Medical concepts involving involuntary commitment and involuntary treatment

Excerpted from a presentation by DJ Jaffe

For purposes of this paper, I will focus on schizophrenia.

I. Schizophrenia is a real disease that can be diagnosed

You will come across people who will argue that ‘mental’ illness is not an illness, but an alternative lifestyle freely chosen. A mere “label” that society uses to discriminate against those who are different. These people are often easy to identify because they usually associate themselves with the disproved theories and writings of Thomas Szasz, Peter Breggin, and/or Ron Hubbard (Scientology). If ‘mental’ illness is not a real disease, they argue there can be no real treatment: voluntary or otherwise.

The American Psychiatric Association, Mental Health Associatio, National Alliance on Mental Illness, and the Substance do frequently announce ‘new’ disorders that seem to cover just about every area of human behavior (shopping disorder, exercise disorder, etc.) so it is not surprising that some have started to question whether mental illness does exist. In addition, like with every other disorder, some people are misdiagnosed.

However, it is conclusively established that schizophrenia, manic-depression, obsessive-compulsive disorder, depression and many other disorders are in fact neurobiological disorders (NBD). As Dr. E. Fuller Torrey wrote:

“In summary, based on studies of gross pathology, microscopic pathology, neurochemistry, cerebral blood flow, and metabolism, as well as electrical, neurological, and neuropsychological measures, schizophrenia has been clearly established to be a brain disease just as surely as multiple sclerosis, Parkinson’s disease, and Alzheimer’s disease are established as real brain diseases.
The dichotomy used in the past, whereby schizophrenia was classified as a “functional” disorder as distinct from an organic disorder is now known to be inaccurate; schizophrenia has impeccable credentials for admission to the organic category…)

-Dr. E. Fuller Torrey, Surviving Schizophrenia

The United States Government’s Congressional Office of Technological Assessment (OTA) found the following evidence that biological factors are involved in schizophrenia, bipolar disorder, major depression, OCD, and panic disorder:

  • * Medications suppress symptoms associated with disorders,
  • * Specific mental disorders can often be typified by distinguishable clinical features, such as age of onset, symptoms, and course. *These disorders may have associated “physical ” symptoms. such as altered sleep patterns in depression.
  • * Known physical agents and drugs can produce some symptoms of mental disorders, demonstrating that biological factors can in fact be causative.
  • * Genetic studies show that the disorders are influenced by inheritance.
  • *Other areas of research provide evidence about correlated biological factors and suggest testable hypothesis as to causation.”

    -The Biology of Mental Disorders: New Developments in Neuroscience. US Congress Office of Technology Assessment.

Neurobiological disorders can be accurately diagnosed: “Contrary to persistent myth, mental illnesses are both real and definable” -Dept. of Health and Human Services Health Care Reform For American with Severe Mental Illnesses: Report of the National Advisory Mental Council

Schizophrenia is a real, diagnosible illness. And certain symptoms of the illness may cause some people to become violent.

II. Symptoms may include hallucinations and delusions and these may make someone violent.

Individuals react to their environment as they perceive it. For example, if you think you are being hit, you may run or hit back. Individuals with schizophrenia may have hallucinations and delusions. In fact, these are often integral to accurate diagnosis. And when someone has a false belief, they may act on it. That may be why some individuals with schizophrenia become violent: they are reacting to delusions and hallucinations which are part of the illness. “Individuals with schizophrenia experience delusions and hallucinations.

Delusions are beliefs that that are clearly implausible but that are compelling and central to individuals’ life experience. Persons with this disorder may be suspicious or paranoid in nature. For example, a patient may believe that he or she is an historical figure or that someone has placed a transmitter in his or her brain…. Hallucinations are perceptions without an objective basis. They most commonly take the form of voices or, less frequently, visions, bodily sensations, tastes or smell. …The voices tend to be highly personal and may direct the patient to do some act, sometime commanding self-mutilation or other violent behavior.” -The Biology of Mental Disorders: New Developments in Neuroscience. US Congress Office of Technology Assessment.

