Homelessness and mental health

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https://en.wikipedia.org/wiki/Homelessness_and_mental_health 

In a study in Western societies, homeless people have a higher prevalence of mental illness when compared to the general population. They also are more likely to suffer from alcoholism and drug dependency. It is estimated that 20–25% of homeless people, compared with 6% of the non-homeless, have severe mental illness. Others estimate that up to one-third of the homeless have a mental illness. In January 2015, the most extensive survey ever undertaken found 564,708 people were homeless on a given night in the United States. Depending on the age group in question and how homelessness is defined, the consensus estimate as of 2014 was that, at minimum, 25% of the American homeless—140,000 individuals—were seriously mentally ill at any given point in time. 45% percent of the homeless—250,000 individuals—had any mental illness. More would be labeled homeless if these were annual counts rather than point-in-time counts. Being chronically homeless also means that people with mental illnesses are more likely to experience catastrophic health crises requiring medical intervention or resulting in institutionalization within the criminal justice system. Majority of the homeless population do not have a mental illness. Although there is no correlation between homelessness and mental health, those who are dealing with homelessness are struggling with psychological and emotional distress. The Substance Abuse and Mental Health Services Administration conducted a study and found that in 2010, 26.2 percent of sheltered homeless people had a severe mental illness.

Nikes and Homeless

Studies have found that there is a correlation between homelessness and incarceration. Those with mental illness or substance abuse problems were found to be incarcerated at a higher frequency than the general population. Fischer and Breakey have identified the chronically mentally ill as one of the four main subtypes of homeless persons; the others being the street people, chronic alcoholics, and the situationally distressed.

The first documented case of a psychiatrist addressing the issue of homelessness and mental health was in 1906 by Karl Wilmanns.

Historical context

United States

In the United States, there are broad patterns of reform within the history of psychiatric care for persons with mental illness. These patterns are currently categorized into three major cycles of reform. The first recognized cycle was the emergence of moral treatment and asylums, the second consists of the mental hygiene movement and the psychopathic (state) hospital, and most recent cycle includes deinstitutionalization and community mental health. In an article addressing the historical developments and reforms of treatment for the mentally ill, Joseph Morrissey and Howard Goldman acknowledge the current regression of public social welfare for mentally ill populations. They specifically state that the "historical forces that led to the transinstitutionalization of the mentally ill from almshouses to the state mental hospitals in the nineteenth and twentieth centuries have now been reversed in the aftermath of recent deinstitutionalization policies".

Asylums

Further information: Greyhound therapy

Within the context of transforming schemas of moral treatment during the early nineteenth century, the humanitarian focus of public intervention was linked with the establishment of asylums or snake pits for treatment of the mentally ill. The ideology that emerged in Europe disseminated to America, in the form of a social reformation based on the belief that new cases of insanity could be treated by isolating the ill into "small, pastoral asylums" for humane treatment. These asylums were meant to combine medical attention, occupational therapy, socialization activities and religious support, all in a warm environment.

In America, Friends Asylum (1817) and the Hartford Retreat (1824) were among the first asylums within the private sector, yet public asylums were soon encouraged, with Dorothea Dix as one of its key lobbyists. The effectiveness of asylums was dependent on a collection of structural and external conditions, conditions that proponents began to recognize were unfeasible to maintain around the mid-nineteenth century. For example, with the proliferation of immigrants throughout industrialization, the original purpose of asylums as small facilities transformed into their actualized use as "large, custodial institutions" throughout the late 1840s. Overcrowding severely inhibited the therapeutic capacity, inciting a political reassessment period about alternatives to asylums around the 1870s. The legislative purpose of state asylums soon met the role society had funneled them toward; they primarily became institutions for community protection, with treatment secondary.

Deinstitutionalization

Toward the end of World War II, the influx of soldiers diagnosed with "war neurosis" incited a new public interest in community care. In addition to this, the view that asylums and state hospitals exacerbated symptoms of mental illness by being "inherently dehumanizing and antitherapeutic" spread through the public consciousness. When psychiatric drugs like neuroleptics stabilized behavior and milieu therapy proved effective, state hospitals began discharging patients, with hope that federal programs and community support would counterbalance the effects of institutionalization. Furthermore, economic responsibility for disabled people began to shift, as religious and non-profit organization assumed the role of supplying basic needs. The modern results of deinstitutionalization show the dissonance between policy expectations and the actualized reality.

Community mental health centers

In response to the flaws of deinstitutionalization, a reform movement reframed the context of the chronically mentally ill within the lens of public health and social welfare problems. Policy makers intentionally circumvented state mental hospitals by allocating federal funds directly to local agencies. For example, the Community Mental Health Centers (CMHC) Act of 1963 became law, "which funded the construction and staffing of hundreds of federal centers to provide a range of services including partial hospitalization, emergency care, consultation, and treatment." Despite efforts, newly founded community centers "failed to meet the needs of acute and chronic patients discharged in increasing numbers from public hospitals". With decreased state collaboration and federal funding for social welfare, community centers essentially proved unable "to provide many essential programs and benefits", resulting in a growth of homelessness and indigency, or lack of access to basic necessities. It is argued that an over reliance on community health has "left thousands of former patients homeless or living in substandard housing, often without treatment, supervision or social support."

State mental hospitals

As debates regarding the deteriorating role of American asylums and psychiatry amplified around the turn of the century, new reformation arose. With the founding of the National Committee for Mental Hygiene, acute treatment centers like psychopathic hospitals, psychiatric dispensaries and child guidance clinics were created. Beginning with the State Care Act in New York, states began assuming full financial control for the mentally ill, in an effort to compensate for the deprivations of asylums. Between 1903 and 1950, the number of patients in state mental hospitals went from 150,000 to 512,000. Morrissey recognizes that despite persistent problem of chronic mental illness, these state mental hospitals were able to provide a minimal level of care. United States president John F. Kennedy signed the Community Mental Health Act that was put in place to give funding for community-based facilities rather than having patients going to state hospitals. Decades later, once the Community Mental Health Act was implemented a lot of state hospitals suffered and were on the verge of forced to close which pushed patients to the community-based facilities. The closures of the state hospitals lead to an overcrowding in the community facilities and there was a lack of support, which lead to patients not having access to the medical help they needed.

Personal factors

Neurobiological determinants

The mental health of homeless populations is significantly worse than the general population, with the prevalence of mental disorders up to four times higher in the former. It is also found that psychopathology and substance abuse often exist before the onset of homelessness, supporting the finding that mental disorders are a strong risk factor for homelessness. Ongoing issues with mental disorders such as affective and anxiety disorders, substance abuse and schizophrenia are elevated for the homeless. One explanation for homelessness states that "mental illness or alcohol and drug abuse render individuals unable to maintain permanent housing." One study further states that 10–20 percent of homeless populations have a dual diagnoses, or the co-existence of substance abuse and of another severe mental disorder. For example, in Germany there is a link between alcohol dependence and schizophrenia with homeless populations.

