Jan 1 Date for Prescriber Prevails in Medicaid Managed Care for Atypical Antipsychotics

Prescriber Prevails in Medicaid Managed Care for Atypical Antipsychotics


Effective January 1, 2013, Medicaid Managed Care Plans will be required to implement “prescriber prevails” for medically necessary prescription drugs in the atypical antipsychotic therapeutic drug class. This change is the result of legislation passed in the 2012-2013 Executive Budget. Once implemented, this initiative will enable the prescriber's reasonable professional judgment to prevail in the prior authorization process for atypical antipsychotics.


Plans will continue to develop formularies and may also administer prior authorization programs for atypical antipsychotics. Prescribers will still be required to provide plans with requested information and/or clinical documentation to support prior authorization requests. As they do currently, plans may provide a temporary (3 day) supply of medication when medically necessary.


Plans are required to meet specific federal determination timeframes in response to requests for health care services. Consistent with these requirements, when the plan is unable to complete a prior authorization due to missing information or because the prescriber’s reasonable professional judgment has not been adequately demonstrated, either by consistency with FDA approved labeling or use supported in at least one of the Official Compendia as defined in federal law under the Social Security Act section 1927 (g)(1)(B)(i), the plan will issue a notice of action to the provider and member. Such notice will describe the information required to complete the authorization and the member’s rights regarding appeals and fair hearings.


NEC Calls for Uncoupling Violence and Mental Health Issues

National Empowerment Center Mourns the Newtown School Shooting,

Calls for Uncoupling Violence and Mental Health Issues

WASHINGTON (12/20/12) – The National Empowerment Center (NEC) wishes to express deep sympathy to all the families and friends of the victims of the unconscionable tragedy that occurred in Newtown, Conn., on Dec. 14, 2012.


“Words cannot convey the horror of the senseless loss of so many innocent young lives and the lives of the heroic adults who tried to save them,” said Daniel B. Fisher, M.D., Ph.D., a co-founder of the NEC. “There is an understandable national outcry for answers, and demands for policy changes to prevent more such violent outbreaks in our society. Yet simplistic calls for more ‘mental health’ treatment for individuals ignore the complexity of the problems we face as a nation,” Dr. Fisher said.


There is no evidence of increased violence among those with mental health issues; indeed, individuals with mental health conditions are more likely to be the victims than the perpetrators of violence. (One study found that, in a recent year, such individuals were nearly 12 times as likely as the general population to be the victims of violent crime.)


“Tragedies such as Newtown’s are an outgrowth of a culture of violence in which guns are glorified in media and entertainment and weapons are accessed with ease,” Dr. Fisher said. “In addition, we view these acts as inextricably linked to the unraveling of our social fabric and the disintegration of communities and families. We believe that social and health policy should be aimed at community-based, peer-run programs supporting providers, families, and communities to address trauma and to promote connected communities of support, tolerance, and understanding.”

Please see the links below for more critical perspectives on the Newtown school shootings.






The mission of the National Empowerment Center is “to carry a message of recovery, empowerment, hope and healing to people with lived experience with mental health issues, trauma, and and/or extreme states.”


Contact: Daniel B. Fisher, M.D., Ph.D., 1-800-POWER2U (1-800-769-3728), info@power2u.org


Study Links Poverty, Inequality with Serious MH Conditions

NYAPRS Note: Here’s more data to support the overdue trend to look at ‘social determinants of health’ like poverty and deprivation as causative factors for serious mental health conditions.


Schizophrenia Linked to Poverty and Inequality, Say Researchers

By Hannah Osborne  International Business Times  December 20, 2012


People who live in poor, urban areas are at greater risk of developing schizophrenia.

Schizophrenia may be linked to deprivation after research showed higher concentrations of the disease in poor urban areas with high population density.

Researchers at the University of Cambridge and the Queen Mary University in London ana lysed 427 people with schizophrenia between the ages of 18 and 64.

They found that there were higher rates of the disease in urban areas linked with deprivation and inequality.

Researchers assessed the social environment by measuring the neighbourhood they lived in at the onset of the disease.

The incidence of schizophrenia was increased by three environmental risk factors: increased deprivation, increased population density and increased inequality. Results, published in the journal Schizophrenia Bulletin, suggest that people living in poorer areas were four per cent more likely to develop the disease.

In the UK, schizophrenia affects around 40,000 adults in England and around 24 million worldwide.

A recent report by the Schizophrenia Commission found the care for people with the disease is failing catastrophically and that many patients with severe psychosis spend time in hospitals that have become "frightening places".


Inequality in Western societies increasing

The latest findings offer further evidence that inequality is linked to health. Lead author James Kirkbride, said: "Inequality seems to be important in affecting many health outcomes, now possibly including serious mental illness ... both absolute and relative levels of deprivation predict the incidence of schizophrenia."

Peter Kinderman, chartered psychologist from the University of Liverpool, added: "Like many other similar pieces of research, it confirms that social, economic and psychological factors are important causes of many mental health problems - even problems as serious as those leading to a diagnosis of schizophrenia.

"Many people seem to believe that all mental health problems - and perhaps especially schizophrenia - are simply brain diseases. Instead, research such as this clearly demonstrates that social causes are crucial and are key elements of helping people too.

"The fact that inequity is linked to a diagnosis of schizophrenia is particularly striking. Inequalities in many Western societies are acute and rising, especially in our current economic crisis.

"We need to understand that our mental health is not merely a biological phenomenon, but is much more a product of how people make sense of their world. And this, in turn, is affected by social, economic and political decisions."

Dr John Williams, head of neuroscience and mental health at the Wellcome Trust said: "This research reminds us that we must understand the complex societal factors as well as the neural mechanisms that underpin the onset of mental illness, if we are to develop appropriate interventions."




Alert: Please Make One Call To Help Save The CASA Program For Foster Children?

Call Now to Save the CASA Program for Foster Children Statewide


The NYS Office of Court Administration which provides funding for the Court Appointed Special Advocates for Children (CASA) has announced that it is eliminating its $800,000 funding for CASA in 2013 because of budget constraints.

“This program provides one- to- one advocacy to help children in foster care grow up in safe, permanent and loving homes,” explains Jackie Boissonault, LMSW, CASA Director at The Mental Health Association of Westchester (MHA). 

CASA programs utilize professionally trained staff and volunteers to monitor the mental health, physical health, education and permanency plans for children placed in foster care.  Their advocacy is life changing for thousands of children across the state.  It is a program that pays for itself many times over at a cost of an average of $1,000 per child served.


  • Please call the Office of Court of Appeals (518) 455-7700 or (212) 661-6787 (or both if you can!) and urge them not to  eliminate funding of the CASA program.
  • NOTE: Judge Lippman’s office is balking at receiving the calls. Let them know you’d like to deliver the message anyway.


