Mentally ill can be unaware they're sick
By E. Fuller Torrey and Mary T. Zdanowicz, 06/08/02

Research in the last decade has clearly established that approximately half of individuals with schizophrenia and manic-depression have an impaired awareness of their illness. This impairment, called anosognosia by neurologists, is caused by damage to areas of the brain that mediate self-awareness. The impaired awareness is thus biological in origin, similar to that seen in Alzheimer's disease, and may vary in degree from individual to individual and even in the same individual over time. It is not the same as denial, a psychological mechanism that we all use at times.
This lack of awareness may explain why a number of the mentally ill are inconsistent in taking their medications, antipsychotic drugs that can help stabilize moods or eliminate delusions.
If these people live in Massachusetts, there is no law requiring that they take their medications in order to remain in the community. In this, Massachusetts differs from 41 other states that do have laws requiring outpatients to follow their treatment plans. In these states, if a mentally ill individual refuses to follow the treatment plan, including taking prescribed medications, he can be involuntarily hospitalized. By contrast, in the Commonwealth, an individual must show ``a very substantial risk of physical impairment or injury'' in order to be hospitalized against his will.
Although laudable from a strictly civil libertarian position, Massachusetts' present laws make it impossible to treat thousands of its citizens who have brain diseases and who also have impaired awareness of their illnesses. Large numbers of these individuals end up living on the streets and in public shelters, making up approximately one-third of the homeless population. Another large number commit misdemeanor crimes as a consequence of their untreated illness and end up in jails.
Based on a 1999 survey by the Department of Justice, there are now proportionately as many mentally ill persons in Massachusetts jails as there were 160 years ago, when Dorothea Dix began her national campaign in Cambridge for treatment, not incarceration, for such individuals.
For others in Massachusetts, the failure to treat individuals with severe psychiatric disorders produces graver consequences. Last July, for example, Gary Sampson killed three people in Massachusetts and New Hampshire while not taking his medication. Sampson had a 24-year history of schizophrenia and proven dangerousness in the past when not taking medication, yet he was not required to take it. Studies have also shown that individuals with severe mental illnesses who are not being treated are seven times more likely to commit suicide compared to those who are being treated.
Any system that allows for involuntary hospitalization or treatment must, of course, include checks and balances to ensure that the system cannot be abused. The old Soviet Union, where political dissidents were sometimes given psychiatric labels and involuntarily hospitalized, demonstrated that psychiatry could be so abused. Other states that permit involuntary treatment, such as the widespread use of conditional release in New Hampshire or the recently passed New York State law allowing for outpatient commitment (``Kendra's Law''), have mechanisms in place to prevent abuse. With over 900,000 trained lawyers in America, mechanisms to prevent abuse are relatively easy to implement.
Massachusetts, then, pays a price for its strict civil libertarian approach to severe psychiatric disorders. By making involuntary treatment virtually impossible to achieve, the state ensures that it cannot be abused. However, by making involuntary treatment virtually impossible to achieve, Massachusetts also traps thousands of severely mentally ill individuals, who have impaired awareness of their illness, into a lifetime of illness and its tragic consequences.
In a 1999 decision, Supreme Court Justice Anthony Kennedy wrote: ``It must be remembered that for the person with severe mental illness who has no treatment, the most dreaded of confinements can be the imprisonment inflicted by his own mind, which shuts reality out and subjects him to the torment of voices and images beyond our powers to describe.'' What are civil liberties for such individuals?
Dr. E. Fuller Torrey is president and Mary Zdanowicz is executive director of the Treatment Advocacy Center in Arlington, Va.

Forced medication is inhumane
By Robert Whitaker, 06/08/02
Thirty-five years ago, we began emptying state mental hospitals in this country, amid promises that we would build a comprehensive system of community care. As a society, we reneged on that promise, and we all know the sorry result. Many people with severe mental illness have no access to decent housing or to any sort of humane care, and so of course we now see disturbed people on our streets. What should we do about this?
