Public mental health plans can be made to work

Mayor Adams’ plan to get homeless individuals with serious mental illnesses off the streets and into treatment echoes past initiatives that failed and has been met by a torrent of criticism. Witness the failure of the Koch administration’s effort to remove mentally ill homeless people from the streets and provide them with health care services whether they wanted them or not, and then-Mayor de Blasio’s NYC Safe and ThriveNYC programs.

These limited efforts pale in comparison to the disastrous policy of deinstitutionalization beginning in the 1960s which reduced the state mental hospital population from 560,000 to the current level of 40,000, by releasing patients to ostensible community care. However, rather than discharged patients residing and receiving treatment in communities, the majority ended up homeless on the streets, in nursing homes or prison.

This dismal history begs the question: Can public mental health initiatives be made to work?

We believe the answer is yes, but only if the key needs of individuals with mental illnesses are also addressed by ensuring the critical components of care.

Hospitalizing the mentally ill under Kendra’s Law (named after Kendra Webdale, a 32-year-old woman pushed to her death in the subway by a homeless mentally ill man in 1999) is merely the first step toward clinical stabilization. Patients must remain in the hospital long enough for a thorough diagnostic evaluation and to determine which medications will control their symptoms.

Only when stabilized, can the patient’s discharge plan be developed which should include assignment to an Assertive Community Treatment (ACT) team, a stable, preferably supervised, residence and case management for navigating the confusing array of agencies providing eligible services and benefits including Medicaid, Medicare and Social Security Disability, each of which have separate and distinct rules. This framework of engagement, stabilization, discharge and community-based care ensures continuous support.

Public mental health initiatives improve with coordinated efforts of local and state governments such as those recently announced in California and New York. Gov. Gavin Newsom signed legislation in September (CARE Court) enabling families, clinicians and first responders to mandate services for individuals suffering from psychotic disorders. Similarly, Gov. Hochul announced that she has committed $1 billion to increase psychiatric beds and outpatient services in New York.

Another innovative initiative in Florida’s Miami-Dade County involved the law enforcement and criminal justice systems. Pre-and post-arrest procedures for diversion of mentally ill offenders to more appropriate systems of care were established. This enabled Miami-Dade County to reduce arrests from 118,000 to 53,000 a year, saving more than 400 years of jail bed days and closing one of its three main jails.

Such post-arrest diversion programs can break the cycle of hospitalization, homelessness, and incarceration. By providing diversion to treatment for individuals charged with non-violent offenses, recidivism has been reduced from about 75% to 25%. These savings have allowed Miami-Dade to create a unique mental health diversion program for the most acutely ill patients who are repeatedly apprehended by police and cycle through a revolving door of costly acute care facilities. This facility will offer comprehensive care psychiatric, medical, dental, ophthalmologic and podiatric services along with psychosocial rehabilitative treatment in one location.

Underlying this discussion is the ethical conundrum of imposing hospitalization and treatment on people who don’t believe they are mentally ill. The U.S. has long since abandoned the policy of “parens patriae” (Latin for “parent of the nation”) where the government cares for persons who can’t manage on their own and only administers treatment if a person poses imminent danger to themselves or others. Individuals who are deranged, disheveled, undomiciled and wandering the streets unsheltered obviously meet the former but not necessarily the latter criterion.

Logical and humane as this policy may seem, advocates consider it a violation of civil rights, and the public views any such infringement of a person’s autonomy, even in mentally ill persons, as heavy handed. But emphasizing personal freedoms at the expense of treating people afflicted with mental illness ensures they, and the communities where they live, will continue to suffer.

In this context Mayor Adams’ and other municipalities’ efforts to help homeless mentally ill persons can succeed, but only if they include the critical components necessary to create a continuum of care.

Lieberman is a professor of psychiatry at Columbia University’s Vagelos College of Physicians and Surgeons and past president of the American Psychiatric Association. Leifman is associate administrative judge of the Miami-Dade County Court Criminal Division. Torrey, a psychiatrist, is the founder of the Treatment Advocacy Center.