Friday, July 18, 2008

The Mentally Ill Sentenced to Misery by Our Indifference

Anyone who has worked in the mental health system can recite a litany of patients who spin through its revolving doors over and over. They become familiar faces and stories, some loved, some disdained.

This subset of patients return again and again for a variety of reasons, but the most common one is noncompliance with medications. This happens often times because of money and access, other times because of flat-out refusal.

Misfortune often laughs at our weakest, and some of these people end up floating face-down in a river after successfully suiciding, or mumbling in the hallways of a state mental hospital where they are psychologically buffed-up to competently stand trial for some bloody violence. The rest? Well, they walk among us.

As I've written in posts past, the mental health system in America is bleeding to death. The causes are most certainly legion, but the hemmorhage can be stemmed by creating law and infrastructure to get the most seriously mentally ill treated. How to do this?

Assisted Outpatient Treatment (AOT)
There's a prima facie impression that only a relative handful of us give a damn about mental health. After all, last week Congress had to pass a law just to push mental health benefits up to par with other medical treatments. Psychiatrists are the lowest paid medical specialists in the nation. Psychiatric programs are often relegated to the farthest corners of medical centers. Mental health staff are often among the lowest compensated employees. Indeed, it can feel like a service begrudgingly given.

Realistically, mental health's black sheep status is more a matter of evasion than indifference, of exasperation than antipathy, although there is a mix of all those. Sometimes they coalesce to create a perfect storm.

Kendra Webdale
On a rainy Sunday afternoon in January 1999, 32-year-old Kendra Webdale was waiting on a Manhattan subway platform. A young man named Andrew Goldstein approached her and asked for the time. Just as the subway train screeched towards them, Goldstein plunged Kendra down to a gruesome death on the tracks.

Andrew Goldstein was one of those caught in the revolving door of mental health. His life had started full of promise as he possessed an exceptional, perhaps beautiful, mind. It was a promise broken, though, when he had first psychotic break as a college freshman.

Diagnosed a paranoid schizophrenic, Andrew went through multiple psychiatric hospitalizations and, in spite of the fact he had assaulted thirteen strangers without provocation-all of them women-and had expressed fears he would act on his violent impulses towards even more women, he was released, again and again.

As you might expect, Andrew had not been compliant with his medications, mostly because of debilitating side effects, and was continually released before he was truly stable.

In the aftermath of this horrific episode, New York passed an Assisted Outpatient Treatment law for the mentally ill and named it Kendra's Law.

Not long afterwards, another tragic incident would underscore the failures of the mental health system, this time 3,000 miles away in California.

Laura Wilcox
On break from Haverford College in 2001, nineteen-year-old Laura Wilcox was working for a few days at a Nevada County mental health clinic. A 41-year-old client named Scott Harlan Thorpe showed up for his appointment on January 10. But to the horror of all around him, he pulled out a gun and opened fire, killing two clinic employees. Laura was one of them. Scott then drove to a restaurant and shot its 24-year-old manager.

As with Andrew, Scott had not been compliant with his treatment, including medications. By the time he went on his shooting spree, he had descended into a delusory hell where he was being tormented and stalked by the FBI. His family stood by, helplessly watching his unraveling, unable to do anything to compel him into treatment.

Like Kendra, Laura did not die in vain, either. Lawmakers California would enact their own AOT law, largely based on Kendra's, and call it Laura's Law.

What It Is
Under AOT, patients with severe and persistent mental illness can be court-ordered into outpatient treatment, rather than leaving it up to them. If the patient fails to show up for treatment, peace officers or field clinicians can bring them to an emergency room. The patient is evaluated for a possible 72-hour involuntary hospitalization (a 5150 in California). For a complete detail of these otherwise complex laws, please visit The Treatment Advocacy Center.

It is money that is the decisive difference between the New York and California AOT structures. New York has a well-organized and funded program. California's until recently had been all talk and no action, a legislative mandate without the cash to implement it. Happily, that is changing as Los Angeles and Nevada counties are now using Mental Health Services Act monies to initiate AOT programs.

Meanwhile, the investment has paid off handsomely for New York, both in societal costs and the toll of human suffering. To wit: A 59% reduction in repeat hospitalizations, a 75% reduction in incarcerations, a 57% reduction in homelessness, and a 53% increase in medication compliance. If that's not enough, the Office of Mental Health's web site features even more impressive data.

Patient's Rights
A subtext, perhaps, to the lack of political and financial will to enforce Laura's Law in California is simple complacency. It has been 36 years since the well-meaning but fundamentally flawed Lanterman-Petris Short Act effectively tied everyone's hands. Compulsory treatment for even the most seriously mentally ill was sacrificed in the name of patient's rights. Hence, a floridly psychotic patient who believes he's the King of Macaroni on a Moon that's made of cheese is considered legally competent to refuse antipsychotic medications. Mind you, I'm not suggesting that we violate or disregard constitutional rights in any way, but to allow severely ill patients to dictate their own treatment appears ludicrous at first blush, and then downright ridiculous in practice.

If you're a patient who has chronic paranoid schizophrenia, 20 or more psychiatric hospitalizations over the last two years, and a pesky penchant for dope on which you spend your entire monthly government check, do we as a society not have a vested interest, if not moral obligation, to force you into treatment? Or, perhaps we just really don't care if you end up dead at 35 behind some Skid Row trash dumpster. One less loser to worry about, right?

Final Thoughts: Rights Can Be Wrongs
The irony is that patient's rights can also be their undoing. Folks with severe mental illness carousel through mental hospital doors because they can't function in monitored settings. They take easy escapes like alcohol and drugs that lead to hard falls such as homelessness and incarceration. They are essentially children and adolescents in adult bodies. They need us to structure their lives, to support them, to help them make decisions, and to give them a time-out when they are spinning out of control.

Continuing with a business-as-usual approach is, in fact, the greatest violation of a mentally ill person's rights we can commit. The AOT laws are a welcome first step for our patients' recovery.

This post was updated on 12/11/2008.

Many thanks to Kristina M. Ragosta, J.D., Legislative & Policy Counsel at the Treatment Advocacy Center for her assistance.

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