E. Fuller Torrey, MD

Healing: Our Path From Mental Illness to Mental Health

Healing: Our Path from Mental Illness to Mental Health

Thomas Insel, MD, gets several important things right in his book, 

. He is right that the public mental illness treatment system in the US is a mess and inferior to most western European countries. He is right that we know what to do, but do not use what we know very well. But he is wrong about one important issue—the role of the National Institute of Mental Health (NIMH). Dr Insel means well and would like to be part of the solution. Unfortunately, because of his blind spot, he continues instead to be part of the problem.

Dr Insel was the director of NIMH from 2002 to 2015. During that time, he oversaw budgets totaling $20 billion and approved a massive transfer of funds from clinical research, which may help people currently affected, to basic research, which may help people in some far off future. In 2017, Dr Insel understood that this transfer of funds had been a mistake

“I spent 13 years at NIMH really pushing on the neuroscience
and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness. I hold myself accountable for that.”

Five years later, that lesson appears to have been lost and Dr Insel no longer understands the relationship between America’s failed mental illness treatment system and NIMH’s failure to fund clinical research. For example, he writes, on page 45: “Adherence to psychiatric medication is reported to be among the worst for all medications, probably below 50 percent.” As clinicians are aware, drug adverse effects and lack of efficacy are major reasons for this lack of compliance. That is why NIMH, until 2 decades ago, had a very active drug treatment trials program. However, this program was decimated under Dr Insel’s leadership.

In 2006, the first year for which accurate data is available, NIMH funded 16 treatment trials for schizophrenia, bipolar disorder, and major depression. By 2015, this program had been reduced to funding only 3 drug trials, an 81% reduction.

 Dr Insel also praises the use of psychotherapy and other nondrug treatments for selected psychiatric patients; NIMH support for research on such therapies was sharply reduced as funds were shifted from clinical to basic research.

Indeed, one can think of myriad ways America’s mental illness treatment system could have been improved with the wiser expenditure of Dr Insel’s $20 billion. Dr Insel correctly identifies mentally ill persons who are homeless or incarcerated as major problems. The homeless problem could have been improved by a multicenter comparison of the 9 available long-acting antipsychotics, critical for treating homeless mentally ill persons. Each drug was approved by the US Food and Drug Administration simply by proving that it was better than a placebo. As a group the drugs have never been compared, even though clinicians suspect that some are much better than others. Research on their comparative efficacy should have been the task of NIMH. The problem of incarceration of mentally ill persons could also have been improved by NIMH research on programs being used by various states to decrease the rate of reoffending by mentally ill persons being released from jails and prisons. Some states use Psychiatric Security Review Boards, others use Forensic Assertive Community Treatment (FACT) teams, and still others use various forms of conditional release.

 Research on all of them is minimal and they have never been compared.

Still another example is the clubhouse model for psychiatric rehabilitation, also praised by Dr Insel. Although the model has been known for more than 60 years, there still are only a handful of fully functioning clubhouses in the United States. The main reason for this is that NIMH has never undertaken a careful, long-term study of outcomes for clubhouse members. It would show that such outcomes are actually less expensive, as well as being more humane, then allowing mentally ill individuals to undergo an endless odyssey from hospitals to streets to shelters to jails to hospitals and back again. States, counties and cities will spend their mental health dollars on what is cost-effective and what works; such research is the responsibility of NIMH.

From the earliest congressional hearings in 1945, leading to the creation of NIMH, it was clearly stated that its primary purpose was to coordinate “research relating to neuropsychiatric disorders to provide for more effective methods of prevention, diagnosis, and treatment of such disorders.”

Although basic brain research was envisioned as being part of its research portfolio, NIMH was never intended to be primarily a basic research institute; that was to be the purpose of the National Science Foundation, created by Congress 5 years later. Nor was NIMH intended to organize or deliver mental health services; that was the responsibility of state and local government and, later, the federal Substance Abuse and Mental Health Services Administration (SAMHSA). NIMH’s job was to do research, including research on treatment and services.

