RAR Final Paper Ankur.shukla

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    Mental Health: A CivilRight?

    H a r v a r d K e n n e d y S c h o o lP r o f e s s o r E l a i n e K a m a r c k

    R e a d i n g a n d R e s e a r c h P e r i o d

    C e l l : 7 7 5 - 5 2 7 - 9 3 9 8

    9 / 3 0 / 2 0 1 1

    Ankur ShuklaThe public mental health system in the US is inshambles. A generation of de-institutionalizationwiped out decrepit asylums, but never substitutedbetter alternatives. Severe mental illnesses causehundreds of billions in economic loss and shattermillions of lives in America every year. In thiscontext, this paper recommends policy solutions andguidance for decision makers.

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    Table of Contents

    Table of Contents .................................................................................................................2Introduction .......................................................................................................................... 2

    Introduction

    A woman with bipolar disorder was found starved to death in New Hampshire after she

    was released from a public mental hospital. (Treatment Advocacy Center 9)

    A schizophrenic man in Massachusetts brutally killed a caretaker in a group home this

    year. He had a history of violence and seemed to reach a semblance of normality when given treatment (usually only while in prison). However, his care never remained

    constant, and he was lost to the voices in his head. Before the age of nineteen, before his

    schizophrenic episodes started, he lived a normal life. He played football in high school.

    He sang in the choir. He was known to be a dapper dresser. Even after his episodesstarted, he became well enough at one point to have ambitions to go to college. His life

    and the life of his victim were destroyed. The lives of several loved ones would never be

    the same.

    Greg Ridges lived in a New York adult home for the mentally ill. Ridges roommate, ErikChapman, threatened to kill him multiple times, and often wandered the halls with a

    knife. The facilitys administration never responded to Ridges requests to be moved to

    another room. One day, after returning from his job as a janitor, Ridges was stabbed

    twenty times in the neck, sternum and arm by Chapman. Ridges mother contacted the facility, Park Manor, worried after not receiving her sons nightly call. A worker

    informed her that her son had been killed.

    These stories are just samples of countless lives affected, ruined and destroyed by severe

    mental illness (SMI). Mental illness is the leading cause of disability in America Despite

    this medical urgency there is serious lack of awareness surrounding mental illness. It is

    not uncommon for an individual with a mental illness to needlessly suffer for years

    before they are diagnosed. The McArthur foundation is working to train primary care

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    physicians to better understand and treat depression the common cold of mental

    illness implying that even medical doctors have a hard time identifying diseases of the

    mind. Indeed, many people with mental illnesses simply suffer without knowing what is

    wrong with them. To add insult to injury, often people with mental illness do not seek

    treatment due to the stigma attached to mental disorders. In our culture, if a person were

    to have heart disease or diabetes, one would not expect a sense of guilt, shame or stigma

    as part of the experience. However, shame, guilt and stigma are very much associated

    with mental illnesses. Mental illnesses seem to be associated with ones character, will

    power or personality in the public eye.

    In this context of suffering, there is the public mental health system. Ideally, such

    a system would provide access to all those who cannot afford treatment. Unfortunately,

    the public mental health system in America is broken. This paper is an attempt to

    describe and analyze parts of the mental health system in the US, specifically in Nevada

    and Massachusetts. Along with the analysis, I try to recommend policy solutions to

    existing problems. However, it is important to recognize the problems and predicaments

    of public mental health are long-standing. Generations of policy makers have tried (and

    failed) to fix them over the years. A study of this size can only venture to describe parts

    of the problem, and propose specific solutions.

    Some facts paint a picture of the problem:

    1) There are three times as many people with bipolar disorder and schizophrenia in

    jails, prisons and homeless, than there are in public mental hospitals.

    2) The largest mental illness treatment facility in the US is not a public mental

    hospital it is Rikers Island prison in New York.

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    3) In the state of Nevada, a person with a mental illness is ten times more likely to be

    taken to jail if they come into contact with the law (due to their mental illness)

    than they are to be taken to a public mental hospital. There simply are not enough

    public mental health facilities for the police to take patients to.

    The current scenario is the result of a long series of events involving policies towards and

    conceptions of the mentally ill. This paper will examine the phenomena of de-

    institutionalization, as its ramifications are still relevant to the mentally ill today. In

    many ways, de-institutionalization was a well intentioned. It attempted to move the

    mentally ill and disabled from decrepit and expensive public institutions to more cost

    effective and compassionate community health centers. Unfortunately, the policy utterly

    failed to help the mentally ill.

    De-institutionalizations effects are heavily felt in a state like Nevada in which

    there are very few community resources for those suffering with SMI. The Nevada

    Department of Corrections is the largest provider of mental health services in the state.

    For ex-convicts who have SMI (and whose illness was a factor in their arrest) there are no

    facilities to provide them care or to help them adjust to society after release. The lack of

    public mental health institutions is a reason that many of these inmates end up in the

    criminal justice system to begin with. Fortunately, mental health courts have started in

    Nevada. This program diverts the mentally ill from jail and prison. The services it

    provides health care, housing and vocational training resemble what community

    health centers were envisioned to be. It is a program with low recidivism rates.

    Unfortunately, it is at risk for getting its funding cut due to the financial crisis. (8

    Palermo,G.B.)

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    Whats needed in Nevada however is access to mental health care. Nevada has

    the second highest suicide rate in the nation. Professionals working in the field say the

    problem is lack of access to care. Overburdened counselors and psychiatrists are not able

    to provide the level of care needed. Nevada used to get a failing grade by the National

    Alliance on Mental Illness (NAMI) a respected advocacy organization for the mentally

    ill for its mental health situation. The rating has since risen, but at a grade of D it is

    still not inspiring. Professionals in the field say that getting treatment at a public mental

    health hospital is difficult to do, unless a patient is clearly suicidal. This makes recovery

    a serious problem, as it can take months and even years to bring a seriously mentally ill

    person back up to full health and productivity.

    Massachusetts is significantly better off than Nevada in terms of public mental

    health. The public mental health system in Massachusetts gets a B from NAMI.

