January, 2023. A recent report in the New York Times described a new program being initiated by New York City Mayor Eric Adams, with the goal of improving the lives of homeless individuals who live on the streets of the city and suffer from mental illness.1

Earlier in my career, I served as Chief Medical Officer for the New York State Office of Mental Health (OMH). When I assumed that role in 1989, there were about 25,000 inpatient state hospital psychiatric beds operated by OMH. When I left New York (NY), in 2002, there were about 4500 such beds. This was the now well-known era of de-institutionalization of the mentally ill, a well-intended process that occurred virtually nationwide, to transition to community-based care. In NY, reinvestment legislation was passed requiring that for every dollar spent on an inpatient state bed to be terminated, equal funding would be provided to expand step-down care and an array of residential and outpatient services. However, this did not happen in many states, and when it did, as in NY, the creation of new services lagged and proved insufficient. Bed shortages became critical, and one result was “trans-institutionalization” into the criminal justice system—ie, into jails and prisons. Although things are better now in some locations, the widespread challenge of homelessness is rampant in many cities throughout the country, such as San Francisco, Los Angeles, Seattle, and many others. Well-funded and well-designed treatment programs such as those being proposed by Mayor Adams are badly needed.

One component of Mayor Adams’ plan is the use of involuntary hospitalization when individuals demonstrate illness-driven behavior that endangers themselves or others. This intervention is, however, controversial. Opponents argue that its very involuntary nature can re-traumatize individuals, and that it interferes with their civil liberties. In my days at OMH, the default standard was for there to be clear evidence that a person was in “imminent danger” to self or others. I argued that things like delusional paranoia that all food was poisoned, or raging addiction and deteriorating health, called for urgent intervention, and that too narrow an interpretation of the legal language would allow individuals on the streets to “die with their rights on” while disregarding illness in plain sight.

To be sure, Mayor Adams’ plan is ambitious and will require a collaborative, persistent team effort. But at least his proposal recognizes critical elements: training of law enforcement officials, more hospital beds, sufficient time in the hospital to embark on appropriate treatment, coordination of discharge planning to provide individualized continuity of care utilizing step-down partial programs, residential care, case management, and outpatient services. A tall order, but a welcome goal, endorsed from the top.

In the September, 2022 Law and Psychiatry column in the Journal, Holliday and colleagues described a structured “Forensic Mental Health Assessment” (FMHA) strategy, as a “critical intercept for enhancing mental health care.” Their focus was primarily on incarcerated individuals, and the need to identify those with mental health issues “early in criminal justice proceedings as well as before re-entry into the community, and to connect these individuals to appropriate, evidence-based care.” Many of these individuals either were homeless before being apprehended by criminal justice, or they were at risk to become so after release. A comprehensive assessment such as an FMHA involves acquiring records and integrating components of care that are otherwise often fragmented and uncoordinated. Incorporating such a process, when possible, into plans such as that proposed by Mayor Adams, would be promising.

In a letter to the editor, responding to the New York Times article, noted bioethicist Arthur Caplan2 wrote: “Claiming autonomy and personal choice as reasons to keep severely mentally ill people who lack competence on our streets makes no sense. Allowing the sick to “rot with their rights on” may appeal to single-minded civil libertarians, but it is deeply disrespectful to the dignity and kindness that mentally ill people deserve.” Amen!

1. Newman A, Fitzsimmons EG. New York City to involuntarily remove mentally ill people from streets. New York Times, November 29, 2022. Accessed December 5, 2022. https://www.nytimes.com/2022/11/29/nyregion/nyc-mentally-ill-involuntary-custody.html 2. Caplan A. Letter to the Editor. New York Times, November 30, 2022. Accessed December 5, 2022. https://www.nytimes.com/2022/11/30/opinion/letters/mental-illness-new-york-city.html