The system fails every single day

From a 46-year-old man with bipolar disorder -

It fails every time a homeless mentally ill person gets stabbed and dumped in the river. It fails every time a mentally ill person goes to prison after committing a crime while untreated. It fails every time a mentally ill person is denied opportunities that most of the population takes for granted. It fails every time a mentally ill person cannot stay on their meds because they can't afford them or can't afford the visit to the doctor to prescribe them.

It fails countless times a year; most of those failures are the little tragedies that affect the ill person, their family, or an innocent victim, but do not draw the attention of the nation as the VA Tech affair has. It fails every time a mentally ill person cannot find a productive role in society because the support system isn't there. It fails miserably and it destroys countless lives and countless families.

Why does it take the loss of so many lives for people to realize the system is broken? How many more lives will be needlessly destroyed before something is done to fix it? I wish I had the answers. I do not. But, I do see that the system is failing the mentally ill, and failing society in general.

My brother's battle: And mine

"Away from home in those early years of my brother's disease, before cellphones, I thought about getting a pager so my mother could reach me if my brother beat her up. I have lived in dread ever since that I'd get a phone call saying that my brother, who lived at home, had killed our parents. When he threatened me last fall, my family and I made a heart-wrenching decision for the sake of everyone's safety: We had him committed to a psychiatric hospital."

- Journalist Asra Nomani's personal account of her family's struggle to get treatment for her brother in West Virginia - "My Brother's Battle: And Mine" - The Washington Post

Horrific, but not uncommon

The story of the Bruce family is horrific – even more so because it is NOT uncommon.

William Bruce brutally killed his mother. His father describes the conversation of two worried parents the night before the murder.

"The night before it happened, my wife and I were in bed talking. I said, 'Amy, I can't believe they allow these people out on the streets. Willie should be in a padded cell, heavily sedated. What do we have to wait for? Do we have to wait for him to hurt somebody or kill somebody before they do something?' "

Unlike Cho Seung-Hui, most severely mentally ill individuals who become violent do not select their victims randomly. Multiple studies have confirmed that between 50 and 60 percent of the victims are family members; by contrast, among homicides committed by non–mentally ill individuals, only 16 percent of the victims were family members.

Joe Bruce spoke eloquently about his family’s story last night on Anderson Cooper 360 and on WCSH Channel 6 in Portland, who noted:

Throughout the family's struggle with Willie's schizophrenia, Joe Bruce said he learned a lot of things about Maine's mental health system that upset him. He learned being psychotic is not enough to get someone committed to the hospital. The patient has to be a direct threat to himself or others. He also learned how difficult it is to require someone to take medication while in the hospital. And he discovered Willie could be deemed well enough to go back into the community after just a couple of weeks in the hospital.

In the Bruce case, some of the parallels with the Cho case are eerie – one of which being the attitude of the mental health care providers charged with caring for people who are so ill.

"Recovery from mental illness is possible," wrote the director of the Maine psychiatric hospital where William Bruce was sent for treatment and released. A week later, Bruce stood accused of bludgeoning his mother to death. After Bruce was accused of killing his mother, the hospital director explained why. "In Maine, a client can choose not to be engaged in treatment ... [t]he major issue is when someone does not appear eminently [sic] dangerous and cannot be committed."

In Virginia, a spokeman for the agency that should have helped Cho after he was court-ordered into community treatment said, "The matter of the individual actually following up and going to that appointment is his or her prerogative." He also said that the court order "can't actually be enforced," despite the fact that the law says that upon failure to adhere to the treatment order, the judge can rescind it and order hospitalization.

As one Maine paper wrote after the Bruce tragedy:

We understand the concern for the civil liberties of people with mental illness, but this case shows the greater need for the patients like William Bruce is to keep ahold of them -- not necessarily in institutions -- but within a system that can treat the symptoms that lead to such tragedies.

Treatment laws that require someone to be a danger to themselves – coupled with providers who shirk their duties to those very people who have actually been found to meet those high standards – it all adds up to tragedy.

