اثرات مراقبت از سلامت روان مدیریت شده بر دستگیری و تعهد قانونی
|کد مقاله||سال انتشار||مقاله انگلیسی||ترجمه فارسی||تعداد کلمات|
|36552||2004||13 صفحه PDF||سفارش دهید||6322 کلمه|
Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : International Journal of Law and Psychiatry, Volume 27, Issue 1, January–February 2004, Pages 65–77
Reducing the use of inpatient treatment has been a consistent theme of American mental health policy for the last half century and, over that time, has been the focus of numerous service system interventions. Among these was passage of reformed civil commitment statutes by state legislatures across the country. These reforms, enacted mainly in the late 1960s and early 1970s, limited the availability of involuntary psychiatric hospitalization as a means for managing deviant behavior in the community, and made a significant contribution to expanding the rights of persons with mental illness (Appelbaum, 1994). But the passage of these reforms was also seen as having a number of unintended and less desirable sequelae. In particular, their enactment was followed by reports of increased involvement in the criminal justice system among persons with mental illness, many of whom were former state hospital patients—an outcome that came to be referred to as the “criminalization” of mental illness (Abramson, 1972). By the 1990s, the use of state hospitals had declined substantially, and the principal locus of inpatient treatment for severe mental illness had shifted to general hospitals. Many advantages were cited in support of this shift, but chief among them, perhaps, was that a portion of the cost of treatment provided in these settings would be borne by the federal government through the Medicaid program Dorwart & Epstein, 1993 and Fisher et al., 1992. But this cost shifting soon contributed to a growing fiscal crisis in these programs, and many states introduced managed care to control the spiraling cost of their Medicaid behavioral health programs. The implementation of managed mental health care was driven largely by economic, rather than civil, liberties concerns. Nevertheless, like the nationwide civil commitment reforms enacted two decades earlier, managed care focused primarily (though not exclusively) on limiting the use of inpatient care. Moreover, viewed broadly, the practices employed by managed care organizations (MCOs) working in Massachusetts and other states to curb unnecessary hospitalization have been similar in many key respects with those mandated in reformed civil commitment statutes. Both specify clinical/behavioral criteria for hospitalization and employ mandatory prescreening processes to assess persons relative to those criteria. In addition, both seek to limit the duration of hospitalization through mandated review of the patients' clinical status—civil commitment through regular court hearings, managed care through the mechanism of concurrent review. The similarity in goals and procedures developed as features of the two interventions raise the question that we address in the study described here: Has one of the most frequently noted consequences of civil commitment reform, the increased criminal justice system involvement among persons with mental illness, also occurred following the introduction of managed care? 1.1. Medicaid managed mental health care: the Massachusetts experience In the early 1990s, Massachusetts, like many other states, was experiencing severe budget shortfalls. Trimming the state's mental health budget by shifting a portion of the cost of inpatient treatment to the federal government through the Medicaid program emerged as among a range of possible remedies. In pursuit of this agenda, an effort was undertaken to enroll as many clients of the Massachusetts Department of Mental Health (DMH) as possible in the state's Medicaid program Callahan et al., 1995 and Dickey et al., 1995. Realizing the expected savings from this cost-shifting effort would prove more complicated, however. As in many other states, Medicaid expenditures were soaring and outlays from Medicaid's behavioral health accounts were increasing more rapidly than were those for general health care. In order to stem this increase, Massachusetts applied for and was granted a 1915b waiver from the Health Care Financing Administration, allowing the state's Division of Medical Assistance to implement a managed care program for its behavioral health plans. A proprietary MCO was retained to administer the plan. When the main features of the initiative took effect in October 1992, Massachusetts became the first state in the nation with a statewide Medicaid managed mental health care program. The outcomes of the Massachusetts initiative have been described in substantial detail elsewhere Callahan et al., 1995, Dickey et al., 1995 and Frank & McGuire, 1997 and need not be recounted here, except to outline briefly the major operational components of the plan and its principal outcomes as they pertain to inpatient treatment. Among the steps taken by the MCO in implementing the managed care plan was the development of prescreening or precertification protocols for approving hospital admissions and the use of a concurrent review process to monitor progress and facilitate discharge planning. A number of changes in inpatient use occurred within the first year of the MCO's operation. Of particular interest here was a 15% reduction in Medicaid-reimbursed hospital days in general and private psychiatric hospitals. Significantly, this reduction was achieved without recourse to “dumping” patients in