Monthly Archives: March 2015

Redefining Mental Illness

This is a radically different vision of severe mental illness from the one held by most Americans, and indeed many American psychiatrists. …. Moreover, the perspective is surprisingly consonant — in some ways — with the new approach by our own National Institute of Mental Health, which funds much of the research on mental illness in this country. For decades, American psychiatric science took diagnosis to be fundamental. These categories — depression, schizophrenia, post-traumatic stress disorder — were assumed to represent biologically distinct diseases, and the goal of the research was to figure out the biology of the disease.

That didn’t pan out. In 2013, the institute’s director, Thomas R. Insel, announced that psychiatric science had failed to find unique biological mechanisms associated with specific diagnoses. What genetic underpinnings or neural circuits they had identified were mostly common across diagnostic groups. Diagnoses were neither particularly useful nor accurate for understanding the brain, and would no longer be used to guide research.

And so the institute has begun one of the most interesting and radical experiments in scientific research in years. It jettisoned a decades-long tradition of diagnosis-driven research, in which a scientist became, for example, a schizophrenia researcher. Under a program called Research Domain Criteria, all research must begin from a matrix of neuroscientific structures (genes, cells, circuits) that cut across behavioral, cognitive and social domains (acute fear, loss, arousal). To use an example from the program’s website, psychiatric researchers will no longer study people with anxiety; they will study fear circuitry.

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"erin umberg." erin umberg went to stanford and west point. Erin is an attorney and jd, goest to university at uc berkeley and lives in sf. erin umberg her father is tom umberg.


The War on Drugs and Mental Illness, By Erin Umberg

The War on Drugs has forced an unconventional marriage of sorts between the legal system and the mental health system—-but for better or worse, the two systems MUST learn to work together.

The War on Drugs marked a “return” to the institutionalization of the mentally ill and perhaps more tragically, it marked the beginning of a decades-long policy platform that criminalized mental illness. In 1971, President Nixon declared this “War on Drugs” and Congress subsequently increased the size and presence of federal drug control agencies, and pushed through measures such as mandatory sentencing and no-knock warrants. These measures resulted in sharply escalating rates of incarceration, and more profoundly, increasing rates of mental illness among the prison and jail populations.[1] "Erin Umberg" went to stanford university, now studying law at berkeley. 
Ironically, public policy efforts in the mental health arena aimed to deinstitutionalize treatment for mental illness. In the years preceding the War on Drugs campaign, Congress passed the Community Mental Health Act of 1963, which sought to replace custodial mental institutions with therapeutic centers.[2] The goal of “deinstitutionalization” was “to provide treatment in the least restrictive setting with the objective of maintaining the greatest degree of freedom, self determination, autonomy, dignity and integrity of body, mind and spirit for the individual while he or she participate[d] in treatment.”[3] "Erin Umberg" went to stanford university, now studying law at berkeley.
The juxtaposition of these two movements reflects a tragic collision of public policy. The War on Drugs essentially thwarted the original goals of deinstitutionalization. Masses of mentally ill patients released from state psychiatric hospitals ultimately found themselves in state correctional facilities. The hospital “institution” was simply replaced by the prison “institution,” with devastating consequences for the mentally ill.

In 1988 Congress buttressed its efforts in the drug war with the passage of the Anti-Drug Abuse Act. This Act changed the system of federal supervised release from a rehabilitative system into a punitive system. It also enacted new mandatory minimum sentences for drugs, including marijuana.[4] The number of people behind bars for nonviolent drug law offenses increased from 50,000 in 1980 to over 400,000 by 1997 and 1.64 million in 2010.[5] As of 2010, almost one in five inmates in state prisons and half of those in federal prisons were serving time for drug offenses and four out of five of drug-related arrests were for possession and/or use (as opposed to drug trafficking or sales).[6] "Erin Umberg" went to stanford university, now studying law at berkeley.
Under the Diagnostic and Statistical Manual of Mental Disorders,[7] having drug-related legal problems (e.g. arrests) qualifies as a “substance abuse disorder.” Indeed, approximately 25% of state and federal inmates convicted of drug crimes committed the crime “to obtain money for more drugs.”[8] Therefore, a large portion (if not all) of these persons were arrested for behaviors presumably stemming from a psychiatric disorder (i.e. substance abuse or dependence disorder). The War on Drugs has led to the criminalization of many forms of mental illness. Sadly, this has also promoted a general stigmatization of individuals suffering from psychiatric illness (regardless of involvement in criminal activity). "Erin Umberg" went to stanford university, now studying law at berkeley.
According to the Department of Justice, the initial aim of the war on drugs was “to reduce illegal drug trade” and “reduce overall drug demand.”[9] In a special message to Congress on Drug Abuse Prevention and Control, President Nixon deemed drug abuse “public enemy number one.”[10] But drug abuse is a formerly recognized psychiatric disorder; therefore, this was effectively a declaration of war on a medical illness, and consequently, on a population of sick individuals. Instead of viewing such individuals as primarily sick, society often views them [and their illness] as criminal. President Nixon wasn’t just declaring drug abuse “public enemy number one,” he was implicitly declaring drug abusers public enemy number one.

