We grieve Sandy Hook as we continue to grieve Aurora, and shudder because we know there will be a “next time.”
During the 23 years I practiced psychiatry in Wisconsin, I (DK) saw many patients in the emergency department whom I judged to be more psychotic and more dangerous than either Adam Lanza or James Holmes appears to have been before the horrors for which we now know their names. Not once was I able to prevail on Crisis Intervention for the county to approve admission of any of those patients to the excellent state mental hospital less than 9 miles away. Instead, outpatient treatment at Community Mental Health Center (CMHC) was mandated. This was because of limited funding and the limited number of inpatient beds available for seriously mentally ill patients—even ones who displayed definite signs of dangerousness.
Politicians are discussing bans on the sale of certain types of guns, magazines, and ammunition. President Obama has focused on the expansion of background checks for certain types of gun sales. There is discussion of infringing on the basic relationship between psychiatrist and patient and relaxing the privacy of mental health records with respect to interested government agencies. Even the US Supreme Court [Jaffee v Redmond, 1996] understood the chilling effect this would have on mental health treatment: “For this reason, the mere possibility of disclosure may impede development of the confidential relationship necessary for successful treatment.”
These proposed initiatives are mostly desperate efforts to find a patch to replace a mental health system we dismantled1—most importantly, the system of state mental hospitals.
As of this writing, more than 150 days have elapsed since a young man with likely significant psychiatric illness did something all of us consider unthinkable. More than 150 days since he walked into an elementary school and murdered 20 children and 6 staff members after killing his mother. In public discourse, the problem has been defined in 2 terms: “gun violence,” and “serious mental illness.” Most proposed solutions in the medical literature focus almost exclusively on the first component.2-4
There is a long tradition in the US of operating institutions for the care of persons with serious mental illness.5 The Society of Friends began admitting patients to the Pennsylvania Hospital in 1752. The Commonwealth of Virginia established the Public Hospital for Persons of Insane and Disordered Minds in 1768. The Government Hospital for the Insane, now known as St Elizabeth’s Hospital, opened in 1855. Virtually every state had one or more state mental hospitals by the mid-20th century.
Is it possible that we as a society care less for the plight of the seriously mentally ill than we did 100 or more years ago? Is homelessness an answer for these suffering individuals? Is incarceration with minimal mental health treatment an ethical solution? When the jails in our most populous counties become our largest public mental health facilities, we definitely have a problem—a problem we created—in how we respond to serious mental illness.6
Borrowing from the movie Field of Dreams, “If you build it, they will come,” we may simply need to build it, and build it, and build it, until a public mental hospital system exists where the seriously mentally ill may come for treatment. Good treatment for serious mental illness must be hospital-based and of sufficient duration to be effective. Outpatient treatment is for people of sufficiently sound mind to make decisions regarding their own health and treatment.
As dramatized in One Flew Over the Cuckoo’s Nest, I (JV) observed that long-term psychiatric hospitalization may lead to paternalism and abuse of power. Our current appreciation of the importance of informed consent and patient empowerment can not only help avoid such dangers but also inspire a truly humane and therapeutic hospital environment.
Dr Kramer is Emeritus Clinical Professor at the University of Wisconsin School of Medicine and Public Health in Madison. Dr Verhulst is Emeritus Associate Professor of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle, and Senior Advisor, The Kinsey Institute for Research in Sex, Gender, and Reproduction at Indiana University in Bloomington. The authors are with the Research Committee, Group for the Advancement of Psychiatry.*
*Members of the Research Committee, Group for the Advancement of Psychiatry also include Dr John Beahrs, Emeritus Professor of Psychiatry, Oregon Health and Science University, Portland; Dr Barbara Hale-Richlen, the Hale-Richlen Center for Psychiatry, Milwaukee; Dr David Keith, Professor of Psychiatry and Behavioral Sciences, Upstate Medical Center, SUNY, Syracuse, NY; Dr Patrick Malone, Psychology Associates, Chapel Hill, NC; and Dr Alan Swann, Professor and Vice Chair for Research, department of psychiatry and behavioral sciences, The University of Texas Health Science Center, Houston.
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2. Kassirer JP. Weapons of mass destruction. JAMA Intern Med. 2013;173:182-183.
3. Steinbrook R, Redberg RF. Firearm injuries as a public health issue. JAMA Inter Med. 2013;173:488-489.
4. Brent DA, Miller MJ, Loeber R, et al. Ending the silence on gun violence. J Am Acad Child Adolesc Psychiatry. 2013;52:333-338.
5. Sacks O. The lost virtues of the asylum. New York Review of Books. September 24, 2009: 50-52.
6. Lamb HR, Weinberger LE. The shift of psychiatric inpatient care from hospitals to jails and prisons. J Am Acad Psychiatry Law. 2005;33:529-534.
7. Centers for Disease Control and Prevention. Injury prevention & control: data & statistics (WISQARS™). http://www.cdc.gov/injury/wisqars/ leading_causes_death.html. Accessed May 6, 2013.
8. Karch DL, Logan J, Patel N; Centers for Disease Control and Prevention. Surveillance for violent deaths—National Violent Death Reporting System, 16 states, 2008. MMWR Surveill Summ. 2011;60: 1-49.
9. Swanson JW, Swartz MS, Essock SM, et al. The social-environmental context of violent behavior in persons treated for severe mental illness. Am J Public Health. 2002;92:1523-1531.
10. Fazel S, Grann M. The population impact of severe mental illness on violent crime. Am J Psychiatry. 2006;163:1397-1403.
11. Kramer DA. The biology of family culture. In: Combrinck-Graham L, ed. Children in Family Contexts. 2nd ed. New York: Guilford Press; 2006: 90-112.
12. Barker J. Police encounters with the mentally ill after deinstitutionalization. Psychiatr Times. 2013;30(1):1, 10-11.
13. US Department of Housing and Urban Development. The 2009 Annual Homeless Assessment Report to Congress. June 2010. http://www.huduser.org/ publications/pdf/5thHomelessAssessmentReport. pdf. Accessed May 6, 2013.
14. Insel T. Assessing the state of America’s mental health system. Testimony before the Committee on Health, Education, Labor, and Pensions, United States Senate. January 24, 2013. http://www.help. senate.gov/imo/media/doc/Insel.pdf. Accessed May 6, 2013.