溫州市甌海區(qū)現(xiàn)代商貿(mào)業(yè)開發(fā)建設(shè)辦

1、The Future ofPsychiatric Servicesin CaliforniaIf Public PolicyDoes Not ChangeE. Fuller Torrey, MDTreatment Advocacy CenterArlington, VAJuly 24, 2021_ The Insanity OffenseSevere psychiatric disorders =SchizophreniaSchizoaffective disordersBipolar disorder with psychosisMajor depression with psychosis

2、California as leader1957: Short-Doyle Act1960s: Introduction of chlorpromazine (Thorazine)19591967: Deinstitutionalization: 37,000 to 19,000 under Pat Brown (D)1967: Lanterman-Petris-Short (LPS) Act1970s: SF was first city completely covered by CMHCs. Westside CMHC considered a model center.Psychiat

3、ric hospital beds in California19601970198019902000202137,000 in 196019,000 in 196910,000 in 20044,000 in 2021Psychiatric hospital beds in California1960: 1 psychiatric bed available for every 400 population2021: 1 psychiatric bed available for every 10,000 populationCalifornia essentially now has 4

4、% of the psychiatric beds it had available 50 years agoThree men who symbolize the phases of the present disasterNicholas Petris: the theoristNicholas PetrisLiberal Democrat from Oakland, in state legislature1967 Chairman of Ways and Means Subcommittee1967 Lanterman-Petris-Short (LPS) ActNicholas Pe

5、trisInfluenced by Thomas Szasz 1961 The Myth of Mental IllnessPetris: “We remember that throughout history some of todays madmen can become tomorrows heroes.Nicholas PetrisIn 1989 Petris acknowledged that LPS had been a mistake. When asked about follow-up of released patients:Nicholas Petris“No, nev

6、er even got off the ground. And then it was very difficult for those who tried, because they had no handle on people. There was no way they could compel them to do anythingNicholas PetrisThey couldnt threaten to run them in again, because of the harsh definition that we adopted and said that you don

7、t incarcerate someone against his will unless hes a danger to himself or others, or hes so gravely disabled that he just cant take care of his normal functions. Well, thats very severe.Three men who symbolize the phases of the present disasterNicholas Petris: the theoristSaul Feldman: the administra

8、torSaul FeldmanPhD in psychology and public administration1970 NIMH Associate Director for Community Mental Health ServicesSaul Feldman“A major impetus behind the community mental health centers program, of course, was the need to develop effective alternatives to extended hospitalization in a publi

9、c mental hospital.Saul Feldman andHarold H. Goldstein, 1971Saul Feldman“If feelings and emotions are so closely linked to living conditions, how then can mental health workers ignore substandard schools, poverty, overcrowding, and other environmental problems?Saul Feldman, 1971Saul FeldmanRecognized

10、 CMHCs were failing as early as 1971, e.g., acknowledged that only 16% of CMHC admissions had been in state mental hospitals.In 1972 ignored report documenting how some CMHCs had used the federal funds to build a swimming pool and tennis court and pay the salaries of a pool lifeguard and swimming in

11、structor.Saul Feldman1978: “In short, it seems clear that community mental health centers cannot now, and will not in the near future, be able to do what the legislation requires, that failure is inevitable and that the cost of this failure may be severe.Saul FeldmanPresident and CEO, HealthAmerica

12、Corp of CaliforniaCEO, United Behavioral Health,“a leading provider of emotional wellness servicesThe chairman of the parent company, United Health Care, was paid $54.1 million in 2000Saul FeldmanThe San Francisco Chronicle reported that Feldman was living in a penthouse atop the Four Seasons Hotel.

13、Three men who symbolize the phases of the present disasterNicholas Petris: the theoristSaul Feldman: the administratorMichael Bowers: the recipientMichael BowersBorn in Pittsburgh; moved to California as a childWorked as a sound man in concert halls and as a chaufferMichael BowersIn 1986, at age 24,

14、 developed paranoid schizophrenia; thought high-level officials wanted to keep him from revealing secret information19862001: For 11 of the 15 years was in Patten State Hospital, Atascadero State Hospital, or prisonWhen in the community, refused to take medicationsMichael Bowers, January 17, 2001Wha

15、t is the outcome of the grand experiment of deinstitutionalization?Successful community livingWhat is the outcome of the grand experiment of deinstitutionalization?Successful community livingVictimization and premature deathVictimization1984: 278 individuals in LA group homes: Two-thirds “reported h

16、aving been robbed and/or assaulted during the last year.1988: In SF: “I know one woman who has been raped 17 times.2006: 308 SMI individuals: in previous6 months, 26% had been robbed, raped, mugged, or assaultedVictimizationThe future:More individuals assaultedMore individuals robbedMore women raped

17、“They are rabbits forced to live in company with dogs.What is the outcome of the grand experiment of deinstitutionalization?Successful community livingVictimization and premature deathHomelessnessHomelessnessBy the mid-1980s, California State Assemblyman Bruce Bronzan estimated that there were “betw

