Just the Facts, Ma’am; The Numbers Don’t Lie: Not Servicing the Mentally Ill

“New York’s Riker’s Island, Chicago’s Cook County Jail and the Los  Angeles County Jail are the largest mental health institutions in the  nation. . . 15 percent of the inmates of those three  jails are mentally ill, making penal institutions — not hospitals —  the three largest U.S. mental health institutions.” ~ 2010 UPI Report

I have a close friend who’s married to a very (how to put this nicely?). . .erratic man. Every 4-5 years she tires of his tantrums, his threats, his raised fists, and he, fearing losing her, attends a local psychiatric clinic, gets a prescription for a mood stabilizer and an antipsychotic, and takes them for a month or two until all has blown over.

This past winter he went into full crisis, and had to be brought to the emergency room–by ambulance, for an added touch of drama my friend didn’t need.

The plan, as any sensible person would know, was to admit him through the ER into a psychiatric hospital that could attend to his needs, and do more than a patch-patch job before sending him back to his long-suffering wife.

The reality? He waited in the ER. And waited. And then he waited some more–all for a bed to open in a psychiatric hospital in the Chicago-land area. In fact he waited so long that he waited himself right on out of the motivation to be admitted–should the opportunity ever arise–and returned home, to a somewhat tepid welcome.

Unstable and threatening to leave, he was monitored by the ER staff working with a psychiatrist from their  own–over-filled–psych unit, and between restraints in the early hours, heavy doses of medication over the next 2 days, and pop-down visits from the psych staff, he calmed down enough to be able to walk himself right on out of the ER–unstable and unwell, his issues unaddressed–fundamentally untreated for his chronic mental illness.

Welcome to health care in America, where we do a very poor job of servicing our mentally ill–and where emergency rooms and jails are the havens of those who can’t get service anywhere else.

This lack of prioritizing mental health crosses many arenas, from federal and state governments to reimbursement for mental health care, to prestige accorded those in the field, and more.

For example, I know that in this economy most people aren’t going to cry over doctors’ salaries. I’m fully sympathetic with that. But we as a society tend to  put our money where our values are.

And so, according to the latest annual survey, “Medscape Physician Compensation Report: 2012 Results,” psychiatrists won the honor of falling into the somewhat ironically titled “Top 5 lowest paid doctors.”

It’s no surprise. It’s a bit of a mess here, and psychiatrist salaries are just a symbolic starting point.

The need and demand are very real.

A report released January 19, 2012, by Substance Abuse and Mental Health Services Administration indicated that 1 in 5 Americans experienced some form of mental illness in 2010, and about 5% are so severely ill that they have difficulty with day-to-day tasks involving school, work or family.*

The numbers and the need speak for themselves–but increasingly the mentally ill have nowhere to go.

The Treatment Advocacy Center analyzed the decline in psychiatric beds in every state, from 1955 and 2005. They found a shocking 95 percent decrease in the number of available beds in the America’s public psychiatric institutions.

There is too little access to credible, affordable health care, and so the mentally ill, like my friend’s husband, can’t be managed and kept out of crisis–so they fill our emergency rooms, which are ill-equipped to deal with them.

News and Numbers,” put out by the Agency for Healthcare Research and Quality found that in 2007 almost 12 million visits to emergency rooms involved patients with a mental disorder, substance abuse problem, or both. That adds up to 1 in 8 of the ER visits that year.

The demands for service are huge, but the supply is not keeping pace–and apparently what supply there is isn’t always affordable–or quite top-notch, either.

The report by the Substance Abuse and Mental Health Services Administration found that a shockingly low 4 in 10 who experienced mental illness in the past year got any treatment for it. Topping out the reasons for not seeking or receiving treatment was ‘could not afford cost,’ which accounted for 43.7% of those who did not receive help.*

Put in words, as an aggregate, among adults surveyed from 2001-2003 [and little has changed in a decade] who received any treatment at all for a mental disorder, whether considered ‘seriously mentally ill,’ or for a more ‘minor’ episode, two out of three didn’t receive “a minimally adequate level of treatment to help ensure good outcomes” (see Wang).

Wang et al found their own results quite alarming. They wrote:

the present results shed light on an enormous public health problem. Among patients with serious mental illness, fewer than 1 in every 6 received treatment that could be considered minimally adequate.

And the danger to life is very real for those who are not treated or not treated sufficiently well.

According to a 2001 Surgeon General report, the major cause of death from mental illness was suicide, and Hoge et al, found suicide to be number 4 in the top 10 causes of death for adults 18-65.

The drain on society of lack of proper treatment–both in terms of the work force and financial costs–is heavy.

2008 statistical data from World Health Organization indicate that

neuropsychiatric disorders have now surpassed other disorders such as cardiovascular diseases and malignant neoplasms as the number one cause of disability . . .

In Canada and the U.S. alone, mental disorders also are the leading cause of disability for ages 15-44.

The Position Paper “Mental Health Care Services by Family Physicians” indicates how great a toll mental illness takes on physical health, too, leading to further debilitation if adequate treatment is not forthcoming:

. . ..[I]]t is important to keep in mind that mental health problems have a significant impact on physical health. . . [A]mong elderly patients with high mean depressive scores, the risk of coronary heart disease increased 40% while the risk of death increased 60% compared with elderly patients with the lowest mean depressive scores. . .

When people complain about health care costs, we need only think what we could save ourselves as a society, if we were willing to pay for an ounce of prevention, being proactive about treating, say, depression, before it led to serious physical disease. [Note from yesterday’s post, “It Just Isn’t Worth That Much: Paying For Mental Illness Prevention,” that people are far less willing to pay to prevent mental illness, although they understand its severity, than to prevent physical suffering].

