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Posted at 2:38 PM ET, 01/14/2011

The real issue in Arizona: Schizophrenia (Part 2)

By Jennifer Rubin

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.

By Jennifer Rubin  | January 14, 2011; 2:38 PM ET
Categories:  Arizona shooting  
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Comments

Rubin's conclusions will cost money. It costs money to do monitoring and evaluation and to implement new programs:

"A results-based system for evaluating the efficacy of various mental health approaches should be implemented"

"make sure states' mental health systems are properly reporting"

"we should examine the problem of untreated people with mental illness"

Also, a study of "how well our mental health programs are treating those who gain access to the system" will reveal inadequacies that will cost a lot of money to fix.

This is the type of federal spending conservatives abhor. So here you have a very clear and relevant example of conservative ideology crashing into reality. It's a welcome back to earth tea party. Will conservatives decide some federal spending for social welfare is acceptable?

Posted by: rgray | January 14, 2011 3:22 PM | Report abuse

"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."

Jennifer, you need a greater awareness of schizophrenia recovery before wading into these waters. True recovery almost always happens when people decide to go OFF their medications. I hate to even utter this self-evident .... thing, but someone in a violent psychotic state in almost all cases initially would benefit from medication which acts as a sedative. The person needs to calm down and drugs are the fastest way to do that. Recovery, however, almost always happens holistically. I encourage you to broaden your reading on this topic.

"It is quite possible Loughner could have been required to undergo an evaluation that could have lead to treatment."

You meant "led," I think.

So much brain research already has been done. That is not really the avenue we need to continue to travel down in terms of the time and dollars we have already spent. We need to broaden our horizons.

Posted by: sugarstreet | January 14, 2011 4:24 PM | Report abuse

The REAL issue is the fact that REPUBLICANS cut funding for public mental health services in Arizona by nearly 40% last year.

Ms. Rubin does not get to blame mental illness without taking responsibility for her party's defunding of psychosocial support programs.

Posted by: bluestatesman | January 14, 2011 4:24 PM | Report abuse

Thanks for this article- you are on the right track. Proper psychiatric care does require proper funding. I guess you could ask the families of the slain victims and the wounded in AZ if spending money on psychiatric care is worth it, not to mention that the mentally ill shooter may have been able to enjoy the benefits of needed treatment and a better life.

Posted by: 10bestfan | January 14, 2011 4:38 PM | Report abuse

Nothing will change in regards to schizophrenia. People are too scared and repulsed by it.

Obama talked about evil. There's nothing evil about a schizophrenic. They are no more responsible for what is happening inside their brain than someone with brain cancer is.

The fact that drugs that affect the brain can pretty much alleviate the symptoms prove the biological component, but people will never admit that. It's too scary and fatalistic.

Posted by: Dalibama | January 14, 2011 5:05 PM | Report abuse

Drugs often exacerbate the symptoms. It's beyond obvious to point out that this guy would have benefited from sedation. But one step in schizophrenia recovery is stopping drugs. There's your biological component.

Not scared.

Posted by: sugarstreet | January 14, 2011 5:11 PM | Report abuse

CHURCHES & MINISTERS SHARE IN THE GUILT

It is the clergy who are the most common source of help sought in times of psychological distress. The mental health professionals tend to view the clergy as mental health gatekeepers. Yet, sadly many among the clergy deny help to memebers of their churches when approached for guidance. According to one study, a whopping 32 to 40 percent of Christian ministers dismiss mental illness as a problem and tell church members that their problem is solely "spiritual in nature."
Ethic Soup has a good post on this:

http://www.ethicsoup.com/2008/10/demon-or-disorder-clergy-dismiss-mental-illness.html

Posted by: s_mceachern | January 14, 2011 5:23 PM | Report abuse

rgray said...

"It's a welcome back to earth tea party. Will conservatives decide some federal spending for social welfare is acceptable?"

Thanks for the welcome back to earth, rgray, but we're not the ones who ever left. You did - orbiting wildly in your little lefty utopian any-problem-can-be-solved-with-just-more-federal-spending spaceships.

Recall: "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

Of course social welfare is acceptable. Provided by "the States."

