Capitol suspect fell through system's cracks Tragedy shows treatment is essential for recovery

August 02, 1998|By Steven S. Sharfstein

The recent killings in the U.S. Capitol underscore the failure of our legal and mental health systems in reaching out to patients and families who suffer with schizophrenia.

Schizophrenia is a chronic and disabling brain disorder that affects approximately 2 million Americans each year. It impairs the individual's ability to think clearly, manage emotions and relate to others. Fewer than 50 percent of individuals with schizophrenia are receiving the treatment they need. Scientific breakthroughs have provided new knowledge of the neurobiology of the disorder, its genetics and new treatments combining medication with psychosocial care. In contrast to the situation several decades ago, the opportunities for recovery have never been greater as long as patients receive the combination of medication and intensive, continuous community support.

The recent tragedy is twofold - tragic because two policemen died, and because the alleged gunman, Russell Eugene Weston Jr., fell through the cracks of our mental health system. News accounts say Weston was hospitalized for schizophrenia and stopped taking his medication after he was released.

Schizophrenia is a highly treatable disorder. Hospitalization might be required to help manage the severe delusions or hallucinations, suicidal behavior, inability to care for oneself and problems with drugs or alcohol that can accompany the disorder. After discharge from inpatient hospital care that results from an acute episode, people with schizophrenia must stay in treatment. Approximately 80 percent of those who stop taking their medication after an acute episode will relapse within one year. Of those who continue their medications, only 30 percent will relapse during the same period.

Individuals receiving treatment for schizophrenia are no more prone to violence than the general public, though some patients with paranoid schizophrenia who have stopped their medications are a danger to themselves or others.

Ten percent of patients with schizophrenia commit suicide. Violence toward others most often occurs within families. Sometimes this violence is directed toward strangers because of persecutory delusions. These manifestations of schizophrenia underscore the public health peril created by large numbers of untreated individuals in our communities.

For patients with schizophrenia to receive the services they need, several elements are necessary. These include adequate insurance coverage that is equal to coverage for other major medical disorders; involuntary inpatient commitment to provide short-term hospitalization to stabilize the acute symptoms of the illness; accessible community-based care after hospitalization to include the medications, treatment and housing and rehabilitation essential for recovery; assertive community programs to provide 24-hour outreach; and crisis support to patients and families.

When people are hospitalized for schizophrenia, outpatient care is necessary and appropriate. Although many patients comply with treatment, others deny that they are ill, discontinue their medications and do not show up for outpatient appointments. Within a relatively short time, acute symptoms re-emerge and, if untreated, will lead to a full relapse of the illness. The risks for homelessness, incarceration and violence escalate for these untreated patients. Therefore, another mechanism - involuntary outpatient commitment - should be available so they can be forced into treatment.

Involuntary outpatient commitment should be considered in cases where schizophrenics are hospitalized numerous times for failing to take medication or for refusing follow-up care. Under the guidelines of outpatient commitment, when these patients fail to comply with the demands of outpatient treatment, the police could be enlisted to deliver the patient to the outpatient treatment facility.

The health and safety issues for untreated schizophrenia are so significant and compelling that coercion is justified. It should not be necessary for patients to deteriorate to such a desperate state that involuntary inpatient care is necessary to prevent real human calamities.

Maryland does not have a commitment statute that would, after due process to protect an individual's rights, allow for involuntary outpatient treatment. This is in contrast to our neighboring states that have such laws.

In Maryland, this presents an often unmanageable burden for families struggling with a family member who has schizophrenia, discontinues treatment and becomes a danger to himself or others. Such a law should be passed.

Senseless tragedies such as the Capitol Hill shootings can be prevented. We need legal and medical services that provide schizophrenics with the treatment and humane care they need to counter this major public health disaster confronting our nation.

Steven S. Sharfstein, M.D., is president and medical director of the Sheppard Pratt Health System and clinical professor of psychiatry at the University of Maryland.

Pub Date: 8/02/98

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