Deblasio policies cause NYC mental illness stabbings

Deblasio administration refuses to use Kendra's Law when needed

Our hearts go out to James Patrick Dillon, his family, those who were stabbed by him, and the  police who had to respond. Like almost all these cases, Mr. Dillon was already known to be seriously mentally ill, had a family that tried to help him get treatment, but could not get him treatment because the DeBlasio administration refuses to focus it's mental health efforts on the most seriously ill. 

Specifically, the DeBlasio administration has failed to robustly implement Kendra's Law. Kendra's Law allows judges to order the most seriously ill, who refuse treatment, to accept six months of mandated and monitored treatment as a condition of living in the community. Kendra's Law reduces homelessness, arrest, incarceration in the 70% range. It keeps patients, public and police safer. 

Our Oped in Manhattan Institute’s City Journal on how ThriveNYC ignores the most seriously mentally ill  http://www.city-journal.org/2015/eon1208dj.html

Our oped in NY Post on how NYC mental health officials ignore the most seriously mentally ill  http://nypost.com/2015/11/15/the-citys-dangerous-mental-health-dodge/

Our oped in Manhattan Institute’s City Journal on how NYC data shows it is failing seriously mentally ill   http://www.city-journal.org/2015/eon0805dj.html

Brian Lehrer (NPR) interview with DJ Jaffe on how NYC mental health officials decided to ignore violent mentally ill   https://www.wnyc.org/radio/#/ondemand/571653

Brian Lehrer (NPR) interviews Chirlane McCray and Dr. Gary Belkin about failure to use Kendra’s Law    http://www.wnyc.org/story/first-lady-chirlane-mccray-kendras-law/

Main Site: http://mentalillnesspolicy.org

NY Site: http://kendras-law.org

Follow us on Twitter: @MentalIllPolicy

Join us on Facebook: Mental Illness Policy Org. 

NYS Needs Kendra's Law & Psychiatric Hospitals. Don't let mental health industry close them

The two trade associations representing NYS mental health providers (NYAPRS and MHA) are having their annual rally in Albany tomorrow (Tue. 2/23). We OPPOSE their attempts to move mental health spending away from the 5% who are the most seriously mentally ill and towards the higher functioning. Their proposals to end Kendra’s Law and close state psychiatric hospitals puts patients, police, and public at needless risk. We will be in Albany on Tuesday to oppose raiding services that treat the seriously mentally ill.

1. Support making Kendra’s Law Permanent and Stronger. (S-04722/A01275).

While NAMI/NYS supports this, the trade associations do not. Kendra’s Law is NY’s most successful program for the most seriously mentally ill. It allows judges to order someone who already accumulated multiple episodes of arrest, violence, incarceration or needless hospitalization to stay in six months of mandated and monitored treatment while they continue to live free in the community. It is only available to those who already refused to accept voluntary treatment that was made available to them. It also allows judges to order community programs to accept these individuals into their programs. Kendra’s Law is proven to reduce arrest, violence, hospitalization and incarceration in 80% range each, cut costs to taxpayers and reduce stigma. 81% of those in it said it helped them get well and stay well.

S04722/A01275 make Kendra’s Law permanent, ensure court orders are reviewed before expiring, requires community directors to take reports from family members about loved ones who might benefit, and lowers cost by allowing patients to voluntarily stipulate to Kendra’s Law orders. The NYS Assoc. of Chiefs of Police support.

2. Oppose Closing more Psychiatric Hospital Beds.

The trade associations are supporting Gov. Cuomo’s budget proposal to close 225 more psychiatric beds that serve the seriously mentally ill. We oppose. The trade associations look at these beds as a bank account and want them closed so the savings can be given to their member organizations. But there are two problems with that. NYS is short at least 4,000 psychiatric hospital beds even if we had perfect community programs. So closing hospitals guarantees the sickest will not receive treatment. Secondly, even when some savings are given to community programs, they refuse to use them to provide actual treatment to the same adults who are being discharged from hospitals. Instead the funds are used on wasteful sideshows like educating the public, fighting ‘stigma’, identifying the asymptomatic, or funding programs with no evidence of efficacy. As a result, NYS has more mentally ill incarcerated than hospitalized. The percentage of prisoners in NYC jails with mental illness shot up 30% between 2010 and 2014.