Trauma

There are patterns of biographical experience that are linked with subsequent mental health problems and pathways into homelessness. Martens states that reported childhood experiences, described as "feeling unloved in childhood, adverse childhood experiences, and general unhappiness in childhood" seem to become "powerful risk factors" for adult homelessness. For example, Martens emphasizes the salient dimension of familial and residential instability, as he describes the prevalence of foster-care or group home placement for homeless adolescents. He notes that "58 percent of homeless adolescents had experienced some kind of out-of-home placement, running away, or early departure from home." Moreover, up to 50 percent of homeless adolescents report experience with physical abuse, and almost one-third report sexual abuse. In addition to family conflict and abuse, early exposure to factors like poverty, housing instability, and alcohol and drug use all increase one's vulnerability to homelessness. Once impoverished, the social dimension of homelessness manifests from "long exposure to demoralizing relationships and unequal opportunities."

Trauma and homeless youth

Youth experiencing homelessness are more susceptible to developing post-traumatic stress disorder (PTSD). Common psychological traumas experienced by homeless youth include, sexual victimization, neglect, experiences of violence, and abuse. In an article published by Homeless Policy Research Institute it notes that homeless youth are subjected to many different forms of trauma. A study was done and found that 80% of youth that experienced homelessness in Los Angeles suffered at least one traumatic experience. Another study was conducted in Canada that showed a more severe statistic that Canadian homeless youth have been through 11 to 12 traumatic experiences. While trauma is prevalent in homeless youth, it is not uncommon for an adolescent to experience an increase of trauma after they experience homelessness. The LGBTQ community represents 20% of the homeless youth population. The reason for this high percentage is due to the issues and/or rejection from their family due to the sexual orientation.

Societal factors

Draine et al. emphasize the role of social disadvantage with manifestations of mental illness. He states that "research on mental illness in relation to social problems such as crime, unemployment, and homelessness often ignores the broader social context in which mental illness is embedded."

Social barriers

Main article: Discrimination against the homeless

Stigma

Lee argues that societal conceptualizations of homelessness and poverty can be juxtaposed, leading to different manifestations of public stigma. In his work through national and local surveys, respondents tended to deemphasize individual deficits over "structural forces and bad luck" for homeless individuals. In contrast, the respondents tended to associate personal failures more to the impoverished than homeless individuals.

Nonetheless, homeless individuals are "well aware of the negative traits imputed to them – lazy, filthy, irresponsible dangerous – based on the homeless label." In an effort to cope with the emotional threat of stigma, homeless individuals may rely on one another for "non-judgmental socializing". However, his work continues to emphasize that the mentally ill homeless are often deprived of social networks like this.

Social isolation

People who are homeless tend to be socially isolated, which contributes negatively to their mental health. Studies have correlated that those who are homeless and have a strong support group tend to be more physically and mentally healthy. Aside from the stigma received by the homeless population, another aspect that contributes to social isolation is the purposeful avoidance of social opportunity practiced by the homeless community out of shame of revealing their current homeless state. Social isolation ties directly to social stigma in that homeless socialization outside of the homeless community will affect how the homeless are perceived. This is why homeless individuals talking with those who are not homeless is encouraged since it can combat the stigma that is often associated with homelessness.

Racial inequality

One dimension of the American homeless is the skewed proportion of minorities. In a sample taken from Los Angeles, 68 percent of the homeless men were African American. In contrast, the Netherlands sample had 42 percent Dutch, with 58 percent of the homeless population from other nationalities. Furthermore, Lee notes that minorities have a heightened risk of the "repeated exit-and-entry pattern"

Institutional barriers

Shinn and Gillespie (1994) argued that although substance abuse and mental illness is a contributing factor to homelessness, the primary cause is the lack of low-income housing. Elliot and Krivo emphasize the structural conditions that increase vulnerability to homelessness. Within their study, these factors are specifically categorized into "unavailable low-cost housing, high poverty, poor economic conditions, and insufficient community and institutional support for the mentally ill." Through their correlational analysis, they reinforce the finding that areas with more spending on mental health care have "notably lower levels of homelessness." Furthermore, their findings emphasize that among the analyzed correlates, "per capita expenditures on mental health care, and the supply of low-rent housing are by far the strongest predictors of homelessness rates." Along with economic hardship, patterns of academic underachievement also undermine an individual's opportunity for reintegration into general society, which heightens their risk for homelessness.

On a psychological level, Lee notes that the "stressful nature of hard times (high unemployment, a tight housing market, etc.) helps generate personal vulnerabilities and magnifies their consequences." For example, poverty is a key determinant of the relationship between debilitating mental illness and social maladjustment; it is associated with decreased self-efficacy and coping. Moreover, poverty is an important predictor of life outcomes, such as "quality of life, social and occupational functioning, general health and psychiatric symptoms", all relevant aspects of societal stability. Thus, systemic factors tend to compound mental instability for the homeless. Tackling homelessness involves focusing on the risk factors that contribute to homelessness as well as advocating for structural change.

Consequences

Incarceration

It is argued that persons with mental illness are more likely to be arrested, simply from a higher risk of other associated factors with incarceration, such as substance abuse, unemployment, and lack of formal education. Furthermore, when correctional facilities lack adequate coordination with community resources upon release, the chances of recidivism increase for persons who are both homeless and have a mental illness. Every state in the United States incarcerates more individuals with severe mental illness than it hospitalizes. Incarcerations are due to lack of treatments such as psychiatric hospital beds. Overall, according to Raphael and Stoll, over 60 percent of United States jail inmates report mental health problems. Estimates from the Survey of Inmates in State and Federal Correctional Facilities (2004) and the Survey of Inmates in Local Jails (2002) report that the prevalence for severe mental illness (the psychoses and bipolar/manic-depressive disorders) is 3.1–6.5 times the rate observed for the general population. In relation to homelessness, it is found that 17.3 percent of inmates with severe mental illness experienced a homeless state before their incarceration, compared to 6.5 percent of undiagnosed inmates. The authors argue that a significant portion of deinstitutionalized mentally ill were transitioned into correctional facilities, by specifically stating that "transinstitutional effect estimates suggest that deinstitutionalization has played a relatively minor role in explaining the phenomenal growth in U.S. incarceration levels."

Responses

Responses to mental health and homelessness include measures focused on housing and mental health services. Providers face challenges in the form of community adversity.