state hospitals; indeed, over this same time period, state hospital use also fell by roughly 15% Callahan et al., 1995 and Dickey et al., 1995. These achievements notwithstanding, many advocates for persons with severe mental illness expressed serious concerns about potential undesirable consequence. Given the increased attention being paid nationally to the criminalization of mental illness, it is not surprising that one such concern, as articulated by the mother of a young man with severe mental illness, was that he and others like him would “all end up in jail.” 1.2. Arrest and reduced access to inpatient treatment There has long been interest in the relationship between the mental health and criminal justice systems and the way in which their complementary roles as social control agents are defined and carried out. As early as the 1930s, Penrose (1939) investigated this issue and noted an inverse relationship between the size of nations' correctional and psychiatric hospital populations. This observation contributed to what has come to be called the “balloon” or “hydraulic” model of social control, which posits that the decreased use of one component of a society's social control system causes the increased use of the other. In the United States, a unique opportunity to evaluate this theory was created in the early 1970s as, one by one, state legislatures across the nation reformed their statutes governing involuntary psychiatric hospitalization and, in so doing, significantly limited the access to this means of controlling deviant behavior among that population. In the wake of these reforms, as we noted earlier, a number of observers reported what they thought to be an outcome that could be consistent with that model Abramson, 1972, ENKI Research Institute, 1972, Kirk & Therrien, 1975, Lamb & Grant, 1980, Urmer, 1975 and Whitmer, 1980. The title of one such report, The criminalization of mentally disordered behavior: Possible side effects of a new mental health law (Abramson, 1972), aptly characterizes the belief held by many that an increased level of criminal justice involvement among former state hospital patients had occurred in the postreform era. The belief that mental illness was becoming increasingly “criminalized” was not without its skeptics, however (cf. Teplin, 1983). Indeed, some of the data supporting this view were more observational and anecdotal than systematic or analytic. System-based examinations of arrest patterns among persons with mental illness suggested that what appeared to be a criminalization phenomenon might be explainable in other ways. Steadman, Cocozza, and Melick (1978), for example, presented data suggesting that the increased criminal involvement of state hospital patients could be attributed at least, in part, to increased numbers of younger people in the patient population. Their data showed that many such patients had criminal histories predating their hospitalization, and as such were at greater risk for future arrest. Arguably, the best data for examining the criminal justice-related effects of mental health legal and policy reforms are those derived from studies examining the overlap of mental health and criminal justice populations before and after such changes have occurred. Viewed as a whole, the findings of such studies are somewhat equivocal in their support for the criminalization thesis. But more importantly, perhaps, they also suggest that where investigators look in the continuum of criminal justice and mental health dispositions may affect what they conclude. For example, Steadman, Monahan, Duffee, Hartstone, and Robbins (1984) examined crossover in the populations of state hospitals and state prisons in six states at two points in time (1968 and 1978), which neatly bracket a period featuring some of mental health's most intense policy and statutory reform efforts. Examining overlap in the populations of two institutions that represent the “endpoints” of their respective systems, they found no evidence of a systematic trend in the rate of crossover. On the other hand, Geller and Lister (1978), observing the behavior of the criminal courts before and after Massachusetts implemented its revised commitment statute, found an increase in rates of defendant referrals to state hospitals for evaluation of competency to stand trial. This finding is consistent both with the more global hydraulic model of social control and also with the view advanced by Abramson (1972) and others that restrictions placed on involuntary psychiatric hospitalization led to increased likelihood of criminal justice system involvement. These data further suggest, however, that given the availability of diversionary mechanisms such as forensic referral, many individuals with mental illness, whose deviant behavior was initially managed via criminal justice intervention, ultimately found their way into the mental health system, albeit by a different route. Taken together, these two studies begin to form a picture of the way in which limits on the availability of psychiatric hospitalization might affect the criminal justice system involvement of persons with mental illness. Basically, they suggest that some mental health system clients do indeed become involved with the criminal justice system, and that the likelihood of this occurrence may be increased when involuntary hospitalization becomes less accessible. However, their pathways through the criminal justice process may be truncated early on—as in the court arraignment phase where competency evaluations are ordered—and may only