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Deinstitutionalization turned deadly

This document contains two op-eds from THE WALL STREET JOURNAL.

Why Deinstitutionalization Turned Deadly

E. Fuller Torrey, M.D., and Mary Zdanowicz, Esq.

In June, Michael Laudor, a Yale Law School graduate who suffers from schizophrenia, allegedly slashed his fiancée, Caroline Costello, to death. Last month, Russell Weston, a drifter with schizophrenia, allegedly murdered two policemen, Jacob Chestnut and John Gibson, in an assault on the U.S. Capitol.

These are only the most publicized of an increasing number of violent acts by people with schizophrenia or manic-depressive illness who were not taking the medication they need to control their delusions and hallucinations. The pattern has been emerging for the past decade. Based on information gathered in the Washington, D.C., metropolitan area, we estimate that approximately 1,000 homicides a year are committed nationwide by seriously mentally ill individuals who are not taking their medication.

A Question of When

The total number of individuals with active symptoms of schizophrenia or manic-depressive illness is some 3.5 million. The National Advisory Mental Health Council has estimated that 40% of them roughly 1.4 million people are not receiving any treatment in any given year. It is therefore not a question of whether someone will follow Michael Laudor and Russell Weston into the headlines. It is merely a question of when.

A 1990 study of families with a seriously mentally ill member reported that 11% of the ill individuals had physically assaulted another person in the previous year. In 1992 sociologist Henry Steadman studied individuals discharged from psychiatric hospitals. He found that "27 percent of released male and female patients report at least one violent act within a mean of four months after discharge." Another 1992 study, by Bruce Link of the Columbia University School of Public Health, reported that seriously mentally ill individuals living in the community were three times as likely to use weapons or to "hurt someone badly" as the general population. A 1998 MacArthur Foundation study found that seriously mentally ill individuals committed twice as many acts of violence in the period immediately prior to their hospitalization, when they were not taking medication, compared with the posthospitalization period when most of them were taking medication.

The emerging pattern of violence is clear. And it is part of a larger pattern: increasing numbers of severely mentally ill individuals among the homeless population, incarcerated in jails and prisons for offenses committed while psychotic, and loitering in parks, public libraries and transportation stations. The pattern is the product of deinstitutionalization gone awry, the discharge of hundreds of thousands of mentally ill individuals from the nation's public psychiatric hospitals without ensuring that they get the medication they need to remain well.

Recent studies have shown that about half of those who have schizophrenia or manic-depressive illness have markedly impaired insight into their illness. That is, they do not know that they are sick, because their brain disease has affected the frontal lobe circuits that are necessary for complete self-awareness. If they are not sick, they reason, why do they need a cure? Mr. Weston repeatedly told his family that he was not sick and rejected their pleas that he take his medication.

Individuals like Mr. Weston will take medication only if it is mandated. And this can be done in 37 states under outpatient commitment statutes, or in a few other states under conservatorships or conditional hospital release arrangements. Both Montana and Illinois, the states that should have been treating Mr. Weston, have outpatient commitment laws under which he could have been required to take medication as a condition for living in the community.

However, these laws are difficult to invoke. Lawsuits brought by the American Civil Liberties Union and Washington-based Bazelon Center for Mental Health Law have changed most states’ criteria for outpatient commitment. Individuals must be classified as an imminent danger to themselves or others before they can be involuntarily treated, either in the hospital or in the community; this criterion is strictly applied. Most psychotic individuals, who are merely making threats against others or living on the streets and eating out of garbage cans, are not deemed legally sick enough to qualify for outpatient commitment.

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. Mr. Weston, for example, had been receiving monthly SSI payments since 1984, but such payments were never linked to his treatment.

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.

State Responsibility

Another necessary step: Washington should hold the nation's governors directly responsible for their states’ mental illness treatment programs. The care of severely mentally ill and disabled individuals has been a state responsibility for 150 years. Most states have no internal monitoring to assess the quality of public psychiatric services. As a condition for receiving federal mental health block grants, states could be required to institute such programs, using audits of mental health centers' clinical activities and unannounced inspections of hospitals and group homes. The state data could then be sent to the Institute of Medicine under the National Academy of Sciences, which would submit an annual report to Congress.

These horrors are preventable. Michael Laudor should be teaching at Yale Law School and Russell Weston should be mining Montana's hills. Their victims should still be alive. The tragedy is that the mentally ill are a threat to society because society has failed them.

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THE WALL STREET JOURNAL.

July 18th, 1996

Stop the Madness

By E. FULLER TORREY, M.D.

Each year, about 1,000 people in the U.S. are murdered by severely mentally ill people who are not receiving treatment. These killings--about 5% of all homicides nationwide--are a testament to the perversity of deinstitutionalization. The emptying of our public psychiatric hospitals, a massive social experiment involving the release of some 830,000 patients, was undertaken on a multitude of flawed assumptions. It's time to reverse course.

Only a small minority of the mentally ill is violent, but many more are worse off than if they had remained in the hospital. They can be found carrying on animated conversations with themselves in public, living in cardboard boxes or, like one man who lived beneath New York's FDR Drive, training themselves for space missions. They often end up victimized, in jail for misdemeanors, or prematurely dead from accidents, suicide or untreated illnesses.

