Abstract: A struggling and inaccessible mental health care system has led some to propose bringing back institutions as a way to prevent modern trends of homelessness and incarceration of the mentally ill. However, this approach is misguided and impedes our progress for needed reform. Institutionalization and other forms of coercive care are ineffective, and instead we need to focus our efforts on expanding community care accessibility and affordability. By modeling mental care after traditional medical and surgical care, we should prioritize regular and preventative treatment rather than reactionary treatment to deteriorated mental states. One of the most important first steps is alleviating insurance barriers to reach this goal.
When discussing modern problems with mental health care or the new homeless mentally ill epidemic, a new wave of thought has emerged which proposes a “back to the future” approach: bring back the asylums of the past in a reformed way as a place of shelter for mentally ill patients. The deinstitutionalization movement of the 1950’s which discharged patients from hospitals to new community mental health centers has transformed the nexus of care for patients to one which emphasizes patient autonomy rather than isolation. However, some policymakers and medical professionals blame this community approach for failing to reach critical patient needs and contributing to the rise of mentally ill people who are homeless or incarcerated. Dominic Sisti’s article “Bring Back the Asylum,” published in the Journal of the American Medical Association in 2015, cites the lack of public psychiatric beds and community resources to support the 10 million Americans living with Serious Mental Illness (SMI). Professionals who support a return to forms of institutionalization frame the discussion as “the choice…between the prison–homelessness–acute hospitalization–prison cycle or long-term psychiatric institutionalization” (Sisti et al.). A lack of a full continuum of resources that emphasize preventative and regular care leads to people with mental illness to eventually land in emergency care or be disconnected from the mental health care system entirely. These issues with community care lead to new proposals that a complete overhaul of our system is needed. However, we should instead focus on improving existing systems to provide the most ethical, effective care for patients. Progressive policy implementation and practices offer a more humane and practical alternative to the debate on how to treat the serious mentally ill.
Arguments for Institutionalization
Health professionals who advocate for a return to asylum-based care say that our community system is deficient and incapable of serving the needs of vulnerable patients. There are currently only 11 public psychiatric beds per 100,000 people, providing few resources for the 10 million Americans who live with SMI. The original deinstitutionalization movement led to careless patient discharge practices such as giving patients a Greyhound ticket to California when hospitals closed in the 1950’s and 60’s (Jones, pp. 156). Only half of projected community centers received any funding, and block grants to states resulted in fragmented mental health agencies. In 2008, only 59% of people with SMI received treatment, mostly in the form of prescriptions. 40% received treatment in an outpatient setting and only 8% in an inpatient setting (Perry, pp. 66). Now, they are more likely to be in prison or homeless. One third of all homeless adults have a major mental illness. Behavior which oftentimes would have been cause for institutionalization now becomes cause for arrest, and the largest inpatient “psychiatric facilities” now are prisons, including the Los Angeles County Jail, and Rikers Island Jail in New York City (Slate, pp. 349). Institutionalization advocates say it is unethical to allow patients to suffer in these places, and it is more humane to provide care in specialized and protected environments.
Evidence against Institutionalization as the Cause for mental health crisis
De-institutionalization is an easy culprit to blame for our ineffective mental health system which ignores the root inequities of a social and political system which disenfranchises people with mental illness. Blaming deinstitutionalization for issues such as rising homelessness puts medical emphasis on the underlying issues of economic inequalities such as “the shrinkage of the safety net, cuts in public services, erosion in living wages” to become a matter of individual incapacity (Ben-Moshe). Living on the streets with constant noise, lack of privacy, and the anxiety of not being able to eat or find shelter itself deteriorates one’s mental condition. It causes depression and agitation and leads to individuals mistrusting authorities and abusing prescriptions. Prison also makes people exhibit signs of mental illness or exacerbates previous conditions with the use of oppressive correctional psychiatry practices of holding group therapy with inmates each inside individual cages (O’Reily). Studies suggest that closing state facilities only increased prison populations by less than 10% (Roth). While deinstitutionalization may have been the catalyst for these negative developments, the larger problem was the lack of sufficient services to replace closing asylum care. Compulsory care in general does not provide optimal patient outcomes and detracts from our need to move forward with community care goals.