Hallucinations and delusions–which are an inherent component of the illness, can cause people to act violently. III. Individuals with NBD, as a group, are more violent than general population One of the main reasons to change involuntary treatment and/or involuntary commitment laws is to prevent individuals with NBD from becoming violent and ending up killing themselves, killing someone else, or winding up in jail for some violent offense.

“Proving” that people with NBD have a greater propensity towards violence than the rest of the population may bring you into conflict with so-called stigma busters who believe it is stigmatizing to acknowledge this. It may also bring you into conflict with minor consumer organizations who (by assuming 20% of the population is ‘mentally ill” or alternatively, denying anyone is mentally ill), erroneously believe that individuals with NBD are not more prone to violence. In other words, in your advocacy efforts, people are going to see ‘data’ to suggest that individuals with NBD are no more violent than others. I encourage you to read those carefully to see

  • 1) What population they are referring to;
  • 2) Were they published in a legitimate peer reviewed publication;
  • 3) Were they authored by someone affiliated with an organization that has a pre-determined point they want to make; and
  • 4) How long ago was the study completed.

On the other side, following are some reports that make the point that there is indeed a correlation between serious NBD and violence:

“Recent studies, including two carried out in random community surveys, have been virtually unanimous in finding that seriously mentally ill individuals, as a group, are significantly more dangerous than the general population. The studies also suggest that this difference is attributable to a small percentage of individuals who are not compliant with their medication.” – Violent Behavior By Individuals With Serious Mental Illness Dr. E. Fuller Torrey Hospital and Community Psychiatry

“The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered, or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social and demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior. Mental disorder may be a robust and significant risk factor for the occurrence of violence as an increasing number of clinical researchers in recent years have averred.”… -Mental Disorder and Violent Behavior John Monahan

IV. Medicines and other treatments can help people function in the community

If indeed hallucinations and delusions (which are integral to schizophrenia) cause some individuals to act violently, can anything be done about it? The fact is: medicines and other treatments can, for many but not all, reduce the symptoms that may lead to violence. The following two charts from the Dept. of Health and Human Services Health Care Reform For American with Severe Mental Illnesses:

Report of the National Advisory Mental Council show that the efficacy of treatments is fairly high: Treatment efficacy chart from Office of Technological Assessment showing the long- term success rate and short term success rates for schizophrenia, depression, manic depression, etc.

V. Individuals with NBD often lack insight into their illness and/or capacity to make logical decisions

If someone does not even know they are ill, they won’t take their medicine since there is nothing to cure. Lack of insight is a common symptom of schizophrenia and is called anosognosia

“The results indicated that poor insight is a prevalent feature of schizophrenia. A variety of self-awareness deficits are more severe and pervasive in patients with schizophrenia than in patients with schizoaffective or major depressive disorders with or without psychosis and are associated with poorer psychosocial functioning. Conclusion: The results suggest that severe self-awareness deficits are a prevalent feature of schizophrenia, perhaps stemming from the neuropsychological dysfunctional associated with the disorder, and are more common in schizophrenia than in other disorders.” Awareness of Illness in Schizophrenia and Schizoaffective and Mood Disorders by Dr Xavier Amador, etc., in Archive of General Psychiatry, October 1994.

Insight is an important component of recovery: “Of studies which have investigated the question of the relationship between level of insight and outcome, a majority indicate that better insight into illness and better insight regarding benefits of treatment auger well for positive clinical outcome and compliance with treatment.” Poor Insight in Schizophrenia by Xavier Amador, Ph.D., and David H. Strauss, M.D., Psychiatric Quarterly, Winter 1993

Even if an individual knows they are ill, they may still lack the capacity to make a treatment decision that is in their own best interest. They may not understand the treatment being proposed or it’s likely courses and outcomes. Between 23 and 52% of individuals with schizophrenia lack decisions making capabilities. “Summary of main findings: First, on the measures of understanding, appreciation, and reasoning, as a group, patients with mental illness more often manifested deficits in performance than did medically ill patients and their non-ill control groups.