The wakeup call wasn’t Cho. It has been sounding regularly in communities across the country. It is just that nobody was listening.

Understanding need for treatment crosses political lines

"Our society continues to wrestle with the question of how to handle individuals whose mental health problems can make them a danger to themselves and to others. "
Statement from Pres. Bush

"...we need to look at what happened and see if there are ways to prevent these kinds of events happening again. We need to understand what was wrong with Mr. Cho and we need to ask ‘Do we need changes in the legal or the mental health system.’ …Should Mr. Cho have been given support and taken out of the ordinary population before tragedy occurred? It gives occasion to look at how the legal and mental health systems work–and recognize that there needs to be serious changes in the way both function."
Former President Bill Clinton on “Larry King Live” (4/19)

Dr. E. Fuller Torrey on Diane Rehm Show

Treatment Advocacy Center’s president, Dr. E. Fuller Torrey was on the Diane Rehm Show this morning on WAMU. Listen to it here.

Virginia AG calls for better mental illness tx law

Virginia Attorney General Bob McDonnell explained to WDBJ 7 Roanoke that he will ask the Virginia legislature to pass Kendra’s Law when they return in January. As regular readers of this blog will remember, legislation to update Virginia’s outpatient commitment standard was passed over by the Virginia Courts of Justice committee in January.

Their reasoning? They wanted to wait for the Supreme Court Commission’s report, due in 2008 and since bumped to 2009.

Recent events at Virginia Tech may finally convince legislators that compelling treatment for a small number of the sickest people is not only humane, but cannot wait 2 more years – people across the state are suffering every day. Just because their stories don’t make international headlines doesn’t mean they aren’t horrible and worthy of attention. For instance, in the same week of the Virginia Tech shooting, a man in Roanoke was killed by police responding to a call that he was suicidal – he had bipolar disorder and was not taking medication.

TAC commends the attorney general for recognizing the many benefits that improved outpatient commitment standards can bring to the Virginia mental health system.

A classic case of shooting the messenger

Thanks to United States Psychiatric Rehabilitation Association (USPRA) for demonstrating so aptly why they shouldn’t be taken seriously. USPRA’s response to the Va Tech tragedies “urges all media networks to avoid over generalizations about the link between mental illness and violence.” That’s right! God forbid the media educate the public about the risks of untreated mental illness so that tragedies can be prevented. Instead follow USPRA’s lead and deceive the public:

USPRA: “Violence is no more prevalent among individuals with mental illness than the general public”
Fact: The CATIE violence study found that patients with schizophrenia were 10 times more likely to engage in violent behavior than the general public (19.1% vs. 2% in the general population).

USPRA: “Public perceptions that violence is strongly associated with mental illness are fueled by graphic media reports of violent crimes.”
Fact: The media does not commit the violent acts. Public perceptions are formed by violent crimes spawned from the dangerous untreated symptoms of mental illness and USPRA should stop trying to intimidate the media into silence.

USPRA: “it is incredibly rare for someone with a mental illness to commit gross acts of violence, especially on such a scale as the Virginia Tech shootings”
Fact: Yes, the scale of the scale of the Va Tech shooting is rare because sadly, this was a record. But, half of all “rampage shootings” such as the one in Blacksburg are committed by mentally ill shooters.

USPRA should be ashamed!

Media recognize flaws in treatment laws

More media on the Virginia Tech shooting is focusing on the need to improve state mental illness treatment laws.

An oped by Dr. Torrey in today’s New York Post notes:

The students and faculty at Virginia Tech correctly identified Cho as being very disturbed and potentially dangerous but that only resulted in a virtually universal refrain: "There was nothing we could do."

