Federal Action to Reduce Violence Should Focus on Mental Health By Dr. TIM MURPHY
Those who need help most face the greatest difficulty in getting treatment.
While the students in Parkland plan their actions to get legislative attention, Congress is still wrestling with what to do. Gun-access restrictions, security measures, and arming teachers are all on the table. We’ve seen this before: lawmakers focusing more on what is in someone’s hands than on what is in his mind. The president has rightly said this is partly a mental-health issue that must be addressed. If lawmakers want to make a difference and not just a law, they will act on the understanding that improving mental-health treatment rather than gun laws is the most cost-effective way to save lives.
A person with mental illness and a history of violence who is not in treatment is 16 times more likely to engage in future violence than the person who is in treatment. Unfortunately, the discussions are not about making it easier to get treatment.
The current law requires names to go on the list — for the National Instant Criminal Background Check System (NICS) — of those prohibited from purchasing a gun if they are deemed “mentally incompetent” or have had a court-ordered involuntary inpatient psychiatric commitment for being in imminent danger of harming self or others. But reaching those standards can be very difficult.
Federal privacy laws often prevent family members from knowing that a person is in treatment, and so it may happen that they do not offer testimony regarding the risk of violence.
With a critical shortage of psychiatric beds around the country, hospitals often solicit voluntary admission instead of involuntarily admitting dangerous patients. A patient who voluntarily commits himself for care saves the providers burdensome court time, and his name will not make the NICS list. This “loophole” is why some mentally ill individuals with violent tendencies are still permitted to purchase and possess a gun.
Others who should be involuntarily committed are not, as patient-rights advocates frequently fight court-ordered treatment, claiming that it is ineffective. Such claims are based on a misguided comparison between voluntary and involuntary care, instead of between treatment and no treatment. Further, the “imminent danger” standard is so high that unless the person is currently threatening harm, involuntary inpatient or outpatient commitment is blocked. The courts release the patient again into the community, where a frightened family provides care until actual harm occurs. The name does not make it to the NICS list, and, worse yet, treatment is delayed.
The gun-related attention so far takes place in the form of calls for a red-flag restriction to temporarily remove guns from a person deemed both mentally ill and at risk for violence. This requires that a judge review evidence while considering the person’s constitutional rights. But just like an involuntary psychiatric commitment, it is cumbersome and requires a preponderance of evidence that the individual is at risk of harm to self and others.
With these gun-related issues so problematic, better treatment may be an easier path to mitigating violence. But even for the person who wants to get help, the plain fact is that we make it the most difficult for those who have the most difficulty. Half the counties in the U.S. have no psychiatrist or psychologist. Many doctors have waiting lists or may not see patients with serious mental illness such as schizophrenia or bipolar disorder or those with violence risk. There is a nationwide shortage of 30,000 child and adolescent psychiatrists, and patients wait on average 7.5 weeks for a first appointment if the child psychiatrist is even taking new patients. Half the cases of mental illness emerge by age 14, and 75 percent by age 24, and so delays in care can and do lead to further neurological harm to the patient as the disease worsens.
There is a nationwide shortage of 30,000 child and adolescent psychiatrists, and patients wait on average 7.5 weeks for a first appointment if the child psychiatrist is even taking on new patients.
There is no end in sight for these shortages, given the very low rate of reimbursement from Medicaid for psychiatric care. In fact, among all branches of medicine, psychiatrists have the lowest percentage of doctors accepting Medicaid. Since a person with serious mental illness is three times more likely to live in poverty, and since a person living in poverty is three times more likely to suffer a mental illness, the Medicaid issue is another barrier to his timely access to care. Low-income and rural families have transportation difficulties — yet another barrier.
Of the 10 million Americans with serious mental illness, 40 percent receive no treatment. Delays in treatment worsen the psychiatric condition and brain function and exacerbate co-occurring physical diseases. The delays are a major contributor to the annual medical costs related to those with mental illness: more than $200 billion, plus $15 billion for incarceration, and $195 billion in lost earnings. Add disability insurance payments, and the annual cost of mental illness in the U.S. approaches $500 billion, according to Tom Insel, former director the National Institute for Mental Health.
So what concrete step should the president and Congress take?
- Provide student-loan forgiveness for psychiatrists and psychologists committing to participation in the Public Health Service Commissioned Corps or specializing in the treatment of the seriously mentally ill or in child and adolescent care. This is essential, as these doctors do not make nearly as much as colleagues in other specialties.
- Fix the HIPAA (Health Insurance Portability and Accountability Act) law. While keeping patient information confidential is paramount, there still needs to be a small and rare exception for “compassionate communication” between the provider and a trusted or known family member when necessary, to protect patient health and safety when the patient refuses signed consent. This is essential in the case of the 40 percent of the seriously mentally ill who have anosognosia, a condition under which they do not even recognize that they are ill.
- Increase the number of quality inpatient psychiatric beds. The national shortage is 100,000 beds. Medicaid needs to remove its limit on inpatient beds from 16 and end the artificial limit of a 15-day stay.
- Increase Medicaid reimbursement rates for care of the seriously mentally ill. For such care, Medicaid pays 20 percent below its Medicare standards — already low — for other treatment.
- Fix the involuntary-commitment loopholes that prevent the seriously ill from being placed on the NICS list. This can be done while maintaining the highest standards for protecting constitutional rights.
Many of these recommendations were part of the Helping Families in Mental Health Crisis Act, which I introduced in both the 113th and the 114th sessions of Congress. Parts were enacted and require robust funding. Other parts were not included in the final version that was amended onto the 21st Century Cures Act, which was signed into law in at the end of 2016. Congress would do well to revisit these issues and make a law that would make big difference. The students at Parkland, Newtown, Columbine, and Virginia Tech deserve no less.