Severe Mental illness
Mental Health. “It must be remembered that for the person with severe mental illness who has no treatment the most dreaded of confinements can be the imprisonment inflicted by [their] own mind, which shuts reality out and subjects [them] to the torment of voices and images beyond our own powers to describe.”
— Justice Anthony Kennedy
Lecture Overview
Continuum of Mental Health and Mental Illness
Epidemiology of Mental Illness
Mental Illness within Specific Populations
Intellectually Disabled
Involuntary Commitments
Expanding Definitions of Dangerousness
Protection and Advocacy for Individuals with Mental Illness
Sex Addictions
Uncertain but Changing Stigma about Mental Illness
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. O-45 – O-47). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Continuum of Mental Health and Mental Illness (1 of 2)
Although mental health and mental illness are points on a continuum, the first Surgeon General’s report ever issued on the topic set forth the most accepted definition of mental health as a condition of successful performance of mental function, resulting in:
Ability to adapt to change and cope with adversity
Fulfilling relationships with other people
Productive activities
Mental disorders may be defined as biologically based health conditions characterized by:
Alterations in thinking, mood, or behavior
Distress, defined as mental anguish and misery characterized by feelings of grief, anxiety, and unhappiness
Impaired mental functioning, characterized by a heightened risk of death, pain, disability, or loss of freedom
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 573). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Continuum of Mental Health and Mental Illness (2 of 2)
Contrary to how public stigma would frame it, mental disorders are not character flaws but legitimate illnesses that respond to specific treatments, just as other physical health conditions respond to medical interventions
Some of the more severe mental disorders include:
Alzheimer’s disease, a mental disorder marked by alterations in thinking, especially forgetting
Bipolar disorder
Borderline personality disorder
Major depression, a mental disorder largely marked by alterations in mood
Obsessive compulsive disorder
Panic disorder
Posttraumatic stress disorder
Schizophrenia
ADHD and ADD are considered to be within the definition of mental illness
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 573). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Epidemiology of Mental Illness
Even though mental illness is widespread in the population, the main burden of severe mental disorders is concentrated in a much smaller proportion
Treatments for severe mental disorders are highly effective; between 70 and 90% of individuals have significant reduction of symptoms and improved quality of life with a combination of pharmacological and psychosocial treatments and support
Without treatment, the consequences of mental illness for the individual and society are staggering:
Co-occurring substance abuse
Homelessness
Inappropriate incarceration
Suicide
Unemployment
Unnecessary disability
Wasted lives
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 574). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Epidemiology of Mental Illness (2 of 2)
Although the federal Mental Health Parity and Addiction Equity Act of 2008 mandates that health insurers treat mental illness in the same manner as physical illness, government funds to treat mental illness are declining and in many instances, simply disappearing
The United States is increasingly facing a shortage of treatment slots; publicly funded and private treatment facilities are generally running at full capacity with growing wait lists
The result of this treatment shortage is that while costs of mental health and co-occurring substance abuse treatment are increasing, the number of individuals being treated remains the same; only the most serious cases are being accepted to receive treatment
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 574). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Epidemiology of Mental Illness: Global Burden of Disease Study
The Global Burden of Disease Study was the first systematic effort to look at mortality and other dimensions of ill health.
The overall burden of disease was assessed using the disability-adjusted life-year (also referred to as the DALY metric)
Focused not just on causes of death but the costs of living with a disease or disability, reveals the magnitude of health issues such as mental illness:
Four of the 10 leading causes of disability in the United States are mental disorders.
Mental disorders collectively account for more than 15% of the overall burden of disease from all causes and slightly more than the burden associated with all forms of cancer.
Mental illness is the second leading cause of premature mortality.
Workers with mental illness can expect to earn less than others; about $16,000/year less for each worker, or, as a group, about $193 billion annually in unrealized earnings
Major depressive disorders are more common in people who have a history of trauma, sexual or physical abuse, bereavement at a young age, alcoholism, or insufficient family structure.
By 2020, major depressive illness will be the leading cause of disability for women and children as the rate of this disease state continues to grow.
The cost to the economy of major depressive disorders exceeds $210 billion every year
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 574-575). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Epidemiology of Mental Illness: Homelessness and Mental Illness
There is a high incidence of mental illness among the homeless with approximately ⅓ of the estimated 600,000 homeless suffering from a severe and persistent mental disorder
Many mentally ill homeless people are unable to obtain access to supportive housing or other treatment services
Consequently, they are over 10 times more likely to be incarcerated than the general population
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 575). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Epidemiology of Mental Illness: Incarceration and Mental Illness (1 of 2)
Involuntary civil commitments by the courts and a safety conscious society have left the prisons and jails in the United States unable to control their inflow and outflow
1 out of every 100 Americans is imprisoned on any given day
The surge in imprisonment of people with mental illness appears to be caused by the failure of the nation’s community mental health sector, combined with criminal sentencing processes that increase penalties for drug and quality of life offenses, while reducing the exculpatory effects of mental illness
Today, it seems that the nation’s largest mental health facilities are in urban jails:
About 2 out of every 3 prisoners have a severe mental disorder.
