Mental Illness and Ethical implications for Special Needs Populations

1. Mental Illness and Ethical implications for Special Needs Populations Nina B. Urban, MD, MScClinical Assistant Professor of PsychiatryNew York UniversityGlobal Bioethics Summer School, NYCJuly 18, 2019

2. Disclosures • No conflicts of interest to report

3. Psychiatric State Hospitals: Asylums • 1900th century psychiatrists: architecture of “insane asylums”, especially their planning, was one of the most powerful tools for the treatment of the insane. • The construction and use of these buildings served to legitimize developing ideas in psychiatry. • Quaker reformers, such as Samuel Tuke, promoted the “moral treatment”: patients should be “unchained, granted respect, encouraged to perform occupational tasks (like farming, carpentry, or laundry), and allowed to stroll the grounds with an attendant and attend occasional dances.”

4. Psychiatric State Hospitals: Asylums • About 300 psychiatric asylums constructed in the US before 1900. • Doctors developed a highly specialized building type for 250 patients. Most notably, Dr. Thomas Story Kirkbridge, devised a widely applicable set of planning principles that ensured classification by type of illness, ease of surveillance, short wards for good ventilation, and clarity of circulation. • This was later replaced by the “cottage plan”, with smaller housing units.

5. Psychiatric State Hospitals: Asylums

6. Psychiatric State Hospitals: Asylums

7. Psychiatric State Hospitals: Asylums

8. Psychiatric State Hospitals: Asylums

9. Psychiatric State Hospitals: Asylums • Treatments on institutionalized patients • Gottlieb Burckhardt, psychosurgery 1890s • & António Egas Moniz, 1935, Nobel Prize for Physiology or Medicine in 1949 for lobotomy • Documentary films: • “Kings Park: Stories from an American Mental Institution” (2015, Lucy Winer & Karen Eaton) • “Children of Darkness” (1983, Ara Chekmayan & Richard Kotuk, Oscar nominated) – set in South Beach, Staten Island • “The Titicut Follies” (1967, Frederick Wiseman) –Bridgewater State Hospital, MA; controversial

10. Deinstitutionalization • 1960s: states reduced and closed their publicly-operated mental health hospitals/asylums •  Vision: the mentally ill will be living more independently with treatment provided by community mental health programs.  • However, insufficient ongoing funding for community programs to meet the growing demand.  • States reduced their budgets for mental hospitals, but provided no proportionate ongoing increases in funding for community-based mental health programs. • Result: hundreds of thousands of mentally ill were released into communities lacking the resources necessary for their treatment.

11. Involuntary commitment • N.Y. MHY. LAW § 9.27 : NY Code - Section 9.27: Involuntary admission on medical certification • May be held in locked inpatient unit against their wishes, if two separate physicians certify the need for psychiatric treatment, without which the patient would be deemed • A, a danger to him/herself • B, a danger to others • C, unable to take care of him/herself in a manner to ensure survival • This application holds for up to 14 days; thereafter a court has to decide over ongoing treatment against the patient’s will, should this continue to be deemed necessary by the physicians.

12. Deinstitutionalization • Where do they go ? • Revolving door in acute hospitals, homeless shelters, and… prison • “Even more than other areas of health and medicine, the mental health field is plagued by disparities in the availability of and access to its services.” • Consequently, many of the individuals released into the community without support ended up incarcerated, in fact “trans-institutionalized” into America’s jails and prisons.

13. Prison and mental illness • US: in 2012, 1 in 35 adults (= 2.9 % of adult residents), was on probation or parole or incarcerated in prison or jail, similar to 1997, but with a 790% increase of incarceration since 1980, partially explained by enforcement of “true”/minimum sentencing laws, requiring to spend at least 85% of sentence behind bars • 2013: 1 in 110 in jail/prison, 1 in 51 on probation or parole • This equals 22% of the ENTIRE WORLD’S PRISON population (at 4.4% of world’s population) • If recent incarceration rates remain unchanged, 1 out of every 20 persons will spend time behind bars during their lifetime

