Can Cure Be Found for a Flawed System?

There was a time when a diagnosis of paranoid schizophrenia probably would have kept John Segreto in a mental institution for life.

But development of anti-psychotic drugs in the 1950s and the “deinstitutionalization” movement two decades later changed that. The new thinking was that most mental patients, with proper medication and treatment, could live at home or in outpatient centers.

It was “a flop,” says Richard Greer, forensic psychiatrist with the University of Florida.

“We oversold ourselves. We didn’t have the necessary medicines . . . and we never got the funding for community centers.”

Marvin Swartz, an associate professor of psychiatry at Duke University, says deinstitutionalization was “not a flop as a concept, but its implementation was gravely flawed.”

Policymakers had too much faith in drugs alone, he said. Many patients who take medicines also need support services to get along in the community.

Few would argue for a return to “warehousing” patients in psychiatric wards. But what to do about those who, once discharged, stop taking medicine and refuse other treatment?

Some advocates say judges need greater power to order patients back to the hospital.

“We’re not doing them any favors if we give them the civil rights to stay in the community without getting the help they need,” says Bev Lewis, the president of the Alliance for the Mentally Ill in Michigan.

Paul Denenfeld, the legal director for the American Civil Liberties Union’s Michigan chapter, opposes making it easier to force treatment on patients.

“That’s a frightening concept to me,” he said. “These are not criminals. These are people who need help.”

He acknowledges that balancing the rights of the mentally ill with those of society means that violent people sometimes slip through the cracks.

“It’s the price we pay for our liberty,” Denenfeld said.

Michigan’s involuntary commitment law is typical of those in most states. It says a person can be required to enter an institution only if he cannot attend to his basic needs, or if he is found dangerous to himself or others.

It also provides for “outpatient commitment,” where judges order mental patients to continue medication and therapy as a condition of leaving an institution.

Such policies appear to have reduced the rate at which mental patients wind up back in the hospital, says Swartz, who is studying the effectiveness of outpatient commitment nationwide.

But critics say take-your-medicine orders are unenforceable in many states. Even if a patient defies a judge, he cannot be returned to the hospital unless he poses a clear threat to himself or others.

That’s not the case in Michigan, says Scott Walker, a spokesman for the state Department of Mental Health. People approved for outpatient commitment are placed in community treatment programs. If they don’t stick with it, they can be ordered back to the hospital or into another program.

Another problem: figuring out which patients might turn violent. John Segreto apparently showed no such tendencies until Jan. 18, when he held up a Houghton bank and was shot dead by police.

In the early 1990s, researchers at the University of Pittsburgh found that chances were somewhat better than 50-50 of predicting violence by male mental patients. For reasons that weren’t clear, violence by women could not be forecast, says William Gardner, statistician in the psychiatry department.

“There are huge numbers of people with serious mental illness who are no more dangerous than anyone else,” Gardner said. “And there are some who are frequently violent. It’s hard to identify which is which.”

John Monahan, a psychologist with the University of Virginia, is directing a study for the Chicago-based MacArthur Foundation. About 1,000 mental patients are being tested for a variety of “risk markers,” such as ability to control anger and willingness to take medication.

After their release from the hospital, “we’re following them into the community . . . to see which of these factors relate to violence and which don’t,” Monahan said.