Dr Insel, in contrast to 5 years ago, now writes: “To be clear, I have no regrets about NIMH funding for genomics and neuroscience,” [page xxvi] even as he acknowledges that the genomics research has produced nothing of value “that is ready for clinical use in diagnosis or treatment” [page133]. In an interview accompanying a review of the book he further noted that,

The mental illness crisis is “not a research problem; it’s an implementation problem.” Good treatments for serious diseases like schizophrenia and bipolar disorder already exist…(I)t is not the job of scientists at the NIMH to provide services.

NIMH scientists should of course not be responsible for providing psychiatric services, but they should be responsible for improving the treatments that already exist, as well as carrying out research on how treatment in the broadest sense of the word can be improved. Until NIMH understands this, our path from mental illness to mental health will be largely uphill.

The opinions expressed are those of the author and do not necessarily reflect the opinions of

is the founder of the Treatment Advocacy Center and the author of 

American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System

1. Rogers A. Star neuroscientist Tom Insel leaves the Google-spawned Verily for . . . a startup? 

. May 11, 2017. Accessed August 5, 2022. 

https://www.wired.com/2017/05/star-neuroscientist-tom-insel-leaves-google-spawned-verily-startup/

2. Torrey EF, Simmons WW, Hancq ES, Snook J. 

The continuing decline of clinical research on serious mental illnesses at NIMH.

3. Torrey EF, Dailey L, Lamb HR, et al. Treat or repeat: a state survey of serious mental illness, major crimes and community treatment. Treatment Advocacy Center. September 2017. Accessed August 5, 2022. 

https://www.treatmentadvocacycenter.org/storage/documents/treat-or-repeat.pdf

4. Congressional hearings, subcommittee of the committee on interstate and foreign commerce, House of Representatives. H.R. 2550. A Bill to Provide for, Foster and Aid in Coordinating Research Relating to Neuropsychiatric Disorders; to Provide for more Effective Methods of Prevention, Diagnosis, and Treatment of Such Disorders; to Establish the National Neuropsychiatric Institute; and for Other Purposes. Sept 18, 19, and 21. 1945. Government Printing Office; 1945.

5. Barry E. The ‘nation’s psychiatrist’ takes stock, with frustration. 

https://www.nytimes.com/2022/02/22/us/thomas-insel-book.html

Articles

In this review of Thomas Insel's book, one doctor analyzes the uphill path from mental illness to mental health.

The Uphill Path to Mental Health: A Book Review

The juxtaposition of 2 recent research reports should give us pause for concern. In September, the National Institute on Drug Abuse reported that 

 use among college students reached 44% in 2020, a significant increase from 38% in 2015 and at its highest level since the 1980s.

 currently available is more potent than that used in the past. This follows a July report from researchers in Denmark who claim that the increasing use of cannabis is a likely cause of increasing incidence of schizophrenia noted in that country over the past 2 decades.

 An increasing incidence of schizophrenia, or psychosis in general, has also been reported in England, Switzerland, and Canada, especially among young people.

 Since 19 US states have already legalized the recreational use of cannabis and other states are considering doing so, a possible relationship between cannabis use and increasing 

 is potentially very important and needs to be confirmed.

The National Institute of Mental Health (NIMH) website describes itself as “the lead federal agency for research on mental disorders.” Schizophrenia is generally considered to be the most disabling mental disorder and in 2013 was estimated to cost the US $155.

 One would therefore expect NIMH to have accurate information on the incidence and prevalence of schizophrenia and some idea whether they are increasing, decreasing, or constant over time. However, when a health reporter asked NIMH for its reaction to the report on cannabis and 

 from Denmark, a NIMH spokesperson had little to offer other than to say that “it’s hard to obtain accurate estimates of the prevalence of schizophrenia because diagnosis is complex and it overlaps with other disorders.”

In fact, NIMH says that it does not know the prevalence of schizophrenia in the US other than within broad limits.

 For the last 4 years, the NIMH website has combined schizophrenia with other “related psychotic disorders” and claimed that together, their prevalence is “between 0.25% and 0.64%” of the population, which translates to between 772,000 and 2.0 million individuals. For every other mental disorder, except schizophrenia, NIMH provides a precise prevalence number.

