Boston Globe oped: Mentally ill can be unaware they are sick 6 9 02

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The Boston Globe

June 9, 2002

EDITORIAL
Mentally ill can be unaware they're sick: Should the mentally ill be allowed to refuse to take their medication?

"Based on a 1999 survey by the Department of Justice, there are now proportionately as many mentally ill persons in Massachusetts jails as there were 160 years ago, when Dorothea Dix began her national campaign in Cambridge for treatment, not incarceration, for such individuals."

Research in the last decade has clearly established that approximately half of individuals with schizophrenia and manic-depression have an impaired awareness of their illness. This impairment, called anosognosia by neurologists, is caused by damage to areas of the brain that mediate self-awareness. The impaired awareness is thus biological in origin, similar to that seen in Alzheimer's disease, and may vary in degree from individual to individual and even in the same individual over time. It is not the same as denial, a psychological mechanism that we all use at times. This lack of awareness may explain why a number of the mentally ill are inconsistent in taking their medications, antipsychotic drugs that can help stabilize moods or eliminate delusions.

If these people live in Massachusetts, there is no law requiring that they take their medications in order to remain in the community. In this, Massachusetts differs from 41 other states that do have laws requiring outpatients to follow their treatment plans. In these states, if a mentally ill individual refuses to follow the treatment plan, including taking prescribed medications, he can be involuntarily hospitalized. By contrast, in the Commonwealth, an individual must show ''a very substantial risk of physical impairment or injury'' in order to be hospitalized against his will.

Although laudable from a strictly civil libertarian position, Massachusetts' present laws make it impossible to treat thousands of its citizens who have brain diseases and who also have impaired awareness of their illnesses. Large numbers of these individuals end up living on the streets and in public shelters, making up approximately one-third of the homeless population. Another large number commit misdemeanor crimes as a consequence of their untreated illness and end up in jails.

Based on a 1999 survey by the Department of Justice, there are now proportionately as many mentally ill persons in Massachusetts jails as there were 160 years ago, when Dorothea Dix began her national campaign in Cambridge for treatment, not incarceration, for such individuals.

For others in Massachusetts, the failure to treat individuals with severe psychiatric disorders produces graver consequences. Last July, for example, Gary Sampson killed three people in Massachusetts and New Hampshire while not taking his medication. Sampson had a 24-year history of schizophrenia and proven dangerousness in the past when not taking medication, yet he was not required to take it. Studies have also shown that individuals with severe mental illnesses who are not being treated are seven times more likely to commit suicide compared to those who are being treated.

Any system that allows for involuntary hospitalization or treatment must, of course, include checks and balances to ensure that the system cannot be abused. The old Soviet Union, where political dissidents were sometimes given psychiatric labels and involuntarily hospitalized, demonstrated that psychiatry could be so abused. Other states that permit involuntary treatment, such as the widespread use of conditional release in New Hampshire or the recently passed New York State law allowing for outpatient commitment (''Kendra's Law''), have mechanisms in place to prevent abuse. With over 900,000 trained lawyers in America, mechanisms to prevent abuse are relatively easy to implement.

Massachusetts, then, pays a price for its strict civil libertarian approach to severe psychiatric disorders. By making involuntary treatment virtually impossible to achieve, the state ensures that it cannot be abused. However, by making involuntary treatment virtually impossible to achieve, Massachusetts also traps thousands of severely mentally ill individuals, who have impaired awareness of their illness, into a lifetime of illness and its tragic consequences.

In a 1999 decision, Supreme Court Justice Anthony Kennedy wrote: ''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.'' What are civil liberties for such individuals?

Dr. E. Fuller Torrey is president and Mary Zdanowicz is executive director of the Treatment Advocacy Center in Arlington, Va.