Seeking treatment for a loved one in Virginia

The Roanoke Times delves into the horribly difficult process of seeking treatment for a loved one with anosognosia in Virginia. Unfortunately, part of that difficulty can also be attributed to Virginia’s community services boards (CSB’s) – the group tasked to provide community mental health services in Virginia. Despite the fact that outpatient commitment has been on the books for years, it’s clear that they are woefully unaware of their own state’s laws. In fact, the director of one CSB recently admitted, “We’re not clear how it will work… We’re trying to get the process in place.”

In the face of challenges like these, it is vitally important that families have all the information they can before a crisis occurs. More on seeking treatment for a loved one is available here.

Handcuffs & commitment standards

Being committed to a psychiatric facility can rescue a person from the uncontrolled symptoms of a severe mental illness. Involuntary treatment, at the same time, should not be used if voluntary care is a viable alternative. No one wants to unnecessarily invoke a measure that, by its very nature, is laced with restriction.

Yet, the coercive tone of an inpatient commitment can be muted.

For too long, for instance, a trip to a hospital has automatically included a police car and handcuffs for people being committed to treatment. Vermont has ended the mandatory use of restraints in that situation. A recent law in the state requires that mechanical restraints not be used unless circumstances dictate that such methods are necessary. Restraints are still used if required to maintain safety, but the justifications for their use must be documented.

Thus in Vermont, patients can be brought in for psychiatric evaluations by mental health professionals and without handcuffs. To the advocates in many other states, the adoption of a similar policy would be frustratingly fruitless. For Vermont allows individuals to be placed in treatment for reasons other than immediate danger. The state’s commitment standard encompasses those who are “receiving adequate treatment, and who, if such treatment is discontinued” will likely become a danger to themselves or others.

As they do not present a current risk, no handcuffs are required for those patients in Vermont. In those states where actual danger is the sole trigger for commitment, there is and will remain no option but law enforcement officers and restraints.

Anosognosia: An Inconvenient Truth?

Mental health advocates who argue that court-ordered treatment is a violation of civil liberties conveniently disregard some scientific facts: severe mental illnesses are diseases of the brain, the very organ that allows us to reason and deliberate; some people with severe mental illnesses are affected to a degree that they are unable to make reasoned treatment decisions for themselves; anosognosia also occurs in some some individuals with strokes, brain tumors, Alzheimer’s disease, and Huntington’s diseases; that this “lack of insight” is a major cause of refusal to take medication; and, that medication can benefit many patients with schizophrenia and bipolar disorder.

Take the Bazelon Center for example. In their blanket opposition to assisted outpatient treatment, they summarily dismiss the science of anosognosia by referring to it as a, “…supposed "lack of insight" on the part of the individual, which is often no more than disagreement with the treating professional…”

There are now more than 100 studies documenting “lack of insight” in individuals with severe mental illnesses. How much longer will treatment opponents ignore the research and continue to make the same uninformed arguments?

New book: Crazy in America

GUEST BLOG:

Written by Mary Beth Pfeiffer, author of “Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill”.

"Children wait in emergency rooms for psychiatric beds, sometimes for days."
--- June 1, 2007, Hartford Courant editorial.

We all know that America had better than a half-million psychiatric hospital beds 50 years ago, beds that were whittled down in a great, silent wave of untethered humanity called deinstitutionalization. But few realize that deinstitutionalization is continuing, and so is the failure of community care to pick up the slack.

The children referred to in the quotation above, who suffer while waiting for psychiatric beds in Connecticut, are just one group of victims. Add to them the homeless, the incarcerated, the two-thirds of Americans with mental illness who go untreated.

From 1990 to 2000, long after deinstitutionalization was believed over, the nation lost an additional 57,000 psychiatric beds, bringing the total to 86,000. But the bloodletting didn’t stop there: Harrisburg State Hospital closed in Pennsylvania last year and with it 260 beds. In Florida, 36 private psychiatric hospitals have closed in since 1992 – taking 4,400 beds. In Iowa, 600 general-hospital psychiatric beds were shuttered from 1998 to 2002 -- nearly half the state’s total. Connecticut had three sprawling public mental hospitals in the 1950s, serving 9,000; with additional cuts in recent years it is down to about 600.

