Recently, a young woman living in New York City returned to her apartment, and a homeless man slipped through the locked entrance before it closed behind her. Following her up the stairs, he would murder her with a knife from her own kitchen.

Exhibiting a lack of escape plan, he barricaded himself in her apartment, forcing the police to break down the door. Calls to 911 by neighbors hearing a woman’s screams alerted them to the situation. The man was arrested and taken into custody, and he may be charged with a hate crime; the woman was Asian-American. Sources investigating the case found the man had multiple instances of criminal behavior and was released on his own recognizance.

This man is one of many who have fallen through the cracks in a mental health system in tatters and created by the well-meaning but inadequately managed deinstitutionalization movement after 1955, which picked up steam in the 1970s.

Unfortunately, it’s not the first time an individual in dire long-term need for care and treatment was left wandering the streets to assault and, in one case, murder a therapist in her office in New York City. The trial and that man’s insanity defense failed to place him in a hospital, and he went to prison.

With the closing of large, self-contained psychiatric hospitals that functioned much like small towns, many patients were sent to live in supervised housing or apartments or with their families. Promises of ongoing care and careful follow-up never materialized to the extent needed, and patients became homeless.

In some cases, repeated incidents of street or subway attacks never resulted in long-term care under strict supervision. Prisons became the “hospitals” for these patients who were now criminals. However, press coverage can lead the public to believe that all patients with a psychiatric illness are potential criminals or murderers, not so.

If the system is failing both the patients and the public, what possible solutions might there be that would meet the needs of both? One, of course, would be a return to the former hospital system where patients could live out their lives. I’m not sure the bucolic moral treatment existence related to me by old-time hospital staff was accurate, but it may have been better than our current state of affairs. Unfortunately, that wasn’t a time of intense data collection, so we have nothing to go on regarding incidents of criminality by the mentally ill.

I’ve worked in these hospitals, I’ve seen patients who could be safely returned to the community and ones that might never recover a rational ability to function outside the institution. One patient who was delusional and had killed his mother kept muttering that all women must die.

Patients on wards where I’ve worked had received treatment from insulin coma therapy, ECT, lobotomy, psychotropics, and behavioral therapies of many types.

Management at the hospitals wasn’t akin to anything resulting from an MBA. Some patients were “treated” with questionable psychotherapeutic techniques as they cycled through the wards. Therapists were unlicensed, physicians weren’t necessarily psychiatrists, and some were pediatricians in a hospital for adults.

The diagnoses ranged from mental developmental disorders, drug-induced delusions, to paranoid schizophrenia. And some of them had murdered one or many people. I worked with those patients, and I know some, who killed their entire families, did so by psychotic reasoning brought on by severe, extended stress. One wanted to die so he could join his family in heaven.

Today, I’m sure many of them live in communities near or far from the hospitals. I am not sure whether some of them would not have another break in their reality testing ability. Often, taking prescribed medication requires a level of care that is either lacking or there is resistance and discontinuance.

Do the mentally ill have constitutional rights regarding psychotropic medications and hospitalization, and how should these individuals be protected? One significant case brought before the US Supreme Court was a clever test of the issue of involuntary detention in a psychiatric hospital.

The case of Kenneth Donaldson was simple. Donaldson refused to take psychotropic medication, and because the hospital was not treating him, he argued he should have been discharged.

After the case was decided in his favor and the court agreed that Donaldson could sue those who took his freedom from him, he would write a book and be interviewed for a podcast. Today, in hospitals, we have legal procedures where psychiatrists decide whether a resistant patient needs meds, and they may then be forcibly administered.

Involuntary hospitalization remains one means of protecting those with mental disturbances from harm to themselves or others, but the question of competence remains. The statutes for obtaining orders to forcibly detain them vary by state, and they are known by many names. In Florida, it’s “Bakering” or the Baker Act. Most provide for several days of hospitalization before a person may request discharge if the medical staff agrees the current need for stabilization is over.

Where do we go from here? One aspect of this serious dilemma remains questionable; funding. If inadequate funds are authorized or poorly utilized when authorized, who will protect both patients and the public? Who is responsible for deaths and destruction of property when a patient is left to wander the streets and had been discharged to a community residential facility?

How much supervision do they receive in those residential housing units? I know of some places where staff leaves at 4 pm each day. There is no overnight coverage in the residence.

I remember a hospital worker once commenting on the excessive discharges of patients unready for release. “She’ll discharge them to a crate in the middle of the street.”

