Emergency-room "boarding" | Law enforcement impacts | Jails and prisons | Violent crimes and homicides | Mentally ill homeless
The consequences of providing an insufficient number of public beds for the treatment of seriously ill psychiatric patients include an increasing:
- number of mentally ill individuals in hospital emergency rooms waiting for psychiatric beds;
- demand on police and sheriffs who, for all intents and purposes, become frontline mental health workers
- number of mentally ill individuals in jails and prisons; and
- number of acts of violence, including homicides, committed by mentally ill individuals who are not being treated;
- number of mentally ill homeless individuals.
Individuals with untreated severe mental illnesses are overwhelming hospital Emergency Departments (EDs) throughout the United States. A 2007 survey reported that one in eight patients seen in EDs had “a mental health or substance abuse condition” and that this problem “has been on the rise for more than a decade.”9 In a March 2012 Congressional briefing, NASMHPD reported that a recent survey of more than 6,000 emergency departments nationwide found 70% reporting they “boarded” psychiatric patients for “hours or days,” and 10% reporting they boarded individuals in psychiatric crisis for several weeks.10
Reports from individual states within the past 18 months suggest that the emergency room problem is becoming increasingly severe in:
- New Hampshire, where “mentally ill people waiting in local emergency rooms for a bed at the state hospital has reached a historic high.”11
- Massachusetts, where it has been reported that “mental health patients [are] flooding local ERs.”12
- New Jersey, where the number of mentally ill individuals seeking treatment doubled between 2005 and 2012.13
- South Carolina, where the director of an emergency room commenting on this problem said, “They say it is going to get worse, but I don’t know how….It is really horrendous.”14
- Louisiana, where “the lack of mental health beds is forcing hospital emergency rooms to become de facto psychiatric units.”15
- North Dakota, where “since just last year the number of patients with psychosis as their primary diagnosis” admitted through the emergency room “has more than doubled.”16
- Arizona, where “emergency room psychiatric consultations have spiked by 40% since last spring.”17
- California, where a director of hospital emergency services complained of being “inundated with these [mentally ill] patients.”18
Staff in emergency departments in some states complain that psychiatric patients can be boarded in EDs for 24 to 48 hours. As remarkably long as that may sound, ED workers in other states scoff at this figure, reporting that they have psychiatric patients stuck in emergency departments as long as four weeks.19
Police and sheriffs in every state have been overwhelmed by an increasing number of mental illness-related calls. A 2011 survey of more than 2,400 law enforcement officials reported that police-related incidents involving individuals with severe mental illnesses were perceived as “a major consumer of law enforcement resources nationally” and are requiring an increasing amount of time and manpower. Respondents reported that mental illness-related calls outnumbered calls for routine larceny, traffic accidents and domestic disputes.20
These findings are consistent with anecdotal reports. For example, “San Diego police have seen a 54% increase in the number of mental health and suicide-related calls”21 and, in Medford, Oregon, police were dealing with “an alarming spike in the number of mentally ill people coming in contact with the police on an almost daily basis.”22 In North Carolina in 2010, sheriffs’ departments “reported more than 32,000 trips last year to transport psychiatric patients for involuntary commitments.”23
Summarizing the situation, the sheriff of Pueblo County, Colorado, in 2007 said, “By default, we’ve become the mental health agencies for the individual counties.”24 Similarly, the president of the Los Angeles County Police Chiefs’ Association noted that “our local police forces have become armed social workers.”25
With law enforcement officers becoming front-line mental health workers, violent, officer-involved confrontations in which mental illness is a prominent factor appear to be on the rise. Because the U.S. Department of Justice does not track the variable of mental illness in officer-involved shootings, precise data is not available about these incidents. However, a majority of the 2,400 respondents in the 2010 survey of police and sheriffs perceived mental illness to be a significant factor in the injury or death of on-duty law enforcement officers,26 and a wealth of data from individual states supports their perceptions.
