`Moments` separate treatment from tragedy

Essential to any individual’s journey from mental illness to recovery are moments when they (or those they know) realize that something is wrong and they need help, that getting treatment can lead to understanding and hope, and that recovery is possible when strengths-based adaptation and ongoing effort are partnered with proper treatment.  

But many Americans who face mental health issues never get to that first moment, realizing that they need help, and of those who do, many find that treatment isn’t available or fall away from treatment before hope can take hold. Among the former group are those with anosognosia, a condition that impairs their ability to recognize that they have a mental illness.

The November 8 sentencing of Jared Lee Loughner, the 24-year-Arizonan diagnosed with schizophrenia after his arrest for the Tucson shootings that killed six and seriously injured 12, reminds us that for the few whose mental illnesses manifest in violent behavior, only moments may separate the paths that lead to treatment, or to tragedy.  

What might have been?

Could the life of Jared Lee Loughner have gone in another direction if he had received psychiatric treatment, including medications? Possibly, yes. But the case of James Holmes, the young man accused in the July movie-theater shootings in Aurora, Colorado, demonstrates that accessing care is not sufficient to prevent violence and tragedy either.  Holmes had seen a University of Colorado psychiatrist, but did not return—and was not sought out— after withdrawing from the university in the middle of June, just five weeks before the shootings.  

According to Paul Appelbaum, M.D., past president of the American Psychiatric Association (APA) and chair of the APA’s Committee on Judicial Action, when violent behavior occurs as a manifestation of a mental disorder, treatment “is likely to diminish the risk of future violence.” (He stresses that most acts of violence are committed by people who are not mentally ill.)

Where there is a connection, however, treatment can help to prevent violence by helping the patient understand that paranoia, for example, is not justified, that the world is not “out to get” them. “Someone with a paranoid delusional system who seeks revenge or preemption in violent behavior is carrying out instrumental violence,” says Appelbaum, who is the Elizabeth K. Dollard professor of psychiatry and law at Columbia University. “They think they have a goal, but it’s a delusional one, protecting themselves from imaginary, malevolent forces.”

Aggression, even when planned in advance, can be a response to being psychotic, agrees William Glazer, M.D., president of Glazer Medical Solutions, based in Florida. “If you believe your food is being poisoned, or that you are being monitored by the FBI, you are going to get very scared,” Glazer says. “At some point you may get so out of touch that you will be violent and aggressive,” he adds, noting that if a patient’s paranoia could be treated with antipsychotic medication and a trusting therapeutic relationship, then “the aggression would be treated as well.”

But establishing an effective therapeutic bond takes time. “Relationship” is the key to earning a person’s trust, convincing them to enter therapy, and motivating them to take medication when it is necessary, says Lori Ashcraft, Ph.D., executive director of the Recovery Opportunity Center at Recovery Innovations, in Phoenix, Arizona. “They know if you are on their side, if you believe in them,” she says.

But such interventions aren’t open to those who refuse treatment or those who don’t realize their own mental illness. What then?  

Involuntary commitment and treatment

Some form of involuntary commitment or treatment laws exist in every state, with New York’s Kendra’s Law (New York) and Laura’s Law (Calif.) among the notable examples. Typically, these laws allow for an individual to be court-ordered either to an institution for a brief period or to an assisted outpatient treatment (AOT) program for a longer period, or both. But laws set a high bar for any intrusion on personal freedom:  petitioners must prove that the individual is gravely disabled or represents a significant or imminent danger to self or others.

The height of the bar against involuntary treatment must be seen in light of the civil rights struggles of the 1950s and ‘60s, and the values of the recovery movement, which stresses the importance of personal choices and strengths as critical elements in the recovery process. But some worry privately that the pendulum has swung too far, making it very very difficult to compel treatment or medication even when the need appears obvious.

