Thursday, August 22, 2013

How to Fix New York State Office of Mental Health (OMH)

Testimony of DJ Jaffe, Executive Director, Mental Illness Policy Org
to NYS Office of Mental Health  
May 3, 2013, NYC

(Note: NYS OMH is the largest agency in the state ($3 billion) and still has no director. The acting director seems intent on following the failed policies of her predecessor which moved OMH from an organization dedicated to helping the most seriously ill, to one focused on "improving the mental health of all New Yorkers." She has stated unequivocally that she wants to close state psychiatric hospitals. NYS has fewer than 4,000 beds and probably 50% of those are for people unfit to stand trial, not guilty by reason of insanity, or were convicted and are mentally ill. -ed)

Thank you. We are a non-profit think tank providing unbiased science-based information to policymakers and media on serious mental illness, and not mental health. We are the only group in New York and one of only two in the country that is focused exclusively on those the NIMH defines as “seriously” mentally ill (primarily schizophrenia, the subset of bipolar disorder classified as “severe bipolar”, the subset of major depression called ‘severe major depression’ and a few others) In order to be considered serious, these diagnosis must be diagnosable currently or within the past year and continue to result in serious functional impairment, which substantially interferes with or limits one or more major life activities in persons 17 years or older.

It is people with serious mental illness who are most likely to become homeless, incarcerated or a headline that stigmatizes the others. It is people with serious mental illness who are likely to commit suicide or become victimized.  

We have two recommendations for you:
  1. Prioritize the most seriously ill and
  2. Make greater use of Kendra’s Law, if for no other reason, than because you have to in order to comply with Olmstead.

Prioritize the most seriously ill.

Today people with serious mental illness are no longer on OMH’s radar except as a cost to be cut. Your predecessor turned OMH from an organization that treated the most seriously ill to one now focused on "improving the mental health of all New Yorkers". It satisfies those with the loudest voices, but not those with the most serious illnesses.   Today, 15,000seriously mentally ill New Yorkers are being incarcerated, largely because less than 4,000 are receiving hospital services.  There are almost three times as many in a single jail; Riker’s Island, than in all New York State psychiatric hospitals combined.  Many more are homeless. The criminal justice system is now running a shadow mental health system. In the ultimate act of hubris, OMH is now advising courts and police on how to do what it won’t do itself: help people with serious mental illness.

 OMH describes itself as a safety-net, yet forces programs like Fountain House that are willing to serve the seriously ill to raise their own funds to stay in operation.  OMH has replaced Haldol, lithium, rehabilitation, housing and hospitals with pretty powerpoint presentations, and words like ‘hope’ and ‘recovery’. It may boost morale, but it’s not helping people with serious mental illness. Mission creep at OMH is putting patients, public, and pocketbooks at-risk.

The OMH “fix” is to close more hospitals. That’s ludicrous.  While OMH has 3,000 beds for the seriously ill, well over half are occupied by forensic patients. Studies show NYS needs at least 4,000 more psychiatric hospital beds to meet the needs of the most seriously ill and that assumes New York State had the best community services. You can call kicking people out of hospitals and adult homes creating Centers of Excellence, but it’s a disaster you know is going to happen.

I know why OMH does this. Your ‘stakeholders’ represent the high functioning. The homeless psychotic, institutionalized have no champion at OMH.  And then there are the trade associations like NYAPRS. Serving people with serious mental illness could put programs they champion at risk, or require them to serve more seriously ill.

I realize what I am saying goes against the advice you are getting from those you fund. Prioritizing the seriously ill is hard work. Put a psychiatric outreach worker in a school, and you’ll be applauded. Open a group home for people with serious mental illness in the community, and they’ll be asking for your head. Require local programs to serve the seriously ill and they howl.

But the core mission of OMH should be serving the seriously mentally ill, not offloading them to shelters jails prisons and morgues because there are other things you would like to do.

Make greater use of Kendra’s Law.

Kendra's Law is New York’s most successful program for the most seriously ill. 80% of the consumers enrolled in it says it helps them get well and stay well. Kendra's Law has been shown to reduce homelessness (74%); suicide attempts (55%); substance abuse (48%); hospitalization (77%); arrests (83%); physical harm to others (47%); property destruction (46%) and incarceration (87%). It is supported by police, the public, families of the most seriously ill and 81% of individuals in Kendra's Law.

In spite of it’s success and universal support the bill had to be passed over OMH objections, improved over OMH objections, and people who need the services can’t get in because of OMH. We thank Assemblywoman Aileen Gunther and Senator Catherine Young and wish OMH would work with them rather than oppose them. At minimum, OMH should stop it’s own behind the scenes activities to oppose AOT and stop funding groups who’s mission is to oppose it.

