Joking Aside: Why a Bus Ticket?

Earlier this month New Orleans Mayor Ray Nagin caused a bit of a stir suggesting the way to solve the city’s post-Katrina homeless problem would be to give all the people living on the Big Easy’s streets a one-way bus ticket out of town.

He later explained he was joking, of course. But not before The New York Times and other major media outlets took notice.
Unity of Greater New Orleans, a network of agencies that help the homeless, reports that some 40 percent of the people living on the city’s streets suffer from a mental illness and an additional 19 percent face a combination of mental illness, disability or addiction.

This summer will mark three years since Katrina tore its path of destruction through the Gulf coast. For those 59 percent of New Orleans homeless with some form of mental illness, there is a good chance they received very little care before the storm struck. Now, proper mental health treatment is at best sparse.

So why a bus ticket?

Why not so many other things?

A new look at treatment and commitment laws should be high on that list.

In the midst of all that needs to be rebuilt in New Orleans, there is an opportunity. There is a chance to build a new mental health infrastructure and to do it right for the start. Reformng Louisiana’s restrictive laws is another critically needed step. Such changes make much more sense than a one way ticket to nowhere. Perhaps the mayor’s ill attempt at humor will shine some light on what needs to be done.

“Max Blake was 7 the first time he tried to kill himself.”

The opening sentence of Mary Carmichael’s article about Max Blake, a child with bipolar disease, is both disturbing and heart breaking.

The Blakes may have a rough road ahead. Max has not yet reached the age of majority, so his parents have control over his treatment plan. Unfortunately, the Blakes will face even more hurdles when it comes to getting treatment for their son Max when he turns 18. Like so many other parents whose grown children have a severe mental illness, they will try to get him help, but will likely encounter a harsh reality when it comes to treatment laws in their state.

In most states, a child (sometimes as young as 14) has the right to refuse treatment - forcing parents to resort to the commitment process. Many times the law leaves parents with no voice in the treatment of their son or daughter. Parents and loved ones of individuals with a severe mental illness are often the driving force behind compliance with treatment plans – they many times have to be for people with a severe mental illness who do not even recognize that they are ill. As it stands now, many states require that a person be immediately dangerous before they may be involuntarily treated, forcing many parents to wait in agony as their child deteriorates before being able to get them treatment.

The number of bipolar diagnoses in children is rising, which is just another pressing reason we need to continue to eliminate barriers to the timely and effective treatment of severe mental illnesses.

Building Awareness that Treatment Works

May is Mental Health Awareness Month. The last several weeks have been marked by studies, events, commemorations, and other activities normally associated with similar markings. For people who have successfully overcome severe mental illnesses, it is indeed a month to be proud.

Sen. Sherrod Brown (D-Ohio) used this month to tell his colleagues in the Senate about one of his constituents with a remarkable story. Many in the field of psychology are well aware of the work of Dr. Fred Frese. Dr. Frese is currently an Assistant Professor of Psychology in Clinical Psychiatry at Case Western Reserve University and Northeastern Ohio Universities College of Medicine. It was at Western Reserve Psychiatric Hospital where he spent 15 years as a department head and author of numerous books, research articles, and studies. His body of work earned him the American Psychological Association’s highest honor, the Hildreth Award. In addition Dr. Frese gives generously of his time in talents in many ways, including serving on the Board of Directors of the Treatment Advocacy Center.

Dr. Frese’s professional accomplishments speak for themselves. But there is much more to his life. Dr. Frese has been living with paranoid schizophrenia since 1966. He is like many people with schizophrenia who are living proof that treatment works.

“Dr. Frese is remarkable,” Sen. Brown notes, “But his recovery is not unusual.”

That is just the point. The consequences of not treating severe mental illnesses like schizophrenia are too familiar. Highlighting the lives of people like Dr. Frese is a great way to break the stigma associated with mental illness. Treatment is the key to more of these success stories.

“Imagine a world where individuals with mental disorders are supported and treated, not marginalized and discriminated against,” Sen. Brown says. “Imagine a world where we see individuals first and disability second. Imagine the wealth of talent and resources that individuals with mental illness can realize with treatment.”

Personal encounters with untreated mental illness, stigma & YouTube

A key and understandable focus of many mental health organizations is fighting stigma. Educating, and sometimes chastising, journalists who propagate derogatory stereotypes is a common way to try and prevent the most severe manifestations of mental illnesses from being associated with all who have them.

