The Magazine

Almost Committed

The House GOP inches toward mental-illness reform.

Jun 10, 2013, Vol. 18, No. 37 • By MARK STRICHERZ
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The leading experts in mental illness agree on two facts. First, severely mentally ill people are different not only from you and me, but also from those with severe physical illnesses. As psychiatrist E. Fuller Torrey noted at the March 5 hearing, “at least half of them have an impairment of their understanding of the fact that they are sick, and the reason is they have damage to the parts of their brains that they use to think about themselves.” This is anosognosia, or lack of self-awareness, which afflicts not only patients with Alzheimer’s disease but also those with bipolar disorder and schizophrenia. He discussed his late sister, Rhoda, a schizophrenic who thought she had been put into a mental hospital because of a cold. Koplewicz, who also serves as president of the Child Mind Institute in New York, affirmed Torrey’s conclusion at the hearing.

Experts also concur that assisted outpatient treatment laws work. A 2001 RAND report, which summarized the findings of two clinical trials, found that a “sustained outpatient commitment order (180+ days), when combined with intensive mental health services, may increase treatment adherence and reduce the risk of negative outcomes such as relapse, violent behavior, victimization, and arrest.” Forty-four states have adopted such a program, including New York, whose “Kendra’s Law” is the best known. There is wide agreement that states need to provide adequate funding for assisted outpatient treatment laws to yield the outcomes the RAND study described. “We agree that [these laws] need to focus on services, but most states don’t fund them,” Michael Fitzpatrick, executive director of the National Alliance on Mental Illness, said in an interview.

What leading practitioners disagree on is the extent to which the severely mentally ill need better access to treatment—and whether they should be forced to take medication. Koplewicz noted the country has only a few thousand child psychiatrists, while Fitzpatrick said schoolteachers and counselors often fail to recognize the symptoms of severe mental illness in students. By contrast, Torrey argued that a lack of access to treatment is not the main problem; the Virginia Tech, Tucson, and Aurora shooters had been diagnosed as severely mentally ill. He contends courts and local agencies don’t force a severely mentally ill person to take his meds unless he has committed violence.

President Obama, who will lead a White House conference on mental illness June 3, proposes spending $235 million to help teachers, counselors, and first responders at schools and universities identify symptoms of mental illness. A bipartisan Senate proposal, which the upper chamber passed as an amendment April 18, mirrors the administration’s plan, but without the funding. Neither proposal addresses the problem Torrey identified: Cho, Loughner, and Holmes had been diagnosed at their schools as psychotic, yet none was forced to remain on medication.

Unfortunately, the House Republicans’ version is little better on this score. A Murphy aide indicated that the congressman will seek to eliminate a $36 million SAMHSA grant awarded to civil-rights organizations that advocate for mentally disordered patients who avoid taking their medication. “I’m supportive of assisted outpatient treatment, but we have to make a clear lobbying effort,” Murphy said.

Rep. Bill Cassidy of Louisiana, a physician, has two further suggestions: Family members of the mentally ill should be able to get full access to their records from doctors, who typically cite a 1996 federal health-privacy law to block them; and they should have greater discretion in committing their mentally ill children to institutions. “A family requesting therapy for their child whose doctor does not feel it’s appropriate should be able to go before a judge to get treatment,” Cassidy said.

Torrey has a better plan. He would give states a $200 million block grant they could use to fund assisted outpatient treatment laws. “I think what we can do is use federal money that’s already available and out there to provide models so that we can understand what proper treatment can and should be,” he said at the March forum, arguing that AOT “decreases hospitalization, decreases violence, and also saves money. This is a proven way to treat people, especially those who are not aware they are sick themselves.”

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