Is it Time to finally Intervene with the Homeless Severely Mentally Ill?

“Serious mental illness (SMI) is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI”.  “In 2020, there were an estimated 14.2 million adults aged 18 or older in the United States with SMI. This number represented 5.6% of all U.S. adults” (Ref.1). It appears that a small fraction, probably the most severely affected of these millions, approximately 125,000, become homeless nationwide, with an increase in mortality, rarely living past 50 y/o (Ref.2).
    Why is it that many of the most severely mentally ill become homeless living in the streets and not under appropriate psychiatric care? The factors leading to this situation were well reviewed in a 1984 essay in the New York Times. It began in the 1960’s with an over reliance on new psychotropic drugs without recognizing their limitations, along with the impression by the public that the existing state mental hospitals were ineffective and “snake pits” with exorbitant costs. At the same time there was an over reliance on community health centers based on a Missouri pilot study of their efficacy that could not be reproduced when in general use. A 1963 federal law funding community centers around the country for four and ½ years assumed the states would pick up the tab thereafter, but that did not materialize. Civil libertarians fought for social justice for the homeless mentally ill as a class, not understanding that in some few cases institutionalization against their will was in the best interest of both the patient and society.  Institutionalization, however, must be based on clinical criteria by qualified physicians and could in many cases be temporary and requiring far fewer beds than existed in the 1960’s. The net result of these several factors is summarized in the initial paragraph. “The policy that led to the release of most of the nation’s mentally ill patients from the hospital to the community is now widely regarded as a major failure. Sweeping critiques of the policy, notably the recent report of the American Psychiatric Association, have spread the blame everywhere, faulting politicians, civil libertarians and psychiatrists”. (Ref.3).
    The situation has festered for decades with severely mentally ill persons being homeless, posing a danger to themselves and to others. Over time several well intentioned interest groups have posed solutions to alleviate this problem without success, probably in large part because they do NOT understand the inherent difficulties of being rationale when having severe untreated mental illness (Ref.4) In November 2022, the mayor of New York City, Eric Adams a former police officer, decided that because the situation had become so severe with violence on the streets and in the subways perpetrated by severely mentally ill individuals, a different approach was necessary.  He announced a plan to train police how to respectfully bring patients for psychiatric evaluation in additional hospital beds supported by the state for much needed care. Special arrangements will probably be needed if long term therapy is necessary.  He emphasized that this is not only a safety factor for the public but importantly in the patient’s best interest. As expected, some advocacy groups are voicing their strenuous objections (Ref.5,6). A plan such as this can only survive if based on individual needs and long-term benefit for patients. Society has a requirement for the safety of both the general population and the mentally ill.

  1. National Institute of Mental Health, Mental Illness, January 2022, available at: https://www.nimh.nih.gov/health/statistics/mental-illness  (accessed November 28, 2022)
  2. Smiljanic Stasha, The State of Homelessness in the US – 2022, Policy Advice, September 29, 2022, available at: https://policyadvice.net/insurance/insights/homelessness-statistics/ (accessed November 29, 2022)
  3. Richard D. Lyons, How Release of Mental Patients Began, The New York Times, October 30, 1984, available at: https://www.nytimes.com/1984/10/30/science/how-release-of-mental-patients-began.html (accessed November 27, 2022)
  4. Stephen Eide, How to Think about Homelessness, National Affairs, Fall 2018, available at: https://nationalaffairs.com/publications/detail/how-to-think-about-homelessness?mkt_tok=NDc1LVBCUS05NzEAAAGIckVOH_nLlBhgk6KB7MRAlaW0glh (accessed December 2, 2022)
  5. Andy Newman, Emma C. Fitzsimmons, New York City Involuntarily Remove Mentally Ill People From Streets, New York Times, November 29, 2022, available at: https://www.nytimes.com/2022/11/29/nyregion/nyc-mentally-ill-involuntary-custody.html(accessed November 29, 2022)
  6. Bobby Caina Calvan, Mayor says NYC will treat mentally ill, even if they refuse, AP News, November 29, 2022, available at: https://apnews.com/article/health-new-york-city-mental-government-and-politics-21d32260d21bee4ac87a81a55234ba11(accessed November 30, 2022)

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