Tuesday, February 28, 2012

This is Just Insane

E. Fuller Torrey. The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens. New York: W.W. Norton & Co., 2012.

Note: These notes use the author’s terminology. 

The author seeks hope for people with severe mental illnesses and their families.  He is troubled that the deinstitutionalization of people with such illnesses such as severe schizophrenia has led to much violence.  He has found over 3,000 cases where a person with paranoid schizophrenia has committed murder.

People became aware of deplorable conditions in mental hospitals with particular intensity in the 1940s and following decades.  This led to patients being removed from mental hospitals. In 1955, there were 558,000 in public mental hospitals (when the national population was 164 million).  In 2006, there were 40,000 in public mental hospitals (with a national population of 300 million).  Many of those who were deinstitutionalized found themselves as victims of violence, were incarcerated, and/or became homeless.

The legal movement to close or reduce mental hospitals argued that involuntary hospitalizations were contrary to our belief in freedom.

The National Mental Health Information Center estimates there are 12.8 million adult (or 5.4% of adults) with a serious mental illness. 4.7 million receive social security for their non-retardation disorder.  It is within this group that exists a subset that creates most of the problems.  England estimates that 10% of its schizophrenics created 80% of totally costs associated with schizophrenia.

The author estimates there are 500,000 “problematic” and 50,000 “most dangerous” people with severe mental problems.  They live primarily in urban areas.  The crimes that often shock the public the most are often committed by people in this group.

The author notes the question facing us is whether or not crazy people “have a right to be crazy”.

Guidelines state a person cannot be hospitalized against the person’s will until they are a threat to themselves or to someone else.  Many families live in fear of a threatening relative, often claiming voices or God is commanding them to commit violent acts.  Yet until a violent act is attempted or occurs, outside help is not available.  Unfortunately, many people have been murdered or harmed before the help is provided.  Conversely, people whose illnesses caused them to threaten others have been killed or injured by those they threatened.

In the 1950s, some conservative political groups believed that mental health treatment was part of Communist-Soviet attempts to control the minds of Americans.  Minute Women, U.S.A, compared mental health hospitalizations to the Soviet concentration camps.  The Daughters of American Revolution noted that 80% of U.S. psychologists were from foreign countries, with many of them from the Soviet Union.  Fiscal conservatives wanted to reduce mental health spending. 

Medicaid and Medicare passed in 1965, providing for benefits for people with mental disabilities.  State governments switched patients from state supported mental hospitals to community settings where the Federal government would pay for the costs of care through Medicaid and Medicare.

Liberals criticized the warehousing of people with mental disabilities in psychiatric hospitals where they were provided with inadequate care.

California responded by passing the Lanterman-Petris-Short Act that diminished mental health treatment in 1969.  The bill passed the legislature unanimously.  Supporters of the legislation believed the patients with psychiatric difficulties were able to make their own decisions as to what treatment they wanted.  It was argued that people with mental health disabilities had lower rates of violent acts than did the general population.  It was not noted that the reason for this lower rate was because many were in institutions where they could not commit violent public acts.

Once California closed psychiatric hospitals, it then faced the problem that it lacked facilities to treat people who sought treatment or met the legal requirements for involuntary treatment.

In 1973, California began closing many psychiatric hospitals.  Governor Ronald Reagan were not impressed that 71% of psychiatrists voted Democratic nor that several psychiatrists had stated that Reagan ally Barry Goldwater was not sane.

California had 37,000 psychiatric patients institutionalized in the mid-1950s.  The deinstitutionalization of patients began under Governor Goodwin Knight, a Republican, and continued under successive Governors Edmund Brown, a Democrat, and Reagan, a Republican.  By 1973, there were under 7,000 people institutionalized as psychiatric patients during Reagan’s tenure.

The number of patient s involuntarily institutionalized by court order decreased by 99% in California from 1969 to 1978.  The average days of hospitalization for those who were involuntarily committed fell from 180 days to 15 days.

Many of those discharged from psychiatric care became homeless.  Many lived in boarding houses in condition worse than they had when institutionalized.  Three studies concluded those discharged lived in ghetto conditions.  Many had not access to psychiatric treatment.  Many eventually entered the criminal justice system.

A 1971 study of the Los Angeles homeless estimated that 30% to 50% had serious mental illness.  They were often victimized with beatings, getting robbed, and being raped.  Later studies confirmed similar results, with one study finding 79% of the homeless surveyed had at some point been in a psychiatric hospital and 74% had been arrested.  This study also found 30% were found to be “too paranoid” to accept psychiatric help. 

Psychiatric services in San Francisco County increased 99% between 1980 and 1993.  Sacramento County jails reported having, in 1995, 28% of its inmates requiring psychiatric medication.  The author notes that prisons had become the largest mental health institutions.

Prison presents problems for mentally ill prisoners.  Violent inmates are sometimes put off by the behavior of the mentally ill and inmates then attack the mentally ill.

No Federal or state government is producing data on the number of violent crimes committed by those with severe mental illness.  It is known there are many instances where this happens.  It is also observed that an increase in managed care and outpatient services seems to lower these rates.