Housing

Modern efforts to reduce homelessness include "housing-first models", where individuals and families are placed in permanent homes with optional wrap-around services. This effort is less expensive than the cost of institutions that serve the complex needs of people experiencing homeless, such as emergency shelters, mental hospitals and jails. The alternative approach of housing first has shown positive outcomes. One study reports an 88 percent housing retention rate for those in Housing First, compared to 47 percent using traditional programs. Additionally, a review of permanent supportive housing and case management on health found that interventions using “housing-first models” can improve health outcomes among chronically homeless individuals, many of whom have substance use disorders and severe mental illness. Improvements include positive changes in self-reported mental health status, substance use, and overall well-being. These models can also help reduce hospital admissions, length of stay in inpatient psychiatric units, and emergency room visits. There is a new intervention called "Permanent Supportive Housing" that was designed help independent living and help with employment and health care. 407,966 individuals were homeless in shelters, transitional housing programs, or on the streets. Those with mental illnesses have difficulty not only with their current housing issues, but have issues with housing if they get evicted. Youth can benefit from permanent housing, increases social activity, and improve mental health. Federally funded rental assistance are in place, but due to the high demand of the funds, the government is unable to keep up.

One study evaluating the efficacy of the Housing First model followed mentally ill homeless individuals with criminal records over a two-year period, and after being placed in the Housing First program only 30% re-offended. Overall results of the study showed a large reduction in re-conviction, increased public safety, and a reduction in crime rates. A significant decline in drug use was also seen with the implementation of the Housing First model. The study showed a 50% increase in housing retention and a 30% increase in methadone treatment retention in program participants.

Mental health services

Uninterrupted assistance greatly increases the chances of living independently and greatly reduces the chances of homelessness and incarceration. Through longitudinal comparisons of sheltered homeless families and impoverished domiciled families, there are a collection of social buffers that slow one's trajectory toward homelessness. A number of these factors include "entitlement income, a housing subsidy, and contact with a social worker." These social buffers can also be effective in supporting individuals exiting homelessness. One study utilizing Maslow's hierarchy of needs in assessing housing experiences of adults with mental illnesses found a complex relationship between basic needs, self-actualization, goal setting, and mental health. Meeting self-actualization needs are vital to mental health and treatment of mental illness. Housing, stable income, and social connectedness are basic needs, and when met can lead to fulfillment of higher needs and improved mental health. Those with a brief history of homelessness and managed disabilities may have better access to housing.

Research calls for evidence based remediation practices that transform mental health care into a recovery oriented system. The following list includes practices currently being utilized to address the mental health needs of homeless individuals:

• Integrated service system, between and within agencies in policy making, funding, governance and service delivery.
• Low barrier housing with support services.
• Building Assertive Community Teams (ACT) and Forensic Assertive Community Teams (FACT).
• Assisted Community Treatment (ACT).
• Outreach services that identify and connect homeless to the social service system and help navigate the complex, fragmented web of services.

Challenges

Fear surrounds the introduction of mentally ill homeless housing and treatment centers into neighborhoods, due to existing stereotypes that homeless individuals are often associated with increased drug use and criminal activity. The Housing First Model study, along with other studies, show that this is not necessarily the case. Proponents of the NIMBY (not-in-my-backyard) movement have played an active role in the challenges faced by housing and mental health service interventions for the homeless.

Conclusion

For some individuals, the pathways into homelessness may be upstream. E.g. issues such as housing, income level, or employment status. For others, the pathways may be more personal or individual. E.g. issues such as compromised mental health and well ‐ being, mental illness, and substance abuse. Many of these personal and upstream issues are interconnected.

Psychiatrist

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Psychiatrist 

Psychiatrist

Occupation
Names	Psychiatrist alienist (archaic)
Occupation type	Profession specialization
Activity sectors	Medicine psychiatry
Description
Competencies	Analytical mind patience
Education required	Doctor of Medicine (M.D.) Bachelor of Medicine, Bachelor of Surgery (MBBS/MBChB) Doctor of Osteopathic Medicine (D.O.)
Fields of employment	Psychiatric clinics
Related jobs	Psychologist psychotherapist Psychiatric-mental health nurse practitioner

A psychiatrist is a physician who specializes in psychiatry. Psychiatrists are physicians and evaluate patients to determine whether their symptoms are the result of a physical illness, a combination of physical and mental ailments or strictly mental issues. Sometimes a psychiatrist works within a multi-disciplinary team, which may comprise clinical psychologists, social workers, occupational therapists, and nursing staff. Psychiatrists have broad training in a biopsychosocial approach to the assessment and management of mental illness.

As part of the clinical assessment process, psychiatrists may employ a mental status examination; a physical examination; brain imaging such as a computerized tomography, magnetic resonance imaging, or positron emission tomography scan; and blood testing. Psychiatrists use pharmacologic, psychotherapeutic, and/or interventional approaches to treat mental disorders.

Subspecialties

The field of psychiatry has many subspecialties that require additional (fellowship) training, which, in the USA, are certified by the American Board of Psychiatry and Neurology (ABPN) and require Maintenance of Certification Program to continue. These include the following:

• Clinical neurophysiology
• Forensic psychiatry
• Addiction psychiatry
• Child and adolescent psychiatry
• Geriatric psychiatry
• Palliative care
• Pain management
• Consultation-liaison psychiatry
• Sleep medicine
• Brain injury medicine

Further, other specialties that exist include:

• Cross-cultural psychiatry
• Emergency psychiatry
• Learning disability
• Neurodevelopmental disorder
• Cognition diseases, as in various forms of dementia
• Biological psychiatry
• Community psychiatry
• Global mental health
• Military psychiatry
• Social psychiatry
• Sports psychiatry

The United Council for Neurologic Subspecialties in the United States offers certification and fellowship program accreditation in the subspecialties of behavioral neurology and neuropsychiatry, which is open to both neurologists and psychiatrists.

Some psychiatrists specialize in helping certain age groups. Pediatric psychiatry is the area of the profession working with children in addressing psychological problems. Psychiatrists specializing in geriatric psychiatry work with the elderly and are called geriatric psychiatrists or geropsychiatrists. Those who practice psychiatry in the workplace are called occupational psychiatrists in the United States and occupational psychology is the name used for the most similar discipline in the UK. Psychiatrists working in the courtroom and reporting to the judge and jury, in both criminal and civil court cases, are called forensic psychiatrists, who also treat mentally disordered offenders and other patients whose condition is such that they have to be treated in secure units.

Other psychiatrists may also specialize in psychopharmacology, psychotherapy, psychiatric genetics, neuroimaging, dementia-related disorders such as Alzheimer's disease, attention deficit hyperactivity disorder, sleep medicine, pain medicine, palliative medicine, eating disorders, sexual disorders, women's health, global mental health, early psychosis intervention, mood disorders and anxiety disorders such as obsessive–compulsive disorder and post-traumatic stress disorder.

Psychiatrists work in a wide variety of settings. Some are full-time medical researchers, many see patients in private medical practices, and consult liaison psychiatrists see patients in hospital settings where psychiatric and other medical conditions interact.

Professional requirements

While requirements to become a psychiatric physician differ from country to country, all require a medical degree.

India

In India, a Bachelor of Medicine, Bachelor of Surgery (MBBS) degree is the basic qualification needed to do psychiatry. After completing an MBBS (including an internship), they can attend various PG medical entrance exams and get a Doctor of Medicine (M.D.) in psychiatry, which is a 3-year course. Diploma course in psychiatry or DNB psychiatry can also be taken to become a psychiatrist.