Newsday’s Jamie Talan writes:

The mental health system has long battled the vexing question about what to do with the small number of psychotic patients who are violent but who have yet to act on their thoughts. Mental health experts say only 5 percent of mentally ill patients with a history of psychosis are violent. That said, according to Dr. E. Fuller Torrey, president of the Treatment Advocacy Center in Arlington, Va., there are about 4 million people in the United States at any given time suffering from psychosis. The majority, 95 percent, of these patients are not dangerous to themselves or others …

"Legally, in these cases, everyone's hands are tied," said Mary Zdanowicz, executive director of the Treatment Advocacy Center. The organization was formed in 1998 to attempt to help states rewrite their mental health laws. "There is a lot that needs to be changed. We know too much now about the risks of these illnesses when patients are not treated."

This indepth piece in the Richmond Times Dispatch captures the horror of the state not providing needed treatment:

"It's outrageous that a young man showing such symptoms to this dedicated teacher somehow never got the treatment that he so clearly needed," said Mary Zdanowicz, executive director of the Arlington-based Treatment Advocacy Center, a national advocacy group for the mentally ill.

And the San Francisco Chronicle covers the Virginia Tech shooting in terms of California’s AOT law, Laura’s Law, which California counties have access to but have not implemented.

"Being completely and absolutely overcome with illness -- walking around and thinking you're on Mars and that everyone is a Venusian -- is not enough to get someone into treatment. They have to be in physical danger at the time," said Jonathan Stanley, assistant director of the Treatment Advocacy Center, a national group based in Arlington, Va., that supports forced treatment.

Media reacts to Cho

Behind some of the plaints of Virginia Tech staff that nothing could be done about Cho, you can hear the undercurrent: Who were we to judge? Of course, if he had occasionally uttered racial slurs rather than frightening those around him with bizarre behavior, the full apparatus of administrative power at Virginia Tech would have been brought down on him.

But Virginia Tech also had to cope with an extremely strict state law that requires that someone represent an "imminent danger" to himself or others before he can be compelled to seek treatment. ...

There is, of course, a balance to be struck between civil liberties and treating the mentally ill. But that balance is now badly off-kilter. Cho Seung-Hui was basically abandoned to his private mental hell at Virginia Tech. While he hatched his lunatic and hateful plot, everyone tried to ignore the scary guy in class behind the sunglasses.

- Rich Lowry, editor of National Review

Cho became by any person's reckoning a danger not only to himself but to others, although his future behavior was hard to predict. Because of that unpredictability, the law in California and elsewhere should allow involuntary detention based on current actions and past history of mental illness.
No one wants anyone held involuntarily without reason. No one wants anyone housed in Dickensian facilities. There can be, however, times when one person's continued liberty collides with the public's safety. This week's shooting spree was such a time.
- San Diego Union Tribune

But when you face a decision about a human life that is crumbling before your eyes, and the law reduces the complexities of a malfunctioning mind -- or, if you prefer, a lost soul -- to a printed checklist ("Alternatives to involuntary hospitalization and treatment . . . were deemed suitable," says choice "A" on Virginia's Form DMH 1006), it's time to treat the law as it treats people in pain: dismissively.
- Marc Fisher, Washington Post

Common sense and human decency also would have dictated some mandated treatment for the tormented Mr. Cho. But the law put that out of reach, as well. And here we are.
This situation is an understandable overreaction to abuses of the past, when the mentally ill were confined too often and too long. But it's time for the pendulum to swing back to a more sensible middle.
That's slowly happening.

- Steve Blow, Dallas Morning News

Hiding from warnings at VA Tech

Still in denial, major mental health organizations are rushing in the wake of the Virginia Tech shootings to deny the increased risk of violence that can accompany the symptoms of untreated mental illness. If caregivers, law enforcement and university officials do not recognize - or are unwilling to acknowledge - the risks, how can we hold them accountable when tragedy strikes? Mental health advocates and officials who engage in this concerted effort to hide the truth about violence are actually contributing to the violence.

