Columbine, Colo.; Fort Hood, Texas; Virginia Tech; Tucson, Ariz.; and now Aurora, Colo. -- and too many other sites of horror -- are often seen as random acts of violence. Perhaps we arrive at this view because these acts and actors are not tied to conspiracies, or to systematic terrorist plans. Instead, they generally are the actions of a severely disturbed person, typically acting alone, but not spontaneously or without careful planning. In other words, they are not random. In fact, the perpetrators of these acts of murder and mayhem generally build their catastrophic scenario slowly, over months or longer; their progressive behavioral deterioration is often evident to others or sometimes the plan is even broadcast by the perpetrator himself. Analyses after the fact from families, friends, neighbors and personal journals painfully demonstrate their angst, rage, loathing of self and others, and intensifying and monocular attention to their day of reckoning.
Many of us will react with horror and think we need to lock these people up, maybe throw away the key. If we let them out, some advocate for the involuntary use of psychotropic medications. But, in fact, the trajectory to these disastrous events calls for more complex actions. These individuals herald their problems by dropping out (of school, work, treatment) or by overuse of hospital services (especially emergency rooms) or by police confrontations. Functioning deteriorates, and their behaviors communicate distress. Most people are responsive to help when it is offered and provided with dignity and quality. Rare yet unthinkably awful cases go on to violence -- and that is when inattention has allowed their conditions to reach an extreme. The mental health system, including substance abuse services, has been too ineffective for too long in detecting and delivering what is needed, despite the dedicated people who work in these settings.
One "solution" (for those already determined to have a serious and persistent mental illness) is called "involuntary outpatient commitment" -- IOC -- (or "assisted outpatient treatment," "mandatory outpatient treatment"); it has been legally adopted in many (but not all) states, though the requirements of this law vary substantially from state to state. As a rule, the law permits courts to mandate outpatient psychiatric treatment for people with severe mental illness who are at risk of clinical relapse or deterioration that may place themselves or others in danger, and who have demonstrated by past behavior that on their own they are not apt to voluntarily comply (laws for inpatient commitment exist in all states and emergency intervention requires imminent dangerousness). What IOC can provide, when effectively organized and delivered, is clear accountability for, and coordination and monitoring of, a person's condition by community service providers; it also places IOC patients at the front of a long queue for limited mental health resources (including case management, clinic and psychiatric visits, medication, even housing). The fact that a court weighs in adds an unparalleled dimension to the accountability of community service agencies.
But the number of people with serious mental (and addictive) disorders who could benefit from accountable, coordinated and accessible care far outnumbers the capacities of any IOC program, which is always time-limited by a court anyway. My colleagues in many states recognize the considerable limits of IOC, and its dependence on undaunted leadership in clinical and legal services as well as adequate and sustained funding to ensure that the involuntary services demanded of the patient are in place and accessible. What this amounts to is that despite the evidence of success of IOC (and its necessity for some people who may not for years come to appreciate that they are ill), it sounds better than it is.
A special commission by a group of experts and government officials was created in 2008 in New York State by Mayor Bloomberg and then Governor Paterson in the wake of a series of violent incidents in New York City that involved people with mental illnesses, including their use of drugs and alcohol., The report emphasizes two key findings: namely, that violence by people with mental illness is generally the result of their not being engaged in treatments (that can be highly effective), and their use of drugs and alcohol. The implication is that for citizens and police to have their risk of harm reduced, people with mental and addictive disorders need better early engagement and retention in proven (so called evidence-based) treatments.
Acute conditions (whether a broken arm, a heart attack, a delirium, a raging psychosis) benefit from doctors stepping in and taking control. But most conditions are chronic (like diabetes, heart disease, asthma, PTSD, schizophrenia, depression and bipolar disorder) where early detection, accessible and patient-centered care (not in slogan but in reality), the involvement of families and significant others, and the provision of proven treatments are basic to their management. The same approach applies for both physical and mental disorders. With chronic disorders, unless those who are ill learn to take responsibility for and manage their illnesses, the disease (not recovery) triumphs -- and everyone loses.
True clinical accountability means that service providers have designated populations of patients (specified caseloads, registries of patients) for whom they are held continuously responsible (not by involuntary outpatient commitment but by contractual and medical standards); this was one idea advanced but not achieved by the Community Mental Health Act of 1963 (!) that was the foundation for the community-based mental health services we have today. We also need better ways to encourage people with mental disorders to come to and participate in treatment. To achieve this latter goal will mean far more responsiveness to what patients want (again, patient-centered care), peers (other patients advanced in their recovery) as community workers, and creating the experience that it is safe to seek treatment (that the result will not be activating police and locked hospital settings). I wish our provision of these effective elements of care was greater and faster than it has been to date. The need is surely there, with 1 in 5 Americans annually suffering from a mental disorder that adversely affects their life and functioning.
We have no perfect treatments for a host of chronic conditions, including cardiovascular disorders, cancer, Parkinson's disease, dementias, schizophrenia and bipolar disorder. But we have learned a lot about chronic disease management. Our challenge is to turn what we know into better delivery of the right treatments that patients receive from doctors and enabling patients to learn to manage their diseases; some call this closing the science-to-practice gap. The challenge is as great in physical medicine as it is in psychiatric medicine. In mental health, we need to be wary of short-term, reactive "fixes" stimulated by agonizing events that may have emotional appeal but are no substitute for an ongoing resolve to apply proven means of systematically improving care and accountability, which are our best chance to reduce risks to the safety of individuals and communities.
"Random" is not so random. We have not adequately implemented prevention, screening, early intervention and ongoing engagement in good treatment that would better recognize patterns, detect disorders and assure accountable ways to respond. We can close this gap, we know how. When we do, and I believe we can, our communities will be able to meet the complex goals of public safety, personal liberty and high-quality clinical care.
1. Smith,TE, Sederer,LI. "Changing the Landscape of an Urban Public Mental Health System: The 2008 New York State/New York City Mental Health-Criminal Justice Review Panel." Journal of Urban Health, Bulletin of the NY Academy of Medicine. No. 87, Vol. 1, January 2010, pp 129-135. [Link]
2. Smith TE, Appel A, Donahue SA, Essock SM, Jackson CT, Karpati A, Marsik T, Myers RW, Tom L, Sederer LI: "Using Medicaid claims data to identify service gaps for high-need clients: The NYC Mental Health Care Monitoring Initiative." Psychiatric Services. Vol. 62, No. 1, January 2011; pp 9-11
Lloyd I. Sederer, MD
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
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