The message is, “We urge you to stop the elimination of funding statewide to the CASA Program. It has been incredibly successful in helping children who have been abused and neglected to navigate the system of foster care, and grow up in safe, permanent and loving homes.”


After what we just witnessed in Newtown, Connecticut, we need even more services to preserve children’s mental health---not the elimination of vital programs.


CSM: Was Adam Lanza Reacting To MH Commitment Plans?

Sandy Hook Shooting: Was Adam Lanza Lashing Out Against Treatment? Two media reports suggest that Sandy Hook shooter Adam Lanza's mother was seeking mental-health treatment for him - perhaps including involuntary commitment. Experts say seeking treatment against someone's will is fraught with difficulties.

By Stacy Teicher Khadaroo | Christian Science Monitor December 19, 2012

Sandy Hook <http://www.csmonitor.com/tags/topic/Sandy+Hook> shooter Adam Lanza <http://www.csmonitor.com/tags/topic/Adam+Lanza> may have been motivated by anger at his mother because of plans to have him committed for treatment, Fox News <http://www.csmonitor.com/tags/topic/FOX+News+Network+LLC> reported Thursday, citing comments from the son of an area church pastor and an unnamed neighborhood source. Fox also cited an unnamed senior law enforcement official saying anger at plans for "his future mental-health treatment" were being investigated as a possible motive.

While the Fox reports are still uncorroborated, other media reports paint a general picture that suggests Ms. Lanza was growing increasingly concerned about the mental health of her son.

These reports are bringing to light a debate over where to set the bar when it comes to forcing an individual into treatment - and whether those caring for people with mental-health issues have enough resources available to head off potential crises before they happen.

On one hand, warning signs are often apparent, so making it easier to commit someone forinvoluntary treatment could save lives.

The young adult men who end up being violent often "have others in their lives ... who are trying desperately to get help before something bad happens. They can see it coming down the pike," says Liza Gold, a clinical professor of psychiatry at Georgetown University School of Medicine <http://www.csmonitor.com/tags/topic/Georgetown+University+Medical+Cente r> . But caregivers "have run up against these commitment laws that are so restrictive - that come down so far on the side of civil liberties and privacy - that it is almost impossible to contain, hospitalize, treat someone with a chronic and escalating mental illness."

On the other hand, forced treatment can also be emotionally wrenching for the patient and cause lingering anger, mental-health experts say.

"People who are forcibly treated so often feel traumatized by it," says Robert Whitaker, author of "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America <http://www.csmonitor.com/tags/topic/United+States> ." "Women in particular will sometimes talk about it almost like a quasi-rape, because sometimes they are held down and injected," he says.

For its part, Connecticut <http://www.csmonitor.com/tags/topic/Connecticut> leans strongly toward supporting the civil liberties of individuals, making involuntary treatment difficult. It is one of six states that does not provide the option of "assisted outpatient treatment," which allows qualifying individuals to receive court-ordered treatment in the community without being committed to a facility.

Moreover, an individual needs to be dangerous before intervention is possible. The state's standard does not take into consideration an individual's past psychiatric history, such as repeated hospitalizations or symptoms of psychiatric deterioration that could culminate in violence.

"Connecticut's civil commitment laws are among the most restrictive in the nation when it comes to getting help for a loved one in psychiatric crisis," said Kristina Ragosta, senior legislative and policy counsel for the Treatment Advocacy Center in Arlington, Va. <http://www.csmonitor.com/tags/topic/Arlington+County+(Virginia)> , which pushes to make it easier to commit people for treatment before they become dangerous.

Connecticut does have a law allowing for someone to be sent to the hospital for 72 hours for evaluation if he or she poses a danger to himself or others, says Kate Mattias, executive director of the Connecticut branch of the National Alliance on Mental Illness <http://www.csmonitor.com/tags/topic/National+Alliance+on+Mental+Illness > .

Emergency mobile psychiatric services in hospitals - including one in Danbury <http://www.csmonitor.com/tags/topic/Danbury> , near Newtown - can come to a home or other location to bring someone into the hospital, she says. And after the 72 hours, if someone can demonstrate that he or she is a continued threat, a judge can order a 14-day stay, she says.

But Ms. Mattias's group and some other advocates oppose involuntary commitment because it "creates an adversary relationship that really poisons any relationship with providers, with caregivers," she says. "This is one of the lingering fears that people who are living with mental illness have when you start to talk about involuntary commitment - you raise this specter of, 'They're going to put me away and throw away the key.' "

According to Fox, Joshua Flashman, a US Marine <http://www.csmonitor.com/tags/topic/U.S.+Marine+Corps> and an acquaintance of the Lanzas, said Ms. Lanza "was petitioning the court for conservatorship and wanted to have him committed.... Adam was apparently very upset about this. He thought she just wanted to send him away."

Fox was not able to confirm that with a court official, who said such records are sealed.

Later Thursday, the New York Daily News <http://www.csmonitor.com/tags/topic/Daily+News+LP> reported that a family friend said Ms. Lanza had brought her son to a psychiatrist as he became increasingly antisocial. But the unnamed friend said Ms. Lanza was not planning to have him committed. "Nancy was so dedicated to Adam," the friend said. "She would never send him away. She just couldn't do that."

Experts say it is plausible that Mr. Lanza's actions could have been triggered by anger over the possibility of forced treatment. "Generally we know that a great many violent acts, particularly between intimates, are triggered by moments of perceived loss," says Christopher Ferguson <http://www.csmonitor.com/tags/topic/Christopher+Ferguson> , a professor of psychology and criminal justice at Texas A&M <http://www.csmonitor.com/tags/topic/Texas+A%26M+University> International University in Laredo. There's a heightened possibility of violence, for instance, after a stalker or abuser is charged or served with a restraining order, he notes.

But even if people are willing to be committed, it's not easy to get such treatment, because the US moved away from the asylum system in the 1950s and '60s, Ferguson says.

There were good reasons for this, but perhaps the pendulum has swung too far and made it overly difficult for people to get mental health treatment, voluntarily or otherwise, he and some others suggest.

"The funding is so limited that the average length of stay is three to seven days, but most psychiatric medications take two to six weeks to kick in," says Professor Gold of Georgetown.

There should be an easier way for people to at least be "contained" temporarily to calm down if someone close to them can see that they are in crisis and could become dangerous, says Gold. "These crises pass. These people don't wake up every day of their lives [homicidal]," she says.

The details certainly aren't clear yet about what kind of treatment, if any, Ms. Lanza previously sought, or wanted in the future, for Mr. Lanza.

She had talked about moving to Washington State <http://www.csmonitor.com/tags/topic/Washington+State+University> with her son because of a school there that she thought could help him, according to a Concord Monitor <http://www.csmonitor.com/tags/topic/Concord+Monitor> article that quoted Mark Tambascio, an owner of My Place, a Newtown restaurant frequented by Ms. Lanza.