A more responsible and credible approach is to acknowledge the risks of violence. A recently published study offers an eerie prediction that might have helped prevent this and future tragedies had the mental health community sounded the alarm rather than hide their heads in the sand:

We found that the greatest risk of homicide being committed by people during psychotic illness was during the early phase of the illness, particularly the first episode. Many subjects had had contact with mental health services in the weeks before the offence, and many of the deaths might have been prevented if the dangerous symptoms had been identified and there had been assertive intervention. In addition to the devastating effect on the families of the victims, who were often also relatives of the perpetrators, the deaths resulted in great cost to the community in legal proceedings and secure hospitalisation.
Homicide during psychotic illness in New South Wales between 1993 and 2002

Warning signs from VA Tech shooter

Lucinda Roy, Virginia Tech English Department, told Neal Conan on Talk of the Nation that the Virginia Tech shooter was a disturbed young man ... and that she had tried to get him some help to no avail.

"I just felt that he was a very depressed youth and seemed to be angry about some things and so I felt that there was some things I needed to do ... because that's what you're meant to do as a teacher ..."

"I contacted the police, contacted counseling, student affairs, the college to try to sound the alarm, and they felt that their hands were tied legally for various reasons ... as you probably know until someone actually threatens to do something, it can be incredibly difficult to make something happen ..."

We’ve heard this all too many times before - one Virginia mother asked “what do I have to do, have him kill someone to get him treatment?” shortly before her son killed her. We’ve been sounding the alarm that Virginia’s law, which is one of the most restrictive in the nation, needs to be reformed. Perhaps someone will now listen.

Questions in Virginia

As details become known from Virginia, questions will grow more specific.

Did the gunman have a history that included any sign of mental instability? Was he treated? Did the school know of his condition and monitor his progress? Did anyone report problems or potential problems? It is worth considering these questions in tandem.

All too frequently, it is easier for a disturbed person, even a psychopath, to get a firearm than to get sound treatment for mental illness.

- excerpt from Boston Globe Editorial, April 17, 2007

It's important to ask

Psychiatric patients are rarely screened for firearm possession.

Researchers found nearly a 10 fold increase in reported access to or possession of firearms when psychiatric inpatients were specifically asked whether they owned or had access to a gun. Researchers suggest involving families or friends in weapons management. However, they also point out that it is more common in the mental health field not to inquire about weapons unless a person has a history of suicidal or violent behavior. This is increasingly becoming a problem for families and friends who are not warned of the risks associated with the untreated symptoms of mental illnesses. It is not uncommon, after the fact to hear responses like this:

McGrath didn't know there were guns in the house, but even if he had, he never dreamed Michael would become violent. …I don't think he ever hit her or threatened to hit her or anything like that.

Base Rates of Firearm Possession by Hospitalized Psychiatric Patients
Dale E. McNiel, Ph.D., Christopher M. Weaver, Ph.D. and Stephen E. Hall, M.D. Psychiatr Serv
58:551-553, April 2007

Treatment reform in Illinois

The Chicago Tribune recently reported on SB 234 in Illinois; a bill that would update the strict treatment standard to provide treatment options for Illinois’ most seriously mentally ill before they are an imminent danger to themselves or others. The Treatment Advocacy Center’s executive director, Mary Zdanowicz was quoted in the article:

We have an obligation to those who are hurting to not withhold treatment.

Studies suggest that, when properly medicated, these folks are no more dangerous than the general population.

New York state data showed significant decreases in homelessness, incarceration and psychiatric hospitalization among people who were ordered into involuntary treatment under Kendra's Law. There were fewer suicide attempts and fewer cases of physically harming others or damaging property.

It's not mental illness that makes them violent, Zdanowicz said. It's untreated symptoms.

Mentally Ill, Homeless & in the Snow

That a large proportion of those who are homeless also have a mental illness is beyond debate. Coming up with the exact number of those coping with both homelessness and mental illness is more problematic.

Counting and categorizing the diagnoses of those among a transient population, whose members tend to be without mailing addresses and phones, is a formidable task. A good estimate, however, is that there are 200,000 people with severe mental illness among the 600,000 who live in America’s streets and shelters. This means that one in three people without homes are homeless, at least in part, because of the symptoms of mostly treatable psychiatric illnesses.

