in 2013. But a 2008 study by the National Institute of Mental Health attributed $193.2 billion dollars per year to lost earnings from mental health disorders in general–largely based on missed workdays because of mental health concerns. That study isn’t accounting for the lost productivity while at work or people who can’t work or are underemployed due to their mental illness. A more recent and more holistic view of the cost of mental illness would cite $444 billion, which includes treatment and the lost wages of patients but not caregivers, according to a report from USA Today. Even that isn’t taking into account the true total economic cost of mental illness.

In effect, what mental health parity does is shift some of the financial burden of treating mental illness to insurance companies, the same way that it does for physical illnesses. But it isn’t a bulletproof solution. One very key component in the bill, which Representative Ramstad addresses, is that mental health treatment would only be provided when it was considered a medical necessity. However, it isn’t clear what qualifies as a medical necessity.

Long-term therapy may be highly beneficial to an individual but may not be considered a medical necessity. A 72-hour psychiatric hold, also beneficial and potentially life-saving in terms of preventing immediate harm, might have a better chance of being considered a medical necessity. The long-term therapy, which could possibly prevent the need for the psychiatric hold, is in all likelihood the more expensive of the two options, just as physical therapy is a very expensive treatment for a chronic medical condition. Insurance companies can and do use medical necessity to thwart patients from using their insurance for treatment of mental illness.

The State of Mental Health Care in America

Mental health parity is an important step, but it does not do anything to address the problem of mental illness for the uninsured and doesn’t do enough to address mental health concerns for those on Medicare/Medicaid. It also does not deal with the much larger problems of access to appropriate treatment and the involvement of the criminal justice system.

The video below, an interview with Liz Szabo of USA TODAY about their series “The Cost Of Not Caring,” explains some of the economic costs of mental health care and how those costs are being borne by millions of Americans. The article that accompanies the series does an even better job of expanding on the concerns with the mental health care system in the United States.

Reduced investment in mental health services by state and local authorities produces a system where we still pay for the mentally ill, just in different ways than you might expect. The main effect of mental health parity is to move some of the burden from the individual to a private insurance provider. While the main consequence of reducing services for mental health shifts the burden from asylums, where the mentally ill used to go, and other institutions that were designed to deal with them, to hospitals and prisons. These already stressed institutions have difficulty coping with the added demands now placed on them, leading to a system that does an ineffectual job because it deals with the physically ill, the mentally ill, and criminals who actually need to be incarcerated as a unit–rather than dividing them into separate categories and treating them accordingly.

Better Alternatives

There are treatment options that can be tried, which may cost more at first, but produce better results in the long run for the individual with a mental illness and his or her community. To compare the problem to a physical one, if amputating a broken arm was cheaper than setting a broken bone and then using physical therapy to regain full range of motion–most of us would still not say that is the best treatment. Because in the long run, the loss of productivity to the individual and to society is much higher and the expense to fix the arm would be viewed as an investment in that person’s future. Why then, when someone comes to the hospital with a chemical imbalance in their brain, rather than misaligned bone fragments, do we not explore more expensive treatment options–ones that would be investments in that person’s most productive future given the nature of the illness.

In 2008, the National Institute of Mental Health began the RAISE project, to research Recovery After Initial Schizophrenia Episode. Researchers in the RAISE trial found that after the two-year study period was concluded, schizophrenic patients who received a model of treatment that included family counseling and help to secure a job–services that are not covered by insurance companies, which typically only pay for drugs and limited therapy for outpatient treatment–did better than patients who only got basic services.

The added cost for these services was about $3,600 a year for each patient and according to the researchers yielded a better quality of life for the patients. Which is, certainly, a difficult thing to quantitatively measure. Because the study only lasted for two years it is hard to say if, over the person’s lifetime with the illness, the initial investment will prove to actually prevent more costly complications like hospitalizations. But the initial results suggest that including this type of counseling and other services may be worth the long-term investment.

For a surprisingly cogent and unsurprisingly hilarious look at the issue of mental health and innovative treatment options, check out John Oliver’s segment on mental health:

Conclusion

Removing the stigma of mental illness by treating it in the same way you would treat a physical ailment is a positive first step towards dealing with the mental health care crisis in this country. But it is only the first step. Thousands of Americans die from mental illness every year. Millions suffer from it chronically and face the challenges of dealing with a mental disease daily.