14. Prison and mental illness • 16-30% of prison inmates have a chronic and serious mental illness (NAMI) • 30-60% have substance abuse problems • 55% of men and 73% of women in state prisons and 63% of men and 75% percent of women in jails, will experience any mental health problem requiring mental health services in any given year (compared to 18.1% of general population, 2014) • Interesting to note: fewer than 5% of 120,000 gun-related killings committed in the past 40 years perpetrated by people diagnosed with mental illness. (Metzl et al., 2015)

15. Prison and mental illness • Increase of severe types of mental illness: • 2.3 - 3.9% of inmates in state prisons have schizophrenia/psychosis (vs. 1% in general population) • 13.1 - 18.6% have MDD (vs. 6.9%) • 2.1 - 4.3% suffer from bipolar disorder (vs. 2.6%) • individuals with severe mental illness are 3 times more likely to be in a jail or prison than in a mental health facility • 40% of people with severe mental illness will have spent time in either jail, prison, or community corrections

16. Prison and mental illness • Jails and prisons have effectively become the no.1 mental health care facility in the US • It is now extremely difficult to find a bed for a seriously mentally ill person who needs to be hospitalized: • 1850: 14 psychiatric beds for every 100,000 Americans • 1955: >300 beds for every 100,000 Americans • 2010: 14 beds for every 100,000 Americans -14% reduction from 2005-2010 alone • majority of the existing beds are filled with court-ordered (forensic) cases (Nat. Sheriff’s Association, 2010)

17. Prison and mental illness  1948 Universal Declaration of Human Rights: • Article 10 of International Covenant of Civil and Political Rights: • Right to humane treatment and rehabilitation – “treatment with humanity and with inherent respect for the human person” • Requires prison management to ensure mental health treatment for prisoners with mental disabilities, as well as humane conditions of confinement. •  highest attainable standard of physical and mental health”

18. Prison and mental illness • Right to be free from abuse – (Art. 7 of ICCPR) nobody shall be subjected to torture, inhuman, degrading treatment or punishment. • Right to health – Committee on Economic, Social and Cultural Rights (Article 12) – “right of everyone to the enjoyment of the highest attainable standard of physical and mental health” • Convention on the Rights of Persons with disabilities – signed by US in 2009, “disability rights are universal rights” • Class action law suit in Alabama just 2 days ago

19. Prison and mental illness • Widespread abuse of mentally ill inmates: • more frequently in solitary confinement • neglect, • improper medical care, • corporeal punishment by officers. • USA were summoned to Human Rights Court in Geneva in May 2015 to defend their human rights record for only the 2nd time ever. • A record turnout of 120 countries had recommendations, such as criticism of police brutality, racial discrimination horrific treatment of mentally ill inmates.

20. Prison and mental illness • This is factually violating prisoners constitutional rights • NYC settled a law suit against the city in May 2015 over the conditions at Riker’s Island. • Further reading: • Human Rights Watch Report • http://www.nytimes.com/2015/05/12/us/mentally-ill-prison-inmates-are-routinely-physically-abused-study-says.html

21. Mental health initiative in NYC • “NYC Thrive” - Facts: • 1/5 adults in NYC will experience a mental health problem per year • 8% of NYC high-school students report attempting suicide; 8% of adult NYers experience sx/o depression each year • Major depressive disorder is single greatest source of disability in NYC, but only 40% receive care for it • substance misuse is leading cause of premature death; unintentional drug OD deaths outnumber both homicide and motor vehicle fatalities. • $14 billion annual loss in productivity tied to depression and substance abuse

22. Mental healthcare: Other special populations • Culturally distinct groups • Refugees • Army veterans • Children & transitional age youth • People in small communities • HIV/AIDS patients • End-of-life care • Drug and alcohol addictions

23. Mental health and self-determination J.-L. David: “The Death of Socrates”

24. Ethical considerations in mental health care • Beneficience – nonmaleficience - justice • Autonomy vs. paternalism • Consent • Confidentiality • Competence • Multiculturalism/Nonuniversality of ethical concepts

25. Overview • Dopamine & addiction • PET imaging • Opioids • Drug laws and outcomes • Treatment options

26. Overview • Dopamine & addiction • PET imaging • Opioids • Drug laws and outcomes • Treatment options

27. Vm PFC – risk, inhibition of impulsivity, emotional decision making; OFC – reward, social decision making; DLPFC - executive functions, i.e. working memory, planning, inhibition, abstract reasoning

28. Background: Animal studies • Microdialysis in rats - drugs abused by humans, including • ethanol, induce DA release in dorsal caudate and N. accumbens (DiChiara, 1988) • Alcohol-preferring rats show reduced ventral striatal D2/3 receptor density , lower extracellular DA levels , and greater VST DA release in response to alcohol • increases in DA induced by drugs are 3-5 fold higher in Nac than by natural reinforcers (quick onset of large magnitude).