18、een 20,000 and 50,000 adults who are chronically mentally ill and may be homeless, a situation he labeled “morally unacceptable and just unbelievable. Homelessness Richard Lamb added,“Probably nothing more graphically illustrates the problems of deinstitutionalization than the shameful and incredibl

19、e phenomenon of the homeless mentally ill.HomelessnessIn LA, a 1985 study reported, 3050% of all homeless persons were seriously mentally ill, and they were being seen in “ever increasing numbers. The study noted, “They are defenseless and frequently victimizedbeaten, robbed and raped dailyand often

20、 eat garbage and sleep in alley ways. Homelessness The study concluded that homeless mentally ill persons “are in part the product of the deinstitutionalization movement and that the “new liberalized Mental Health laws making involuntary psychiatric treatment almost impossiblethe Streets have become

21、 The Asylums of the 80s.HomelessnessA 1988 study of 529 Los Angeles street persons reported that 44% had had a previous psychiatric hospitalization; among that group, 28% obtained “some food from garbage cans and 8% utilized garbage cans as their primary food source. Homelessness Another study of me

22、ntally ill street persons found that 79% of them had been previously psychiatrically hospitalized.HomelessnessIn LA in 2005, Mayor Antonio Villaraigosa visited skid row and commented, “I mean that almost looked like Bombay or something, except with more violence. There is no place in the city where

23、the chaos and degradation are as pronounced. You see a complete breakdown of society. Homelessness The LA Times called the skid row scene “a human catastrophe unfolding and concluded that “l(fā)aws intended to protect the rights ofmentally ill people are well-intended but inhumane.HomelessnessIn 1976, c

24、olumnist Mike Royko called California “the worlds largest outdoor mental asylum.It has now become literally true.HomelessnessThe future:More homeless on the streetsMore crime: 1983 study showed that homeless persons with a previous psychiatric hospitalization had3 times more felony convictions than

25、homeless persons without a previous psychiatric hospitalizationInvasion of city hallWhat is the outcome of the grand experiment of deinstitutionalization?Successful community livingVictimization and premature deathHomelessnessIncarceration in jails and prisonsIncarceration inJails and Prisons1972, M

26、arc Abramson:“The criminalization of mentally disordered behavior1973, James Stubblebine: “Specific information is not available.Incarceration1980, Richard Lamb, LA County Jail19801993: SF Jail psychiatric services increased 99%1995: LA Jail recognized as the largest de facto mental institution in t

27、he United StatesIncarcerationOvercrowdingBizarre behaviorVictimization of SMI prisonersSuicideCostsConsequencesIncarcerationThe future:Percentage of SMI in jails and prisons will increase to 33% or higherIncrease in jail and prison suicidesIncrease in costs, especially due to lawsuitsSheriffs may be

28、gin refusing to take SMI prisonersRenovating/building prisons as mental hospitalsWhat is the outcome of the grand experiment of deinstitutionalization?Successful community livingVictimization and premature deathHomelessnessIncarceration in jails and prisonsInteractions with the policeInteractions wi

29、th the Police19871993: annual calls to LA Police Mental Evaluation Unit increased from 12,613 to 54,73719922001: Ventura County police killed 32 people, 18 of whom were SMI1996 cost study: City police departments in CA were spending $445 million/year “on handling mentally ill offendersInteractions w

30、ith policeThe future:Police will increasingly become social workers? Separate police department?Increasing numbers of SMI killed by police and police killed by SMIIncreasing costs for police departmentsWhat is the outcome of the grand experiment of deinstitutionalization?Successful community livingV

31、ictimization and premature deathHomelessnessIncarceration in jails and prisonsInteractions with the policeHomicidesU.S. studies of homicides by SMIMatejkowski et al, J Am Acad Psychiatry Law 2021;36:748619902002, sample of all individuals in Indiana convicted of homicide53/518 (10.2%) of homicides h

32、ad schizophrenia, BP, or other psychosisHomicidesU.S. studies of homicides by SMIWilcox, Am J Forensic Psychiatry 1985;6:315197880 in Contra Costa County, CA:7/71 (10%) of the people who had committed a homicide had schizophreniaHomicidesExamples of prominent homicidesHomicides1970: John Frazier, Sa

33、nta Cruz1973: Herb Mullin, Santa Cruz1976: Edward Allaway, Fullerton1988: Dorothea Montalvo, Sacramento1993: Linda Scates, Walnut Creek1999: Steven Abrams, Costa Mesa1999: Julie Rodriguez, Sacramento2000: Marie West, Van NuysHomicides: examples2001: David Attias, Santa Barbara2001: Scott Thorpe, Nev

34、ada City2005: Lashuan Harris, San Francisco2006: Jennifer San Marco, Goleta2006: Lawrence Woods, Pismo Beach2021: Lee Leeds, Santa Maria2021: Charlie Sekona, San Francisco2021: Layla Trawick, West HollywoodHomicidesA total of 10,240 deaths over 39 yearsAn average of 263 deaths each yearAn average of

