Nina B. Urban, MD, MSc, FAPA

Assistant Professor of PsychiatryColumbia University

Division of Substance Abuse

Global Bioethics Summer School, NYCJuly 2, 2015

Nina B. Urban, MD, MSc, FAPA

Assistant Professor of PsychiatryColumbia University

Division of Substance Abuse

Global Bioethics Summer School, NYCJuly 2, 2015

Ethical implications of mental health care, institutionalization, and free will

Disclosures

• No conflicts of interest to report

Psychiatric State Hospitals: Asylums

• 1900th century psychiatrists: architecture of “insane asylums”, especially their planning, was one of the most powerful tools for the treatment of the insane.

• The construction and use of these buildings served to legitimize developing ideas in psychiatry.

• Quaker reformers, such as Samuel Tuke, promoted the “moral treatment”: patients should be “unchained, granted respect, encouraged to perform occupational tasks (like farming, carpentry, or laundry), and allowed to stroll the grounds with an attendant and attend occasional dances.”

Psychiatric State Hospitals: Asylums

• About 300 psychiatric asylums constructed in the US before 1900.

• Doctors developed a highly specialized building type for 250 patients. Most notably, Dr. Thomas Story Kirkbridge, devised a widely applicable set of planning principles that ensured classification by type of illness, ease of surveillance, short wards for good ventilation, and clarity of circulation.

• This was later replaced by the “cottage plan”, with smaller housing units.

Psychiatric State Hospitals: Asylums

Psychiatric State Hospitals: Asylums

Psychiatric State Hospitals: Asylums

Psychiatric State Hospitals: Asylums

Treatments on institutionalized patients

Dr. D. Ewan Cameron, Project MKUltra

Deinstitutionalization

• 1960s: states reduced and closed their publicly-operated mental health hospitals/asylums

•  Vision: the mentally ill will be living more independently with treatment provided by community mental health programs. 

• However, insufficient ongoing funding for community programs to meet the growing demand. 

• Concomitantly, states reduced their budgets for mental hospitals, but provided no proportionate ongoing increases in funding for community-based mental health programs.

• Result: hundreds of thousands of mentally ill were released into communities lacking the resources necessary for their treatment.

Involuntary commitment

• N.Y. MHY. LAW § 9.27 : NY Code - Section 9.27: Involuntary admission on medical certification

• May be held in locked inpatient unit against their wishes, if two separate physicians certify the need for psychiatric treatment, without which the patient would be deemed

• A, a danger to him/herself

• B, a danger to others

• C, unable to take care of him/herself in a manner to ensure survival

• This application holds for up to 14 days; thereafter a court has to decide over ongoing treatment against the patient’s will, should this continue to be deemed necessary by the physicians.

Deinstitutionalization

• Where do they go ?

• Revolving door in acute hospitals, homeless shelters, and… prison

• “Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services.”

• Consequently, many of the individuals released into the community without support ended up incarcerated, in fact “trans-institutionalized” into America’s jails and prisons.

Prison and mental illness

• US: in 2012, 1 in 35 adults (= 2.9 % of adult residents), was on probation or parole or incarcerated in prison or jail, similar to 1997, but with a 790% increase of incarceration since 1980, partially explained by enforcement of “true”/minimum sentencing laws, requiring to spend at least 85% of sentence behind bars

• This equals 25% of the ENTIRE WORLD’S prison population

• If recent incarceration rates remain unchanged, 1 out of every 20 persons will spend time behind bars during their lifetime

Prison and mental illness

•20% of prison inmates have a chronic and serious mental illness

•30-60% have substance abuse problems

•50% of men and 75% of women in state prisons and 63% of men and 75% percent of women in jails, will experience a mental health problem requiring mental health services in any given year (compared to 18.6% of general population)

Prison and mental illness

• Increase of severe types of mental illness:

• 2.3 - 3.9% of inmates in state prisons have schizophrenia/psychosis (vs. 1% in general population)

• 13.1 - 18.6% have MDD (vs. 6.9%)

• 2.1 - 4.3% suffer from bipolar disorder (vs. 2.6%)

• individuals with severe mental illness are 3 times more likely to be in a jail or prison than in a mental health facility

• 40% of people with severe mental illness will have spent time in either jail, prison, or community corrections

Prison and mental illness

•Jails and prisons have effectively become the no.1 mental health care facility in the US

•It is now extremely difficult to find a bed for a seriously mentally ill person who needs to be hospitalized:

•1955: one psychiatric bed for every 300 Americans

•2005: one psychiatric bed for every 3,000 American

•majority of the existing beds are filled with court-ordered (forensic) cases (Nat. Sheriff’s Association, 2010)

•50% of men and 75% of women in state prisons and 63% of men and 75% percent of women in jails, will experience a mental health problem requiring mental health services in any given year.

Prison and mental illness

• Widespread abuse of mentally ill inmates:

• more frequently in solitary confinement

• neglect,

• improper medical care,

• corporeal punishment by officers.

• USA were summoned to Human Rights Court in Geneva in May 2015 to defend their human rights record for only the 2nd time ever.

• A record turnout of 120 countries had recommendations, such as criticism of police brutality, racial discrimination horrific treatment of mentally ill inmates.

Prison and mental illness

• This is factually violating prisoners constitutional rights

• NYC settled a law suit against the city in May over the conditions at Riker’s Island.

 

• Further reading:

• Human Rights Watch Report

• http://www.nytimes.com/2015/05/12/us/mentally-ill-prison-inmates-are-routinely-physically-abused-study-says.html

Mental health and self-determination

J.-L. David: “The Death of Socrates”

“Belgian law allows euthanasia for patients who suffer from severe and incurable distress, including psychological disorders.”

PHOTOGRAPH: TOM MORTIER

“The Death Treatment:When should people with a non-terminal illness be helped to die?”

The New Yorker, June 22, 2015

Treatment resistant depression

• 10%–30% of MDD pts. do not improve or show only partial response to medication and therapy, coupled with functional impairment, poor quality of life, suicidal ideation and attempts, self-injurious behavior, and a high relapse rate

• 3.4% of all pts. Succesfully commit suicide

• TRD targeted by integrated therapeutic strategies, including optimization of medications, a combination of antidepressants, switching of antidepressants, and augmentation with:

• non-antidepressants, psychosocial and cultural therapies, and somatic therapies including electroconvulsive

• therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy,

• deep brain stimulation, transcranial direct current stimulation, and vagus nerve stimulation.