Time to Fly Back to the Cuckoo’s Nest, Mental Illness and Homelessness

I must be crazy to be in a loony bin like this.

McMurphy.

http://www.surgeongeneral.gov/library/mentalhealth/chapter2/sec7.html

http://www.schizophrenia.com/szfacts.htm

Emergency rooms are the bottom string in American society’s safety net. In addition to taking care of the ill and injured, emergency rooms become the primary point of care for many of the mentally ill. The tragic reality confronting both the psychotic and those taking care of them is that there is often no other alternative. Dirty, disoriented, hungry, and sick, without friends or family, they wander the streets of America until crime, violence or disease brings them to the emergency room.

Thousands of pages have been written about the dysfunctional history of American mental healthcare. One of the referenced articles is a good history for the power readers among you. The politically correct way to characterize the changes in the last 40 years is the replacement of inpatient state sponsored mental hospitals by “community” centered care. Additionally, mental health advocates and patient rights groups have passed very strict laws restricting the scope of involuntary commitment.

In my training I spent several weeks at the Massachusetts state mental hospital. It was a terrible place, representing the archetype of the mental hospital in the movies, very similar to “One flew over the Cuckoos Nest”. Patients were kept in large, noisy and often neglected wards. Restraints and padded cells were common. The popular revulsion which led to the closure of these facilities is certainly easy to understand. Unfortunately, closing these facilities just shifted the problem to the streets of America.

Hundreds of thousands of those patients are now wandering our cities and highways, becoming the most hopeless of the homeless. Some estimates put the number of schizophrenic homeless as high as 300,000 or more. Patients don’t take their medications, and quickly fall out of the system. No mechanism exists for finding these people. Laws prevent doctors from forcing them to receive care.

Legal and human rights considerations aside, tossing these patients out onto the streets, exposing them to violence, poverty, and the manifold abuses of homelessness is not a kindness. The mental health advocates, no matter what their motivations, have done these people no favors. As I discussed in yesterday’s post, we cannot apply our own understanding and experience to the severely mentally ill. Nonsensical theories and fanciful good intentions have inflicted unconscionable harm upon these people. Like children, they need to be protected, from both the world and their own actions. I suggest anyone who disagrees go to a big city emergency room and see the hell these people live in daily.

Our Crazy Mental Health Policies, What Your Doctor Knows That the New York Times Doesn't

You Can't Out-Think Crazy

John Stewart

http://www.latimes.com/news/nationworld/nation/la-na-jared-loughner-20110116,0,2115673.story

When I was in medical school there was a time honored ritual for students on their first psychiatry rotation. Students were put in a room and asked to speak with a schizophrenic patient. In that time before the universal use of anti-psychotic medications, you learned pretty quickly that people can be “crazy” in a far different manner than we generally use the term. They are irrevocably and tragically locked into their own private world, which is not accessible to others. They often do not respond to outside stimuli, but even if they do, their actions make no sense. These patients cannot function in society, cannot be reasoned with, cannot be bargained with, and do not respond to therapy. The first emotion the aspiring doctor feels is frustration, followed by resignation and eventually acceptance. Anti-psychotic drugs help, sometimes substantially, but patients don't like them, and frequently quit taking them.

Without firsthand knowledge, our natural tendency is to interpret mental illness in terms of our own experience. We assume the mentally ill are just like us, only more so. New York Times writers, politicians, and most of the population make this mistake, and do not understand that this disease cannot be understood rationally. As John Stewart points out so clearly, you cannot use reason to delve into the motivation of a schizophrenic, and doing so is useless.

1% of a population, or 3 million Americans are schizophrenic. Most exist at the borders of society. Even when treated, they function at a low level. Many become homeless, some self-medicate with alcohol and illegal drugs, and full recovery is very rare. Unless you are a mental health worker, ER physician or policeman, most of us go through our lives with only minimal contact with these unfortunate people. Nevertheless, they have major, if under-appreciated impact upon our healthcare system.

Unfortunately, as the Tucson tragedy has pointed out, many who make policy and form public opinion have no grasp of the issues involved. The decrepit level of political discourse in this country probably had little influence on the personal demons of Jerold Louugner. The care of the those with severe mental illness in this country has been and remains a tragedy, not addressed by Obamacare, more to come.