Think Tank

Should Calif. Be Model for National Mental Health System?

As a response to the killing of elementary schoolers in Connecticut last month, President Obama asked Vice President Biden to oversee a White House task force to identify policy proposals for curbing violence and tightening gun laws.

California legislators and experts have offered several ideas.

California Senate President Pro Tempore Darrell Steinberg (D-Sacramento) sent a letter to Biden suggesting the nation should build a national mental health care system using California’s Mental Health Services Act as a model.

Rep. Doris Matsui (D-Sacramento), who last year introduced the Excellence in Mental Health Act in Congress, said she supports Steinberg’s proposal.

California Democratic Sen. Dianne Feinstein said she plans to introduce new gun control legislation in Congress.

In the California Legislature, Sen. Ted Gaines (R-Roseville) and Assembly member Nancy Skinner (D-Berkeley) have said they plan to introduce legislation dealing with mental health and firearms.

We asked experts and lawmakers how policymakers in Sacramento and Washington, D.C., should respond to the public debate triggered by the killing of 26 people at an elementary school.

We got responses from:

Laws, Policies on Mental Health, Guns Need Improvement

There is a lot we can do in the face of Sandy Hook, Tucson, Virginia Tech and other homicidal acts associated with mental illness. Homicide is preventable in as much as 65% of cases. The structure of our laws pertaining to firearms possession, severe mental illness, access to crisis mental health services and the quality of supervised mental health care need to be improved.

More restrictive firearm laws are associated with reduced homicide rates. The gun is a tool used to express aggression, and access should be restricted. 

Civil commitment law enables the state to confine and treat people in hospital and the community who, because of their mental illness, are considered dangerous to themselves or others or gravely disabled (in 46% of states) or more broadly (in 54% of states) because the person needs treatment for the protection of health and safety. The broader criteria are associated with 1.42 fewer homicides per 100,000 people. While we can reliably identify those who have committed a dangerous act, it is often too late to save them or others from their disturbed actions. In jurisdictions where broader criteria are used, patients come to treatment almost 25 weeks sooner, most likely preventing engagement in dangerous behavior. Civil commitment criteria should be broadened in those states relying solely on dangerousness presentations.

Civil commitment to hospital — involuntary inpatient commitment — is allowed in U.S. law only as a “least restrictive alternative.” A majority of states, therefore, use involuntary outpatient commitment as an alternative to inpatient care. Outpatient commitment allows a person to stay home and participate in a program of prescribed treatment. Failure to comply with mandated treatment results in hospitalization. Patients released from a psychiatric facility to outpatient commitment have a 14% lower death rate than those released from hospital without the benefit of such structured oversight. States that currently lack involuntary inpatient commitment or fail to enforce their laws need to adopt adequate implementation and enforcement.

The mental health court also offers mandated treatment programs as a jail diversion after a required guilty plea. Violation of treatment provisions however sends people to jail as opposed to hospital. This strategy should be used when a less restrictive means like outpatient commitment is not working.

These programs require psychiatric beds in hospitals and crisis facilities. Lower bed access is associated with an increase of 1.08 homicides per 100,000 in the U.S. The Affordable Care Act allows trial use of Medicaid funding for crisis care in institutions of mental disease. Previously, costs of care in such facilities were not covered by Medicaid. It would be helpful to see an expansion of this effort.

In 10 California general hospital psychiatric emergency departments, 29% of patients were involuntarily returned within 12 months for reasons closely akin to their initial visit.

Pushing people out of hospital too early often results in their return in a more deteriorated condition. The ACA has provisions that will penalize hospitals for inappropriate re-hospitalizations of patients with cardiac conditions. This provision needs to be applied to individuals with severe mental disorder.

Proposition 63 has made an excellent contribution to the care of people with severe mental illness. In expanding it nationally, however, we need to learn from its omissions. It fails dismally in recognition of the need to fund involuntary care and discourages students from learning how to deal with crisis patients by failing to fund training in situations where students are most likely to see such patient behavior — psychiatric emergency services. Such legislation adopted nationally with targeted funding for crisis and involuntary supervision is needed.