Part of the problem is that NIMH has not undertaken a serious study of the incidence or prevalence of 

 or other major mental illnesses in 40 years. At that time, it reported the 1-year prevalence of schizophrenia among adults in the US to be 1.1%, equivalent to 2.6 million adults based on 2010 census data.

 NIMH used that percentage as its official estimate for the prevalence of schizophrenia until 2017. At that time, for reasons it has yet to explain, NIMH declared that the true prevalence of adult schizophrenia was really only 0.3%, or 704,000 individuals. As justification for this new number, NIMH cited a study from 2005that only counted people with schizophrenia who were living at home (including college students); those residing elsewhere—including hospitals, group homes, 

 Since NIMH had effectively made 2 million people with schizophrenia disappear without justification, the number was publicly ridiculed.

 NIMH’s response was to acknowledge that it really does not know the prevalence and to offer the range of numbers cited above.

In order to ascertain whether any disease is increasing or decreasing over time, one needs a reliable baseline number as well as repeated surveys. Since NIMH has never repeated the prevalence survey for the 40-year-old study or established another reliable baseline number, it has no way to tell whether schizophrenia is increasing or decreasing. In fact, since the 1990s, there are suggestions that it may be increasing. The number of seriously mentally ill individuals who are homeless or incarcerated has appeared to increase in recent years, and schizophrenia is a significant part of that population. Schizophrenia is a major, and apparently increasing, contributor to the cost of the Medicaid and Medicare programs. And the “mental disorders” diagnostic category has been 1 of the fastest-growing parts of the Supplemental Security Income and Social Security Disability Income programs.

It is an embarrassment to American medicine that NIMH has so little to contribute on such an important question. At a minimum, NIMH should issue a request for proposals to try and confirm the Danish study in another country which has appropriate data so that we will have a definitive answer to this question.

is the founder of the Treatment Advocacy Center and the author of 

1. Marijuana use at historic high among college-aged adults in 2020. National Institute on Drug Abuse. September 8, 2021. Accessed December 22, 2021. 

https://www.drugabuse.gov/news-events/news-releases/2021/09/marijuana-use-at-historic-high-among-college-aged-adults-in-2020

2. Hjorthøj C, Posselt CM, Nordentoft M. 

Development over time of the population-attributable risk fraction for cannabis use disorder in schizophrenia in Denmark.

3. Boydell J, Van Os J, Lambri M, et al. 

Incidence of schizophrenia in southeast London between 1965 and 1997.

4. Ajdacic-Gross V, Lauber C, Warnke I, et al. 

Changing incidence of psychotic disorders among the young in Zurich.

Increase in schizophrenia incidence rates: findings in a Canadian cohort born 1975-1985.

6. Cloutier M, Aigbogun MS, Guren A, et al. 

The economic burden of schizophrenia in the United States in 2013.

7. Hunt K. Schizophrenia linked to marijuana use disorder is on the rise, study finds. CNN Health. July 22, 2021. Accessed December 22, 2021. 

https://www.cnn.com/2021/07/22/health/marijuana-schizophrenia-study-wellness/index.html

8. Gordon JA. On the prevalence of schizophrenia-and transforming care through research. 

https://www.psychiatrictimes.com/view/prevalence-schizophrenia-and-transforming-care-through-research

9. Gordon JA. Letter to Senator Bernard Sanders. February 6, 2019.

10. Regier DA, Narrow WE, Rae ES, et al. 

The de-facto US mental and addictive disorder system. Epidemiologic Catchement Area retrospective 1-year prevalence rates of disorders and services.

11. Kessler RC, Birnbum H, Demler O, et al. 

The prevalence and correlates of nonaffective psychosis in the National Co-Morbidity Survey Replication (NCS-R).

12. Torrey EF, Sinclair E. Hocus pocus: how the NIMH made 2 million people with schizophrenia disappear. 

https://www.psychiatrictimes.com/view/hocus-pocus-how-nimh-made-2-million-people-schizophrenia-disappear

13. Torrey EF, Simmons W. Where did the schizophrenics go? 

. March 26, 2019. Accessed December 22, 2021. 

https://www.wsj.com/articles/where-did-the-schizophrenics-go-11553640973

14. Torrey EF. Severe psychiatric disorders appear to be increasing. 

https://www.psychiatrictimes.com/view/severe-psychiatric-disorders-may-be-increasing

Is cannabis’ effect on schizophrenia being downplayed? 