Indeed, when the most highly impaired subgroups were identified on each measure, they were composed almost entirely of patients with mental illness….(A)mong patients with schizophrenia, the minority with poorer performance on the measures of understanding and reasoning tended to manifest greater severity of psychiatric symptoms, especially those of thought disturbance…These results are in keeping with both theory and empirical findings regarding cognitive deficits associated with schizophrenia. …For any given measure (understanding, appreciation, and reasoning) approximately 25% of the schizophrenic group scored in the ‘impaired’ range compared to 5%-7% of Angina patients and 2% of community controls. When all measures are combined, 52% of patients with schizophrenia showed impairment on at least one measure. Clinical implications:. The results suggest that a diagnosis of schizophrenia should increase ones attention to the possibility of deficiencies in abilities related to legal competence.” -Thomas Grasso and Paul Applaud, The MacArthur Treatment Competence Study (III): Abilities of patients to consent to psychiatric and medical treatments. Law and Human Behavior, Vol. 19, No 2. 1995.

VI. Individuals with schizophrenia frequently resist treatment

As a result of lack of insight into the fact they are ill, or the lack of capacity to make a treatment decision, many individuals with NBD fail to follow the treatment plans that can prevent them from becoming violent. “Approximately 7% of patients hospitalized for mental illness refuse treatment. ” Hoge, et al. Archives of General Psychiatry 1990 There is a big difference between those who take medicines and those who don’t “The monthly relapse rates are estimated to be 3.5% a month for patients on maintenance neuroleptics and 11% a month after patient-initiated medication discontinuation.

Post discharge noncompliance rates in the community settings are estimated to be 7. % a month.” -Cost of Relapse in Schizophrenia Peter Weiden and Mark Olfson Bulletin. Schizophrenia (In press) This non-compliance diverts resources from other areas “An estimated 257,446 multiple-episode (greater than or equal to 2 hospitalizations) patients were discharged from short stay (less than or equal to 90 days) inpatient units in the U.S. during 1986.

The estimated aggregate baseline inpatient costs for the index hospitalizations of this cohort were $2.3 billion (1993 dollars). Within two years after discharge the aggregate cost of readmission approaches $2 billion. Loss of neuroleptic efficacy accounts for roughly 60% of the rehospitalization costs and neuroleptic noncompliance for roughly 40%….The specific cost of rehospitalization attributable to neuroleptic noncompliance is approximately $700 million with $370 million for the first year and$335 million for the second.” Cost of Relapse in Schizophrenia, by Dr. Peter Weiden and Dr. Mark Olfson. Schizophrenia Bulletin (In press)

We can say from this information, that schizophrenia is a genuine biological disease of the brain. That one of the symptoms of the disorder is a lack of insight. Another symptom can be an inability to make rational decisions. As a result of this lack of insight, and other issues, many individuals do not follow their treatment plans. Lack of compliance with treatment plans is one of the contributing factors to violence. Therefore it should be societies obligation to incorporate these scientific findings in current legislation.

DJ Jaffe is Executive Director of the non-partisan Mental Illness Policy Org., and author of Insane Consequences: How the Mental Health Industry Fails the Mentally Ill. He is a critic of the mental health industry for ignoring the seriously ill, and has been advocating for better treatment for individuals with serious mental illness for over 30 years. He has written op-eds on the intersection of mental health and criminal justice policy for the New York Times, Wall St. Journal and the Washington Post. New York Magazine has credited him with being the driving force behind the passage of New York’s Kendra’s Law and Congress incorporated ideas proposed by DJ in the Helping Families in Mental Health Crisis Act.