Commitment Phobia

By E. Fuller Torrey

Wall Street Journal
April 27, 2007
Reprinted with permission of the author. Visit the Wall Street Journal online

The question inevitably follows the carnage at Virginia Tech: Are individuals with severe mental illnesses more dangerous than the general population? Since the 1960s, when the emptying of public mental hospitals went on fast forward, this question has recurred with each publicized psychiatric tragedy. And each time, mental health organizations have replied with an identical mantra: Psychiatric patients are not more dangerous than the general population.

This answer may be politically correct, but it is factually incorrect. To be precise, mentally ill individuals who are taking medication to control the symptoms of their illness are not more dangerous. But on any given day, approximately half of severely mentally ill individuals are not taking medication. The evidence is clear that a portion of these individuals are significantly more dangerous.

Since 1994, nine U.S. studies have illustrated this fact. The best known, the Violence Risk Assessment Study, funded by the MacArthur Foundation, followed 961 seriously mentally ill individuals for one year after hospital discharge. During that time, these individuals committed 608 acts of serious violence (physical injury, threat of or actual assault with a weapon, or sexual assault), including six homicides. The most important finding: Those who regularly attended treatment sessions had less than one-quarter the rate of violence compared to those who did not. This is one of the clearest demonstrations that treatment markedly reduces violence.

Studies in Scandinavia, where national case registers exist, are also useful for quantifying the dangerousness of mentally ill individuals. Separate studies in Denmark and Finland both found the conviction rate for violent crimes of individuals with schizophrenia to be seven times the rate for the general population.

Specifically regarding homicides, a 1985 study in Contra Costa County, Calif., found that individuals with severe mental illnesses were responsible for 10% of homicides. Multiple European studies have reported a range from 5% to 18%. Using the most conservative estimate of 5% for the United States, individuals with severe mental illness would have been responsible for 885 of the 16,192 total homicides in 2005. And if this 5% were applied to all homicides in the U.S. between 1966, when deinstitutionalization got underway, and 2005, the total would be 37,969 homicides. Most of these would not have happened if the perpetrators had been receiving treatment.

The Virginia Tech tragedy is a special type of homicide in which several people, usually strangers, are killed at one time. Such “rampage murders” are much more likely than the usual homicides to be carried out by mentally ill individuals like Cho Seung Hui. One published study of rampage murders found that almost half of the perpetrators were seriously mentally ill. There is also evidence that the incidence of rampage murders has increased significantly in the past two decades.

All of this is known but assiduously ignored by most mental health organizations. The reason usually given is that to talk publicly about violence increases stigma against all individuals with mental illness. The problem with such reasoning is that the violent episodes themselves are the main source of stigma — until the issue of violence is addressed the stigma will remain. This was illustrated by a 1996 survey that found that 31% of Americans associated mental illness with violence, an unexpected increase from a similar survey in 1950 that had reported that only 13% did. The general public apparently bases its opinion on actual events, not on mythology fashioned by mental health organizations.

The most remarkable aspect of psychiatrically related tragedies is that most of them can be avoided. Studies suggest that problems of violence are associated with a small percentage — approximately 10% — of all individuals with serious mental illnesses. These are often the same individuals who are intermittently homeless, incarcerated and rehospitalized. Because of their brain disease, these individuals have little or no awareness of their illness and will not voluntarily take medication, because they believe there is nothing wrong with them.

There are two solutions. First, state commitment laws must be modified to reflect current scientific knowledge. For example, Virginia is one of only five states to require people to be imminently dangerous before they can be treated, and many other states have commitment criteria that impede access to treatment. Having an imaginary girlfriend who flies through space and stalking female students merely got Cho an overnight stay in a hospital, but no effective treatment. The present laws in most states are based upon discredited ideas about mental illness from half a century ago. The Treatment Advocacy Center, the only national organization working for legal reform of these laws, has a model law designed to ensure treatment for those who need it — and also protect individual rights.

Second, court-ordered assisted outpatient treatment must be utilized to ensure that the Chos of this nation take the medication needed to control their symptoms. Assessments of assisted outpatient treatment have shown it to be highly effective in producing an increase in medication compliance and a decrease in rehospitalization, homelessness, victimization and arrest. A study of assisted treatment in New York (“Kendra’s Law”) showed that those on it “physically harmed others” only half as often as before being placed on it; a similar reduction in violent behavior was shown in a North Carolina study. Despite such data, assisted outpatient treatment is rarely used in most of the 42 states in which it is available and does not even exist in the other eight states.

The tragedy of Virginia Tech is a microcosm of our failed mental health system and our confusion about civil rights. Mentally ill individuals have a civil right to receive treatment, even when their brain disease precludes awareness of their illness. And the public has a civil right to be protected from potentially dangerous individuals. We are failing both the patients and the public.

Dr. Torrey is president of the Treatment Advocacy Center and author of “Surviving Schizophrenia” (Collins, 5th ed., 2006)