Is Cannabis Use Increasing Schizophrenia? 

 an additional $98 million as part of the National Institutes of Health budget resolution in December 2019, which brings the NIMH budget to just under $2 billion and represents a 35% increase since 2015, one of the largest increases in the history of the NIMH. Yet, during the 5 years from 2015 through 2019, NIMH funded a total of 2 new drug treatment trials for schizophrenia and bipolar disorder, according to 

. This contrasts with the 5-year period from 2006 through 2010 when NIMH funded 48 such trials. NIMH has thus almost entirely given up its role of evaluating drugs for the treatment of 2 disorders.

Schizophrenia and bipolar disorder are among the most serious psychiatric disorders and play a disproportionate role among individuals who end up homeless, incarcerated, and who commit suicide. The cost of schizophrenia alone in the US was estimated to be $155.7 billion, based on a 2013 

 Traditionally, the pharmaceutical industry and NIMH have been the main developers of new psychiatric drugs. In recent years, the former has reduced its efforts to develop such drugs, at least in part because of the failure of genetic research to identify new targets for new drug development. Given the semi-withdrawal of the pharmaceutical industry, it would seem reasonable to expect the NIMH to increase, rather than decrease, its efforts.

A big part of the problem is the NIMH policy of requiring the identification of specific biological targets in the brain for treatment trials. This has been widely interpreted to mean that the NIMH is not really interested in supporting clinical trials at this time. Indeed, the NIMH has been widely criticized for focusing exclusively on basic brain research rather than clinical research that could help people currently affected by diseases such as schizophrenia and bipolar disorder. For example, in 2016, 20 current and former members of the NIMH National Advisory Mental Health Council published an editorial in the British Journal of Psychiatry criticizing the NIMH’s overemphasis on basic research.

 Joshua Gordon, MD, PhD, the current NIMH director, has “

that neither genetic research nor the study of complex circuits was likely to produce new treatments anytime soon.”

In fact, genetic findings relating to the immune system have been among the strongest genetic findings to date, and there is substantial genetic overlap between serious psychiatric disorders and a range of autoimmune diseases.

from small studies indicating that immune modulatory drugs have promise for the treatment of schizophrenia and bipolar disorder should be followed with larger scale studies.

 In addition, there are neuro-hormones such as estrogen that are promising as well as probiotics and other agents to modulate the microbiome and gut-brain axis.

 Given the fact that the last new psychiatric drug for psychosis was 

, which was approved 30 years ago, the time is long past due when the NIMH should undertake an aggressive search for better drugs. And now it has $2 billion in taxpayer funds to do so.

The opinions expressed here are those of the authors and do not necessarily reflect the opinions of 

 and Associate Director for Research at the Stanley Medical Research Institute; 

 is Theodore and Vada Stanley Distinguished Professor of Neurovirology in Pediatrics, Johns Hopkins University Medical School, Baltimore, MD.

1. Cloutier M, Aigbogun MS, Guerin A, et al. The economic burden of schizophrenia in the United States in 2013. 

2. Lewis-FernÃ¡ndez R, Rotheram-Borus Mj, Betts vt, et al. Rethinking funding priorities in mental health research. 

3. Heimer H. ICOSR 2017: The Prospects for New Drugs to Treat Schizophrenia. 

https://forum.schizophrenia.com/t/icosr-2017-the-prospects-for-new-drugs-to-treat-schizophrenia/78131

4. Hoeffding LK, Rosengren A, Thygesen JH, et al. Evaluation of shared genetic susceptibility loci between autoimmune diseases and schizophrenia based on genome-wide association studies. 

5. Severance EG, Dickerson F, Yolken RH. Autoimmune phenotypes in schizophrenia reveal novel treatment targets. 

6. Mueller N. Inflammation in schizophrenia: pathogenetic aspects and therapeutic considerations. 

7. Kulkarni J, Gavrilidis E, Wang W, et al. Estradiol for treatment-resistant schizophrenia: a large-scale randomized-controlled trial in women of childbearing age. 

