March/ April 2013 Reality-Based Mental Health Reform

Preventing mass killings like the one in Newtown may be impossible. But there’s plenty we can do to reduce violence by the mentally ill in general. And the tools are right there in Obamacare.

By Harold Pollack

Criminal offending is especially prevalent among young men with emergent symptoms. An Australian study explored crimes committed by individuals with schizophrenia. Among those convicted of violent offenses, 64 percent had their first conviction before their first contact with mental health services. This pattern arises in many other populations. Serious psychiatric disorders often emerge or strike during adolescence and young adulthood, precisely the point in the life cycle when people have the most tenuous contact with social services or medical care—and precisely the point when people face the highest general risks of becoming either perpetrators or victims of violent crimes.

“Dual diagnosis,” the combination of SMI and substance abuse disorders, appears to be an especially strong risk factor for violent offending, with alcohol use playing a particularly prominent role. A much larger fraction of violent crimes is associated with alcohol disorders than is associated with severe mental illness. Indeed, crime rates among individuals with SMI who do not have co-occurring substance use disorders appear surprisingly similar to those of their peers of the same age and gender, living in the same communities, who don’t suffer from mental illness.

The Australian study underscores the strength of this relationship. Among male schizophrenia patients, 29.7 percent of those with known substance abuse problems were convicted of a violent offense, compared with only 7.4 percent of their counterparts without substance abuse problems. Studies here in the U.S. suggest that roughly two-thirds of jail inmates with severe mental illnesses are dual diagnosed. Dual-diagnosed individuals are also far more likely than others to re-offend after they are released from jail or prison.

Mental health services are not cure-alls. Fisher and colleagues examined arrest records of almost 14,000 individuals who had received services from the Massachusetts Department of Mental Health during 1991 and 1992. Between 1991 and 2000, 28 percent of this group was arrested for committing a crime. More than half the young men ages eighteen to twenty-five were arrested over the same period. Especially concerning were the 13.6 percent of the entire sample arrested for “serious violence against persons.”

Harvard mental health expert Richard Frank notes that many of the most dangerous young men have contact, albeit sporadic, with mental health service systems. Yet they are rarely properly assessed for drug or alcohol disorders or referred to the most effective interventions designed for dual-diagnosed individuals. “These people are touching the system,” Frank says. “They’re one step away from what you need to do.… We just don’t manage to make the connection.”

Many disturbed and violent individuals are especially easy to spot for one simple reason: they’ve been violent before. They are already locked up, or they are under some other form of criminal justice supervision. In Chicago, the massive jail complex at Twenty-sixth and California may be the largest de facto psychiatric facility in the Midwest. The sheriff’s office estimates that about 22 percent of the jail population has been diagnosed with some form of mental illness. On any given day, that’s about 2,000 people. Research spearheaded by Northwestern University’s Linda Teplin suggests that there may be an even higher prevalence of psychiatric disorders among juvenile detainees.

Many dual-diagnosis inmates are what you might call frequent flyers. They are detained and re-detained because they shoplift, yell at passers-by, urinate in the street, or in other ways become a public nuisance. Some receive mental health services while in jail; some pass through in therapeutic isolation. They are then returned to the street, where their mental health and substance use disorders often go (or remain) untreated. Over time, some portion of this group turns violent. This dual-diagnosis group is rearrested much more frequently and quickly than are other released inmates, including those suffering from SMI without co-occurring substance use disorders.

We can’t ethically perform randomized trials that compare a treatment group that is provided mental health services to a control group that is not. We can, however, compare innovative approaches to usual modes of care. Evidence-based programs appear especially valuable when they provide transitional services into or out of secure institutions.

Because the social costs of crime are so high, even highly imperfect services—which is to say, most of the services offered to this population—tend to wildly pass any reasonable cost-benefit test. Anirban Basu, David Paltiel, and I published an economic analysis of substance abuse treatment services that included (but were not restricted to) individuals with co-occurring disorders. We found that the economic benefits of reducing the incidence of armed robbery alone—which was only committed by a small subgroup of treatment patients—were sufficient to offset the entire cost of the intervention.

One promising approach is known as Forensic Assertive Community Treatment (FACT). This intervention engages severely mentally ill patients through the delivery of psychiatric and addiction treatment, transportation, financial services, and vocational support. FACT augments treatment models for severe mental illness used outside the criminal justice context with the legal leverage provided by judicial monitoring.

A randomized trial performed by Chapel Hill mental health services researcher Karen Cusack and colleagues indicated that mentally ill individuals supervised with a high-quality FACT program were less likely to commit crimes. Over a two-year period, the FACT group demonstrated a 41 percent reduction in the number of jail days and a 19 percent lower conviction rate than was observed among their counterparts receiving usual care.

