Courts must be able to order help

March 01, 2001|By Steven S. Sharfstein and Mary Zdanowicz

IT IS SHOCKING. Within 48 hours in Maryland, a police officer, sheriff's deputy, a mother and a teen-ager are dead -- killed by men with symptoms of schizophrenia, violent histories and medication noncompliance.

What should really shock us is that we can expect more of these tragedies in Maryland unless the law governing treatment for the mentally ill is reformed.

On Feb. 11, a 25-year-old painter and writer with a diagnostic history of schizophrenia allegedly bludgeoned and stabbed to death his mother and a young boarder in the family's Columbia home. It happened hours after he sought help at a local mental health service, in a state of noncompliance with his medication.

Two days later, on the Eastern Shore, a 41-year-old man with a history of psychiatric treatment as a result of psychotic episodes and a history of medication non-compliance allegedly shot and killed two police officers who were responding to a complaint at his residence.

In both of these tragic incidents, family members had expressed fear that the men's failure to maintain their treatment might lead to violence.

Maryland is one of only nine states with a law that doesn't permit court-ordered community treatment for the mentally ill.

After a man who was not taking medication to treat his schizophrenia shot a lawyer in downtown Baltimore in 1998, the Maryland legislature wanted to know whether changes in the state's involuntary commitment laws could have prevented such tragedies.

A year ago, a work group recommended that self-management plans in the form of advanced directives were preferable to court-ordered treatment, citing concerns about infringing on civil liberties, misallocation of scarce resources and driving patients away from voluntary services.

But New York's recent experience with Kendra's Law proves that the work group's concerns were unfounded.

Kendra's Law was enacted in 1999 after a man with untreated schizophrenia and a history of mental illness pushed 32-year-old Kendra Webdale to her death in front of a subway train. It allows for court-ordered community treatment for individuals with a history of medication noncompliance, violence and repeated hospitalization.

The law carefully guards civil liberties by providing strict standards and due process protections. Less than 1 percent of the state's mentally ill citizens were referred in the last 14 months, and half of those cases were dismissed. Since the program started, 512 people who would not accept treatment have been ordered to do so and were provided services. Nearly twice as many previously non-compliant individuals accepted services voluntarily after being referred to the program.

Contrary to the Maryland work group's predictions, New York's experience shows that court-ordered outpatient treatment targets services to the highest-risk clients, protects civil liberties and increases voluntary participation in treatment.

The work group also did not have access to data from the most recent and comprehensive study of long-term court-ordered outpatient treatment that showed that it reduces violent behavior in people with severe mental illnesses.

While people who are being treated for severe mental illness are no more violent than the general public, those who are medication noncompliant are more likely to be violent.

Research results from North Carolina released in April showed that long-term outpatient commitment combined with regular outpatient services cut the probability of violence in half. The study also showed that reductions in violence did not occur with services in the absence of a court order for the high-risk clients.

We were reminded recently that these dreadful tragedies are not going to disappear. But we should also remember that there was a time when we were shocked by the homeless mentally ill who now occupy our streets virtually unnoticed.

The Maryland legislature should reconsider enacting a court-ordered outpatient treatment law this session and join the 41 other states in the country that have these laws. Otherwise we risk becoming so accustomed to these senseless killings that they we are no longer shocked and compelled to act.

Steven S. Sharfstein, M.D., is president and chief executive officer of the Sheppard Pratt Health System in Baltimore and Mary Zdanowicz is executive director of the Treatment Advocacy Center, Arlington, Va.

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