The results of an extensive survey of people in Minnesota who are homeless found that 52 percent of them had a serious mental illness, such as severe depression, bipolar disorder or schizophrenia. That percentage is significantly ones found by other researchers. That could be a sign that the prevalence is increasing. A perhaps more likely alternative is that people incapacitated by a severe mental illness are less likely to appreciate that escaping the frigid Minnesota winters can make being homeless at least a little less arduous.

Bloody Monday in CA

Not a good week in California if you need treatment but instead encounter police.

In Santa Rosa, officers responded to a 911 call from a woman who claimed her husband was firing shots into the ceiling of their home because he believed there was an intruder in the attic. The woman also told authorities her husband was bipolar and needed his medication. Officers opened fire on Richard DeSantis, who was killed in his driveway. His wife and 2 young children were home at the time.

In Van Nuys that same evening, John Eric Goudeaux ignored orders by police to drop his weapon, a 3-foot-metal bar, when they responded to a call that Goudeaux was holding his ex-wife hostage.

Goudeaux’ mother asked: "Why didn't they shoot him in the leg and take him to a mental hospital?" That is the same question posed by the family of Jason Paul Yule, killed by police in Sacramento the previous Saturday.

What could police do differently? We ask again … what could the mental health community have done differently? Why are people who are so ill allowed to keep deteriorating until the only action their family can take is to call 911?

If you live in one of these counties, consider putting pressure on your county supervisors to actually implement Laura’s Law – designed to get people help before they deteriorate.

Kendra's Law- more important than ever

A recent investigative report by WABC TV in New York showed in the past 15 years, the number of inmates with mental illnesses in New York state prisons has grown by 71 percent, and that many of these prisoners have spent months, even years in total isolation, with virtually no therapy. According to Jack Beck, an attorney for a prison watchdog group:

"Often people with mental illness start their Southport Correctional Intuition sentence not because they've done some terrible act, but they've done some smaller act," Beck said. "But then, once they’re in this environment, that is so difficult for them to cope with, they start yelling and screaming and just being non-cooperative."

"Instead of having mental health beds, we have prisons and jails for the mentally ill. And that is the story."

Meanwhile, Kendra’s Law in New York has had stunningly successful results- For those in the AOT program: 77 percent fewer experienced psychiatric hospitalization; 83 percent fewer experienced arrest; and 87 percent fewer experienced incarceration.

The continued use of Kendra’s Law – a proactive approach to get treatment for people with severe mental illness before they deteriorate and commit a crime- is more important than ever.

Closing state hospitals doesn't eliminate need for care

The use of general hospitals to treat serious mental illnesses increased 34.7% between 1995 and 2002 according to a new study published in Psychiatric services this month. This raises a number of questions, not the least of which is whether psychiatric units in general hospitals are equipped to provide the kind of treatment, rehabilitation and discharge planning that state psychiatric hospitals can provide.

Take Virginia for instance. In 2006, the average length of stay for acute admissions to a state psychiatric hospital was 47.2 days compared to 5.4 days in community psychiatric inpatients beds. The abbreviated treatment provided in general hospital psychiatric beds may account for these hospitals’ “revolving doors” through which 3,514 patients passed 3 or more times in 2002 at a cost of about $111 million. Maybe closing state psychiatric hospital isn’t such a good thing – for patients or budgets.

Analysis of U.S. Trends in Discharges From General Hospitals for Episodes of Serious Mental Illness, 1995–2002, Shinobu Watanabe-Galloway, Ph.D. and Wanqing Zhang, M.D., M.Ed., Psychiatr Serv 58:496-502, April 2007

Long road to treatment for Vitali Davydov

At least Vitali A. Davydov won’t be going to prison.

