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.

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?”