In 1955, California had 37,500 state hospital beds, or 1 for every 352 of the state’s 13.2 million.  In 2003, there were 4,275 such beds, or 1 for every 8,304 of the state’s 35.5 million.

A 2008 San Diego study found that homelessness was the reality for 20% of patients treated for schizophrenia and for 17% of patients treated for bipolar disorder.

A 1999 California study found 20% of state prisoners and 11% of county inmates were severely mentally ill.

Every California county has more people with severe mental illness in prison than in a hospital.

The cost of California prison psychiatric treatments was $21 million in 1993 and $245 million in 2003.

Some opinions have changed over time.  Frank Lanterman, the legislator who sponsored the Lanterman-Petris-Short Act, argues the Act needs to be changed.  Ironically, a day before holding  a hearing on allowing court ordered outpatient treatment for dangerous people who refuse to take the medicine for their disorders, a psychotic person drove his 18 wheel tractor into the side of the California Capitol building.  The proposal passed and became law.

Fiscal conservatives fought a movement towards providing more psychiatric services. The costs, in Los Angeles in 2004, for one day of psychiatric hospital care was $607, for prison was $85, for jail was $64, and for a public shelter was $3.  The author notes this failed to consider cost of the numerous criminal justices arrests of people with psychiatric problems.

It is estimated that people with severe mental illness committed at least 4,700 homicides between 1970 and 2004 in California.

In 1972, a three judge panel in the Lessard Decision created specific criteria that made it more difficult to involuntarily treat someone for a mental illness. This overturned 700 years of civil law going back to England that a government is responsible for protecting people who can’t protect themselves.

There is a risk that government may have civil suits for failing to provide proper mental illness care.  A Federal judge awarded $5.4 million in such a suit in 1999.

Dane County Wisconsin has a team of 5 to 15 mental health professionals who take round the clock responsibility for mental health patients.  They provide care including medication maintenance, housing, job training, and rehabilitation.

It was found in a study that 57% of schizophrenic patients studied were not aware they had schizophrenia to a “moderate to severe” degree.  In these cases, the brain often has anosognosia, which means the person in unable to recognize it has a disorder.  With Alzheimer’s patients, anosognosia is a permanent condition.  Anosognosia in schizophrenics exists in the frontal lobes, the parietal lobes, and connections between these two lobes.  Anosognosia thus affects multiple brain areas.  Anosognosia is the primary reason why someone with mental illness does not take their medication for their mental illness.  When the law requires a person to request treatment in order to receive treatment, a person with anosognosia will not be treated.  Sadly, anosognosia is linked to increased violent behavior.

After the Lesard decision, every state by 1980 had adopted laws restricting the involuntary institutionalization of the mentally ill.

A New York study found that mentally ill homeless who were supposed to be but were not taking their medications were 40 times more likely to commit a violent crime and 27 times more likely to commit a non-violent crime than were mentally ill people requiring medication who were in stable housing environments.

Studies indicate that at least 5% to 10% of people with severe psychiatric illness will engage in at least one serious act of violence per year.

It is conservatively estimated that people with severe mental illness commit at least 5% of murders.  About 50% to 60% of murders committed by a mentally ill person are of a family members.  By contrast, a family member is killed in 16% of murders committed by someone without a mental illness.

The violent behavior of a minority of people with mental illness has created a stigma for all people with mental illness.

People with epilepsy are required to make medication before operating vehicles.  The author notes further laws requiring the taking of medication by people with additional mental health issues may be required.

A New York study found that 40%of mentally ill patients discharged from hospitalization are re-hospitalized within six months. An Illinois study found 30% of mental health patients discharged are re-hospitalized within one month.

A study showed that mental illness patients who likely were taking their medication were 3% more violent than others in a 10 week period compared to those who were not likely taking their medication who were 14% more likely to commit violence.  This study concluded that mentally ill people were not significantly more likely to commit violence than their neighbors.  The author notes those with a anosgosia were not included in this study, which skewed the sample. This study also compared rates of crime within the high crime rate neighborhoods were mentally ill people tend to live.

The author supports a law that broadens the scope of requiring involuntarily treatment.  Assisted Outpatient Treatments laws have passed several states to allow for the involuntary treatment of seriously mentally ill people who pose a danger.  These treatments are given to people with past experiences with violence, are substance abusers, have anosognosia, are refusing to properly take their medications, are displaying antisocial behaviors, and have a neurological impairment.  It is noted that 85% to 90% of people in this category are male.

A hospital uses criteria to know when to have extra security on hand.  Using similar criteria as descried previously reduced violent acts in one hospital study by 92%.

The author recommends developing a data base of high risk people by judicial order.  This would be available only to law enforcement officers, authorized mental health personnel, and to a limited degree to firearm dealers who would not be allowed to sell a firearm to a name that checks against this list.

There are numerous ways to move people towards treatment.  Those charged with misdemeanors could be provided the option of taking their medications versus imprisonment. The author also mentions that government benefits could be withdrawn to those not taking their medication. 

State governments are urged to collect more data.  A lack of data is keeping some problems hidden,


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