August 4, 1998
By E. Fuller Torrey, M.D. and Mary Zdanowicz, Esq.
In June, Michael Laudor, a Yale Law School graduate who suffers from schizophrenia, allegedly slashed his fiancée, Caroline Costello, to death. Last month, Russell Weston, a drifter with schizophrenia, allegedly murdered two policemen, Jacob Chestnut and John Gibson, in an assault on the U.S. Capitol.
These are only the most publicized of an increasing number of violent acts by people with schizophrenia or manic-depressive illness who were not taking the medication they need to control their delusions and hallucinations. The pattern has been emerging for the past decade. Based on information gathered in the Washington, D.C., metropolitan area, we estimate that approximately 1,000 homicides a year are committed nationwide by seriously mentally ill individuals who are not taking their medication.
A Question of When
The total number of individuals with active symptoms of schizophrenia or manic-depressive illness is some 3.5 million. The National Advisory Mental Health Council has estimated that 40% of them – roughly 1.4 million people – are not receiving any treatment in any given year. It is therefore not a question of whether someone will follow Michael Laudor and Russell Weston into the headlines. It is merely a question of when.
A 1990 study of families with a seriously mentally ill member reported that 11% of the ill individuals had physically assaulted another person in the previous year. In 1992 sociologist Henry Steadman studied individuals discharged from psychiatric hospitals. He found that "27 percent of released male and female patients report at least one violent act within a mean of four months after discharge." Another 1992 study, by Bruce Link of the Columbia University School of Public Health, reported that seriously mentally ill individuals living in the community were three times as likely to use weapons or to "hurt someone badly" as the general population. A 1998 MacArthur Foundation study found that seriously mentally ill individuals committed twice as many acts of violence in the period immediately prior to their hospitalization, when they were not taking medication, compared with the posthospitalization period when most of them were taking medication.
The emerging pattern of violence is clear. And it is part of a larger pattern: increasing numbers of severely mentally ill individuals among the homeless population, incarcerated in jails and prisons for offenses committed while psychotic, and loitering in parks, public libraries and transportation stations. The pattern is the product of deinstitutionalization gone awry, the discharge of hundreds of thousands of mentally ill individuals from the nation's public psychiatric hospitals without ensuring that they get the medication they need to remain well.
Recent studies have shown that about half of those who have schizophrenia or manic-depressive illness have markedly impaired insight into their illness. That is, they do not know that they are sick, because their brain disease has affected the frontal lobe circuits that are necessary for complete self-awareness. If they are not sick, they reason, why do they need a cure? Mr. Weston repeatedly told his family that he was not sick and rejected their pleas that he take his medication.
Individuals like Mr. Weston will take medication only if it is mandated. And this can be done in 37 states under outpatient commitment statutes, or in a few other states under conservatorships or conditional hospital release arrangements. Both Montana and Illinois, the states that should have been treating Mr. Weston, have outpatient commitment laws under which he could have been required to take medication as a condition for living in the community.
However, these laws are difficult to invoke. Lawsuits brought by the American Civil Liberties Union and Washington-based Bazelon Center for Mental Health Law have changed most states’ criteria for outpatient commitment. Individuals must be classified as an imminent danger to themselves or others before they can be involuntarily treated, either in the hospital or in the community; this criterion is strictly applied. Most psychotic individuals, who are merely making threats against others or living on the streets and eating out of garbage cans, are not deemed legally sick enough to qualify for outpatient commitment.
At the same time as civil liberties lawyers have been making it virtually impossible to treat severely mentally ill individuals involuntarily until they commit some horrific act, state mental health officials have been increasingly abdicating their responsibility for these individuals. More than 90 % of state psychiatric hospital beds that existed in 1960 have been eliminated. Many states have turned over the responsibility for treating severely mentally ill individuals to health-maintenance organizations. Some of them, mostly nonprofits, are doing a creditable job. But for-profit HMOs, with few exceptions, have been disastrous for the severely mentally ill, who are expensive to treat. The newest antipsychotic medications, which are essential for some mentally ill patients, can cost $400 a month.
If we hope to stem this tide of unnecessary violence and preventable tragedies, we will have to address squarely the issue of involuntary treatment. Outpatient commitments, conservatorships, and conditional hospital releases should be used much more widely to ensure that discharged patients comply with the requirement that they take their medication. Since most severely mentally ill individuals also receive federal subsidies such as Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or Veterans' Administration benefits, such subsidies could be linked to treatment compliance. Mr. Weston, for example, had been receiving monthly SSI payments since 1984, but such payments were never linked to his treatment.
We prevent individuals with Alzheimer's disease from living on the streets, because we understand that they have a brain disorder. We mandate involuntary treatment for some tuberculosis sufferers who refuse to take medication, because we understand that they are potentially dangerous to other people. We should do the same for individuals with schizophrenia and manic-depressive illness.
Another necessary step: Washington should hold the nation's governors directly responsible for their states’ mental illness treatment programs. The care of severely mentally ill and disabled individuals has been a state responsibility for 150 years. Most states have no internal monitoring to assess the quality of public psychiatric services. As a condition for receiving federal mental health block grants, states could be required to institute such programs, using audits of mental health centers' clinical activities and unannounced inspections of hospitals and group homes. The state data could then be sent to the Institute of Medicine under the National Academy of Sciences, which would submit an annual report to Congress.
These horrors are preventable. Michael Laudor should be teaching at Yale Law School and Russell Weston should be mining Montana's hills. Their victims should still be alive. The tragedy is that the mentally ill are a threat to society because society has failed them.
Reprinted with permission. Copyright 1998 Dow Jones & Company, Inc.. All rights reserved.