Because it touches so many of us so intimately, mental health treatment in America is not an easy topic for most to discuss. Usually, it only becomes part of our public discourse in the wake of a mass shooting. But that’s like only talking about a disease if it is an air-born pathogen. Those diseases are the most obvious for us to see as a threat; nothing is sexier on the evening news than a flu pandemic. But it is the less glamorous food poisonings that might be more deserving of our attention. It’s messier and more embarrassing to talk about, but you are also more likely to be affected by it.

Resources

USA TODAY: Mental Health System Crisis

Goodreads: A Common Struggle 

American Psychological Association: Help Center: Parity Law Resources

Washington Post: Seven Facts About America’s Mental Health Care System 

The Kennedy Forum: Parity 

Centers for Disease Control: Mental Health 

The Huffington Post: US Mental Healthcare System

Slate: Is My Work Medically Necessary? How Insurance Companies Get Around Rules For Mental Health Care

New York Times: New Plan To Treat Schizophrenia Is Worth Added Cost, Study Says

Mary Kate Leahy

Mary Kate Leahy (@marykate_leahy) has a J.D. from William and Mary and a Bachelor’s in Political Science from Manhattanville College. She is also a proud graduate of Woodlands Academy of the Sacred Heart. She enjoys spending her time with her kuvasz, Finn, and tackling a never-ending list of projects. Contact Mary Kate at staff@LawStreetMedia.com

The post Mental Health Care: Should We Be Treating the Mind the Same As The Body? appeared first on Law Street.

Mental illness is something that the American justice system has been dealing with for decades; particularly how to handle suspects suffering from it, how to determine who is mentally ill, and what are the best practices for apprehending, sentencing, and holding those people.

Mental illnesses are defined medically as “disorders that affect your mood, thinking, and behavior. Examples of mental illness include depression, anxiety disorders, schizophrenia, eating disorders, and addictive behaviors.” There’s no easy way to define a mental illness, and certain diseases don’t affect everyone in the same ways. That ambiguity is where many problems stem from–how should police deal with those who have mental illnesses?

Accusations of Police Brutality Against the Mentally Ill

The United Nations

The United States had to stand before the United Nations in Geneva last week to defend its human rights record. While this is a routine endeavor, it is still something that reflects badly upon the country and its leaders. There were a lot of topics to cover, but the most prevalent was police brutality. A staggering 120 countries were there to offer recommendations, making it one of the best-attended hearings in the history of the UN, and each country was given 65 seconds to speak. Countries from every corner of the globe stressed that police brutality and discrimination has to end. One of the main things that the discussions centered upon was the way that police officers treat mentally ill suspects.

Human Rights Watch Report

That wasn’t the end of the criticism over the way that the United States treats people with mental illnesses in the justice system. Also last week, Human Rights Watch produced a report that chronicled the daily lives of mentally ill inmates in America’s prisons, showing that the issues in the justice system extend far beyond police brutality. The report, coming in at a staggering 127 pages, is packed with stories of neglect, abuse, improper medical care, corporal punishment, and unnecessary solitary confinement.

Some of the stories reported were particularly troubling. There is one incident about a man with schizophrenia who lunged for a police officer. As punishment, they strapped him to a chair, put a mask over his face, and sprayed pepper spray directly into his face under the mask. There are stories of many inmates who were found dead or unconscious laying in pools of their own urine, vomit, blood, and feces.

One of the most harrowing stories is what happened to 50-year-old Darren Rainey, who, according to the report, had a “diagnosis of schizophrenia, [and] was housed in the inpatient mental health unit at Florida’s Dade Correctional Institution while serving two years on a cocaine charge.” His mental health caused him, at times, to smear feces on himself. The correctional officers would then have to transport him to the showers and help him clean up. The report alleges that the officers took Rainey to a broken shower that could be turned to scalding. He could not control the water nor leave the shower as the police closed the door. He stayed in the scalding shower for nearly two hours. When the police finally opened the door, they found him unresponsive and without a pulse. When they moved him, it was discovered that “he had burns over 90 percent of his body, and his skin was hot/warm to the touch and slipped off when touched.” There has not yet been a medical report on his death and the police investigation is ongoing.

