From the Editor

What can we do for those with severe mental illness?

Homelessness: can we do better?

This week, we look at a series of excellent essays that have run on mental illness in The New England Journal of Medicine. They are well written and insightful. We particularly focus on the first of the three essays, which considers treatment and rights.

DG

Mental Illness and Society

“Liberty versus Need — Our Struggle to Care for People with Serious Mental Illness”

Lisa Rosenbaum

The New England Journal of Medicine, 13 October 2016

http://www.nejm.org/doi/full/10.1056/NEJMms1610124

In 1985, when internist Jim O’Connell, cofounder of the Boston Health Care for the Homeless Program, began doing outreach to homeless people, one of the toughest questions he faced was whether to commit someone to the hospital for involuntary psychiatric treatment. States vary in their criteria for involuntary commitment: some permit consideration of psychiatric need, whereas others allow such infringement of civil liberties only if one is believed to pose an immediate physical danger to self or others. Nevertheless, the application of legal criteria to the unique circumstances of someone’s life requires subjective interpretation. So despite 30 years of navigating this tension between liberty and need, O’Connell remains conflicted about when commitment is appropriate. ‘I’ve never found a comfort zone,’ he explained to me. ‘I’ve only had experiences that are bad and experiences that are good.’

One man with paranoid schizophrenia who shaped O’Connell’s early worldview lived for months under a bridge. When winter came, O’Connell pleaded with him to come into the shelter. But the man explained that ‘Out here, I know all the voices are mine. If I go to the shelter, I don’t know who they belong to.’ Cold was better than cacophony, and who was O’Connell to disagree?

But O’Connell’s willingness to honor patients’ wishes has also backfired. One woman lived on a stoop for 2½ years but wouldn’t allow the outreach team to give her a sandwich or socks, screaming incessantly whenever they approached. One day she became so unmoored that the police brought her to the emergency department for psychiatric evaluation — an intervention authorized by Section 12 of the Massachusetts Health Act and colloquially called ‘sectioning.’ Three years later, O’Connell ran into her at a meeting of a nonprofit organization. She was a board member, all dressed up, totally transformed.

‘You look fabulous,’ he told her.

And she said, ‘Screw you. You left me out there for all those years and didn’t help me,’’ O’Connell recalls. ‘And she walked away.’

Dr. Lisa Rosenbaum

So begins the first essay in a series of “Medicine and Society” papers, published in The New England Journal of Medicine.

The rest of the series can be found here:

http://www.nejm.org/doi/full/10.1056/NEJMms1610125

http://www.nejm.org/doi/full/10.1056/NEJMms1610127

She frames her discussion by noting public policy decisions, and their implications for people with mental illness:

· “Of 9.8 million U.S. adults with serious mental illness, an estimated 40% receive no treatment in any given year. Those who get care often face protracted delays: the average lag between onset and treatment of major depressive disorder, for instance, is 8 years.”

· “Deinstitutionalization, the closing of state mental hospitals that was initiated in the mid-1950s, is often blamed for the fragmentation of mental health care. Sick people were released, but promised resources for community-based care never materialized. One consequence was ‘transinstitutionalization’: prisons replaced state hospitals as treatment sites for the highest percentage of people with mental illness.”

· “Despite recognition of the crisis, inpatient-bed availability continues to decline: we now have 11.7 psychiatric beds per 100,000 population, as compared with 337 beds per 100,000 population in 1955.”

Dr. Rosenbaum calls for better resources and training for providers. But she notes that the task is greater. She notes that many people with severe mental illness deny that they are ill.

She pushes further: “Money can’t readily fix two key causes of undertreatment.” First, “we draw rather arbitrary lines in our willingness to treat people who can’t acknowledge their deficits.” She notes the aggressive with which we treat cancer, but the hesitation with mental illness. Second, she notes the tension between care and liberty. “The particular emphasis on autonomy for persons with mental illness and our resultant aversion to compulsory treatment reflect, in part, a desire to right past wrongs, such as forced electroconvulsive therapy and frontal lobotomy.”

Dr. Rosenbaum goes on to consider the rise of the recovery model – finding this both satisfying and unsatisfying.

“Is there a more humane way forward — one that acknowledges the impairment caused by serious mental illness without repeating past abuses of patients?” She notes several “middle ground” approaches, including advanced directives and assisted outpatient treatment.

She concludes her essay by calling for more compassion:

Such good and compassionate care is possible, but only if we acknowledge that people with mental illness need treatment to function in society and are willing to accept, not deny, their differences.

1. This is a terrific essay.

2. The whole series is excellent.

3. At some level, it’s surprising that these essays were written by a cardiologist – not someone in the mental health field. Perhaps that’s just concrete of us. Cardiologists see our patients, just in different settings.

4. The tension between care and liberty is well described. It should resonate with all of us in the field. Yes, we can treat so many successfully – including those who are homeless. On the other hand, patient autonomy is a cornerstone of our health care system (and society). Earlier in my career, I was short with lawyers and annoyed at Consent and Capacity Board hearings. But today, I’ve seen the hurdles as being more than historic artifact.

5. If this topic is engaging, please keep reading the series. In the next paper, Dr. Rosenbaum notes the mortality gap between those without mental illness and those with – and then touches on issue of consent.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.