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Involuntary Treatment – Civil Rights or Civil Wrongs?

In the 1950s, 558,000 people were in mental institutions in the U.S. Many were there against their will and were being warehoused or treated badly. Deinstitutionalization was intended to restore their civil rights and improve their lot. Did it? By 2006, there were only 40,000 people in institutions. What happened to the other 518,000?

Some of them are living in the community with supportive family members, taking their medications, and contributing to society. Some of them have been ghettoized in halfway houses or group homes in crime-ridden and run-down neighborhoods. Some of them are homeless, living on the streets and eating out of garbage cans. Some of them are in jail. Some of them have killed family members or have killed multiple people in “rampage” murders provoked by their psychotic delusions.

Accurate numbers are difficult to obtain. By some estimates, as many as 30-50% of the homeless (and even more of the hard-core homeless) and as many as 40-50% of the jail population are mentally ill. There are more mentally ill people in jails than in hospitals. The mentally ill are more likely to be victims of violence and rape and are more likely to be shot by the police in “justifiable homicide” incidents.

Mentally ill people who are adequately treated are no more violent than the non-mentally ill, but a disproportionate number of murders are committed by the mentally ill. The risk of violence increases with past history of violence, substance abuse, anosognosia with medication noncompliance, antisocial personality disorder, paranoid symptoms, and male sex.

Civil rights advocates argue that patients with other illnesses like heart disease or cancer have the right to refuse treatment – but those patients presumably are capable of understanding that they are ill. About half of psychotic patients are incapable of understanding that they are ill – the lack of insight or anosognosia is part of their disease, similar to the anosognosia of a stroke patient whose brain damage makes him unable to recognize that he is paralyzed on one side. If you truly believe you are God, you’re not about to let anyone give you pills intended to make you think otherwise. If you can’t recognize that you are ill, why would you accept treatment for a condition you firmly believe you do not have? Are we really giving these patients their civil rights, or are we denying them their right to be treated?

There is precedent for involuntary treatment – TB patients are a prime example. If they refuse medication or take it inconsistently they are putting their communities at risk, so the courts allow compulsory treatment under direct supervision. The Virginia Tech shooter had been hospitalized after harassing two female students and was under court order to get outpatient treatment; the University knew about the court order but did not enforce it. We can never know for sure, but there is a good chance that if he had been forced to take antipsychotic medication his 32 victims would still be alive.

It has become next to impossible to get a patient involuntarily committed. You have to show that they are an immediate danger to themselves or others. When they are committed, the typical course is that they are given medication, their symptoms subside, they are discharged, they go off their meds, and the symptoms recur. One police officer described picking up the same woman and taking her to the hospital 16 times for lying down in the street.

To put a human face on the dilemma, imagine you are the parent of a paranoid schizophrenic who has been repeatedly hospitalized and jailed, whose psychotic symptoms disappear when he takes his meds but who refuses to take them. He has repeatedly threatened to kill you and other family members, saying God wants him to root out the evil. You awaken in the middle of the night to find him hovering menacingly over your bed. He sleeps with an ax. He regularly gets drunk and disorderly. He has battered down the door of your apartment in the middle of the night, causing your landlord to evict you. You are desperately afraid for your life and for the lives of your family members. You have repeatedly pleaded with police and mental health authorities for help, and all they do is tell you to make him take his meds – which you can’t do. Society will do nothing to help you until he actually hurts someone. Families have even moved out and left the house to the mentally ill person, but it did no good – he followed them. One woman had a psychotic brother who had repeatedly threatened to kill her only daughter; she believed the threats and was desperate to save her daughter’s life. After years of fruitlessly begging for help from every available resource, she ran out of options, killed her brother and went to jail for murder. Imagine pleading repeatedly and unsuccessfully with the authorities to get treatment for your wife and coming home to find she has killed all your children because Satan told her to. Imagine begging authorities for help because your son has threatened his mother, being told he does not meet the criteria for involuntary commitment, and then coming home to find he has beaten his mother to death.