We do support increasing housing options, but first we must increase those that provide 24/7 onsite support (group homes), versus the independent housing options supported by the trade associations that serve the higher functioning.

Research Shows Assisted Outpatient Treatment (AOT) Works

AOT allows courts to order six months of mandated and monitored treatment in the community for a very small group of people with very serious mental illness who have previously become arrested, incarcerated, violent, homeless or hospitalized multiple times as a result of their failure to comply with treatment, often because they are so ill they don't know they are ill ("anosognosia").

More than two decades of research and practice show it works. AOT reduced hospitalizations[i], arrests[ii], incarcerations, crime[iii], victimization[iv] and violence[v] and improved treatment adherence[vi] The Department of Justice deemed AOT to be an effective evidence-based program for reducing crime and violence[vii]; AOT also produces significant taxpayer/system cost savings. New York’s program achieved savings of 50% in the first year and an additional 13% in the second year. A study in North Carolina reported similar cost savings of 40%[viii]. These savings free up mental health funds to treat more people or provide better treatment.

Research showing AOT (Kendra's Law) in New York works

Research showing AOT (Laura's Law) in California works is here

Footnotes 

Biggest Police Group Endorses Greater Use of Assisted Outpatient Treatment (AOT)

“AOT helps prevent mental health officials from offloading 
the most seriously mentally ill to jails, shelters, prisons and morgues.” 

(Oct. 29, 2014) The International Association of Chiefs of Police (IACP) took steps to improve care for people with serious mental illness and protect the safety of officers by endorsing greater use of Assisted Outpatient Treatment (AOT) at their 2014 annual meeting in Orlando, FL. Research collected by Mental Illness Policy Org shows AOT reduces arrest, suicide, hospitalization and violence by people with the most serious mental illnesses over 70% each. By replacing more expensive and liberty-depriving inpatient commitment and incarceration with less expensive outpatient treatment, AOT cut taxpayers’ costs in half. DJ Jaffe, Executive Director of Mental Illness Policy Org. said “Police step in when one condition has been met: the mental health system failed. This resolution will encourage mental health departments to do the right thing. If implemented it will save the lives of patients and police.”

AOT allows judges to order a small group of the most seriously ill to stay in six months of mandated and monitored treatment while they live in the community. It is limited to those who have already accumulated multiple episodes of homelessness, hospitalization, violence, arrest or incarceration associated with going off treatment. Representative Tim Murphy (R. PA) included funding for AOT in the Helping Families in Mental Health Crisis Act (HR 3717). AOT is known as “Kendra’s Law” in New York and “Laura’s Law” in California after two women who were killed by persons with untreated serious mental illness. Families of the seriously ill in those states had been arguing for AOT to help their ill family members get treatment, but could not get mental health departments to listen to them until after the tragedies.

As the result of the mental health system’s refusal to deliver services to the most seriously ill, and preferring to treat the highest functioning, there are now ten times as many mentally ill incarcerated as hospitalized according to the Treatment Advocacy Center. New Windsor, NY Police Chief Michael Biasotti conducted a survey of 2400 senior law enforcement officers and recently told Congress “We have two mental health systems today, serving two mutually exclusive populations: Community programs serve those who seek and accept treatment. Those who refuse, or are too sick to seek treatment voluntarily, become a law enforcement responsibility.” “AOT will help return care and treatment of the seriously mentally ill back to the mental health system where it belongs” said Jaffe. The National Sheriff’s Association and Department of Justice previously endorsed AOT as has almost every major organization concerned about care and treatment of the most seriously ill. Chief Michael Biasotti and outgoing IACP President Yost Zakhary were responsible for obtaining the IACP endorsement. Mental Illness Policy Org urges local chiefs to encourage their mental health departments and legislatures to make greater use of it.

