Madness in the streets

By Lori Leibovich

And interview with Dr. E. Fuller Torrey in Salon Magazine

Last year an estimated 2.2 million Americans went untreated for severe mental illnesses such as schizophrenia, manic depression, obsessive-compulsive disorder and autism. Of those, about 300,000 were either homeless or in prison. About 4 percent of U.S. homicides are committed by the mentally ill each year. And with cutbacks in government spending on health and the move to managed care, the situation is likely to get worse.

In his recent book, “Out of the Shadows: Confronting America’s Mental Illness Crisis” (John Wiley & Sons, 244 pages), research psychiatrist E. Fuller Torrey writes that the deinstitutionalization of hundreds of thousands of mentally ill people has wreaked havoc on America’s streets. In a recommendation that is bound to stir controversy, he calls for increasing the involuntary hospitalization of the mentally ill.

Torrey has written several books on mental health, including “Surviving Schizophrenia.” He works at the Neuroscience Center of the National Institute of Mental Health and is a founder of the National Alliance for the Mentally Ill, an educational and support organization for the mentally ill and their families.

Lori Leibovich talked with Torrey about what he calls the “crisis” of mental illness in America and a health-care system he says fails to help its sickest patients.

Lori Leibovich: Emptying America’s mental hospitals — “snake pits,” many people called them – and moving towards “community care” was supposed to be a sign of progress. But you say deinstitutionalization has failed. Why?

Dr. Torrey: It hasn’t failed completely. There are lots of folks – about 50 percent of the mentally ill population — who have done reasonably well since leaving the hospital, especially those who have insight into their illness and who recognize they need medication.

Take my sister, for example. She has had schizophrenia for 30 years. She was in a state hospital for 25 years continuously. She is now living in a group home where the quality of her life is substantially better than it was — she can visit with her boyfriend in the evenings, go out to dinner. She is an example of someone who would still be in a state hospital if it weren’t for deinstitutionalization.

The problem is with the other 50 percent who do not have insight into their illness. They often stop taking their medications as soon as they walk out the hospital door. These are the people who end up on the streets, in jail or committing violent acts. We have no mechanism to get these people back on medication.

Lori Leibovich: And for these people, you favor a return to involuntary hospitalization and forced treatment?

Dr. Torrey: Yes. Consider the issue of Alzheimer’s disease. If Mrs. Jones with Alzheimer’s wants to wander around outside without shoes and socks on in the middle of winter, we don’t say, “OK, you have a right to do that,” because that would be inhumane. And we don’t have much problem taking someone with Alzheimer’s disease and putting them on a locked ward saying, “Yes, you can go outside, but you’re going to have to go with someone so you can find your way back.” In that case, people don’t say you are infringing on the patient’s civil liberties.

But in the case of the mentally ill, we say we are infringing on their liberties, thanks to the civil liberties movement, which adopted the mentally ill as one of their causes back in the 1960s. Civil liberties lawyers have been very successful in changing the laws in many of the states, making it very difficult to keep the mentally ill safe and sound, inside.

I see mentally ill women all the time who have been raped on the streets. Civil libertarians say they don’t like these women getting hurt but if they don’t want to go to the hospital then they have a right to stay on the street.

Lori Leibovich: So you would put them away, no questions asked?

Dr. Torrey: I propose a model similar to the one Ed Koch had in New York when he was mayor: When there is someone who is obviously mentally disabled and living on the street, we have the right to pick them up and put them in the hospital for 30 days, try them on medication and see if they respond. Then an evaluation would be done.

I don’t say we should have the right to do this on a doctor’s signature alone. No one wants to go back to the 1930s. The mentally ill person should definitely have his day in court and be able to appeal these decisions. But ultimately we should have a mechanism to involuntarily treat people who have brain disorders, who have no insight into their illness, and are clearly a danger to self or others.

Lori Leibovich: Is “having their day in court” sufficient protection for those involuntarily committed?