    Within the Boston/Cambridge/Somerville area access seems to be reasonable. However,

    experts in the field point out deficiencies in the field and in the system. Psychiatric

    services are not re-reimbursed enough by Medicare and Medicaid to cover costs. Often

    the psychiatric department of a hospital does not make enough money to support itself,

    and needs funds from other departments to meet its costs. Psychiatry is one two lowest

    paying medical specialties (pediatrics being the other). The result is that psychiatry has

    the greatest shortage of physicians of any medical field, making care even scarcer.

    This situation invokes the question, is mental health a civil right? Is it ethical to

    leave a person who is disabled by mental illness suffering? Is it possible for a person to

    enjoy the right to pursue life, liberty, and happiness if they have a genetic disease that can

    jeopardize all of these? A person with a serious mental illness has a clear disadvantage in

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    life when compared to a person that does not suffer from a mental illness. Mental illness

    can destroy a career, end relationships, impact physical health, and simply eliminate the

    ability to live a satisfactory life. What can and should society do to alleviate this

    situation? We explore that question.

    History of De-institutionalization and Mental Illness

    To better understand the state of public mental health today, it is important to

    understand how American society has historically managed the care of its mentally ill

    citizens. According to the National Institute of Mental Health, mental illnesses such as

    schizophrenia, bipolar disorder, and depression are caused by a combination of genetic,

    environmental, behavioral and psychological factors. (26 National Institute of Mental

    Health 2011) Thus we can safely presume that they have been around as long has

    humankind has. Different cultures have managed the mentally ill in different ways.

    Community mental health treatment can be traced back as early as 400BC in China. In

    rural communities, mentally ill people who did not cause too much of a disturbance were

    often tolerated. They were left to wander around, if they were homeless. Or often they

    simply stayed with their families, and this has continued to be the case in some countries,

    such as India. If they became a nuisance, they were often driven out of the community. (1

    Kemp,Donna R., 1945- 2007)

    The moral treatment movement arose in Europe in the nineteenth century and its

    objective was to treat the mentally ill humanely so as to help them heal. Ironically, this

    movement produced asylums, which were the antithesis of the moral movements

    objective. Asylums were often known for decrepit living conditions, overcrowding, lack

    of hygiene, neglect and even abuse of patients. In the 1920s and 30s, community health

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    centers, providing mental health care closer to a patients home, started coming up. Later,

    in the 1950s and 60s, the idea of de-institutionalization arose. Community services

    started coming up and costs were similar to hospitalization. But these new services did

    not live up to expectations. De-institutionalization is an international, but western

    phenomena. In recent years, there has been a shift to re-institutionalization, re-building

    hospitals. This may prove to be a problem because institutions are expensive. Patients in

    institutions may lack autonomy. The quality of care can vary from something that looks

    like a madhouse to a golden cage that is nice but makes patients dependant. Even these

    new institutions do not provide care on research-based evidence. (17 Fakhoury,W.)

    De-institutionalization has two key definitions. The first is that de-institutionalization

    is the process of de-populating mental institutions those housing the mentally ill, as

    well as the mentally disabled (mental disabilities include mental retardation, acquired

    brain injuries and neurodegenerative diseases among others). De-institutionalization

    occurred through three processes: 1) releasing patients in mental institutions, 2)

    shortening the length of stays in mental institutions, and 3) reducing the number of first

    admissions and readmissions. The second definition of de-institutionalization is to

    reduce custodial care with truly re-habilitating care. Custodial care refers to institutional

    processes that create dependency, hopelessness, learned hopelessness, and other

    maladaptive behaviors.

    De-institutionalization was brought about by six main forces:

    1) Criticism of the way public mental hospitals were run.

    2) Advent of psychotropic drugs to manage the symptoms of mental illness.

    3) President Kennedys support of policy changes in the treatment of the mentally ill

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    and retarded (Kennedys sister suffered from mental retardation).

    4) The 1963 Community Mental Health Centers Act making the shift to community

    based care for the mentally ill possible.

    5) Shift in public opinion and advocacy for the mentally disabled.

    6) States wanted to reduce the growing expense of operating mental hospitals and

    seized the opportunity brought on by de-institutionalization.

    The impact of de-institutionalization was significant. The resident population in state and

    county psychiatric hospital plummeted from 512,501 in 1950 to a mere 56,424 in 1997!

    This is even more astonishing when we take into account that the US general population

    grew from a little over 150 million in 1950 to over 266 million in 1997 and the

    occurrence of mental illness and disability remains constant as a percentage of population

    (for example, bipolar disorder generally occurs in 1% of the population). This means

    there were approximately 2.66 million Americans with bipolar disorder alone in 1997, far

    outstripping the patient population (and probably capacity) in public mental health

    hospitals. (27 Stroman,Duane F. 2003) In fact, even if 1% of Americans with bipolar

    disorder, approximately twenty-seven thousand people, needed to be institutionalized at

    any point in 1997, these numbers would indicate that the public mental health system

    might have been overwhelmed and that is just one mental illness.

    As institutions were shut down, people were released without adequate support.

    At first, the less seriously ill who understood their illnesses well enough and were able to

    take well enough care of themselves were released. Often these people still had the

    family and social connections to help them adjust back to the community. Then, the

    more seriously ill, those who had not gotten their illness under control, and may even

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    have lost important ties to friends and family due to their illness, were released. These

    people had far less capacity for taking care of themselves. Many ended up homeless, in

    prison, or dead. This is a continued effect of de-institutionalization. (28 Levine, Murray,

    1928- 1981)

    Much of the modern history of de-institutionalization and mental health in

    America has been determined by Presidents. It started with Kennedy his zeal for the

    plight of the mentally ill was fueled by personal family experience. Kennedys approach

    was to establish independent community centers offering a full range of services for the

    mentally ill. This work was embodied in the Community Mental Health Centers Act

    perhaps the most ambitious legislation on mental health service development. The

    centers that were created however were criticized for not being able to serve the seriously

    mentally ill, and only being able to handle the less severe patients.

    In 1977, Jimmy Carter set up the Presidents Commission on Mental Health to

    investigate the nations mental health system and make recommendations for legislation.

