The real issue in Arizona: Schizophrenia (Part 2)
Earlier today, I reviewed medical experts' explanations of the causes of schizophrenia. In this post, I'll look at how the illness manifests, whether lay people can identify it, and what changes may be needed in the mental health system.
Dr.Stephen Marder, an expert on schizophrenia at UCLA, explained that schizophrenia often manifests in people's late teens and early 20s. On average, it appears somewhat earlier in men than it does in women, and men do worse initially than women.
Marder emphasized that violent behavior is "not common to the larger group of people with the illness, but to a very small group of individuals." Among the small number of people with schizophrenia who do become violent, we may see headline-grabbing crimes related to their symptoms -- paranoia, visual or auditory delusions, and social isolation. Moreover, the number of victims or the involvement of a high-profile individual is a hallmark of these crimes.
Can lay people recognize schizophrenic behavior? Marder said: "There really is a continuum of behavior. Take suspiciousness, and you will find that, yes, at the extreme end, people with schizophrenia may believe the government is out to harm them."
Charles Currie, a former administrator of the U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration, also emphasized that most people with schizophrenia are not violent. But he said we should be able to alert the public, educational authorities and law enforcement -- as we do in public health campaigns on suicide, for instance -- about behaviors that are indicative of schizophrenia. He said there are relatively inexpensive things we could do, including implementing Mental Health First Aid, a program first pioneered in Australia. The idea is to make training about the risk factors and warning signs of mental health problems as common as first aid training. The program has already conducted training in 43 states.
The tragic fact is that in Arizona, school officials and classmates did recognize that Jared Loughner was unstable and possibly violent long before the Tucson incident.
The records of Loughner's interaction with law enforcement are now available. In February 2010, a dean at Loughner's community college called campus police about his behavior. She reported that Loughner, in response to a fellow student's poem, "about abortion, wars and killing people and 'why don't we just strap bombs to babies.'" In April, campus police were called to the college library because Loughner was making loud noises. In May, the police were called to a classroom when Loughner became "very hostile." And in June, the dean showed campus police bizarre e-mails Loughner wrote and a math exam on which Loughner scrawled "Mayhem Fest!". On all of those occasions, campus police determined that there wasn't anything more they could do.
It wasn't until the Fall that officers mentioned the possibility of mental illness. In September, campus police responded to a report that Loughner was disrupting his class. One officer wrote that Loughner was not able to "process" why police had been called in and that when Loughner spoke "his head was tilted to the left and his eyes were jittery." At that point, the officers actually verbalized to a school official that there might be a mental health issue, but neither the police nor the administrators apparently contacted the mental health system. Nor was there a mental health referral when Loughner was suspended over a violent video later that month.
This appears to be an egregious failure by law enforcement to bring mental health experts on to the scene. They were dealing with a mental health problem and not a law enforcement matter. It remains unclear why school officials, too, did not encourage a mental evaluation of Loughner.
Meanwhile, the sheriff's office had four relatively innocuous interactions with Loughner. CBS News reports: "Taken alone, Loughner's run-ins with police, including one arrest for marijuana possession and another for being drunk in school after fighting with his dad, seem normal for a slightly rowdy teenager. In context of the horrendous crime he is accused of, they may provide some insight into the deterioration of Loughner's mental state." Had the sheriff's office had the benefit of the campus records, it might well have brought in mental health authorities.
Can someone suspected of having schizophrenia be evaluated involuntarily? It depends on which state you are in. Many states require proof that an individual is a risk to himself or others or that an individual is unable to meet his or her basic needs.
Quite tragically, however, Arizona is one of the few states that has a very low threshold for forcing a psychiatric evaluation -- so long as the person is experiencing mental anguish, an examination can be triggered. It is quite possible Loughner could have been required to undergo an evaluation that could have lead to treatment. But the mental health system apparently did not have Loughner on the radar screen. "We need to know more" as to why campus authories "sat" on the wealth of information, said Brian Stettin of the Treatment Advocacy Center.
Of course, even once someone has been diagnosed with schizophrenia, he or she may resist sustained treatment. In some states, a court order for outpatient treatment may be otained. While people with schizophrenia may have trouble recognizing their own condition, the threat of a court order is something they may "take seriously," Stettin said. In addition, many states allow an advanced directive, Currie said. A patient who has been treated and is lucid can authorize involuntary treatment should he go off his medication. "We need to study how well this works," Currie said. There is also progress with injectable medication that can work for up to 30 days -- eliminating the daily decision to continue medication.
So what the actual lessons from the Arizona massacre? First, we need greater public awareness of the symptoms of schizophrenia and to inform them that violent behavior only occurs in a small percentage of patients. More important, they need to understand the mechanisms for getting a mentally ill patient evaluated. In states with laws that inhibit potentially life-saving committment, we need to re-examine the impact of those laws on public safety. A results-based system for evaluating the efficacy of various mental health approaches should be implemented so we are spending money wisely. We need to make sure states' mental health systems are properly reporting mental health patients to the federal data base to prevent them from purchasing firearms.
But we shouldn't repeat the fallacious reasoning that characterized much of the media chatter. As President Obama eloquently put it at the memorial service:
Scripture tells us that there is evil in the world, and that terrible things happen for reasons that defy human understanding. In the words of Job, "When I looked for light, then came darkness." Bad things happen, and we have to guard against simple explanations in the aftermath.
Nevertheless, it would help if we started at least discussing the issues raised by this horrific incident. We aren't going to prevent all crimes by those with schizophrenia who behave violently, but we should examine the problem of untreated people with mental illness and also how well our mental health programs are treating those who gain access to the system.
| January 14, 2011; 2:38 PM ET
Categories: Arizona shooting
Save & Share: Previous: Cut defense, ask questions later
Next: Freedom House tracking human rights or promoting liberal agenda?
Posted by: rgray | January 14, 2011 3:22 PM | Report abuse
Posted by: sugarstreet | January 14, 2011 4:24 PM | Report abuse
Posted by: bluestatesman | January 14, 2011 4:24 PM | Report abuse
Posted by: 10bestfan | January 14, 2011 4:38 PM | Report abuse
Posted by: Dalibama | January 14, 2011 5:05 PM | Report abuse
Posted by: sugarstreet | January 14, 2011 5:11 PM | Report abuse
Posted by: s_mceachern | January 14, 2011 5:23 PM | Report abuse
Posted by: meadelaurence | January 14, 2011 5:47 PM | Report abuse
Posted by: marybel9999 | January 14, 2011 7:16 PM | Report abuse
Posted by: TYoke | January 14, 2011 7:28 PM | Report abuse
Posted by: marybel9999 | January 14, 2011 7:31 PM | Report abuse
Posted by: kryon77 | January 14, 2011 8:30 PM | Report abuse
Posted by: Larry3435 | January 14, 2011 9:56 PM | Report abuse
Posted by: Arjuna1 | January 15, 2011 1:20 AM | Report abuse
Posted by: DDiorioNDallas | January 15, 2011 8:37 AM | Report abuse
Posted by: sugarstreet | January 15, 2011 10:07 AM | Report abuse
Posted by: ejoe1 | January 15, 2011 12:25 PM | Report abuse
Posted by: werehawk | January 15, 2011 4:54 PM | Report abuse
Posted by: sugarstreet | January 15, 2011 5:16 PM | Report abuse
Posted by: sugarstreet | January 15, 2011 5:18 PM | Report abuse
Posted by: lowonprozac | January 15, 2011 9:09 PM | Report abuse
Posted by: claygooding | January 17, 2011 2:32 PM | Report abuse