Yet would stigma be eliminated if advocates were given the final say on every article, movie and TV Show? Hardly. Opinion is forged through personal experience.

People who have overcome mental illnesses don’t wear tags marked “I have Bipolar Disorder” or “successfully dealing with Schizophrenia.” Many of those in the grips of the untreated symptoms of such illnesses make their conditions distinctly apparent. An encounter with someone in the midst of a psychotic episode can shape an individual’s opinion about mental illness for life. E-mails, phone calls, and media education can’t prevent such encounters – only treatment can.

Nafiza Ziyad is “an ambitious, bright and happy person.” She also has bipolar disorder, but “thinks she can do without the medicine.” A manic episode recently led to Ziyad angrily, confusingly confronting an elderly woman on an Atlanta train and to becoming the face of mental illness for most of the other passengers.

As it happens, Ziyad’s behavior also provided an “education” for many others. It was recorded and posted on YouTube. The video is entitled “Crazy Girl on Train.”

Currently, 847,638 people have viewed the sad incident and 10,274 have posted written comments concerning it. Should you wish to watch the video of this sad episode, please be aware that it contains a great deal of profanity.

And does this create stigma?...below are a sample of comments from the YouTube posters (profanity has been excised).


“Oh my God...what a horrible person.”

“That was scary”

“what a nutcase.”

“She needed to be popped in the mouth.”

“some forgot to take her meds..”

“i'd hit her in the middle of the face with a baseball bat if i was just sitting there in the train going home or anything. i'm pretty sure i would have support”

“Yall can't see that this girl is mentally insane.”

“shes disturbeddd”

“If i had been on the train i would have ------ kicked her in the face.”

“that chick needs to be medicated.”

“THIZ FEMALE CRAZY”

“Somebody call the doctor. This girl is obviously not healthy in the head”

“Definitely psychotic”

“Schizophrenia is a terrible illness of the mind. She needs meds STAT! Or she needs to up her dosage.”

“This girl is having a psychotic episode. Somebody should have called the doctors in white coats to take her to the nearest state mental hospital.”

“...wow...get this b---- a straight jacket...”

“nuuuuuuuuuuuuuuuttssssssssss”

Protection?

“I’m sorry, we are not allowed to share that information with you.” Is a phrase that family members seeking information about their loved one hear frequently. HIPAA (Health Insurance Portability and Accountability Act of 1996) is a long and complicated statute that most people, including many mental health professionals, do not understand. The Treatment Advocacy Center routinely receives phone calls from family members who are frustrated by the privacy laws concerning patient medical records.

Although many times it makes sense for patient medical records to be protected, countless situations challenge whether absolute confidentiality is the best option for patients and the public. What many families seeking information may not know (and mental health professionals for that matter) is that a covered entity (i.e., health care provider) can provide family members with information if the entity obtains informal permission from the patient by either asking the person outright or by circumstances that clearly give the person the opportunity to agree or object to the disclosure. This “protection” of information many times functions as an impairment to individuals with severe mental illness.

At What Cost?

Serious mental illness cost the U.S. at least $193 billion a year in lost earnings, estimates a new study by the National Institute of Mental Health. This staggering figure just begins the scratch the surface of the financial toll schizophrenia and other serious illnesses cause.

In fact, we know this study included very few people with schizophrenia. Nor did it access people in hospitals or prisons. The number is undoubtedly much, much higher. This leads to some obvious question:

Why did a NIMH study leave these patients out?
How much higher could the real figure be? Twenty percent? Fifty percent? Double?

And, most importantly: At what cost do we as a nation get serious in providing access to treatment?

Oops, Wrong Patients

A new study published online by the Journal of Clinical Psychiatry concludes that there may be a serious problem with the over diagnosis of bipolar disorder. Mark Zimmerman who oversaw the study at the Rhode Island Hospital stated:

“We hypothesize that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication responsive.”

If this study is correct, it means that many psychiatrists may be subjecting patients who do not even meet the clinical criteria for a bipolar disorder diagnosis to unnecessary treatments and medications. The great irony is that while many such patients may be receiving improper diagnoses and treatments they don’t need, literally hundreds of thousands of other people who are most severely ill and who are imprisoned by their psychosis are receiving no treatment at all.

We desperately need a mental health system that prioritizes helping the sickest of the sick.

