The Government's Stand On Severe Mental Illness

 The discovery and marketing of the first, effective anti-psychotic medication Thorazine, in 1955 unleashed deinstitutionalization, the moving of patients out of psychiatric hospital settings and into the community. Deinstitutionalization increased more rapidly following the enactment of Medicaid and Medicare in 1965. While in state hospitals, patients were the financial responsibility of the states, but by discharging them, the states transfered the monetary responsibility to the federal government.

When enacting Medicaid, the federal government specifically excluded payments for patients in state psychiatric hospitals and other institutions for mental diseases, or IMDs, for 2 reasons to promote deinstitutionalization; and to put costs back to the states which were viewed by the federal government as responsible for this type of care.  The states transferred a huge number of patients from state hospitals to nursing homes and the community where Medicaid reimbursement was available.

Impoverished persons who need treatment in a hospital can count on Medicaid to pay for diseases of the heart, and most other body organs. Medicaid will not cover the individual if they are between the ages of 21 and 65 has a disease in his or her brain and needs care in a psychiatric hospital. The Federal government's Institute for Mental Disease Exclusion prohibits Medicaid from covering any treatment, even non-psychiatric, in state and private psychiatric hospitals and other IMDs.

For the most severely mentally ill, private insurance is fundamentally meaningless. Because of their illnesses, most individuals with the severest forms of brain disease are unemployed and private insurance is something that they cannot afford. While the federal government seeks equality for treatment of lesser forms of mental illness by private insurers, it continues to discriminate against those with severe mental illnesses by denying them coverage under Medicaid when they require hospitalization in a psychiatric hospital.  

The federal government reimburses states for between 50 and 80 percent of treatment under Medicaid. Because treatment in an IMD is excluded from Medicaid reimbursement, the states have a major financial incentive to limit treatment in psychiatric hospitals. This is the force behind deinstitutionalization as states force patients out of the hospitals and into Medicaid eligible services where the federal government to take up most of the cost, even though treatment may be unsatisfactory, more costly and less effective.

Approximately 500,000 individuals were inpatients in state psychiatric hospitals when the Medicaid program started, compared with fewer than 60,000 in 1999. Hospital closures have actually in recent years.  About forty state hospitals completely shut their doors between 1990 and 1997, and many more closures were planned.

As state psychiatric hospitals improved in quality, it became increasingly common to discharge patients from relatively good hospitals with active rehabilitation programs and institutionalize them in nursing homes, general hospitals with markedly inferior psychiatric care and no rehabilitation programs at all. States save state funds, but institutionalized patients pay a considerate price for the substandard care.

Costs in general hospitals are generally $200 per day more than the costs in public psychiatric hospitals. These additional costs are of little importance to the states; since federal Medicaid dollars are paying the majority of the bill; the states' costs are lower and that is the maximum of their concern. Evidence shows that general hospitals admit psychiatric patients with less severe illnesses, but turn away those who are more seriously ill. Inpatient stays for people with serious brain disorders are typically shorter in general hospitals, which puts the person's ability to stabilize on medication in jeopardy.

Medicaid's denial of coverage results in homelessness, incarceration, victimization and even death for many people; who are extremely ill and are unable to care for themselves. Of the 4 million Americans with schizophrenia and manic-depression, approximately 50 percent are not being treated on any given day. There are currently more than 250,000 mentally ill people locked up in the jails and prisons.  Another 100,000 to 200,000 mentally ill are homeless, and 28% eat from garbage cans. More than ten percent will die from suicide. Others will commit acts of violence against family, friends and even unfamiliar persons.

Help For The Severely Mentally Ill

Deinstitutionalization has progressed since the 1950's. It has been successful for many individuals, but it has been a failure for others. The failure of the system is shown by the drastic increase in homelessness, suicide, and violent acts among persons with severe mental illness.   Deinstitutionalization has hurt the mentally ill so seriously that there are many who are increasingly re-admitted to hospitals. It is common to find persons who have been hospitalized 15-20 times over a 10 year period. There are more persons with mental illness in jails and prisons than there are in state hospitals.