    He assigned his wife Roslyn Carter as honorary chairperson. The first lady had promoted

    community mental health centers while her husband was governor of Georgia. The

    Presidents Commission recommended the community centers provide only the services

    needed. It recommended integrating medical and mental health services, and providing

    more funds for mental health services. Finally, a focus needed to be placed on the needs

    of the underserved: children, the elderly, and people in rural areas. The result of the

    recommendations was the Mental Health Systems Act of 1980 which provided more

    federal funds for the development of community mental health programs. The programs

    honed in on children and youth, the elderly, the chronically mentally ill, and rural and

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    minority populations. The law also protected the rights of mental patients. There was no

    time for the law to be implemented however.

    In 1981, Ronald Reagan rescinded much of the Mental Health Systems Act with

    the Omnibus Budget Reconciliation Act. This did not come as a surprise however, as

    Governor Reagan has pushed de-institutionalization in California; Reagan now pushed

    de-institutionalization on a national level. Federal funds to community mental health

    programs were cut. The public mental health system did not recover from that blow. As

    statistics in this paper have already shown, fewer than 60,000 patients were being

    hospitalized in psychiatric hospitals in 1997.

    Presidents following Reagan did not take actions nearly as sweeping, or nearly as

    damaging, in public mental health. Clinton talked about how no American should have

    to fear mental illness in his 1999 State of the Union address. Clinton would later work to

    establish health insurance parity between mental health and medical health coverage with

    the 1996 Mental Health Parity Act. In the 1997 Balanced Budget Act, Clinton worked to

    include $24 billion to provide health coverage with a strong mental health component to

    millions of uninsured children. Bush also worked to improve public mental health he

    established the New Freedom Commission on Mental Health in 2002. The Commission

    found that mental disorders often go undiagnosed, and recommended that schools screen

    pre-school children for mental health conditions. Bush would instruct twenty-five

    agencies to implement the recommendations of the Commission.

    Due to de-institutionalization, the psychiatric inpatient population has declined

    precipitously over the last generation. Estimates differ. According to Mechanic and

    Rochefort in 1955, the patient population in US public mental health hospitals was

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    559,000. In 1990, the population was 110,000. The community centers meant to replace

    the hospitals never materialized. In turn, the most severely ill either ended up on the

    streets or in the criminal justice system. (6 Mechanic, David) A state like Nevada

    particularly suffers from the aftermath of de-institutionalization if a mentally ill person

    in Nevada comes into contact with the law, there simply are not many places for them to

    go besides jail. The problems resulting from de-institutionalization have led to talk about

    initiating re-institutionalization in some circles. In fact, Fakhoury and Priebe (Fakhoury

    and Priebe 313-316) discuss the very fact that there is an international move towards re-

    institutionalization. Mechanic and Rochefort warn against the impulse between de-

    institutionalization and re-institutionalization. First off, after a generation of de-

    institutionalization, re-institutionalization would be prohibitively expensive. Second,

    such a knee-jerk reaction would miss the point that serving the full range of mental

    illness likely requires complementary work between hospitals and community

    organizations. (6 Mechanic, David )

    In any case, the negative effects of de-institutionalization are hard to deny. Yoon and

    Bruckner found that a reduction in public psychiatric beds led to an increase in the

    suicide rates. There was no evidence that increasing not-for-profit or for-profit beds

    compensated for the reduction in public sector beds. However, increased community

    mental health funding may alleviate the effects of decreasing public psychiatric beds,

    according to this study. The authors conclude that further reduction of public psychiatric

    beds will lead to more suicides. (14 Yoon, Jangho)

    De-institutionalization may have been well intended. In deed, giving the mentally ill

    better options than decrepit and confining hospitals makes all the sense in the world.

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    However, de-institutionalization has been poorly implemented. In the American case,

    when Kennedy proposed de-institutionalization, he meant for failing mental institutions

    to be replaced by compassionate mental health facilities in the community. He likely

    imagined facilities where he would feel comfortable sending his disabled sister.

    However, while asylums were closed down, the states never made good use of the funds

    to build community centers. (10 Accordino, MP )

    Overall Picture Systemic Failures and Why They Happen

    Mental illness creates suffering in many ways. One such way is through stigma.

    Unlike many other diseases (diabetes or heart disease for example), those with mental

    illnesses face significant stigma. A study found that people would rather prefer that a

    prison, garbage landfills or homes for AIDS patients be built in their neighborhoods

    rather than mental health facilities. Stigma can lead to inappropriate treatment of the

    mentally ill, unemployment, homelessness, and even resistance to getting treatment. The

    mind is the seat of our being. Unique from other bodily organs, it is identified with ones

    fundamental personality and character. Understandably, admitting that one has a mental

    disorder can be traumatic. One way to counter the stigma is to spread awareness of the

    very real nature of mental illness as well as of the fact that mental illnesses are responsive

    to appropriate treatment. This is the approach the National Alliance on Mental illness

    advocates on its website.

    The personal pain and suffering that goes with any disease is likely expected by most.

    What may be news to many is that mental illness can also be a significant factor in

    homelessness. Individuals with co-occurring mental and addictive (substance abuse)

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    disorders are the most likely to be in the homeless population. An estimated 50-60

    percent of homeless individuals have co-occurring mental and addictive disorders.

    The mentally ill have always faced incarceration. However, the number of mentally

    ill in jails and prisons increased sharply after the passage of the Mental Retardation

    Facilities and Community Mental Health Centers Act of 1963 (passed by John F.

    Kennedy). This act lead to significant de-institutionalization many states closed

    psychiatric hospitals, but never built the community health centers to take care of the

    newly released patients. These patients end up in the criminal justice system, and it is

    estimated that the cost arising from mental illness related crime, criminal justice costs and

    property loss is about $6 billion a year. A study by Pacific Research Institute for Public

    Policy found that governments spend far more in dealing with the mentally ill in the

    criminal justice system than they would if they were to simply build a mental health care

    system that could handle them. This is tragic and ironic at the same time, as two of the

    intents behind the de-institutionalization movement were to reduce cost to society from

    expensive mental institutions and to provide more hospitable care to the mentally ill.

    Instead, many patients face the worst fates possible homelessness, imprisonment and

    even death, as studies have found and society pays more.

