Psychiatric Care Fails When It Becomes a Law Enforcement Job

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President Biden’s 2023 State of the Union Address was laden with urgent discussion around public health and treatment access, as has been the case since the COVID-19 pandemic. There were allusions to Affordable Care Act accessibility, a call to codify national rights to an abortion after the overturn of Roe v. Wade in 2022, and mentions to advanced research and drug development in chronic diseases including cancer and Alzheimer disease.

There was also a great deal of discussion regarding mental health in the US. Some of it was on the point, much of it was actually harmful to national rhetoric, and all of it showed how far we still have to go in our way of thinking about psychiatric care and awareness.

On the subject of the police force, Biden lamented that the modern officer is tasked with too many responsibilities, including “to be counselors, social workers, psychologists; responding to drug overdoses, mental health crises, and more.” He later called on the addition of “first responders and other professionals” to help aid in this work.¹

Okay. There are a few things to say about that—none more pressing than this: the average police officer is not a professionally trained, licensed nor qualified psychologist. Neither the initial nor annual education they receive on the subject is enough to make that distinction—and in fact, likely for the very same reason Biden made that allusion in his address, there is evidence showing their background in psychology is either underutilized or outright counterintuitive to optimal outcomes in their line of work.

Of the approximate 10 million individuals incarcerated in the US every year, patients with mental disorders constitute a disproportionate rate. An analysis of arrested civilians in New York state showed up to 6 in every 100 arrestees were treated for a major mental illness in the last year; this group had a more than 50% increased risk of incarceration than the general public.²

Another study of inpatient psychiatric facility residents in Georgia showed that 7 in every 10 had been previously arrested at least once. Of that population, mean lifetime arrests were 8.6 per individual.³ Greater counts of arrest were positively associated with lower education, Black or African American race, substance use and mood disorders, and female sex.

The over-involvement of law enforcement with psychiatric health can have far worse outcomes than incarceration, however. Saleh et. al reported that, of a compilation of approximately 1100 civilians killed by US police in 2015, 22.8% (n = 251) displayed signs of mental illness. In fact, they estimated a six-fold increased risk of police-related fatalities among individuals with a mental illness than those without (relative risk, 7.16; 95% CI, 6.21 – 8.25).⁴

Despite these findings, the evidence supporting a correlation between mental illness and criminal behavior is very limited—so much so that experts believe people with mental illnesses are more likely to be the victim of violent crimes than the perpetrator.⁵

These data likely aren’t surprising to the average American in 2023; embedded in the growing national criticism of police is their oftentimes blunt approach to mentally ill civilians. So this has to be asked: Why are we still doing this?

As long as we accept and even expect this destructive coupling of police officers and people with mental illness, we perpetuate the association between treatable psychiatric disorders and criminality—and we increase the likelihood that the undiagnosed remain just that.

This is a critical issue reaching an inflection point in our country, and not just because the President mentioned it in his national address this month. Psychiatry is going through structural changes—in its patient populations and the very definitions of disease.

At the American Psychiatric Association (APA) 2022 Annual Meeting in New Orleans last year, I spoke with Jonathan Alpert, MD, PhD, chair of the department of psychiatry and behavioral sciences at Montefiore Health Systems and Albert Einstein School of Medicine. Alpert described recent discussions around revising and amending the fifth-edition Diagnostic and Statistic Manual of Mental Disorders (DSM-5) to increase diagnostic capabilities that consider not only neurological pathophysiology of conditions like substance use disorder, but the social factors that foster mental illnesses.⁶

“There’s so much heterogeneity in psychiatry—people come in all shapes and sizes, and being able to come up with treatments and ultimately, predictors for who does best with which of those combinations of treatments (is the goal),” Alpert said.

This all impacts the training and prioritization of care givers, pharmaceutical researchers and prescribers. What’s more, the pandemic and resulting remote care expansions also led to a boom in psychiatric counseling; telehealth services for mental health care increased about 20-fold from January – December 2020 alone.⁷

The issue with these advancements is there is still opportunity to leave behind the psychiatric patients most adversely impacted by law enforcement: people of color, and those with mood or substance disorders.