Other media outlets have reported that Mr. Lanza spent time in a variety of school settings and had also been home-schooled by his mother.

Parents of troubled young people may need therapeutic support themselves, says Mattias of theNational Alliance on Mental Illness. There's a strong stigma in society where parents get the message that their child's problems are somehow the parents' fault, she says, and "parents over time can become isolated.... It's very very hard to handle these things on your own."

Mothers are the highest percentage of the people murdered by mentally ill young men, Gold adds. "The [young men] are usually living at home because they are dysfunctional.... The moms don't bail. These are their children. They hang in with them, they try to get them help. And they're the ones that get killed."

But mental-health advocates caution against drawing overly broad conclusions. "You can't predict what the reaction would be [to a family member seeking to impose treatment] or whether it would increase dangerousness," says Michael Fitzpatrick <http://www.csmonitor.com/tags/topic/Michael+Fitzpatrick> , executive director of the National Alliance on Mental Illness.

Advocates also urge a renewed commitment to prevention, so that fewer caregivers end up having to make such difficult choices

There have been comprehensive reports on how to improve mental-health care, dating back to President Carter <http://www.csmonitor.com/tags/topic/Jimmy+Carter> 's administration, says Robert Bernstein <http://www.csmonitor.com/tags/topic/Robert+Bernstein> , president and CEO of The Bazelon Center for Mental Health Law <http://www.csmonitor.com/tags/topic/Judge+David+L.+Bazelon+Center+for+M ental+Health+Law> in Washington <http://www.csmonitor.com/tags/topic/Washington%2c+DC> . Early intervention and prevention are key, he says, but "when funding gets cut those are the first programs to go.... What we have now is a system that only in rare instances does anything preventive."

http://news.yahoo.com/sandy-hook-shooting-adam-lanza-lashing-against-tre atment-231300962.html

TH: National MH Advocates Have Momentum in Wake of CT Tragedy

Advocates For Mental Health Have Momentum After Conn. Massacre

By Elise Viebeck and Sam Baker – The Hill December 20, 2012


The mental-health community has begun a major lobbying effort for federal action in response to last Friday’s school shooting in Newtown, Conn. 

Major advocacy groups are already meeting with Capitol Hill offices and formulating an agenda that they say has forward momentum as a result of the new public dialogue on mental illness.

“The field as a whole has agreed. There is a lot of interest among other national organizations in getting something done,” said Rebecca Farley with the National Council for Community Behavioral Healthcare. 

Advocates say the most important objective is strengthening community-based mental health services. They are also focused on early diagnosis and treatment of ill children, and efforts to erase the stigma that surrounds mental health problems.

The advocates already have a number of bills to rally behind. The Excellence in Mental Health Act, from Sen. Debbie Stabenow (D-Mich.) and Rep. Doris Matsui (D-Calif.), would create federal standards and oversight for community mental health providers. Rep. Grace Napolitano (D-Calif.) has sponsored legislation to support new mental health services in schools. And Sen. Mark Begich (D-Alaska) and Rep. Jason Altmire (D-Pa.) have a bill to encourage first-aid-style training on mental health in colleges. 

Outside of Capitol Hill, advocates are preparing their own efforts. Wayne Lindstrom, president and chief executive of Mental Health America, said a coalition of mental-health groups would soon be sending a proposal to the White House and congressional leaders.

That letter will ask lawmakers to double the country’s capacity to provide mental-health services.

“It’s probably going to be a hard one to bite off and chew, but we feel a strong need to put it on the table,” Lindstrom said.

Polls taken since last Friday’s massacre have found that the public supports a renewed emphasis on mental health treatment. 

A survey released by Gallup on Wednesday found that 84 percent feel that increasing government spending on mental health would be either “very” or “somewhat” effective in preventing mass shootings. And Rasmussen found that a plurality, 48 percent, endorsed a renewed focus on mental health issues in response to the crisis.


The Sandy Hook shooter, Adam Lanza, was the latest in a recent series of disturbed young men to engage in mass shootings. His mother was reportedly trying to institutionalize him before he murdered her and 25 other people last week.

President Obama named mental illness as a priority on Wednesday as he announced the creation of a task force on gun violence led by Vice President Biden.

“We’re going to need to make access to mental healthcare at least as easy as access to a gun,” Obama said.

Advocates told The Hill that they plan to emphasize the role of Medicaid in paying for mental-health services and urge Congress not to cut the program in an agreement to avoid the “fiscal cliff.” 

Specifically, Mental Health America and its counterparts want the Obama administration to expand access to a Medicaid program that provides mental-health screenings for children younger than 5.

“It’s when kids get basically hard-wired,” Lindstrom said.

He said mental health services have been cut by some $4 billion recently, when Medicaid reductions are included.

“We’re in a much weaker position today to attempt to meet service demands,” Lindstrom said.

Children do better when they’re treated in familiar settings — their home or school — than when they’re sent away to an inpatient facility, he said. And mental health needs to be a priority beginning at a young age.

“When we talk about access, we’re talking about having good, comprehensive assessments available as early as possible,” Lindstrom said.

The coalition will also press Congress to take up Napolitano’s legislation.

“If Congress is really serious about doing something, and doing something immediately, it should begin scheduling hearings and moving forward,” he said.

Mental Health America and other organizations might also wade into the gun-control debate — an area they have avoided in the past. Lindstrom said policies like the assault-weapons ban might be necessary in conjunction with greater access to screening and treatment.

“Limiting automatic weapons and magazine capacity is something our field historically has not been out front on, but I think given the immensity of this tragedy ... maybe this is something that seems to be a safeguard that could have a role in reducing the likelihood” of another attack, he said.

He also emphasized full implementation of the Mental Health Parity law, as well as President Obama’s signature healthcare law, which he said makes needed investments in shifting mental health toward the same prevention-focused model as physical care.

“This is first time mental health has an opportunity to be an equal at the table,” he said.

Napolitano, who leads the Congressional Mental Health Caucus, said the time is ripe to move forward, though she blamed Republicans for opposing targeted spending.

“My colleagues are not willing to put forth anything that has an earmark,” she said, “and this is an earmark thing.” 

Napolitano also lamented that no Republicans have signed on to her bill, and that the Mental Health Caucus she leads has only nine GOP members, compared to 74 Democrats.

“They don’t consider it a priority,” she said. “I hope things will be different now that the president is getting in on the act.” 

Kate Mattias of the Connecticut chapter of the National Alliance on Mental Illness said she hopes lawmakers can adjust their thinking to integrate mental health into larger healthcare discussions. 

“Whenever there is a conversation about health, mental health needs to be part of that conversation,” she said. 

“It’s thought of differently, but we need to talk about it broadly, just like we talk about lowering diabetes or cardiovascular issues.”




SAMHSA: Facts About Mental Illness and Violence

NYAPRS Note: Some very timely information for us to share with the media today and through the next few weeks.