rarely proceed to the point of incarceration in state prisons, as may be inferred from the findings of Steadman et al., 1984. Two means have been described by which the probability of arrest among persons with mental illness increased as a result of limiting access to hospitalization, one involving the police and the other the courts. Police officers summoned to manage a person with mental illness may pursue involuntary hospitalization but fail in their attempt if hospital gatekeepers determine that the individual fails to meet admission standards. Repeated failures of this kind may lead officers to perceive the mental health system as difficult to access. Hospital staffs also are under legal and economic pressures to discharge patients as quickly as possible. But as they comply with these mandates, police officers may come to perceive the duration of hospitalization as too short, requiring repeated interventions with the same individuals. Frustrated by such responses on the part of the mental health system, police may choose to bypass it altogether and resort to arrest. The likelihood of their doing so may be increased if adequate community-based services are not available as alternative sites for disposition Durham et al., 1984 and Steadman, 1990. These and other factors have contributed to the perception held by some that local jails have become surrogate psychiatric hospitals (cf. Torrey et al., 1992). The second of these pathways involves actions by criminal courts with regard to the issue of defendants' competency to stand trial. Criminal defendants have a constitutional right to participate in their own defense. Pursuant to the Supreme Court's ruling in Dusky v. U.S. (362 U.S. 402 80 S. Ct. 788, 4 L.Ed.2d 824, 1960), it must be established that a defendant “has sufficient present ability to consult with his lawyer with a reasonable degree of rational understanding and …a rational as well as factual understanding of the proceedings against him…” All states have made provisions for evaluating the competency of persons whose fitness to stand trial may be impaired due to mental illness. In many states, including Massachusetts, judges have the option of committing defendants for a period of inpatient assessment at a state hospital if they believe circumstances require it (Grisso, Cocozza, Steadman, Fisher, & Greer, 1994). The legal basis for inpatient competency evaluation represents the process's “manifest” or stated function. But this referral process has been shown also to have additional unintended or “latent” functions. As Geller and Lister (1978) argued, such commitments may, in some cases, be issued less to ascertain competency and more to accomplish the hospitalization of a person deemed noncommittable under civil statutes, a practice which has been termed “back door commitment” (Appelbaum, Fisher, Nestelbaum, & Bateman, 1992). Evidence of the prevalence of such practices on the part of the court can be inferred from the findings of a survey of the Massachusetts judiciary conducted in the mid-1990s. In this survey, 45% of respondents indicated that they had greater confidence in the forensic system than the civil mental hospital system and they utilized forensic commitment when the opportunity presented itself (Appelbaum & Fisher, 1997). As we noted earlier, the expanded use of inpatient forensic commitment was shown to be associated with the imposition of restrictive civil commitment criteria in the 1970s (Geller & Lister, 1978). More recently, such a trend was observed in the wake of Massachusetts's Medicaid managed care intervention. Following that intervention, the likelihood of inpatient forensic commitment was higher for Medicaid beneficiaries than for nonbeneficiaries, a pattern that had not been evident in the year prior to managed care's taking effect (Fisher et al., 2002). These scenarios suggest that in seeking to determine whether an inadvertent criminalization process has been triggered by Medicaid managed care, attention should be focused on pre-post managed care trends in crossover from the mental health system to the criminal justice and forensic evaluation systems. Such crossover could manifest itself in two ways: (1) increased likelihood of arrest and/or (2) increased likelihood that arrestees would be committed to the forensic mental health system. To examine the extent of any such crossover, we developed and evaluated three hypothetical scenarios. The first is simply the null hypothesis that managed care had no effect on either arrest or forensic commitment. The second posits a generalized postmanaged care increase in criminal justice and forensic system involvement among clients of the mental health system. This scenario assumes that police officers and judges, finding the mental health system's operation increasingly frustrating, use arrest and forensic commitment as a means of disposition in cases involving persons with mental illness. The global nature of this effect would be the result of these actors' perceptions of the adequacy and accessibility of the mental health system, not the beneficiary status of actual or potential detainees, about which they likely would have no information. The third scenario posits a more focused effect. It envisions that, in the postmanaged care era, clients of the mental health system who are Medicaid beneficiaries were at greater risk for either arrest or forensic commitment-given arrest, or both, than they were (1) prior to managed care's taking effect and (2) than are other mental health system clients who were not Medicaid beneficiaries.