    The gravity of the situation that mentally ill Americans are in is better understood

    with the following facts. There are approximately four-and-half times more people with

    mental illnesses in jails and prisons than in public mental hospitals. More than twice as

    many people with bipolar disorder and schizophrenia live on the streets or homeless

    shelters as there are in public psychiatric hospitals. More people with bipolar disorder

    and schizophrenia reside in jails and prisons than in public psychiatric hospitals. The

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    largest public mental health facility in America is not a hospital it is Rikers prison in

    New York. Without proper treatment, people with serious mental illnesses can exhibit

    increased violence. (1 Kemp, Donna R., 1945- 2007)

    Mental illnesses are diseases that, if not covered and treated, could lead to

    consequences such as productivity loss (at best) with the lesser effects of illnesses such as

    attention deficit hyperactivity disorder (ADHD can also cause serious problems with

    employment and in relationships) and even death and criminal behavior in the cases of

    serious mental illnesses such as schizophrenia, bipolar disorder and major depression.

    The cost of not treating these illnesses would be higher than the cost of treating them.

    Not just medical costs, but also human costs. (29 Kelly, Timothy A. 2009)

    According to Jonathan Burns, the rights of the mentally disabled need to be discussed

    in terms of human rights. Furthermore, the mentally disabled should be at the center of

    any such advocacy according to the author. This same argument can be extended to the

    mentally ill, in that they should be at the center of any advocacy, and that their rights are

    human rights. (30 Burns, Jonathan Kenneth 2009) Those who battle mental illness have

    the right to be able to live a normal life to have access to a normal life. I am not

    advocating for giving the mentally ill a leg up rather, they need medical help and access

    to mental health care simply to be on a level playing field with everyone else. People

    with mental illnesses needlessly end up in prisons and on the streets. They also roam the

    halls of the finest universities in the world. In the latter group, students with mental

    illnesses need mental health support to be able to function normally and live up to their

    potential. Without treatment, it is quite possible to endure significant failure. Similarly,

    all citizens suffering from mental illnesses need support.

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    There are some serious problems in the public mental health system in America.

    According to the Treatment Advocacy Center, the United States has a shortage of almost

    100,000 psychiatric beds. (4 Treatment Advocacy Center 2008) However, Dr. Kenneth

    Duckworth, the medical director of the National Alliance on Mental Illness, stated in a

    phone interview that there really is no broad consensus on the exact number of beds that

    are needed. Currently, after the effects of de-institutionalization, there simply are not

    enough beds. Aside from the human cost in pain and suffering, serious mental illness

    also costs Americans and estimated $193 billion annually. Individuals with serious

    mental illnesses earn a staggering forty percent less than average. That is a frightening

    statistic an individual, simply because he or she have a few undesirable genes in their

    DNA, may have his or her economic potential nearly halved when compared to someone

    who is a peer in terms of simple ability or background. Persons with SMI had no choice

    in getting these conditions they were born with them. In addition to suffering mental,

    physical and emotional pain from the disorders, they will also suffer in material and

    economic terms. It is easy to imagine that the medical concerns may exacerbate the

    financial concerns, or vice versa, and perhaps even create a vicious downward spiral. (4

    Treatment Advocacy Center 2008)

    The current mental health situation in the US is that on any given day, 2 million

    Americans suffer from severe mental illness (SMI). Five percent of all homicides every

    year can be attributed to SMI, and over 5000 people lose their lives every year to suicide.

    In any give year, 22% of American adults suffer from a mental disorder (not necessarily a

    severe mental illness). Unipolar (as opposed to bipolar) major depression is second only

    to ischemic heart disease as a source of disease burden in developed economies (as of

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    1990). 98.7 million people in developed economies suffer from mental illnesses. (1

    Kemp, Donna R., 1945- 2007)

    According to a 2008 Treatment Advocacy Center (TAC) study, in 1955 there were

    340 public psychiatric beds available per 100,000 citizens in America. By 2005 there

    were only 17 beds per 100,000. According to a TAC panel of experts, the minimum

    number of public psychiatric beds needed per 100,000 population is 50. The only state to

    meet that minimum is Mississippi - and it only just meets it with 49 beds per 100,000

    population. The situation in Massachusetts is rated as Severe (12-19 beds per 100,000

    citizens), and in Nevada it is Critical (

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    According to the Office of Suicide Prevention Suicide in Nevada Fact Sheet (2007)

    Nevada has the second highest suicide rate in the nation at 19.2/100,000 (second only to

    Alaska). Nevada seniors over 60 have the highest suicide rate in the nation. More

    Nevadans lose their lives to suicide than to homicide, HIV/AIDS or automobile

    accidents. When interviewed, a former mental health access professional in Nevada,

    Casey Gilham, said that the issue of suicide Nevada was primarily due to lack of access

    to mental health care, particularly in rural Nevada. According to the Treatment Advocacy

    Center, Nevada incarcerates ten times as many people with mental illnesses as it

    hospitalizes in its public hospitals. (Treatment Advocacy Center 1)

    Nevada is perhaps the classic example of a state that was not ready for the

    negative consequences of de-institutionalization. According to experts in the state it

    simply did not have the institutions in place to take care of people released from hospitals

    and it still does not. The mental health system in Nevada has been the victim of

    successive and deep cuts since 2008. Even while visiting and interacting with various

    departments in the Nevada mental health system, one gets a sense that the system is

    budget constrained. Professionals in the system feel that they could provide more

    services if they had the funds. However, as NAMI finds, the mental health system failed

    to serve Nevadans long before the great recession induced cuts. (National Alliance on

    Mental Illness) In my high school days (1995-1999) I remember a teacher talking about

    how Nevada had one of the highest suicide rates in the nation.

    Nevadans do however deserve some credit for attempting to fix the problems and

    for trying new things. An innovation in Nevada is the mental health court system, a

    diversion from jail. Defendants who commit misdemeanors or felonies are given a

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    choice: go to jail, or accept a year of treatment in which their housing and medical care

    will be taken care of. The program seems to be a success. Participant arrest rates decline

    by 79% while they are in the program, and 91% once they graduate from the program.

    (Glee and Breen)

    There is also a sense of confusion in the Nevada mental health system. I

    contacted the University of Nevada, Reno, which is the states flagship university. It is

    also home to the states primary medical school, and to a school of public health and a

    psychology department. I could not find one academic who was intimately familiar with

    the public mental health situation in Nevada. The department of psychiatry directed me

    to an academic they said was the most familiar with the field. That person himself

    admitted that he really only had opinions, and not data backed insight. He then directed

    me to the Nevada Division of Mental Health and Developmental Services (MHDS).

