Reaction to police shootings ...

When a tragedy occurs involving a police officer and someone with mental illness, the general outcry is for more police training. Recent tragedies in Philadelphia, Chicago, and two in Oregon follow this pattern.

Everyone seems to accept that this is the way the world is – that people will get sicker and sicker, deteriorating into psychosis. That family members will be left with no choice but to call police. That police will arrive and be faced with someone in deep psychosis.

That seems to be where most people see the breakdown in the system. The letters to the editor, editorials, news articles, all call for police to be trained to better handle someone in psychosis.

There are places long before that point of confrontation with law enforcement where intervention would mean helping someone get back into treatment, keeping them from deteriorating in the first place, ensuring family members do not reach the point of fear, ensuring that confrontation never even happens.

By all means, train police officers. Just remember that this step is a safety net to prevent tragedy after all else fails. As Alan Orr, assistant police chief in Tiger, Oregon, said:

“There are cases where you could have a triple-Ph.D. in psychiatry, and you’re not going to get through to an individual.”

Early intervention through assisted outpatient treatment is a way to intervene before the downward spiral begins.

Tuberculosis treatment

“Civil libertarians who have argued against mandatory treatment of people with mental illness have not objected to forced treatment for contagious diseases.” –Portland Press Herald, Sept. 28, 2006

Can psychiatry learn from tuberculosis treatment? Dr. Torrey asked that question seven years ago in Psychiatric Services:

To increase medication compliance for tuberculosis, public heath authorities in several states have introduced directly observed therapy (DOT) programs. An outreach worker visits patients twice weekly or more to watch them take their drugs. Compliance with medications is rewarded with food supplements, fast food vouchers, transportation tokens, movie passes, clothing, and sometimes money, with increased rewards for increased compliance ...

People with active tuberculosis who refuse to participate in DOT can be involuntarily hospitalized and treated. In New York City between 1993 and 1995, an average of eight detention orders a month were issued, with a peak of 47 patients involuntarily treated at any one time. According to city health officials, the credible threat of involuntary treatment is an important reason for DOT’s success. Under DOT, the city’s tuberculosis rate decreased 55 percent between 1992 and 1997.

The story in Maine this week notes a TB carrier was jailed as a public risk.

"The patient was not concerned about what tuberculosis meant for his own individual health, " said Dr. Kathleen Gensheimer, state epidemiologist with the Maine Center for Disease Control and Prevention. "If you're not concerned about something that can hurt others, like tuberculosis, then it's our mandate ... to ensure treatment."

“In New York City, 11 percent of patients involuntarily treated for tuberculosis also had schizophrenia,” noted Dr. Torrey. “Some were a danger to themselves and others for both conditions. Their tuberculosis could be treated, but not their schizophrenia, Is there something inherently different in brains and lungs? Or is it that our brains are not thinking clearly?”

The forgotten floor

Miami's CBS station broadcast a two-part news series spurred by Pete Earley's book Crazy. The jail psychiatrist calls conditions in the Miami-Dade jail "morally incomprehensible" for inmates with severe mental illnesses. Miami Judge Steven Leifman is outraged.

“There are five times as many people in our jail with mental illness than any psychiatric hospital in Florida,” pointed out Judge Leifman. “Five times, right here.” ...

Judge Leifman said, “It’s a tough place. It’s not a great condition for anybody that is sick because it is not conducive for treatment. People with mental illness stay in jail eight times longer than sometime without mental illness for the exact same charge and it cost the taxpayers seven times more to treat him here. It doesn’t really accomplish anything here. It’s a warehouse.”

Watch part 1 and part 2 on the website, or read the transcripts.

Kudos for Kendra's Law

Albuquerque Journal editorial praises Mayor Chavez and the City Council for their persistance in getting Kendra's Law to Albuquerque citizens. [Read more from New Mexico.]

"I wonder how my kids are doing ..."

Lashaun Harris (or in some news reports, LaShuan Harris) has pleaded not guilty by reason of insanity in the murder of her three young children. The sad recounting of her current delusions is even sadder because if and when she is restored to competency, she will know the full weight of what she did.

In her videotaped confession to police, Harris described how she struggled with two of her boys as she stripped them and plunged them from Pier 7 in an area where tourists stroll along the waterfront. Her youngest boy laughed, thinking it was a game ....