An estimated 700,000 people with severe mental disorders are placed in American jails each year, about three-quarters of who also have co-occurring substance abuse disorders.
Fewer than half of the prisoners who have a mental disorder have ever received treatment for their problem; less than a third received mental health treatment after their incarceration.
The incidence of schizophrenia in state prisons is 3 to 5 times higher than in the general population, and 2 to 3 times higher in local jails than in the general population likely to suffer from severe mental disorders and psychosis
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 575-576). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Epidemiology of Mental Illness: Incarceration and Mental Illness (2 of 2)
Self-Defeating Cycle of Delusion
Prisoners commonly suffer from a delusional disorder, a psychiatric diagnosis denoting a psychotic mental illness that involves holding the fanciful delusion that they are unfairly imprisoned or that if a judge or someone in the criminal justice system would simply understand what happened to them, they would no longer need to be incarcerated
While these prisoners think that the more appeals they file, the more likely they will be released, the judiciary becomes convinced the prisoners are precisely where they should be and sees their endless appeals as a failure to accept responsibility for their criminal behavior
Constitutional Rights of Prisoners with Severe Mental Disorders
While the constitutional rights of prisoners with severe mental disorders may be violated by the nation’s systemic failure to provide adequate treatment before, during, and after their imprisonment, the courts have repeatedly indicated that government has an affirmative duty to act
The failure of prisons to provide adequate treatment for mental illnesses, not to mention the variety of sexually transmitted and communicable diseases, including those acquired while in prison, threatens those communities to which prisoners are released with physical and financial harm, infection, and illness
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 575-576). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Mental Illness within Specific Populations: College-Age Adults
Mental illness usually strikes during adolescence and young adulthood – all ages are susceptible, but college-age adults are especially vulnerable because their lives are generally characterized by rapid intellectual and social development
The National Institute on Alcohol Abuse and Alcoholism recently released the National Epidemiologic Survey on Alcohol and Related Conditions, a nationwide longitudinal survey of alcohol and drug use and associated psychiatric and medical comorbidities, looking at the 19- to 25-year-old college-age adult population in the United States and found:
1 in 5 has a severe mental disorder that disrupts their daily lives
Less than 1 in 4 with severe mental disorders actually seeks treatment (5% of the total college-age adult population seeks treatment)
The most common disorder is alcohol abuse
While these incidence numbers may be increasing, the increase may be partly because:
The stigma attached to mental illness is fading, and therefore mental illness is diagnosed more often
New drugs are allowing college-age adults to function better while acknowledging that they are having difficulty adjusting to life on their own
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 577). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Mental Illness within Specific Populations: Health Care Professionals
While the health care industry continues to be accused of not prioritizing mental health within its four walls, health care professionals seem to have rates of substance abuse similar to the general population, no higher and no lower:
About 10 to 15% of all health care professionals misuse drugs during their career.
Roughly, 6 to 8% of physicians have substance use disorders.
About 15% of physicians have alcohol use disorders.
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 578). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Mental Illness within Specific Populations: Returning Combat Veterans (1 of 2)
Early evidence suggests the mental toll of U.S. troops deployments, many involving prolonged exposure to combat-related stress over multiple deployments, may be disproportionately high compared with the physical injuries of combat
Increasing problems for returning veterans include preventing suicides and treating:
Depression
Posttraumatic stress disorder (PTSD)
Traumatic brain injury
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 578-580). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Mental Illness within Specific Populations: Returning Combat Veterans (2 of 2)
One issue that must be addressed is the denial of medical and disability benefits to veterans of the wars in Afghanistan and Iraq who were diagnosed with PTSD
The Veterans Administration often decides that they do not qualify for coverage because their condition is not severe enough
The magnitude of severe mental disorders in returning veterans from conflict zones also needs to be addressed:
About 1 in 3, or about 300,000, returning veterans have severe mental disorders, generally posttraumatic stress disorder or major depression.
More than 1 in 5 returning veterans has traumatic brain injury.
Roughly half of the returning veterans who need treatment for posttraumatic stress disorder, traumatic brain injury, or depression seek it.
Only slightly more than half of the returning veterans who seek treatment actually obtain quality, evidence-based care (meaning that less than one in four who need quality evidence-based care, in fact receive it).