Seymour Kaplan, a psychiatrist who was one of the pioneers of deinstitutionalization in New York State, later called it the gravest error he ever made. The Empire State, which has released some 90% of its mental patients, typifies the policy's failures. Perhaps the ultimate symbol is the Keener Men's Shelter. For 75 years it was part of Manhattan State Hospital. As the state emptied the hospital through deinstitutionalization, Keener became a homeless shelter. When I visited a few years ago, it housed 800 men, 40% of whom were severely mentally ill. Several had been hospital patients in the same building--only then, they got the intensive psychiatric care they needed.

Deinstitutionalization has wreaked havoc on the quality of life, especially in New York City. Recent reductions in crime notwithstanding, New Yorkers still live with the fear that, as one local columnist put it, "from out of the chaos some maniac will emerge to . . . cast you into oblivion." The presence of even nonviolent mentally ill homeless in the streets and parks creates an inescapable sense of squalor and degradation.

Ideology, Not Science

How have things gone so wrong? It is important to realize that the original underpinning for deinstitutionalization was ideology, not science. The idea had appeal across the political spectrum: Liberals found civil libertarian demands for mental patients' "freedom" persuasive; conservatives were happy to cut mental health budgets by shutting down state hospitals.

When deinstitutionalization shifted into high gear in the early 1960s, only one study had been done on the effects of moving severely mentally ill individuals from psychiatric hospitals to community living. The 20 schizophrenics in that study, published in England in 1960, did relatively well when moved from a hospital to a supervised community facilities. Virtually every American advocate for deinstitutionalization in the 1960s and '70s cited this paper--and did not mention that the 20 patients had been selected for the experiment because they were functioning at a high level and were able to work, unlike the vast majority of U.S. patients who would be sent packing.

Advocates of deinstitutionalization based their argument mostly on such texts as Erving Goffman's "Asylums" (1961), which asserted that psychiatric patients' abnormal behavior was mostly a consequence not of mental illness but of hospitalization. Research in the past decade has proved this assumption false: Studies using such techniques as positron emission tomography scans have shown that schizophrenia and manic-depressive illness are physical disorders of the brain, just as Parkinson's disease and multiple sclerosis are. Patients with such illnesses need medications to control their symptoms, which usually get worse without treatment.

Advocates assumed that mentally ill individuals would voluntarily seek psychiatric treatment if they needed it. As it turned out, about half of the patients discharged from psychiatric hospitals did not seek treatment once out of the hospital. Many of those who suffer from schizophrenia and manic-depressive disorder do not believe themselves to be ill. These untreated individuals constitute most of the mentally ill population who are homeless or in jail, and who commit violent acts. States, meanwhile, shirked their responsibility, in part because the mentally ill were newly eligible for a variety of federal programs.

During the mass exodus of patients from psychiatric hospitals, nobody bothered to ask what was happening to them. Incredibly, despite the vast scale of deinstitutionalization, the federal and state governments never commissioned evaluations of this social experiment, which after all had been launched with virtually no empirical base. As late as 1981, when deinstitutionalization had been under way for over 15 years, an academic review of research on the subject found only five studies concerned with outcomes, three of which were methodologically flawed. During these same years, the National Institute of Mental Health discovered that patients being released from state psychiatric hospitals were not, with only occasional exceptions, receiving aftercare.

What can be done to correct this debacle? First, responsibility for mental illness services should be fixed at the state and local levels. This is not something the federal government does well. Federal funds now being used for mental illness services should be given to the states in block grants. With responsibility should come accountability. State mental illness services should undergo an annual evaluation carried out by a private contractor that would partially determine the size of the next federal block grant. How would mental illness services change? States would doubtless discover that eliminating all state hospital beds is ultimately not cost-effective. A small percentage of seriously mentally ill persons need long-term hospitalization, and many more need monitoring to ensure their compliance with a treatment regime.

A second, more controversial reform is no less essential: The mental health system must provide for the occasional involuntary treatment of seriously mentally ill individuals. The crux of any commitment law is the conditions it sets for involuntary commitment to be legal. In many states, patients may be committed only if they can be shown to pose a danger to themselves or others. Courts often interpret this provision very strictly. The standard should not be dangerousness but helplessness. Society has an obligation to save people from degradation, not just death.

Temptation to Accept

A major danger in thinking about the disaster of deinstitutionalization is the temptation to accept it. An entire generation of young adults has grown up seeing homeless mentally ill individuals living on the streets and in the parks. From their perspective, why shouldn't these people always live there? They are just one more inescapable blight on the urban landscape, along with broken-down cars at the curbs and garbage under the bridges. It is important for those of us who are older to speak out. We remember when homelessness was rare. We must not accept as inevitable the debacle of deinstitutionalization and its consequences. We made this problem, and we can correct it.

Dr. Torrey, a Washington, D.C., psychiatrist, is author of "Out of the Shadows: Confronting America's Mental Illness Crisis" (John Wiley, 1996). This article is adapted from the summer issue of the Manhattan Institute's City Journal. (Posted 2/1999)

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