Consequences of Compulsory Treatment
Assertive treatment does not provide patients with sufficient care that would allow them to live independently in their communities. Institutionalization has not shown to be effective in reducing future hospitalizations or promoting prescription adherence and is even worse at preparing patients to inevitably live in their community. For example, a 1970’s Assertive Community Treatment program aimed at helping patients with schizophrenia transition to community living after discharge found that due to the condition of the disorder itself, such as cognitive impairment and limited ability to transfer knowledge from one setting to another, transitional treatment did not help them retain those skills in their new communities (Solomon and Petros, pp. 1198). Structured confinement or even continual surveillance gives no incentive for the patient to behave accordingly once removed from this environment. Coercive treatment is a vestige practice from institutionalization that has persisted due to insufficient or inaccessible community care. We should move away from these practices because they are harmful for patient well-being.
Involuntary detainment changes patient behavior after discharge and leads to treatment dissatisfaction. Patients after discharge report anxiety, post-psychiatric depression, and self-denigration. Some patients even feel suicidal due to a lost sense of community integration. The common association of involuntary admission with fear and anxiety delays patient recovery. While patients who do seek such help voluntarily are known to express their appreciation through thank you cards, those detained involuntarily are quite the opposite. They develop a pessimistic view on the mental health system, and some develop post-hospitalization stress disorder. If they do not trust their provider or feel coerced, it can result in treatment dissatisfaction especially if the patient experiences debilitating side effects of medication such as obesity and being susceptible to diabetes. These hospitalizations do not guarantee that conditions are resolved, as short length hospitalizations of people in crisis are associated with higher rehospitalization rates (“The Medicaid IMD”). In some cases, involuntary detainment is necessary such as if the patient is suicidal. However, this is a symptom of an ineffective community response system that should act preventatively rather than reactively to a downward spiraling suicidal outbreak. For such patients without psychotic conditions, they are often very conscious of the hospital environment and experience high rates of PTSD (Pandarakalam).
The nature of mental illness is more conducive to care which emphasizes community integration, recovery, and patient autonomy. There is a misconception that there needs to be an option of involuntary confinement for especially dangerous patients, whose harm potential to society outweighs the need to respect patient autonomy. However, only 4% of US violence cases attributed to mental illness, and targets are usually family members. Instead, those with mental illness have greater risk of self-harm and being victims of violence. Mandated outpatient care programs for six months were shown to be effective at reducing hospital admissions only if effective community services were in place to take care of the patient after their duration of mandated care was over (“Civil Commitment”). It is not guaranteed that patients will be met with supplemental care, as states have cut community and substance abuse services to balance their budgets since the federal government stopped funding community care 40 years ago. Psychologist and professor Joseph Morrissey of University of North Carolina Chapel-Hill affirms this by writing: “legislating outpatient commitment without reinvesting in the restoration and growth of intensive and high-quality community services is nothing more than a cruel hoax” (Solomon and Petros, pp. 1194). Providing effective preventative care will prevent psychotic escalations requiring commitment.
What Needs to be Fixed in the Community Care Model
Insurance access and stability are crucial for patients to have a wide range of treatment options at their disposal. Currently, insufficient payment options means that only half of people with mental health conditions receive treatment (Guth). States do not take full advantage of Medicaid funding to provide care for a large proportion of people with SMI who depend on it. Medicaid is currently the largest payer of mental health services, covering 26% of adults with SMI in 2020. With new expansions of Medicaid such as the Affordable Care Act, it appears that states have even more resources to effectively assist people with mental illness. However, since a 2012 court ruling, states are not required to expand Medicaid despite federal pressure. If the remaining 12 states expanded care, it would give an additional 3.7 million people coverage (Buettgens and Ramchandani). Where Medicaid is available, people with SMI experience barriers to access such as coverage disruptions. People can lose eligibility due to changing family circumstances, housing instability, and not being able to navigate the renewal process. This leads to 20% of SMI individuals experiencing coverage disruptions, which are associated with increased involuntary hospital admissions and use of emergency services (Wilson et al., pp. 731). If insurance access and stability is increased, people can have the full continuum of community resources at their disposal.