Netherlands

In the Netherlands, one must complete medical school after which one is certified as a medical doctor. After a strict selection program, one can specialize for 4.5-years in psychiatry. During this specialization, the resident has to do a 6-month residency in the field of social psychiatry, a 12-month residency in a field of their own choice (which can be child psychiatry, forensic psychiatry, somatic medicine, or medical research). To become an adolescent psychiatrist, one has to do an extra specialization period of 2 more years. In short, this means that it takes at least 10.5 years of study to become a psychiatrist which can go up to 12.5 years if one becomes a children's and adolescent psychiatrist.

Pakistan

In Pakistan, one must complete basic medical education, an MBBS, then get registered with the Pakistan Medical and Dental Council (PMDC) as a general practitioner after a one-year mandatory internship, house job. After registration with PMDC, one has to take the FCPS-I exam. After that, they pursue four additional years of training in psychiatry at the College of Physicians and Surgeons Pakistan. Training includes rotations in general medicine, neurology, and clinical psychology for 3 months each, during the first two years. There is a mid-exam intermediate module and a final exam after 4 years.

United Kingdom and the Republic of Ireland

In the United Kingdom, psychiatrists must hold a medical degree. Following this, the individual will work as a foundation house officer for two additional years in the UK, or one year as an intern in the Republic of Ireland to achieve registration as a basic medical practitioner. Training in psychiatry can then begin and it is taken in two parts: three years of basic specialist training culminating in the MRCPsych exam, followed by three years of higher specialist training referred to as "ST4-6" in the UK and "Senior Registrar Training" in the Republic of Ireland. Candidates with MRCPsych degree and complete basic training must reinterview for higher specialist training. At this stage, the development of special interests such as forensic or child/adolescent takes place. At the end of 3 years of higher specialist training, candidates are awarded a Certificate of Completion of (Specialist) Training (CC(S)T). At this stage, the psychiatrist can register as a specialist, and the qualification of CC(S)T is recognized in all EU/EEA states. As such, training in the UK and Ireland is considerably longer than in the US or Canada and frequently takes around 8–9 years following graduation from medical school. Those with a CC(S)T will be able to apply for consultant posts. Those with training from outside the EU/EEA should consult local/native medical boards to review their qualifications and eligibility for equivalence recognition (for example, those with a US residency and ABPN qualification).

United States and Canada

In the United States and Canada, one must first attain the degree of M.D. or Doctor of Osteopathic Medicine, followed by practice as a psychiatric resident for another four years (five years in Canada). This extended period involves comprehensive training in psychiatric diagnosis, psychopharmacology, medical care issues, and psychotherapies. All accredited psychiatry residencies in the United States require proficiency in cognitive behavioral, brief, psychodynamic, and supportive psychotherapies. Psychiatry residents are required to complete at least four post-graduate months of internal medicine or pediatrics, plus a minimum of two months of neurology during their first year of residency, referred to as an "internship". After completing their training, psychiatrists are eligible to take a specialty board examination to become board-certified. The total amount of time required to complete educational and training requirements in the field of psychiatry in the United States is twelve years after high school. The average salary for psychiatrists in the U.S. is $220,000 per year. Subspecialists in child and adolescent psychiatry are required to complete a two-year fellowship program, the first year of which can run concurrently with the fourth year of the general psychiatry residency program. This adds one to two years of training.

Mentally ill people in United States jails and prisons

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Mentally_ill_people_in_United_States_jails_and_prisons 

Mentally ill people are overrepresented in United States jail and prison populations relative to the general population. There are three times more seriously mentally ill people in jails and prisons than in hospitals in the United States. Scholars discuss many different causes of this overrepresentation including the deinstitutionalization of mentally ill individuals in the mid-twentieth century; inadequate community mental health treatment resources; and the criminalization of mental illness itself. The majority of prisons in the United States employ a psychiatrist and a psychologist. There is a consensus that mentally ill offenders have comparable rates of recidivism to non-mentally ill offenders. Mentally ill people experience solitary confinement at disproportionate rates and are more vulnerable to its adverse psychological effects. Twenty-five states have laws addressing the emergency detention of the mentally ill within jails, and the United States Supreme Court has upheld the right of inmates to mental health treatment.

Prevalence

There is a broad scholarly consensus that mentally ill individual's are overrepresented within the United States jail and prison populations. In a 2010 study, researchers concluded that, based on statistics from sources including the Bureau of Justice Statistics and the U.S. Department of Health and Human Services, there are currently three times more seriously mentally ill persons in jails and prisons than in hospitals in the United States, with the ratio being nearly ten to one in Arizona and Nevada. "Serious mental illness" is defined here as schizophrenia, bipolar disorder or major depression. Further, they found that sixteen percent of the jail and prison population in the U. S. has a serious mental illness (compared to 6.4 percent in 1983), although this statistic does not reflect differences among individual states. For example, in North Dakota they found that a person with a serious mental illness is equally likely to be in prison or a jail versus hospital, whereas in states such as Arizona, Nevada and Texas, the imbalance is much more severe. Finally, they noted that a 1991 survey by the National Alliance for the Mentally Ill concluded that jail and/or prison is part of the life experience of forty percent of these mentally ill individuals. In addition to mood and anxiety disorders, other psychopathologies have also been found in the US Prison System. Antisocial personality disorder is found in less than 6% of the general American population, but seems to be found in anywhere between 12% and 64% of prison samples. Estimates of Borderline Personality Disorder seem to make up around 1% to 2% in the general public vs 12% to 30% within prisons. Personality disorders, especially of the inmate population, are often found to be comorbid with other disorders.

A separate research study "The Prevalence of Mental Illness among Inmates in a Rural State" noted that national statistics like those previously mentioned primarily pull data from urban jails and prisons. In order to investigate possible differences in rural areas, researchers interviewed a random sample of inmates in both jails and prisons in a rural northeastern state. They found that in this rural setting, there was little evidence of high rates of mental illness within jails, "suggesting the criminalization of mental illness may not be as evident in rural settings as urban areas." However, high rates of serious mental illness were found among rural prison inmates.

A 2017 report issued by the Bureau of Justice Statistics used self-report survey data from inmates to assess the prevalence of mental health problems among prisoners and jail inmates. They found that 14% of prisoners and 25% of jail inmates had past 30-day serious psychological distress, compared to 5% of the general population. In addition, 37% of prisoners and 44% of jail inmates had a history of mental health problems.