America’s system of mental health care is broken. Emergency rooms, which saw psychiatric cases rise by 56 percent from 1992 to 2003, take the brunt in this severely strained system. And jails and prisons act as de facto mental institutions where there is always a bed – and where at least 330,000 mentally ill people now reside.

America needs leadership on mental health care. We need leaders who are willing to equate the needs of people with mental illness with those who suffer from cancer and heart disease. We need legislators willing to provide funding for housing, clinics and subsidized insurance. We need a media willing to explore the ills of a forgotten and under-funded system.

This isn’t too much to ask.
---Mary Beth Pfeiffer

***
Visit Mary Beth Pfeiffer’s web site at www.crazyinamerica.com to see photographs of her profile subjects and get other information. To buy the book, go to http://www.amazon.com/Crazy-America-Tragedy-Criminalized-Mentally/dp/0786717459/ref=pd_nr_b_8/103-2156816-0667067?ie=UTF8&s=books.

The opinions expressed by guest bloggers are their own and not necessarily that of the Treatment Advocacy Center.

Want to be a guest blogger? Tell us why at info@treatmentadvocacycenter.org.

No drugs in Cho's system

The anti-psychiatry crowd tried to use the Virginia Tech case to paint the frightening image that psychiatric medications caused Seung-Hui Cho to go on a murderous rampage. In an unsigned letter, one group issued a demand for the toxicology report under the Virginia Freedom of Information Act, threatening legal action.

Last week, the results of toxicology tests were released. But, the fearmongers won’t be pleased. The state medical examiner's office found no trace of prescription drugs or toxic substances in Cho's body.

In this day and age, it is hard to believe that there are still people who deny the existence of severe mental illnesses and point to everything but untreated psychotic symptoms as the cause of harmful behaviors. But, the research shows that schizophrenia and bipolar disorder are diseases of the brain. And as most people suspected, it was Cho’s untreated symptoms that caused so much devastation.

Increasing population; decreasing hospital beds

Peg Falcone, a licensed clinical social worker who works at Southern Illinois Regional Social Services, brings up an excellent point in a recent op-ed – the care in psychiatric hospitals is not what it used to be. It is better.

Improved medications and methodologies of care make the experience of a patient in a modern-day facility far removed from what inspired Ken Kesey to write One Flew Over The Cuckoo's Nest. Indeed, much of the trepidation still invoked by the possibility of psychiatric hospitalization is an echo of conditions in some – but by no means all – facilities from decades past.

It is not only the hospital conditions themselves that have changed; so too have the characteristics of the patients and the purpose of their stay.

In 1955, there were 560,000 patients in state psychiatric hospital. In 2000, there were about 56,000. Even those startlingly disparate figures do not fully reflect the fading role of inpatient facilities. During that same period, the population of the United States increased from 193 million to over 280 million. Adjusted for population, fourteen out of fifteen people who would have been in a psychiatric hospital in 1955 were living in the community by the millennium – over three-quarters of a million people.

The chief role of facilities is no longer as long-term residences for and – as was necessary for some before the advent of effective medications – containment of those with severe mental illness. The main function of a modern psych hospital is stabilization and the facilitation of reentry into the community. Stays are no longer counted in months and years but in months, weeks and even days. That evolution continues. Stays in private psychiatric hospitals averaged 21 days in 1980; that had shrunk to 5-6 days by 2004.

This radically altered role for inpatient psychiatric hospitals also impacts on judicial determinations to place people in such facilities. The better the hospitals are and the shorter the anticipated stay is, the less the burden placed on someone being placed in one by a court. And the less that burden, the greater is the relative value of the treatment.

Violence, mental illness and stigma: A misleading combination

A recent letter to the editor in the Frederick Free Lance-Star takes the politically correct stance that people with mental illnesses are no more violent than the general public. This myth is further asserted by claims that recognizing and trying to address the correlation between violence and untreated mental illness creates stigma which in turn is the greatest barrier to treatment. This is mental health sophistry.