Dr. Torrey: In terms of checks and balances, I would involve public defenders on this. If you have a well-run system where there are unannounced inspections, it is possible to measure quality of life on the wards and in outpatient systems. We haven’t done this very well.

Lori Leibovich: Let’s say we accepted involuntary commitment. Would there be room in state facilities for all of them?

Dr. Torrey: No. That’s why the state hospitals will never push this, because it would mean they would have to reopen some of those hospital beds, which would mean putting more money back into the system. When a state closes one of their hospitals, they have then shifted the cost to Washington. So when you ask them, “Wouldn’t you like to open three more wards to take on these people?” they look at you like you are crazy. The states save money by discharging people. They don’t save money by providing care for them.

Lori Leibovich: You call the treatment of the mentally ill a “disgrace.” But with new medications, new technologies and an increased understanding of the brain, shouldn’t our treatment of the mentally ill be advancing?

Dr. Torrey: Yes. It should be. There are hosts of new anti-psychotic drugs that are very effective, but they can cost $6,000 to $10,000 a year. I run a clinic for homeless mentally ill people, and by begging the drug companies I have gotten these medications for two of my clients, but it was enormously complicated. I see people all the time who should have access to these medications, but they don’t.

Lori Leibovich: Is that why so many mentally ill people — 2.2 million by your estimate — are left untreated?

Dr. Torrey: Cost is one of the reasons. The single largest issue is the insight issue. The majority of people wouldn’t take the medication even if you offered it them. Because they don’t think there is anything wrong with them.

Lori Leibovich: And many of them are broke and homeless. The homeless are the most visible evidence of a failed system. Many of them are on the streets because they were prematurely discharged from the state hospital. Some of them don’t even make it to a hospital because the states closed so many beds. They are severely disabled, but they are not receiving medication or outpatient treatment of any kind. By the way, the vast majority of panhandlers are not schizophrenics, they are substance abusers.

Lori Leibovich: You say there are large numbers of prisoners who are mentally ill.

Dr. Torrey: In California, according to the numbers, about 20 percent of those in the prison system are severely mentally ill. Being in a prison or jail when your brain is working normally is no bargain. Being in there when you are hallucinating is living hell. In some states there are separate pods or treatment facilities for the mentally ill. In fact, there are a fair number of families who say they were unable to get their loved one help until they got into the prison system. That’s a sad commentary on our system.

Lori Leibovich: Tipper Gore and others have said mental health insurance should be more widely available. But is that likely in an era of managed care?

Dr. Torrey: We can’t blame what we are seeing on the streets today on managed care. But it is definitely going to make things worse. While now you only pass four homeless mentally ill individuals on the way to the grocery store, five years from now you are going to pass six.

Lori Leibovich: Why can’t managed care do a better job?

Dr. Torrey: HMOs can provide excellent care for the severely mentally ill, if they want to. There is nothing inherent in the HMO model that dictates that you can’t serve the mentally ill well. The problem is with the for-profit model. When the earnings of the top executives and the stock price of the company are dependent on being able to save money there is an enormous conflict of interest. People with severe mental illness — like people with other chronic brain disorders like Parkinson’s or multiple sclerosis — are relatively expensive to provide care for. In for-profit managed care, it is not surprising that they are going to fall through the cracks most quickly.

Lori Leibovich: They don’t like to pay for long-term therapy, but they will pay for drugs.

Dr. Torrey: I don’t advocate expensive long-term treatments for everyone who is unhappy. I differ from many of my colleagues who say mental illness should be covered just like any other physical illnesses. For example, people who have experienced a death in the family or parents whose teenage son won’t talk to them, or the professor who doesn’t get tenure – these are all examples of what I call “problems of living.” But brain disorders like schizophrenia should be covered equally. A major problem now with the coverage issue is the reluctance of psychiatrists, psychologists and psychiatric social workers to make that distinction.

Lori Leibovich: Why?

Dr. Torrey: Money. From the point of view of mental health providers, if the insurance companies don’t cover “problems of living,” there would be an awful lot of therapists looking for other jobs.

Salon Magazine January 1997 Reprinted with permission.