Hacker News Reader

This fatalistic attitude isn't wrong, but it is manifestly unhelpful and surprisingly expensive. Being homeless is not a zero-cost alternative to real treatment; in many cases, the cost of lavish treatment is far lower than the cost of ER visits and criminal proceedings that would otherwise be incurred. I believe Malcolm Gladwell wrote an article about chronic homelessness a few years ago, about Denver rolling out a program to take some number of homeless folks and set them up in an apartment free of charge with on-site nursing 24/7, and it was saving the city millions just by keeping them out of the ER. I believe the program ultimately came under fire because of how essentially un-American such a system is, even when it makes both ethical and financial sense.

It's 2012 - no one in the world should go homeless, unclothed, or hungry. It's inhumane.

But I don't think that's what this article was about.

The author is arguing that his son would not be homeless if institutional care had not be shut down, not that his son would be a productive member of society. It's practically tautological.

"The author is arguing that his son would not be homeless if institutional care had not be shut down"

Actually, he isn't. The only institutional care he mentions in the What I realize now section is "supportive short-term and long-term community housing and treatment", which doesn't sound like institutional care, in the sense of "When he was in jail, with its regular routines and meals, Tim usually stabilized". There was a reason why total institutions were, well, total.

In fact, his "if I were a legislator today" comments are essentially the same as the "I jumped at the opportunity to" do actions in the 1980's.

That's a good point. The article begins with him discussing the shutdown of institutional care in favor of integrative approaches. But you're right, the solution he's promulgating at the end isn't really the same thing.

And that's what shocked me as well. He made the right diagnosis with the right title and the right observations, but jumped to the wrong conclusions :-/

He made the right conclusions and these programs have already been implemented. (at least in my state)

There are many community-based mental health providers. They are private-sector companies, usually nonprofits, that provide treatment paid for by state funding (medicaid, etc.).

No, it contradicts his own title and facts : When he was in jail, with its regular routines and meals, Tim usually stabilized. But when he was released (...) he destabilized right away

The "humane reforms" may not have been just for the good. More details in http://news.ycombinator.com/item?id=4662700

The point I was trying to make is that these smaller community-based facilities do provide the stability that clients need to compensate. In fact they do a better job than a large impersonal institution.

It's actually not a good point, see my reply above.

Upvote for using the word 'promulgating' though. Good show :o)

Saying "that's a good point" has as much or more to do with social courtesy than "winning" the conversation. (Have you seen this? http://www.newyorker.com/humor/2012/09/03/120903sh_shouts_si... )

I say it's a good point because it may be worth making a distinction between early-mid 20th century institutional care in an asylum and early 21st century institutional care through a variety of assistance programs. You have presented a good case that the distinction is either meaningless or that there is a direct relationship between the former and the latter, but either way, the article doesn't spell out the link between the two.

That's true, the article really didn't explain much about the programs he would like to see. I could have done a better job of explaining myself but it was late.

These residential programs are providing the type of solid routines that allows a client to stabilize and are actually doing a better job than the large institutions (according to my data). Think of the difference between how well most students do in a large impersonal lecture hall vs. 1 on 1's with teachers who take a real interest in their education.

> "supportive short-term and long-term community housing and treatment", which doesn't sound like institutional care

But it is. The housing/treatment he is referring to covers a range of facilities from supported housing to crisis centers to residential and secure residential treatment facilities based in the community. The goal of these facilities is to provide the stability necessary for a person to compensate and, ideally, re-enter society.

Some folks need to enter a crisis center for a short stay during a time of instability. Some simply need a place to live (supported housing) with just a little more structure. There are also people who are chronically ill and do well (some not so well) in a residential or secure residential treatment program, but will never leave because they are unable to function without the stability of an institution.

Mental illness is a spectrum, hence the array of different support tools. The programs the OP was if'ing about exist, and are progressing. For instance, there is new legislature in my state that expands these programs to include general medical and dental care.

Just curious, which state are you in?

Oregon, specifically Multnomah County.

Part of my job includes tracking (arguably) quantifiable data on how clients respond to community-based residential treatment. I have not been in this space long, and I'm still learning about the underlying process/politics that our business model exploits. But I do have the data to show that residential treatment works, sorry I can't share.

> when it makes both ethical and financial sense.

It saves money on a small scale because no one's trying to defraud it yet.

On the other hand, you have to ask whether the cost of trying to make sure not a single dollar is given to the undeserving outweighs both the monetary savings and benefits to society overall. Don't throw the baby out with the bathwater.

I envision this to be a lot like crime. You'll never get rid of it completely, so you put into place some (ostensibly) cost-effective measures to mitigate the worst of it.