35、 1 death every 1.4 daysTotal homicides in CA, 19702021:If individuals with SMI were responsible for 10%, that would be:102,396HomicidesComments on homicidesKenneth Springer, foreman of the 1973 jury that convicted Herb Mullin:Springer likened the effects of LPS to “releasing known killers from our p

36、risons, arming them, and then turning them loose on society. Homicides: comments “The closing of our mental hospitals, he added, “is, in my opinion, insanity itself. Finally, Springer asked, “Was Herb Mullin any more responsible for those 13 lives than those public officials who perpetuate this insa

37、ne law that allowed him to be free to kill 13 people?HomicidesState Department of Mental Health comment on homicidesDr. Andrew Robertson, testifying in 1973 before a select committee of the legislature:“It LPS has exposed us as a society to some dangerous people; no need to argue about that. People

38、whom we have released have gone out and killed other people, maimed Homicides: comments other people, destroyed property; they have done many things of an evil nature without their ability to stop and many of them have immediately thereafter killed themselves. That sounds bad, but lets qualify itthe

39、 odds are still in societys favor, even if it doesnt make patients innocent nor the guy who is hurt or killed feel any better.HomicidesThe future:Increasing number of homicides by individuals with SMI who are not being treated: 15%? 20%?Who gets killed?1. What is its magnitude?There are 4 million se

40、riously mentally ill individuals in the U.S. (population 302 million)Therefore:Per1,000 popPermillion popNumber of seriously mentally ill individuals1313,000Number of seriously mentally ill individuals who are problematic (10%)1.31,300Number of seriously mentally ill individuals who are dangerous (1

41、%)0.13130Solving the ProblemWhat does this translate to?California37 millionBay Area2.5 millionNumber of seriously mentally ill individuals481,00032,500Number who are problematic (10%)48,1003,250Number who are dangerous (1%)4,810325History of past violenceSubstance abuserNoncompliance with medicatio

42、n/anosognosia2. Identify the target population: 10% of SMI3. Why do people with severe psychiatric disorders not take medication?The biggest single reason, confirmed in several studies, is that they do not think they are sick. They have limited or no awareness of their illness. In neurological terms

43、, this is called anosognosia.The supramarginal gyrus (BA40) has vertical lines.The angular gyrus (BA39) has horizontal lines.Inferior parietal lobeNicholas Petris laypersons description of anosognosia(from his 1989 retrospective understanding):“Well, what are you going to say? Nice seeing you? Well,

44、 Ill tell you what I would say. Id say, Damn it, dont I have a right to treatment? If I had broken a leg or had a heart attack, Nicholas Petris on anosognosia you would be swarming all over the place with doctors and nurses and this and that. Why the hell didnt you get me treatment? Well, because yo

45、u resisted. Well, baloney I resisted! Of course I resisted, because I didnt know what the hell I was doing.4. Implement Lauras Law in each countyIt will decrease rehospitalization, homelessness, victimization, arrests, and violent behaviorThus, it will protect both individuals with SMI and the publi

46、cIt will also decrease stigmaIt will be cost-effectiveIdentify the target population: 10% of SMIEffectiveness of Assisted Outpatient TreatmentPrior to being on AOTOnAOTDecreaseDistrict of Columbia5538-31%North Carolina2214-36%Ohio13344-67%Iowa335-85%New York10044-66%North Carolina335-85%Decrease in

47、days hospitalized per yearEffectiveness of Assisted Outpatient Treatment, contdDecrease in homelessness:19% to 5% (NY)Decrease in victimization:42% to 24% (NC)Decrease in arrests:45% to 12% (NC)30% to 5% (NY)Decrease in violent behavior:42% to 27% (NC)15% to 8% (NY)Multiple studies have shown that v

48、iolent acts committed by individuals with severeAndrea YatesRussell WestonAndrew Goldsteinpsychiatric disorders are the single largest cause of this stigma.The 1999 Surgeon Generals Report on Mental Health cited studies showing that “the perception of people with psychosis as being dangerous is stro

49、nger today than in the past (p. 7).Percentage of people who believe that mentally ill persons are violent1950: 13%1996: 31%5. Focus on costsMental illnessassociated costs of Medicaid, Medicare, SSI, and SSDI are among the fastest growing costs in the federal budget.CostsNIMH studies: SMI are 13% of

50、all mental disorders yet utilize 40% (1993 study) or 58% (2000 study) of all treatment costs.English study of schizophrenia: the sickest 10% of patients utilize 80% of costs.Petrila et al, 2021Florida study of 813 individuals with psychoses who were arrested calculated their median incarceration and treatment costs as $11,684 per year.CostsCostsHigh-cost Medicaid enrollees with diagnoses of SMI or mental retardation have average costs of $61,794 per year.Sommers and Cohen, 2006Social costs of violent crime:$925,000 per violent crime (Congressional t