In January, she said, ''I wonder how my kids are doing, if someone good is looking over them.'' She told one family member, ''T.J. is in school and Josh is walking and talking.'' She said her dead grandmother bathes them and ensures they eat properly.

Upcoming hearing on AOT

This Monday, the Virginia Senate Education and Health Committee will be holding a second special subcommittee hearing on Senate Bills 18 & 309 – which would update Virginia’s AOT standards to allow for more effective use throughout the Commonwealth. The last hearing was very interesting, highlighted by testimony from advocates from around Virginia each detailing the need for reform. We expect an even stronger turnout this time, and encourage everyone with an interest in the Virginia mental health system to attend.

The hearing will take place in Senate Room A in the General Assembly Building at 10:00AM, this Monday, September 25^th. Directions and information on visiting the Capitol are available here.

NY Times on violence and mentally ill

Would that everyone would talk about violence and mental illness as cogently as Dr. Bruce Link.

Dr. Link highlights the problem in the New York Times' careful coverage of the tragic death of Dr. Wayne Fenton ...

Violence is less common among those with mental illnesses than is sometimes assumed. Many people with schizophrenia are withdrawn, more likely to be targets of an assault than to commit one, said Bruce Link, a professor of epidemiology at Columbia.

But studies suggest that those with untreated psychosis — often characterized by intense paranoia and imaginary voices issuing commands — are at least two to three times as likely as people without mental disorders to get into physical altercations, including fights using weapons, Dr. Link said.

Albuquerque passes Kendra's Law

The Albuquerque City Council last night passed Kendra's Law. The measure now goes to Mayor Martin Chavez for signature. Chavez has been an outspoken advocate for the law, which will help a small number of Albuquerque's sickest citizens who cannot make informed treatment decisions.

In an editorial supporting the ordinance – and a statewide version of the law as well - The Albuquerque Tribune said, “[U]ntil the country and the state get serious about mental health, this city ordinance is a responsible step toward helping those in need and protecting society from any harm they might inflict on others.”

The sad case of Joe Martens

Police have been called to Joe Martens’ house 88 times in the past 5 years. Eight times he was actually arrested. The last time officers came to his home, it took three officers and a stun gun to subdue him.

Joe has been diagnosed with bipolar disorder and regularly goes off his medications, though family members say he is fine when he is on his medications. A loud public debate is raging in the community – neighbors want him arrested, but he has done nothing wrong. He isn’t dangerous, so he cannot be committed.

"When Joe (stops taking his medicine), I can't get him to go to Broadlawns," says [Joe’s father] Gary Martens, referring to Polk County's hospital. "So, I just sit and wait until he looks at someone cross-eyed. Then the West Des Moines Police Department comes and takes him away."Martens says he can't force his son to get help. The law says that Joe Martens is an adult, capable of making his own decisions.

Nobody can win this terrible standoff.

• Joe, as he describes it, is a prisoner in his own home. If he feels like the neighbors are watching him, it is because they are.
• The neighbors are afraid and feel unsafe in their own homes.
• Joe’s family can’t help their son stay on medication and are forced to watch him regularly deteriorate, worrying that the next encounter with police or neighbors might end Joe’s life.
• Police are expending inordinate resources in responding to incidents caused by the symptoms of this one man’s untreated mental illness.
• And likely, people with mental illnesses in the area, probably others in that very neighborhood, are feeling stigmatized by the public reaction to Joe.

Stories like this are infuriating precisely because this scenario is what many in the mental health community support. Their advocacy against tools like assisted outpatient treatment mean standoffs like these will continue. One wonders how they will react if Joe’s outbursts actually end up hurting a neighbor, or if police end up hurting Joe.

Humanitarian concerns

U.S. District Judge Michael Mukasey found Susan Lindauer so sick as to be incompetent to stand trial. It is only a slight simplification to describe the threshold of being competent to stand for a criminal trial as being able to tell the difference between the judge and the prosecutor.

According to an Associated Press article, the Judge explained that expert examinations determined that Lindauer suffers from "hallucinations, grandiose and persecutory delusions and mood disturbances, including purported gifts of prophecy and spiritual visitations."

Judge Mukasey also doubted the government could prove the charges against Ms. Lindauer, in large part because an element of the crime could not be proven because she was so sick that "even lay people recognize that she is seriously disturbed." After expounding on how very sick Lindauer is, Judge Mukasey then refused to impose an order for her treatment.

The judge had "humanitarian concerns" about ordering medication for Ms. Lindauer, wary of a procedure that "necessarily involves physically restraining defendant" in order to inject "mind-altering drugs."