8. Dickerson F, Adamos M, Katsafanas E, et al. Adjunctive probiotic microorganisms to prevent rehospitalization in patients with acute mania: a randomized controlled trial. 

Schizophrenia and bipolar disorder are among the most serious psychiatric disorders and play a disproportionate role among individuals who end up homeless, incarcerated, and who die by suicide. Why the lack of research?

Riches Abound, So Where Are the Trials for Schizophrenia and Bipolar Disorder?

Editor's note: This commentary is part of a 3-part collection

Introduction: Lies, Dam Lies, and Statistics

HOCUS POCUS: How the NIMH Made 2 Million People With Schizophrenia Disappear

, by E. Fuller Torrey, MD and Elizabeth Sinclair.

A RESPONSE FROM THE NIMH DIRECTOR: On the Prevalence of Schizophrenia and Transforming Care Through Research

is Founder of the Treatment Advocacy Center and Associate Director for Research at the Stanley Medical Research Institute. 

is a Research Associate at the Treatment Advocacy Center.

Although he has been the Director of the National Institute of Mental Health (NIMH) for less than 2 years, Dr. Joshua A. Gordon has made 2 million individuals with schizophrenia disappear. NIMH has not said where they went but officially, they no longer exist. This is a remarkable accomplishment, especially given the lack of attention NIMH has given serious mental illness

Until November 2017, NIMH had claimed that the 1-year prevalence of schizophrenia in adults in the US was 1.1%. In other words, in any given year approximately 11 out of every 1,000 adults would be diagnosed with this disease of the brain. The Bureau of the Census estimated in 2017 that there were 252.1 million adults in the US; thus approximately 2.8 million would have been diagnosed with schizophrenia.

This estimate was based on the last major epidemiological study of serious mental illness in the US, the Epidemiologic Catchment Area (ECA) study. This NIMH-funded study sampled 5 areas (Los Angeles, St. Louis, New Haven, Baltimore, and rural counties in North Carolina) in the early 1980s. At least 3,000 adults living in households and 500 individuals living in mental hospitals, prisons, nursing homes and other institutions were directly interviewed in each area, then surveyed by telephone 6-months later and re-interviewed another 6-months after that. The results are considered to be the most accurate mental illness prevalence data available for the US. In 1993, at the request of the US Senate Committee on Appropriations, the ECA data were given to the Senate so that they could be used to assess the costs of these disorders. The ECA data have thus been the standard in the US for the past 3 decades.

Inexplicably, in November 2017, NIMH changed its website and declared that the 1-year prevalence of schizophrenia is now 0.3%, or 3 cases in 1,000 adults. Based on the current census estimates, this means that there are now only approximately 750,000 adults with schizophrenia each year in the US. Since there were 2.8 million previously, just over 2 million have been made to disappear.

How does NIMH justify this remarkable feat? They no longer make any mention of the ECA study and instead cite as the basis of their estimate a National Comorbidity Survey carried out in 2001-2003. This survey was a sampling of 9,282 people living at home and specifically excluded individuals in institutions, including in psychiatric or other hospitals, nursing homes, jails, prisons, homeless shelters, or individuals living on the street. Thus the official count of individuals with schizophrenia in the US now excludes anyone not living at home. The refusal rate for participating in the survey was 29%, and the authors cite a study reporting that people with paranoid symptoms are more likely to refuse to participate in such surveys. For screening their original sample of 9,282 people living at home, the study used the Composite International Diagnostic Interview (CIDI), a screening tool known to be poor in identifying individuals with schizophrenia. Among the original 9,282 persons, 2,382 had some psychiatric symptoms and were then screened using an instrument for non-affective psychosis (schizophrenia, schizoaffective disorder, delusional disorder, non-affective psychosis not otherwise specified). The final psychiatric diagnoses for this survey were based on telephone interviews with 73 people.

