They were already insane, and they were already violent.
Then they were told they couldn't smoke cigarettes.
And yet, to the surprise of some patients and staff members alike, the roof has remained squarely in place over the Clifton T. Perkins Hospital Center, Maryland's hospital for the criminally insane that went smoke-free nearly three weeks ago.
"Nobody went bananas," said Nathan Bergstein, a manic-depressive who has been forced to give up a two-pack-a-day habit he enjoyed for 30 years.
The ban has left Mr. Bergstein, 43, free of the chest pains that had bothered him. But it has also left him, like other smokers at the hospital, frustrated and hurt. Calling cigarettes a rare source of "solace in a grim and lonely place," Mr. Bergstein unsuccessfully sought an injunction to overturn the smoking prohibition. Other patients have launched petition drives or berated hospital officials for depriving them of their smokes.
Smoking, insisted one woman patient, who did not want to be identified, "is a coping mechanism" for Perkins patients.
"For many of the patients, they no longer have family or friends or any life at all outside the hospital," she said. "Cigarettes were their best friends."
Still, much to the pleasure of Perkins officials, violence has decreased since the smoking ban began, and patients have not needed more medication to cope with it.
"It's been amazing," said acting Superintendent Christiane Tellefsen, who ordered the smoking prohibition. "Some of the patients were angry, very angry, but they didn't act out, which is very interesting because these are patients who are here because they did act out."
Perkins adopted the ban Jan. 8 to comply with national regulations that give all U.S. hospitals until 1994 to prohibit smoking or risk losing their accreditation. The state's other psychiatric hospitals are also adopting non-smoking policies.
While most doctors applaud smoking bans at general hospitals, some are ambivalent about depriving mental patients of their cigarettes. And a few believe that the criminally insane, who aren't allowed to go outside to smoke, have been selected for special punishment.
"If I had to quit cold turkey, it might drive me crazy, and these people are already there," said Andy Penn, a lawyer with the Maryland Disability Law Center, which represents Perkins patients in grievances, including one filed against the smoking ban.
Smoking, Mr. Penn said, occupies a place of special importance for patients at Perkins, who in the past received cigarettes as rewards for good behavior. "This is home for them and what a home it is," he said. "Smoking is one of their major activities. It provides some kind of relief for people in miserable straits."
That is a convincing argument for some psychiatrists, who readily acknowledge the lethal quality of cigarettes. "For long-term patients, the hospital is their home, and I think it is a mistake not to allow them to smoke as they would at home," said Roger Peele, chairman of psychiatry for the District of Columbia's mental health services. "I do think there are patients for whom [withdrawal from cigarettes] would create an additional psychiatric and physiological burden."
Alexander Glassman, a psychiatrist at Columbia University and an expert on the links between nicotine and mental illness, agreed. He said that studies have found that people with a history of depression often deteriorate when they quit smoking.
"There's reason to suspect that nicotine withdrawal may make symptoms worse," said Dr. Glassman, who runs a smoking cessation clinic at New York Psychiatric Hospital. "That should have been studied before a ban was instituted."
The rate of nicotine addiction is much higher among psychiatric patients than in the general population. Michael P. Resnick, director of psychiatric education at Providence Medical Center in Portland, Ore., said that slightly more than a quarter of all American adults smoke but that three out of four hospitalized psychiatric patients smoke.
"They use it as self-treatment," said Dr. Resnick. "It calms their anxiety, increases their concentration" and moderates their behavior."
That does not mean, however, that he opposes a smoking ban. His own research, he said, has proved that psychiatric patients XTC can give up cigarettes without severe reactions.
"Yes, cigarettes may be a cheap, available means of calming patients," he said, "but I'm hard-pressed to accept that it is better to provide cigarettes than it is to give patients active treatment. If you treat depression with nicotine and the patient dies of lung cancer, you haven't done a lot of good."
Dr. Tellefsen and other psychiatrists who support a smoking ban insist that smoking is an addiction that must be broken like any other addiction. "We have patients who are alcoholics, and we don't give them alcohol," she said. "We have patients who come here addicted to cocaine, and we don't give them cocaine."