- Ventura County, California in 2007, sheriff’s deputies used Taser guns to subdue people 107 times, and “the majority of those shot by deputies were mentally ill.”27
- Santa Clara County, California, “of the 22 officer-related shootings from 2004 to 2009 in the county, ten involved people who were mentally ill.”28
- West Warwick, Rhode Island–a city of 29,000 people–five persons described as having “mental health issues” died in police-related incidents in a six-month period in 2008.29
- Syracuse, New York–a city of 185,000–three of the five officer-related shootings in 2011 involved “emotionally disturbed people.”30
- New Hampshire, at least four of the six officer-related shootings in 2011 “had some mental health issues.”31
- Albuquerque, New Mexico–a city of 546,000–24 men were shot by police officers between January 2010 and May 2012, and “11 of those men had a history of either mental illness, substance abuse or both.”32
In an effort to determine whether such reports reflect a trend of statistical significance, data on arrest-related deaths collected by the U.S. Department of Justice was assessed. Available by state and cumulative for 2003-2009,4 this data is known to have variable levels of completeness from state to state and does not track what percentage of the deaths occurred in individuals who were mentally ill.
These limitations notwithstanding, the number of arrest-related deaths for 2003-2009 and the per capita state hospital expenditures by state for 2008 (r= -0.333, p= 0.012) were found to show a statistically significant inverse association, with those states spending less money on state psychiatric hospitals reporting more arrest-related deaths.
While correlation does not prove causation, and the failure of the Department of Justice to collect data on the role of mental illness is problematic, the consistency of this data with law enforcement experience and anecdotal evidence suggests at least suggests that further study is warranted.
Increased numbers of jail and prison inmates with severe mental illness have been inversely associated with public hospital bed numbers since the initiation of deinstitutionalization. A 2010 Treatment Advocacy Center study, “More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States,” found “there are now three times more seriously mentally ill persons in jails and prisons than in hospitals.”33
The U.S. Department of Justice in 2006 reported that 24% of inmates in county jails and 15% of inmates in state prisons were psychotic.34 By bed population, the largest psychiatric inpatient facilities in the United States are the county jails in Los Angeles, Chicago and New York City. Unlike the state psychiatric hospitals they have succeeded, these institutions provide little or no treatment. The same 2006 Department of Justice report found that 84% of jail inmates and 75% of federal prisoners with mental illness receive no treatment.
Since 2006, reports from many jurisdictions suggest that the number of mentally ill individuals in jails and prisons is increasing.
- The Massachusetts Sheriffs’ Association reported that 26% of all jail inmates “have major mental illness.”35
- Stark County, Ohio, “30% of the jail population suffers from mental illness.”36
- Boone County, Missouri, “at least 30% of the jail population” is mentally ill37
- New York’s Rikers Island Jail, “one in three prisoners” is mentally ill.38
- Alabama’s Tuscaloosa County Jail, “about 40% of the inmates … receive some form of psychiatric care”39
- Texas’s El Paso County Jail, “about 40% of inmates” need “some type of psychotropic drugs.”40
- Iowa’s Black Hawk County Jail, the sheriff says that “more than 60% of the inmates are mentally ill.”41
- Mississippi’s Hinds County Detention Center, “about two-thirds of the 594 inmates … take anti-psychotic medicine”42
- Montana’s Cascade County Detention Center, the sheriff in 2012 estimated that “80% of the people in our jail suffer from a mental illness.”43
In many of these jurisdictions, law enforcement officials have noted a relationship between the closing of public psychiatric beds and an increase in mentally ill individuals in the jail. Following the closure of the local public psychiatric hospital in Gwinnett County, Georgia, “the jail’s population of inmates with mental illness increased dramatically.” According to the director of the jail, “The schizophrenic and chronically ill mental population just exploded and we found ourselves being the hospital.”44
When individuals with severe mental illness receive appropriate and effective treatment, their risk of committing violent acts is no greater than that of the general population. When they do not receive treatment, multiple studies have found their risk of violent behavior, including homicides, to be significantly elevated. In the United States, a small study in Albany County, New York, reported that eight individuals, all diagnosed with schizophrenia, were responsible for 29% of all homicides in the county during a six-year period.45 Another small study in Contra Costa County, California, reported that seven out of 71 (10 %) of homicide offenders were diagnosed with schizophrenia during a three-year period.46
A larger study in Indiana, published in 2008, examined the records of 518 individuals imprisoned for homicide.47 Among the 518, 53 or 10.2% had been diagnosed with schizophrenia, bipolar disorder or other psychotic disorders not associated with drug abuse. An additional 42 individuals (8.1%) had been diagnosed with mania or major depressive disorder. This suggests that at least 10% of homicides are associated with severe mental illnesses, a number consistent with the findings of multiple studies in Europe. Because the Indiana study only included homicide offenders who went to prison and not those found not guilty by reason of insanity, the actual prevalence of mental illness among individuals committing homicide was doubtless understated.