    However, he cautioned that he would be surprised if MHDS had the data that the

    academics would need to answer the questions that I had presented. I was shocked. It

    almost seemed like no one in Nevada had a comprehensive picture of the mental health

    situation in the state. In deed, when I contacted MHDS, the current director was getting

    ready to retire in two months. The executive assistant to the director told me that

    currently she and one other executive assistant were the most knowledgeable sources of

    information in the department, and that they were handling all of the responsibilities of

    the director.

    Finally, I visited the joint facility of Northern Nevada Adult Mental Health

    Services (NNAMHS - the public psychiatric hospital in northern Nevada), the mental

    health court, and the forensic hospital. I contacted the Interim Agency Director, Allan

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    Mandell, of this joint facility (he had just started his job a few days ago). In email

    exchanges the Interim Director indicated that he was unable to answer questions such as

    What is the public mental health situation in Nevada? because he felt they were too

    broad and unanswerable. He was unwilling to answer any of the other questions emailed

    to him. One can always prepare better interview questions, but Dr. Mandell is one of a

    handful of key public mental health leaders in Nevada and has a PhD. The idea that he

    could not give a general answer to whats mental health like in Nevada? or simply

    answer the questions he did feel comfortable answering, seems uncooperative at best.

    Fortunately, he does preside over a good system. The good thing for patients is that

    NNAMHS takes Medicare and Medicaid. The wait time for an initial evaluation seems

    to be as low as a week, after which doctors can recommend how the patients treatments

    should proceed (of course, staff said that demand for services can fluctuate). NNAMHS

    seems to be a fully functional mental health facility. The mental health court is showing

    excellent results, and the forensic hospital is serving the needs of the state.

    Remarkably, the Nevada Department of Corrections seems to be doing well in its

    mandate to provide mental health services to its inmates. In fact, when I visited the

    Washoe County Jail (Reno, Nevada) I noticed a trophy by NAMI recognizing the jail as

    the agency of the year in 2006 (remember, that 2006 was also the same year that NAMI

    gave a grade of D to the entire public mental health system of Nevada). The Nevada

    Department of Corrections has a prison in Carson City. The Departments Medical

    Divisions mission is given on the website as (Nevada Department of Corrections):

    To provide quality, constitutionally mandated health care, using an efficient system of managed care, that

    is professional, humane and appropriate, and in support of the mission of the Nevada Department of

    Corrections.

    The State has a moral and legal obligation to provide health care for those people whom it incarcerates. The

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    Federal Courts have mandated that inmates, though incarcerated, remain entitled to basic medical care.

    This mandated health care includes mental health care.

    I interviewed Dr. Robert Schofield, PhD, Psychologist 3 at the Nevada

    Department of Corrections prison facility in Carson City, Nevada. The prison is a full

    services mental health facility. It even has a 54-bed inpatient hospital, and Schofield

    claims that his staff is good at identifying and treating mental illnesses. Schofield said

    that about 16% of the inmates in prison suffered from mental illness, and he estimated

    that of the patients with mental illness, for 75% of them, their mental illness may have

    played a role in their incarceration. All Nevada bureaucracies have faced budget cuts due

    to the great recession the Nevada Department of Corrections is no different. However,

    according to Schofield, this has not lead to any changes in the quality of mental health

    services delivered at the prison a remarkable outcome! The budget cuts were absorbed

    as salary cuts for all prison staff across the board hence, programs at the facility were

    not affected.

    Not surprisingly, Schofield feels that the Nevada Department of Corrections is

    already doing a good job in terms of providing mental health services. Where he sees

    need for improvement is in services available to inmates outside of the prison system

    both before and after their incarceration. There are not sufficient public mental health

    services available to the mentally ill in the community - especially in rural communities

    Schofield feels there simply is not access. Schofield would like to see improvement in

    the area of taking care of people once they are released. There are very few resources in

    the community to assist with that thats the external problem symptoms come back

    and ex-prisoners get in trouble and end up in prison again. Schofield thinks there need to

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    be more resources in the community in general to take care of this problem community

    mental health centers, public psychiatric hospitals, rehabilitation centers, vocational

    training services, etc. Schofield feels that there simply needs to be an across the board

    improvement in the system external to the correctional department (i.e., mental health

    courts, public mental hospitals, views of public officials and society towards the mentally

    ill, etc.) so that fewer people end up in prison due to mental illness.

    The key challenges Schofield foresees the Nevada Department of Corrections

    having in the future in terms of mental health provision is in the area of rehabilitation.

    Therapeutic, educational, and vocational programs need to be developed. The

    Department needs to do a better job of re-habilitating prisoners and getting them ready to

    live a life in the community theres simply nothing to help them make that adjustment

    right now. Fortunately, the Nevada Department of Corrections enjoys some key

    strengths in terms of mental health provision and related issues. The Department is

    strong in identifying those with need, treating them, and taking care of emergencies. It is

    a good mental health facility overall. Schofield feels that it may be, sadly, the best

    mental health facility in the state. Everyone who needs access is given access in the

    Nevada Department of Corrections inmate population that is a lot more than can be said

    for citizens with SMI in rural Nevada, for example.

    Nevada seems to have some basic infrastructure for serving the mentally ill.

    Access is clearly an issue in rural Nevada. Budget cuts affect the services that can be

    delivered by facilities like NNAMHS. There is even some work being done with tele-

    medicine with which patients in hard to access areas can be evaluated through electronic

    means. However, the idea that the Nevada Department of Corrections is the largest

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    provider of mental health services is shocking and disappointing. Nevada clearly needs

    to invest in services outside of those legally mandated in prison to improve the public

    mental health situation in the state. Otherwise, more Nevadans will continue to lose their

    lives to suicide than homicide, Nevadans with SMI will have a likelihood of being jailed

    for mental illness related crimes, and they will have higher mortality rates than

    HIV/AIDS patients and motor vehicle accident victims.