A Quest For Answers

Everyday people contact us in a quest to navigate their state’s commitment laws and fractured mental health systems. Many times they are seeking help to get treatment for family members and friends who have stopped taking their medication and who no longer recognize that they are ill. For anyone that has a loved one who may need involuntary treatment at some point, it is imperative to become acquainted with the commitment process now, rather than waiting for a crisis to occur. The illogical and confusing process of commitment is difficult to understand at anytime, let alone during a crisis. One important step is to look up your state’s commitment laws. The more you know about the law in your state the more effectively you will be able to act in a crisis situation.

Learn what forms you will need to fill out and who you will need to contact if a crisis arises. A good place to start is the courthouse in the county where your loved one lives. Many times, the clerk of the court is a great resource for finding out the procedures for filing an involuntary commitment petition in your county. Another resource is your state/local mental health departments. They may have helpful materials that they can provide. Also, the local NAMI chapter in your family member’s area is a great resource. Most of the NAMI members have been in similar situations and can give you the benefit of their experience.

More tips and strategies, including information on preparing for a crisis and creating a CARE kit, are available on our website.

Increasingly Popular Skid Row

Employees of an Orange County hospital are accused of driving a psychiatric patient 42 miles, past multiple homeless facilities, in order to dump the man in L.A.’s Skid Row. If the allegation is correct, it would not be the first such reprehensible shirking of responsibility by a hospital.

A chief reason to not just dump a patient but to do so far away is to ensure that, when the almost inevitable next crisis occurs, the inadequately treated and discharged patients end up at someone else’s door, i.e., another hospital or a jail. Skid Row dumping in L.A. is emblematic of our mental health system’s failure, sometimes even blatant refusal, to take responsibility for the most problematic patients in the post-deinstitutionalization treatment framework.

For those with acute mental illnesses that psychiatric treatment providers do abandon to skid row, there remains the hope of getting help from L.A. County Sheriff's Deputy Craig McClelland – a fitting symbol of our mental health system’s growing abdication of its responsibilities to criminal justice facilities, programs and personnel.

Where is the mental health community?

The mission statements of local departments of mental health frequently declare a goal to, “[ensure] … the availability and accessibility of effective, efficient, culturally competent services.”

Unfortunately, everyday tragedies prove that the current laws do not provide access to those individuals most in need. How can someone who doesn’t even realize they are ill access mental health services?

Everyday we are faced with countless tragedies where a family was unable to get treatment for their son/brother/mother because the law would not allow it. Weak treatment laws often require a person to be a danger to themselves or others before they can get help. Where is the mental health community when those individuals most in need of help are unable to access treatment?

A Benefit of Outpatient Commitment Often Overlooked – Preventing Victimization

On Saturday night, Troy Green's body was found on the sidewalk in a crime-prone section of Los Angeles. The 23-year-old had been shot and then died alone.Green’s sister Lillian knew that his mental illness, which she believed to be paranoid schizophrenia, left him vulnerable to harm on the dangerous streets he refused to leave. A few hours after her brother’s death a police officer came to Lillian Green’s door. “The officer got out only two words – ‘your brother’ -- and she broke down and cried.”

Lillian Green also commented on California’s restrictive commitment laws: "It shouldn't be that way. It should be based on whether they need help."

A group of published research articles collectively know as the Duke Studies are the largest and most respected of the controlled examinations of assisted outpatient treatment (AOT). The Duke Studies proved the remarkable benefits of assisted outpatient treatment for people overcome by severe mental illnesses to the point of being incapable of maintaining obviously needed treatment.

Some of the findings from the Duke Studies have more prominence than others. Best known are the eye-opening reductions in hospitalizations, arrests and violent acts.

The researchers found that assisted outpatient treatment for 6 months or more combined with routine outpatient services (3 or more outpatient visits per month):

· Reduced hospitalizations by 57% and the average length of hospital stays by 20 days;

· Slashed arrests by almost three-quarters (12% versus 45%) for a subgroup with a history of multiple hospitalizations as well as prior arrests and/or violent behavior; and

· Cut violent incidents by those in AOT in half (24% versus 48%).

Placed far less often in the public’s eye is another of the Duke researchers’ core findings – AOT can stop people rendered vulnerable by untreated psychiatric illness from becoming the prey of criminals.

AOT also decreased victimization by 43%. Over one year, 42% of those in the Duke control group were victims of crimes like rape, theft, mugging, or burglary versus only 24% of those in AOT for 6 months or more who had routine services.