The Treatment Advocacy Center estimates that there are about 360,000 prisoners in 5,100 American jails and prisons with serious mental illnesses–particularly schizophrenia, bipolar disorder, and severe depression. That statistic has caused many people to wonder what exactly are the “rules” that the police have to follow when dealing with the mentally ill?

Should the mentally ill even be incarcerated?

There have been many discussions about exactly what rights a person with a mental illness has when he is arrested. Of course, there should be differences depending on the type and severity of the mental illness. But as a general rule, most protocols haven’t been broken up that way–instead, there are blanket policies for everyone, and they often deal more with procedures that need to be followed after the arrest. There are many allegations that the police act too harshly when dealing with suspects who have mental illnesses.

Some states have taken their own unique approaches. California, for example, has thoroughly questioned whether or not the Americans with Disabilities Act protects mentally ill suspects from being arrested and brought into the traditional justice system. That notion stems from a situation where a mentally ill woman, Theresa Sheehan, was shot five times after she waved a knife at police officers–police officers who knew she was mentally ill, as she had a history of mental breaks and was in a halfway house. The case was recently investigated by the United States Supreme Court.

In light of that case, Ron Honberg, Director of Policy and Legal Affairs at the National Alliance for Mental Illness (NAMI), said that law enforcement officers “have become first responders to people in psychiatric crisis,” but that “oftentimes, their traditional academy training doesn’t really teach police how to respond to such crisis.”

The Supreme Court found that the police were “immune” in the Sheehan case, stating:

A federal district court sided with the police, ruling that it would be unreasonable to ask officers trying to detain a violent, mentally disabled person to comply with the ADA before protecting themselves and others. But the 9th U.S. Circuit Court of Appeals said a jury should decide whether it was reasonable for the officers to use less confrontational tactics.

Testing and Treatment

So what are the policies once someone who may have a mental illness is actually arrested? If the police arrest someone whom they suspect is mentally ill, they are supposed to have them checked out by a mental health professional, which will typically result in a 24-to-72-hour stay in a mental health facility.

Family members of the mentally ill person can also ask for a police transport to the hospital if that was not an option during the arrest. This is sometimes called a “5150 hold.”

Certain states have stipulations against arrests of the mentally ill. A New York State guide for lawyers explains:

Under Criminal Procedure Law section 730, a judge who has reason to believe that a criminal defendant may be ‘incapacitated’ must order that the defendant undergo a psychiatric examination. ‘Incapacitated’ in this context means that because of mental disease or defect, the defendant is unable to understand the proceedings against him or assist in his own defense. A ‘730 exam,’ as such exams are referred to, can be requested by a defense attorney or an assistant district attorney, or may be ordered upon the judge’s own initiative.

Other states have similar stipulations. Denver has seen 11 deaths in 2015 after police have been called to the site of a mental breakdown–including one where a veteran was wielding scissors. The state is looking at its training and laws, but also considering on-site questions and tests.

The Supreme Court of Michigan recently ruled in a case against police that they used force against a mentally ill inmate:

That the evidence provided by plaintiff, indicating that the police were inadequately trained in dealing with the mentally ill and using impact projectiles, is sufficient to survive summary judgment. Plaintiff’s expert, retired Captain Van Blaircom, who is former chief of police for the City of Bellevue, Washington, testified that the Defendant officers should have known that the manner in which they approached the decedent would escalate the confrontation. According to Van Blaircom, the officer’s treatment of the situation, combined with their statements that a mentally ill person should be treated as any other person, regardless of the situation, indicates that the police department’s training dealing with the mentally ill falls well below the reasonable standard of contemporary care.

Conclusion

Overall, there seems to be some movement toward reform for police brutality against the mentally ill, but there is still a lot of ground to be covered, and covered quickly before anyone else dies. Procedures need to be enacted to ensure that officers deal fairly and effectively with suspects who are dealing with a mental illness. It is only through developing those policies that we can ensure all Americans are treated humanely.