> On the other hand, you have to ask whether the cost of trying to make sure not a single dollar is given to the undeserving outweighs both the monetary savings and benefits to society overall. Don't throw the baby out with the bathwater.

based on no data, what-so-ever? I believe the parent claiming that there would be no monetary savings at-scale or in the long term

And you believe that, based on no data what-so-ever? ;)

Right now, we spend a lot of money and get very little. If we chose to spend more rather than passively leak money, we'd at least be able to exercise some control over how it's spent, benefit from economies of scale, and so on.

To be explicit, I'm drawing a distinction between efficiency of dollars and raw quantity of dollars. Given the choice between spending $250 and getting nothing versus spending $500 and receiving something of substantial value, I'd opt for the latter. And that's what the qualifier about "benefits to society overall" is about; there's more value to be had from this than some dollar amount.

But if all we're thinking about is a) how many dollars it costs (and not how we're wasting money now), and b) that some small subset of people might game the system (which will always happen, regardless of counter-measures), I think that's self-defeating.

The article I'm remembering actually addressed that. The program was limited to a very small number of people--tens, or fewer. They actually had one that wrecked his apartment every week, and still it was cheaper to fix it back up than to let this guy back on the street, where he would incur about $1M a year in ER bills. One of the big objections to this program came from the fact that the scale was so limited.

One of the big objections to this program came from the fact that the scale was so limited.

You would think that this kind of operation would get cheaper at scale. You might not need 2X wrecked-apartment-repairmen for 2X people housed.

The fraud that jumps to my mind is a hypothetical person taking a free apartment, when they are perfectly capable of supporting themselves and would do so if the alternative was homelessness. That's certainly not cheaper.

I make no claims about how common this kind of fraud would actually be.

This argument irks me. Have you been on the inside of a homeless shelter?

The constant bed bug invasions, bunking right next to a paranoid schizophrenic, living in constant fear of rape (yes, even for men)? Treated like a social pariah on a good day, non-existent the next? This isn't even the tip of the iceberg, I assure you.

Life inside the system is not nearly as rosy as you might think.

Often I feel like people should be made to work directly with the homeless before letting them spout off on this particular topic.

Nothing in the GP post says anything about the rosiness of life inside the system.

Your post suggested that the system wouldn't scale due to fraud - the implication being that people would take advantage of the free housing being provided.

What I said was that the conditions in these institutions is so inhumanly bad, that no one in their right mind would voluntarily do it. So what kind of fraud are you thinking of?

People running shelters taking advantage of government funding perhaps? Still seems the money is too little to make much profit through fraud, but there's no shortage of bottom-feeding hustlers and slumlords to try...

Banks combat fraud by investing in fraud prevention. They make it work because the margins are greater than the expense of the fraud prevention.

Without calculating the expense spread between the criminal justice system and the mental health system, I'd wager that the savings will be great enough that we can afford fraud prevention too.

pretty bold claim... source? below you said it was tried on "tens" of people. both ethics and finance differ quite a bit at any larger scale.

Aha, I found it: http://www.gladwell.com/2006/2006_02_13_a_murray.html

His son might not have been contributing, but having him homeless and bouncing in and out of jails is more expensive to society than appropriate institutional support.

Furthermore one of the stated issues is his unwillingness to take antipsychotic medication, and one of the characteristic traits is that in a structured jail environment, where he's presumably receiving those medications, he is able to function well. That indicates that with a proper support system that includes support to make sure that he takes the required medication, he might have a shot at being a contributing member of society.

Anti-psychotic medication isn't like taking Tylenol. It can completely change a person's personality, and people have likened it to living in a fog.

Agreed - I cannot find any fault in any of your arguments. My brother in law has schizophrenia and takes anti-psychotics. He sleeps all the time, finds it hard to concentrate and lives in a permanent fog.

He needs these medications. But it has definitely changed him.

What is your point? Schizophrenia already horribly changed the patients personality, medication just helps them deal with the symptoms. Before we had these drugs, schizophrenic patients were basically tortured (e.g. Lobotomy) because there was no way to help them.

The point is that it's an imperfect solution, and maybe if we fund research in this area a bit more, we can find a better one.

Also, this is a bit tangential, but I don't really perceive schizophrenia as changing one's personality. I have a close friend who is schizophrenic, and when she has episodes, hardly a bit of her real self remains. It's not a personality shift, it's more like a personality stroke/seizure.

> Before we had these drugs, schizophrenic patients were basically tortured (e.g. Lobotomy) because there was no way to help them.

  The drugs are no better. I have done a couple stints in a private mental health (inpatient and outpatient) facilities when dealing with what was diagnosed as Schizo-affective disorder (which is basically the presence of schizophrenia and a mood disorder) and there was a teen there who was schizophrenic. He was a large dose of Risperdal (one of the major anti-psychotics) to treat the schizophrenia. I don't think I will ever forget the few weeks the doctor took him off his Risperdal. He was completely different. When on the drug, he was slow and almost catatonic at times. After been weened off, he actually had personality.

