Monday, June 23, 2008

E. Fuller Torrey's The Insanity Offense

Dr. Hilkert was of the view that involuntary commitment provides important protections to patients and society, and spoke to me about how people were dying for lack of psychiatric care. So, when I saw this review of The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizensin the Wall Street Journal last week by Dr. Paul McHugh:, I thought of him, once more...
The new laws deprived psychiatrists of the authority to hold patients under surveillance. In the past, psychiatrists could keep patients in a hospital if they were "of such mental condition . . . [as being] in need of supervision, treatment, care, or restraint." Now patients could not be held unless "immediately" or "imminently" dangerous to themselves or others.

The harrowing effects were evident almost immediately, and Dr. Torrey recounts them in vivid detail in "The Insanity Offense." First he offers plenty of statistics to indicate the state of the problem as it exists today -- citing, for instance, the number of seriously mentally ill who are in prison (218,000) or homeless (175,000) at any given time. But just as "numbers are too abstract" to convey the magnitude of a large-scale tragedy such as an earthquake or flood, he says, the true horror that resulted from the "deinstitutionalization" of the seriously mentally ill is best conveyed by individual stories.

Dr. Torrey recounts murder after murder by mentally ill patients, each of whom was actively avoiding treatment. We learn about William Bruce, who was diagnosed with schizophrenia and hospitalized but refused to take his medication. His mother "tried to get help everywhere," a friend related, but "at each phase she was turned away because he never hurt anyone." Bruce bludgeoned his mother to death in 2006 and slit her throat.

The most awful example was the murder last year of 32 students and faculty at Virginia Tech by Cho Seung-Hui, a 23-year-old student who had been court-identified as in need of treatment but allowed by the college to attend classes because the school would not treat mentally ill students -- even those suffering from schizophrenia -- unless the students requested it. Mr. Cho could not be involuntarily committed because he was not an "imminent danger" to himself or others and was not "substantially unable to care for himself." As Dr. Torrey writes: "This is one of the most stringent state commitment statutes in the United States and another example of how changes in mental illness laws in the 1970s and 1980s continue to have real consequences."

Given the difficulty of committing the seriously mentally ill for involuntary treatment, our jails and prisons have become de facto mental institutions. Dr. Torrey's data indicate that more than 30% of inmates are mentally ill. He also describes the abuse they suffer in these brutal environments and the increase in suicides by mentally ill prisoners. The hellish scenes described by Dorothea Dix in 1843 have returned -- with a vengeance, given the huge increase in the American population since the mid-19th century.

What is to be done? "The Insanity Offense" calls for a restoring of some central state responsibility for these patients in ways that would permit monitoring them regularly, keeping them on their medications and insisting on a protected-care setting if they relapse. It is not necessary to reopen all the old state hospitals: The programs that are needed could be carried out in clinic offices with backup, shorter-stay hospital beds.