Putting aside that the large majority of court-ordered medication does not involve the use of restraints and the patently obvious need for her treatment, we wonder how "humanitarian" was Judge Mukasey’s alternative solution. He allowed Susan Lindauer to walk out the courtroom door, apparently still psychotic.

Short bits

• TAC executive director Mary Zdanowicz is interviewed for Officer.com on law enforcement and the mentally ill. [Also see our briefing paper on this subject.]
• Pete Earley will be a guest on "Community Matters Weekend Edition" at 6 a.m. Sunday (Sept. 17, 2006) on KPTK-AM (1090) in Seattle. Pete is the author of "Crazy: A Father's Search Through America's Mental Health Madness." (Already read his book? Let him know what you thought.)
• "I am unable to talk with him about anything except his delusions now," a social worker says about Rosario "Russell" Miraglia.
• Christine Wilhelm accepts plea deal.

Echoing throughout the mental health system

Virginia is facing a mental health crisis. Inpatient beds are in short supply, treatment standards are woefully outdated, and jails and prisons are brimming with individuals with a severe mental illness. When facing a problem this monumental, it’s easy to throw up your hands and give up. But another option is to realize that while no one solution will fix every problem, there are things that can be done that will begin to address part of the problems.

A powerful example is a series of reports released by the Central Virginia Health Planning Agency in 2004 documenting patterns of inpatient hospitalization taking place in Central Virginia. The reports found that 1244 people (305 from one planning district, 939 from another) had been hospitalized three or more times within one year. Although these individuals represented a minority of the total number of individuals hospitalized in that year, their care accounted for more than a third of all reported charges:

• Planning district 15 residents with three or more admissions comprised only 14% of the total number hospitalized, the charges associated with their hospital care equaled 37% ($27.6M) of the total reported charges.
• Planning district 19 residents with three or more discharges comprised only 16% of the total number hospitalized, the charges associated with their care also equaled 37% ($7.9M) of the total reported charges.

Imagine if this group of individuals was able to receive consistent care, without revolving in and out of inpatient hospitalizations. Imagine if Virginia had effective AOT provisions, which have been shown to significantly reduce inpatient hospitalizations for similar populations. The cost savings associated with helping this small group could free up monies for a myriad of different mental health programs. A small step, but one that would echo throughout Virginia’s mental health system.

Posted by John Snook - email John with comments

Better off committing a crime?

A 23 year-old man with paranoid schizophrenia says "I'm doing better now. I know what medication to take and when to take it."

And the cost? First he had to beat his father to death with a baseball bat, and then spend the last 5 years locked in a state psychiatric hospital. He was found not guilty by reason of insanity, something the article reports is “unusual and very difficult” under Florida law. And yet it was easier than getting help under Florida’s then-too-restrictive commitment law (the Baker Act) before he killed his father just 10 days after administrators released him from a Palm Beach County Mental Health Center. He was released against the advice of two doctors who said Morgan thought the TV was telling him what to do. It is another story with the familiar refrain “His parents worked hard to get him appropriate psychiatric treatment.”

Florida law has been reformed since this man killed his father. But, the question remains whether it is still easier to get an NGRI plea than it is to get treatment.

"Why I can't save my brother"

A powerful opinion editorial in this Sunday's Washington Post ...

My brother BJ has not killed anyone. Not yet. And I hope he never will. But in various disturbed, hyper-vigilant and paranoid states over the past 30 years, he has slashed screen doors, severed phone wires at the family home, tossed scalding coffee at our now-deceased mother, left bizarre or menacing messages on his siblings' phones and otherwise exhibited behavior that screams: "I am a danger to myself and others."

New Mexico - Recycling the old fallacy about Andrew Goldstein

The Albuquerque Tribune ran commentaries for and against Kendra's Law, the "for" argument authored by TAC executive director Mary Zdanowicz.

In the "con" commentary, the authors note in part:

The reported incidents of violence cited as justification for Kendra's Law, including the incident for which Kendra's Law was named, involved perpetrators who had repeatedly asked for help and were turned away. Our position is if there had been adequate resources, including stable housing, treatment and case management, these incidents would have not occurred.