In 2015 lawyer and activist Bryan Stevenson claimed in his book Just Mercy that over fifty percent of inmates in jails and prisons in the United States had been diagnosed with a mental illness and that one in five jail inmates had had a serious mental illness. As for the gender, age, and racial demographics of mentally ill offenders, the 2017 Bureau of Justice Statistics report found that female inmates, when compared to male inmates, had statistically significantly higher rates of serious psychological distress (20.5% of female prisoners and 32.3% of female jail inmates had serious psychological distress, versus 14% of male prisoners and 25.5% of male jail inmates) and a history of a mental health problem (65.8% of female prisoners and 67.9% of female jail inmates compared to 34.8% of male prisoners and 40.8% of male jail inmates). Significant differences between race and ethnicity were also observed. White prisoners and jail inmates were more likely to have serious psychological distress or a history of mental health problems than black or Hispanic inmates. For example, in local jails, 31% of white inmates had serious psychological distress compared to 22.3% of black inmates and 23.2% of Hispanic inmates. Finally, with regards to age, there were virtually no statistical differences between age groups and the percentage of those who have serious psychological distress or a history of a mental health problem.

Potential reasons for the high number of incarcerated people diagnosed with mental illnesses

Deinstitutionalization

Researchers commonly cite deinstitutionalization, or the emptying of state mental hospitals in the mid-twentieth century, as a direct cause of the rise of mentally ill people in prisons. In the 2010 study "More mentally ill persons are in jails and prisons than hospitals: a survey of the states," researchers noted, at least in part due to deinstitutionalization, it is increasingly difficult to find beds for mentally ill people who need hospitalization. Using data collected by the Department of Health and Human Services, they determined there was one psychiatric bed for every 3,000 Americans, compared to one for every 300 Americans in 1955. They also noted increased percentages of mentally ill people in prisons throughout the 1970s and 1980s and found a strong correlation between the amount of mentally ill persons in a state's jails and prisons and how much money that state spends on mental health services. In the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails As Mental Hospitals, researchers note that while deinstitutionalization was carried out with good intentions, it was not accompanied with alternate avenues for mental health treatment for those with serious mental illnesses. According to the authors, Community Mental Health Centers focused their limited resources on individuals with less serious mental illnesses, federal training funds for mental health professionals resulted in lots more psychiatrists in wealthy areas but not in low-income areas, and a policy that made individuals eligible for federal programs and benefits only after they'd been discharged from state mental hospitals unintentionally incentivized discharging patients without follow-up.

In the article "Assessing the Contribution of the Deinstitutionalization of the Mentally Ill to Growth in the U.S. Incarceration Rate" researchers Steven Raphael and Michael A. Stoll discuss transinstitutionalization, or how many patients released from mental hospitals in the mid-twentieth century ended up in jail or prison. Using U.S. census data collected between 1950 and 2000, they concluded that "those most likely to be incarcerated as of the 2000 census experienced pronounced increases in overall institutionalization between 1950 and 2000 (with particularly large increases for black males). Thus, the impression created by aggregate trends is somewhat misleading, as the 1950 demographic composition of the mental hospital population differs considerably from the 2000 demographic composition of prison and jail inmates." However, when estimating (using a panel data set) how many individuals incarcerated between 1980 and 2000 would have been institutionalized in years past, they found significant transinstitutionalization rates for all men and women, with the largest rate for white men.

Accessibility

A main contributing factor as to why the US is seeing a steady increase in those who are mentally ill within the prison system, can be due to the lack of accessibility in various communities. Specifically, those who come from a lower income background face these issues, in which there are little to no resources being offered that are readily available for those experiencing ongoing difficulty with their mental health. The AMA Journal of Ethics discusses more specific factors as to why there are consistently high arrest rates of those with severe mental illness within communities, stating that the arrests of drug offenders, lack of affordable housing, as well as a significant lack of funding for community treatments are main contributors. With the introduction of Medicaid, many state-run mental health facilities closed due to a shared responsibility of funding with the federal government. Eventually, states would entirely close a good portion of their facilities, so that mentally ill patients were being treated at hospitals where they would partially be covered by Medicaid and the government. The National Council for Behavioral Health conducted a study in October 2018, which included survey results that confirmed “nearly six in 10 (56%) Americans [are] seeking or wanting to seek mental health services either for themselves or for a loved one...These individuals are skewing younger and are more likely to be of lower income and military background”.

Criminalization

A related cause of the disproportionate amount of mentally ill people in prisons is criminalization of mental illness itself. In the 1984 study "Criminalizing mental disorder: The comparative arrest rate of the mentally ill", researcher L. A. Teplin notes that in addition to a decline in federal support for mental illness resulting in more people being denied treatment, mentally ill people are often stereotyped as dangerous, making fear a factor in action taken against them. Bureaucratic and legal impediments to initiating mental health referrals means arrest can be easier, and in Teplin's words, "Due to the lack of exclusionary criteria, the criminal justice system may have become the institution that cannot say no." Mentally ill people do indeed experience higher arrest rates than those without mental illness, but in order to investigate whether or not this was due to criminalization of mental illness, researchers observed police officers over a period of time. As a result, they concluded, "within similar types of situations, persons exhibiting signs of mental disorder have a higher probability of being arrested than those who do not show such signs."

The authors of the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails As Mental Hospitals claim that nationwide, 29% of jails will hold mentally ill individuals with no charges brought against them, sometimes as a means of 'holding' them when psychiatric hospitals are very far away. This practice occurs even in states where it is explicitly forbidden. Beyond that, according to the authors, the vast majority of people with mental illnesses in jails in prisons are held on minor charges like theft, disorderly conduct, alcohol/drug related charges, and trespassing. These are sometimes "mercy bookings" intended to get the homeless mentally ill off the street, a warm meal, etc. Family members have reported being encouraged by mental health professionals or police to get their loved ones arrested as a means of getting them treatment. Finally, some mentally ill people are in jails and prisons on serious charges, such as murder. The authors of Criminalizing the Seriously Mentally Ill claim many such crimes wouldn't have been committed if the individuals had been receiving proper care.

Malingering

Some inmates feign psychiatric symptoms for secondary gain. For example, an inmate may hope to receive a transfer to a more desirable setting or receive psychotropic medication.

Exacerbation of mental illness in a prison setting

Another proposed reason for the high number of incarcerated with mental illness is the way how a prison setting can worsen mental health. Individuals with pre-existing mental health conditions can worsen, or new mental health problems may arise. A few reasons are listed as to how prisons can worsen the mental health of the incarcerated:

• Separation from loved ones
• Lack of movement/isolation
• Overcrowded prisons
• Witnessing violence in the prison setting

Mental health care in prisons and jails

Psychologists report that one in every eight prisoners were receiving some mental health therapy or counseling services by the middle of the year in 2000. Inmates are generally screened at admission and depending on the severity of the mental illness they are placed in either general confinement or specialized facilities. Inmates can self report mental illness if they feel it is necessary. In the middle of the year in 2000, inmates self-reported that State prisons held 191,000 mentally ill inmates. A 2011 survey of 230 correctional mental health service providers from 165 state correctional facilities found that 83% of facilities employed at least one psychologist and 81% employed at least one psychiatrist. The study also found that 52% of mentally ill offenders voluntarily received mental health services, 24% were referred by staff, and 11% were mandated by a court to receive services. Although 64% of providers of mental health services reported feeling supported by prison administration and 71% were involved in continuity of care after release from prison, 65% reported being dissatisfied with funding. Only 16% of participants reported offering vocational training, and the researchers noted that although risk/need/responsivity theory has been shown to reduce the risk for recidivism (or committing another crime after being released), it is unknown whether it is incorporated into mental health services in prisons and jails. A 2005 article by researcher Terry A. Kupers noted that male prisoners tend to underreport emotional problems and don't request help until a crisis, and that prison fosters an environment of toxic masculinity, which increases resistance to psychotherapy. A 2017 report from the Bureau of Justice Statistics noted that 54.3% of prisoners and 35% of jail inmates who had past 30-day serious psychological distress has received mental health treatment since admission to the current facility; and 63% of prisoners and 44.5% of jail inmates with a history of a mental health problem said they had received mental health treatment since admission.