A copy of the IACP Resolution follows or get PDF version to share with local law enforcement and mental health officials. Learn about AOT in New York (Kendra's Law) and about AOT in California (Laura's Law)

Mental Illness Policy Org. is an independent science based think tank on serious mental illness (not mental health) @MentalIllPolicy

IACP Endorses Assisted Outpatient Treatment 
Resolution adopted by IACP October 28, 2014
PDF VERSION

WHEREAS, law enforcement officers are often the first responders to individuals in mental health crisis; and

WHEREAS, law enforcement officers continue to experience an increase in interactions with people with severe mental illness[1]; and

WHEREAS, such interactions consume a disproportionate amount of limited law enforcement resources[2]; and

WHEREAS, approximately forty percent of individuals with severe mental illness are not receiving treatment, primarily because the illness affects their ability to voluntarily participate in needed care[3]; and

WHEREAS, noncompliance with treatment, specifically non-adherence to medication, is strongly associated with hospitalization,[4] suicide,[5] victimization,[6] violence[7] and relapse;[8] and

WHEREAS, noncompliance with treatment is also strongly associated with arrest and incarceration,[9] resulting in a disproportionate representation of individuals with severe mental illness in the criminal justice system; and

WHEREAS, a 2014 report found that 10 times more mentally ill persons are in prisons and jails than are receiving treatment in state psychiatric hospitals[10]; and

WHEREAS, Assisted Outpatient Treatment (AOT) provides court-ordered treatment in the community for high-risk individuals with severe mental illness and a history of treatment noncompliance, as a less restrictive alternative to inpatient hospitalization; and

WHEREAS, more than two decades of research and practice document AOT as an effective tool to improve outcomes for this focus population, including reduced hospitalizations[11], arrests[12], incarcerations, crime[13], victimization[14] and violence[15] while increasing treatment adherence[16] and substance abuse treatment outcomes; and

WHEREAS, numerous state and local law enforcement associations support and have championed the passage and implementation of AOT programs; and

WHEREAS, the Department of Justice deemed AOT to be an effective evidence-based program for reducing crime and violence[17]; and

WHEREAS, studies amply demonstrate AOT’s effectiveness in reducing arrests and incarcerations, e.g., a recent study of New York State’s signature AOT program (“Kendra’s Law”) concluded that the “odds of arrest in any given month for participants who were currently receiving AOT were nearly two-thirds lower” than those not receiving AOT[18]; and

WHEREAS, AOT also produces significant taxpayer/system cost savings, ultimately increasing overall service capacity and leading to greater access for both voluntary and involuntary recipients. A cost-impact study in New York City found net cost savings of 50% in the first year and an additional 13% in the second year; a study in North Carolina reported similar cost savings of 40%[19]; now, therefore be it

RESOLVED, that the International Association of Chiefs of Police (IACP) recommends the authorization, implementation, appropriate funding, and consistent use of Assisted Outpatient Treatment (AOT) laws to ensure treatment in the least restrictive setting possible for individuals whose illness prevents them from otherwise accessing such care voluntarily.

---

[1] Biasotti, Michael C. Management of the severely mentally ill and its effects on homeland security. Naval Postgraduate School Monterey Ca. Dept. of National Security Affairs, 2011.

[2] Biasotti, Michael C. Management of the severely mentally ill and its effects on homeland security. Naval Postgraduate School Monterey Ca. Dept. of National Security Affairs, 2011.

[3] Substance Abuse and Mental Health Services Administration. (2013). Results from the 2012 National Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-47, HHS Publication No. (SMA) 13-4805.

[4] Valenstein, M., Copeland, L., Blow, F., et al. (2002). Pharmacy data identify poorly adherent patients with schizophrenia at increased risk for admission. Med Care 40:630–639.

Weiden, P., Kozma, C., Grogg, A., et al. (2004). Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. Psychiatric Services 55:886–891.

Gilmer, T., Dolder, C., Lacro, J., et al. (2004). Adherence to treatment with antipsychotic medication and health care costs among Medicaid beneficiaries with schizophrenia. American Journal of Psychiatry 161:692–699.

Ascher-Svanum, H., Faries, D., Zhu, B., et al. (2006). Medication adherence and long-term functional outcomes in the treatment of schizophrenia in usual care. Journal of Clinical Psychiatry 67:453–460.

Velligan, D., Weiden, P., Sajatovic, M., Scott, J., Carpenter, D., Ross, R., Docherty, J., (2009). The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry. 70 Suppl 4:1-46; quiz 47-8.

[5] Muller-Oerlinghausen, B., Muser-Causemann, B. & Volk, J. (1992). Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication. Journal of Affective Disorders, 25(4),261-269.