NIMH then tries to justify the use of a schizophrenia adult prevalence rate of 0.3% per year by citing 2 summaries of a worldwide prevalence study. This study included 188 prevalence studies, including the ECA study, carried out in 46 countries, some as early as 1935. The main finding of this study was the very wide range of prevalence in different countries, with the US being among the highest. Many of the studies were carried out in developing and rural countries that have reported a low prevalence of schizophrenia until recent years. Taking the median prevalence from these 188 studies to justify a current estimate for the US is scientifically irresponsible.

The new estimates from NIMH are also egregiously inconsistent with the majority of other prevalence estimates, even within the federal government. The latest data from the Substance Abuse and Mental Health Services Administration (SAMHSA) state that schizophrenia accounts for 22% of people with serious mental illness, or about 2.3 million adults based on current estimates. The Centers for Medicare and Medicaid Services reports that 4% of all Medicare beneficiaries have schizophrenia, increasing to 11.2% all individuals who are dual-eligible for Medicare and Medicaid. In addition, widely-cited academic literature has prevalence estimates consistently between 0.9%–1.1%.

Why did NIMH wish to massively reduce the official prevalence of schizophrenia in the US? In the past 2 years, members of Congress have become much more interested in problems associated with untreated severe mental illness. With the passage of the 21st Century Cures Act and appointment of the nation’s first Assistant Secretary for Mental Health in the Department of Health and Human Services, it seems likely that federal mental health agencies like NIMH may be held accountable in a way that they have not been previously. Having to account for 750,000 people with schizophrenia is much easier than having to account for 2.8 million. In addition, NIMH has already been widely criticized for ignoring the needs of individuals with schizophrenia, specifically by failing to support research on the development of new medications and other effective treatments.

It should also be noted that NIMH has not funded a major study to determine the current prevalence of schizophrenia since the ECA study in the early 1980s-more than 30 years ago. Thus we really have no idea whether the prevalence of schizophrenia has increased, decreased, or stayed the same. The lack of data in the US on this question stands in sharp contrast to almost every European country. In England, for example, 7 major studies on the prevalence of schizophrenia were carried out between 1986 and 2009, including studies of whether the prevalence is increasing; why the prevalence is so high among certain immigrant groups; and whether there are regional differences in prevalence. A measure of England’s interest in these issues is a 258-page report, “Systematic Review of the Incidence and Prevalence of Schizophrenia and Other Psychoses in England,” prepared for the Department of Health in 2012. The Scandinavian countries, of course, have even more sophisticated prevalence studies based on their national case registers. Compared with these countries, the data available in the US on the prevalence of schizophrenia are equivalent to the data available in some developing countries.

The last major study of the prevalence of schizophrenia in the US was carried out in the early 1980s. The results from that study have been used for 3 decades to estimate the annual prevalence of schizophrenia at 1.1% (11 in 1,000 adults). For unknown reasons, NIMH decided in November 2017 to no longer use that data. Instead, it adopted a 2001–2003 study that only assessed schizophrenia in people living at home. Individuals who are hospitalized, in nursing homes, in jail or prison, or homeless are no longer included in the measure of prevalence, which NIMH claims to now be 0.3% (3 in 1,000 adults). This decreases the number of people estimated to have schizophrenia in the US from approximately 2.8 million to 750,000. The very fact that NIMH would make such a change is a measure of the institute’s lack of interest and expertise on this important issue.

We have 2 recommendations that the agency should take to address this major discrepancy. First, it should restore the previous estimate of the prevalence of schizophrenia (1.1% annual rate for adults) until more updated data become available. Second, NIMH, perhaps in collaboration with SAMHSA, should undertake a major new study of the prevalence of schizophrenia, including individuals in psychiatric hospitals, in jails or prisons, and who are homeless. When Dr. Gordon became the Director of NIMH, he stated that his highest priority was to support good science. Let us hope that making individuals disappear is not representative.

The last major study of the prevalence of schizophrenia in the US was carried out in the early 1980s. The results from that study have been used for 3 decades.

Individuals with serious mental illness who have committed major crimes pose a unique problem for balancing the clinical needs of the patient against the protection of the public. A 2011 summary of studies from 10 developed countries suggests that the US does a poor job in this task; recidivism for individuals with psychotic disorders was twice as high in the US compared with 9 other countries.

