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Treat the 1 Percent

by E. Fuller Torrey

Our mental-health system is failing those most at risk

Erika Menendez, the 31-year-old woman who is alleged to have pushed a man to his death beneath a subway train in New York City, represents everything that is wrong with America’s system of treating the mentally ill. This was the second fatal subway pushing in New York in less than a month. In both cases the person who allegedly did the pushing was described as having a severe mental illness that was not being adequately treated.

An attendant in the psychiatric ward at Elmhurst Hospital Center in Queens said of Menendez, “We know her very well.” State mental-health officials declined to confirm that Menendez had been diagnosed with a psychiatric condition, invoking patient privacy. Such invocations have become standard practice in mental-illness-related crimes, such as the massacres in the theater in Colorado and in the elementary school in Connecticut. In truth, these invocations of patient privacy have little to do with the privacy of the patient — federal law allows the release of information for issues of “serious threat to health and safety” and “public interest and benefit activities” — and much to do with covering up the incompetence of the mental-health institutions.

According to the National Institute of Mental Health, there are in the United States 7.7 million people who suffer from the most severe mental illnesses — schizophrenia, schizoaffective disorder, and bipolar disorder. Among these, approximately 1 percent — 77,000 individuals — are responsible for most of the problems associated with untreated mental illness. Most of them are, like Erika Menendez, well known to the mental-health and corrections systems. They have been in and out of psychiatric hospitals, emergency rooms, jails, and homeless shelters more times than they can count. Walk into a police station in any city or town in America and ask the officers to identify the mentally ill people in their community who present law-enforcement problems, and they will have no difficulty doing so.

Before she allegedly pushed a man to his death, Erika Menendez had attacked another stranger, a man in Queens who was taking out his garbage. “I was covered with blood,” he recalled in a news interview. Since 2005 the police had been called to her home at least five times, and on one occasion she threw a radio at a responding officer. According to the police, in each incident “it appeared she had not taken her medication.”

This 1 percent used to be hospitalized, but over the past half-century we have closed down 95 percent of the accommodations in public psychiatric institutions, so there are almost no beds remaining for people like Menendez. Left on their own, most of them decline to take the medications necessary to control their symptoms because they do not think they are sick, a belief that itself is caused by their psychiatric disorders. Untreated, they are more likely to commit crimes. So it is that this 1 percent of the severely mentally ill are responsible for approximately 10 percent of all homicides in the United States. They account for 20 percent of those incarcerated in jails and prisons and more than 30 percent of the homeless.

The glaringly obvious solution is to treat these individuals. There is no evidence that severely mentally ill people who are being treated are more dangerous than the general population. New York State has a law under which people like Erika Menendez should be treated. It is called Kendra’s Law, and was named after a young woman who was pushed to her death under a subway train by a man with untreated schizophrenia. Kendra’s Law mandates that people with severe mental illness who have a history of dangerous behavior and of resisting treatment comply with treatment as a condition of living in the community. Their compliance can be assured by giving them a long-acting medication, for example, or regularly checking the level of medication in their blood. These and other forms of mandatory treatment, known as “assisted outpatient treatment,” are available in all but six states. (Connecticut is one of the six.) They have been shown in studies to be effective in decreasing rehospitalization and incarceration, and in preventing acts of violence.

These laws have also been shown to save money. In a small county in California, the use of assisted outpatient treatment saved $1.81 for every $1 spent. In North Carolina, severely mentally ill individuals who were randomly assigned to assisted outpatient treatment for at least six months had mental-health-services costs 40 percent less than those of patients in the control group.

We do not know yet why Erika Menendez was not receiving adequate treatment. We do know that our mental-health system is not as effective as it could be. States fail to prioritize services for the most severely mentally ill individuals, especially those who are potentially dangerous. For example, in California in 2004, voters passed Proposition 63, the so-called millionaire’s tax, specifically to improve mental-health services. It has resulted in an additional $7.4 billion in mental-health funds, but California’s legislature has not allowed them to be used on assisted-outpatient-treatment programs. As a result, much of the money has been spent on “wellness” programs such as yoga, horseback riding, and therapeutic drumming.

Tragedies related to untreated mental illness will continue to happen more often than they otherwise would until governors, state legislatures, and state mental-health departments are held responsible for the treatment of severely mentally ill individuals. In Arizona, six months before the shooting of former congresswoman Gabrielle Giffords and others in Tucson, the Arizona Department of Health reduced by half the funds available for the involuntary inpatient evaluation of people with severe mental illnesses, people like Jared Loughner. In Connecticut, the commissioner of the Department of Mental Health and Addiction Services has consistently opposed the use of involuntary psychiatric treatment, treatment that might have helped Adam Lanza if he had been referred. The people in charge of these state departments are political appointees of the governors, who are ultimately responsible.

If the authorities would simply focus on the 1 percent, we would see an immediate improvement. Attempts to implement such treatment, however, inevitably face opposition from critics who say that mandatory treatment violates the civil liberties of the mentally ill persons. But it is possible to respect the civil liberties of patients who must receive involuntary treatment, and model treatment laws such as those proposed by the Treatment Advocacy Center include provisions to this effect. What we have lost sight of is that other people — who, for example, want to take the subway or go to a movie — have a right not to be killed.

There is currently much debate over gun control, but gun control would not have prevented the crime alleged to have been committed by Erika Menendez, nor would it prevent crimes in which the weapon is an axe, a knife, or a vehicle. Guaranteeing that the 1 percent receive treatment would substantially reduce the number of homicides committed by the severely mentally ill.

We are unlikely to end such homicides completely, because people who become mentally ill for the first time may commit crimes before their disorders are recognized. But certainly the number could and should be lower, for the sake of both potential crime victims and the mentally ill.

– Mr. Torrey, a research psychiatrist, is the founder of the Treatment Advocacy Center in Arlington, Va., and the author of The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens.

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