29. Dopaminergic pathways

30. Dopaminergic pathways

33. Overview • Dopamine & addiction • PET imaging • Opioids • Drug laws and outcomes • Treatment options

34. PET imaging in addiction research Volkow et al., 2003

35. Average [11C]ABP688 BPND (calculated per voxel) images in the healthy volunteers (top row) and cocaine abusing subjects (second row) for each group. These images illustrate that cocaine abuse is associated with a decrease in [11C]ABP688 BPND compared to healthy volunteers. Martinez et al., Biological Psych, 2013

36. DA release is decreased in cocaine dependence Martinez et al., AJP 2007, 164: 622-629

37. Background • Chronic stage: • Martinez et al, 2005, Biol Psych.: Alcoholics also had lower D2 receptor binding at baseline than controls • Volkow, J Neurosci. 2007: 20 controls and 20 detoxified alcoholics, VST and Putamen, 70 and 50% lower than controls, respectively • Early Stage: vulnerability • Volkow et al, 2005, Archives of Gen Psych: high levels of D2 in unaffected family members protect against drinking • Munro & Wand, 2006, Alcoholism: no difference in baseline binding or DA release post-amphetamine healthy subjects with positive family history vs. negative

38. Healthy Control Alcohol Dependent Dopamine release in alcoholism * [11C]raclopride displacement (∆BPND) Martinez et al., 2004, 2006

39. Alcohol dependence: Cortical DA release Narendran et al, Am J Psych, 2014

40. Dysruption in dopaminergic pathways through enhanced value of drug leads to addiction Volkow et al, 2003 Enhanced value of the drug in the reward, motivation, and memory circuits overcomes inhibitory control of the prefrontal cortex, favoring a positive-feedback loop initiated by the consumption of the drug and perpetuated by the enhanced activation of the motivation/drive and memory circuits.

41. Overview • Dopamine & addiction • PET imaging • Opioids • Drug laws and outcomes • Treatment options

42. Opiate receptor & dopamine

44. Background: US Opioid epidemic

45. Prescription Opioids use and abuse: Scope and Impact

46. Background: US Opioid epidemic • past: prescribing of opioids limited to post-surgery and cancer pain • total number of opioid analgesics prescribed in the United States has skyrocketed in past 25 years  (IMS National Prescription Audit) • 1990s: drug companies and medical experts began arguing that opioids could be used to treat chronic conditions like back pain without addicting patients. • aggressive marketing by pharmaceutical companies. • Pain as “fifth vital sign” — a body function to be assessed after temperature, heart rate, respiration rate and blood pressure — and that opioids could help mitigate it safely. • Opioid sales 1992 - 2015: rising nearly 10-fold, from $1 billion to nearly $10 billion (IMS).

47. Background: US Opioid epidemic 2015: 20.5 Mio Americans 12 y or older with substance use: 2 Mio with dx involving prescription pain relievers; 591,000 withsubstance use disorder involving heroin (SAMHSA) Drug overdose is leading cause of accidental death in the US, with 52,404 lethal drug overdoses in 2015. Opioid addiction is driving this epidemic, with 20,101 overdose deaths related to prescription pain relievers, and 12,990 overdose deaths related to heroin in 2015 (>60%) Opioid related deaths began rising in the early part of the 21st century: 2002 – first time death certificates listed opioid analgesic poisoning as a cause of death more commonly than heroin or cocaine. (Paulozzi et al., 2006)

48. Past year initiates for specific illicit drugs among persons aged 12 or older: 2010. Source: Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health:Summary of National Findings

50. Opioid Prescriptions Dispensed by US Retail Pharmacies IMS Health, Vector One: National, years 1991-1996, Data Extracted 2011. IMS Health, National Prescription Audit, years 1997-2013, Data Extracted 2014.