Violence and Mental Illness: The Facts

Facts about Mental Illness and Violence

It is important to note that behavioral health research and practice over the last 20 years reveal that most people who are violent do not have a mental disorder, and most people with a mental disorder are not violent.*

In fact, studies indicate that people with mental illnesses are more likely to be the victims of violent attacks than the general population. *

Demographic variables such as age, gender and socioeconomic status are more reliable predictors of violence than mental illness. *

Misconceptions about mental illness can cause discrimination and unfairly hamper the recovery of the nearly 20 percent of all adult Americans who experience a mental illness each year.

Family, friends, employers and school personnel can be a line of "first response" if they notice a person is behaving differently and is of concern.  The choice to seek treatment is more likely if others are compassionate and supportive.   Mental health treatment can be effective and can enable a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.

Treatment is effective and people recover from mental illnesses to live productive lives in our communities.

The discrimination and stigma associated with mental illnesses largely stem from the link between mental illness and violence in the minds of the general public, according to Mental Health: A Report of the Surgeon General (1999). "For instance, 61 percent of Americans think that people with schizophrenia are likely to be dangerous to others," notes the report of the President’s New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America (2003).

This link is promoted by the news and entertainment media. For example, the National Mental Health Association reported that, according to a survey for the Screen Actors’ Guild, characters in prime time television portrayed as having a mental illness are depicted as the most dangerous of all demographic groups: 60 percent were shown to be involved in crime or violence (three times the average rate). In addition, “[s]tudies showed that as many as 75 percent of stories dealing with mental illness focus on violence (Shain and Phillips 1991). Although more recent research suggests the prevalence of these kinds of stories is diminishing (Wahl, et al. 2002), at least a third of stories continue to focus on dangerousness. Also, the vast majority of remaining stories on mental illness either focus on other negative characteristics related to people with the disorder (e.g., unpredictability and unsociability) or on medical treatments. Notably absent are positive stories that highlight recovery of many persons with even the most serious of mental illnesses (Wahl, et al. 2002)

The average citizen finds these images persuasive.  According to Americans’ Views of Mental Health and Illness at Century’s End: Continuity and Change, between 1950 and 1996, “the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behavior nearly doubled.”

As a result, Americans are hesitant to interact with people who have mental illnesses: 38 percent are unwilling to be friends with someone having mental health difficulties, 64 percent do not want someone who has schizophrenia as a close coworker, and more than 68 percent are unwilling to have someone with depression marry into their family. (Pescosolido, et.al., 1996)

But, in truth, people have little reason for such fears. A consensus statement signed by more than three dozen lawyers, advocates, consumers/survivors, and mental health professionals reads in part: “The results of several recent large-scale research projects conclude that only a weak association between mental disorders and violence exists in the community. Serious violence by people with major mental disorders appears concentrated in a small fraction of the total number, and especially in those who use alcohol and other drugs.” (Monhan, J. and Arnold, J., 1996)

In addition:

  • "Research has shown that the vast majority of people who are violent do not suffer from mental illnesses." (American Psychiatric Association, 1994).
  • “Clearly, mental health status makes at best a trivial contribution to the overall level of violence in society” (Monahan, John, 1992).
  • “...[T]he absolute risk of violence among the mentally ill as a group is still very small and . . . only a small proportion of the violence in our society can be attributed to persons who are mentally ill.” (Mulvey, 1994)
  • “Most people who suffer from a mental disorder are not violent — there is no need to fear them. Embrace them for who they are — normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support.” (Grohol, 1998)
  • “Compared with the risk associated with the combination of male gender, young age, and lower socioeconomic status, the risk of violence presented by mental disorder is modest.” (Policy Research Associates, December 1994)

People with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime. (Appleby, et.al., 2001)

A new study by researchers at North Carolina State University and Duke University has found that people with severe mental illness — schizophrenia, bipolar disorder or psychosis — are 2 1⁄2 times more likely to be attacked, raped or mugged than the general population.” (— Chamberlain, Claudine. “Victims, Not Violent: Mentally Ill Attacked at a Higher Rate,” ABC News

Hiday et al., 2001 V.A. Hiday, J.W. Swanson, M.S. Swartz, R. Borum and H.R. Wagner, Victimization: A link between mental illness and violence?, International Journal of Law and Psychiatry 24 (2001), pp. 559–572. SummaryPlus | Full Text + Links | PDF (99 K) | Abstract + References in Scopus | Cited By in Scopus, Hiday et al., 1998 V.A. Hiday, M.S. Swartz, J.W. Swanson, R. Borum and H.R. Wagner, Male and female differences in the setting and consruction of violence among people with severe mental illness, Social Psychiatry and Psychiatric Epidemiology 33 (1998), pp. 68–74.


American Psychiatric Association. (1994). Fact Sheet: Violence and Mental Illness.” Washington, DC: American Psychiatric Association.
Appleby, L.,  Mortensen, P. B., Dunn, G., and Hiroeh, U., Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study.” The Lancet, Vol. 358, iss. 9299, (2001), 2110-2112.


Corrigan, P.W., Markowitz, F.E., & Watson, A.C. “Structural levels of mental illness stigma and discrimination.” Schizophrenia Bulletin. Washington: 2004. Vol. 30, iss. 3;  481-492.

Grohol, J. M. “Dispelling the violence myth.” Psych Central. (June, 1998).

Mental Health:  A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999. 

Monahan, J. “Mental Disorder and Violent Behavior: Perceptions and Evidence.” American Psychologist vol. 47 iss.4 (1992): 511-521.

Monahan, J. & Arnold, J. “Violence By People With Mental Illness: A Consensus Statement By Advocates and Researchers.” Psychiatric Rehabilitation Journal vol.19, iss.4 (Spring 1996): 67-70.

Mulvey, E. P. “Assessing the Evidence of a Link Between Mental Illness and Violence.” Hospital and Community Psychiatry vol. 45 iss.7 (July 1994): 663-668.

National Mental Health Association. American Opinions on Mental Health Issues. Alexandria: NMHA, 1999. Pescosolido, Bernice A., et al. Americans’ Views of Mental Health and Illness at Century’s End: Continuity and Change. Americans’ Views of Mental Health and Illness at Century’s End: Continuity and Change. Public Report on the MacArthur Mental health Module, 1996 General Social Survey.  Bloomington: Indiana Consortium forMental Health Services Research and Joseph P. Mailman School of PublicHealth, Columbia University, 2000.

New Freedom Commission on Mental Health, Achieving the Promise: Trasnforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD:  2003. Pescosolido, B.A., Martin, J.K., Link, B.G., et.al.  Americans’ Views of Mental Health and Illness at Century’s End: Continuity and Change. Public Report on the MacArthur Mental health Module, 1996 General Social Survey. Bloomington: Indiana Consortium forMental Health Services Research and Joseph P. Mailman School of PublicHealth, Columbia University, 2000.www.mentalhealthcommission.gov/reports/reports.htm

Pescosolido, B.A., Martin, J.K., Link, B.G., et.al.  Americans’ Views of Mental Health and Illness at Century’s End: Continuity and Change. Public Report on the MacArthur Mental health Module, 1996 General Social Survey. Bloomington: Indiana Consortium forMental Health Services Research and Joseph P. Mailman School of PublicHealth, Columbia University, 2000.