Yes, mentally ill people have civil rights, but so do their families and other victims. There are effective, humane programs for outpatient treatment of the mentally ill, and some have ingenious incentive programs to increase medication compliance. Unfortunately, these programs only reach a tiny fraction of the patients at risk. And unfortunately, it is the most dangerous patients who are the least likely to recognize that they are ill and the most likely to refuse treatment. Surely as a society we can do more to help these unfortunate patients and their just-as-unfortunate families and victims.

Perhaps it is wrong to confine patients against their will. But, as Supreme Court Justice Anthony Kennedy said,

It must be remembered that for the person with severe mental illness who has no treatment, the most dreaded of confinements can be the imprisonment inflicted by his own mind, which shuts reality out and subjects him to the torment of voices and images beyond our powers to describe

One of the creators of a strict state statute later said,

I wanted the LPS act to help the mentally ill. I never meant for it to prevent those who need care from receiving it. The law has to be changed.

To quote Stephen Rachlin,

The paramount civil right of the patient should be that of adequate treatment.

We are abandoning sick patients to live on the streets, forage from garbage cans, and bounce in and out of jail, and we are exposing our society to unnecessary violence. Surely we can do better.

For further reading:
The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers its Citizens, by E. Fuller Torrey.
There is a well-balanced editorial in the New England Journal of Medicine A recent review of violence and mental illness
An article on poor insight in schizophrenia and its effect on compliance.

Posted in: Neuroscience/Mental Health, Politics and Regulation

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37 thoughts on “Involuntary Treatment – Civil Rights or Civil Wrongs?

  1. DLC says:

    I’ve seen this before. “you can’t make me be well! ” cries the psychotic. And if he cracks and kills someone, we stick him in a prison where he’ll be mistreated and assaulted. It says bad things about how we imprison people as well as about how we deal with the mentally ill. no one should be assaulted while in prison.

  2. spalfram says:

    The same issue exists in Canada, although it’s easier to get someone involuntarily committed and harder, once they are committed, to get them medicated. My spouse spent 3 weeks at a secure psych ward, and refused medication the entire time.

    I agree 100% that the right to refuse treatment for those with anosognosia is bizarre and cruel. It protects the ill from doctors – and that’s terrible. The Canadian Mental Health Association tracked the decline in institutional populations with the increase in prison populations, and estimated the majority of mentally ill patients ended up in prison. Imperfect, yes, but of concern.

    There is nothing I can do to help my husband when he’s ill, I need to focus on his very long intervals between psychoses to encourage him to accept treatment. Mostly that consists of limiting alcohol intake, avoiding marijuana and exercising.

    This is a terrible problem for the sick individuals and their families. I’d hate to be the victim of a murder suicide, and know it’s a very real possibility – as do the police, but they are as frustrated as the families as their hands are tied too!

    I’m lobbying as best I can for changes to the legislation. Unfortunately it frequently takes a high profile murder – like the individual who beheaded a passenger on a bus – to get the impetus for change.

  3. hatch_xanadu says:

    “Mentally ill people who are adequately treated are no more violent than the non-mentally ill, but a disproportionate number of murders are committed by the mentally ill.”

    Do you think, perhaps, that’s because in many cases the natural conclusion is that someone who murders is by definition mentally ill?

    That’s a very compelling scenario you paint there with the ax cuddler, Harriet, but do you think it accurately represents even a tiny portion of people with mental illness? A better focus might be on what I suspect is the overwhelming majority — folks who need help with daily tasks, things like keeping a job, maintaining personal hygiene, remembering to feed themselves. To those who see these folks as a “burden” on society, the answer may be quite clear — we need only suggest that they could turn into rampaging ax murderers and forced treatment is easily justified. Perhaps exploring the ethics of treating the gray-area cases would be more productive. And we should keep in mind that confinement and force is not the only way to persuade people to take their medication.

  4. Danio says:

    @hatch_xanadu:

    That’s a very compelling scenario you paint there with the ax cuddler, Harriet, but do you think it accurately represents even a tiny portion of people with mental illness?

    I think Harriet makes it pretty clear that she is specifically discussing cases of psychosis and schizophrenia.

    To those who see these folks as a “burden” on society, the answer may be quite clear — we need only suggest that they could turn into rampaging ax murderers and forced treatment is easily justified.