Even during the expansion of mental health care in the US, minorities are far less likely to seek and receive treatment. Nationally representative cross-sectional data of US adult primary care outpatient visits show mental health concerns have been increasingly addressed since 2006. All the while, Black patients were 40% less likely to have a mental health concern addressed during a primary care visit than a White patient, as were Hispanic patients versus a non-Hispanic patient.⁸ These same populations are at greater risk of arrest—both with and without a diagnosed mental illness—than the general population.

Additionally, 2015 data show correlations between individuals with bipolar disorder, increased criminal activity during acute and psychotic episodes, incarceration rates, substance use disorder, reincarceration, and suicide attempts. Individuals with both a mood disorder and comorbid substance use disorder are at a ten-fold increased likelihood of committing a crime. The investigators highlighted the need for more timely screening and treatment initiation to avoid the cyclical nature of incarceration and disease exacerbation in these populations.⁹

“The relationship between psychiatric care outside prison and psychiatric services within prison is a significant factor in improving care for these patients,” they wrote. “Such improvements are critical to providing better outcomes for patients with bipolar disorder.”

Biden’s call for more trained first responders to aid police in managing mental and addiction health issues may not be among the systemic improvements these experts are speaking to. Really, it’s a Band-Aid on a gaping wound. The US has a problem with punishing, not treating, psychiatric patients. We need to bolster awareness, screening tools and access, post-incarceration counseling and treatment access, and representation in psychiatry.

Improving awareness and screening are as straightforward as concepts come in public health solutions; getting a mental health patient deliberate care after their incarceration is just as simple and worthwhile. A study from British Columbia showed that among adults with mental disorders released from prison, those who accessed care services through traditional means—whether via primary care, emergency department visits or hospitalizations—were 39% less likely to be reincarcerated than those who did not access care.¹⁰

The investigators stressed that timeliness is critical in this benefit; prisoners with mental disorders should have a clear plan for follow-up care well before being released.

Regarding people of color with mental disorders, there is still a greater need to initiate care altogether. Another expert at APA 2022, Rachel Talley, MD, director of the Fellowship in Community Psychiatry at University of Pennsylvania, discussed the issue of underrepresentation of psychiatrists with Black and Latinx backgrounds in the field. This not only limits how often a person of color will seek out or continue mental health care, but caps the field’s capability to provide specific care for its most adversely impacted patients.¹¹

“There’s absolutely data that suggest for people of marginalized identity, race and cultural concordance can be a very powerful and important factor in terms of initial access to care or retention to care,” Talley said. “I think there’s a lot to do around really hearing the voices of our trainees of color and understanding what their experiences are like, and being thoughtful about how we build training environments to be hospitable to folks who have been traditionally shut out of that training, such that they’re excited to stay in the field.”

To Biden’s credit, he additionally called for improved mental health care access for children and adolescents at school—a concept which nearly all experts in psychiatry would advocate for over increased first responders at the point of arrest.

Relative to many fields in the wake of the pandemic, psychiatry has made fantastic public health strides to become more representative and amenable to its impacted population. For the first time in at least my adulthood, I have genuine faith mental health is being prioritized, not pandered to, in our country. But still, we significantly lack equitable, preventive care.

We cannot continue to allude mental and behavioral disorders to criminality; we cannot assign law enforcement to the responsibilities of care givers; we cannot prioritize systems that cycle patients through penalties and worsened outcomes over systems that could prevent that cycle altogether.

We have made too great of progress in psychiatry to continue accepting dire circumstances and half-measure solutions.

Kevin Kunzmann is the associate editorial director of HCPLive. The presented analysis reflects his views, not necessarily those of the publication.

Health care professionals and researchers interested in responding to this piece or similarly contributing to HCPLive® can reach the editorial staff by submitting a request here.

References

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