One proposed solution, a step which 41 states have taken, is to pass an involuntary outpatient commitment law. Massachusetts has no such law, but it is being urged to join the pack. We need to be very clear about what is at stake here. States have always had legal methods for committing disturbed people to psychiatric facilities and a process for forced drug treatment in that environment. By passing involuntary commitment legislation, states are asserting the right to demand that people living in the community take ``antipsychotic'' drugs, which represents a profound expansion of state control over the mentally ill.
Here are a few critical facts that we need to know in order to assess the ethical and practical merits of such legislation - facts that involuntary commitment proponents never tell the public.
First, we have made antipsychotic drugs the cornerstone of our care for the past 50 years, and the long-term results have been dismal. The World Health Organization has twice found that outcomes for schizophrenia patients in the United States and other rich countries are much worse than in poor countries like India and Nigeria, where only one in six patients were regularly maintained on these medicines. In a similar vein, Harvard Medical School researchers announced in 1994 that outcomes for US schizophrenia patients had worsened during the past 20 years and were now no better than they were at the start of the 20th century.
Second, we are often told that the mentally ill do not take their ``meds'' because they don't know they are sick. In some instances, that may be so. But patients may also have very rational reasons for not wanting to take these drugs. The older agents like Thorazine and Haldol, which are still in use, regularly induce Parkinsonian symptoms and an extremely painful agitation known as akathisia (which has been linked to homicide and suicide.)
As for the newer generation of antipsychotics like Zyprexa and Risperdal, they are proving to be problematic as well, even if their side effects are of a different sort. With Zyprexa, for instance, extreme weight gain and drug-induced diabetes are evident risks. Nor are physical side effects the extent of the problem. Many patients complain that they are spiritually deadening. They say that the drugs rob them of any sense of joy, of their willpower, and of their sense of being.
Third, consumer groups - the voice of those who would be so treated - are adamantly against commitment laws. They believe that such laws are a gross violation of their civil rights and argue that they are counterproductive, in that forced treatment drives people away from medical care.
Fourth, there is good evidence that good evidence that assertive outreach programs can be just as effective as involuntary commitment provisions in getting the mentally ill to voluntarily take their medications. The Bazelon Center for Mental Health Law, a Washington, D.C.-based advocacy group that reviewed the research literature on this issue, concluded that if patients are provided with access to services on a voluntary basis, then society can ``accomplish the same ends without coercion, without the trauma of a court appearance, and without violating the individual's right to make decisions about his or her own health care.''
Finally, the public has a greatly exaggerated sense of the dangerousness of the mentally ill. Studies have found that the risk of violence associated with major mental illness is ``small'' in comparison with the risk associated with substance abuse. In other words, we have more to worry about from people who are drunk or stoned on some street drug. Involuntary commitment proponents who hold up high-profile murders are simply using scare tactics, and that is never the stuff of good public policy.
Once these facts are considered, the rationale for involuntary commitment legislation disappears. We can use assertive voluntary programs to achieve the stated goals of the laws. By going this route, we also avoid the very real ethical problem of forcing people to take drugs that regularly induce physical illness of some kind (Parkinson's, obesity, diabetes, etc.), and which many find emotionally deadening. Indeed, it is noteworthy that during the 1970s the Soviet Union used antipsychotics to punish dissidents, who bitterly protested that such drugging was a form of torture.
Involuntary outpatient commitment calls up all the sins of the past, of forced lobotomies and forced electroshock. What we need to do today is focus on creating a more humane future, one that involves listening to consumer groups and providing the mentally ill with good housing, vocational help, and other forms of social support. Many people so treated will welcome antipsychotic medications, and take them readily. And for those who don't want to take such drugs, then the obvious challenge for our society is to provide alternative methods to help them cope with their delusions and voices.
Robert Whitaker is author of ''Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill.''