    No, the point is that even the folks who are already strongly disposed to becoming rampaging ax murderers are beyond ‘forced treatment’ under the current system. If even these folks with demonstrably threatening behavior can’t be involuntarily committed, what hope is there for the ‘overwhelming majority’ you describe?

    And we should keep in mind that confinement and force is not the only way to persuade people to take their medication.

    And yet the examples in Harriet’s piece make it extremely clear that whatever those other ways of persuasion might be, the family caregivers are uninformed of them or unable to effectively avail themselves of them.

  5. Kimbo Jones says:

    The treatment of mentally ill people is a huge problem where I am (Eastern Canada). If the severely anosognosic mentally ill aren’t institutionalized, they typically end up criminalized. Unfortunately, the criminal justice system is as unequipped to deal with the mentally ill as the community in which they failed to thrive. It was a noble pursuit to decrease institutionalization and mistreatment of the mentally ill, but it was foolish to do so without adequate social and community support.

    The examples of violence that Dr. Hall provides are extreme, to be sure, but not outside the realm of reality. Having worked at a mental health institution in the past, I can anecdotally confirm that families, patients, and communities have these fears and they are not always unjustified.

    Patients who are chronically ill and can’t manage in the community have to stay in the hospital with acutely ill patients who agitate them. Patients who are not violently ill (for example, anxiety and depression) are on the same floor as violent psychotic patients, which contributes to their symptoms. Patients in general get fewer visitors than on medical floors because people are afraid to visit an acute mental health facility. Communities don’t want “those people” living in special care homes in their neighbourhoods because of the false assumption that all people with psychosis are dangerous. Dangerous mentally ill people end up in prisons because of a lack of available beds in forensic institutions.

    The system for the mentally ill is broken. Low budgets, lack of community support, and social stigma contribute to criminalizing and isolating mentally ill people. People have plenty of patience for the fatigue someone with mono, for example, but when someone has depression they can be seen as “lazy” or “weak”. An infection we understand, a personality trait we have trouble with because “why can’t they just cheer up?”

    I agree with Dr. Hall. We can definitely do better, but we have to get off our butts and write our local government. Make noise. It’s the only way this will change.

  6. wertys says:

    The situation in Australia is one of critically understaffed public and private mental health systems where getting appropriate care is difficult even for those who are keen to accept it. The case of a mentally ill woman who was kept in immigration detention involuntarily for 2 years because she refused to identify herself and was not properly treated for her mental illness has polarized lay opinion even more, and made psychiatrists and public organizations such as the Mental Health Review Board which rules on cases of involuntary confinement very wary of using powers under the relevant state legislation.

    To the credit of the system, it is at least recognized formally the size and complexity of what the solutions may encompass, and scarce resources are being directed into early-psychosis intervention programs and relapse prevention strategies. The appropriate management of insightless psychiatric patients is one of the most complex and challenging problems facing democratic societies. The pendulum has swung alternately from paternalism to libertarianism and back again, and each time some lessons have been learned. Unfortunately while the skills and knowledge gained by clinicians may improve, the access to services and to the people with these skills is scarce.

    Personally I can’t see how it benefits agitated patients to be treated forcefully if there is any other option. Having said that, experienced psychiatric clinicians can also discern when the time for persuasion has ended and compulsion is required. It can be humanely done if enough resources are applied, including training of police, emergency services personnel and relatives of sufferers. Mental illness continues to be one of the major sources of long-term disability in younger people and the complexity of the issues involved is one reason why not so much progress has been made over the years…

  7. hatch_xanadu says:

    Danio: Actually, the “examples” in Harriet’s piece are a conglomerate of anecdotes — some fragmented, some embellished, some just plain invented. In the only case in which she describes an actual murder, the murderer is in fact not a mentally ill person at all, but his sister who “ran out of options”. This is incredibly biased and incredibly disjointed, based wholly on emotional appeal. It doesn’t belong on SBM. There in fact isn’t a shred of science here.

  8. daedalus2u says:

    What about the Virginia Tech shooter? Or are you considering those 32 deaths to not be “murder” because the shooter likely was not “sane” in a legal sense and so was incapable of “murder”?