Civil rights and mental health issues clash frequently, and the outcomes are not precisely what is needed unless knowledgeable, caring, and prolonged planning is created. I once offered training for judges hearing mental health disability cases and never received a response. What type of training do judges receive in this area? I question whether they receive any.

The current state of affairs ensures that people will wander, people will be seriously injured or die, and the media will howl each time. But who will step up and attempt to fix the broken system? Anyone who presents themselves must be prepared for a rain of ire and accusations. It is not a pretty picture.

The post Senseless Murder Mandates Prison or a Psychiatric Hospital Admission? appeared first on Medika Life.

“One day, I made a remark that I might work with people with mental illness, and somebody in the press heard it, and it was in the paper. And the more I thought about it and found out about it, the more I thought it was just a terrible situation with no attention. And I’ve been working on it ever since.”

Mental illness is a hidden scourge that attacks far too many people, especially those who have schizophrenia. It grinds down people’s dignity, throws their lives into disarray, and leaves them vulnerable to misunderstanding and derision even by mental health professionals.

Too often, I have heard patients belittled by staff, including psychiatrists, who threatened them with forceable IM medication or seclusion and restraint because “you aren’t taking your medication.” When the patient pleaded that they were medication compliant, they were viewed as liars. Coercion is not unusual in some settings.

“If you were taking your medication, you wouldn’t be having symptoms now,” was the retort. But they were taking their medication. The problem was that the professionals hadn’t caught up with genetic research in their field. Ok, it wasn’t as advanced then as it is now.

Then began a seemingly endless process of prescribing serial meds or, on the other hand, polypharmacy which returned to favor after years of disrepute. Washout of meds was ignored as a new med was added in place of the existing one.

My quandary was how spectacular someone would have to be at biochemistry to know the interactions of all those metabolites in the brain. Too many patients developed tardive dyskinesia (TD), which never resolved. The symptoms of TD were hidden by prescribing yet more medications.

A Change in Understanding

The dark days of psychiatry, I would hope, are behind us, but I can’t say that definitively. Some serve as psychiatrists who had their medical residencies and experience in pediatrics, cardiology, and other unrelated specialties. I say this because I’ve seen it first-hand. At least one man failed the psychiatry boards three times and then gave up on them.

The dawn of medical understanding regarding the role of genetics has come, and with it, a new appreciation for what works and what doesn’t. Are patients still blamed when a med doesn’t work? Possibly.

“Pharmacogenomics is the branch of pharmacology which deals with the influence of genetic variation on drug response in patients by correlating gene expression or single-nucleotide polymorphisms with a drug’s efficacy or toxicity.”

Psychiatry has gained sophistication in the knowledge of drug-patient interaction, but not everyone in the field has kept up. Such a failure can only mean more patient blaming.

Movement in the direction of consideration of genetic differences leading to medication inefficacy has begun.

Individual Differences Are the Key

“Pharmacotherapy is one of the primary treatments for psychiatric disorders. Given the variation in individual responses, a more personalized approach is needed. This paper will discuss methods for user-friendly referrals, recruitment criteria, data storage and dissemination, biological sample and clinical questionnaire collection, and advertising.”

The suggestion of biological sampling has begun at how many sites, practices or hospitals? Has anyone provided research to determine this and, if not, why is this gap in the literature permitted to exist? Is patient-blaming too easy?

Undoubtedly, the tests take time and funding, and the metabolic difficulties presented by cytochrome P450 which is always a consideration. But there is literature pointing toward the importance of this research.

“It has gradually been demonstrated that genetic differences in ion channels reflect differences in the distribution of polymorphic traits, such as disease susceptibility and drug efficacy…”

This approach to evaluating psychotropic medications’ efficacy has been further underscored in additional portions of the medical literature.

“For most psychiatric diseases, pathogenetic concepts as well as paradigms underlying neuropsychopharmacologic approaches currently revolve around neurotransmitters such as dopamine, serotonin, and norepinephrine…the effectiveness of these medications is limited, and relapse rates in psychiatric diseases are relatively high, indicating potential involvement of other pathogenetic pathways…”

Absolving the Patient From Blame

How can patients with psychiatric or any other illnesses be viewed as non-compliant with their medical regimes when there is a persistent failure to investigate how their race and genetics are affecting treatment? The answer is obvious, and the blaming must stop. How can we treat patients when this type of neglect persists in the face of overwhelming evidence that is being ignored?

One example that might be remediated if psychiatric treatment were fully compliant with recommended protocols would be homelessness. If patients’ illness can be brought under control, would they choose to live and die on the streets and remain resistant?

The post Blaming the Psychiatric Patient When It’s a Drug-Genetic Interaction appeared first on Medika Life.