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Mental health in the US: New ideas on care emerge

Mass shootings by mentally unstable people have focused attention on the inadequacies of the US mental health care system, in which less than half of the seriously ill can get treatment. 

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"It's unlike any other health-care system in this country," says Ron Hornberg, national director for policy and legal affairs at the National Alliance on Mental Illness. "It's geared toward not intervening until a person goes into crisis. Early identification, intervention, and continuous care are frequently not available for people. With any other medical disorder, if you waited until somebody was in crisis until you intervened, the death rates and costs would be much higher – but that's pretty much how the mental health care system functions in many parts of the country…. We don't have any comprehensive system of care in place, and by definition many of these people need care on an ongoing basis."

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For Sacher, one of her biggest frustrations was one common to many families of the very seriously ill: Her daughter was putting herself in dangerous situations. At one point Lisa believed that the heroin she was injecting would be safer if she diluted it with aloe, and while she was homeless for a while, living on the streets of New York's East Village, she was raped and beaten. But, to use the common medical term, she "lacked insight" into her disease. She didn't believe she needed to treat it and she didn't like the side effects, like weight gain, of the medications doctors prescribed. And her mother had limited ability to force her to get treatment.

Can treatment be forced?

There is perhaps no more controversial subject among advocates of better mental health than forced treatment. The current bar to pass – that the person must pose an imminent risk to himself or others – can be very hard to prove in some states. Many family members are told their best option is to lie about exactly what was said or when it was said in order to get someone admitted to a hospital, if they believe a person needs immediate help and the illness is preventing them from seeking that help.

Others point out that mandated treatment is often unsuccessful and may only alienate the patient from family and friends. The current bar for mandatory treatment is appropriately high, they say, and making it easier to force treatment could lead to an infringement of civil rights.

"The problem isn't our system of legal compulsion; it's our mental-health system," says Ira Burnim, legal director for the Bazelon Center for Mental Health Law.

Anytime an incident like the Newtown shooting occurs, there’s a push to make mandatory treatment easier, on grounds that it’s needed to prevent violence. Mr. Burnim and others acknowledge that a very small number of people may be both mentally ill and dangerous. But trying to screen out those individuals and force them into hospitals, before they’ve done anything wrong, would be akin to going into a poor community and rounding up young men who are flunking out of school or exhibiting some other trait that puts them in a group at risk for violence, says Burnim.

"There may be people who are mentally ill and become violent, and you can't identify them [beforehand], but that's true of all people," says Burnim. "And mental illness tells you almost nothing about the likelihood they'll be violent."

Indeed, people with a mental illness are far more likely to be victims of violence than to commit violence themselves, studies show. Burnim, like many in the mental-health community, would like to see the biggest emphasis placed on getting support and treatment for people early on, before their illness hits a crisis stage. And he’d like to see money put into interventions with a proven track record – like the growing number of programs using the Assertive Community Treatment approach. ACT involves teams of professionals helping patients with wraparound services such as housing and employment, as well as treating clients’ illness and getting them on board with treatment. ACTs also sometimes use supportive housing programs.

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