  9. hatch_xanadu says:

    I was referring to the “imagine” paragraph re: ax cuddler.

    The Virginia Tech shooter, I do readily concede, was a murderer. And that court order should certainly have been enforced.

    But this is what frightens me:

    “If even these folks with demonstrably threatening behavior can’t be involuntarily committed, what hope is there for the ‘overwhelming majority’ you describe?”

    “hope” meaning what? Meaning, if they won’t even let us lock up the dangerous crazies, then how can we ever hope to succeed in locking up the non-dangerous crazies?

  10. Peter Lipson says:

    I may be being a bit dense, hatch, but i’m not sure what your point is. HH wrote a compelling piece about a real problem, supporting herself with statistics, and illustrating her point with “thought problems”.

    There is a horrible gap in our health care system—we ignore mental illness, we don’t fund its treatment, and people are suffering—some remain functional and are doctors and machinists, etc, and some do not and end up living on the streets.

    Since Kennedy’s de-institutionalization, we went from locking up the severely mentally ill to negleting them. The topic is relevant.

  11. daedalus2u says:

    As I read HH’s article, she was not calling for locking everyone up. She was calling for a more rational and evidence based approach to mental health treatment. If people got appropriate treatment, they wouldn’t need to be locked up. In some cases locking people up is (part of) the appropriate treatment.

    A big barrier to treatment is cost. Who pays a few dollars a day for the meds that may keep someone safe and out on the street? No one, so it doesn’t happen.

    Who pays to lock that person up for life after they have committed a serious crime? Prison costs come out of a different budget than does health care, and there is no limit to people’s willingness to spend on prisons.

    Prisoners are the one group in the US that is mandated to have appropriate medical care. Why prisoners who have committed a crime, been convicted and have been incarcerated for it have a right to health care but honest citizens don’t is not something that I understand.

  12. Danio says:

    Actually, the “examples” in Harriet’s piece are a conglomerate of anecdotes — some fragmented, some embellished, some just plain invented.

    In which she specifically refers to conditions of psychosis and/or schizophrenia, counter to your original objection that she was generalizing about the mentally ill as a more broadly defined group.

    “hope” meaning what? Meaning, if they won’t even let us lock up the dangerous crazies, then how can we ever hope to succeed in locking up the non-dangerous crazies?

    I apologize if this wasn’t clear. The point I’m trying to make is that if the current system will not oversee the treatment of those patients who can and do commit violent acts toward themselves and others, there is little hope that this same system would be at all effective in helping the non-violent majority group you seem to be championing. I’m categorizing involuntary committal as ‘help’, as it facilitates treatment of a mental condition which, if untreated, could pose a danger to the patient or to others. Obviously, such a move would not be necessary if the patient were compliant in taking his or her meds, but the very nature of the conditions for which these people are being treated often leads to non-compliance.

    I’m certainly not advocating wholesale incarceration of any and all mentally ill people who might cause Jane Q. Public to clutch her pearls in discomfiture, and I can’t find a word in Harriet’s original post to suggest that she is, either. The slippery slope you seem to be proposing is a Straw Man.

  13. hatch_xanadu says:

    My apologies as well — I should have been more clear in that my “issue” was with that long paragraph beginning “To put a human face on the dilemma”. That hodgepodge of emotional appeals paints a face that isn’t human at all. It feeds off stigma that is already plenty rampant and doesn’t need any encouragement.

    Making an extreme example out of a pieced-together Satan-worshipping child-stalking ax murderer character is not the way to begin a rational discussion or bring about a real solution to all the deficits in the mental health/legal systems. Perhaps none of us has a clear solution right now — I admit I certainly don’t — but more facts and less fearmongering might help to begin the process.

  14. @HX:

    There is a legitimate argument to be made against forced hospitalizations, which can be used recklessly or perniciously. It appears that you are hinting at that argument. I agree with Danio, Peter Lipson, and d2u, however, that Dr. Hall was not advocating such use of forced hospitalizations. Rather, she was explaining how the de-institutionalization movement of the past few decades has left many people even worse-off than they were under the old system. I don’t think she’d argue that we forcibly re-institutionalize every person who might formerly have been so, but merely that we use this unfortunate history to recognize the need to improve the entire situation. Some do need occasional hospitalizations, some don’t, but in both cases many are falling through the cracks.