Certainly, when people with a severe mental illness are receiving appropriate treatment, they are no more violent than the general population; however, a number of studies show that a portion of people with mental illnesses ARE more dangerous when not receiving treatment.

As TAC president, Dr. E. Fuller noted in his recent op-ed in the Wall Street Journal:

Since 1994, nine U.S. studies have illustrated this [link to violence and untreated mental illness]. The best known, the Violence Risk Assessment Study, funded by the MacArthur Foundation, followed 961 seriously mentally ill individuals for one year after hospital discharge. During that time, these individuals committed 608 acts of serious violence (physical injury, threat of or actual assault with a weapon, or sexual assault), including six homicides. The most important finding: Those who regularly attended treatment sessions had less than one-quarter the rate of violence compared to those who did not.

As for stigma as the greatest barrier to treatment? Hardly. Surely stigma exists and keeps some people from seeking treatment, but as we’ve witnessed with the recent Virginia Tech shootings, the greatest barriers to treatment are misinformation, lack of education amongst mental health professionals, and poor treatment laws.

Are you going to the 2007 NAMI convention?

Visit the Treatment Advocacy Center at the 2007 NAMI Convention in San Diego, June 20-24. On Friday, TAC will be hosting a workshop: "Family advocacy, family rights: Overcoming legal and political obstacles to getting care for a loved one who lacks insight" from 2:30 - 3:30 p.m., and on Saturday, Dr. Torrey will be presenting "Causes and consequences of our failure to treat individuals with severe psychotic disorders" from 12:45 - 1:45 p.m.

Make sure to stop by our booth – #209 at the convention. See you there!

A common sense mental health system? We can only hope.

In his Sunday column in the Washington Post, Marc Fisher makes the following observation about the arcane application of confidentiality in mental health:

“But any system that lets rigid laws take precedence over common sense, human caring and the free flow of information is destined to fail.”

He quotes Marcus Martin, an emergency room physician who is on Virginia Governor Kaine's commission investigating the Virginia tech shooting whose common sense view leads him to observe:

"We keep head-injured patients, trauma patients, involuntarily all the time," said. "We don't rely on the legal system. It should be the same for mental health."

But, it’s not just in Virginia that questions about the mental health system’s hyper-vigilance about confidentiality have arisen. Maine Senator Peter Mills (R-Somerset) introduced a bill this session that is intended to clarify confidentiality provisions so that mental health professionals can disclose information to families and caregivers who may be at risk of harm from a psychiatric patient.

Hopefully, this is all part of a trend to bring common sense in the application of confidentiality in mental health cases.

His medication is free, if only he were willing to take it

How many times will we have to read the same terrible story? How many more lives and families will be destroyed, simply because a state fails to employ its laws correctly?

Today’s Fort Worth Star Telegram details the Matthews family’s long struggle to get care for their brother, a veteran of the United State Navy. Their story echoes ones we hear from families everyday – when their brother receives a daily regimen of medication and counseling, he becomes more lucid. But when he is discharged, he doesn't take his medication and invariably relapses. Usually, he ends up living on the streets.

Texas law allows for much more than what is currently being done. Texas has an effective AOT law, one that allows a judge to order treatment in the community and looks to the person’s history of care and ability to participate voluntarily in treatment. In far too many parts of the state, it isn’t being used. And so consumers, and their families, will continue to needlessly suffer.

Report to the President- Commitment laws & practices

After the tragedies at Virginia Tech, President Bush sent three of his most important advisors in search of ways to help prevent such horrific events in the future. Health Secretary Michael Leavitt, Education Secretary Margaret Spellings and Attorney General Alberto Gonzales met with educators, mental health experts, and law enforcement leaders in a dozen states. Yesterday they issued their report to the President.

One of the key findings: “It is critical to get people with mental illness the services they need.” That goal is obvious to set and easy to state but momentously difficult to achieve, which the report’s authors – to their credit – recognize. They advise states to:

“Review emergency services and commitment laws to ensure the standards are clear, appropriate, and strike the proper balance among liberty, safety for the individual and the community, and appropriate treatment.”

