In the aftermath of the January shooting of Congresswoman Gabrielle Giffords and 18 others by the probably mentally ill Jared Lee Loughner, the problem of violence by people with serious mental illness has once again dominated headlines. At a time when unprecedented state and municipal deficits are forcing cutbacks to a host of government services, including treatment of the mentally ill, can we expect more such catastrophes? The answer in New York is probably yes, unless Governor Andrew Cuomo and the legislature force the states Office of Mental Health (OMH) to change its ways.
The problem isnt OMHs budget, which has plenty of money; its how the agency spends it. OMH claims that 50 percent of New Yorkers, including everyone from struggling students to dissatisfied spouses, will have a diagnosable mental-health issue during their lifetimes. Under Commissioner Michael Hogan, OMH continues to spend its resources on these people, rather than on the 3 to 9 percent of New Yorkers who, the agency says, are the most severely impaired, suffering from genuinely serious mental illnesses like schizophrenia and bipolar disorder. Of the 700,000 people whom OMH is serving this year, only 3,600 are seriously mentally ill individuals in state hospitals, according to the agency; another 1,876 seriously ill receive treatment in outpatient programs, and perhaps a few hundred thousand others are scattered throughout the system. Who are the remaining hundreds of thousands? Hogan describes them as people who need hope filled, humanized environments and relationships in which people can grow.
One reason to be concerned about OMHs skewed priorities: studies show that when the truly ill receive treatment, they are no more violent than the general population, but when treatment is lacking, their violence rises. Currently, there are twice as many mentally ill people in prison on Rikers Island as in all OMH-run psychiatric hospitals combined.
For another sign of OMHs poor spending practices, look to its response to Governor Cuomos 2011 budget, which cuts a net $95 million from the $3.6 billion that OMH had in 2010. That $95 million consists of $135 million in spending reductions offset by a $40 million increase intended to help OMH comply with a specific court order, which requires the agency to stop warehousing people with serious mental illness in non-therapeutic group-adult homes meant to house the elderly indigent and instead house them in facilities that provide case management, medication, and rehabilitation. But despite that $40 million, OMH has announced that it plans to take housing away from other seriously mentally ill people (we dont know yet whether this housing would be bestowed on the people covered by the court order).
Cuomos proposed budget itself continues the expensive and inhumane policy of cutting services for people with serious mental illness. Most of the $135 million in cuts that it imposes will come from cutting back on services for the most seriously ill and reducing the workforce that provides those services. But a study that I coauthored with lead author E. Fuller Torrey and the Treatment Advocacy Center estimates that New York needs 4,311 more inpatient beds to meet the minimal needs of the seriously ill. The proposed budget also contemplates reducing staff in the states psychiatric hospitals, which still accept the most seriously mentally ill as patients. New York has already dramatically reduced state psychiatric hospital beds, from 10,500 in 1993 to 3,600 today. Further cuts could be particularly problematic, given that a number of those beds are now occupied by sexually violent predators; the result would likely be an increase in homelessness and incarcerations. Cuomos budget also wants OMH to rationalizein other words, cutthe reimbursement of providers of mental health clinical services, who provide prescriptions, case management, counseling, and medical services to people with serious mental illness.
What to do? If Cuomo hopes to save money, improve care, and keep the public and patients safer, he has to force major reform at OMH. A new commissionerperhaps one with an M.D., as was formerly requiredmight be more willing to focus on treating mental illness, as opposed to improving mental health. Cuomos Savings and Government Efficiency (SAGE) Commission should propose eliminating OMH and transferring its vital functionsthose that actually have to do with serving the seriously mentally illto the Department of Health. There is a precedent for merging the departments. In the 1990s, the New York City Department of Mental Health, Mental Retardation and Alcoholism Services was as overextended as OMH is today. Like OMH, that agency cut services for the most seriously ill and expanded social-services programs for others. In 1999, city residents voted to eliminate the agency and transfer its vital operations to the health department. Limited resources were then directed to where they were most needed.
Even if Cuomo keeps OMH, other reforms could make a difference. The state legislature should establish a definition of serious mental illness that covers no more than 5 percent of the population. The legislature should then require all programs that get OMH money to use at least 60 percent of their funds for that defined population. State and local hospitals that provide care to truly mentally ill patients should have their resources increased, not cut.
Another reform: OMHs education budget should be eliminated, since it tends to be wasted on conferences and brochures of dubious quality and utility. The agencys public-relations budget should likewise be done away with: its largely spent justifying needless expenditures and shifting blame when a mentally ill person commits an act of violence. Even OMHs research budget should be scrutinizedand eliminated, if OMH refuses to focus on serious mental illness. It pains me to say this, because OMH conducts research that has the potential to save money, improve care, and keep the public and patients safer. But because OMH mostly avoids serving the seriously ill and implementing this research, few benefit from it.
Its also time that OMHs operations came under sharper scrutiny. Rather than merely reporting increases and decreases in categories of spending, it should provide specific details on the Internet about where every dollar is spent. OMH sends funds to 2,500 nonprofits. Some serve people with serious and persistent mental illness. Many dont. And some are simply misusing the money they receive. The New York Posts Andrea Peyser revealed, for example, that one OMH-funded organization that purportedly managed money for people with mental illness was instead giving the funds directly to patients, knowing theyd often use it to purchase illicit drugs.
Finally, the state must make greater use of Kendras Law, New Yorks most successful reform for the seriously mentally ill. Kendras Law, enacted in 1999, allows judges to order potentially violent mentally ill people to stay in outpatient treatment. In 2005, OMH conducted a study of people six months before and six months after they entered court-ordered treatment. The results were unambiguous: treatment dramatically reduced the rates of arrest, incarceration, psychiatric hospitalization, attempted suicide, and violence to others. In spite of this success, Hogan has vigorously opposed making the law permanent, preferring to let it expire in 2015, and he has also opposed closing loopholes, like those that allow mentally ill prisoners or involuntarily committed patients to be released into the community without first evaluating them to see if a court should order them to stay in treatment. In addition, by failing to fund the caseworkers and housing programs that are necessary for Kendras Law to work, and by creating bureaucratic disincentives to enroll patients in treatment, Hogan has succeeded at limiting enrollment to less than half of what OMH anticipated ten years ago.
If New York State wants to save money and improve care for the seriously mentally illand, yes, lessen the chances of a Tucson-like incident hereits elected officials must address OMHs willful failure to assist those it is supposed to serve. The problem of the seriously mentally ill is a pressing social, political, and moral issue that has been ignored for far too long.