Freezing with his rights on

As reported by WLBZ of Bangor, Reid Emery, a 61 year old man, was released from the Down East Community Hospital in Machias Maine last Tuesday night. The following morning, he was found dead in a snowdrift just a few hundred feet from the hospital’s entrance.

When Mr. Emery walked out of the hospital, he was reportedly delusional. He was wearing a light jacket and slippers. He left against the advice of doctors. And he walked out into the height of a brutal January snowstorm. Weather records for East Machias show that the low temperature that night dropped to four degrees.

Nevertheless, a hospital administrator, Ann Marie Knowles, explained that there was nothing that could be done to stop Mr. Emery. “Patients have the right to leave against medical advice.”

In Maine, a person may be admitted on an emergency basis for the treatment of mental illness upon a showing that this person suffers from a mental illness and poses a likelihood of serious harm to himself or others.

We know no details about Mr. Emery’s history of mental illness. We also do not know why hospital personnel deemed themselves unable to intervene on Mr. Emery’ behalf. What we do know is that hospital personnel did nothing to stop an elderly, delusional, and under clothed man from stepping out into subfreezing temperatures and a raging snowstorm.

Any caring and reasonable person should have been motivated under these circumstances to take some action to intervene on behalf of Mr. Emery. Instead, we find a hospital trying to justify the practices and procedures that resulted in this tragic and unnecessary death. What is wrong with this picture?

At least those who champion the civil liberties of the mentally ill can take some comfort in knowing that Reid Emery froze to death with his rights on.

Homeless shelters are the new mental health facilities

Roughly 150,000 to 200,000 individuals with schizophrenia or bipolar disorder are homeless. In the absence of psychiatric hospitals, homeless shelters are yet another example - along with jails and prisons- of today’s “mental hospitals”.

Out on the streets, people with mental illness and addiction problems are guaranteed neither a home, food, health nor safety.

As [Dennis] Marble [executive director of the Bangor Area Homeless Shelter] and many others see it, the morphing of the homeless shelter into what Marble calls an "underfunded mental health facility" is one of the unintended consequences of the "downsizing" of the state’s mental health institutions, including Bangor Mental Health Institute, now known as the Dorothea Dix Psychiatric Center.

A major complaint of the critics of deinstitutionalization was that adequate community resources were not put into place to support patients after their release. As a result, many did and still do wind up in homeless shelters or jails, which are increasingly hard-pressed to house them adequately.

"I look at some of the folks who come here and it’s pure and simple — they can’t [fend for themselves]," Marble said. "And for me to say the right thing for them is to live their lives in this shelter and that’s their choice? That ends up ringing hollow really fast."

Turned Away

It is often debatable which is more likely lead to irrational situations – the untreated symptoms of severe mental illnesses or the laws governing their treatment.

Of those turning to Riverview Psychiatric Center and sick enough to meet the criteria for admission, 85 percent were turned away due to lack of capacity in a five-month period.

Those patients did not have the mental capability necessary to volunteer for treatment under Maine law but were not, at the same time, dangerous enough to meet the state’s restrictive criteria for commitment.

Almost six out of seven of those turning to this state hospital for care were left instead, by law, in a psychotic limbo.

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.

Too Sick To Treat, Per Regulation

A surprising, if unintentional, admission that some patients incapable of helping themselves are consciously abandoned to the symptoms of serve psychiatric disorders comes from the regulations governing the care of patients in outpatient care set out by the Maine Office of Adult Mental Health.

These regulations require that treatment must be predicated on informed consent, which is when “the recipient or his or her guardian possesses capacity to make a reasoned decision regarding the treatment and/or services and the recipient or his or her guardian is provided with adequate information concerning the treatment and/or services.”

“Capacity” is defined as “sufficient understanding to comprehend the information [provided on the proposed treatment] and to make a responsible decision concerning a particular treatment and/or service.”

A large portion of those with the most acute psychiatric conditions are affected by anosognosia, a physiological symptom that can render them incapable of comprehending that they are sick. Virtually de facto, such a person would no have capacity and be incapable of informed consent absent a guardian.

The regulations require the initial determination of incapacity be by a qualified mental health professional and confirmed by a physician or clinical psychologist. Once the incapability of informed consent is established, notice must be sent to the rights protection and advocacy agency of the Maine mental health system, the head of the mental health facility and, if the patient does not object, the recipient's next of kin.

At that point the mental health professional recommending the treatment and a representative of the treatment team must meet with the recipient to essentially solicit reconsideration and explore alternatives.

And should that prove unsuccessful, the concluding line of the pertinent section of regulations is explicit: “The head of the program may conclude that the recipient's termination from services is the only available option.” No other alternatives are delineated.

Once carefully determining and documenting that the person is so sick as to be incapable of making treatment decisions, the state encourages closing off the possibility of care in the future.