    Not easy to fix, of course, but one of the biggest barriers is that the issue is not on the front burner of most health policy stoves and is easy to ignore. Harriet’s essay is a reminder, and as such is absolutely appropriate for this blog, even if science has only a limited role in the matter.

  15. hatch_xanadu says:

    And simply for the record, even folks who have diagnoses of psychosis/schizophrenia are not as a rule (or even more often than not) dangerous.

    An anecdote of my own: a family member’s hallucination convinced her that my uncle’s house was on fire and my uncle was “covered in blood”. She called 9-1-1.

    While it was certainly *inconvenient* to say the least for all involved, including the EMS who showed up at a non-flaming house, I still contend that this family member did the “right” thing given the circumstances. Likewise, if Satan tells you to kill, you could technically tell Satan to fuck off. And if you still have faculties enough to tell Satan to fuck off, you might still be receptive to a talented and well-trained counselor who can convince you by means other than force to get back on the meds. (Now, how does the system go about getting more talented and well-trained counselors?)

    I realize that this opens me up to all sorts of propositions/speculation to the effect of “Well, what if a hallucination tells someone that their brother is Satan and that she should kill Satan?” But those would be just that — propositions and speculation. We have to get beyond that, particularly if the discussion is to take place in a forum called Science-Based Medicine.

  16. Peter Lipson says:

    I think i get something i didn’t before, Hatch. I think you objected to the example of a very ill and violent person. That’s understandable, as we wouldn’t want to further stigmatize the mentally ill. Still, that’s not what I got from the tone of the piece.

  17. David Gorski says:

    I may be being a bit dense, hatch, but i’m not sure what your point is. HH wrote a compelling piece about a real problem, supporting herself with statistics, and illustrating her point with “thought problems”.

    Indeed. I agree. In fact, I’m puzzled at HX’s comments, which got rather nasty, actually.

  18. ImperfectlyInformed says:

    Are there any statistics on this stuff?

    When it comes down to it, I’m inclined to think that if you offered the average homeless person a nice place to stay with (optional) medication, they’d love it — whether they’re schizophrenic or not. I was under the impression that the political and legal support for this type of welfare dried up a long time ago. Interesting opinions are expressed in the article, but it’s hard to know how “evidence-based” they are. I’m also skeptical of the unsourced claim that “medicated” mental illness is harmless while unmedicated is quite dangerous.

    In Derk Pereboom’s Living Without Free Will, I first came across the argument that behavioral therapy and rehabilitation for prisoners was wrongly abandoned in the late 70s based largely upon a 1974 essay by Robert Martinson, who later retracted it his statement — but the media had picked up his conclusion, and it became accepted as fact and restated uncritically by people who have a tendency to accept what they hear uncritically and then spread it far and wide. In 1980 Martinson killed himself; who knows if it was partly over guilt over negatively impacting the lives of so many prisoners. As a modern review of the situation (www.aic.gov.au/conferences/hcpp/sarre.pdf) notes, later reviews found that many things worked, and worked well. The issue is a testament to the fact that social propaganda and politics can trump science with longlasting effects, which is perhaps what we’re seeing with the rise of questionable therapies and pseudoscience. It also has to do with mainstream medicine’s neglect of highly promising and plausible herbal and dietary supplement therapies until very recently.

  19. ImperfectlyInformed says:

    By the way, when I ask “are there any statistics”, I’m also asking about the source of the statistics provided.

  20. Tervuren says:

    We have been – are going – through this. Our son is a 23 year old paranoid schizophrenic who could get no help at all, we could only get him into a hospital after he lay down on RR tracks. He has been victim to everyone on the street who will take advantage of a Deaf PS person. We cannot help him. We cannot force him to get the help he needs. He continues to stay in a facility only because he periodically attacks staff.

