Wednesday, January 26, 2005

Much psych-blogging at Instapundit today....

about homeless mentally ill, and the failure of the "de-institutionalization" movement.

Throughout my training, I heard grim stories about the emptying of psych hospitals in the 1970's. Civil rights activists targeted commitment laws, calling them unconstitutional restrictions of liberty. Thomas Szasz spoke for many activists when he said, "...psychiatric diagnoses are stigmatizing labels phrased to resemble medical diagnoses and applied to persons whose behavior offends or annoys others." There was a movement to limit the power of psychiatrists, to close the dehumanizing wards, and to provide outpatient care (which was never adequately funded).

State legislatures re-wrote statutes. Psychiatrists protested and were overruled.
A hodge-podge of commitment laws evolved, with a maze of legal petitions, hearings, rulings, and appeals. Criteria for "dangerousness" were vague and hard to apply. Soaring costs and declining tax revenues further reduced our treatment options. Here's Dr. E. Fuller Torrey, MD, and attorney Mary Zdanowicz:
At the same time as civil liberties lawyers have been making it virtually impossible to treat severely mentally ill individuals involuntarily until they commit some horrific act, state mental health officials have been increasingly abdicating their responsibility for these individuals." More than 90% of state psychiatric hospital beds that existed in 1960 have been eliminated. Many states have turned over the responsibility for treating severely mentally ill individuals to health-maintenance organizations. Some of them, mostly nonprofits, are doing a creditable job. But for-profit HMOs, with few exceptions, have been disastrous for the severely mentally ill, who are expensive to treat. The newest antipsychotic medications, which are essential for some mentally ill patients, can cost $400 a month.

If we hope to stem this tide of unnecessary violence and preventable tragedies, we will have to address squarely the issue of involuntary treatment. Outpatient commitments, conservatorships, and conditional hospital releases should be used much more widely to ensure that discharged patients comply with the requirement that they take their medication. Since most severely mentally ill individuals also receive federal subsidies such as Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or Veterans' Administration benefits, such subsidies could be linked to treatment compliance...

We prevent individuals with Alzheimer's disease from living on the streets, because we understand that they have a brain disorder. We mandate involuntary treatment for some tuberculosis sufferers who refuse to take medication, because we understand that they are potentially dangerous to other people. We should do the same for individuals with schizophrenia and manic-depressive illness.

Here in Oregon, at commitment hearings, the judge asks, "Is this person imminently dangerous to himself or others, by reason of a mental illness? " I ask, "What do you mean by imminent?" He hands me a copy of the statute, and says, "Gravely dangerous to self or others within the next two weeks." Apparently, two weeks is considered "imminent" in Oregon (who knows why?).

We can't even predict what will happen this afternoon. I try to bring the court's attention back to the severity of the illness, and any history of violent behavior. But if I can't convince the judge that the next two weeks are critical, the patient goes free.

Is "Cuckoo's Nest" to blame for our current predicament, as Jeff Jarvis says? Ken Kesey is a hero in Eugene. (He lived not far from here.) The movie did generate support for the activists. But they had plenty of ammunition, well before the movie (and book, and play). Some hospitals had become terrible places.

I saw the movie when it first came out, and it had a huge effect on me. I was horrified. Were they doing that to people? How could they do that to people? I couldn't sleep for several days. In med school, I discovered that it wasn't really like that (at least, not where I trained). Now I'm a psychiatrist...and I live about one hour south of Oregon State Hospital, where it was filmed. Those initial impressions have stayed with me. I think I try very hard to not be like the doctors and nurses in Cuckoo's Nest...

It should not be an easy thing, to take away people's freedom and coerce them to take medication. Imagine being given a psychiatric diagnosis you don't agree with. Imagine being told by the state that you must not leave the hospital, and that you must accept treatment. Our patients tell us the horror and pain of that experience, every day. Is there a just way to protect society from potentially dangerous, mentally ill people, and to provide basic care to those who need it, even when they refuse? Your comments are welcome here. (My e-mail is shrinkette01 followed by
Click for Eugene, Oregon Forecast