Our insane mental health system

I first heard E. Fuller Torrey critique America's mental health non-system nearly two decades ago-and the evidence of breakdown has only increased since then. The mentally ill now form probably half of the homeless and prison populations. Exploited and victimized by others, and often terrorized by their own phobias, they are a threat to themselves and to others, causing one-tenth of the homicides in the United States.

Torrey, a psychiatrist who specializes in helping schizophrenic and bipolar patients, founded the Treatment Advocacy Center (www.treatmentadvocacycenter.org), a national nonprofit trying to improve treatment of those with severe mental illnesses. He has persevered in helping men and women who are truly the poorest among us in that they don't even own their own brains any more.

WORLD: How many seriously mentally ill individuals are homeless or incarcerated in the United States at any given time?

TORREY: Conservatively it is estimated that there are about 175,000 seriously mentally ill persons who are homeless and another 220,000 who are in jails and prisons. By "seriously mentally ill" I mean individuals with schizophrenia, bipolar disorder, and severe depression with psychosis. This definition does not include individuals who only have alcohol and drug abuse problems. Thus, individuals with serious mental illnesses make up at least one-third of the homeless population and at least 10 percent of the jail and prison population. Both numbers have been, and still are, increasing.

WORLD: What was the trendsetting California legislation during the Reagan years, and who were the strange bedfellows pushing it?

TORREY: In the late 1960s California set the standard for emptying its state mental hospitals and other states then followed its lead. In 1969 it implemented a law, widely known as the Lanterman-Petris-Short (LPS) Act after its sponsors, which made it exceptionally difficult to involuntarily hospitalize psychiatric patients. Once in the hospital, patients could only be held for 17 days unless they met very strict criteria for dangerousness. The new law resulted in a major exodus of patients from the hospitals, a movement known as deinstitutionalization.

WORLD: Which strange bedfellows pushed for that law?

TORREY: A very odd coalition: politically left-leaning civil libertarians, who believed that nobody should ever be involuntarily hospitalized, and politically right-leaning fiscal conservatives who saw closing the hospitals as a way to reduce state expenditures and thus reduce taxes.

WORLD: Who was Herb Mullin and why did you write about him?

TORREY: Herb Mullin was a young man with untreated schizophrenia who, because of his delusions, killed 13 people in Santa Cruz, Calif., in 1972 and 1973. As is typical for schizophrenia, Herb had been a promising young man until his disease began after he completed high school. I used Herb as a case example because he is typical of the individuals with untreated schizophrenia and bipolar disorder who account for about 10 percent of all homicides in the United States. Most of those homicides could be prevented if the people were being treated.

I also used Herb because his untreated illness was at least partially a product of the new LPS legislation which had just been implemented in California. In 2005 I visited Herb, who is serving a life sentence in a California state prison. He still has schizophrenia. So far his incarceration has cost California taxpayers over $1 million. The cost of the antipsychotic medication needed to treat his illness in 1972, and thus prevent the homicides, would have been a few dollars.

WORLD: What effect did Wisconsin's mental health reforms have?

TORREY: Wisconsin, like California, passed legislation in 1972 that made it very difficult to treat people with serious mental illnesses. Following the passage of the new legislation Wisconsin witnessed an immediate increase in mentally ill persons who were homeless, in jails and prisons, and committing violent acts, including homicides.

WORLD: With mental hospitals closed, which public officials are now the front-line screeners of mentally ill individuals?

TORREY: In the past, psychiatrists, psychologists, and social workers were the screeners; now, it's police and sheriffs. They are the ones called when mentally ill persons become disturbed. For example, in New York City in 1976 the police responded to approximately 1,000 mental illness calls each year. By 1998 this had increased to over 25,000 such calls each year. Police and sheriffs are not recruited or trained to be mental health screening officials and it of course takes time from other law enforcement duties that they should be performing.

WORLD: What is "dying with one's rights on"?

TORREY: Dr. Darold Treffert, a psychiatrist in Wisconsin, originally used the term. He kept track of the increasing number of deaths of individuals with serious mental illnesses who died from accidents, suicides, starvation, etc., because of the new laws making it difficult to treat them. Dr. Treffert wanted to emphasize the fact that the new laws were effective in protecting the person's civil liberties and their right to refuse treatment, but in doing so the laws put the person in danger. Dr. Treffert is one of only a few American psychiatrists who have spoken out forcefully regarding the abysmal job we are doing in providing appropriate care for individuals with severe mental illnesses.

WORLD: Why don't more patients who need medication take it?

TORREY: The single biggest reason why individuals with mental illnesses do not take medication is because they do not believe they are sick. Schizophrenia and bipolar disorder are diseases of the brain and the disease often affects the part of the brain we use to think about ourselves. We see this also in other patients with brain disease, especially in Alzheimer's disease, and in neurological terms it is called anosognosia. It is seen in approximately half of all patients with schizophrenia and bipolar disorder. Such patients, no matter how sick they are, deny that they are sick and refuse to take medication. Other reasons why some patients do not take medication include side effects and cost of the medication.

WORLD: What are the consequences of our failure to treat people with serious mental illnesses who need treatment?

TORREY: Horrendous. Beyond the problems of becoming homeless, incarcerated in jail or prison, and becoming violent, mentally ill people who are not being treated often become confused and thus easily victimized. Their judgment is impaired, leading them into potentially dangerous situations. A study of seriously mentally ill individuals in Los Angeles reported that two-thirds of them had been robbed or assaulted in the previous year. Suicide also occurs frequently among mentally ill persons who are not treated.There are additional consequences: For example, hospital emergency rooms are often crowded with mentally ill persons waiting for hospital beds. Many public libraries have become de facto centers for mentally ill persons who have nowhere else to go. Many public parks have been taken over by homeless mentally ill individuals.

WORLD: Are any religious groups helping?

TORREY: I volunteered in homeless shelters for 16 years and have visited shelters in many states. I have been consistently impressed by the quantity and quality of services for the homeless that are being provided by religious organizations. If not for them, we would be much worse off than we are.

WORLD: How do we fix the system?

TORREY: The system can be fixed but the first thing required will be leadership from federal, state, and local officials. Such leadership has been in very short supply. I do not know of a single governor, for example, who has made the treatment of individuals with serious mental illnesses a priority. At the federal level the Center for Mental Health Services, which theoretically should be providing leadership, is one of the least effective agencies in all of Washington, and that is saying a lot!

We need to focus on the sickest patients. Of the 4 million seriously mentally ill individuals in the United States, about 10 percent of them, or 400,000 patients, are homeless, in jails and prisons, and causing most of the problems. And about 10 percent of those, or 40,000 individuals, are overtly dangerous and need to be on mandated medication for the safety of themselves and others.