    The Current State of Public Mental Health Massachusetts

    Massachusetts is quite different from Nevada. NAMI upgraded Massachusetts to

    a B grade in 2009 from a C grade in 2006. The state has a history of innovation in

    mental health care. The 2006 Health Care Reform Act is a step toward universal

    healthcare it has already helped Massachusetts achieve the lowest rate of uninsured

    (3.7%) in the country. (National Alliance on Mental Illness) Massachusetts is also home

    to two of the top three psychiatric hospitals in the nation, according to US News and

    World report: Massachusetts General Hospital and McLean Hospital. (US News and

    World Report) Leaders in the field of psychiatry have been connected to the area an

    example would be Dr. David Burns, a former lecturer at Harvard Medical School, whose

    land mark book, Feeling Good: The New Mood Therapy, is the backbone of

    psychotherapy practice at the leading psychiatric hospitals. (Burns 706)

    Massachusetts is also home to the Cambridge Health Alliance (CHA) which is

    recognized for having made its footprint in mental health and for providing services to

    underserved populations. In fact, if a person is on the public health insurance created by

    the 2006 Health Care Reform Act, Mass Health (because they have no other source of

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    insurance), they can get quality service at CHA (Mass Health is also known as

    Commonwealth Care). These services range from talk therapy, psychiatric consultations,

    prescription medications, group therapy, and skills based therapy (such as cognitive

    behavioral therapy), psychiatric hospitalization and so on. CHA is a Harvard affiliated

    teaching hospital. (Cambridge Health Alliance)

    This not to say the Massachusetts model is right for the entire country.

    Massachusetts also has the unfortunate distinction of having the most expensive health

    care per capita in the world. This is largely because Massachusetts relies on expensive

    teaching hospitals. From a pure fiscal perspective, this model is prohibitive for national

    expansion. The vast majority of America, particularly rural America, does not have

    access to teaching hospitals. And so a model will need to be developed that is both

    accessible and less expensive. Fortunately, this is perhaps more possible today than at

    any other time in history. Psychiatric consultations and evaluations can be done visually

    and through interviews. Several skills courses such as cognitive behavioral therapy could

    be administered this way, too. It is imaginable that a psychiatrist could regularly see a

    patient through Skype or other forms of video monitoring. In fact, telemedicine is

    already used in Nevada, and independent psychiatrists and psychologists are already

    using Skype in their practice. (Government of Massachusetts) Of course, if telemedicine

    is already used in Nevada, it needs to be explored why it has thus far been unable to

    resolve the issue of access in mental health care. More acute care would have to be done

    in a hospital setting maybe even a setting that is semi-confined for the patients safety.

    That said, this does not shut out the possibility of some aspect of care being supported by

    technology.

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    According to mental health professionals, there are deeper structural problems.

    Psychiatry, particularly child psychiatry, has the highest shortage of physicians.

    According to Dr. Marshall Forstein, Associate Professor or Psychiatry at Harvard

    Medical School, compensation has a lot to do with the shortage. Psychiatry is one of the

    two lowest paying specialties in medicine, along with pediatrics. Forstein told me a story

    of a woman who went to a state medical school, is now doing a psychiatry residency, and

    expects that it will take her thirty years to pay back her loans. Conversely, a surgeon can

    often expect to pay back his or her loans in as little as five years. Part of the reason that

    psychiatry is such a low paying medical profession is because the reimbursements from

    benefits programs for services are so low. Mental health benefits have never paid for the

    cost of the service, according to Forstein, unlike cardiovascular disease or diabetes.

    These reimbursement levels are set by Medicare and Medicaid these programs do not

    pay for the full cost of psychiatric services, and private benefits programs follow their

    lead. Recent parity legislation has gotten Medicare and Medicaid to cover 80% of mental

    health services, as they do other services. However, in the case of other illnesses,

    diabetes or heart disease for example, patients often have supplemental insurance to

    cover the remaining 20%. Patients with mental health problems are often on disability

    incomes and cannot afford supplemental insurance, or afford to pay out of pocket. Too

    often, people simply do not come to treatment because they cannot afford it. Payments

    for services need to be income adjusted so that people who are currently unable to get

    care are able to access services. This is already being done successfully with the

    Massachusetts public insurance plan, Mass Health.

    Even in a state like Massachusetts that is far wealthier than a state like Nevada,

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    and has some of the best medical care in the world, mental health is a problem. Whereas

    in Nevada the problem is of access, the problems in Massachusetts are more of being able

    to attract talent into the field of psychiatry. It is a problem of getting mental health to

    cover its own costs. It is a problem at the policy level of ensuring that those who set the

    rates for Medicare and Medicaid value psychiatry on greater par with the other

    specialties.

    Policy Recommendations

    The political reality is that Congress is trying to cut once sacred programs like social

    security. New mental health funding is hard to imagine. However, this paper will

    attempt to identify new potential funding streams, mental health models to replicate,

    policies to hold Washington accountable for, possible areas for public-private

    partnerships, changes to Medicaid and Medicare re-imbursement policy, and changes in

    medical education policy. Finally, this paper will review evidence based literature for

    policy direction as to what to fund as the economy recovers and it becomes more feasible

    to fund mental health care.

    The first thing that a mental health advocate must emphasize is that we are looking to

    save the country money, not spend new money. Studies have shown that it is more cost

    effective to treat the mentally ill rather than to not treat them. Currently, SMI cost the

    country about $200 billion per year in lost earnings and in SMI related costs to the

    criminal justice system. We can save money by increasing access to care productivity

    will be increased, cost to the criminal justice system will be reduced, and hospitals and

    emergency rooms will have reduced burden from patients who cannot pay for care. At a

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    tax rate of 25%, approximately $50 billion in revenue can be generated from the above

    indicated savings. And this does not even factor in the social value creation from reduced

    pain and suffering for patients and their families.

    Right now, mental health care is being provided to patients who cannot afford it in

    Massachusetts. A state government program called Commonwealth Care (also known as

    Mass Health) provides health insurance which includes mental health and substance

    abuse benefits. (Government of Massachusetts) Fees for Commonwealth Care are income

    adjusted, and so those unable to work due to illness are not charged for the insurance

    coverage. Commonwealth care has been recognized as a model of innovation in

    governance by the Ash Center for Democratic Governance and Innovation at the Harvard

    Kennedy School. The Patient Protection and Affordable Care Act of 2010 covers mental

    health and substance abuse. Advocates will need to hold the federal government

    accountable to ensuring that mental health is covered in any universal coverage plan.