This is one of those old fallacies that is recycled anew each time AOT is debated. If you look at the actual report on Andrew Goldstein (pseudonym David Dix), you will see that in the two years prior to pushing Kendra Webdale to her death in front of a New York City subway train, Goldstein received 199 days of inpatient and emergency room services, on 15 different occasions, in six different hospitals from 1997 to 1999. Four different clinics provided outpatient services in this time period.

This is hardly the profile of a patient who was refused services. In fact, it was Goldstein who often refused services. He consistently stopped taking his medication after discharge from a hospital unless he was closely monitored. When he wasn't taking medication, he exhibited hallucinations, delusions, and unprovoked acts of aggression. On some occasions, when his untreated symptoms deteriorated to the point where he suffered anxiety, insomnia, or other unpleasant conditions, he went to an emergency room seeking relief. Other times, he was brought to the emergency room following a violent outburst.

And in 1998 alone, the State of New York and the federal government expended $95,075 for his mental health and residential care.

So the oft quoted "fact" that he frequently asked for help but was turned away is untrue.

DOJ survey discovers the obvious: Inmates are unhappy

Don't be so overwhelmed by the stunning numbers in the new DOJ report to be released later today that you miss the absurdity of the whole thing.

The data come from surveys completed by inmates themselves, asked about symptoms in the past 12 months, or since admission, of things like “feelings of worthlessness or excessive guilt,” “increased/decreased interest in sexual activities,” or even “thoughts of revenge.”

One wonders why they didn’t ask if any of these jailed prisoners felt a sense of social isolation.

The very real problem of criminalizing the mentally ill can only be addressed by identifying the failures of the mental health system responsible for keeping them out of jail.

Everyone is sad ...

TAC's official statement: In memorium: Dr. Wayne Fenton

Groups like NIMH, NAMI, and AFSP issued statements, and the story was retold around the country, in papers like the LA Times and popular blogs like Liz Spikol's.

No other choice

Dr. Wayne Fenton’s death is a poignant reminder of the woeful inadequacy of options for emergency care when severely mentally ill patient are in crisis and refusing medication. Families struggle with a mental health system that claims nothing can be done until the patient is dangerous.

One of the most tragic aspects of Dr. Fenton’s death is that he was an exception in a mental health system that is geared almost exclusively to patients who are able to seek treatment voluntarily. Like the difficult patients he tried to help, he was a victim of the system that turns a blind eye to patients who lack the insight into their need for treatment.

Dr. Fenton never should have been in the vulnerable position of trying to help his patient alone, but he was in that position precisely because he was a compassionate professional who understood too well the alternatives for the young man he wanted to help. Most of his colleagues would have referred the family to the police, who also have few options in Maryland and Virginia until the patient becomes dangerous.

Perhaps this tragedy will prompt Dr. Fenton’s colleagues to refocus the mental health system on the patients most in need – those Dr. Fenton refused to neglect.

Dr. Fenton's wisdom

"All one has to do is walk through a downtown area to appreciate that the availability of adequate treatment for patients with schizophrenia and other mental illnesses is a serious problem in this country. We wouldn't let our 80-year-old mother with Alzheimer's live on a grate," he said. "Why is it all right for a 30-year-old daughter with schizophrenia?"

- Dr. Wayne Fenton (more from the Washington Post on his murder)

Mourning the loss of Dr. Wayne Fenton

We mourn the crushing loss of Dr. Wayne Fenton. Dr. Fenton was truly one of the good ones – a rare breed of psychiatrists who devote their careers to the most severely mentally ill. Motivated not by political correctness, but by a mission to understand and treat the most devastating symptoms of schizophrenia.

His research was pure – probably in part because he served some of the most difficult patients in his private practice and therefore witnessed the terrible toll of psychosis on patients and their families. He was more concerned about helping the most severely ill than worrying about where his next research dollar was coming from.

The director of the National Institute of Mental Health,where Dr. Fenton was an associate director, called his killing particularly tragic.

"He was without question one of the nation's experts in schizophrenia," Insel said.

He said that Fenton concerned himself particularly with research aimed at making it possible for people with severe psychiatric illnesses to become functioning members of the community.

In addition to his administrative and research work, Insel said Fenton was "a very accomplished clinician" who continued to see patients one-on-one evenings and weekends.

In private practice, Insel said, Fenton worked with people "who would be categorized as psychotic" and therefore subject to a disorder that could make them dangerous if not properly treated.

Dealing with such patients is "a risk one takes" in psychiatry, Insel said.

Fenton was "absolutely committed" to helping people with the most severe psychoses, Insel said.