 Policy Research Associates, “What do we know about mental disorder and violence?” December 1994.

For more information about how to address discrimination and stigma, contact the SAMHSA Resource Center to Address Discrimination and Stigma (ADS Center), e-mail stopstigma@samhsa.hhs.gov, or call 800-540-0320, a program of the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.



RC: After Shooting, Congress Ponders Mental Health Role

After Shooting, Congress Ponders Mental Health Role

By Melissa Attias  Roll Call  December 17, 2012


Murphy called for Congress to initiate a “full-scale” effort into reviewing mental health issues. The lawmaker said he would also work to prevent end-of-year cuts to services.

Lawmakers in both chambers are calling for Congress to start a conversation about mental health issues in the wake of last week’s deadly shooting at a Connecticut elementary school, with one goal of ensuring adequate funding for services for those who need treatment.

Although much of the discussion since last week’s shooting has focused on gun policy, several members are also emphasizing the role mental illness has played in many national tragedies. Congress has taken little action on the issue this year, and mental health leaders are hopeful that events in Newtown, Conn., could spur lawmakers to move forward.

“What I think is absolutely essential is Congress has to have an honest dialogue to look at the issues of mental illness,” said Pennsylvania Republican Tim Murphy, a child psychologist and co-chairman of the Congressional Mental Health Caucus. “We need to put a full-scale effort into reviewing this and understanding it better.”

Beyond a broader policy push, the shooting in Connecticut could also make it more difficult for Congress to allow spending reductions for mental health services as part of the fiscal cliff, deficit reduction efforts or the appropriations process next year.

Murphy said he would work to prevent cuts as the end-of-the-year fiscal negotiations continue, and his mental health caucus co-chairwoman, Grace F. Napolitano, echoed that sentiment in a statement released Dec. 14, the day of the Connecticut shooting.

“We must all work together to secure and protect the federal funding needed to carry out mental health services and programs for all Americans,” the California Democrat said. “We must ensure that mental health support is made available for all children, their families, first responders, and the community of Newtown to help deal with this tragic event.”

Last year, Napolitano was the lead author of a letter urging House Republican and Democratic leadership to reject an appropriations bill (HR 3070) that included cuts to mental health and addiction services. She has also introduced legislation (HR 751) across multiple Congresses that was designed to increase access to mental health services in schools to avert harmful outcomes.

Murphy said he wants to review what services are available in schools, as well as societal attitudes and what information is out there in general so Congress can understand where the country currently stands. But he cautioned his colleagues against thinking that there is a simple fix to the issue.

“I’m just afraid that someone will think that they just pass one bill or deal with one law and this is going to go away. Because it’s not,” he said.




KHN: After Newtown Shootings, Mental Health Insurance Coverage will Rise Under ACA

After Newtown Shootings, Questions About Mental Health Insurance Coverage

By Jenny Gold  Kaiser Health News  December 18, 2012

In his speech at the memorial service for the Newtown victims, President Barack Obama included mental health in calling for a national response to the massacre, a conversation that so far has focused on gun control. "I will use whatever power this office holds to engage my fellow citizens -- from law enforcement to mental health professionals to parents and educators -- in an effort aimed at preventing more tragedies like this," the president said.

On Monday White House spokesman Jay Carney pointed to the federal health law as evidence that the administration has already started to tackle the issue. Mental health issues are "clearly a factor that needs to be addressed in some of these cases of horrific violence," Carney said. "Obamacare, if you will, has ensured that mental health services are a part of the services" provided under the health law.

Insurance coverage for mental health treatment has long been spotty. More than a quarter of U.S. adults have a diagnosable mental health problem in any given year, but fewer than half receive treatment. While the Affordable Care Act, along with the Mental Health Parity Act of 2008, go a long way toward assuring coverage for most Americans, some gaps persist. There are questions, for example, about just what counts as equivalent treatment under the parity law, and whether it's being fully enforced. 

Here are some answers to frequently asked questions about mental health coverage:

Didn't the Mental Health Parity Act already guarantee coverage for Americans with insurance?

The Mental Health Parity and Addiction Equity Act, signed into law in 2008, made a big dent in the problem of mental health coverage.

Under that law, employers with more than 50 workers that include mental health services in their insurance plans were barred from covering them at a lower level than other medical conditions. That means that the plans could not provide fewer inpatient hospital days or require higher out-of-pocket costs, more cost sharing or separate deductibles for mental health conditions.

An estimated 140 million Americans were expected to benefit from the changes. But Paul N. Samuels, director and president of the Legal Action Center, says that some people still aren't receiving equal coverage, and the law is not always enforced. "That's a problem we're really concerned about," he says.

And while the law guaranteed parity for employees of companies that chose to offer mental health coverage, the law didn't require employers to offer such coverage. Even so, in 2012, 85 percent of employers offered some form of mental health benefits, according to the Society for Human Resource Management.

Mental health coverage under small business and individual market plans was not included in the Parity Act. In short, whether you have mental health coverage in an employer-sponsored insurance plan depends on where you work.


What if I don't have mental health coverage in my employer’s insurance plan? Will the ACA change that?

Employers with 50 or more workers can continue to not offer the benefits. But small group and individual plans will be required to offer the coverage in 2014 through online exchanges created under the law.


I'm planning to buy an insurance plan through one of the new exchanges. What kind of mental health coverage will I have?

All plans sold in the exchanges will be required to provide coverage for mental health and substance abuse as one of 10 essential benefit categories. That coverage must also comply with the parity laws already required for large employers. The exchanges will be open to individuals and small businesses.

The same rules will apply to small group and individual plans purchased outside of the exchange.

This means that beginning in 2014, if you, or your small employer, are purchasing any new insurance plan, coverage will include mental health benefits on par with any other medical condition. It’s not clear what exactly will be covered – for example, group home and residential treatment outside of a hospital.


I'll be covered under the Medicaid expansion authorized by the law. What kind of mental health coverage will I get?

If you earn less than 138 percent of the federal poverty level (about $32,809 for a family of four), you may be newly eligible for Medicaid coverage in 2014. Like people who purchase coverage through the exchange, new Medicaid beneficiaries will receive mental health benefits on par with other medical or surgical needs.

That coverage is less robust than the current traditional Medicaid coverage offered by states, says Jennifer Mathis, deputy legal director at the Bazelon Center for Mental Health Law. That's because most states offer mental health benefits for Medicaid recipients that are more generous than the coverage offered by commercial insurance plans. But the new Medicaid benefits will be modeled on and measured against private insurance purchased by small businesses now.

