Tragedy spot­lights le­gal lim­its on treat­ment for men­tally ill

Austin American-Statesman - - BALANCED VIEWS - Pliszka is a psy­chi­a­trist and a mem­ber of the Texas So­ci­ety of Psy­chi­atric Physi­cians.


mur­der of so many chil­dren and their teach­ers in New­town, Conn. is a ter­ri­ble tragedy for the na­tion; made greater by the fact that it is one of many.

One of the is­sues unit­ing the Columbine shoot­ers, Se­ungHui Cho (Vir­ginia Tech in­ci­dent), Jared Lee Lough­ner (Gif­fords), James Holmes (Aurora) and Adam Lanza is their his­tory of men­tal ill­ness and the fail­ure of so­ci­ety to deal with it. In 1955, there were nearly 550,000 pa­tients with men­tal ill­nesses in state hos­pi­tals. The U.S. pop­u­la­tion has dou­bled since then, yet the pop­u­la­tion of per­sons in state hos­pi­tals has fallen to less than 100,000.

There are good rea­sons for some of this de­cline.

An­tipsy­chotic med­i­ca­tion, devel­oped in the 1950s, was not a cure for schizophre­nia but al­lowed many pa­tients to func­tion more fully in so­ci­ety (when it was taken). The Sup­ple­men­tal Se­cu­rity In­come (SSI) pro­gram pro­vided a mea­ger in­come to those men­tally ill who were un­able to work.

Those pa­tients who did leave the state hos­pi­tals were sup­posed to be cared for in com­mu­nity men­tal health cen­ters, such that in the 1960s, men­tal health pro­fes­sion­als looked for­ward to a new era in the treat­ment of men­tal ill­ness in­volv­ing com­mu­nity ser­vices and in­ten­sive re­ha­bil­i­ta­tion ser­vices. Then it all went hor­ri­bly wrong.

To­day, we have thou­sands of men­tally ill per­sons wan­der­ing our streets or liv­ing in board­ing homes, re­fus­ing to take med­i­ca­tions and, in some cases, com­mit­ting acts of ag­gres­sion against them­selves, their fam­i­lies and the com­mu­nity. Many peo­ple have “a state hospi­tal in the back bed­room” — a child or sib­ling who with­draws from so­ci­ety and shows signs of se­ri­ous men­tal ill­ness. Adam Lanza, by re­ports, showed this pat­tern — an early his­tory of with­drawal, poor so­cial skills and lack of func­tion­ing in daily life. There ap­pears to have been no par­tic­u­lar trig­ger for his be­hav­ior — but he was at the age that many with se­ri­ous men­tal ill­ness have their first episode of psy­chosis. His mother was wor­ried about him — but where would she have gone, es­pe­cially if he did not wish to seek treat­ment? She would have found few op­tions.

What got us on this track? In 1975, in O’Connor v. Don­ald­son, the Supreme Court sharply re­stricted in­vol­un­tary hos­pi­tal­iza­tion, and any treat­ment had to take place in the “least re­stric­tive en­vi­ron­ment.” To­day, com­mit­ment pro­ce­dures are dif­fi­cult to ini­ti­ate and re­quire im­mi­nent dan­ger. Sub­se­quent court de­ci­sions have pre­vented manda­tory treat­ment of the men­tally ill ex­cept in “emer­gency” sit­u­a­tions and es­tab­lished a “right” to refuse treat­ment. In essence, this means that even an in­vol­un­tar­ily com­mit­ted pa­tient can­not be made to take med­i­ca­tion once re­leased from a hospi­tal. All of th­ese de­ci­sions are based on a false premise: that be­ing men­tally ill is a life­style choice that should not be in­ter­fered with un­less there is “dan­ger to self or oth­ers.” But schizophre­nia and manic-de­pres­sive ill­ness are brain dis­or­ders which rob a pa­tient of in­sight; even when there is no overt dan­ger the pa­tient still suf­fers. We would not leave an epilep­tic to lay seiz­ing on the street, so why do we al­low a schiz­o­phrenic to wan­der the streets talk­ing back to tor­ment­ing voices?

The con­cept of “least re­stric­tive treat­ment” led to the con­cept of a “right” to com­mu­nity as op­posed to hospi­tal treat­ment of men­tal ill­ness. To­day, there are so few long-term hospi­tal beds that even pa­tients who want to be ad­mit­ted of­ten are not. We do not want to go back to the days of state hos­pi­tals lo­cated in ru­ral ar­eas far from fam­i­lies and qual­i­fied staff. Pa­tients who are well sit­u­ated in the com­mu­nity should re­main there. We need, how­ever, a whole­sale re-ex­am­i­na­tion of Amer­i­can men­tal health care pol­icy of the last 50 years. If we place more bar­ri­ers to the treat­ment of the men­tally ill, then the New­ton tragedy may be re­peated many times more.

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