Suspect’s Tortured Path Typifies Treatment Pitfalls

Neighbors wondered what went wrong, why “the system” didn’t take better care of Russell Eugene Weston Jr.

Montana, where the 41-year-old man charged with killing two Capitol policemen received treatment for paranoid schizophrenia, is widely known for its poor mental health care system. But even under the best of circumstances, specialists say that treatment of Weston’s disease--marked equally by profound and persistent mistrust, and by noncompliance on the part of most patients--remains notoriously difficult.

“This is not a Montana problem or an Illinois problem,” said Ron Honberg, legal director of the National Alliance for the Mentally Ill, an advocacy group in Arlington, Va. “This is something that could happen in Anytown, USA.”

An estimated 2 million Americans are known to suffer from one of five forms of the brain disorder known as schizophrenia. Many hear voices. They suffer from feelings of persecution, and often display signs of grandiosity. Like Weston, it is not uncommon for them to bear a bitter grudge against authority. Weston is also achingly typical in believing, for example, that radio transmitters had been implanted in his teeth.

Treatment is difficult, and many patients--again, like Weston--complicate the possibility of recovery by bouncing from state to state, or facility to facility, receiving what is sometimes called “Greyhound therapy.” Patients often shun intervention. Follow-up care is rare--one of the biggest obstacles, experts say, to effective treatment. In the age of managed care, benefits are shrinking.

But at least one program, an intensive, community-based intervention effort in Madison, Wis., stands out as a model of schizophrenic treatment.

Long misunderstood, schizophrenia is viewed now as “primarily a biological, genetic disease,” said Dr. Adrian Raine, a clinical neuroscientist at USC. It is also progressive, debilitating and, Raine said, particularly vexing to manage because so many patients--Weston is once again an example--take medication only under constant, direct supervision.

“Although they’re a bit scary, they don’t all commit violence. But one in a thousand does,” Raine said. He cited a recent MacArthur Foundation study showing that schizophrenics are four to six times more likely to commit violence than the general population (though they are less violence-prone than people generally believe).

“We could institutionalize all of these people, keep them in forever--at a great cost,” Raine said. “But then we have that balance between freedom and security. It’s very tough.”

Difficulties in Diagnosis

Schizophrenia carries a powerful social stigma, and many psychiatrists resist applying the label until they are certain of the diagnosis, said Dr. Mark Feldman, a psychiatrist at the University of Alabama at Birmingham. Schizophrenia also shares symptoms with some other conditions, such as manic depression and substance abuse.

“The symptoms can be seen as eccentricity, and very early on it can be difficult [to diagnose],” Feldman said. The condition emerges gradually, he said, and “over the years, the features become unmistakable.”

Even so, said Mary Rappaport of the alliance for mentally ill, “as many as 50% of the people who have schizophrenia are not aware that they have a disorder, and don’t appreciate their need for treatment.”

State commitment policies vary widely, but most require that a person pose an immediate threat to society or himself. Commitment hearings may not focus on the patient’s history, or on an arguable need for compassionate intervention. To guard against arbitrary involuntary confinement, California has particularly rigorous commitment standards, said Elyn Saks, a professor of law and psychiatry at USC and a specialist in mental health law.

Under the state’s Welfare and Institutions Code, an individual may be placed in a California psychiatric hospital for 72 hours if the person is a danger to himself or others, or is gravely disabled.

“Unless there’s conclusive evidence that you intend to follow through on threats, it’s pretty hard to commit,” said Los Angeles psychologist Robert R. Butterworth. “It’s about the most difficult thing you can do in the state of California.”

As a consequence, brief and intermittent hospitalizations are not uncommon, said forensic psychiatrist Dr. Michael Stone of New York. A new generation of anti-psychotic drugs can quickly relieve many schizophrenic symptoms and are considered extremely effective. “But what happens to many patients is that they become less crazy, their thinking clears up--then they go home and leave their pills in the drawer,” Stone said. “Then, shortly thereafter, they become crazy again.”

Many patients complain of the drugs’ side effects, such as sexual dysfunction. Others view the medication through the veil of their own paranoia, regarding it as a poisonous plot. In any case, noncompliance is rampant.

The new drugs, such as Zyprexa, Clozaril and Risperdal, cost as much as $200 a month. Some managed care plans have cut psychiatric visits and sliced prescription budgets so these drugs aren’t covered, Butterworth said. California recently extended Medi-Cal coverage to some of these drugs.

But Stone noted that “you can’t rely entirely on medication.” In the case of Weston, “this man was a misfit, he was a loner, not working at anything productive.” To treat this kind of a patient, “you would want to rehabilitate him to the point where he would feel some level of pride. But that’s a tall order,” Stone said. “It’s expensive, and it takes time.”

Lack of adequate follow-up is one of the major obstacles to managing the care of schizophrenia, many experts say. But PACT, the Program of Assertive Community Treatment in Wisconsin, is based entirely on a formula of follow-up. The 25-year-old research project, supported jointly by the state and the National Institute of Mental Health, provides individualized intervention for about 140 schizophrenic clients, said social worker Deborah Allness, who helped design the program.

She likened it “to a relationship with a good family doctor; over the years, you get to know them and they get to know you.” Many mental health facilities operate on a revolving-door basis--both for patients and staff. At PACT, she said, “Through individual relationships and assessments, you map out a client’s needs. If someone needs a ride to work for several months, there’s a flexibility of the staff to do that.”

Allness said the average cost is low, from $7,000 to $9,000 per year. She added that most clients do not require rehospitalization.

Sufferers Are Often Transient

One more roadblock in the mental health marathon is that many schizophrenics move from state to state. Employment is difficult, and many lead transient lives. If they are committed for treatment, voluntarily or otherwise, their mental health records become part of an institutional bureaucracy. Even families can have trouble tracking down a patient’s medical history, and future caregivers are often stymied by confidentiality regulations.

The same complications apparently apply to laws governing gun ownership. Illinois state police say Weston obtained a registration card allowing him to own certain types of weapons, even though he spent time in a Montana mental hospital. Although Illinois law prohibits anyone who was in a mental hospital within five years from getting a gun card, there is no unified system for sharing mental health records among states.

For their part, Weston’s relatives stressed they do not blame any agency for what happened with him; they just wish things had happened differently.

Russell Weston Sr. said Monday he would like to see patients who are institutionalized be released only on the condition that they stay on their prescribed medication, and that they be returned to the facility if they fail to do so.

His mother, Joey Weston, added that schizophrenia “is a disease that people back away from. People don’t know what to do, they don’t know where to go.”

Times staff writer Eric Slater in Valmeyer, Ill., contributed to this story.

SAD RETURN TO WORK: Sorrow hangs over Capitol after last week’s killings. A10