What should we do with the mentally ill?

Another year.  Another tragedy involving guns, violence, the internet and the mentally ill.  The archetype of the sadly deranged misanthrope becoming disenfranchised and turning to serious violence has become all too routine for our nation.

This time the tragedy is in Arizona in a Safeway parking lot with 6 dead and dozens more  wounded.  As I watched the memorial service two weeks ago for the victims I can not help but recall the spat of memorial services our nation has watched and experienced over the last several years.  From the massacre at Columbine High School to the horrors at Virgina Tech to this recent  shooting at Congresswoman Gabrielle Gifford’s event our nation has suffered a seemingly continuous chain of high-profile and tragic gun massacres. 

The reports detailing the alleged perpetrator Jared Loughner portray a disturbed individual.  The excerpts from his writings and his social media pages detail an intelligent mind overcome with delusion, paranoia and disorganized thinking.  In my opinion, from the information available I believe it is reasonable to question if this young man suffered from paranoid schizophrenia. 

It is presumptious to assume we know anything about this person but whether he fits the diagnostic criteria of a schizophrenic there is a pattern in our society of  high profile violence that takes it’s roots in mental illness.  This recent shooting brings to mind some of the larger issues surrounding this pattern as well as calling into question some of the ways that our country is managing those with severe mental problems.

For those who don’t know much about it Schizophrenia is a tragic mental illness that ruins lives and destroys families.  It is often miscategorized in the popular media, and many people with this diagnosis go on to lead functional and normal lives. That said, Schizophrenia is every bit as much a tragedy as a diagnosis of cancer, ALS or any other “medical disease.”    Schizophrenia is categorized by disorganized thought patterns, delusions, auditory hallucinations, poor communication ability/social skills, occasionally paranoia and some other bizarre symptoms. 

 Contrary to its categorization in the popular media schizophrenic patients do not typically experience visual hallucinations.   Despite what drug companies or even some psychiatrists might insist, the underlying cause of schizophrenia is extremely poorly understood and there are no clear cut genetic or biological roots, though the disease does tend to run in families with a stronger predilection for twins.

This crime in Arizona taken by itself is a tragedy but in the context of a string of other similar crimes committed by similar minded individuals it also raises the larger question of what we as a society are doing with our mentally ill.

In 2011 for the most part the mentally live among the general population in the community.  It has been almost a half a century since John F. Kennedy began the process of closing the insane asylums that, now abandoned, eerily dot the nation.  Prior to the 1960’s the mentally ill were locked away from the rest of society but now serious mental illness today is usually managed with quick inpatient hospitalizations to stabilize patients for several days and outpatient psychiatric care in the community.  

This approach was made possible by the development of the so-called “antipsychotic” drugs, such as Thorazine and Haldol, which were used to treat schizophrenia and help schizophrenic people function so that they could theoretically survive in the community.   A second “generation” of these drugs such as Seraquil,  were released in the 1980’s and 1990’s because they initially advertised a better side effect profile than the older drugs, but subsequent studies have questioned that.

The drugs used to treat schizophrenia work by blocking Dopamine receptors in a part of the brain called the mesolimbic cortex.  There is no concrete evidence that dopamine oversensitivity plays a role in psychosis, but this area of the brain is key in allowing communication between the frontal lobes of the brain, which processes judgement and cognition and the limbic areas which is responsible for processing emotions (this is extremely simplified).   No one knows what makes a schizophrenic, but these medicines likely work by blocking neurotransmitters and therefore suppressing cognition, which to the tortured mind of a schizophrenic can produce symptom relief and improve  lives.

Well this sounds all well and good, the problem is that these drugs come with tremendous side effects to some users.  Some patients report that they make them feel unhuman and zombie like.  Others suffer severe neuromuscular disorders or weight gain and other endocrine problems.  While to some patients the medicines are a god send,  some mentally ill patients won’t or can’t tolerate the side effects.

Furthermore, the medicines seem to show different efficacy in different people.  For some the medicines work well, but for others they don’t show the same effectiveness.  The truth is that for all we know, the disease we call schizophrenia is hundreds of diseases with similar outward traits, but very different underlying disease processes.

The end result is that many schizophrenic patients either don’t take these medicines or don’t experience a radical change in their symptoms and are untreated.   This is a problem because studies repeatedly show that the schizophrenic people especially when untreated have a much higher incidence of violent crime than the rest of the population (as an aside the type of mental illness that has the most violent crime associated with it is substance abuse, including alcohol).

Considering the pitfalls of treating schizophrenia, the tendency of schizophrenic to violence and the rash of high profile violent crimes involving victims who appear to be suffering from the symptoms of this disease, I think it is reasonable to question if our strategy for managing the seriously mentally ill in the community is the best approach for our society to take.

 As a former residential counselor for the Italian Home for Children, a former social worker for Massachusetts DCF and now a medical resident I can say that I have seen up close schizophrenia in all the stages of its natural history from in utero to early in life to adulthood and even to death.  I believe that schizophrenia is a horrible tragedy and that the people who suffer from it are themselves very much victims.   I like the idea of these people being included into society as much as possible because I think they suffer a real, terrible disease and I feel uncomfortable with them being punished for that.  After all we don’t lock away people with AIDS or Cancer.  

In my opinion there is no perfectly “just” way to manage this situation and the question is how do we as a society handle a sub-segment of the population that has a disease that is difficult to manage and makes them apparently more prone to violent acts.   It is not “just” to lock away the victims of mental illness but the question here is is it more just than the alternative.  Is it more fair to restrict the freedoms of the mentally ill than it is to expose innocent people to violence?   Is there a middle solution? What is the greater injustice?  

I feel a tremendous amount of compassion for those who suffer mental illness but I also feel compassion for the victims of violence.   When I see the faces of the victims of the tragedy in Arizona I can not help but wonder if we are doing the right thing and if it is preventable.   I can say for sure that I do not have an answer to this question, but I do believe it is a question based on recent events that is worth asking.

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About insightmd

Greetings. Welcome to my blog! My name is Dr. Dennis Teehan. I am an intern in medicine now going into public health and preventive medicine. My long term goals are to get my MPH and to complete a residency in Preventive Medicine. I enjoy thinking and writing about the important health care issues of the day. Hope you enjoy my blog and please feel free to comment.
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