Posted by: meadelaurence | January 14, 2011 5:47 PM | Report abuse

Drugs often exacerbate the symptoms. It's beyond obvious to point out that this guy would have benefited from sedation. But one step in schizophrenia recovery is stopping drugs. There's your biological component.
Posted by: sugarstreet | January 14, 2011 5:11 PM
***********

As a licensed mental health practitioner, I disagree completely with you. Anti-psychotic medications for schizophrenia are very effective, do not increaswe symptoms, but alleviate them. You must be confused with anti-depressants, which are an entirely different class of medications. Often, patients fear the side effects, but they are a miracle for many, many schiozophrenics who can lead a far more decent life if they will comply with taking their meds.

Sugarstreet, WHERE are you getting this absolutely erroneous info? With over 20 years of mental health experience, I simply cannot read this drivel and not respond. Sedation? Are you saying schizophrenics need to go through their lives in an unending haze of sedation?

Your ignorance about this subject is scary.

Posted by: marybel9999 | January 14, 2011 7:16 PM | Report abuse

rgray said:

"Will conservatives decide some federal spending for social welfare is acceptable?"

This is the sort of hyperbole that causes many conservatives to simply give up on liberals. The federal government is now spending 25 percent of GDP, never mind all the unfunded mandates. The historical average over the past 40 years by comparison is about 20 percent. State and local governments spend another 25% of GDP. The vast majority of this moolah is for "social welfare".

The most severe 'cuts' that conservatives can reasonably hope to see is a return to 2008 spending levels. I personally would be thrilled with that degree of reduction.

rgray, we're talking about TRILLIONS of dollars here for 'social welfare' even in the best(2008) case. How much of the taxpayers money would it take to satisfy YOU?

Please try to bear in mind that the only reason most people trudge off to create the goods and services that constitute GDP, is the pay that they actually get to take home.

Take enough of it for the government and NO one will work, and there will be no economic pie to divide. You imply that conservatives are too mean spirited to help the have nots, but it is your program of limitless government that is truly lethal, as history amply proves.

Posted by: TYoke | January 14, 2011 7:28 PM | Report abuse

Yet, sadly many among the clergy deny help to memebers of their churches when approached for guidance. According to one study, a whopping 32 to 40 percent of Christian ministers dismiss mental illness as a problem and tell church members that their problem is solely "spiritual in nature."
posted by: s_mceachern | January 14, 2011 5:23 PM
*********

While this may be true of some unenlightened pastors, it certainly was not my experience. I worked for over 20 years as a mental health professional and the majority of my referrals came almost exclusively from mainstream Christian and Catholic churches.

Posted by: marybel9999 | January 14, 2011 7:31 PM | Report abuse

"There is also progress with injectable medication that can work for up to 30 days -- eliminating the daily decision to continue medication."

To the scientists in Big Pharma developing this technology, Thank You. This innovation could save so many lives, in contrast to partisan vitriol and sanctimonious pontificating we've had to endure post-Tuscan.

Posted by: kryon77 | January 14, 2011 8:30 PM | Report abuse

Dalibama says: "There's nothing evil about a schizophrenic. They are no more responsible for what is happening inside their brain than someone with brain cancer is."

I think I have never seen a statement so simultaneously true and false. If the Arizona shooter had diabetes or a blocked artery, nobody would say that made him do evil. But nobody would deny that he was doing evil, given his actions, just because he had those conditions.

Mental illness has nothing at all to do with the legal concept of insanity. Insanity means the inability to distinguish right from wrong. A person with a disease in their brain is not responsible for the disease, but they are responsible for their actions.

Posted by: Larry3435 | January 14, 2011 9:56 PM | Report abuse

HOW the college MANAGED to have viewed the YouTube video by Jared Loughner - which formed the basis of their having expelled him - and FAILED to have made some effort to direct him to support and evaluation IS MORE THAN I CAN LOGICALLY COMPREHEND.

The boy was HURTING! And obviously so. Is it too much to ask that you should go out of your by-the-books-way to reach out to a clearly disturbed person?

That 9 year old girl who was killed demonstrated an intellect and consciousness which would have been an asset to Pima College - and society - once she matured.

You'll never get the chance to see her develop; because you dropped-the-ball toward Jared Lee Laughner.

Posted by: Arjuna1 | January 15, 2011 1:20 AM | Report abuse

No one is talking about the collateral damage of untreated schizophrenics - the decimated families who struggle to deal with them because the mental health professionals refuse to if they are not already at a stage of physical threat to themselves or others.

