Out of the psych ward, into the city streets

When 29-year-old William Anthony Ramos was shot and killed during a scuffle with two Ventura, Calif., police officers last June, he had evidently been off his medication for some time. The day before the fatal incident, family members had repeatedly called police asking that he be taken to a psychiatric hospital after he began marching the streets of central Ventura-arms to the heavens-bellowing Bible passages. A paranoid schizophrenic, Mr. Ramos had been in and out of psychiatric hospitals and jails for the last several years. But California law stipulates that mentally ill people can only be hospitalized if they are a danger to themselves or others, regardless of whether they need treatment or not. "[Police] said he was fine and wasn't any threat," his sister Cindee remarked after the shooting. "Now he's dead."

The events that led to Mr. Ramos's death are far from unusual, experts say. Family members are frequently powerless to get treatment or institutionalization for loved ones, even if they are unable to function or are threatening violence. Only half of the diagnosed population with severe mental illnesses who could benefit from treatment are receiving it. The number of severely mentally ill persons in the United States not receiving treatment is estimated at 2.2 million.

E. Fuller Torrey, one of the country's foremost experts on serious mental illness, works in a small office at St. Elizabeth's Hospital, just off the Southeast Freeway in Washington's predominantly black Anacostia section, a part of the city that most D.C.-area residents have little reason-or inclination-to visit. Founded in 1855 as the Government Hospital for the Insane, St. Elizabeth's now inhabits 334 acres of land in a complex of some 125 impressively ornate stone buildings, some of them apparently abandoned and dilapidated. Anacostia is a high-crime area.

In most parts of the nation's capital, including tony Northwest, it is not only muggers that the average traveler now looks out for. It is also the mentally ill homeless, many of them harmless enough, muttering distractedly to themselves, carrying their possessions in bags or shopping carts, clothes, smell, and appearance all indicating that they have been on the street for some time and don't plan on going anywhere anytime soon. But some of them can be positively menacing: abusive, aggressive, and violent, a danger to themselves and others. As a result, most city dwellers have learned to ignore the street people they pass each day, adopting-for defensive purposes-an attitude of indifference.

The problem is, it has become more than just an attitude. As a society, Dr. Torrey argues, citizens are so accustomed to ignoring the mentally ill homeless that they have become indifferent to their plight, indeed to their very existence. In his book Dr. Torrey makes a compelling case that the mass deinstitutionalization of the past 35 years has not been without serious costs to society, and devastating consequences for the many individuals and families touched by serious mental illness. Characterizing deinstitutionalization as "the largest failed social experiment in 20th-century America," he suggests it is high time that we rethought the whole policy and its consequences.

At its peak of operation in the 1950s, the total number of residents in state-run mental institutions such as St. E's across the country was about 560,000; today, the institutionalized population of the United States is just 72,000-a drop of 92 percent when the growth in total population is factored in. While much of that decline was due to medical advances that have allowed those with serious mental illnesses to function normally outside institutions with the aid of medication, a far more substantial portion is due to a combination of ideology and politically driven economic pressure.

The trend of deinstitutionalization first became pronounced in the years between 1955 and 1965 when the first anti-psychotic drugs became available. If the downward trend had continued at that rate, Dr. Torrey estimates that the number of patients in state psychiatric hospitals today would be approximately 350,000 instead of the estimated current figure of 72,000. But after the enactment of Medicaid and Medicare in 1965, federal dollars became available for income support, medical and psychiatric care, and food supplements for the mentally ill. By discharging their patients from state-run and -funded institutions, states were effectively transferring the cost of caring for the severely mentally ill to the federal government. The relatively modest pace of deinstitutionalization was thus greatly accelerated, and states had no incentive to provide follow-up care after release, since patients requiring readmission or treatment could now be diverted to general hospitals where Medicaid would cover most of the cost.

The result was not so much deinstitutionalization as what Dr. Torrey terms trans-institutionalization, a phenomenon in which patients are discharged from mental institutions only to be transferred to the care of homeless shelters, nursing homes, public hospitals, and prisons. In fact, it is now common in many states to find former residents of psychiatric hospitals residing in the same buildings that they once knew as mental institutions, now shut down by the state and reopened as homeless shelters.

But a huge number of former mental patients wind up on the streets, due largely to inadequate provisions for continuing treatment and a series of court rulings that make involuntary commitment almost impossible. Dr. Torrey estimates that the number of homeless people who have serious mental illnesses exceeds 150,000, which is about 35 percent of the total homeless population in the United States. (If drug and alcohol abusers are included, the mentally ill make up a full 95 percent of the homeless population.) And the number of severely mentally ill persons incarcerated in the nation's prisons probably exceeds the number who are homeless.

Tragically, the vast majority of the mentally ill homeless-as well as many of those serving time for violent crime-could live a normal life with adequate treatment; 70 to 90 percent of those with serious mental illnesses respond positively to medication. But effective treatment of severely mentally ill outpatients requires follow-up supervision, since those who suffer from serious mental disorders often have a weak grasp of their condition and subsequently fail to see the need to take their medicine.

The chief reason for the cautious approach to mandatory treatment on the part of states and law-enforcement officials is the work over the past 30 years of civil-liberties advocates and judges who have put up virtually insuperable barriers to institutionalization and mandatory treatment. Court decisions that mandated strict guidelines for commitment were seized on by civil-liberties lawyers in order to force the discharge of psychiatric patients and to pressure institutions not to admit new patients, often with the express intent of closing down the state institutions.

Dr. Torrey proposes giving fiscal responsibility for the treatment of the severely mentally ill back to states in the form of block grants that ensure a minimum standard of follow-up care for released mental patients. At least one state has attempted reforms along the lines that Dr. Torrey proposes; during John Sununu's tenure as governor of New Hampshire in the mid-1980s, the state legislature passed legislation mandating "conditional discharge" of mental patients who have been hospitalized. Among the conditions: avoiding drugs and alcohol, continuing to take any needed medication, and agreeing to follow-up visits from certified psychiatric hospital staff. After a decade, the results have been impressive, including a sharp decline in the number of released psychiatric patients readmitted to hospitals and significantly improved stability in employment and housing.

The idea of greater fiscal responsibility at the local level is in keeping with the policy trend toward devolving federal powers and programs to the states, and Dr. Torrey has some sympathetic ears among the members of the GOP majority in Congress. But in order to carry out any plan that involves mandatory follow-up and treatment for persons with serious mental illnesses who wish to continue living in the community, legal reform will be necessary, and many civil libertarians oppose such changes. But Dr. Torrey has noticed less resistance to such ideas in the last few years. "After all," he says, "if you push the civil libertarians into a choice between mandatory outpatient commitment and reinstitutionalization, there is little doubt that most would choose the former."

Mr. Robertson is a writer in Washington.