Leucht S., Heres S. (2006). Epidemiology, clinical consequences, and psychosocial treatment of nonadherence in schizophrenia. Journal of  Clinical Psychiatry, 67(Suppl. 5), 3–8.

Nordentoft, M. (2007). Prevention of suicide and attempted suicide in Denmark. Epidemiological studies of suicide and intervention studies in selected risk groups. Danish Medical Bulletin, 54(4),306-69.

Chapman, S.C., Horne, R. (2013). Medication nonadherence and psychiatry. Current Opinion in Psychiatry, 26(5),446-552.

[6] Hiday, V., et al. (1999). Criminal Victimization of Persons with Severe Mental Illness. Psychiatric Services, 50, 62-68.*

*Individuals with severe psychiatric disorders who were not taking medication were found to be 2.7 times more likely to be the victim of a violent crime (assault, rape, or mugging) than the general population.

[7] Swartz, M., Swanson, J., Hiday, V., Borum, R., Wagner, H., Burns, B. (1998). Violence and severe mental illness: The effects of substance abuse and nonadherence to medication. American Journal of Psychiatry, 155, 226-31.

Substance abuse, medication non-compliance and low insight into illness operate together to increase violence risk. Van Dorn, R., Volavka, J., Johnson, N. (2011). Mental disorder and violence: is there a relationship beyond substance use? Social Psychiatry and  Psychiatric Epidemiology.

Witt, K., Van Dorn, R., Fazel, S. (2013). Risk factors for violence in psychosis: Systematic review and metaregression analysis of 110 studies. PLOS  ONE, 8, e55942.

Belli, H., Ozcetin, A., Erteum, U., et al. (2010). Perpetrators of homicide with schizophrenia: sociodemographic characteristics and clinical factors in the eastern region of Turkey. Comprehensive Psychiatry, 51,135-41.

Alia-Klein, N., O’Rourke, T., Goldstein, R., et al. (2007). Insight into illness and adherence to psychotropic medications are separately associated with violence severity in a forensic sample. Aggressive Behavior, 33, 86–96.

Elbogen, E., Van Dorn, A., Swanson JW, et al. (2006). Treatment engagement and violence risk in mental disorders. British Journal of Psychiatry, 189,354–360.

Swanson, J., Swartz, M., Essock, S., et al. (2002). The social-environmental context of violent behavior in persons treated for severe mental illness. American Journal of Public Health, 92, 1523–1531.

Bartels, J., Drake, R., Wallach, M., et al. (1991). Characteristic hostility in schizophrenic outpatients.  Schizophrenia Bulletin, 17, 163–171.

[8] Robinson, D. (2010). First-episode schizophrenia. CNS Spectrum, 15 (Supplement 6), 4-7.

Ayuso-Gutierrez, J., Del Rio, V. (1997). Factors influencing relapse in the long-term course of schizophrenia. Schizophrenic Research, 28, 199-206.

Morken, G., Widen, J., Grawe, R. (2008). Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC Psychiatry, 8,32-8.

Suppes, T., Baldessarini, R., Faedda, G., Tohen, M. (1991). Risk of recurrence following discontinuation of lithium treatment in bipolar disorder.  Archives of General Psychology, 48(12),1082-1088.

Franks, M., Macritchie, K., Mahmood, T., Young, A. (2008) Bouncing back: is the bipolar rebound phenomenon peculiar to lithium? A retrospective naturalistic study. Journal of Psychopharmacology, 22(4), 452-456.

[9] Munetz, M.R., Grande, T.P., & Chambers, M.R. (2001). The incarceration of individuals with severe mental disorders. Community Mental Health, 34:361-71.* * Nearly 90 percent of a sample of individuals with severe mental illness in a local jail were partially or completely non-complaint with medication in the year before they were incarcerated.

Lattimore, P. K., Broner, N., Sherman, R., Frisman, L., & Shafer, M. S. (2003). A comparison of prebooking and postbooking diversion programs for mentally ill substance-using individuals with justice involvement. Journal of Contemporary Criminal Justice, 19(1), 30-64.* *Individuals with co-occurring mental illness and substance abuse who are noncompliant with medication have a threefold increase in risk for arrest and are significantly more likely to be at risk for violent behavior.