Wasn't MDMA (ecstasy) once considered for schizophrenic patients? It was supposed to not affect the patient as much. I never head the results.

MDMA is currently being tested (in sessions combined with therapy) for treating PTSD. I've heard nothing about its consideration for schizophrenia but it wouldn't be surprising.

Looked it up and this article mentions PTSD, schizophrenia, and Autism. There are some scholarly reference out there too. Seems mixed, but they want further studies.

http://psychcentral.com/news/2010/12/17/drug-‘ecstasy’-may-h...

Given that those suffering from the illness so often hate the medication (I say this based on having 2 or 3 people tell me this, which is hardly data), doesn't that indicate how bad the medication is? If the disease is felt to be better (by some) than the treatment then we aren't doing very well.

I am fully aware of this. My phrasing might have a shot was meant to indicate that he would face an uphill battle and success was still a somewhat unlikely proposition.

However when he's left to drift around homeless and without medication, his odds of success are currently 0. "Somewhat unlikely" is a significant improvement on that present reality.

Schizophrenia is a severe mental disease that can absolutely be treated with a comprehensive treatment plan, including medication and psychosocial interventions (including an IEP).

I didn't think the author was stating that his son wouldn't have schizophrenia if the schools had done better. I think he was saying that his son would have a better outcome with his chronic severe mental illness if various government agencies and actors were better organizing to identify and treat the illness.

Perhaps it's fair to say that Tim is where he is today because of his mental illness and a host of public policy decisions we've made in this country around how we treat mental illness.

It can be treated if you're in the lucky few who happen to have medication work for them and are able to tolerate the side effects (glad I fall into this category). Treatment's by no means guaranteed to work.

I think you've missed the point of the article. The author isn't saying that Tim would be normal but for the policy changes. He's saying Tim wouldn't be out on the street. Which is true--there has been a huge scaling back of mental health services in this country, not just in the down economy but over the past 30 years.

> The author is wrong, and I'm sorry for that, but it's very unlikely that his son would have ever been a contributing member of society. Schizophrenia is a severe mental disease that cannot be treated like a 'special need.'

I have met very many people with a diagnosis of schizophrenia. Some of those people were drug users (or had been drug users); some of those people were "forensic" patients and were being held in secure hospitals; some of those people were in the community, on medication, with full time work.

Schizophrenia is a complex illness that expresses in a wide range of behaviours, and a broad depth of severities of behaviours. One person may hear a few voices, but be able to cope well with those voices, while another people may hear more voices which are very threatening and hard to cope with.

Please, I understand what you're saying. (Some people with schizophrenia are very ill, and will need extensive support just to avoid homelessness) but I find your comment a bit stigmatising. Many people with schizophrenia do work; not all of them work full time paid employment but it's certainly possible for someone with a diagnosis of schizophrenia to lead a full and productive life.

All of what you said is true but this guy's son hsd early onset schizophrenia. The prognosis for late onset is really bad but for late onset it's terrible. Most schizophrenics are not capable of a full and productive life unless medicated and many, many people fail to keep up their treatment regimen because the drugs are hell for many too.

> No, he isn't. The author is wrong.

How about partially wrong? Maybe it's more accurate to say "Tim is where he is today partially because of a host of health policy decisions..."

absolutes often lead to unnecessary, counterproductive arguments.

"The author is wrong, and I'm sorry for that, but it's very unlikely that his son would have ever been a contributing member of society."

In many less developed countries people with schizophrenia have better outcomes. It's only in the US where the condition is usually debilitating for life, because:

A) The US healthcare system relies on longterm use of anti-psychotic medication as the main form of treatment, which tends to lead to worse outcomes in the long run.

B) Family relationships in the US are generally not conducive to properly recovering from schizophrenia.

In other countries the people aren't completely normally, but they're also generally not completely unable to hold a job for their entire lives like in the US.

Can you elaborate? Are you saying in other countries the family/extended family generally care for the individual? Why are they more likely to hold down a job?

"Are you saying in other countries the family/extended family generally care for the individual?"

Schizophrenia is basically triggered & exacerbated by stress. If one becomes schizophrenic then it's possible to mostly recover from psychosis in low stress environments, but in higher stress environments it basically becomes permanent.

I think that Ethan Watters discusses why it is that people in poor countries do better due to social factors in his book Crazy Like Us, and Robert Whitaker discusses the role of anti-psychotics in Anatomy of an Epidemic.

