Point of view: Serious medicine can deter rampages

By Jeffrey A. Lieberman

Raleigh News and Observer
Reprinted with permission.

CHAPEL HILL — Russell Weston’s killing of two U.S. Capitol security officers should remind us of the litany of senseless tragedies in which persons whose smoldering symptoms of schizophrenia went untreated before culminating in murderous rampages.

These include Theodore Kaczynski (the “Unabomber”), John du Pont (who shot an Olympic wrestler) and Colin Ferguson (the Long Island Railroad gunman), just to name a few who have recently come to national attention. We should also collectively remember John Hinckley, President Reagan’s would-be assassin, and Wendell Williamson, the UNC law student who killed two people in Chapel Hill in 1995.

Indeed, my own medical career has been framed by such events. David Berkowitz, who was manifestly psychotic, visited a two-year reign of terror as the “.44 caliber killer” on New York City, where I took my medical training in the mid 1970s. Berkowitz, it was ultimately found out, had been in and out of psychiatric treatment for much of his adult life. When on medication he was docile and rational. However, when he stopped his “meds,” as he did repeatedly, he came under the sway of his symptoms (auditory hallucinations) in which a dog’s voice (he called it the Son of Sam) commanded him to kill long-haired young women.

Sound crazy? It was, as were the ostensible reasons for all of the above-mentioned crimes that were in reality motivated by the delusions or hallucinations of these unfortunate persons.

It seems paradoxical that such incidents have become more frequent even as our understanding and ability to treat severe mental illnesses like schizophrenia has progressed enormously. However, the reasons seem readily apparent and directly a consequence of changes in social policy.
Prior to 1960, most patients with severe chronic mental illness were kept in state mental hospitals. With the introduction of highly effective antipsychotic medications it was thought that patients could be effectively treated in the community as outpatients. This wholly reasoned and laudable idea gave rise to a policy of deinstitutionalization in which large numbers of patients who had responded to treatment were discharged from hospitals with the expectation that they continue their treatment as outpatients.

The irresistible appeal of this policy, both humanitarian and economic, resulted in a massive reduction in the number of state mental hospital inpatients (90 percent since 1960). In this sense the policy worked all too well. It was, however, fatally flawed in that it relied on patients to follow through on their treatment plan voluntarily.

Most didn’t and the result has been a disaster of varying proportions throughout the country. (It has been estimated that 40 percent of the homeless are displaced persons with mental illness).

The problem is that most patients neither want nor understand the need for treatment. It’s not like a person who experiences chest pain or suffers a broken bone and knows or is prompted by their pain to see a doctor. Schizophrenia and manic depressive illness are brain disorders. Among the functions of the brain that are affected by these disorders are the capacities for insight, awareness and judgment. Consequently, most patients don’t believe that they are ill, much less need treatment.

It is not even the same as a person who has diabetes or hypertension but eats excessively, smokes and doesn’t take their medication. They are usually consciously denying their illness in favor of their lifestyles and irresistible appetites. With mental illness the organ that enables understanding and judgments to be made (the brain) is impaired.

An analogous condition would be Alzheimer’s disease. Not for a moment do we question the need to assist patients with this illness in finding and accepting treatment. Similarly, for infectious diseases that are communicable and pose a public hazard like tuberculosis, we require that patients accept treatment not just for themselves but for the public good.

There are two major reasons why we don’t do this for schizophrenia. First, people are generally ignorant of the nature of mental illness. When a person develops strange behavior this is often ignored, euphemised or tolerated. Even if the person’s family or friends do recognize that something is wrong, they don’t know how and where to seek help.

The second reason has to do with the distinctly American ideal of autonomy and the right to self-determination. Our society is loath to infringe upon individuals’ expressions of self unless they break or threaten to break laws. Translated in to mental health law, this principle protects patients from being treated against their will even if they are flagrantly psychotic unless they pose a clear and present danger to themselves or others. Some states even require showing past history of dangerousness to meet the required legal standard.

If there is a silver lining to this cloud, it is that something good may yet come from these highly publicized incidents. Care of the mentally ill has been the responsibility of the states for 150 years. In recent years, 37 states (including North Carolina) have adopted outpatient commitment statutes in addition to the pre-existing voluntary and involuntary hospitalization procedures.

In North Carolina this statute allows a family member or physician to seek an order to have a person evaluated and treated if they are dangerous to themselves or others, or to prevent mentally ill persons from experiencing further serious disability and deterioration. In addition to limiting patients’ suffering, this is designed to avert the potential for violent behavior.

Some states have also adopted conservatorships and conditional hospital release programs, which provide further custodial measures to ensure that patients continue their treatment where necessary. Indeed, North Carolina’s state mental health director, John Baggett, last week proposed a measure allowing physicians the option to require six months of supervised treatment following hospital discharge.

The legislature is also considering a bill to establish a health care power of attorney in which persons subject to illnesses (physical or mental) that can impair decisional capacity may provide advanced directives for their treatment and designate a guardian in effect.

Since these policies abridge individual autonomy and civil liberties (albeit in the interests of society as well as the person), organizations like the ACLU, the Bazelon Center for Mental Health Law and some patient groups have expressed concerns.

Such concerns notwithstanding, these policies properly utilized should reduce the incidence of untreated illness and violent incidents. However, in order to work these procedures must be used, and up till now they have neither been widely known nor frequently employed. Again the reason is lack of awareness about mental illness and its remedies.

The tragedy of such violent crimes is compounded by the fact that we have the knowledge and means to treat schizophrenia effectively. The need to raise awareness of mental illness and the programs to treat it remains one of our greatest public health challenges.

North Carolina has a unique opportunity in this regard. The state’s mental health care system is well developed and highly regarded. (It was ranked seventh in the nation by the National Alliance of the Mentally Ill). The state’s legislative policy on mental illness is current and in some respects almost enlightened.

With effective integration of public and private sector services and combined with a campaign for increased public awareness, North Carolina can set the standard for mental health care in the 21st century, and in the process improve the lives and safety of its citizens.

Jeffrey A. Lieberman, M.D., is director of the Mental Health and Neuroscience Clinical Research Center and professor of psychiatry at the UNC School of Medicine.


Raleigh News and Observer
August 9, 1998
Reprinted with permission. Copyright 1998 Raleigh News and Observer. All rights reserved.