Benign Coercion

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© Colour | stockfresh.com

Recently, two psychiatrists, Sally Satel and E. Fuller Torrey, wrote their second article, “Stop ignoring the needs of the seriously mentally ill,” for the American Enterprise Institute in support of the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646).  In their November 3, 2015 article, they bemoaned the opposition of what they referred to as a small but vocal faction of “advocacy groups opposed to all involuntary mental-health care” who have the ear of some committee Democrats.  According to Satel and Torrey, the problem is that these critics and the lawmakers receptive to their claims don’t seem to grasp the difference between serious mental illnesses and less disabling psychiatric conditions.

They highlighted three areas that in their opinion are particularly important aspects of H.R. 2646 that need to be passed. They want to see the creation of a new position, an assistant secretary for mental health and substance abuse, who would: “focus on coordinating the federal government’s programs and elevating the importance of caring for the most debilitated patients.” All the current funding and authority of the existing federal agency, SAMHSA, (Substance Abuse and Mental Health Services Administration) would be placed under this new assistant secretary. Allegedly, these radical advocacy groups oppose the creation of the position because of a threat to their current funding from SAMHSA.

The second major area of concern is the so-called assisted outpatient treatment (AOT) provision. AOT is said to be “a cost-saving and effective form of civil-court-ordered community treatment,” that targets individuals who habitually fall into a pattern of “self-neglect, self-harm, or dangerousness” when they are not taking medication. A judge could order these individuals into mandated and monitored “treatment” while they continue to live in the community. A violation of the court-ordered treatment conditions could results in “an evaluation of a patient’s need for further treatment.”

The third perceived concern is the expansion of psychiatric beds. The main culprit they point to seems to be the “outdated” law called the IMD exclusion, which prohibits Medicaid from paying for care delivered by “institutions for the treatment of mental diseases” (IMDs) for individuals between the ages of 22 and 64. This is supposed to have contributed to a shortage of psychiatric hospital beds. The authors claim there is a need for twice number of existing inpatient beds. Citing data from H-CUP, they said schizophrenia and bipolar illness represented two of the top three causes of 30-day Medicaid inpatient re-admissions. “Along with diabetes, these conditions resulted in about $839 million in hospital costs.”

In truth, these provisions are vital to the reversing the marginalization of the sickest patients by SAMHSA and the inadvertent problems caused by Medicaid’s disincentives. Misconceptions about the needs of these patients must not be allowed to interfere with the bill’s mark-up, so it will emerge from the Health Subcommittee with its bold and much-needed provisions intact.

David Shern, a Senior Associate in the Department of Mental Health at the Bloomberg School of Public Health, John Hopkins University, responded to the article by Satel and Torrey in “We Need REAL Change in Mental Health Policy, Not the Illusion of Reform.” Shern described the above three changes as simplistic approaches that ignore core parts of the problem. “They are ‘quick fix’ solutions that have little promise of doing much to address our contemporary crisis.” He agreed with the key features of the problem: incarcerating too many people with severe mental illness and a lack of effective engagement strategies with the mentally ill population. He agreed that a comprehensive approach to the problems was necessary. But “Drs. Satel and Torrey propose more of the same – strategies that have characterized the last 50 years.”

He said there was no reason to believe that adding an Assistant Secretary title to the existing bureaucracy would make any difference within HHS. Additionally, the new position would have no effect on other governmental departments critical for the community life of mentally ill individuals. “We’ve repeatedly learned that reorganizations are appealing but rarely accomplish the magic that the reorganizers hope to achieve.”

He then observed how “Involuntary Outpatient Commitment” has been renamed as “Assisted Outpatient Treatment” in H.R. 2646. The current legislation does nothing to improve the existing community service capacity. Provisions in the original version of the Helping Families in Mental Health Crisis Act actually called for cut backs in funding for existing community services. I’m not sure if those same cuts are still there. So according to Shern, “Creating a legal mechanism to compel individuals into a non-existent system is a cruel fiction that creates the illusion of fixing a problem.”

Ostensibly, for people who are not compliant with the system’s idea of care, having a judge order an individual to comply with the treatment plan will fix the problems of an inadequate system. (An inpatient stay is the ‘punishment’ for noncompliance.)

The third leg of the proposed reform involved “opening a spigot” of funding for inpatient services that was initially closed to keep states from shifting inpatient costs onto the federal government (the IMD exclusion). “That danger still exists.” Any expansion of residential alternatives should involve a systematic appraisal of the system of care available in each community and a plan for allocation of resources to ensure the range of needed services. “Preferentially funding one component of the system while neglecting others isn’t a smart approach.”

I found an additional problem with the call made by Satel and Torrey for expanding the number of psychiatric beds. They curiously lumped schizophrenia and bipolar in with diabetes to then give a cost figure of $839 million in hospital costs for causes of 30-day Medicaid inpatient re-admissions for adults between the ages of 18 and 64. I thought it was strange to have schizophrenia and bipolar disorder lumped in with diabetes in assessing hospital re-admission costs. Following the above link they provided to the H-CUP data they referenced, it seemed they took their cost figure from Table 3, which contained ten conditions with the most all-cause, 30-day re-admissions for Medicaid patients (aged 18-64).