Ascher-Svanum, H., Nyhuis, A.W., Faries, D.E., Ball D.E., & Kinon B.J. (2010). Involvement in the US criminal justice system and cost implications for persons treated for schizophrenia. BMC Psychiatry, 10:11.

Shelton, D., Ehret, M. J., Wakai, S., Kapetanovic, T., & Moran, M. (2010). Psychotropic medication adherence in correctional facilities: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 17(7), 603-613.

[10] Torrey, EF, Zdanowicz, MT, Kennard, AD, et al. The treatment of persons with mental illness in prisons and jails: a state survey. Treatment  Advocacy Center and National Sheriff’s Association, April 8, 2014.

[11] Swartz, M., Swanson, J., Wagner, H., Burns, B., Hiday, V., & Borum, R. (1999). Can involuntary outpatient commitment reduce hospital recidivism: Findings from a randomized trial with severely mentally ill individuals. American Journal of Psychiatry 156: 1968-1975.

Swartz, M., Swanson, J., Steadman, H., Robbins, P., & Monahan J. (2009).  New York state assisted outpatient treatment program evaluation. Duke University School of Medicine.

[12]Gilbert, A., Moser, L., Van Dorn, R., Swanson, J., Wilder, C., Robbins, P., Keator, K., Steadman, H., & Swartz, M. (2010). Reductions in arrest under assisted outpatient treatment in New York. Psychiatric Services 61: 996-999.

[13] New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.

[14] Hiday, V., Swartz, M., Swanson, J., Borum, R., & Wagner, R. (2002). Impact of outpatient commitment on victimization of people with severe mental illness.  American Journal of Psychiatry, 159: 1403-1411.

[15] Phelan, J., Sinkewicz, M., Castille, D., Huz, St., & Link, B. (2010). Effectiveness and outcome of assisted outpatient treatment in New York state. Psychiatric Services 61: 137-143.

[16] New York State Office of Mental Health. 2005. Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.

[17] National Institute of Justice, Program Profile Assisted Outpatient Treatment (AOT). Retrieved August 27, 2014, from  http://www.crimesolutions.gov/ProgramDetails.aspx?ID=228

[18] Gilbert, A., Moser, L., Van Dorn, R., Swanson, J., Wilder, C., Robbins, P., Keator, K., Steadman, H., & Swartz, M. (2010). Reductions in arrest under assisted outpatient treatment in New York. Psychiatric Services 61: 996-999.

[19] Swanson, J., Van Dorn, R.,  Swartz, M., Robbins, P., Steadman, H., McGuire, T., & Monahan, J. (2013). The cost of assisted outpatient treatment: Can it save states money? American Journal of Psychiatry 170:1423-1432.

About Assisted Outpatient Treatment (AOT)

Assisted Outpatient Treatment (AOT) is for a very small group of the most seriously mentally ill who already accumulated multiple incidents of hospitalization arrest or incarceration associated with their failing to stay in voluntary treatment. AOT allows judges, after full due process to require certain mentally ill to accept six months of mandated and monitored treatment as a condition for living in the community. It provides an off ramp before incarceration. As Linda Dunn said, Assisted Outpatient Treatment is like putting a fence by the edge of the cliff rather than an ambulance at the bottom. (Barnidge 2014)

The research on AOT is extensive and positive. (Mental Illness Policy Org 2013). Six months of mandated and monitored treatment has been shown to reduce homelessness 74%; hospitalization 77%; arrest 83%; incarceration 87%, physical harm to others 47%; property destruction 46%; suicide attempts 55%; and substance abuse (48%). By replacing expensive incarceration and hospitalization with less expensive community care Assisted Outpatient Treatment cuts costs to taxpayers in half. (Swanson, et al. 2013). AOT also reduces victimization. (V.A. Hiday 2002). These results are particularly outstanding because AOT is limited to the most seriously ill, often a very hard to treat population.

NYC Mental Health Dept. must Prioritize Serious Mental Illness Rather than Mental Health

Testimony by DJ Jaffe, to NYC Dept of Health and Mental HealthNov. 1, 2013

My name is DJ Jaffe. I am Executive Director of Mental Illness Policy Org.

