Attacks Spur Call to Force Medications

DATE: Tuesday, June 1, 1999
SOURCE: By Lisa Anderson, Tribune Staff Writer

In January, Kendra Webdale, a young receptionist, was pushed to her death under a Manhattan subway train by a man who had stopped taking his medicine for schizophrenia.

A month ago, both legs of Edgar Rivera, a father of three, were severed by a rush-hour subway train after he was shoved onto the tracks by a homeless man believed to be off his medication for schizophrenia.

Earlier in April, New York police shot Charles Stevens eight times after he threatened them with the sword he was brandishing at commuters in Penn Station. Stevens, who survived the attack, had refused to take his medication for schizophrenia.

Under state law, there was nothing his family legally could do to force Stevens to get help until he demonstrated that he was a danger to himself or others, his mother said later.

Confronted with a constituency horrified by such incidents, New York lawmakers last week introduced legislation that would make it easier for family members and caregivers to get court orders to compel seriously mentally ill patients to take their medications and receive treatment before they become dangerous and without committing them to a hospital.

New York is one of only 11 states without some form of outpatient commitment or assisted outpatient treatment, but the issue of involuntary treatment remains controversial and problematic even in states, such as Illinois, where such a law already is in effect. Raising questions about the rights of the individual versus the safety of society, the issue has received increased national attention after a recent spate of violent acts committed by mentally ill people who had stopped taking their medication.

Among these were the April 15 shooting in the Mormon library in Salt Lake City, in which two people died before the gunman was killed by police, and the May 4 case in which two children were killed in Costa Mesa, Calif., after a man deliberately drove his car into a playground.

Perhaps the most publicized case occurred last July, when Russell Weston Jr., an untreated schizophrenic from Illinois, allegedly fired shots in the U.S. Capitol, killing two Capitol police officers. Called "Kendra's Law," the proposed New York legislation focuses on patients with serious mental illnesses, such as schizophrenia and manic depression, who have a history of hospitalization or violent behavior, have been shown to benefit from medication and are deemed unable to make an informed decision about their treatment. If found eligible for outpatient commitment, they would receive supervised treatment for an initial six-month period, which could be extended. While medications, especially new drugs with fewer side effects, have been shown to be extremely effective in controlling the delusions, voices, hallucinations and other symptoms of serious mental illnesses, getting patients to take the medication continues to be a major problem, according to Mary Zdanowicz, executive director of the Treatment Advocacy Center. The Virginia-based non-profit organization, dedicated to eliminating legal and clinical barriers to timely treatment for the mentally ill, supports outpatient commitment laws.

About half of the seriously mentally ill, Zdanowicz said, "have the symptom that they lack awareness of their illness." As a result, some refuse to take medicine because they don't consider themselves sick, or they stop taking medication when their symptoms subside because they feel they no longer need it.

Untreated, these people become vulnerable to a host of problems, including becoming crime victims themselves, according to Dr. John Davis, a professor of psychiatry at the University of Illinois at Chicago. `If patients go off their medication, they go downhill. Some die, they freeze to death (or) commit suicide. Patients can get violent and threaten their families and, if too many destructive acts go on, the family may give up and the patient may gradually drift away and become a homeless person or a prisoner.

"Actually, Cook County Jail is the largest psychiatric hospital in Chicago," Davis said. "The jail admits 350 prisoners a day, 365 days a year, of which 10 percent are seriously mentally ill. That adds up to some 10,000 seriously mentally ill patients a year. They are, by and large, patients who don't come to outpatient facilities, don't take their medicine and get jailed for a wide variety of offenses." For those reasons, Davis considers outpatient commitment important. "It's the right thing to do. It's good for the patient. It's good for the family members. It's good for society," he said, describing outpatient commitment as "a reasonable compromise" between respecting a person's autonomy and the need for treatment.

Laura Young strongly disagrees. "What happens is that the police come and put (the patient) in handcuffs. It's not actually as benign a situation as it sounds. It's pretty horrifying," said Young, senior director of adult mental health services at the National Mental Health Association, a non-profit network of mental health advocates, which opposes outpatient commitment.

Young believes there already are laws on the books that deal with involuntary treatment when the standard of dangerousness is met and that laws that lower that standard, such as outpatient commitment, may make it too easy to infringe on patients' rights.

"I know sometimes it's difficult to wait until people pose a danger to themselves or others," she said. "I'm not insensitive to the plight of the caregivers and the families, but we can't sacrifice the rights of people with mental illness."

What is needed is not more laws, but more community mental health services, Young said.

Dr. Harold Bursztajn, co-Director of the program in psychiatry and law at Harvard University Medical School, also sees no need for more laws. "The biggest complaint isn't that we don't have the laws on the books, but that we don't have anywhere to treat these people," he said, referring to shortages of community treatment centers, crisis intervention teams and programs such as supported-living homes.

Dr. Phyllis Solomon, a professor of social work at the University of Pennsylvania, fears that outpatient commitment is a political quick fix that sounds a lot better than it really is. "I find it to be a knee-jerk reaction to a much larger problem, which is the lack of mental health services, the need for more supported housing and the need for more intense case management."

Moreover, although there have been some studies that show outpatient commitment to be effective, there is not yet a large enough body of evidence to arrive at definitive conclusions, according to both critics and advocates.

In Illinois, which has had a version of outpatient commitment since 1996, the law largely has been ineffective, according to Randy Wells, Illinois state director for the National Alliance for the Mentally Ill, an organization that advocates research and services for patients and their families. Wells said part of the problem has been a lack of awareness of the law, even among judges, and that, when it is used, it isn't uniformly applied.

The Illinois law, called the Mental Health Treatment Preference Declaration, provides for patients to create, in effect, a living will. Under it, while they are competent, they designate their treatment preferences and a person who is authorized to make treatment decisions for them should they become unable to do so for themselves.

In the long-run, outpatient commitment in tandem with an array of community-based mental health services would be more effective and far less expensive than the cost of hospitalizing or imprisoning patients, Davis said.

The Institute for Community Living, a New York-based non-profit agency, said that on an annual basis, "it costs less to fund community housing and support services for the mentally ill ($12,500 per person) than it does to incarcerate ($60,000 per person) or house one person in a psychiatric hospital ($113,000 per person)." Court-mandated outpatient care "is an agonizing issue," said Bob Carolla, spokesman for the National Alliance of the Mentally Ill in Virginia.

"It is one positive solution," he said, "but it requires other kinds of actions in order to make it effective. And that's said from the perspective of an organization that is supporting Kendra's Law, but also being soberly aware of the broader realities that families and anyone who is going to come under tis law are going to face."