Finally, the book Criminalizing the Seriously Mentally Ill: The Abuse of Jails As Mental Hospitals points out that 20% of jails have no mental health resources. In addition, small jails are less likely to have access to mental health resources and are more likely to hold individuals with mental illnesses without charges brought against them. Jails in richer areas are more likely to have access to mental health resources, and jails with more access to mental health resources also dealt less with medication refusal.

Recidivism

Research shows that rates of recidivism, or re-entry into prison, are not significantly higher for mentally ill offenders. A 2004 study found that although 77% of mentally ill offenders studied were arrested or charged with a new crime within the 27-55 month follow-up period, when compared with the general population, "our mentally ill inmates were neither more likely nor more serious recidivists than general population inmates." In contrast, a 2009 study that examined the incarceration history of those in Texas Department of Criminal Justice facilities found that "Texas prison inmates with major psychiatric disorders were far more likely to have had previous incarcerations compared with inmates without a serious mental illness." In the discussion, the researchers noted that their study's results differed from most research on this subject, and hypothesized that this novelty could be due to specific conditions within the state of Texas.

A 1991 study by L. Feder noted that although mentally ill offenders were significantly less like to receive support from family and friends upon release from prison, mentally ill offenders were actually less likely to be revoked on parole. However, for nuisance arrests, mentally ill offenders were less likely to have the charges dropped, although they were more likely to have charges dropped for drug arrests. In both cases, mentally ill offenders were more likely to be tracked into mental health. Finally, there were no significant differences in charges for violent arrests.

Tools for effective mental healthcare

A research paper published in 2020 by M. Georgiou remarked that having a well defined consultation process of mental health services will allow for effective care. This is called the Care Programme Approach. It lists six steps to effective care of the prisoner:

1. Identify the health and need of care of the prisoner.
2. Written and clear plans.
3. Having key persons in supervision of the program.
4. Regular assessments of the program.
5. Interprofessional involvement.
6. Career involvement.

Solitary confinement

A broad range of scholarly research maintains that mentally ill offenders are disproportionately represented in solitary confinement and are more vulnerable to the adverse psychological effects of solitary confinement. Due to differing schemes of classification, empirical data on the makeup of inmates in segregated housing units can be difficult to obtain, and estimates of the percentage of inmates in solitary confinement who are mentally ill range from nearly a third, to 11% (with a "major mental disorder"), to 30% (from a study conducted in Washington), to "over half" (from a study conducted in Indiana), depending on how mental illness is determined, where the study is conducted, and other differences in methodology. Researchers J. Metzner and J. Fellner note that mentally ill offenders in solitary confinement "all too frequently" require crisis care or psychiatric hospitalization, and that "many simply won't get better as long as they are isolated." Researchers T. L. Hafemeister and J. George note that mentally ill offenders in isolation are at higher risk for psychiatric injury, self-harm and suicide. A 2014 study that analyzed data from medical records in the New York City jail system found that while self-harm was significantly correlated with having a serious mental illness regardless of whether or not an inmate was in solitary confinement, inmates with serious mental illness in solitary confinement under 18 years of age accounted for the majority of acts of self-harm studied. When brought before federal courts, judges have prohibited or curtailed this practice, and many organizations that deal with human rights, including the United Nations, have condemned it.

In addition, scholars argue the conditions of solitary confinement make it much more difficult to deliver proper psychiatric care. According to researchers J. Metzner and J. Fellner, "Mental health services in segregation units are typically limited to psychotropic medication, a health care clinician stopping at the cell front to ask how the prisoner is doing (i.e., mental health rounds), and occasional meetings in private with a clinician." One study in the American Journal of Public Health claimed that health care professionals must "frequently" conduct consultation through a slit in a cell door or an open tier that provides no privacy.

However, some researchers disagree with the scope of claims surrounding the psychological effects of solitary confinement. For example, in 2006 researchers G. D. Glancy and E. L. Murray conducted a literature review in which they claimed that many frequently-cited studies have methodological concerns, including researcher bias, the use of "volunteer nonprisoners, naturalistic experiments, or case reports, case series, and anecdotes" and concluded "there is little evidence to suggest the majority...kept in SC...experience negative mental health effects." However, they did support claims that inmates with preexisting mental illnesses are more vulnerable and do suffer adverse effects. In their conclusion they claim "we should therefore be concerned about those with pre-existing mental illness who are housed in segregation because there is nowhere else to put them within the correctional system."

Community standpoint and outcome

Social stigma regarding this issue is significant due to the public's outlook and perception of mental health, where some may not recognize it as a health factor that needs to be addressed. It is for this reason that some may avoid or deny the assistance being offered to them, thus further suppressing feelings and experiences that eventually need to be dealt with. The NCBH notes that about one-third of Americans, or 38%, state that they worry about their peers and family members judging them if they were to seek mental help.

Without the presence of these facilities within communities, there is an outcome of mentally ill individuals carrying on with no preventative treatment or care to keep the severity of their condition to a healthy level. Just about 2 million of these individuals go to jail each year, moreover, data shows that 15% of men and 30% of women who are taken to prison, do in fact have a serious mental health condition. The National Alliance on Mental Illness further looks into the results of decreased mental health services, and they found that for many, individuals do ultimately become homeless, or they find themselves in emergency rooms, as a result of inaccessibility to mental services and support groups. Statistics show that about 83% of jail inmates did not have access to needed treatment, prior to their incarceration, within their community which is why some may be rearrested for crimes as a way to return to some form of assistance. The Marshall Project has gathered data regarding those being treated in jail, and what they found was that the Federal Bureau of Prisons implicated a new policy to be initiated that was meant to improve the care for inmates with mental health issues. It ultimately led to decreasing the number of inmates who were categorized as needing higher care levels by more than 35%. After this policy change, the Marshall Project noted the steady decline since May 2014 of inmates receiving treatment for a mental illness. Research shows that within recent years, those with “serious psychotic disorders, especially when untreated, can be more likely to commit a violent crime”.

