Transcript Ethical implications in Mental Health

Ethical implications of mental health care,
institutionalization, and free will
Nina B. Urban, MD, MSc, FAPA
Assistant Professor of Psychiatry
Columbia University
Division of Substance Abuse
Global Bioethics Summer School, NYC
July 2, 2015
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)
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-prisoninmates-are-routinely-physically-abused-study-says.html
Mental health and self-determination
J.-L. David: “The Death of Socrates”
“The Death Treatment:
When should people with a
non-terminal illness be
helped to die?”
The New Yorker, June 22, 2015
“Belgian
law
allows
euthanasia for patients
who suffer from severe
and incurable distress,
including
psychological
disorders.”
PHOTOGRAPH:
TOM MORTIER
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.