 We undertook a state survey of forensic practices to ascertain why the US does so poorly.

Treat or Repeat: A State Survey of Serious Mental Illness, Major Crimes and Community Treatment

, released September 19 by the Treatment Advocacy Center, is the result.

 In the first such study, surveys and interviews were conducted with mental health and correction officials in each state to determine what laws, policies, and programs are used to decrease recidivism for individuals with serious mental illnesses who are released from jails or prisons or discharged from hospitals. States were graded A, B, C, D, or F on their efforts. Overall grades reflect whether the state has adopted enumerated evidence-based laws or programs so that they are theoretically available for the target population. Analysis of implementation, either in the quality of the programming or the uniformity of service availability throughout a state, was beyond the scope of this report.

The results were less than encouraging and help to explain why the US lags behind other countries in this regard. No state received an A, but 4 states-Hawaii, Maine, Missouri, and Oregon-achieved a B+. On the other end of the spectrum, Alaska, Idaho, Indiana, Massachusetts, Mississippi, New Mexico, Texas, and Wyoming were graded F. It should be emphasized that the grades reflect states’ efforts only for this specific population of patients; for other patient populations, the state may do better or worse. We emphasize that the grade is a composite, since programs often vary widely among counties, especially in large states. The grade reflects what is theoretically available for a program within the state without the need for legislative or policy change.

The good news from this state survey is that programs were identified in many states that can be used as models to improve outcomes for this patient population. For individuals with serious mental illness who have committed major crimes, past studies have shown that if they do not continue treatment when they are placed in the community, their re-arrest rate is 40% to 60% within 5 years. However, if such individuals maintain treatment upon community reentry, their re-arrest rate can be reduced to 10% or lower.

The most widely used effective treatment is conditional release. This requires that individuals who live in the community follow a treatment plan or be subject to possible rehospitalization. The states with the largest number of individuals on conditional release per population are Hawaii, Arkansas, and Maryland. Follow-up studies of conditional release in California, Connecticut, Maryland, and Virginia have shown it to be highly effective in reducing recidivism. Conditional release is available in all states except Idaho, Indiana, Massachusetts, New Mexico, North Carolina, Pennsylvania, and Texas-all of which were graded D or F.

A second effective mechanism for reducing recidivism in individuals with serious mental illness living in the community is the creation of psychiatric security review boards (PSRBs). Pioneered in Oregon and Connecticut, these review boards centralize the authority for the release of and follow-up for forensic patients in a single small group of people. The Oregon PSRB, for example, consists of a psychiatrist, psychologist, lawyer, parole or probation officer, and member of the public appointed by the governor to 4-year terms. Virtually all individuals found not guilty by reason of insanity (NGRI) are assigned to the PSRB, which has full authority over the individual, including duration of inpatient care, conditional release, and discharge. Follow-up studies of PSRBs have shown them to be highly effective. Many states have a body that operates similarly, but the best results have been achieved where the legislature has created such a centralized authority.

A third effective mechanism for reducing the re-arrest rate is the use of Forensic Assertive Community Treatment (FACT) teams. The FACT team model for psychiatric patients in general has been in wide use since the 1970s and is highly effective. When it is used for forensic patients, a criminal justice professional is added to the treatment team. Such teams are responsible for the patients assigned to them 24/7 and also address the other needs of patients such as housing, job training, and money management. Studies of FACT teams have reported their effectiveness in significantly reducing convictions for new crimes, number of days in jail, and use of inpatient psychiatric services, compared with a control group.

Yet another mechanism for reducing recidivism in individuals with serious mental illness who have committed crimes is assisted outpatient treatment (AOT). While AOT is a civil remedy, its availability relates to maintaining treatment within the community both before and after criminal justice involvement. It is available in all states except Connecticut, Maryland, and Massachusetts but is underused in most states. AOT consists of a court order that allows the person to live in the community as long as he or she follows the treatment plan. Under Kendra’s Law (New York’s version of AOT), in follow-up studies for individuals with serious mental illness who had committed any crime, recidivism was reduced by 71%. In California, where AOT is called Laura’s Law, there was a 56% reduction in recidivism and a 75% reduction in days incarcerated.