It is said that an institutional shift would be more effective in reducing the number of incarcerated through the collaboration of multiple agencies, especially when it comes to the criminal justice system and the community. This collaboration between agencies deviates from the "self-perpetuating" system meant to incarcerate and process individuals in an administrative manner; therefore, it focuses closely on people with severe mental illness, and ensure ongoing care within and out of prison to reduce recidivism.

Legal aspects

Current Laws

The Federal Bureau of Prisons has claimed to have made policy changes, but those changes only apply to the rules within the system, and they did not fund resources to carry those new implementations out. It should also be noted that within the prison system, states have laws and responsibilities to ensure as well, one being within the Eighth amendment that requires prisoners' medical needs to consistently be met. The Prison Litigation Reform Act upholds this right in federal court cases.

As of late December 2018, the First Step Act (S 756) was signed into law as a way to a way to reduce recidivism and provide overall improvements to the conditions faced within federal prisons, as well as working to reduce the mandatory sentences given. Although, this Act primarily applies to about 225.000, or 10%, of individuals in federal prisons and jails, whereas this reform may not be applied to those in state prisons and jails. Some of the provisions that result from this act include staff training as to how to identify and assist those suffering from a mental illness and providing improved, accessible treatment regarding drug abuse with programs like medication-assisted treatment.

The implementation of significantly more Certified Community Behavioral Health Clinics has been discussed as a solution to the issue of mental health in the prison system as well. Its primary goal is to cater to the needs of its specific communities and expand access to mental health treatment for everyone. The claims of an organization like this is to reduce criminal justice costs, as well as hospital readmissions, and, once again, to reduce recidivism. They strive to treat individuals with mental illness early on, rather than allowing them to carry on without professional care and general support.

Emergency detention

One major area of legal concern is the emergency detention of the non-criminal mentally ill in jails while waiting for formal procedures for involuntary hospitalization. Twenty-five states and the District of Columbia have laws that specifically address this practice; eight of these states, as well as D. C., explicitly forbid it. Seventeen states, on the other hand, explicitly allow it. Within this set, the criteria and circumstances necessary differ by state, and most states limit the detention periods in jails to one to three days. One distinguishing factor of this practice is that it is often initiated by a non-medical professional such as a police officer. In many states, especially those in which a non-public official such as a medical health professional or concerned citizen can initiate the detention, a judge or magistrate is required to approve it before or soon after the initiation.

When emergency detention in jails has been brought to court, judges have generally agreed that the practice itself is not unconstitutional. One notable exception was Lynch v. Baxley; however, later cases, particularly Boston v. Lafayette County, Mississippi, have connected the ruling of unconstitutionality in that case with the conditions of the jails themselves rather than the fact that they were jails. That being said, the Supreme Court of Illinois has stated that this practice is unconstitutional if the person being detained doesn't pose an imminent threat to himself or others.

Supreme court cases

Several landmark Supreme Court cases, notably Estelle v. Gamble, have established the constitutional right of prison inmates to mental health treatment. Estelle v. Gamble determined that "deliberate indifference to serious medical needs" of prisoners was a violation of the Eighth Amendment to the U.S. Constitution. This case was the first time the phrase "deliberate indifference" was used; it is now a legal term. In order to determine "serious medical need" later cases would use tests such as the treatment being mandated by a physician or an obvious need to a layman. On the other hand, other cases, notably McGukin v. Smith, used much stricter terms, and in 1993 researchers Henry J. Steadman and Joseph J. Cocozza commented that "serious medical need" had little definitional clarity. Langley v. Coughlin involved a prisoner "regularly isolated without proper screening or care" and clarified that a single, distinctive act is not necessary to constitute deliberate indifference but rather "if seriously ill inmates are consistently made to wait for care while their condition deteriorates, or if diagnoses are haphazard and records minimally adequate then, over time, the mental state of deliberate indifference may be attributed to those in charge."

The landmark case Washington v. Harper determined that although inmates do have an interest in and the right to refuse treatment, this can be overridden without judicial process even if the inmate is competent, provided there this act is "reasonably related to legitimate penological interest". Washington's internal process for determining this need was seen as affording due process. In contrast, in Breads v. Moehrle, the forcible injection of drugs in jail was not upheld because sufficient procedures were not taken to ensure "substantive determination of need".

Court cases

George Daniel, a mentally ill man on Alabama's death row was arrested and charged with capital murder. In jail, George became acutely psychotic and couldn't speak in complete sentences. Daniel had been on death row until several years later, Lawyer Bryan Stevenson uncovered the truth about the doctor who lied about the examination of Daniels's mental illness. Daniel's trial was then overturned and he has been in a mental institution since. Another mentally ill man, Avery Jenkins, was convicted of murder and sentenced to death. Throughout Jenkins's childhood, he had been in and out of foster homes and developed a serious mental illness. Jenkins erratic behavior didn't change, so his foster mother decided to get rid of him by tying him to a tree and left him there. Around the age of sixteen, he was left homeless and started to experience psychotic episodes. At the age of twenty, Jenkins had wandered into a strange house and stabbed a man to death as he perceived him to be a demon. He then was sentenced to death and spent several years in prison as if he had been sane and responsible for his actions. Jenkins then got off death row and was put into a mental institution.

In the past, overall living and treatment conditions within US prisons were not up to par, which can be seen through the details and points made by the Coleman v. Brown case that went to trial in 1995. The district court judge in this case ultimately recognized the systemic failure within the system to properly care for and provide resources to mentally ill inmates. These individuals were not receiving treatment prior to prison, and were sent there with expectations from others that they would be receiving treatment there, but that expectation was not fulfilled.

With Coleman v. Brown, a special court, including three judges that can make final decisions on whether or not a problem is significant enough to enact change, came to the conclusion that overcrowding was in fact a reason for poor conditions in prisons, therefore they called for a reduction in the prison population to partially relieve said issue. Justice Alito at this time questioned whether the solution of reduction was actually helpful when they could be looking into constructing additional prison medical and mental health facilities. Although, the decision did not take care of the living conditions that were problematic before and even after the case. It has been noted that psychotic prisoners were often held in small, narrow essentially restricted areas in which standing on their own secretions was common. As far as actual mental health treatment conditions, the waiting time to even receive care could take up to a year, and when they finally reached that date, the screenings for such lacked privacy for those being evaluated as the spaces were often shared by several physicians at a time. Other cases that has been discussed, is John Rudd, who was being a federal prison in West Virginia as of 2017. Rudd had a history of mental health disorders consisting of posttraumatic stress disorder, as well as schizophrenia. He was evaluated and diagnosed by a doctor as early as 1992. In 2017, he stopped taking his psychiatric medication, then proceeded to inform staff of his intentions to take his own life. Staff proceeded to put him in a suicide watch cell, where he would physically and violently hurt himself. Staff injected him with haloperidol, an anti-psychotic drug, to treat him, but after some time they concluded that Rudd was not ill enough to receive proper, regular treatment and continued to categorize him as a level one inmate, meaning no significant mental health needs. Although they were aware of his pre-existing conditions, the prison staff claimed those were resolved and simply adjusted it to Rudd having an antisocial personality disorder.