Resources

ABC News: High Court: Police Immune Over Arrest of Mentally Ill Woman

Human Rights Watch: Callous and Cruel

Guardian: Police Shooting of Mentally Ill Woman Reaches US Supreme Court

Mayo Clinic: Mental Illness

Public Agency Training Council: Dealing With the Mentally Ill and Emotionally Disturbed in the Use of Force Context

Urban Institute: The Processing and Treatment of Mentally Ill Persons in the Criminal Justice System

Urban Justice Center’s Mental Health Project: How to Help

Aljazeera America: US Cited for Police Violence, Racism in Scathing UN Review on Human Rights

Coloradoan: Supreme Court to Rule on Arrests of Mentally Ill

Mother Jones: There Are Ten Times More Mentally Ill People Behind Bars Than in State Hospitals

National Alliance on Mental Illness: A Guide to Mental Illness and the Criminal Justice System

National Institute of Corrections: Mental Illness in Corrections

Schizophrenia: How to Help a Mentally Ill Family Member Who Has Been Arrested

Treatment Advocacy Center: More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States

LA Times: L.A. Police Accused of Excessive Force in Arrest of Mentally Ill Man

Mental Illness Policy Org: Criminalization of Individuals with Severe Psychiatric Disorders

Noel Diem

Law Street contributor Noel Diem is an editor and aspiring author based in Reading, Pennsylvania. She is an alum of Albright College where she studied English and Secondary Education. In her spare time she enjoys traveling, theater, fashion, and literature. Contact Noel at staff@LawStreetMedia.com.

The post Police Brutality and the Mentally Ill in America appeared first on Law Street.

Recently, Johnson & Johnson had a $2.2 billion settlement, rendering it the third highest pharmaceutical fraud settlement made with the United States government. Will this trend continue, or will Johnson & Johnson learn from their mistakes as well as those of their predecessors?

Although consultant pharmacists purported to provide “independent recommendations based on their clinical judgment, Johnson & Johnson viewed the pharmacists as an ‘extension of [J&J’s] sales force,” the Justice Department claimed. That, more or less, is what Johnson & Johnson was sued for; drug-makers are legally only allowed to promote their product for cures in the way that the FDA has approved of them.

In a class action case, Johnson & Johnson was said to have wrongfully marketed their drugs created to treat schizophrenia, Risperdal and Invega, as dementia medication for elderly patients. Furthermore, the company allegedly lied about Risperdal’s side effects and withheld information that the medication led to diabetes. Although legally settling, the company still denied the allegations. Claiming innocence, Johnson & Johnson stated, “the settlement of the civil allegations is not an admission of any liability or wrongdoing, and the company expressly denies the government’s civil allegations.” In defending their drug, they claimed Risperdal to be “safe and effective for its approved indications”, and “an important treatment option for people with serious mental illness.”

Sure, the government has cracked down on Johnson & Johnson, and now the company is paying $2.2 billion, but does that actually mean anything? Johnson & Johnson has a net worth of $65.03 billion. In preparation for this case, the company set aside money to pay their penalties, rendering the fine insignificant for a company of great wealth and success.

So, will anything change from this settlement? Michael Ullmann, Vice President and General Counsel of Johnson & Johnson reflected, “today we reached closure on complex legal matters spanning almost a decade. This resolution [which] allows us to move forward and continue to focus on delivering innovative solutions that improve and enhance the health and well-being of patients around the world.”

I speculate that the government will tighten the reigns and harshly proctor the company, as well as extend this strict scrutiny to others drug-providers. But as a result of the simple nature of medications, being that they were released to the public shortly after their creation, and the system of pharmaceutical representatives, a heavily corrupted system, long term changes or consequential changes seem extremely unlikely to occur.

Shedding light on the impact of this case, Attorney General Eric Holder said “every time pharmaceutical companies engage in this type of conduct, they corrupt medical decisions by healthcare providers, jeopardize the public health, and take money out of taxpayers’ pockets.” Pharmaceutical representation is a capitalist system that encourages sales people to push drugs onto doctors, hospitals, and nursing homes which economically resonates, and yet morally conflicts with our way of conducting business. People become less important than businesses, as finances dictate our capitalist ways. C’est la vie. Being third in the country sounds significant, but the ranking, like China’s GDP, its just an arbitrary number in this case, meaningless.

[NPR] [NYTimes] [CNN] [J&J]

—

Featured image courtesy of [DraconianRain via Flickr]

Vasudha Sadana

The post Our Everyday Drug Dealer appeared first on Law Street.