Other recommendations for improving services

Treat or Repeat identified several other ways to improve the treatment of individuals with serious mental illness who have committed major crimes. It emphasizes that these individuals are a relatively small percentage of the total psychiatric case load. Based on studies discussed in the report, at any given time there is estimated to be approximately 200,000 individuals with serious mental illness who have committed a major crime living in the community; this is just 2% of all individuals with a serious mental illness. Because of their known high rate of reoffending if they are not being treated, such individuals should be given priority for psychiatric services.

Arkansas, for example, does so explicitly on the website of the Division of Behavioral Health Services, which lists “individuals found NGRI” and “individuals committed by the courts for dangerousness to others” as the top 2 priorities for treatment. Similarly, in Missouri the state contract with the regional community mental health centers explicitly states that forensic patients are a priority population for treatment. These are models for other states.

Another way to improve the treatment of this forensic subgroup of psychiatric patients is the greater use of clozapine, the only antipsychotic that has been demonstrated to decrease aggressive behavior. In an important 2001 article, Frankle and colleagues

 reported a reduction in re-arrest rates in psychotic patients with criminal histories who were treated with clozapine. Clozapine is grossly underutilized in this country compared with other developed countries, and this failure to utilize our most effective antipsychotic is another likely reason why our re-arrest rate is so high.

Finally, it is important to provide routine screening and discharge planning for seriously mentally ill individuals being released from jails and prisons. California’s mentally disordered offender designation enables screening and prioritization of services for those most in need of them in a corrections setting, including discharge planning. It is one of the only states to recognize the congruency of needs across departments, enabling enrollment of corrections inmates into its CONREP program (conditional release) and providing a model for other states to “de-silo” these 2 populations.

Ohio’s Department of Corrections utilizes a universal risk assessment tool to screen for potential dangerousness before release. Other notable corrections programs include Kentucky’s jail mental health crisis network, Kansas’s Sedgewick County Jail programming in Wichita, and Cook County’s successful discharge unit in Illinois.

Dr. Elinore McCance-Katz, the newly appointed Assistant Secretary for Mental Health and Substance Abuse, has explicitly stated that reducing the number of individuals with serious mental illness in the nation’s jails and prisons is a priority. Targeting individuals who have already been incarcerated by using programs proven to reduce recidivism is effectively going after the low-hanging fruit. Why would we not do that?

Dr. Torrey is a research psychiatrist who specializes in schizophrenia and bipolar disorder. He is Founder of the Treatment Advocacy Center, Associate Director of the Stanley Medical Research Institute, and the author of 

. Ms. Dailey is a legislative and policy counsel at the Treatment Advocacy Center. She is a lawyer and has a master’s degree in International Human Rights.

 Fazel S, Yu R. Psychotic disorders and repeat offending: systematic review and meta-analysis. 

 Torrey EF, Dailey L, Lamb HR, et al. Treat or Repeat: A State Survey of Serious Mental Illness, Major Crimes and Community Treatment. Treatment Advocacy Center. September 2017. 

http://www.treatmentadvocacycenter.org/treat-or-repeat

 Lamberti JS, Weisman RL, Cerulli C, et al. A randomized controlled trial of the Rochester Forensic Assertive Community Treatment Model. 

 Frankle WG, Shera D, Berger-Hershkowitz H, et al. Clozapine-associated reduction in arrest rates of psychotic patients with criminal histories. 

 Torrey EF, Knable MB, Quanbeck C, et al. Clozapine for Treating Schizophrenia: A Comparison of the States. Treatment Advocacy Center. November 2015. 

http://www.treatmentadvocacycenter.org/storage/documents/clozapine-for-treating-schizophrenia.pdf

How to decrease recidivism for individuals with serious mental illnesses who are released from jails or prisons or discharged from hospitals? Here are several effective mechanisms.

Treating the Sickest: Why Does the US Lag Behind?

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After lounging on the doorstep of respectability for the past decade, assisted outpatient treatment is here to stay. But some still balk at the notion.