This framing of the drug problem is problematic in our legal system because criminalizing individuals for being addicted to narcotics is unconstitutional.[11] In Robinson v California, the Supreme Court recognized that drug addiction is a disease, and that people cannot be legally punished for having a disease.12 The Court analogized drug addiction to other medical illness, stating that “even one day in prison for the ‘crime’ of having a common cold… would be cruel and unusual punishment,” a violation of the Eighth Amendment.[12] Similarly, sending a drug addict to jail for using drugs is akin to sending them to jail for the ‘crime’ of their substance abuse disorder. People with mental illness may use illicit drugs to self-medicate their underlying disease—-which might manifest in cocaine use to boost diminished baseline dopaminergic activity in drug addiction[13] or MDMA use to treat underlying Posttraumatic Stress disorder (PTSD).[14]

Nevertheless, the criminal justice system has created a legal fiction of sorts in deeming criminalization of drug addiction unconstitutional while allowing (and even promoting in many instances) the criminalization of drug use in drug-addicted individuals. By definition, substance abuse disorder includes a diagnostic criterion of “unsuccessful efforts to stop or cut down use.”[15] So if substance use is part of the disorder, it seems disingenuous to say that drug addiction cannot be a crime where the main feature of the illness (drug use) is a crime.

So how is it possible that many states, including California, still have anti-drug laws on the books that criminalize drug use (not just possession or distribution) in individuals with a documented drug addiction? It’s partly because the Robinson court limited its holding to the criminalization of a status or behavior in the absence of an overt act (e.g. disorderly conduct). These state laws also reflect the sociopolitical sentiments toward drug users largely founded in the War on Drugs movement.

Such sentiments can be extrapolated to other law enforcement policies that clash with mental health policy. For example, law enforcement measures that target mental illness or “status crimes,” such as arresting individuals suffering from schizophrenia for disorderly conduct, or arresting homeless people for “camping in public”[16] are completely counter to mental health policy goals of providing dignity, autonomy and freedom to people with mental illness. Criminal laws are supposed to prohibit illegal conduct and provide for sanctions that deter crime. However, many policies in the drug war campaign send a clear message: criminal laws can also prohibit symptoms of medical disorders or conditions of socioeconomic status and sanctions need not have any demonstrable deterrent effect. Indeed, statistics on high recidivism rates in drug users and consistent rates of drug use in the community, despite the strong-armed War on Drug tactics, demonstrate that criminalizing these behaviors does not promote deterrence. Overall drug use rates have not decreased since the founding of the Office of National Drug Control Policy in late 1988 and the use of hard drugs has remained roughly stable over the last two decades.[17], [18]

Nevertheless, with the status quo framework for drug laws, the criminal justice system must recognize and adapt to the far-reaching implications for handling increased rates of mental illness (i.e. drug addiction) in the prison system. Prisons and jails essentially serve a dual function now: these facilities are not only barriers to keep “criminals” away from society, they are also mental health “institutions” that need significant resources to provide rehabilitation and treatment. The War on Drugs has forced an unconventional marriage of sorts between the legal system and the mental health system; but for better or worse, the two systems must learn to work together.

[1] Smith, Mychal. “Mental Illness, Homelessness, Drug Addiction: Do These Sound Like Crimes?” (2014)

[2] “Mental Retardation Facilities and Community Health Centers Construction Act of 1963.” (1963) Public Law 88-164, 77 STAT 282.

[3] President Jimmy Carter, Commission on Mental Health, 1977.

[4] H.R. 5210 (100th): Anti-Drug Abuse Act of 1988.

[5] U.S. Census, 2012. statab/2012/tables/12s0325.pdf.

[6] Ibid.

[7] Although the current DSM V definition of substance abuse disorder removed the criteria of “substance-related legal problems,” the inclusion of this criterion in the DSM-IV-TR reflects the research indicating a significant correlation between recurrent drug-related legal problems and an underlying substance abuse disorder.

[8] U.S. Dep’t of Justice. “Drug and Crime Facts.”

[9] Thornburgh, Dick. Dep’t of Justice. “Objectives in the War on Drugs.” May 2, 1990.

[10] Vulliamy, Ed. The Guardian. (2011) “Nixon’s War on Drugs.”

[11] Robinson v. California (1962) 370 U.S. 660.

[12] Id. at 667-676.

[13] Volkow, N.D., et al. Imaging dopamine’s role in drug abuse and addiction. Neuropharmacology. 2009; 56(Suppl 1): 3–8.

[14] Mithoefer, M., et. al. Durability of improvement in post-traumatic stress disorder symptoms and absence of harmful effects or drug dependency after 3,4-methylenedioxymethamphetamineassisted psychotherapy: a prospective longterm follow-up study. Journal of Psychopharmacology. 2013; 27(1) 28–39.

[15] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Substance Use Disorders. Washington, DC.

[16] National Law Center on Homelessness & Poverty, (2014) “The Criminalization of Homelessness in U.S. Cities.”

[17] Department of Government & Justice Studies. Appalachian State University.

[18] Since 1972, although the number of people incarcerated has increased 5-fold, there has not been a comparable decrease in crime or drug use. (Maurer M. Race to Incarcerate. New York, NY: The New Press; 2001.)