Why do severely mentally ill go untreated?

When the news broke that fatal shots were fired in the Capitol Building, the most obvious question was, “Why did this happen?” Soon we learned the answer: The suspected gunman, Russell E. Weston, Jr., suffers from schizophrenia. But that only raised puzzlement over why someone diagnosed with a severe brain disease was living in the community without the benefit of medications to control the symptoms of his illness.

The deaths of the two brave Capitol Police officers focused the nation’s attention on questions that are repeated at least a thousand times each year in this country. Why do we allow nearly one million people who suffer from severe brain diseases to go untreated when we have medications that can control their debilitating symptoms? Why do we fail to ensure that patients continue taking the medications that enable them to return to the community after hospitalization?

Homicide is just one consequence of the failure to help those who are not receiving treatment. Other consequences are homelessness, victimization, imprisonment, suicide, and acts of aggression upon family members. Nearly 30 years ago, civil libertarians forced a national agenda that has made it virtually impossible to treat a large number of people with severe psychiatric disorders. It was a purely ideological campaign based on the premise that the right to refuse treatment is paramount, regardless of its consequences.

No one will argue that an individual’s constitutionally protected interests can only be subverted for compelling reasons, and only then with due process of law. But the reality is that approximately half the people with schizophrenia or bipolar disorder are afflicted with a little understood symptom of the illness: lack of insight. That is, the disease impairs the part of the brain that enables us to evaluate ourselves. For individuals whose insight is impaired, there is no self-recognition of the illness. They do not realize that the other symptoms (hallucinations, delusions, paranoia, and withdrawal) are, in fact, symptoms. The really believe they are related to the Kennedys or that the CIA is after them.

The irony is that Weston and a vast number of others like him do not think they need treatment because they are unable to recognize that they are ill. The laws of most states prohibit involuntary treatment for these individuals until they become an “imminent danger to self or others.” Translation? We must often wait until it is too late. And even when they are stabilized on medication, we send them back into the community without ensuring that they continue the medication.

There is no compassion in this approach because the result is that people are forced to languish in a state of altered reality that in most cases results in a life of torment. And when the unimaginable happens – and the ill commit an act of violence – lives are lost or ruined.

The most important question that has been asked since the shots rang out a week ago is, “How can these tragedies be prevented?” First, we must recognize that people like Weston also lack the capacity to make an informed decision about treatment. A person who does not realize he is sick does not have an opportunity to make a meaningful choice between being sick or getting better. Substituted judgment is appropriate in these cases, just as it is for the victims of other brain disorders, such as Alzheimer’s disease. We would never allow Alzheimer patients to walk barefoot in the snow, yet we allow the victims of schizophrenia to sleep under bridges and eat from garbage cans. This disparate treatment is particularly egregious because we have a means of treating the symptoms of schizophrenia.
Treating the one million untreated ill will not require that we reopen all the beds that were closed when the states moved toward deinstitutionalization. There is no need to hospitalize someone who is stabilized on medication if he no longer poses a danger. But, living in the community should be conditioned on continued medication compliance. This requires building a network of outreach services in communities to ensure compliance with treatment and to provide the supports needed for daily living and to prevent relapse. It means building the services that were promised to replace the closed state hospitals – promises that were never fulfilled.

In the 1950s, our nation was disgraced by exposes of deplorable conditions faced by psychiatric patients in state institutions. The problems were never resolved, just moved to our streets. In the 1990s, we are disgraced once again by preventable tragedies. We must provide humane treatment for citizens who suffer from serous mental illness. Otherwise, these tragedies will continue and we will be endlessly asking “why?”

The Boston Globe
August 1, 1998
Reprinted with permission. Copyright 1998 The Boston Globe. All rights reserved.