Convincing the patient

Persuading the patient to take medication, oral or injectable, is often part of good treatment. But, as noted, informed consent requires discussion of a potential litany of side effects, which may trigger patient concern. “But fear that the patient will say no to the medication is not a reason to deceive or to withhold information – whether they’re mentally ill, or paranoid, or not,” says Appelbaum. He believes that honesty—even about unpleasant side effects—is most likely to win a patient’s trust.

Mental Health America (MHA) recognizes that involuntary treatment may be necessary, on an inpatient basis for crisis purposes. But MHA does not support involuntary outpatient treatment. Almost everyone, including people with serious mental illnesses, “are capable of making their own decisions about whether to seek treatment and support and what treatment and support they should receive,” MHA says.

Though MHA agrees that psychotropic medications are effective, they maintain that the known risks of these meds entitle consumers to refuse them. “For this reason and because of its commitment to the autonomy and dignity of persons with mental health conditions, MHA strongly agrees with the judgment of the United States Supreme Court that all persons, even persons lawfully convicted and serving a sentence of imprisonment, have a right to refuse medication and that medication may not be imposed involuntarily unless rigorous standards and procedures are met,” says MHA, citing the 1990 case Washington v. Harper, 494 U.S.210.

Meds can reduce violence risk . . .

How antipsychotic medications reduce the risk of violence in people with schizophrenia living in the community has long been a question for clinicians. Jeffrey Swanson, Ph.D., and colleagues found that antipsychotics did not reduce the risk of violence in patients whose childhood history of antisocial behavior suggests that their violent behavior was a result of that, and not of their psychosis – the reduction was from 16 percent to 9 percent in the retained sample (“Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia,” published in the British Journal of Psychiatry in 2008). The report is part of the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) study sponsored by the National Institute of Mental Health, which found that the atypicals are no more effective than the older – and much less expensive – medications.

Being abused as a child is a definite risk factor for later violence, whether the person is psychotic or not, says Swanson, professor of psychiatry and behavioral sciences at Duke University School of Medicine. But that doesn’t mean that someone who has been abused can’t be helped after the fact, he says. “It may be that because of the abuse they take a more hostile attitude to the world.” If they also have schizophrenia, the medication would help prevent delusions that could compound violence related to that hostility.

But supportive services are essential, too

Being on medication doesn’t mean that patients with mental illnesses will be cured, or that they won’t be violent, says Marvin S. Swartz, M.D., professor of psychiatry and behavioral sciences at Duke University School of Medicine. “When deinstitutionalization started, we thought all they needed to do was to take the medications,” he says. “Now we recognize that even with optimal medication, there are aspects of schizophrenia, for example, that probably don’t get addressed by medication – the self-care deficits, the lack of awareness of illness, the cognitive deficits.”
Ashcraft asserts that supportive relationships, partnerships, really—are at the heart of recovery.  But programs like Ashcraft’s are not reimbursed by Medicaid, which only pays for medications in many states. And in a time of budget cuts, states are cutting back on enhanced services like Assertive Community Treatment (ACT) teams and recovery-oriented programs.

The cost of the latest medications means that payers—whether state programs or MBHOs, are squeezing money out of psychosocial treatment, says Swartz. “As a result, it’s going into the pharmacy formulary, and now we’re spending a huge amount on the formulary,” he said. “We seem to be facing a situation where patients have a branded medication like Risperdal Consta and no psychosocial treatment,” he said. “Maybe we should consider using a generic like Prolixin D with intensive psychosocial treatment – this cost tradeoff might make sense.” The problem occurs, he said, because the federally mandated basic Medicaid plan pays for the medication and simple doctor visits. The services that have become the hallmark of good schizophrenia treatment – ACT teams and case managers – are optional enhanced benefits and subject to budget cuts.

Most professionals would agree that if a choice has to be made between the enhanced services—ACT teams, for example—and medications, that the medications should come first, says Glazer. “But let’s not kid ourselves that medications alone will take care of the problem. Unless we can provide supportive services for these kinds of patients, we’re going to have more violence, more hospitalizations, and more transfers to prisons which are now becoming the home for the mentally ill.”