Dr. E. Fuller Torrey estimates that more than 4,000 New Yorkers with schizophrenia who need assisted outpatient treatment are not receiving it.

 As will be seen, NYS is required to make greater use Kendra’s Law to ensure individuals with mental illness receive treatment in the most integrated setting as required by Olmstead v. LC

  “It is a common phenomenon that a patient functions well with medication, yet, because of the mental illness itself, lacks the discipline or capacity to follow the regime the medication requires.” . (Olmstead V. L. C. (98-536) 527 U.S. 581 (1999))
It must be remembered, for the person with severe mental illness who has no treatment the most dreaded of confinements can be the imprisonment inflicted by his own mind, which shuts reality out and subjects him to the torment of voices and images beyond our own powers to describe.... (Olmstead V. L. C. (98-536) 527 U.S. 581 (1999))
Olmsted v. L.C., Held: Title II of the ADA requires services provided in the “most integrated setting appropriate to the needs of the disabled, considering available resources.

New Yorkers with serious mental illness are not living "in the most integrated setting appropriate to the needs of the disabled"
  • 15,000 New Yorkers with mental illness are living in jails and prisons
  • 4,000 New Yorkers with mental illness are living in state psychiatric hospitals
  • Others are living in shelters

Research shows Kendra’s Law cuts down on the time individuals spend institutionalized in hospitals, jails and prisons. Of patients enrolled in Kendra's Law:
  • 77% fewer experienced psychiatric hospitalization
  • On average, AOT recipients' length of hospitalization was reduced 56% from pre-AOT levels.
  • 83% fewer experienced arrest
  • 87% fewer experienced incarceration. (March 2005 N.Y. State Office of Mental Health “Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.)

  • Individuals who received court ordered treatment in addition to enhanced community services spent 57 percent less time in psychiatric hospitals than individuals who received only enhanced services.
  • Individuals who had both court ordered treatment and enhanced services spent only six weeks in the hospital, compared to 14 weeks for those who did not receive court orders. 1998 Policy Research Associates, Inc. Research study of the New York City involuntary outpatient commitment pilot program.
  • Patients given mandatory outpatient treatment - who were more violent to begin with - were nevertheless four times less likely than members of the control group to perpetrate serious violence after undergoing treatment. February 2010 Columbia University. Phelan, Sinkewicz, Castille and Link. Effectiveness and Outcomes of Assisted Outpatient Treatment in New York State Psychiatric Services, Vol 61. No 2
  • For those who received AOT the odds of any arrest were 2.66 times greater and the odds of arrest for a violent offense 8.61 times greater before AOT than they were in the period during and shortly after AOT. The group never receiving AOT had nearly double the odds of arrest compared with the AOT group in the period during and shortly after assignment. March 2005 N.Y. State Office of Mental Health “Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment. “
  • (AOT) improves likelihood that providers will serve seriously mentally ill: It is also important to recognize that the AOT order exerts a critical effect on service providers stimulating their efforts to prioritize care for AOT recipients. Swartz, MS, Swanson, JW, Steadman, HJ, Robbins, PC and Monahan J. New York State Assisted Outpatient Treatment Program Evaluation. Duke University School of Medicine, Durham, NC, June, 2009
  • Providers of both transitional and permanent housing generally report that outpatient commitment help clients abide by the rules of the residence. More importantly, they often indicate that the court order helps clients to take medication and accept psychiatric services. 1999 NYC Dept. of Mental Health, Mental Retardation and Alcoholism Services. H. Telson, R. Glickstein, M. Trujillo, Report of the Bellevue Hospital Center Outpatient Commitment Pilot

The problem is not lack of “available resources.” NY has “available resources”
  • NYS spends in excess of $3 billion on mental health
  • Using integrated settings saves money over institutions
  • Individuals with serious mental illness are largely excluded from OMH programs especially if they lack the ability to volunteer. The seriously ill go to the end of the line while worried well go to front.
  • OMH has never improved services for the most seriously ill, absent a court order.
  • $665 million of OMH budget (1/3) wasted per Dr. LlloydSederer: “Thus, taken together, $665 of the $814 (more than 80 percent!) was spent, perhaps unnecessarily, on people with mental disorders, principally for the serious medical illnesses that they frequently suffer.  

OMH refuses to focus existing resources on the most seriously ill. OMH serves 650,000. Only 3,600 are seriously mentally ill individuals in state hospitals and 1,871 are in assisted outpatient treatment programs. Maybe 100K are in other programs that help seriously mentally ill.
To be compliant with Olmstead, NY must make greater use of Kendra’s Law. To offer humane care for the most seriously ill NY should make use of Kendra’s Law.


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