And, yes, if you add ER visits, physical illness, hospitalization–the costs add up, and it seems at first like we’re spending a lot on mental illness. But perhaps we aren’t spending enough.

Mental disorders come in 5th in terms of cost of treatment in the U.S., the fact is that they are more common than heart disease and cancer combined, which handily beat them out in spending. Mental illness is also more common in children than asthma. We simply aren’t putting the money where it’s required.


As of 2009, a research study cited in “Who’s Healthy? Mental Illness in Australia compared to around the world” provided the figures below on mental health spending as percent of a total health budget. Interestingly, America, so proud of its superior health system comes in 7th place–out of 8–if the data is properly corrected from American sources:

Britain 12.1%
Germany 10%
Netherlands 8%
Denmark 8%
Ireland 6.8%
[Australia 6.7%]
U.S.A (from study: 7.5%): Correction: 6.2% **]
Canada 4.8%

And, lucky for us, if one’s to be quite cynical about it, we do some of our ‘treatment’ on the cheap. According to a 2003 report by  Human Rights Watch, prisons have three times more people with mental illness than do psych hospitals.

A presentation from a March, 2011, Texas conference entitled “Impact of Proposed Budget Cuts to Community-Based Mental Health Services,” emphasizes the importance of ‘community-based mental health services,’ which they define as including ‘medications, case management and therapies.’ Those services are the

foundation of an effective treatment system capable of moving individuals with serious mental illnesses into productive, stable lives and keeping them out of more expensive psychiatric hospitals, emergency rooms, and jails.

Turns out the average cost per day of such services is $12 for adults and $13 for children.

When you move into the realm of the State Hospital it’s $401 per day for a bed (DSHS reference).

But. . .it only costs  137 per day for an inmate with a serious mental illness to be housed in prison (see Criminal Justice Uniform Cost Report).

Just think of the savings!

And that’s not to mention the 40% of the homeless who have a chronic, severe mental illness. It’s getting away with financial murder.

[Worth noting: It’s $986 per day for an emergency room visit.]

Responding to Chicago’s plan to close 6 of 12 mental health facilities by May, Professor Amy Watson, from University of Illinois, Chicago, notes that the overflow will wind up in jails–and that seems to be just fine with the powers that be:

We’re more willing to fund criminal justice than mental health. 

I’d like to say that awareness brings improvement, that with Mental Health Awareness Month and Schizophrenia Awareness Week and Borderline Personality Disorder Awareness Month and  National Eating Disorders Awareness Week and  Older Americans Mental Health Week well, mental health care should be on an upward trend.

But I’d be lying.

For example,  according to the National Alliance for the Mentally Ill, in the past 3 years states have cut more than $1.6 billion in general funds from their state mental health agency budgets for mental health services, a full 39%, even as demand for the services increases.

And that is how we wind up near where we started–back in the emergency rooms.

Bloomberg News looks at it from a financial standpoint–but they’re right. In “Mental-Health Cuts by U.S. States Risk Boosting Health Costs,” Melissa Silverberg and Bob Kazel write:

U.S. states looking to balance budgets by cutting mental-health facilities and Medicaid payments risk increasing health-care costs by pushing psychiatric patients into emergency rooms.

 In my own city of Chicago, this  year is expected to see the Public Health Department closing half of its 12 psychiatric clinics this month. Those who need help, and now have nowhere to seek it? Back to the ER they go.

And pity the emergency rooms, who can’t find other hospitals to take the psychiatric patients. In the past 10 years, inpatient psych beds in Illinois dropped 28%, leaving my friend’s husband hanging out in the ER until the urge for real mental health care has passed.

Seems like it’s time to start paying those psychiatrists a bit extra, encouraging more to go into the field, enabling better treatment for those who seek help, and preventing people from seeking their treatment along with trauma patients.

But then again, you’d have to put some preventative money into the system, and, as we learned yesterday, people don’t want to do that.

They seem happier dealing with a full-on crisis than taking steps to avoid it.

Which should make a lot of people very happy, since a crisis in mental health care is precisely what we’ve got.

^^NOTE: It’s a day for blogging about Mental Health. Join in.  Find out all you need to know here.

*[See the detailed report for yourself–it’s fascinating–at “Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings“.]
**Corrected from numerous internal sources, including Mark et al, below.


A neglect of mental illness (Anonymous). Scientific American 2012;, 306(3):8.

Department of State Health Services. DSHS Hospitals, Hospitals Section, Hospitals Statistics, FY 2010 data

Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023-1032.

Legislative Budget Board, Criminal Justice Uniform Cost Report, 2008‐2010, January 2011. http://www.lbb.state.tx.us/PubSafety_CrimJustice/3_Reports/Uniform_Cost_Report_0111.pdf

**Mark TL, Levit KR, Coffey RM, et al. National Expenditures for Mental Health Services and Substance Abuse Treatment, 1993—2003: SAMHSA Publication SMA 07-4227. Rockville, Md, Substance Abuse and Mental Health Services Administration, 2007.

McCanse C. Surgeon general announces national strategy. FPReport. 2001;7(6):1-2.

Torrey EF, Entsminger K, Geller J, et al. The shortage of public hospital beds for mentally ill persons: a report of the Treatment Advocacy Center. Available at http://www.treatmentadvocacycenter.org.

Wang PS, Demler O, Kessler RC. Adequacy of Treatment for Serious Mental Illness in the United States. American Journal of Public Health 2002; 92(1):92–8.

Leave a Reply