In addition to a lack of insurance, providers are more likely to discriminate against those with mental health needs compared to other medical conditions. Although some rules require equal accessibility and provider reimbursement for both types of services, in practice there are few mental specialists to serve SMI needs. Low Medicaid reimbursement to clinics disincentivizes providers from accepting patients on Medicaid, and mental treatment is not as profitable as other medical treatments. In 2017, behavioral health providers received only 76 cents for every one dollar that insurance companies reimbursed primary care physicians (Rapfogel). Although the Mental Health Parity and Addiction Equity Act (MHPAEA) requires behavioral services to be reimbursed at the same rates as non-psychiatric services, states have great discretion on implementing these parity requirements and may only focus on enforcing them for Medicaid managed care organizations (Maxwell et al.). Furthermore, full equality in terms of available networks and care access is not guaranteed. Due to a shortage of behavioral health providers, mental health specialists can work without needing to accept insurance or shift to private practice to have greater control over the types of patients they accept (Cunningham et al., pp. 700). In 2010, psychiatrists only accepted private insurance 55% of the time compared to 89% for traditional medical and surgery needs. Insurers themselves limit treatment accessibility to their interpretation of “medical necessity;” for people with private insurance, they were more than twice as likely to be denied mental health care compared to other care. This allows health plans to “create and operationalize self-serving, overly restrictive medical necessity definitions,” creating a crisis response system that denies coverage for underlying conditions and leads to patient relapses. Patients on Medicaid are even less likely to be accepted by behavioral specialists as providers accept Medicaid coverage only 43% of the time for psychiatric care compared to 73% for non-psychiatric needs (Rapfogel).
Another barrier to care is that states tend to offload their mental health spending onto Medicaid which leads to a lack of resources for uninsured people. With Medicaid expansion, some states have pulled back funding for community health centers and other programs, citing “a continuingly constrained budgetary environment,” with states like Rhode Island cutting mental health funding by as much as 20% (Ollove). This greatly disadvantages uninsured people with serious mental illness, as 56% of this population does not receive treatment (Maxwell et al.). Compared to increased spending on private health care, states allocating funds to public mental health agencies spending has dwindled. This leads to closing state psychiatric facilities which increases the burden on inpatient and outpatient facilities (Cunningham et al., pp. 699). By expanding state resources, we can extend our net of care for vulnerable patients instead of a catch-all fix of sentencing patients to involuntary confinement.
Solutions
Involuntary care and the discussion on bringing back reformed asylums should be replaced with productive discussions about improving community care to be more accessible, evidence-based, and affordable for SMI patients. Besides the unfeasible costs associated with institutionalization, it is impossible to create some sort of “enlightened” involuntary care: “Any time you take one group of people, force them together because they share a stigmatized characteristic, isolate them from the broader community… it’s an inherently bad thing” (Piccuito). We should improve the functionality of insurance coverage and bring it up to the standards we require for all other forms of medical care. This includes increasing mental service reimbursements to providers which would increase the number of providers joining networks. Rate review committees can be established to set treatment payment rates outside of budget constraints to at least recommend acceptable rates to pay psychiatric services. Requiring greater oversight in state parity requirements would force insurers to include both responses to critical conditions and preventative measures as methods of treating psychiatric conditions. States should be encouraged to expand Medicaid because it leads to higher employment rates for people with behavioral issues, greater medication adherence, and increased utilization of mental health services (Tipirneni et al.). States can also remove barriers to care such as allowing nurse practitioners to prescribe medications for patients who do not have easy psychiatrist access. Working toward achieving these measures will stop the unproductive discussion on forcing patients into asylums, which have proven to be a failed practice of the past which should stay in the past.
References
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