  21. mhtapa says:

    Assisted outpatient treatment (AOT) legislation wasn’t mentioned in this article and it has proven outcomes and statistics that confirm just how effective sustained outpatient treatment in a community can be.

    One example of successful AOT legislation is New York’s Kendra’s Law which shows reductions in homelessness, hospitalizations, and incarcerations:
    http://www.omh.state.ny.us/omhweb/Kendra_web/finalreport/

    Providing timely treatment in the community for someone with a severe mental illness who lacks the insight to seek and remain in treatment and meets the stringent criteria for AOT is the most compassionate, humane way to help someone regain their life and move forward in their recovery.

    Anyone interested in this common sense approach should visit the Treatment Advocacy Center’s web site for more information: http://www.treatmentadvocacycenter.org/index.php

  22. niarte says:

    Good afternoon everyone – I’m an on and off reader, avid skeptic, and forensic psychiatrist working for in the Northeast United States. I actually work for the State itself. I work with a violent population of mentally ill individuals and believe me, I’m all for civil commitment, involuntary treatment, and outpatient commitment. All of course with strong due process protections.

    I have some issues with Dr. Hall’s post. I am in agreement with Hatch_Xanada regarding it’s anecdotal nature. Dr. Hall – can you provide a reference for your statement that a disproportionate number of murders are committed by the mentally ill?

    My understanding of the literature is that there is an association between mental illness and violence. The primary determinants of that association are active psychosis/ mania and substance abuse. Despite this association, the amount of violence in our society today that is due to mental illness is not particularly significant. In society as a whole, a major determinant of violence is substance abuse which increases risk many – fold.

  23. Harriet Hall says:

    The references are listed at the end of my post. It is not that mentally ill people commit high numbers of murders, but that a psychotic person is more likely to commit murder than a normal person. A mentally ill patient is more likely to murder when under the influence of psychotic delusions than when his symptoms are controlled with medication. I pointed out that “The risk of violence increases with past history of violence, substance abuse, anosognosia with medication noncompliance, antisocial personality disorder, paranoid symptoms, and male sex.”

  24. ImperfectlyInformed says:

    When there’s nothing inline and they’re called further reading, I don’t consider them references. I looked at those references briefly and couldn’t find the support I was looking for (medication decreases violence).

    That review (http://archpsyc.ama-assn.org/cgi/content/abstract/66/2/152), incidentally, states this: “Bivariate analyses showed that the incidence of violence was higher for people with severe mental illness, but only significantly so for those with co-occurring substance abuse and/or dependence”. One might also find that the incidence of violence was higher in the general population of those with substance abuse. Nothing about medication in the abstract.

  25. Kimbo Jones says:

    “I’m inclined to think that if you offered the average homeless person a nice place to stay with (optional) medication, they’d love it — whether they’re schizophrenic or not.”

    Not if they are actively delusional that their medication is poison and the shelter is controlled by the government so they can spy on him/her… There are a number of barriers that can prevent people from voluntarily participating in treatment.

  26. niarte says:

    Dr. Hall wrote: “It is not that mentally ill people commit high numbers of murders, but that a psychotic person is more likely to commit murder than a normal person.”

    I’m not seeing that in review and unfortunately I can only get the abstract of the Archives article. The editorial cites a British Journal of Psychiatry that found a lifetime prevalence of Schizophrenia of 5% in a national sample of homicide offenders in England and Wales. This is above the population rate of schizophrenia, though the article notes that this figure is higher than any published prevalence. If this finding holds up, one would be able to say that if convicted of a homicide in England the likelihood of that person having schizophrenia is substantially higher than the general population. Whether this would hold true in the USA is unknown to me.

    ImperfectlyInformed wrote that “one might also find that the incidence of violence was higher in the general population of those with substance abuse.” In fact, this is what is found in Swanson’s work and is cited in the graph in the editorial. The lifetime prevalence of violence is cited at 7% in the “no disorder” category, 16% in the major mental illness only category, and 35% in the substance abuse only category. The combination of MI and substance abuse was 43%.

    Of note is that the lifetime prevalence of schizophrenia is typically cited as 0.5 to 1% of the population, and 1% for Bipolar I disorder (the most severe form) – diagnoses more typically associated with violence. The point prevalence for substance abuse (illicit drug use in the last month) looks to be about 8% in the US in recent SAMHSA studies.