Davydov, 20, pled guilty this week to murdering Dr. Wayne Fenton, a psychiatrist who, as we’ve said before, was the exception in a mental health system that is geared almost exclusively to patients who are able to seek treatment voluntarily. Dr. Fenton embraced the most difficult cases and never turned people away who were really suffering, including Davydov.

"The average psychiatrist in the Washington area is on Connecticut Avenue and he's seeing . . . some executive who got passed over for a promotion and is having a midlife crisis," said Fuller Torrey, a local psychiatrist who often referred severe cases to Fenton. "Wayne was one of the few out here seeing the severely mentally ill. He was strongly committed to providing care and promoting research for the sickest people."

Davydov will be committed to a Maryland psychiatric facility until he is no longer considered dangerous. Hopefully, that means he will finally receive the treatment Dr. Fenton was trying to get him the day he was murdered.

Librarians as mental health care providers?

Nationwide, more than 200,000 people living on the streets have severe mental illnesses. And, at any given time, there are more people with untreated severe psychiatric illnesses living on America’s streets than are receiving care in hospitals. Since these people aren’t receiving treatment, the burden of care falls on groups other than the mental health community. As Chip Ward explains in an op-ed in the LA Times, librarians are one of those de facto care groups.

So where are we to turn for help? Social workers are too few, under funded, overworked and overwhelmed. If a homeless guy is inside the library, then the view is, "Hey, mission accomplished."

Local hospitals also are uncertain allies. They have little room for the indigent mentally ill and often can't get reimbursed for treating them. So they deal with the crisis at hand, fork over some pills and send them on their away.

The cost of this mad system is staggering. Cities that have tracked chronically homeless people estimate that a typical transient can cost taxpayers $20,000 to $150,000 a year. You could not design a more expensive, wasteful or ineffective way of providing healthcare to individuals who live on the street than by having librarians dispense it through paramedics and emergency rooms.

Involuntary detention – He “willingly put others at risk”

A common retort by opponents of civil commitment is that “we don’t lock up people with diseases other than severe mental illnesses.”

But that isn’t true. Take the involuntary detention of a man with treatment-resistant tuberculosis in an Arizona jail since July. Robert Daniels refused to wear a mask and take other measures to prevent spreading his disease to the public.

Drug-resistant TB, or drug-resistant staph infections, or pandemic flu can create the need for involuntary isolation. So why is it more common for people with mental illnesses to be involuntarily detained compared to other illnesses?

"It's very uncommon that someone would both not want to take treatment and will willingly put others at risk," one expert said of Daniels.

And that is likely the rub – the word “willingly.” Unlike most other illnesses, about half of patients with schizophrenia and bipolar disorder suffer from a condition that affects their ability to recognize the risks associated with failing to treat their illnesses. Anosognosia, or lack of insight, impairs the patient’s ability to recognize that they have an illness - therefore it is more likely that they will not accept treatment that can reduce the risks associated with their untreated illness.

Committing someone to restore them to competency – so they can recognize their illness and the consequences of its nontreatment – is a measure that protects not just society, but also the patient. Most cases of people with untreated severe mental illnesses who endanger the public later turn out to be because the person thought they were saving the world from aliens, or escaping a CIA plot, or responding to commands from ethereal voices. They aren’t choosing to put people at risk – their disease leaves them with no choices.

Research update: Metabolic abnormalities in schizophrenia

TAC relies on its supporting organization the Stanley Medical Research Institute (SMRI), which carries out research to ascertain the causes of and develop better treatments for schizophrenia and bipolar disorder. A recent update from SMRI follows.

One of the most successful SMRI grants has been to the Institute of Biotechnology at the University of Cambridge in England. The program, directed by Dr. Sabine Bahn, has continued to publish studies describing metabolic abnormalities in individuals with schizophrenia. Many of these abnormalities involve glucose metabolism, which is especially important since it is now known that antipsychotic medication can also disturb glucose metabolism. Dr. Bahn’s group is utilizing their findings to try to develop new medications for treating schizophrenia.