Lawmakers Should Fund Robust Mental Health System

It’s hard now to think of any good that might come from the situation in Connecticut. However, if there is a silver lining, it could be that it forces us as Americans to face this crisis we have in our country, to confront the stereotypes we embrace, to take steps to learn more about mental illness and what we can do to ensure that people have the care and treatment they need. Violent tragedies should not have to occur before the country realizes that mental health care must be a priority.

NAMI California will continue to work closely with Sen. Steinberg and the president to tackle these critical issues. Identifying and providing adequate funding for mental health services must be a priority in continuing to improve the lives of Californians and people across the nation with serious mental illness.

We must intervene earlier and ensure that essential mental health services and treatment are available at the earliest stages. We must demand:

  • Ease of access to mental health professionals;
  • Earlier and more assessable treatment; and
  • Access to effective treatments and strategies.

Millions of Americans face the day-to-day reality of living with a mental illness or caring for a family member who is suffering. It can be overwhelming. The reality is that when families get support from many directions and programs, outcomes in all areas are improved.

Mental illness exists in every state, city and neighborhood in the United States. One in four adults experiences a mental health problem in any given year. That’s nearly 60 million Americans. One in 10 children lives with a serious mental or emotional disorder. Yet less than one-third of adults and one-half of children with a diagnosed disorder receive mental health care.

We must demand that lawmakers focus on providing funding for a robust mental health system, one that leaves no one behind.

Time To Bolster Funding, Services for Mental Health Care

There are no words to describe the horror of the tragedy in Newtown, Conn., one month ago. That so many of the victims were young children who had their entire lives ahead of them makes this shooting all the more heartbreaking.

In the weeks since the shooting, there has been great discussion about what policymakers should do to address gun violence in our country. The reality is that there is no simple answer to this question. If we hope to reduce gun violence, a comprehensive approach is necessary. 

While I respect a citizen’s right to bear arms, I feel strongly that the government must take some common-sense steps to promote responsible gun ownership and to keep guns out of the hands of criminals. For example, Congress should act to strengthen background checks, eliminate large-capacity magazines and close gun show loopholes, all of which are current pieces of legislation that I have co-sponsored. Congress should also reinstate a federal assault weapons ban, as these deadly weapons have no place in our communities. 

In addition to common-sense gun violence prevention measures, the tragic shooting in Newtown has brought renewed attention to the necessity of investing in mental health prevention and treatment. I strongly believe that now is the time to bolster funding and services for mental health care and ensure all Americans have access to the treatment they need. To help achieve this, I will be reintroducing the Excellence in Mental Health Act this month. This legislation addresses our nation’s fragmented mental health system by enhancing Medicaid funding for organizations, clinics and health centers that offer community-based treatment and support for millions of low-income and vulnerable people with mental health and addiction disorders.

Community mental health providers have been ignored for far too long. It is time for mental health to be treated on a level playing field with the rest of our nation’s health care system. The federal government must step up and strengthen the mental health safety net, which has faced tremendous struggles across the country. Failure to do so not only jeopardizes the individuals who need these services the most, but would also be a complete disregard for the critical role mental health plays in overall public safety.

Ammunition -- Along With Guns -- Should be Regulated

California has multiple safeguards in place for the sale and purchase of guns, so why is it so easy to buy bullets the very thing that makes a gun deadly?

For the past decade, about 3,000 Californians have died each year from gunshots, and about that many are hospitalized each and every year from gunshot wounds. 

Yet, today there are more restrictions in place to buy alcohol, cigarettes or certain cold medicines than there are to buy bullets.

The few controls California does have in place — for example, restrictions that make it illegal for people with certain criminal or mental health records to buy bullets — are difficult to enforce because ammunition sellers don’t have to check IDs or keep records.

With support from law enforcement, city, school, youth and faith leaders, I introduced legislation that would put into place some of the same procedures on the sale and purchase of bullets that we now have on gun sales. 

My bill, AB 48, will help bulletproof our communities by requiring sellers of ammunition to be licensed, to check the ID of ammunition purchasers and to keep a record of bullet sales.

Those records would then be incorporated into the Department of Justice’s existing gun sales database. Maintaining a database on ammunition sales will help enforce existing law and enable local law enforcement to be notified if someone purchases a very large quantity of ammunition over a short time period.

AB 48 would also ban the sale of high-capacity ammunition clip kits that are used to convert a gun into an assault-style weapon that can shoot many bullets quickly without having to be reloaded.