In the 1950's, new treatment beliefs which put into practice short-term and community based treatments. However, the community supports which were necessary to maintain persons with severe mental illness in the community have not been developed in most communities. Also, the legal development of an environment  which has often been described as independent living for all patients, regardless of whether the setting is based on a clinical foundation

About 2.8% of the US adult population suffers from severe mental illness in a year. Among these persons, there are those who do not respond to traditional community treatment. It is estimated that this high risk group includes an estimated 1,000,000 individuals. Unfortunately, research of this group has been neglected. The most severely disabled have been forgotten by society, and by most mental health advocates,

Medical illnesses frequently go undiagnosed and untreated among persons with severe mental illness. The degree to which medical problems interfere with treatment and rehabilitation efforts and the danger that the presence of mental illness creates in the management of medical disorders has not been researched adequately.  Clients are often unable to communicate their symptoms and give a coherent account because of their psychiatric illness and the illness may become severe before it is recognized and treated. Medical problems may also result as a consequence of the poor health habits of these persons and the side effects of medications. For example, many persons with severe mental illness are overweight from side effects of their medications. This and heavy smoking leads to additional cardiac risks.  

The most commonly cited medical diagnoses were arthritis, hypertension, and diabetes.  Medical problems were frequently made worse by lack of a protective setting.  Bad health habits and side effects of medications are commonly contributing to poor physical health.

Many people with a diagnosis of severe mental illness also have a diagnosis of substance abuse disorder.  These people may self medicate because symptoms of the illness are not under control or as a way to deal with their social isolation. Consequences include noncompliance with medications, frequent re-hospitalization and homelessness. The occurrence of substance abuse may be caused by a variety of factors, including lack of case management and social isolation.   The consequences of noncompliance account for at least 40% of all episodes of schizophrenia relapse and for at least one-third of all in-patient treatment. The reasons clients do not take their medication are varied and may include lack of insight, side-effects of medications and inadequate structure and support within the environment that surrounds them.  Lack of insight into the illness was often associated with noncompliance.  Discharging the client prematurely from the hospital or removing the ill person from a highly structured setting resulted in noncompliance.  Noncompliance resulted in a progressively lower level of functioning.

The duration of stays in hospitals has become shorter under managed care standards. . Patients are often diverted from a familiar hospital to an available bed in another hospital where staff is unfamiliar to them. Stability and consistency is a requirement of quality care.

Recent studies of persons with schizophrenia point out that about one-third will attempt suicide, and about 1 in 10 will complete suicide. The suicide rate for those with mood disorders is 15%. This is in contrast to the suicide rate for the general population which is 1%.  Of those who attempted suicide, most had made 2 or more attempts.  Many are primarily male, single, unemployed and often live alone. They also have chronic, relapsing illness which requires frequent hospitalization; have poor response to their medications and feel hopeless about their future.  Suicide and attempts were attributed to lack of adequate services and medication non-compliance.

A fact that is seldom discussed but alarmingly true is that the death rate is significantly higher for those who are severely mentally ill than it is for the general population.  It has been established that individuals with schizophrenia die at a younger age than do individuals who don't have schizophrenia. The largest single contributor to this statistic is suicide which is 10-15% as compared with 1% in the general population. Also contributing to early death are poor health habits including heavy smoking, obesity and alcohol abuse. The presence of undiagnosed and untreated diseases; heart disease and diabetes, account for a significant number of those who die young. Homelessness also increases the mortality rate because of increased susceptibility to accidents and diseases.

There is a need for both a structured and long-term care environment for these high risk people.  Research indicates that many persons with schizophrenia lack the ability to create their own internal structure.  If placed in the community in a living arrangement without sufficient structure they may quickly decompensate and return to the hospital or to the streets.  Medication supervision was identified as the most important on-site service.

 The federal Medicaid exclusion of institutions of mental diseases is a major barrier to the development of long term care facilities with adequate structure and support services for individuals suffering from severe mental illnesses. This law has become a major barrier to the availability of economical long-term settings which can provide structure and professional supervision and should be abolished.