If we don't undo the damage of laws that lower the bar that says the mentally ill have the "right" to choose mental illness instead of medications and treatment, we are going to continue this abuse of the mentally ill and their families.

Whatever their excuses, the mental health people have washed their hands of the horrific plight of the mentally ill and their families trying to deal with them. They do not care. I speak from a 4 decades experience as one of those families broken down by the desertion of the mental health system.

Posted by: DDiorioNDallas | January 15, 2011 8:37 AM | Report abuse

You're right in the sense that psychiatry has no alternative to medication/drugs. That's all they have to offer. They do not do talk therapy anymore (psychiatrists).

But it's not completely true that mental health "people" have abandoned the mentally ill. Or rather, that the system has.

"According to the Treatment Advocacy Center (TAC), roughly half of all U.S. states allow involuntary commitment under a “need for treatment” (NFT) standard. Individuals can meet this standard without posing an immediate physical threat to themselves or others, and without suffering from “grave disability.” If it can be demonstrated that a person will experience severe mental deterioration in the absence of treatment, he or she can forcibly be evaluated and then hospitalized."

This is scary stuff, to me.

Your advocating forced pill taking for diagnosed schizophrenics precludes them from full recovery which can in many cases occur without medications (the definition of full recovery means no meds among other things). There are intractable cases, probably, where people will be on meds for the rest of their lives. But there are also people who are candidates for full recovery. Your solution prevents that.

I'm very sorry for you and your family. I understand what you've gone through. There is not enough support, I agree. And the support that does exist is expensive and out of reach for most. But forced medication is not the solution for all people receiving a diagnosis of schizophrenia.

Posted by: sugarstreet | January 15, 2011 10:07 AM | Report abuse

Jennifer, thank you for this info. Is the violent behavior part of the biological disorder? Or, given it only appears in a small number, is the violence a learned behavior?

Posted by: ejoe1 | January 15, 2011 12:25 PM | Report abuse

Sugarstreet:

I'm not Psychologist but as biologist I can make the following observations. In the case of Schizophrenics the issue isn't with their mind itself it is with the underlying hardware (The brain) that is not functioning in a correct manner. What the drugs do is enable the brain's underlying neural biochemistry to better support mental activity in the case of schizophrenics without those drugs their minds cannot adequately process social and environmental interactions with the drugs they at least have a chance of doing so.

And I would also state that it is far crueler to those with mental disease to not adequately treat their disease. It would be nice to be able to cure many diseases that have their basis in genetics or congenital damage however at our current level of technology that is impossible, as we are unable as of yet to rewire the human brain to any extent at all or permanently correct issue with the underlying biochemistry. We are able to address to a degree the biochemical end of things.

Posted by: werehawk | January 15, 2011 4:54 PM | Report abuse

I do not buy into the exclusive biology based notion of mental illness.

"And I would also state that it is far crueler to those with mental disease to not adequately treat their disease."

Crueler than what? Crueler than someone who is capable of functioning without meds to come off them?

Did I say that people should be DENIED meds?

Posted by: sugarstreet | January 15, 2011 5:16 PM | Report abuse

Crueler than what? Crueler than someone who is capable of functioning without meds to come off them?

should be

Crueler than what? Crueler than PREVENTING someone who is capable of functioning without meds to come off them?

Posted by: sugarstreet | January 15, 2011 5:18 PM | Report abuse

A thoughtful and insightful article.

Posted by: lowonprozac | January 15, 2011 9:09 PM | Report abuse

As the US has the greatest number of marijuana users,according to statistics,
and marijuana causes schizo's to have episodes,allegedly,then why are we at the same percentage of mental health issues as the other countries?
Marijuana does not cause people to commit violent crimes and for the people,such as Krum,that make their livings through prohibition to stand up and blame Loughner's actions on marijuana use is just one more piece of propaganda trying to keep marijuana prohibited,any way they can.
Besides,according to his friends and acquaintances,he quit smoking marijuana and cigarettes 2 years ago and the least that Krum and his fellow prohibitionists could do is wait for the toxicology reports before making blind accusations for the furtherance of their agenda.

Posted by: claygooding | January 17, 2011 2:32 PM | Report abuse

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