The first thing I saw was that diabetes costs could have been easily left out of their figure, meaning that $839 million should have been $588 million for schizophrenia and bipolar re-admissions alone. The second thing I noticed was Satal and Torrey referred to the H-CUP category of “Mood disorders” as “bipolar.” Bipolar disorders are mood disorders, but so are the depressive disorders.  The NIH estimate of the prevalence of severe bipolar disorder among U.S. adults was 2.2%. The estimated prevalence for major depression among U.S. adults was 6.7%. If the combined re-admission costs for all mood disorders was $588 million, what was the cost for just bipolar disorders? If the ratio was evenly distributed, it would be roughly one-third of the $588 million figure—$196 million. Or do Satel and Torrey support “assisted outpatient treatment” for individuals refusing to remain on medication for major depression as well as bipolar disorder? What about the less serious mood disorders, like anxiety?

Was the reference of the H-CUP category of “mood disorders” as “bipolar disorder” intentional or not? Traditionally, bipolar disorder is seen as the most serious mood disorder. I don’t believe they were confusing the difference between serious mental illnesses and less disabling psychiatric conditions, as they suggested of the critics of H.R. 2646 and lawmakers above. So unless it was an unintentional slip, they were intentionally referring to the general category of mood disorders by its most serious condition: bipolar disorder.

The underlying assumption for the need of an assisted outpatient treatment (AOT) provision is that the targeted individuals fall into this pattern of self-neglect, self-harm, or dangerousness” because they are not taking medication. But the treatment efficacy for psychiatric medications has been increasingly questioned. Antidepressants have been shown to be of minimal value (See “Dirty Little Secret” and “Do No Harm with Antidepressants” and The Emperor’s New Drugs, by Irving Kirsch for more information). And the adverse consequences from neuroleptics and mood stabilizers have raised serious questions about the long-term use of such medications for schizophrenia and bipolar disorder (See “Creating Chemical Imbalances,” “Antipsychotic Big Bang,”  “Abilify in Denial” and Anatomy of an Epidemic, by Robert Whitaker for more information).

There is nothing benign about the assisted outpatient treatment provision within the Helping Families in Mental Health Crisis Act of 2015 (H.R. 2646). But it certainly is coercion. See “Murphy’s Law” for more on H.R. 3717, the original bill. See “Regarding Representative Tim Murphy’s Helping Families in Mental Health Crisis Act” for more information on H.R. 2646.


Murphy’s Law

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© Icefields | Dreamstime.com

In December of 2013, Congressman Tim Murphy, a Republican representing the 18th District of Pennsylvania, introduced H.R. 3717, the Helping Families in Mental Health Crisis Act. You can red a shorter summary of it here. Almost immediately, it drew opposition from several advocacy groups. H.R. 3717 says it’s purporse is: “To make available needed psychiatric, psychological, and supportive services for individuals diagnosed with mental illness and families in mental health crisis, and for other purposes.” Why would advocates for the mentally ill be opposing a bill that is supposed to help the mentally ill?

One of these was MindFreedom, a nonprofit organization that seeks to nonviolently unite “people affected by the mental health system with movements for justice.” MindFreedom noted that the bill eliminated legal advocacy on behalf of those with psychiatric disabilities. It cut 85% of the existing funding for protection and advocacy programs. Under the bill individuals with psychiatric disabilities won’t get the same HIPPA protections. It would increase institutionalization, giving more money to psychiatric institutions than programs to help people live within the community.

A press release from the Mental Health Advocates suggested the measure would reverse some of the advances of the last 30 years in mental health services and supports. “It would exchange low-cost services that have good outcomes for higher-cost yet ineffective interventions.”  The bill was said to target the rights of individuals with mental illnesses and restructure federal funding “to heavily encourage the use of force and coercion.” It would seek to expand involuntary outpatient commitment (IOC), where an individual with serious mental illness would be court-mandated to follow a specific treatment plan, typically requiring medication.

Several bloggers for Mad in America also voiced their opposition to the legislation. Corinna West said the bill “replaces peer support, which works, with forced treatment, which doesn’t.” She cited the National Association of State Mental Health Program Directors, who after a review of forced treatment found it wasn’t helpful. Additionally, peer support was the #1 most effective method. She also noted in her December 2013 article that two of the top five industries donating to Rep. Murphy’s reelection campaign were healthcare professionals and the pharmaceutical industry. We’ll return to this issue later.

Faith Rhyne noted the legislation presented itself as having “worst case scenarios in mind;” that it was “not about most people” with psychiatric diagnoses. However, the criteria in the bill for patients eligible for IOC are not limited to individuals with a history of violence and incarceration. “It includes those with a record of non-medical hospitalizations,” and those deemed unable to care for their basic needs. “In many ways the legislation carries the theme and intent of E. Fuller Torrey’s Treatment Advocacy Center, which is noted on Representative Murphy’s website as being a leading supporter of the bill.”