With new safeguards in place, we may avert devastating tragedies and reduce the gun violence ravaging our communities.

California legislators have demonstrated their interest in regulating ammunition, having passed two recent bills by Sen. Kevin DeLeón (D-Los Angeles). But controls like these are always a struggle. Support from throughout the state will be necessary to withstand any push back.

I applaud President Obama for demonstrating national leadership and presenting a comprehensive plan aimed at reducing the gun violence and, hopefully, lessening the rash of mass shootings that have become an all-too-common occurrence.

Federal action like President Obama has proposed is needed to ensure that existing state efforts are effective. California and a number of other states have tough gun laws, but our ability to address gun violence is undermined when one can bypass California’s rules just by crossing state lines. 

As public opinion shows, there is strong national support for gun controls and for enforcement that can begin to reverse the gun violence devastating our communities.

$10 Billion Investment Plan for National Programs

The vast majority of Californians suffering from a mental illness will never commit a misdemeanor, let alone pick up a gun and kill. Mental illness does not equate to violence. But if a national tragedy instigates a national conversation about mental health, advocates for mental health services should not shy away from a discussion.

More than one in four Americans suffers from some form of mental illness or substance abuse annually, yet core mental health services are woefully underfunded. Since 2009, state governments have cut $4.35 billion collectively from mental health spending. If we’re serious about mental health, we have to act on what’s proven to work and fund it.

Next week, in meetings with Congress and the Biden Commission, I will present a $10 billion federal investment plan for mental health programs nationwide, based on a proven model: California’s Mental Health Services Act , enacted by Proposition 63 in 2004. (Editor’s note: Steinberg authored Prop. 63.)

Prevention and early intervention: Early intervention is the most effective form of mental health treatment. Up to 85 percent of people who receive appropriate treatment while experiencing a first episode of psychosis will recover completely. California invests 20 percent of MHSA revenue into prevention and early intervention programs. Nationally, this approach is overlooked too often.

School-based health centers: Initial episodes of severe mental illness usually occur between the ages of 12 and 24 years old. While mental health services are available at nearly 2,000 school-based health centers nationwide, most schools lack the resources to help students in need of more intensified care. A federal investment to expand such centers will help the next generation overcome mental and behavioral disorders in their early stages.

Comprehensive mental health treatment: California has provided a “whatever it takes” approach for 60,000 Californians of all ages who need the most intensive treatment. This provides mental health or substance abuse treatment, but can also include safe housing, work-training, help in school and physical health care.

Mental health treatment is not the singular solution to combat gun violence. But we know what works, we know what will improve lives, and we must be prepared to fund it.

We Need Proactive Mental Health Strategy

In the aftermath of the Newtown shootings, we can all agree that only a very mentally disturbed person would commit such a horrific crime. However, the tendency to assume that this means such a person is easily identified as someone who has known dangerous tendencies and should be hospitalized and treated involuntarily makes many inaccurate assumptions.

There are laws to order someone into treatment when they are dangerous to themselves or others or have a history of violence and resistance to treatment. However, very few people exhibit such noticeable symptoms and from what we know, the shooter in Connecticut was not one of them. 

The fundamental issue is that we are illiterate in reading the signs of mental illness. We need a proactive strategy as people will not on their own seek help as it is very difficult to see when our stress and upset is beyond normal ranges and represents a serious medical problem. Most suffer silently when only modest investments in a few therapy sessions and/or medications could help them early in the onset of their illness before their condition becomes disabling. 

It would be easy to include assessment and support for mental illness as a routine part of visits to primary care doctors. To do so would not only save lives but also save dollars as studies show that people with untreated mental illnesses have significantly greater incidence of diabetes, heart disease, hypertension, obesity, smoking and other costly medical conditions. 

Similarly, classroom teachers know who these students are but we don’t provide our schools with the support or connection to our health care system to provide the supports on campus where they will do the most good.

No, it won’t help everyone, especially the so-called “street people” whose mental illnesses have already become severe and disabling. For them, we also already know what to do and our California model Proposition 63 programs are successful in helping 60,000 on the road to recovery. Even with that funding, we can’t reach everyone who needs it, and more funding is needed. The Affordable Care Act will help, but more support is needed.

We have much work to do. Perhaps this latest tragedy can be the wake-up call to address these longstanding neglected parts of our health care system.