In terms of social factors though, I vaguely remember that in poor countries families are more likely to let people with schizophrenia just hang out and work on recovering for years at a time, whereas in more developed countries this is less likely to happen. (Possibly because this isn't as possible due to the higher costs of living and the greater stresses of living in a society with a very unequal distribution of wealth, but I forget the exact mechanism.)

As for the basic data, here is one book that summarizes it:

http://ajp.psychiatryonline.org/article.aspx?articleid=98965

The stress trigger remains an unproved theory - there are other many potential explains (vitamin D, parasites, sociological baed on family dysfunctions...) but so far there is not a good fit.

Outcome from schizophrenia is routinely better in developing world settings, and this difference becomes apparent during the initial 2 years of illness. But even for developing world patients with a poor early course, outcome is superior to that of developed world patients with an equivalent early course. Employment rates are substantially greater for developing world subjects, and some authors have attributed this to the freedom from the economic disincentives to employment that can accompany the provision of disability benefits in the industrial world (1).

In the UK we have something called the Sainsbury Centre for Mental Health.

They provide evidence based advice. They've provided some advice about getting people with mental health problems who are claiming incapacity benefits off benefits and back into work.

The traditional response is a long slow curve; don't rush anything; work is stressful; start with a bit of part time voluntary work; build that up; there aren't enough jobs around anyway and no-ones going to employ mentally ill people and the stress of rejection is harmful. They also used to have a stock of low grade jobs (shelf filling at supermarkets) so when people turned up they'd get kludged into whatever was available.

The evidence shows that many people actually want to be much more active. We now have strong anti-discrimination laws. And "place then train" (get someone a job that they want, then support them to keep that job) is much more effective. If someone is a good employee an employer probably wants to keep them on, and if there's funding available to make reasonable adjustments then letting them know is good.

Here's a list of the Sainsbury Centre publications

(http://www.centreformentalhealth.org.uk/publications/publica...)

I'd be very surprised if this were true. Care to elaborate?

I completely agree with you. I think these demands on society are unrealistic. You can't expect that out of teachers and pediatricians.

My experience with the school system (I have a daughter with autism) has been much better then his sounds (I hope so given it's 40 years later). We have no push back in getting our developmental pediatricians' input into our daughter's IEP. Our school provides speech and occupational therapy. But as you mentioned, schizophrenia is a whole other world (even from autism in my opinion). There is no cure. There are only lesser of many evils. You can't expect society to fix that.

One thing that really bothers me are these crazy statistics - "one in every five children and one in every four adults has a diagnosable mental illness. A quarter of all mental illnesses are considered serious." One in four? Come on. If the bar is so low that one in four have a mental diagnosis it makes the term meaningless. It drives my wife and I crazy when parents claim there kid had autism but after a month on this fad diet or other they are now cured. Guess what - your kid never had autism! Don't tell that to a parent who knows their daughter will likely never leave home, never marry, and probably never hold down a meaningful job. It's just insulting.

I assumed that that "one in every four adults" statistic includes things like depression.

> it's very unlikely that his son would have ever been a contributing member of society.

I'm having trouble getting past this comment. I don't wish to malign you debacle - I'm sure you're not being malicious - but it seems like a very unkind & privileged mindset. I hope this isn't representative of the community.

Paul Gionfriddo certainly doesn't consider his son to lack contribution.

> but it seems like a very unkind & privileged mindset.

You think being of sound mental health is a privilege? In Europe we think health is a right, which is why we have public health systems. It may sound a bit strange at first, but it works quite well.

In this context, privilege is being used in the sense of, "he was a child of privilege."

I don't see any argument that his son with "no job prospects and a debilitating mental illness" is currently capable of doing work that benefits society. He's rightly only concerned with his son's survival in the crude conditions we provide, and how he might have turned out differently.

My brother is mentally disabled. I love him dearly, and I've fight tooth and nail for him to have as normal a life as possible. However, I would not describe him as being a likely candidate for being a "contributing member of society." His affliction fundamentally prevents him from doing almost any job. That's just the reality of it.

> ADHD or blindness are not even in the same room a schizophrenia.

25% of prisoners are there because of ADHD. In aggregate it probably causes much more harm than schizophrenia.

"25% of prisoners are there because of ADHD"

Source?

ADHD has a lot to do with poor impulse control. Most prisoners have low impulse control and are stupid.

That's rather narrow minded. If a country has a large prison population there are more people to blame than just those in the prison.

Your second sentence is true. What I said is also true; Most prisoners have low impulse control and are stupid.

"Most prisoners have low impulse control and are stupid."

Source?

Russel Barkeley's books on ADHD. He is one of the foremost scientists who studies ADHD and has found it causes devastating problems for several percent of the population. For example, it is associated with a 10 point dificit of IQ, which is itself a major problem before you even consider poor impulse control.