On January 8, 2011, the attention of the American public was directed to the potential negative consequences of untreated severe mental illness when Jared Lee Loughner, a young man with untreated schizophrenia, killed six people and wounded thirteen, including Congresswoman Gabrielle Giffords, in Tucson, Arizona.
In the previous five years, at least ten similar multiple shootings were committed around the nation by mentally ill individuals who were not being treated in:
- New York, Matthew Colletta killed one and injured five;
- Pismo Beach, California, Lawrence Woods killed two;
- San Francisco, Omeed Popal killed one and injured fourteen;
- Goleta, California, Jennifer San Marco killed eight;
- Maine, Newry, Christian Nielsen killed four;
- Seattle, Naveed Haq killed one and injured five;
- Colorado Springs, Matthew Murray killed four and injured five;
- Virginia, Seung-Hui Cho killed 32 and injured 24;
- Seattle, Isaac Zamora killed six and injured four; and
- Binghamton, New York, Jiverly Wong killed 13 and injured four.
Thus, between 2005 and 2010, a tragic pattern became increasingly apparent.
This pattern is also consistent with a 2006 study of 81 American cities. That study reported a statistically significant correlation between the number of public psychiatric beds available in that city and the prevalence of violent crimes (defined as murder, robbery, assault and rape).48 It is also consistent with a 2011 state study in which it was reported that having fewer public psychiatric beds was statistically associated with increased rates of homicide.49 Thus, the consequences of closing public psychiatric hospitals beds have become abundantly–if painfully–clear: The more beds you close, the more adverse consequences you can expect.
In the present study, possible relationships between the availability of public psychiatric beds and available measures of violence were examined by state. A statistical inverse trend was found between state hospital expenditures per capita and rates of aggravated assault (r= -0.249, p= 0.082). Similar statistical trends were found in the relationship between the loss of public psychiatric beds between 2005 and 2010 and aggravated assault (r= 0.273, p= 0.097) and the loss of beds and total violent crimes (r= 0.275, p= 0.095) (2010 data). These are relatively weak statistical associations but, given the many possible causes of increased violence, it is surprising to see even a weak association emerge. This is another topic with significant implications for public safety that warrants further study.
The proportion of mentally ill individuals within the homeless population is typically estimated at roughly one-third of all males and two-thirds of all females. As the homeless population grew between 2005 and 2010, it is reasonable to presume that the number of homeless individuals with mental illness grew as well. Victimization was common, occurring from 2.3-140 times more frequently than in the general population.50 Anecdotal information abounds:
- Colorado Springs (2009): "As many as two-thirds of the 400 chronically homeless people … suffer [from] severe mental illnesses."51
- San Francisco (2009): Forty-three homeless individuals had been killed on the streets, "the highest level in a decade."52
- Philadelphia (2000-2002): The average cost for public services to 438 homeless individuals with mental illness was $22,372 per person. These individuals represented 16% of the homeless population during the three-year study period but produced 60% of the city’s entire expenditures for the homeless.53