As the standard for intervention in Virginia is “imminent danger” and the focus of the report is prevention of violent incidents, the target of this instruction is clear – the adoption of reformed treatment laws.

Additionally, the Department Secretaries and Attorney General warn that interventions must not only be made more available, but also followed through on. They recommend to the states that “Where a legal ruling mandates a course of treatment, make sure that systems are in place to ensure thorough follow-up.”

Does HIPAA help or hurt patients?

The HIPAA law is long and complicated and most people, including many mental health professionals, do not understand the law’s provisions. Our office routinely receives phone calls from patients and family members alike that are frustrated by the privacy laws concerning patient medical records.

While it makes sense for patient medical records to be protected, there are situations that call into question whether absolute confidentiality is the best option for patients and the public. This is a question facing the Governor-appointed panel investigating the senseless deaths of 32 students at Virginia Tech. In an effort to understand what caused that tragedy and to prevent another one like it, should the panel be able to review the medical records of the deceased gunman?

Missing mentally ill

These stories rarely make national headlines. But, for the family of an adult with a severe mental illness who has gone missing, it’s nerve-racking and devastating. The families know the danger their loved one is facing.

For a person experiencing delusions as the result of untreated severe mental illness such as schizophrenia or bipolar disorder, following their delusions may seem logical. Meanwhile, families are left to wait, wonder and worry about their loved-one who is unable to care for themselves without appropriate medication.

In California, Donald Wayne Tomason’s father is still clinging to hope that his 33 year-old son with bipolar disorder who has been missing since February, will return.

According to news stories, there has been “no sign of the 33-year-old, who has delusions of being chased when not on medication to treat bipolar disorder”

Tomason’s father says he has “catastrophic fantasies” about what has happened to his son.

Unfortunately these stories are not uncommon. Last week in Missouri, a 67 year-old who suffers from schizophrenia was reported to be missing for more than a month, and in Texas a 47- year-old man with a mental illness has been reported missing for at least a week. The families of both of these men are deeply concerned about their safety.

A missing adult might not make national headlines, but when that person has a severe, untreated mental illness, it certainly deserves our attention.

The price of free will

Dr. Partovi found herself helpless trying to care for a dementia patient whose “heart failure was very treatable, but only if he would take his medications appropriately.”

[T]he hospital psychiatrist claimed that William knew his name and where he lived — and that he was very insistent on not being placed.

"But he can't take care of himself, he doesn't have food, he can't pay his bills, he won't take his medications," I replied. "It's his free will to not take his medications." Thus, he was deemed "fully competent."

Dr. Partovi tells the sad story of her patient William who eventually could barely breathe and still refused to go to the hospital. By the time he was taken to the emergency room, it was too late – he died that night.

In California it seems that people with dementia face the same standards for treatment intervention as do people with mental illnesses. William’s story may be a wake-up call for the millions of baby boomers who face the prospect that they or a loved one might become incapacitated by Alzheimer’s or dementia. Are we as a society finally going to care for all people who lack capacity to make medical treatment decisions? Or do we accept "free will" as the propaganda that allows us as taxpayers to avoid paying for proper treatment for these individuals?

New study on the role of insight in violence & criminalization

An upcoming study of factors contributing to violence and criminality of patients with schizophrenia illustrates the importance of addressing lack of insight and treatment nonadherence.

Researchers reviewed German crime registries for records of criminal offences committed by 1662 patients with schizophrenia treated between 1990 and 1995 at the Psychiatric Hospital of the University of Munich. Of the 1662 individuals, one hundred and sixty nine (10.2%) had been convicted in the 7–12 years after discharge. The rate of violent crimes was especially high: 62 (3.7%) patients were convicted for physical injury offences. Significantly higher rates of criminal conviction and recidivism were found for patients with lack of insight at discharge.

A Blessed Papal Encounter

Americans awoke yesterday to news of an apparent attempted attack on Pope Benedict XVI. Footage from St. Peter's Square showed a man in a pink t-shirt, shorts, hat and sunglasses leap from a barricade in a frenzied effort to reach the pontiff’s uncovered vehicle. The rushing man made it to the back of and even touched the slow-moving Popemobile before being swarmed by Vatican security personnel.