Mathis says, however, that it will likely be difficult for states to maintain two parallel Medicaid programs, one for current beneficiaries and a second for the newly eligible. She hopes that most will choose to offer all Medicaid recipients the more robust benefits instead.


What else in the ACA may improve mental health treatment?

The ACA has several other provisions that will affect mental health coverage and treatment.

The Prevention and Public Health Fund created by the law, for example, includes $35 million to integrate primary care and mental health care, $10 million to train and recruit mental health professionals, and an additional $53 million in mental health screening, surveillance, and suicide prevention funds.

The ACA also requires that plans offer depression screening for adults without a copayment, co-insurance or a deductible.


What problems might arise?

While the ACA "provides enormous potential and opportunity to make sure than many millions more Americans obtain the services they need," says Samuels, "that will only happen if the implementation of those reforms is effective." Samuels worries that the rules from HHS will not be clear or strong enough to make the parity laws meaningful. He also worries about getting everyone who is eligible for coverage enrolled, particularly those with severe mental health disorders who be may homeless or living on the fringes of society.

In addition, governors in several Republican states have said that they will not expand Medicaid, leeway they were given by the Supreme Court's health law decision in June. That could leave many Americans without any form of insurance coverage, including mental health benefits.

Access to treatment will likely also remain a serious stumbling block. States have cut $4.35 billion in public mental health spending from 2009  to 2012, a trend that is likely to continue over the next several years, according to the National Association of State Mental Health Program Directors. At the same time, the system has seen nearly a 10 percent increase in usage.

As many as 30 million people are expected to gain insurance coverage beginning in 2014. Of those, the U.S. Substance Abuse and Mental Health Services Administration estimates that 6 to 10 million will have untreated mental illnesses or addiction, adding additional demands to a system that is already overwhelmed. Patients may experience long wait times to see a psychiatrist, for example, and may require additional investments to expand the mental health workforce.

"I think there will be initial period where you may see folks with mental health coverage waiting longer than they'd like to get care," says Joel Miller, senior director of policy and health care reform at the state mental health program directors group.




Mental Health and the ACA

by John McDonough  Health Stew December 17, 2012 10:24 PM


In the wake of the shootings in Newtown Connecticut, it has been encouraging to hear so many calls for attention to improving mental health services in the U.S. Like oral health, mental health is a poor step-sister in our nation's behemoth health care system, mostly on the outside, shouting for attention, and having to settle for second class.

So it's good to hear voices saying we have to do better.

Here's a question: regarding U.S. mental health policy, what's the most important and consequential federal legislation ever signed into law?

Answer: the Affordable Care Act, also known as the ACA and Obamacare. Hardly anyone appreciates the enormous advance in mental health policy created by the ACA, and it's true.

Really. Permit to me to explain.

First, go the actual text of the law right here.  When you get there, go to Title I and look for section 1302. Take a look, please. Section 1302 defines "essential health benefits," those services which every single health insurance policy, beginning on January 1 2014, must include and cover to qualify as health insurance in the United States. There are ten listed services, and number five is:

"Mental health and substance use disorder services, including behavioral health treatment."

Today, and until 1/1/2014, the inclusion of mental health services in health insurance is optional. Many states, not all, require it -- but those state mandates don't apply to the majority of large employers who self-insure. In 2008, Congress passed a law to require "parity" or equality of treatment for mental health care -- but that law only applies to employers who choose to offer mental health services, not to those who don't, and doesn't apply to employers with 50 or fewer workers.

The ACA changes all that, and that's not all. As David Mechanic explains in a 2012 article in the journal Health Affairs:

"The Affordable Care Act, along with Medicaid expansions, offers the opportunity to redesign the nation's highly flawed mental health system. It promotes new programs and tools, such as health homes, interdisciplinary care teams, the broadening of the Medicaid Home and Community-Based Services option, co-location of physical health and behavioral services, and collaborative care. Provisions of the act offer extraordinary opportunities, for instance, to insure many more people, reimburse previously unreimbursed services, integrate care using new information technology tools and treatment teams, confront complex chronic comorbidities, and adopt underused evidence-based interventions."

One could make the case that the 1963 Community Mental Health Centers Act, signed by President John Kennedy, was more consequential.  It's fair argument, either way. I say the ACA.

I do have a hunch that some people now talking about the need to focus on mental health in the wake of the Newtown tragedy are really trying to turn the conversation away from the need for more effective gun control.

But here's a question for some of them: Governors Rick Perry (R-TX), Bobby Jindal (R-LA), Rick Scott (R-FL), Chris Christie (R-NJ), Tom Corbett (R-PA), Scott Walker (R-WI) and many more -- you all now say that you will not implement the ACA in your states. As you say that, do you realize that you also standing in the way of the most important expansion of mental health coverage and services in U.S. history, ever?

Are you feeling proud of yourselves today?




DB: Stop Blaming Newtown Tragedy On Mental Illness

Stop Blaming Newtown Tragedy On Mental Illness

If mental illness were the key factor in multiple gun homicides, other countries would regularly experience similar acts of carnage. But they don’t.

by Peter Jukes  The Daily Beast  December 18, 2012

In the wake of the terrible events of last Friday in Newtown, which left 27 dead-20 of them young schoolchildren-social media such as Twitter and Facebook played a key role in communicating the shocking news and expressing an international sense of outrage and grief. But they also spread misinformation and misapprehensions just as quickly. The gunman was initially misidentified, and his murdered mother was erroneously connected to Sandy Hook Elementary School. But while these errors of fact were soon corrected, a deeper misunderstanding took hold over the following few days as a shattered nation tried to understand an inexplicable tragedy.

An uncorroborated rumor about the gunman, Adam Lanza, suggested that he suffered from Asperger’s syndrome-a now out-of-use term for a higher-functioning form of autism. By Saturday, a blog post by Lisa Long- "I Am Adam Lanza’s Mother: A Mom’s Perspective On The Mental Illness Conversation In America" -had gone viral, been re-tweeted hundreds of thousands of times, and republished on Gawker, Britain’s Daily Mail, and on the Huffington Post. Long, the mother of a 13 year old with behavioral problems, argued, “It’s easy to talk about guns. But it’s time to talk about mental illness.”

There are various problems with Long’s impassioned piece when it comes to “talking” about mental illness, partly due to the fact it contained a slew of questionable diagnoses-Autism spectrum, ADHD, Oppositional Defiant, or Intermittent Explosive Disorder-which aren’t officially recognized as mental illnesses at all. Police Inspector Michael Brown, who runs the highly respected Mental HealthCop blog, called it “potentially the worst article I have ever read about mental health and violence following an atrocity.” Other critics took issue with the way Long had publically demonized her son as a potential mass murderer. While some complained that Long herself was being demonized as a bad mother, the author from Boise, Idaho, issued a joint statement with one of her erstwhile critics about the need for accessible and affordable mental health care in the U.S.

