A better, cheaper way to treat people with mental health crises
The system failed Jordan Neely long before his violent killing on a New York subway train. At age 14, after his mother was murdered, Neely fell into depression. He dropped out of school, and his mental illness progressed untreated until he was homeless and cycling through jail cells and emergency rooms.
Friends and family say Neely lived with schizophrenia and post-traumatic stress disorder. He was hospitalized so often that he was on the Top 50 list kept by the New York City Department of Homeless Services of people in need of acute care. Despite hundreds of encounters with social work teams and a week-long stay at Bellevue in one of the city’s few psych beds, his life ended in tragedy.
Neely’s story highlights the cruelties of a broken system. People with serious mental illness are shuttled among prisons, encampments and hospitals for crisis care that costs the nation billions. There’s a better way.
Roughly a quarter of the unsheltered homeless in the United States are people with untreated mental illness. Many with schizophrenia or bipolar disorder languish in urban single-room occupancy hotels or board and care homes.
Despite all efforts, the problem only gets worse. Why?
The painful answer is that society has failed to ensure that people with serious mental illness, especially those of color, get the care that could help them recover. They might receive medication in jail or the hospital. They might get emergency services. But less than 5 percent of the 14 million Americans with serious mental illness receive the kind of rehabilitative services that could have helped Neely.
These services include peer support, family education and supportive housing. They can be as effective as dialysis is for renal failure or physical therapy is after a stroke. And none is new. Outreach workers, known as assertive community treatment (ACT) teams, and supported employment proved their worth more than 30 years ago.
This is equally true of the clubhouse model, developed by and for people with serious mental illness. Here the creation of community is a therapeutic intervention. Clubhouses address the social determinants of health: poverty, housing insecurity and isolation. The sanctuary they provide results in long-term recovery and thriving.
The original one, Fountain House in New York, where we’re all board members, was created 75 years ago. It has demonstrated its potential to reduce homelessness, increase employment and lower rates of incarceration — as one of us, Arvind Sooknanan, can attest from personal experience.
Hospitalized nearly two dozen times for mental illness by the age of 20, Sooknanan found each trip to these “health jails” made him feel as if on trial, untrustworthy, less than human. A few years later, at the height of a manic episode, he ran away from home and spent many nights on the subway, hoping to escape the voices, judgment and fear.
He recovered through his involvement with Fountain House. He now lives independently, is finishing his studies, has run a political campaign and is no longer disabled by psychosis. He is aware every day that his fate could have been very different.
Why are these powerful and time-tested interventions not available to 95 percent of the people who would benefit? Follow the money. A nation that spends $4.3 trillion on health care leaves rehabilitation after a psychotic break to local nonprofits that run on charitable contributions.
Medicaid, the largest payer of health services for people with serious mental illness, covers emergency room and hospital care for psychosis but not, in most states, the range of psychosocial services essential for recovery.
Yet these services are popular across the partisan divide.
Recent polling reveals that 81% of Democrats and 65% of Republicans and independents would be more likely to vote for a candidate who supported increased funding for serious mental illness interventions and programs, even if this increased taxes. To many, this is personal. Nearly half of voters say they have a close connection to someone with a serious mental illness.
It’s difficult to imagine that public or private health insurance would pay for acute care after a stroke but leave rehabilitation to cash-strapped nonprofits, often staffed by volunteers. People with other brain disorders are not abandoned to become homeless or incarcerated rather than receive medical help.
The good news is that healthcare providers know what to do. Public and private insurers should pay for rehab at rates that attract a workforce to deliver the services.
The current approach, cramming patients into emergency rooms and correctional facilities, is surely the most expensive and least effective. Sooknanan’s year in the clubhouse cost less than the price of two weeks in a hospital. And it has put him on track for meaningful recovery, connection and the sustained support needed to prevent or lessen crises.
Jordan Neely deserved the same.
Thomas Insel is a co-founder of Vanna Health and former director of the National Institute of Mental Health. Arvind Sooknanan is on the board of directors of Fountain House in New York. Ken Zimmerman is chief executive of Fountain House.