On December 7, 2020Thomas Lee Rutledge died of hyperthermia at the home of William E. Donaldson in Bessemer. According to a lawsuit filed by his sister, Rutledge had a core temperature of 109 degrees when he was found unconscious in his psychiatric cell. List prison staff, guards, and contractors as defendants.

A more recent case is that a mentally ill man froze to death at an Alabama jail as of 2023, according to a lawsuit filed by the man’s family who say he was kept naked in a concrete cell and believe he was also placed in a freezer or other frigid environment. Anthony Don Mitchell, 33, arrived at the hospital's emergency room with a body temperature of 72 degrees (22 degrees Fahrenheit) and was pronounced dead hours later, according to the lawsuit. He was rushed to the hospital on January 26 from the Walker County Jail, where he had been held for two weeks. The paramedic who tried unsuccessfully to resuscitate Mitchell writes, "I believe hypothermia was the ultimate cause of death," according to a lawsuit filed by Mitchell's mother in federal court Monday. Mitchell, who had a history of substance abuse, was arrested on January 1st.12 after a cousin asked authorities to check on his well-being for wandering through portals to heaven and hell at his home and apparently suffering a nervous breakdown. According to the lawsuit, prison video shows Mitchell being held naked in a solitary cell with a concrete floor. The lawsuit speculates that Mitchell was also taken to the prison kitchen "freezer" or similar freezing environment and left there for hours "because his body temperature was so low."

Prison staff in general, have also been experiencing issues for various years now. Previously in the 1990s, just about one-third of positions went unfilled for mental health staff, and it became increasingly impactful on inmates when the vacancy rates for psychiatrists reached 50% and up. Staffing shortage is still seen today in which some counselors can be pulled and asked to serve as corrections officers for the time being. This situation had worsened due to the Trump administration and the hiring freeze that was meant to reduce costs. Rudd, now out of prison and receiving counseling and taking medication, speaks on triggers within the prison environment that are not in any way healthy for those who are mentally ill.

Mental health law

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Mental_health_law 

 

Mental health law includes a wide variety of legal topics and pertain to people with a diagnosis or possible diagnosis of a mental health condition, and to those involved in managing or treating such people. Laws that relate to mental health include:

• employment laws, including laws that prohibit employment discrimination on the basis of a mental health condition, require reasonable accommodations in the workplace, and provide mental health-related leave;
• insurance laws, including laws governing mental health coverage by medical insurance plans, disability insurance, workers compensation, and Social Security Disability Insurance;
• housing laws, including housing discrimination and zoning;
• education laws, including laws that prohibit discrimination, and laws that require reasonable accommodations, equal access to programs and services, and free appropriate public education;
• laws that provide a right to treatment;
• involuntary commitment and guardianship laws;
• laws governing treatment professionals, including licensing laws, confidentiality, informed consent, and medical malpractice;
• laws governing admission of expert testimony or other psychiatric evidence in court; and
• criminal laws, including laws governing fitness for trial or execution, and the insanity defense.

Mental health law has received relatively little attention in scholarly legal forums. The University of Memphis Cecil C. Humphreys School of Law in 2011 announced the formation of a student-edited law journal entitled "Mental Health Law & Policy Journal."

United States

Employment

Title I of the Americans with Disabilities Act of 1990 ("ADA") is a civil rights law that protects individuals with depression, posttraumatic stress disorder ("PTSD"), and other mental health conditions in the workplace. It prohibits employers with 15 or more employees from firing, refusing to hire, or taking other adverse actions against a job applicant or employee based on real or perceived mental health conditions. It also strictly limits the circumstances under which an employer can ask for information about medical conditions, including mental health conditions, and imposes confidentiality requirements on any medical information that the employer does have.

The ADA also requires employers to provide reasonable accommodations to job applicants or employees with mental health conditions under some circumstances. A reasonable accommodation is a special arrangement or piece of equipment that a person needs because of a medical condition to apply for a job, do a job, or enjoy the benefits and privileges of employment. Examples include a flexible schedule, changes in the method of supervision, and permission to work from home. To have the right to a reasonable accommodation, the worker's mental health condition must meet the ADA's definition of a "current disability." Conditions that should easily qualify include major depression, PTSD, bipolar disorder, obsessive-compulsive disorder ("OCD"), and schizophrenia. Other conditions may also qualify, depending on what the symptoms would be if the condition were left untreated, during an active episode (if the condition involves active episodes). The symptoms do not need to be severe or permanent for the condition to be a disability under the ADA.

Under the Family and Medical Leave Act of 1993 (FMLA), certain employees are entitled to up to twelve weeks of job-protected and unpaid leave to recover from a serious illness or to care for a family member with a serious illness, among other reasons. To be eligible, the employer must have had 50 or more employees in 20 or more workweeks in the current or preceding calendar year, or else must be a public agency, elementary school, or secondary school, and the employee must have worked for the employer for at least 12 months, must have at least 1,250 hours of service for the employer during the 12-month period immediately preceding the leave, and must work at a location where the employer has at least 50 employees within 75 miles.

United Kingdom

Various pieces of legislation including Mental Health Act 1983 and the Mental Capacity Act 2005 govern mental health law giving mental health professionals the ability to commit individuals, treat them without consent and place restrictions on them while in public through outpatient commitment, according to the rules of this legislation. These decisions can be challenged through the mental health tribunals which contain members of the judiciary, though the initial decisions are made by mental health professionals alone.

Around the world

Civil commitment

Mental health legislation is largely used in the management of psychiatric disorders, such as dementia or psychosis, and developmental disabilities where a person does not possess the ability to act in a legally competent manner and requires treatment and/or another person to act in his or her best interests. The laws generally cover the requirements and procedures for involuntary commitment and compulsory treatment in a psychiatric hospital or other facility.

In some jurisdictions, court orders are required for compulsory treatment; in others, psychiatrists may treat compulsorily by following set procedures, usually with means of appeal or regular scrutiny to ensure compliance with the law such as through mental health tribunals.

Sources of law

Mental health law includes areas of both civil and criminal common and statutory law.

Common law is based on long-standing English legal principles, as interpreted through case law. Mental health-related legal concepts include mens rea, insanity defences; legal definitions of "sane," "insane," and "incompetent;" informed consent; and automatism, amongst many others.

Statutory law usually takes the form of a mental health statute. An example is the Mental Health Act 1983 in England and Wales. These acts codify aspects of the treatment of mental illness and provides rules and procedures to be followed and penalties for breaches.

Not all countries have mental health acts. The World Health Report (2001) lists the following percentages, by region, for countries with and without mental health legislation.^[1]

Regions	With legislation	No legislation
Africa	59%	41%
The Americas	73%	27%
Eastern Mediterranean	59%	41%
Europe	96%	4%
South-East Asia	67%	33%
Western Pacific	72%	28%