SHORT BITS

• One Florida judge gives the state 60 days to figure out how it will move mentally ill inmates out of Orange and Osceola jails and get them the treatment they need, saying “"I wanted to have something done today, but years of neglect of the mental health system is nothing something that's going to be fixed overnight."
• A Maine advocate applauds Robert Bruce’s lawsuit against the state claiming state negligence played a role in his wife's death at the hands of their son. The letter-writer noted “What a shame when the difference between life and death are a few pills a day, and you can't make your loved one take them. His fight isn't just for him, but for all of us who have been there.”
• A Virginia paper comes out in support of Virginia State Supreme Court Chief Justice Leroy Hassell’s Commission on Mental Health Law Reform.
• Kaiser Permanente is charged in skid-row dumping in Los Angeles, California.

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?”

How to get into an inpatient psychiatric facility ...

Is the only way to access inpatient treatment for someone who is extremely ill an act of unfathomable violence?

William Bruce will be moved from prison to a psychiatric facilty at least long enough for evaluation - the local sheriff is relieved, noting the prison isn't a good place for inmates with serious mental health conditions. Bruce killed his mother, his family had been trying desperately to help him.

Too often such horrible events spur a call for punishment instead of compassion. Andrea Yates' fate is being decided in the deaths of her 5 children for a second time, but recall that the first time, she ended up in jail. That is where Brenda Drayton is headed as well - for the next 20-30 years, for killing her daughter.

Most often weak state laws make us wait until a crime is committed to help someone ... and then the focus is on punishment, not treatment. People with severe mental illnesses deserve to get real help from the civil treatment system before situations occur that lead them to be punished by the criminal one.

William Bruce, Andrea Yates, Brenda Drayton - if they could have been on an outpatient commitment order long before they committed murder, they might not have gotten so sick to need a hospital bed ... or land in a jail cell.

Fighting generalizations with science and truth

There is a big difference between someone who has schizophrenia, is in treatment, and is doing well vs. someone like William Bruce.

For too long, it seems the only choice in public discourse about the role of violence in schizophrenia has been to demonize EVERYONE with schizophrenia as being potentially violent, or to preach that NOBODY with schizophrenia has a greater risk of violence than anyone else. Neither is reasonable or logical.

Implying that all people are violent is simply not true and is hurtful to the majority of people with schizophrenia who are taking medication and not violent. Failing to acknowledge that under some circumstances some people with schizophrenia have an increased risk of violence is not only misleading, it can lead to dangerous situations when caregivers, police, or the mentally ill do not recognize the warning signs such as paranoid delusions.

We are grateful that the editors at the Kennebec Journal and Morning Sentinel chose a third option – clarifying who of that larger group really needs humane intervention and helping them. Educating the general public to not paint everyone with either the broad brush of violence or the broad brush of nonviolence is the best way to not only remove stigma from the majority of people with mental illnesses, but also to avert tragedies.

Waiting for danger? Here it is.

“What do we have to wait for? Do we have to wait for him to hurt somebody or
kill somebody before they do something?”

Seems like far too often, the answer is yes.

Wait until he escalates. Until you can prove he is a danger. Until danger is imminent.

The latest result of such twisted and irrational policies is making headlines in Maine this week.

Robert and Amy Bruce spent years trying to help their son deal with his mental illness, even letting him live at home despite their fears. But on Tuesday, the illness won out and authorities say William Bruce, 24, bludgeoned his mother to death. Efforts to help William Bruce through the years were stymied, first by the hope that he would grow out of it and later by confidentiality laws and civil liberties intended to protect his freedom, but at the expense of the treatment he badly needed but refused to accept.

The Bruce family, barred from having a say in many of their son's treatment decisions, were left to either turn their back on him or accommodate his illness and accept the risks.

Bad week all around ...

Law enforcement and people with mental illnesses had a particularly bad week.

• June 3. A man trying to commit suicide in Barrett Township, Pennsylvania, threatened to attack police with a knife during a standoff. His mother said he needs psychiatric help.
• June 5. Jury selection began for a man in Rhode Island accused of killing a police officer. “His family and girlfriend have said he was mentally ill and experiencing hallucinations,” notes the story. “They said they had tried to get him psychiatric help before his arrest.”
• June 6. A man in Seattle, Washington, is shot and killed by police during a routine traffic stop. Diagnosed with schizophrenia and bipolar disorder, he had been committed in the past for threatening to kill his parents.
• June 8. A man in Portland, Maine, is sentenced to 11 years in prison. He attacked two homeless men, knocked out one police officer and choked another officer to the point of unconsciousness. He had four assault convictions since 1996, most occurring in a period when he was hospitalized three times for mental illness.
• June 8. A paranoid and delusional man in West Chester, Pennsylvania is sentenced to 18 to 36 years in prison for attempting to kill two sheriffs.

No Beds? Lots of Problems.

Psychiatric hospital after psychiatric hospital have been closed since the 1960s, in large part because of federal funding policies.

Despite the increasingly critical shortage of inpatient capacity, many mental health administrators continue to push for the elimination of more psych beds.

Take Maine’s experience with its new hospital, which replaced a much larger one that was closed. Insufficient capacity in the new hospital forced administrators to turn away 61% of qualified patients seeking admission to the facility in the first month of operation. That isn't a shortage due to changed circumstance, but rather of short-sightedness.

A lack of inpatient facilities doesn't only result in people with psychiatric illnesses ending up in jail … It can also, like in Texas, keep them there.