    In states such as Nevada where a high number of mentally ill end up in prison,

    rehabilitation programs should also be looked into. Arizona (where those with severe

    mental illnesses are only slightly less likely to end up in prison than they are in Nevada)

    has started an award winning program that trains inmates for life outside of prison

    (including vocational training) so they dont end up back in prison. This is another

    program that should be looked at as it could help people with SMI. (Office of Justice

    Programs) This program has also been recognized by the Ash Center at Harvard.

    Mental illness is a bipartisan issue. On its official website the GOP claims to want to

    increase quality care advocates would need to push them to see what that means in

    terms of mental health. (Republican Party) Mental health has become a bipartisan issue

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    over the years. Both Clinton and the second George Bush advanced the cause of mental

    health parity. Senator Pete Domenici, perhaps the most committed elected advocate for

    mental healthcare, is Republican.

    Psychiatric services are not reimbursed at the cost of the service. A psychiatric

    department in a hospital is often funded by one of the other departments so that it can

    balance its budget. Psychiatry is one of the two lowest paying medical specialties but

    physicians who enter psychiatry carry the same student debt burden. Is it any surprise

    that psychiatry has the greatest shortage of any medical specialty? As a policy we need

    to start valuing psychiatry more. One way to do this is to increase the

    Medicare/Medicaid re-imbursement rates to psychiatry. This would not increase costs to

    tax payers because all specialties are paid from one pool of money. The money is

    divided up by a group of twenty-nine physicians who make up the Specialty Society

    Relative Value Scale Update Committee. These doctors decide how much the fund will

    pay for the services of each specialty. (Mathews, A. W., McGinty, T) Some how this

    panel needs to be persuaded to value psychiatric services more one way may be to get

    more psychiatrists on the Committee. Cost of services should at least be met, and ideally

    enough to draw more and the best talent into the field. Another way to tackle the extreme

    shortage of psychiatrists would be to reduce the debt burden of students who chose

    psychiatry. Medical schools could offer reduced tuition to these students. To mitigate

    the costs, they could charge students who go into higher paying specialties a higher

    tuition, since they will be getting a higher monetary return on their investment. Top

    schools in other professions currently subsidize students who go into public service

    careers. Psychiatry can and should be considered a public service profession.

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    So far we have covered ideas that can be applied right away. However, the mental

    health access problem will not be fixed in a year and this paper does not pretend to have a

    quick fix. What can be done is to point out the direction in which mental health policy

    should go based on evidence. Investments will need to be made over time to provide

    access to all those who need it. The political climate may be hostile to such investments

    today. However, we must remember the work of Pete Domenici and Paul Wellstone on

    mental health parity legislation, and how it came about over years. From the political

    history of federal mental health and addiction insurance parity, we can learn important

    lessons. Specifically, there were three factors that lead to the passage of the 2011 Mental

    Health Parity Act. Evidence showed that parity would not cost significantly more than

    not having parity between mental and physical health benefits. Members of congress

    who led the fight for parity had personal experience with mental illness and addiction.

    Finally, the congressional champions of parity adopted particular political strategies, such

    as attaching the parity law to the larger, Troubled Assets Relief Program, making it easier

    to pass. (Barry et al. 404-433) These factors are instructive in the larger fight to provide

    access to good quality public mental health, and to transform the perception of mental

    health as a civil right in this country. Of course, a law the magnitude of TARP does not

    come along every day. However, according to Dr. Forstein, there is sufficient literature

    to show that it is more cost effective to provide mental health care than to deal with the

    costs of not providing it. This paper has already identified sources that reinforce Dr.

    Forsteins assertion. It is estimated that a quarter of Americans experience mental illness

    at some point in their lives hence, statistically speaking it is probable that members of

    Congress or their loved ones have experienced a mental illness or even an SMI.

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    Persuading even a handful of Congressional champions of the fiscal and moral imperative

    of providing mental health care may pave the way for a future when mental health is seen

    as a civil right. In addition to persistent persuasion, advocates must adopt the

    opportunism of parity champions and keep their eyes peeled for unexpected chances to

    pass a bill.

    To help those most in need and to build a compelling case, we must prioritize severe

    mental illnesses for coverage under mental health policy. Timothy Kelly prioritizes the

    following illnesses that must be covered under any parity legislation:

    1. Psychotic disorders (e.g., schizophrenia)2. Mood disorders (e.g., bipolar disorder, major depression)3. Anxiety disorders (e.g., panic disorder)4. Childhood disorders (e.g., attention deficit/hyperactivity disorders)5. Eating disorders (e.g., anorexia)6. Substance-related disorders (e.g., alcohol dependence)

    Medical care is expensive and we have to start somewhere. If these illnesses are the

    logical ones to prioritize under insurance parity, then they should also be prioritized

    under any plan ensuring mental health access. These SMI afflict approximately 6% of the

    general population. (Kelly 193)

    It is also important to think about how such care will be provided. Lapsley et. al. find

    that it is cheaper to provide mental health care in the community than in psychiatric

    hospitals. This research was done in Australia, but it is likely to be applicable to the US

    setting also. Australia is a developed nation that is western culturally (i.e., may have

    similar perceptions of mental illness), and which went through de-institutionalization

    around the same time as the US (as did many western countries). Thus, solutions that

    work in that environment should certainly at least be considered in the American

    environment. (Lapsley et al. 491-495)

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    In Australia Hobbs et. al. found that when de-institutionalization is done with

    adequate investment in community care, it can be done well. Hence, the problem is not

    that the hospitals and asylums were shut down the problem is that no other viable

    options replaced them. When the intended replacement institutions are built, outcomes

    are good. Hence, perhaps one might say that it was not the idea of de-institutionalism

    that failed. Rather, the ideal of de-institutionalization, transferring the mentally ill and

    handicapped from decrepit institutions to more compassionate and effective community

    alternatives, failed to be implemented. (Hobbs et al. 476)

    The implementation of de-institutionalism has been such a disaster that there is

    suggestion by some of starting a new movement: re-institutionalism. The idea is that we

    need more hospitals. Of course, such an approach may be prohibitively expensive, and

    the obvious challenge would be to keep these new hospitals from becoming like the old

    ones. Indeed, The New York Times reported on private mental hospitals in New York