Preliminary reports were that the apparent assailant was unarmed; he had no intention of harming the Pontiff but was merely seeking attention. Vatican spokesman Rev. Federico Lombardi added that the man "looked a little crazy."

The person who so fervently strove to reach the Pontiff is Roberto Sperling, a 27-year-old from Karlsruhe, Germany. German newspapers reported that he chained himself to a church gate in his home town several weeks earlier, insisting Mary had given him a message for the Pope. That had seemingly not been enough to get him treatment for his mental illness.

Father Lombardi reported that the Vatican is not interested in criminal charges. Instead, “psychiatrists of the Vatican Hospital intervened and decided that the young man should be hospitalized and undergo mandatory treatment in a specialized and protected center.”

Although perhaps not in the way he expected, Roberto Sperling’s encounter with the Pope may have resulted in a minor miracle after all.

Is the law really dangerous?

Mental health professionals and others frequently say that, “by law, you have to be a danger to self or others” in order to get court-ordered treatment for severe mental illness. But, is that actually TRUE?

No. In most states, an individual with severe mental illness may qualify for court-ordered inpatient or outpatient treatment before deteriorating to a point of “dangerousness.” Many states have provisions for treating who are “gravely disabled” and some permit treating people based on their “need for treatment.”

Don’t just accept the word of your local officials – read the law for yourself and be accurately informed! TAC has online resources to help: a compilation of TEXT excerpts from the actual state commitment codes and a CHART summarizing the required criteria for treatment in each state.

An overloaded criminal justice system

A news article in the Eagle Tribune in Massachusetts describes the current situation in the Rockingham County Jail in which an estimated 15 percent of the jail population has a severe mental illness. Jail superintendent Al Wright says it feels like he’s running a psychiatric ward rather than a forensic facility. “I tell people I’m the superintendent of Rockingham County jail, the biggest provider of services for the mentally ill in the county.”

The article continues:

Also, there is a shortage of psychiatric beds at the state hospital — down from 3,000 beds in the 1960s to 300 today. This leaves police little choice but to transport mentally ill suspects to jail.

There is no doubt the criminal justice system is overloaded with patients who should have received psychiatric treatment long before they landed in jail.

Ken Braiterman, coordinator with the National Alliance for Mental Illness in New Hampshire, hit the nail on the head when he said:

Treatment has never been better for mental illness, but it has never been harder or those in need to get it.

When the brain fools itself

The Treatment Advocacy Center’s advocacy is based in large part on the increasing evidence of the role that anosognosia, or lack of insight, plays in causing patients with schizophrenia and bipolar disorder to believe they are not ill and therefore refuse needed treatment.

It is sometimes easier to conceptualize the impact of the neurological deficit, anosognosia, as it occurs in other brain disorders. In a fascinating article about the brain, Shelby Martin describes a famous case of anosognosia:

In his book “Descartes’ Error,” neurologist Antonio Damasio describes the 1975 case of Supreme Court Justice William Douglas. A debilitating stroke left him confined to a wheelchair, paralyzed on his left side. Against medical advice, Justice Douglas checked himself out of the hospital, dismissing reports of his paralysis as “a myth,” and publicly invited reporters to go hiking with him.

Douglas, like other patients with anosognosia, was completely unaware of his injury. He went so far as to claim he was kicking 40-yard field goals with his paralyzed leg. Clearly delusional, Douglas was forced to retire from the Supreme Court.

Upcoming opportunities for Virginia advocates

Following the tragedy in Blacksburg, Virginia has taken a hard look at its mental health system. The process continues with a series of upcoming hearings and meetings throughout the Commonwealth. On June 5, the Richmond Times-Dispatch is hosting a public square discussion on mental health; on June 11, the Virginia Tech Review panel will hold a public meeting at George Mason University in Fairfax; and on June 20, the Virginia House Health, Welfare and Institutions Committee will hold the first of a series of public hearings to get a better grasp of the shortcomings in Virginia's mental health system.