Mad in America wrote an editorial opposing the bill, focusing on the dangers of the mandated treatment relying on antipsychotic medication. The editorial referred to research showing that these medications shrink the brain and may actually impair recovery. “But American psychiatry and the NIMH have never publicized those findings.” The false impression of the benefits of antipsychotics made passage of H.R. 3717 possible.

The House Subcommittee on Health held a hearing on H.R. 3717 on April 3, 2014. You can watch a video of the hearing and review documents associated with it here. Still trying to gain support for the bill, Rep. Murphy addressed the American Psychiatric Association in May of 2014. In his introduction, he was called “a friend of psychiatry.” He gave an impassioned plea of support for his “comprehensive mental health legislation.” The APA President, Paul Summergrad said:

The APA is committed to achieving needed legislation to transform mental health care on the basis on the best science and clinical care. We are pleased to work closely with Representative Murphy as well as Representative Barber and others to craft the best bill to benefit the American people.

Elise Viebeck reported for The Hill that House Republican leaders announced in June of 2014 they were going divide the Murphy Bill into pieces in an attempt to pass the less controversial provisions. This was said to be a major blow to the bill and Rep. Murphy, who had argued that only “dramatic and comprehensive reform” would help people with serious mental illness. “The defeat of the comprehensive bill is a victory for the broad swath of national mental health groups that were uneasy about or opposed to Murphy’s legislation.”

But Murphy continued to lobby for support of his comprehensive bill.  A December 2014 updated summary of H.R. 3717 listed 34 organizations supporting the bill, including the American Psychiatric Association and the American Psychological Association and the Treatment Advocacy Center. There were 115 cosponsors of H.R. 3717.  The twenty-one media outlets included: The Wall Street Journal, The Washington Post, the Pittsburgh Post-Gazette, the Seattle Times, and the Houston Chronicle.

In February 2015, Congressman Tim Murphy was a keynote speaker at an event, “Fixing America’s Mental Healthcare System.” He said he hoped to reintroduce H.R. 3717 as early as March of 2015. Senator Chris Murphy, who participated in the same panel discussion event as Congressman Murphy, voiced his intent to introduce similar legislation in the Senate this year. Senator Murphy is from Connecticut, where the Sandy Hook shooting took place.

Rob Wipond of Mad in America, citing a 2013 analysis of the bill by the National coalition for Mental Health recovery, once again noted how the existing legislation would “heavily encourage the use of force and coercion.” This would likely involve “treating people with pharmaceuticals. It would undermine the rights and legal support of people seeking non-drug options. It would cut funds for community-based services with a proven track record of helping people stay out of the hospital. “(T)his bill would cost more money for worse outcomes.”

Wipond also cited information on donors to Congressman Murphy for the 2014 election cycle. Maplight listed contributions from pharmaceutical companies such as: GlaxoSmithKline, AstraZenaca, Pfizer, Johnson & Johnson, Merck & Co, Eli Lilly & Co.—many of them on multiple occasions.  Murphy received $95,830 from 10/1/2012 to 9/30/2014 from pharmaceutical/health care product companies.

OpenSecrets.org reported that within Murphy’s top 20 contributions from industry were health professionals, pharmaceuticals/health products, hospitals/nursing homes, and health services/HMOs. Murphy received over $283,000 from the political action committees related to these industries for the 2014 election cycle. There were individual contributions in addition to these. His campaign committee reported that during the 2013-2014 fundraising cycle they raised $1,854,010. In his political career from 2001-2014, he has received $701,235 in contributions from health professional political action committees, and $430,030 in contributions from pharmaceuticals/health products political action committees.

In all the readings linked here; in the videos I watched of Congressman Murphy gathering support for his bill, I did not hear any substantive reference made to the concerns raised and noted above by MindFreedom, Mental Health Advocates, or Mad in America. Specifically, I did not hear anything addressing the concern for the proposed IOC.

Congressman Murphy advocates for increased social control over individuals with “mental illness.” He’s a friend of psychiatry, who dismissed the opponents to his legislation as marginal and “anti-psychiatry” in his rhetoric to the American Psychiatric Association. He is passionate in his views and has a well-polished stump speech that he gives as he drums up support for his legislation. He has been heavily supported by the medical and healthcare industry throughout his political career. And he is getting ready to try again to get Congress to approve legislation giving psychiatry increased power and authority.

This is happening just as the validity of what he has referred to as “anti-psychiatry” is becoming more widely known and accepted. What’s more, there is scientific evidence to support much of it. The evidence-based “treatment” of psychiatric medications has been repeatedly shown to be marginally effective at best. Look at the information on Mad in America; Psychiatric Drug Facts and PsychRights.

Any legislative reform that gives psychiatry more power should be sidelined until the existing questions on the validity of psychiatric diagnosis and practice are resolved. Otherwise, we may have to live with the consequences of a different Murphy’s law—anything that can go wrong, will go wrong. If we really want to help the “mentally ill,” we should wait until we are clear that the proposed changes will help and not harm them.