    The point is that yes, the mentally ill with active psychosis and violence histories are dangerous, but as a society we use anecdotal cases to stigmatize when there are much greater risks out there. Similar to sex offenders, the absolute horrendoma cases get the media attention, but the dirty little secret is that the bulk of sexual abuse takes place in the home and is perpetrated by friends and relatives.

  27. hatch_xanadu says:

    Thank you, niarte, for the eloquence I couldn’t muster without coming off like an ass.

    Yes. When one makes statements like “a disproportionate number of murders are committed by the mentally ill”, it’s misleading to then rely on anecdote and emotional appeals as “evidence” for those statements. Especially when one is aware that the stigma attached to mental illness is already such that the statements will likely be easily accepted as fact. “Hmm, mentally ill people are more violent—that sounds about right.”

    And again, if there are studies available, I’d be interested to know what percentage of people who commit violent acts are determined to be mentally ill *because* they committed the violent acts, and what percentage of folks found to commit violent acts had pre-existing diagnoses that should have clued in the authorities to help prevent the acts.

  28. Harriet Hall says:

    You guys are missing the point. A psychotic person who is actively delusional and is hearing voices telling him to kill is surely more likely to kill than that same person when he is on medication that banishes his psychotic symptoms. No matter how few these people are and no matter how low the actual crime rate, we owe it to those patients to find a way to treat their illness. If we are not able to reach even the worst ones, how can we hope to help the less severely affected?

    We don’t want to stigmatize the mentally ill unfairly, but neither do we want to deny the reality of cases like Andrea Yates who drowned her 5 children in the bathtub, or like the Virginia Tech shooter. I think it is a reasonable assumption that adequate treatment probably would have prevented those tragedies. Do you disagree?

  29. daedalus2u says:

    HH, I completely agree that many cases of acute psychosis can be improved. In the case of Andrea Yates, I suspect that her psychotic state was induced by metabolic stress. I think that some other cases of post partum psychosis are induced by metabolic stress too, by an insufficient liver metabolic capacity to generate sufficient glucose to support lactation. In “the wild”, when a mammalian mother is unable to provide sufficient milk of sufficient nutritional value to sustain her infant, the generic mammalian response is infanticide.

    There is an absolute need for 3-carbon substrates to generate the glucose needed for lactose. 2-carbon substrates such as are obtainable from fatty acids are incapable of supporting glucogenesis.

    http://daedalus2u.blogspot.com/2007/08/low-nitric-oxide-acute-psychosis.html

    Infanticide in the case of insufficient metabolic resources to support lactation is not a “bug”; it is a “feature”. An evolved feature that may preserve the maternal reproductive capacity such that she might reproduce at another time if conditions get better. If she dies, any nursing infants will die too. If she survives, her dead infant may have a surviving sibling born when times get better.

    A mother who is under such metabolic stress that the infanticide instinct has been triggered needs help desperately. Putting her under more stress to try and “deter” infanticide will only make it more likely.

  30. hatch_xanadu says:

    Harriet, I imagine I will continue to miss the point as long as you keep moving the goalpost. No, of course I cannot disagree with that statement. Only a fool would, right?

    I respect your work and your prowess as a critical thinker, Harriet, and because of that I know that you would not accept it if, say, a woo-peddler were to, upon being asked for sources to back up her original blanket statement about an entire group of people, first attempt to call a list of related reading “sources”, and then when that didn’t work, say “you guys are missing the point”. But under these circumstances, it seems the discussion is reaching a point where further engagement just makes it seem like we’re harassing you.

    I fully understand that the study of mental illness by its very nature is by no means an exact science, but surely it’s not subject to an outright double standard—or is it? Maybe. Maybe it is. This I might be tempted to concede.

    So . . . no studies, then?

  31. mandalasarah says:

    And what about the cases in which people commit crimes because of the medications that they are prescribed, often involuntarily? In some of these cases, the people have been released due to involuntary intoxication. In others, people weren’t so lucky.

    http://www.thesaveproject.com

  32. niarte says:

    ” A psychotic person who is actively delusional and is hearing voices telling him to kill is surely more likely to kill than that same person when he is on medication that banishes his psychotic symptoms. ”

    This certainly makes sense.