Why do so many people at risk—many of them young low-income men—fail to receive appropriate mental health services? The most important single reason is this: most are categorically ineligible for Medicaid. These men are not custodial parents. They are not veterans. They have not (yet) been diagnosed with federally recognized disabilities. Many get into trouble because they have serious drug or alcohol disorders. Since 1996, substance use disorders are no longer qualifying conditions for federal disability programs.

People often assume that an unattached adult might qualify for Medicaid if he is sufficiently poor. In fact, only a handful of states provide such coverage, even for individuals with no income at all. The homeless man who is not deemed physically or mentally disabled but who does suffer from chronic alcohol or crack dependence is typically ineligible for Medicaid. He might need substance abuse treatment or mental health care (not to mention care for any number of other health needs). If he’s locked up, the correctional service is required to provide these services. If he’s out in the community, he’s both more vulnerable and more bereft of help. He’s reliant on a patchwork of safety-net services, public hospitals, clinics, and emergency departments that’s financially stressed and disorganized under the best of circumstances, and that often allows vulnerable and occasionally dangerous people to fall through the cracks.

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.


  • Jonathan Sanchez on March 04, 2013 12:40 PM:

    There's something wrong with the link to the third page of this article--it's looping back to the first page.

  • bigtuna on March 04, 2013 5:04 PM:

    Two thoughts

    1. Perhaps ACA will help with some aspects of mental health and violence. However, you omit another source of death and debilitation regarding weapons and the mental health system - suicides and attempts to prevent suicides. Here, the access to guns is a very big issue, as is the fact that many people who attempt suicide are likely battling depression or other mental health issues.

    2. In this regard, AND in regard the mental health and violence towards others, I wonder about how well ACA will help. Yes, more people will be insured. However, I think many elements of ACA that will govern reimbursements to health care provides will rely on evidence-based care - that is, covreing more people, and we hope at lower costs, will mean a tight control on the nature of care given, the amount of drugs, tests., etc. So if a heart med is 85% likely to reduce hearth attacks in patients, it will be paid for. Bone marrow transplants for various cancers? Various radiological scans for certain conditions that have a 30% rate of showing something? Probably not so much. There is nothing wrong with this sort of system - it injects a level of evidence based medicine to our system, and has to be done if we are going to offer basic care to people w/o insurance.

    However, When it comes to mental health, I bet the stats are much harder to come by; while some treatments will be pretty verifible, others are not. THis is going to be pretty tricky territory for the system as it is reformed.

  • Rich on March 11, 2013 11:49 AM:

    What about services funded by CSAT and CMHS? What is Illinois doing with this money? What about locally raised funds? In many places, much of teh funding is raised locally.

    ACA-related insurance, including Medicaid expansion will require the same things that make it difficult to maintain entitlements. Marginal mentally ill people may lack a permanaent address or ways to remain in touch with whatever system manages these benefits.

  • Dana on March 16, 2013 10:21 PM:

    However accessible or effective we make mental health care, it is useless against violence as long as the mental health system refuses to define violence as pathological. For all the controversy surrounding DSM-V, there was not one peep suggesting that - just as one example - domestic abusers should have a diagnostic code. Half of the mass killings in the United States are honor killings. But as defined by our mental health system, most of the perpetrators are perfectly sane.

  • Ron Wagner RN, MA on April 03, 2013 12:37 PM:

    An interesting article. It really doesn't offer anything valuable in the way of solutions however. It seems to be a plea to support Obamacare. Dual diagnosis of substance abuse and mental illness does offer some indication of mental illness, but just substance abuse alone is the primary indicator. Behavior period, is the key indicator. Diagnosis is over rated. Past behavior is the best indicator of future behavior. Past behavior may not be violence itself, but preparations for it. That is not illegal, unless it involves illegal weapons.

    The best solution is actually for individuals to learn to avoid, and defend against dangerous people. For schools, that means being able to keep them out. Mass murderers are attracted to places where people are known to be defenseless.
    Police must keep records on those who are dangerous, for whatever reason. They should request mental evaluations, and treatment should be considered. Anyone can be committed if a trained medical provider can be convinced that a person is a danger to himself or others. There is a danger to civil liberties inherent in the abuse of the ability to commit, and it is difficult to keep someone for more than a few days. Society cannot afford to, and should not commit many people. Once committed guns can be taken from the patient, but they can always obtain them on the black market, along with other weapons.

  • Cary on July 15, 2013 11:09 PM:

    The comment that the reason the mentally ill don't get help is they don't have access to Medicaid is ridiculous. Definitely plugging obamacare. I have a brother who is bipolar, ptsd and alcoholic. He is a vet so has been in and out of va many, many times. They can't legally hold him long enough to stabilize him. I've been told so many times that he has the right to be crazy--in other words, unless he's pointing a gun at himself or someone else, that's just fine. Very frustrating that its impossible to get a mentally ill person help with or without insurance. Obamacare won't change that. Sickening to even suggest it.