Today is World Human Rights Day and in honor of that I thought I would share a bit about the current state of America’s mental health system, both the good and the bad.

United Nations Human Rights Council logo.

United Nations Human Rights Council logo. (Photo credit: Wikipedia)

The Good News

In many areas there is great improvement, particularly in the area of self-help support groups and community peer-run mental health centers funded by the government. I am especially proud of my home state of California, where we passed The Mental Health Services Act, a 1% tax on personal incomes more than a million dollars a year. This has funded existing and new peer-run community centers, plus other comprehensive program to help mental health consumers in the community. It is a guaranteed source of funding so that they do not have to depend on the state general fund anymore.  The wonderful thing is that we are getting great results which can be quantified, more of the mentally ill are living independently as a result of this Act:

Here is a run-down on how this funding is being used and the outcome so far:

One unqualified success story from the MHSA thus far involves the implementation of Full Service Partnerships (FSPs) demonstrating the “whatever it takes” commitment to assist in individualized recovery whether it is housing, “integrated services, flexible funding [such as for childcare], intensive case management, access to care.”FSP interventions are based upon evidence from such programs as Assertive community treatment (ACT), which has effectively reduced homelessness and hospitalizations while bettering outcomes. But the FSP model looks more like that of the also-popular MHA Village in Long Beach, which is a center that offers more comprehensive services besides those specifically mental health-related. Beyond these guiding principles, however, there has not been much consensus over unifying strategies to define and implement an FSP – resulting in varying FSP structures across counties.

Overall, though, the Petris Center, funded by the DMH and California HealthCare Foundation to evaluate the MHSA, has reported quantifiable improvements in many areas:

  • Homelessness rates
  • Entry rates into the criminal justice system
  • Suffering from illness
  • Daily functioning
  • Education rates
  • Employment rates
  • General satisfaction with FSP

But there is room for improvement:

According to the UCLA Center for Health Policy Research, the 2007 and 2009 California Health Interview Surveys (CHIS) demonstrate continued mental health needs of almost two million Californians, about half of which were unmet in 2011. In spite of steady tax revenue ($7.4 billion raised as of September 2011) earmarked for the MHSA, the unremittingly high numbers of mentally ill who lack treatment contrast starkly with the implementation of new programs like the FSPs, which may cost tens of thousands of dollars annually per person. The MHA Village program, for example, averages around $18,000 annually per person. One of the major growing concerns regarding MHSA implementation is its unintentional but worrying tendency to create silos of care. As directed by the DMH, counties search for “unserved” mentally ill or at-risk individuals to enroll in their new programs, while keeping existing and perhaps underserved clients in old programs that are usually underfunded, but cannot take MHSA funds. Ironically, while the MHSA was established in part to address racial/ethnic disparities in health care, it may be perpetuating the disparity in services delivery between underfunded and well-funded, new programs.

Although these are significant problems, the law was amended in 2012 to address many of these issues. Click here for more information on the Mental Health Services Act. and the amended 2012 Act.

The Bad News, But With a Smidgen of Hope

 As with other states, California’s biggest “Mental Institutions” are unfortunately, jails and prisons. It is unlikely that we are going to get any more mental hospitals anytime soon. All across the nation, the mentally ill in prisons are denied treatment and often are kept in solitary confinement for extended periods of time. Studies have shown that even people without any history of mental illness can develop serious mental problems from being confined with barely any contact with other people. It is a form of torture.

The problem is that prisons have very few people trained in mental health care.  They may have a doctor who authorizes medication and someone who infrequently checks up on the patient, but that is it. No counseling. There may be times when the person has an acute episode and is transferred to a mental health facility for short-term stabilization, but then is transferred back to the prison, living with the same unhealthy conditions as before.

Even for some jails that have mental health facilities, it still is not an ideal place to get treatment.

Things have gotten so bad in the Los Angeles County prison system that the DOJ has stepped into the fray:

In June, the U.S. Department of Justice issued a 36-page statement and accompanying two-page letter criticizing the county for deplorable and unconstitutional jail conditions, and for inadequate suicide prevention practices, as it sought federal court oversight. DOJ acknowledged that “the delivery of mental health services in the corrections environment is difficult and presents unique challenges.”

This is giving impetus for L.A. county to come up with a new way of doing things. No there won’t be any more hospitals, but thanks to the to the new Third District Diversion and Alternative Sentencing Program, many low level offenders are going to be diverted to community mental health programs. This was made possible by the state’s Public Safety Realignment Act, aimed at reducing crowding in state prisons. Implemented in 2011, the act shifts responsibility from the state to county level for supervising people convicted of certain crimes.

Here are some of the changes being made:

Designed for adults who are chronically homeless, seriously mentally ill, and who commit specific misdemeanor and low-level felony crimes, the demonstration project could help reduce recidivism by as much as two-thirds, Third District Supervisor Zev Yaroslavsky said.

Similar diversion programs have produced promising results in other metropolitan areas — Bexar County (San Antonio), Texas andMiami-Dade County in Florida, for example — fueling hopes for change here, according to L.A. program supporters.

“Clearly, treating mental illness in jail does not produce the best results,” Yaroslavsky said. “At present we put offenders into the mental health unit of the jail — it’s the largest mental health facility in the state. We provide mental health treatment and custodial care for approximately 3,500 people each day.”

The program will divert adults from the traditional fines, probation and incarceration typically imposed, and instead place them on a path to secure permanent, supportive housing and treatment, the MOU says.

Up to 50 adults — including as many as 20 U.S. military veterans — who elect to participate in the program will be released to San Fernando Valley Community Mental Health Center. The diversion program provides bridge and permanent supportive housing, health and mental health care, group and individual treatment and support, and employment and vocational services, said Yaroslavsky.

Misdemeanor offenders will receive a post-filing of criminal charges option and the pre-plea diversion program. Once they’ve completed the 90-day program, they can continue to earn permanent, supportive housing, as well as have charges against them dismissed. For felons who successfully complete the program, the court will consider whether to terminate probation early and or dismiss the case. The program for felons runs at least 18 months, and begins with a court order of 36 months of formal probation.

Let us hope that the pressure to change things continues:

By every measure of public policy, I’d give what the county (Los Angeles) had been doing an ‘F’ grade,” said Peter Eliasberg, legal director of the American Civil Liberties Union of Southern California. “This is a very positive step. What I hope is that it is not just a pilot program that ends up being a feel-good measure. It would be criminal if the county doesn’t take this pilot and build upon it county-wide for every criminal court.”

Read more on this issue here.

This of course barely even touches on all the issues regarding mental health care in this country. But I do see hope, although changes come more slowly than I would like!