The Huffington Post published a corrective article, “No Link Between Asperger’s Syndrome And Violence, Experts Say.” But to date, the corrective article has only received 2,500 Facebook “likes” compared to the more than a million received by Long’s original piece. The misinformation had circled the virtual world before the truth had even begun to get its cyber-boots on.

By Sunday, the line had grown into a swelling chorus. Erik Erickson, the founder and editor of the popular Republican website Redstate, was averring: “Discussions of gun control are easier to have than discussions about mental health.” The owner of one of the many gun ranges in the rural rolling hills around Newtown, Conn., was telling The New York Times: “A gun didn’t kill all those children, a disturbed man killed all those children.” David Rivkin, a constitutional lawyer who served in both the Reagan and Bush Sr. administrations, appeared on the BBC World Service to tell millions of listeners overseas: “It’s not about gun ownership, it is about mental illness.” “If there’s one unifying feature of all these atrocities,” Rivkin stated in an interview for the popular Newshour program on Monday night, “it’s that they were all committed by mentally unbalanced people who need to be confined for the protection of those around them and other people.”

Despite the promise of a conversation about mental health, misinformation and ignorance became the norm in the aftermath of the Newtown tragedy.

The only problem with this argument is that it has no basis in fact. If mental illness were the key factor in multiple gun homicides like Newtown, then other countries would regularly experience the kind of carnage visited on towns and cities in the U.S. on almost on a monthly basis. But they don’t. In Britain, an advanced study by Manchester University into “Suicide and Homicide by People with Mental Illness” has found most people who kill more than one person are neither mentally ill, nor mental health patients, As Dr. David H. Barlow, a senior expert in comparative mental health-care systems and Emeritus Professor at Boston University, told The Daily Beast, “the incidence of mental illness is quite consistent across Europe and America.” Yet the statistics for the homicide and suicide rates are much higher in the U.S. than most of the rest of Europe, with Americans 100 times more likely to die to a gun-related death than in the U.K.

Despite the promise of a conversation about mental health, misinformation and ignorance became the norm in the aftermath of the Newtown tragedy.  British CNN host Piers Morgan suggested that anyone with a history of mental illness should be banned from owning a gun in the U.S., but that would include almost 50 per cent of Americans who are expected to suffer from some condition in their lifetime.  The Center for Disease Control and Prevention estimates that about 25 percent of U.S. adults currently suffer from some kind of mental ilnness-though this would include phobias and obsessive disorders. In 2011, government data calculated that around 5 percent of the U.S. population suffered from severe mental illness, while Professor Barlow estimates that somewhere around 1 percent  of the U.S. population will be suffering from psychosis—including delusions and hallucinations—at any one time. “But even they show an only slightly elevated risk of violence,” Barlow told The Daily Beast, “with a small increased risk of around 5 or 10 percent above normal.” Meanwhile, those who suffer from psychosis are much more likely to be the victims of homicide or kill themselves.

For Dr. Nadine Kaslow, professor and chief psychologist at Emory University School of Medicine—who was recently elected to the presidency of the American Psychological Association—the recent spate of generalized and pejorative statements made about mental illness are “extremely unfortunate” as they “stigmatize a whole group.”

“When I talk to my patients after an incident like Newtown,” Kaslow told The Daily Beast, “my patients differentiate themselves from these killers, because they say these people lack empathy.” Though Kaslow acknowledges that those with learning disabilities or mood disorders can be aggressive and display challenging behaviors, this doesn’t translate into calculated acts of violence. “We really do not see any correlation between Asperger’s syndrome and gun violence,” Kaslow reiterated.

Those millions of Americans who suffer from mental illnesses and learning disabilities have therefore become collateral damage in the soul-searching since the Newtown massacre. What conditions Lanza suffered from, or didn’t, will take a long investigation, but like other multiple-gun homicides, his atrocity required almost military-style planning and execution, which is unlikely given against the cognitive and emotional deficits of acute psychiatric illness. It was this element of forethought and calculation which led to Anders Behring Breivik, the Norwegian right-wing extremist who killed eight with a bomb in Oslo then shot dead 69, mainly teenagers, holidaying on Utøya Island in 2011, being considered sane enough to face trial and a prison term in Norway. Though Breivik’s Islamophobic ideology could be described as crazy, the means Breivik chose to pursue his apocalyptic race war were rational and deliberative given those precepts, and he showed no sign of clinical psychosis.

In this light, Long’s imprecation to “start talking about mental illness rather than guns” looks like a distraction from the more probable factor to explain America’s elevated homicide and suicide rates: the U.S. is a complete outlier compared to other industrialized nations in its startling, almost 90 out of 100, number of guns per capita. Apart from the extreme youth and number of his victims, the other hallmark of Lanza’s massacre was the use of a semi-automatic Bushmaster AR-15 assault rifle (which has horrifically doubled in price since the Newtown attack). Assault weapons were banned until 2004, when the Federal Assault Weapons Ban was not renewed—largely thanks to the lobbying power of the National Rifle Association.

In what must count as one of the most successful campaigns in U.S. history, the NRA has managed to reduce support for gun control in the U.S. by 50 per cent in the last 20 years. One of its key lines of argument throughout that time has been that, “It’s not guns that kill people, but people who kill people.” On Friday the NRA’s Facebook page was taken down, and its Twitter feed went silent, and the organization seemed to have no response to the mounting calls for gun control in the wake of the most recent tragedy.

According to Mark Borkowski, a British PR titan with extensive knowledge of crisis-management campaigns, “anybody in this territory is equipped to deal with extreme events like this, and defend against or capitalize on them depending on what happens.” “The key thing is to sow doubt,” Borkowski told The Daily Beast. “Doubt is a product, and you have sleepers and advocates who are well briefed to construct a counter-narrative in times of crisis.”

There is no evidence that the NRA or any of its lobbying arms has been involved in any kind of crisis management in the last few days. However, opponents of gun control are now using a variant of the old NRA adage, “It’s not guns who kill people, but mentally disturbed people who killed people.” In doing so they are perpetuating what is effectively a slur against millions of Americans who suffer from mental illness, and stigmatizing a group who already suffer enough.




In Gun Debate, a Misguided Focus on Mental Illness

By Richard A. Friedman, M.D.  New York Times  December 17, 2012


In the wake of the terrible shooting at an elementary school in Newtown, Conn., national attention has turned again to the complex links between violence, mental illness and gun control.

The gunman, Adam Lanza, 20, has been described as a loner who was intelligent and socially awkward. And while no official diagnosis has been made public, armchair diagnosticians have been quick to assert that keeping guns from getting into the hands of people with mental illness would help solve the problem of gun homicides.

