Sunday, April 21, 2013

Bipartisan Push for Better Mental Health Care Won’t Be Helpful

In the aftermath of the shootings at Sandy Hook Elementary School, with memories of the Aurora movie theater shooting, the Gabby Giffords shooting, and the Virginia Tech shootings still in mind, people demanded that the U.S. Congress do something. These shootings, along with many others, were perpetrated by mentally ill individuals. Liberals wanted more gun control. Conservatives wanted more armed guards and armed civilians to take down the shooters. The divided congress was unable to pass a gun control measure. But apparently liberals and conservatives were able to agree on one thing, according to a recent New York Times article: better care for the mentally ill. According to the article, “[t]he emerging legislation would, among other things, finance the construction of more community mental health centers, provide grants to train teachers to spot early signs of mental illness and make more Medicaid dollars available for mental health care.” There would also be support for children who faced trauma, and suicide prevention initiatives. Approximately 1.5 million additional people with mental illness would be treated each year.

This is a good, thing, right? What’s there to complain about more mental health treatment? There’s nothing to complain about, if one believes in the current drug-based model of care. Treatment in this context will be primarily psychoactive drugs. The community mental health center will recruit and encourage people to see a doctor and get a prescription for a psychotropic medication. Teachers will spot early signs of ADHD, depression, and bipolar disorder in children, and put the children on the road to chronic stimulant, antidepressant, and antipsychotic drug treatment. Medicaid is notorious for drugging up the children who rely on it for health care. Suicide will be prevented by prescribing antidepressant drugs. The vast majority of the 1.5 million additional treated people will be prescribed drugs.

After reading Anatomy of an Epidemic (which I review here), I stopped believing that psychotropic drugs are an effective long-term solution for most mental disorders. The evidence is just not there. Some drugs, such as antipsychotics and benzodiazepines, are effective short-term solutions to psychotic or anxious symptoms. The problem is that they don’t help the patient function better over the long term. While the evidence isn’t clear that drugs caused the explosion of debilitating mental illness in recent years, they certainly haven’t helped prevent it. Drugging of children in particular (for ADHD or bipolar disorder) has likely led to poor long-term outcomes, including mental (psychotic disorders, increased suicide rate, rapidly-cycling bipolar) and physical (extreme weight gain and type 2 diabetes for children taking atypical antipsychotics).

I would have preferred to see congress pass a gun control measure. The mentally ill and guns go together like North Korea and nuclear weapons. People with mental illness should not be allowed to purchase firearms. They should not have access to them in their homes. Adam Lanza’s mother was tragically irresponsible for having guns in her home. Her son used these guns to kill her in her home, then 26 people at Sandy Hook Elementary, including 20 children.

I have lived with serious mental illness for some 30 years. Mine has been under better control than many people. I have never been hospitalized for mental illness. I have never had to quit or leave a job due to mental illness. But I would never trust myself with owning or having possession of a gun. The reason is that there are times when my emotions become extreme or difficult to control. In those times, I don’t want access to a gun. It only takes one mistake for a personal or public tragedy to occur.

Gun sales and ownership should be banned for anyone who has been treated for a psychiatric disorder—I mean anyone treated at any time in their life. This would be a major change from current American law, and would require confidential records being unsealed, but it is for the greater good. Anyone living with someone who has been treated for mental illness should be required, if they own a gun, to keep it locked and inaccessible. The NRA will be furious and scream that we are becoming Nazi Germany, but tough. The NRA’s refusal to consider any type of gun control legislation, and their control of most Republican legislators, have allowed these preventable tragedies to happen.

If the government wants to spend money, what should it spend it on, if not treating mental illness? What about research? The problem with research is that the biochemical / drug paradigm still dominates psychiatric research, decades after it’s been clear that the chemical imbalances that drugs supposedly treat don’t exist. The drugs themselves cause chemical imbalances, but after millions of dollars and decades of research, no one has been able to show that any psychiatric disorder is caused by a chemical imbalance. Any government research money will be wasted on new drugs, new brain imaging, new tests, and other things that won’t do anything to improve the lives of the mentally ill. Research on alternative treatments would be more promising, but only a tiny fraction of any allocated funds would go into this type of research.

I’d like to see the government spend its money on providing a solution to the homeless problem. Current policy is to leave the homeless to their own resources. If they want to live on the street, or in a public park, fine. Short-term treatment with medication is useless, since they go off the medication as soon as they leave the hospital or treatment center. Many homeless are afflicted with mental illness and substance abuse. The fact that they are living on the streets is an indictment of the entire drug-based psychiatric paradigm. Deinstitutionalization began in the 1960’s, a half-century ago. Drugs were supposed to provide the severely mentally ill the stability and mental resources to live outside the hospital. But, as I've said above, drugs are not an effective long-term solution for most mental disorders. Thus many deinstitutionalized patients were not able to control their problems, and live independently on their own. Those without financial or family resources to fall back on ended up on the streets. They are the government’s responsibility, and the fact that they are still on the streets decades after deinstitutionalization began is a sign of abject public policy failure.

I have a recent personal experience with the homeless problem in Salt Lake City. On a rainy night, I stopped in at the city library. The Salt Lake City Library is an architectural masterpiece. Here are some pictures of it:

The city library may be a masterpiece of modern architecture, but it’s a leaky masterpiece. There were many containers filled with leaking water that rainy night. This indicates that beautiful and practical architecture are not equivalent. More relevant for the current discussion is that on every floor of this spectacular library there were homeless people. They were sitting on the chairs, using the Internet, and using the bathrooms. One of the homeless guys camped out in the handicapped stall, prompting a man in a wheelchair to complain. The city library is basically a homeless shelter. This is an insult to the taxpayers who support it, to the patrons who want to enjoy its resources, and to the homeless themselves. They should have a permanent home, and the government should provide it.

During most of my lifetime, American homelessness was largely a problem of mentally ill and substance abusing people. Recent years has seen more short-term economic homelessness. What we need to do is to separate out those who are capable of being employed, and those who aren't. Programs for the short-term economic homeless should focus on getting them a temporary residence, and preparing them to get a job. Even better, prevent them from being homeless in the first place by having available state-supported short-term housing for them if they become evicted from their homes. The long-term homeless, those who are too physically or mentally disabled to work, should have permanent state-subsidized housing. This housing must provide care for their disabilities. They should not have the option to be homeless. If they don’t like the state-subsidized housing, let them show that they can independently live in regular housing, or can live with friends or relatives.

Commitment laws need to be changed. This doesn't mean that mentally ill people should be committed to short-term hospitalization, to undergo forced drugging. It means that homeless mentally ill people should be committed to long-term housing. In some cases, those who are most impaired, this will mean state hospitalization.

This change to our homeless policy will be expensive. It can be paid for with reduced entitlement spending (Medicare and Social Security), reduced defense spending, and increased taxes. The benefits will be enormous—we can reclaim our public spaces, our libraries, parks, and streets, and the homeless will no longer be homeless. It would be a much better use of state funds than expanding mental health drug treatment.


  1. Hello, again, Harry,
    May I have your permission to repost your latest two blogs on my blog later this week? Full credit to you, of course. I will link back to your full posts.

    1. Yes, Rossa, you have my permission to repost my latest blogs on your blog.