The number of returning veterans diagnosed with posttraumatic stress disorder is growing by about 8,000 per year
Court Decision: DeJesus v. U.S. Department of Veterans Affairs
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 578-580). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Intellectually Disabled: Medical Decision-Making
There is a critical shift occurring in the perspective of what is referred to as intellectual disability
During this transition, courts are struggling with providing medical care for intellectually disabled people
Court Decision: Doe ex rel. Tarlow v. District of Columbia
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 580-581). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Intellectually Disabled: Defining Intellectual Disability
Current clinical definitions of the intellectually disabled, as recognized by the U.S. Supreme Court, require not only sub-average intellectual functioning but also significant limitations in adaptive skills to care for themselves and a diminished capacity to:
Abstract from mistakes and learn from experience
Communicate
Control impulses and act pursuant to a premeditated plan
Engage in logical reasoning
Self-direct themselves (in group settings they are followers)
Understand and process information
Understand the reactions of others
Significant sub-average intellectual functioning is defined by an IQ standard score of approximately 70 to 75 or below
The consensus is that a person is intellectually disabled when they fail to achieve minimal functional capability levels
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 581-582). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Involuntary Civil Commitments
There are at least two divisive issues confronting health care providers as they provide treatment to mentally ill people with severe mental disorders:
Conditional releases of mentally ill people from involuntary civil commitment
Involuntary civil commitment procedures for the mentally ill, especially for people suffering from dangerous mental disorders
Mentally ill people enter the process through an emergency court order requiring they be taken into custody and examined.
Following the evaluation, they are either released or detained for additional evaluation and treatment under a temporary detention order.
Courts may order involuntary civil commitments only if there is clear and convincing evidence that individuals:
Have no less restrictive alternative treatment available
Are largely incapable of caring for themselves
Pose a danger to themselves or others
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 582). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Involuntary Civil Commitments: Dangerous Mental Disorders
The law continues to struggle with involuntary civil commitment procedures for people who are dangerous to themselves and to society
Court Decision: Ernst J. v. Stone
Though the Ernst v. Stone case allows New York to continue recommitting people not responsible by reason of mental disorder or defect at a lower evidentiary standard, it is not clear this policy will remain in place indefinitely
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 582-584). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Involuntary Civil Commitments: Conditional Releases
Involuntary confinement cannot be justified absent:
Need for mental health treatment
Public safety concerns
Some courts have added nonmedical conditions to the conditional release of mentally ill patients from involuntary civil commitment, if the patients have been found not responsible due to mental disorder or defect of insanity
Court Decision: U.S. v. Franklin
The decision raises the issue of patient confidentiality for the mentally ill
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 584-586). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Expanding Definitions of Dangerousness
Involuntary civil commitment procedures are being extended to:
Convicted pedophiles who have served their criminal sentences
Pregnant women who smoke or abuse alcohol or drugs (including prescription drugs that are teratogenic) to safeguard the health of their fetuses
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 586-587). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Protection and Advocacy for Individuals with Mental Illness
Congress adopted the federal Protection and Advocacy for Individuals with Mental Illness Act of 2000 to curb abuse and neglect of the mentally ill, primarily in institutions
Today many physicians, hospital administrators, and mental health workers claim patient advocates endanger the mentally ill by fighting for their right to refuse treatment when the mentally ill actually present a risk of causing harm to themselves or others.
Proponents of patient advocates say refusals to accept treatment are essential to protecting the human rights of the mentally ill from inappropriate incarceration and homelessness, as well as unnecessary seclusion and restraint
Court Decision: Davis v. Rennie
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 587-588). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Sex Addictions: Human Trafficking for the Purpose of Sexual Exploitation
Trafficking for sex is a sophisticated underground industry that generates billions of dollars in profit every year, yet destroys the lives of innocent victims
Many of the trafficked victims are impoverished children and young women from economically depressed countries who are forced to work as prostitutes under brutal conditions in the United States
To date, the legislative and law enforcement attention has focused on the supply side of the sex trafficking equation in the United States, namely, the traffickers and the victims
Little focus has been directed to the demand side of the problem, namely the sex addicted patrons of the prostitutes
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 589). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Sex Addictions: Sex Addiction or Mental Distractions and Internet Pornography
While the research continues to grow and demonstrates a serious mental health issue, whether Internet pornography is a mental disorder or an excuse to behave badly remains to be determined.
One thing is certain, Internet pornography is a growing industry, generating over $12 billion a year in revenue
While many believe that viewing online pornography is a harmless expression of sexual curiosity, its effects are often more profound.
For 15% of regular pornography viewers, viewing pornography develops into compulsive behavior that disrupts their lives
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 589). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
Uncertain but Changing Stigma About Mental Illness
Most Americans still believe mental disorders are character flaws as opposed to something physiological; they believe that if someone wants to change their thinking, mood, or behavior, they could just do it.
These beliefs are a reflection of the current values of American society and are reflected in the treatment of people with a mental disorder at any given time.
The mentally ill are the most misunderstood patient group of our time.
Source: Hammaker, D. K., & Knadig, T. M. with Tomlinson, S.J. (2017). Processes for thinking about the U.S. health care system. In Health care management and the law: Principles and applications (pp. 590). (2nd Ed.) Burlington, MA: Jones & Bartlett Learning.