Arguing against stricter gun-control measures, Representative Mike Rogers, Republican of Michigan and a former F.B.I. agent, said, “What the more realistic discussion is, ‘How do we target people with mental illness who use firearms?’ "

Robert A. Levy, chairman of the Cato Institute, told The New York Times: “To reduce the risk of multivictim violence, we would be better advised to focus on early detection and treatment of mental illness.”

But there is overwhelming epidemiological evidence that the vast majority of people with psychiatric disorders do not commit violent acts. Only about 4 percent of violence in the United States can be attributed to people with mental illness.

This does not mean that mental illness is not a risk factor for violence. It is, but the risk is actually small. Only certain serious psychiatric illnesses are linked to an increased risk of violence.

One of the largest studies, the National Institute of Mental Health’s Epidemiologic Catchment Area study, which followed nearly 18,000 subjects, found that the lifetime prevalence of violence among people with serious mental illness — like schizophrenia and bipolar disorder — was 16 percent, compared with 7 percent among people without any mental disorder. Anxiety disorders, in contrast, do not seem to increase the risk at all.

Alcohol and drug abuse are far more likely to result in violent behavior than mental illness by itself. In the National Institute of Mental Health’s E.C.A. study, for example, people with no mental disorder who abused alcohol or drugs were nearly seven times as likely as those without substance abuse to commit violent acts.

It’s possible that preventing people with schizophrenia, bipolar disorder and other serious mental illnesses from getting guns might decrease the risk of mass killings. Even the Supreme Court, which in 2008 strongly affirmed a broad right to bear arms, at the same time endorsed prohibitions on gun ownership “by felons and the mentally ill.”

But mass killings are very rare events, and because people with mental illness contribute so little to overall violence, these measures would have little impact on everyday firearm-related killings. Consider that between 2001 and 2010, there were nearly 120,000 gun-related homicides, according to the National Center for Health Statistics. Few were perpetrated by people with mental illness.

Perhaps more significant, we are not very good at predicting who is likely to be dangerous in the future. According to Dr. Michael Stone, professor of clinical psychiatry at Columbia and an expert on mass murderers, “Most of these killers are young men who are not floridlypsychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”

Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.

Jeffery Swanson, a professor of psychiatry at Duke University and a leading expert in the epidemiology of violence, said in an e-mail, “Can we reliably predict violence?  ‘No’ is the short answer. Psychiatrists, using clinical judgment, are not much better than chance at predicting which individual patients will do something violent and which will not.”

It would be even harder to predict a mass shooting, Dr. Swanson said, “You can profile the perpetrators after the fact and you’ll get a description of troubled young men, which also matches the description of thousands of other troubled young men who would never do something like this.”

Even if clinicians could predict violence perfectly, keeping guns from people with mental illness is easier said than done. Nearly five years after Congress enacted the National Instant Criminal Background Check System, only about half of the states have submitted more than a tiny proportion of their mental health records.

How effective are laws that prohibit people with mental illness from obtaining guns? According to Dr. Swanson’s recent research, these measures may prevent some violent crime. But, he added, “there are a lot of people who are undeterred by these laws.”

Adam Lanza was prohibited from purchasing a gun, because he was too young. Yet he managed to get his hands on guns — his mother’s — anyway. If we really want to stop young men like him from becoming mass murderers, and prevent the small amount of violence attributable to mental illness, we should invest our resources in better screening for, and treatment of, psychiatric illness in young people.

All the focus on the small number of people with mental illness who are violent serves to make us feel safer by displacing and limiting the threat of violence to a small, well-defined group. But the sad and frightening truth is that the vast majority of homicides are carried out by outwardly normal people in the grip of all too ordinary human aggression to whom we provide nearly unfettered access to deadly force.





Speculating About Adam Lanza's Mental State

By Dr. Harold Koplewicz Child and Adolescent Psychiatrist; President, Child Mind Institute 

Huffington Post  December 17, 2012


As we struggle to come to terms with the tragic shootings in Newtown, Conn., the hardest thing to grasp is why anyone would be moved to kill small children and the teachers trying heroically to protect them. We search for clues that would make this horrific act understandable, and we do not find them.

We do know that whatever was going on in the mind of 20-year-old Adam Lanza when he went on this appalling shooting spree, it did not come from a place of good mental health. But to blame this violence on Asperger's or a personality disorder, as many media outlets currently are, is a serious mistake.

At this point, any comment on the psychiatric profile of Adam Lanza, the 20-year-old man responsible for these murders, is complete hearsay. We don't know whether he had a history of psychiatric illness or if had been exhibiting signs of a psychotic breakdown. Unfortunately, that hasn't stopped extensive speculation that Lanza had Asperger's disorder, or a personality disorder, and even obsessive-compulsive disorder. Much has been made of the reports that Lanza was a smart but quiet kid who carried a briefcase to class instead of a backpack and felt at home with computers, perhaps more so than with his peers. By themselves these traits do not indicate any diagnosis at all, although we have been quick to dissect them in the search for meaning.

These amateur diagnoses based on unconfirmed information are very harmful. To my mind perhaps the worst is the suggestion that the unimaginable nature of this violence -- the fact that children were targeted -- somehow indicates a lack of empathy that can be associated with autism spectrum disorders. This is completely untrue. Individuals on the spectrum are in no way predisposed to this kind of violent behavior. Ample research proves otherwise. And while individuals with autism may be less adept at picking up nonverbal social cues, they are just as capable of experiencing emotional empathy as anyone else. I have known many autistic children who would be crushed knowing that a sibling, a parent, or even a spider was suffering.

Trading in rumors and misinformation sensationalizes real disorders and leads to stereotypes and bigotry. It fuels the stigma that mental disorders are dangerous or scandalous and prevents people from seeking the life-changing help they need. And because untreated psychiatric disorders are more likely to result in violence, it makes tragedies like this one more likely to happen again. So let's stop speculating about the things we don't know and start focusing on what we do know.

We know that when we see someone suffering, we shouldn't look away. And when we see young people coughing, wheezing or bleeding, we insist that they get attention. But when we see young people with disturbing behavior, or young people in clear emotional distress, we ignore them and hope these problems will go away.

The first signs of 75 percent of all psychiatric disorders appear by the age of 24. We need to be on the lookout for signs of distress in young people to get them help as soon as possible. Research shows that early intervention improves the outlook for anyone with a psychiatric disorder -- and drastically reduces the likelihood of violence.

As a nation, we need to change our attitude about mental illness. We need a better plan for giving mental health care parity with other medical care. Improving access to the best evidence-based interventions should be a national priority. The economic cost as well as the human cost of untreated mental illness makes that clear.

Finally, we know our first graders should never fear for their lives when they sit down in a classroom. We know we need to do everything we can to make sure this never happens again.

Harold S. Koplewicz, M.D., is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For expert advice on how to help children cope with frightening news, go tochildmind.org, which offers resources on trauma and resilience as well as a wealth of information on childhood psychiatric and learning disorders.