NYC and State used to focus all their resources on people with serious mental illness, but both are engaged in massive mission-creep that now leaves the most seriously ill to fend for themselves. Bullying is the newest cause celebre used by NYC to justify ignoring serious mental illness[1]. The fact that bullying isn’t a mental illness matters not a whit when it comes to spending money. Peer support-in spite of lack of evidence that it reduces violence, arrest, homelessness, suicide and incarceration is flooded with money while Kendra’s Law proven to help the most seriously ill is largely ignored.

NYC has largely abandoned efforts at symptom amelioration for the most seriously ill and instead focuses on ‘recovery’ and ‘wellness’ services for those who are higher functioning. The mental health system, which used to be a mental illness system, has offloaded the most seriously ill to the shelters, prisons, jails and morgues. As a result Riker’s Island is now the primary provider of services to the seriously ill in NYC. There is no known way to prevent mental illness, but ‘prevention’ ranks high in the department’s activities. “Early Identification” is the  new buzz word, when those identified can’t get treatment. Mission-creep and ignoring the elephant in the room: untreated serious mental illness has become policy.

We would ask that NYC stop shunning the seriously mentally ill, end mission creep and return to making serious mental illnesses like schizophrenia and treatment resistant bipolar disorder a department priority.

Here is how NYC can help people with serious mental illness 

Two Studies Should Lead to Radical Change in Mental Illness Treatment

The first study was conducted in Australia and found  individuals with schizophrenia – even those who do not have substance abuse problems – are significantly more violent than the general population.  The study found

·      25% of individuals with schizophrenia were charged with a criminal offense during their lifetime, compared with 10% of community controls.

·      6.4% of those with schizophrenia were found guilty of a violent offense, and 22.8% of those with schizophrenia plus substance abuse were found guilty of a violent offense compared to 2.4% of the general population

Assisted Outpatient Treatment for Seriously Mentally Ill Cuts Costs in Half

According to a just released study in the July 30, 2013, American Journal of Psychiatry, mandating Assisted Outpatient Treatment (AOT) for a narrowly defined group of persons with serious mental illness results in substantial savings. AOT allows courts to order individuals with serious mental illness and a history of treatment noncompliance to stay in treatment as a condition of staying in the community. It is only available for those who are so ill, they have a past history of going off the treatments that prevented them from becoming hospitalized, arrested, homeless or incarcerated. For this small group of the most seriously ill, AOT is a less expensive, less restrictive, more humane alternative to involuntary inpatient commitment and incarceration.

Researchers at Duke found that treatment costs declined 50 percent in New York City after the first year of AOT, and another 13 percent the second year. Even larger cost savings were reported in five other New York counties. Previous studies have proven AOT dramatically improves care for people with serious mental illness who have trouble staying in treatment voluntarily.

How to Fix New York State Office of Mental Health (OMH)

Testimony of DJ Jaffe, Executive Director, Mental Illness Policy Org

to NYS Office of Mental Health  

May 3, 2013, NYC

(Note: NYS OMH is the largest agency in the state ($3 billion) and still has no director. The acting director seems intent on following the failed policies of her predecessor which moved OMH from an organization dedicated to helping the most seriously ill, to one focused on "improving the mental health of all New Yorkers." She has stated unequivocally that she wants to close state psychiatric hospitals. NYS has fewer than 4,000 beds and probably 50% of those are for people unfit to stand trial, not guilty by reason of insanity, or were convicted and are mentally ill. -ed)

Thank you. We are a non-profit think tank providing unbiased science-based information to policymakers and media on serious mental illness, and not mental health. We are the only group in New York and one of only two in the country that is focused exclusively on those the NIMH defines as “seriously” mentally ill (primarily schizophrenia, the subset of bipolar disorder classified as “severe bipolar”, the subset of major depression called ‘severe major depression’ and a few others) In order to be considered serious, these diagnosis must be diagnosable currently or within the past year and continue to result in serious functional impairment, which substantially interferes with or limits one or more major life activities in persons 17 years or older.

It is people with serious mental illness who are most likely to become homeless, incarcerated or a headline that stigmatizes the others. It is people with serious mental illness who are likely to commit suicide or become victimized.  

We have two recommendations for you:

1. Prioritize the most seriously ill and
2. Make greater use of Kendra’s Law, if for no other reason, than because you have to in order to comply with Olmstead.