Personal Health: The New York Times, 11/19/19
When Mental Illness Is Severe
Programs called assertive community treatment provide the kinds of services offered in psychiatric hospitals, within a home setting.
By Jane E. Brody, Illustration by Gracia Lam
There are some crimes that are almost impossible to forget.
For me, they include the death in 1999 of Kendra Webdale, an aspiring young journalist who was pushed in front of a New York subway train by a 29-year-old man with schizophrenia who had stopped taking his medication. That same year, two mentally ill teenage boys massacred 12 students and one teacher at Columbine High School in Colorado.
Thirteen years later, a seriously emotionally disturbed 20-year-old man murdered 20 young children and six adults at Sandy Hook Elementary School in Connecticut. This year, a homeless 24-year-old man bludgeoned four men to death while they slept on the streets of my city.
Although New York is now far safer than when I was a child in the 1940s and ’50s who walked to and from school unescorted, like most big cities, it still harbors untold numbers of men and women with known or undiagnosed severe mental illness that can and should be treated before yet another personal or societal tragedy occurs.
What, I wondered, is or can be done to help them and avert further disasters?
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Contrary to politically motivated claims, I learned that people with serious mental ills are not necessarily prone to commit violent acts — they are far more likely to become victims of crime. Rather, the issue is that treatments known to be effective are underfunded or wrongly dismissed as ineffective or too dangerous; basic research in university and government laboratories into new and better drugs is limited and also underfunded; and pharmaceutical companies have shown little interest in developing and testing treatments for severe mental illness.
Also at issue is that, as was true for cancer until recently, acknowledgment of mental illness carries a stigma that impedes its early recognition, when it can be most effectively treated or reversed.
Early intervention is critical, but even when mental illness is recognized in a family member, the person may resist treatment, often claiming that he or she is not the one who is sick.
As Dr. Kenneth P. Rosenberg recounts in his new book, “Bedlam: An Intimate Journey into America’s Mental Health Crisis,” when the huge, disgraceful psychiatric asylums were shuttered in the mid- to late 1900s, the assumption was that community mental health centers would take over, allowing those with serious mental illness to be treated as outpatients.
But neither the centers nor the communities that housed them were prepared to deal with the influx of extremely needy patients.
housing the mentally ill are jails: the Twin Towers in Los Angeles, the Cook County Jail in Chicago and Rikers Island in New York City.
“Mental illness crises are the only health emergency in which law enforcement are the first responders,” Dr. Rosenberg, a New York psychiatrist specializing in addiction treatment, writes. “At least 21 percent of all 992 people who were shot and killed by police in 2018 had a mental illness.” In New York, nearly 500 9-1-1 calls a day involve the mentally ill. Last month, in response to the murder of the four homeless men, Mayor Bill de Blasio announced a $37 million commitment to address this crisis, an amount criticized as a highly inadequate sum.
But Dr. Rosenberg and others who specialize in severe psychiatric disease say it doesn’t have to be this way. There is an expanding number of cost- and lifesaving outpatient options available to people with disorders like schizophrenia, bipolar disorder and major depression.
But people have to know about them and be willing and able to take advantage of them. One in New York City called OnTrackNY helps to stabilize young people with early signs of mental illness, when the disease is easiest to derail.
Another program, called Navigate, provides comprehensive treatment for people suffering a first psychotic episode to head off full-blown schizophrenia. It includes four critical elements: pharmacology, individual resilience training, family psychoeducation and supported employment.
Nationally, a growing number of programs called assertive community treatment provide the kinds of services offered in psychiatric hospitals but within a home setting, which works for “a certain percentage” of those with severe mental illness, said Kim T. Mueser, director of psychiatric rehabilitation at Boston University.
A major benefit, especially for those who live alone, is making sure patients take their medication as prescribed as well as fulfilling their basic needs.
“Mental illness is highly treatable, and many cases can be completely eliminated with effective treatment, or they can be managed effectively so that people can go on living rewarding and effective lives,” Dr. Mueser said.
“When someone’s mind is taken over by psychosis, the consequences are epic,” Dr. Rosenberg said. In lieu of jail, he advocates “therapeutic jurisprudence that leverages the mentally ill who tangle with the law toward health, not jail.”
He added, “We need to create laws that are more amenable to getting treatment for people who don’t know they’re sick, because people who don’t know they’re sick will fight against treatment. We also need more beds in a place that feels inviting, not a jail by another name.”
A major stumbling block is fear of two of the most effective treatments, especially for patients with severe mental illness who have failed to respond to other remedies: the drug clozapine and electroconvulsive therapy (ECT). As currently administered, the serious side effects of decades past are avoidable.
“Clozapine has been a miracle drug for many people, giving them a new lease on life,” Dr. Mueser said. “And ECT is not given to as many as would benefit from it. It still suffers from the very outdated depiction in the 1975 movie ‘One Flew Over the Cuckoo’s Nest.’”
Still, Dr. Rosenberg is optimistic. “Something unprecedented is happening in America,” he wrote. “We are no longer standing by helplessly as our family members get thrown away by society without care, taking outdated medicines, living in cells or on the streets.”
I can only hope he’s right, if not now then in the near future.
Meanwhile, there are resources that can help guide troubled families to needed services, like the National Alliance on Mental Illness. Dr. Rosenberg’s book also provides lots of practical advice both in accessing effective medical care and using the law. One suggestion I found intriguing is the creation of a psychiatric advance directive, a form for which is available at nrc-pad.org, to help guide families and therapists when a patient is in the throes of a psychotic episode.