    “No matter how few these people are and no matter how low the actual crime rate, we owe it to those patients to find a way to treat their illness.”

    Of course. No one would argue with you except for the bean counters. We should be treating all of these individuals, regardless of crime. What about drug related murders, what about other gun violence etc. These are much larger sources of violence than mental illness.

    “We don’t want to stigmatize the mentally ill unfairly, but neither do we want to deny the reality of cases like Andrea Yates who drowned her 5 children in the bathtub, or like the Virginia Tech shooter. I think it is a reasonable assumption that adequate treatment probably would have prevented those tragedies. Do you disagree?”

    This is the point. These are two horrible cases. Anecdotes. Andrea Yates was in treatment. Hindsight bias is clear that she was treated inadequately, however, it’s hard to predict a crime of such horrendous proportions, even in someone delusional.

    As far as Va Tech is concerned, adequate treatment might have prevented it, adequate gun control laws might have prevented it, lots of things might have prevented it. Should the prior stalking allegations have been taken more seriously? There are many proximate causes.

  33. Tyr says:

    HH,

    As someone who has worked in both the prison setting and am currently in the crisis setting (hospital ER) I agree with you. Many of those “regular” clients that are seen in the ER because they are in a crisis could be helped much more if there was a setting that would be more helpful.

    When we closed all those hospitals we dumped a lot of these people into a limbo land. Now we see prisons, nursing homes and homeless shelters filled with a large number of these people.

    Someone earlier asked for some stats. Here are a few from a recent article:

    • In 2006, 56 percent of inmates in state prisons and 64 percent of jail inmates had a diagnosable mental illness.

    • One out of three offenders at the Ohio Department of Youth Services has a mental illness; three of four have a substance-abuse disorder.

    • Cuyahoga County found that one in three homeless people is severely mentally ill.

    • More than half the students 14 or older who suffer from a mental disorder will drop out of high school.

    • Ohio has two suicides on average for every homicide; 90 percent of those who take their own life have a mental disorder.

    http://www.dispatch.com/live/content/local_news/stories/2009/03/08/fact_box_text.ART_ART_03-08-09_A6_J8D54SD.html?sid=101

    The sources are quoted at the end of the article.

  34. Anthro says:

    “Making an extreme example out of a pieced-together Satan-worshipping child-stalking ax murderer character is not the way to begin a rational discussion or bring about a real solution to all the deficits in the mental health/legal systems.”

    Obviously you are not the parent of a delusional and sometimes violent child who has woken up to see that child with a large knife who says “I could kill you in your sleep”.

    No one says this is common, but it happens more than you might think according to my son’s pdoc and, to me, it’s an excellent way to begin a rational discussion and bring about a real solution to all the deficits in the mental health/legal systems.

    In my state, a child over the age of 14 cannot be forced to take medication or even be forced to see a doctor, so the need for reform is great as is the need for discussions that HH has tried to have here.

  35. bridgeross says:

    An absolutely brilliant article. Thank you for it. Sorry for the plug but I have a great deal of statistics from all over the world in my own book on schizophrenia called Schizophrenia: Medicine’s Mystery – Society’s Shame. I also have information from other countries that do things a lot better than we do in North America in treating patients with psychosis in the community.

    The example you gave of the person with the ax is similar to a true case that I used but one that had a much more tragic end. The young man in question was so delusional that he thought his parents were inhabited by someone else – Capgras Syndrome I believe. He murdered both his parents who had tried desperately to get him help but could not.

    He was found not criminally responsible, his on medication and now realizes and must live with what he did.

  36. Fu Manchu says:

    “We do not have a clear-cut lab test” to diagnose such an imbalance. He later stated, “In order to survive, we (psychiatrists) must go where the money is.”–Steven Sharfstein, Ex-President, American Psychiatric Association

    Recent research has shown, that the vast majority of people who are violent do not suffer from mental illnesses. –American Psychiatric Association website.

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