    City in 2002. These hospitals were so bad that patients regularly committed suicide, died

    prematurely due to poor living conditions (they often lived in sweltering conditions

    without AC and their medications made them more susceptible to heat), and there was

    even a reported instance of a man murdered by his roommate (the roommate had been

    threatening murder for months). The government was completely incompetent in

    regulating the hospitals. They regularly rated the hospitals as inadequate, but then never

    held anyone accountable for fixing the problem. (Levy 1) The operative question is,

    regardless of what institutions are built, how do we solve these problems and make sure

    that the mentally ill are well cared for? From my literature review and interviews I would

    say that the key lies in building the right balance of community health centers as well as

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    hospitals and ensuring the Medicare and Medicaid reimburse services at the actual cost of

    service (at minimum). This will set the bar for other benefits programs also reimbursing

    the mental health community center services at cost, and ultimately allowing such centers

    to survive financially. (Fakhoury and Priebe 313-316)

    People who leave the hospital and go to live at community mental health facilities

    actually prefer the community. Freedom and simple liberties mean a big deal to them.

    Properly executed de-institutionalization helps people stay out of the hospital, and it and

    improves their quality of life. (Newton et al. 484)

    Most people transferred to the community did not require intensive 24-hour care at

    the 6-year follow up. These people remained stable in terms of their mental health. They

    achieved clinical stability and there was a significant reduction in medications. This

    study also found that community-based residents reported improvement in quality of life

    and preferred living in the community. (Accordino et al. 16-21)

    If we take the Brookline Community Mental Health Center as an example, its annual

    budget is $4.6 million to provide 6000 clients broad range of both psychotherapeutic and

    psycho-pharmacologic treatments. That is yearly cost of $767 per patient. If we run

    some back of the envelope calculations, we with a total US population (2011) of

    approximately 312 million, if 6% of that population suffers from an SMI, that is 18.7

    million people. Giving those citizens access to mental health care via a community

    mental health center would cost approximately $14 billion annually. If we try to cover

    the approximately 20% of Americans who statistically suffer some form of a mental

    illness every year, that cost comes out to $47 billion. These figures are mere fractions of

    the annual estimated cost of $200 billion that Americans bear from mental illness.

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    Earlier calculations show that simply the estimated tax revenue (approximately $50

    billion) from the earnings of the former SMI victims should be sufficient to cover the

    annual operating costs of these centers. The remaining fiscal gain to American society

    annually ($150 billion) can be considered as a financial source for building these centers.

    I have not calculated the cost for building these centers here. These numbers show that

    rather than seeing mental health provision as a cost, we should see it as an investment in

    our citizens and in our economy.

    Creative steps at financing the building of community centers (or even new public

    hospitals) can and should be sought. For example, the pharmaceutical industry makes

    significant profits off of mental illness medications. However, the fact that many people

    with mental illnesses go untreated means that an untapped market exists. To use a term

    from international development, these patients are essentially at the base of the pyramid.

    Profitability may be reached due to the sheer number of customers. A public-private

    partnership may prove beneficial to both the government and private companies. The

    companies could generate additional revenue by investing in community mental health

    centers. The government could save money by sharing costs to build the centers, and by

    mitigating the costs to society of SMI (reduced burden on criminal justice system, fewer

    expensive emergency room visits by those with SMI, and greater tax revenue from

    healthier citizens). A way to reduce costs for building community mental health centers

    may be to look at a land-grant model that has been used so effectively to build

    universities. A sparsely populated state like Nevada should have no trouble finding land

    to spare. On the financing front, government might consider re-directing National

    Institutes of Mental Health research dollars towards setting up of community mental

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    health centers and raising awareness about mental illness. The main problem in mental

    health does not seem to be lack of effective treatments it is lack of access and the

    stigma resulting from lack of understanding about the disease. People often do not seek

    treatment because they do not understand mental illness, and because they attach stigma

    to it. Public funding should be aimed at fixing these problems.

    Innovative steps that treat mental illnesses and save Americans money are possible.

    We as a society and policy makers in particular must realize that treating SMI is in our

    best interests.

    Conclusion

    Severe mental illness takes a significant toll on American society both financial and

    in human suffering. Over the year, policy decisions such as botched de-

    institutionalization have lead to greater agony for millions of Americans with SMI.

    Shamefully, these citizens too often hide in fear of the stigma that comes with SMI.

    Their symptoms often disable them to the point that they are unable to work and afford

    care. A downward spiral happens, and too often individuals with SMI end up on the

    streets and shelters, in jails and prisons, or dead.

    As a nation we believe that all people have the right to life, liberty and the pursuit of

    happiness. However, an SMI by its very nature limits and even prohibits the ability to be

    happy. The behavior that an SMI precipitates can land a person behind bars and thus rob

    them of liberty. In the worst cases, and SMI can lead to suicide. It is a commonly held

    value that a person in a wheelchair or someone with deaf blindness visible disabilities

    should be given the resources to be able to access as much of a normal life as possible.

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    However, people with invisible disabilities such as SMI are yet to be accorded similar

    consideration. Mental health has to be considered a civil right because without mental

    health a person cannot access other fundamental civil rights.

    If the moral case for providing universal mental health care access is not sufficient,

    we need only look to the fiscal argument for provision of care. It costs American society

    far more financially to not treat the aftermath of SMI than it would to prevent SMI.

    Mental health care is more than a fundamental right it is sound fiscal policy.

    However, on some level, these feel like superficial arguments. The mother of a

    handicapped son who has been stabbed to death because of institutional failure, does not

    care about fiscal policy. A schizophrenic whose life has been ruined because of the

    voices in his head is not thinking about civil rights. It is too late for policy innovation for

    the family of a woman who starved to death in a barn because of her bipolar disorder.

    Yet, it is not too late to save the millions of friends, family members and colleagues who

    live with SMI. These people did not choose the genetic accident that may force them on

    to the streets or destroy their careers and relationships. They did not choose the societal

    stigma and discrimination they now face. However, as a society, we can choose to ensure

    that citizens with SMI have access to a normal life and to pursuits we all want.

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