Even 6 months after the tragedy at Shady Hook Elementary School, we’ve all been asking what may have caused the horrific shooting. We may or may not agree that the ready availability of assault weapons and the playing of violent video games may have contributed to the rampage, but we can surely agree that failures in the mental health system also played a significant role. We don’t know if his mother struggled to obtain mental health services for her son, although we know that she had home-schooled him for a time. What we do know, however, is that for many families, providing mental health services for their desperately ill children is an extraordinary challenge. And many, many children, as well as adults, are falling through the cracks. I see the struggle for mental health services occur on a daily basis.
According to the National Alliance on Mental Illness (NAMI), 4 million children and adolescents in this country suffer from a serious mental disorder that causes significant functional impairments at home, at school, or with peers. Additionally, 21% of children between ages 9 and 17 have been diagnosed with a mental or addictive disorder that causes at least minimal impairment. Despite this high prevalence rate, NAMI reports that in any given year, only 20% of children with a mental disorder are identified and treated. That’s a lot of kids to not receive treatment, and the consequences can be tragic. Suicide is now the third leading cause of death among youth aged 15 to 24. Of those children who commit suicide, over 90% have been diagnosed with a mental disorder. Additionally, 50% of teens with a mental disorder will drop out of school. Many of these youth will wind up in the criminal justice system. The National Institute of Mental Health found that 65% of boys and 75% of girls in juvenile detention have at least one mental disorder.
Liza Long, in her controversial blog “I am Adam Lanza’s Mother,” asked for a national conversation on mental health. One anonymous psychiatrist responded in a blog titled, “I am Adam Lanza’s Psychiatrist: A Response from the Mental Health Trenches to ‘I am Adam Lanza’s Mother.’” The unknown psychiatrist acknowledges psychiatry has limitations in judging when a patient could become violent. It is hard to predict when a patient who is a ticking time bomb (characterized as chronically dangerous) becomes acutely dangerous (in need of immediate hospitalization). Sometimes patients are missed, and we wind up hearing about them on the evening news after yet another rampage. The anonymous psychiatrist in his blog quotes the APA Council on Law and Psychiatry: “The ‘absolute risk’ message is that the vast majority of people with mental illness in the community are not violent. The ‘relative risk’ message is that people with serious mental illness are, indeed, somewhat more likely to commit violent acts than people who are not mentally ill. And the ‘attributable risk’ message is that violence is a societal problem caused largely by other things besides mental illness (ready availability of guns, for example.”
We would never know from watching the 24/7 news coverage after these shootings that most persons with mental illness are far more likely to be the victims of violence rather than the perpetrators. Yet some patients are dangerous and need involuntary treatment; they fail to grasp how desperately ill they are or how disordered is their thinking. Dr. Paul Steinberg, in an editorial in The New York Times states that in our squeamishness to impose treatment on the seriously mentally ill, we are in fact neglecting the rights of ordinary citizens, particularly since pharmacologic treatment of schizophrenia, can be “remarkably effective.”
Within the field of psychiatry there appears to be disagreement on the types of involuntary treatment which should be imposed and under what circumstances, topics clearly beyond the scope of this blog. However, both Dr. Steinberg and the anonymous blogger have wish lists of what they feel should happen. Among other things, Dr. Steinberg asks for reasonable restrictions on semi-automatic weapons; criminal penalties for those who sell weapons to individuals who are clearly mentally ill; better insurance coverage, including longer hospital stays; more hospital beds; and a “greater willingness” to impose treatment on those who are threats to themselves or others. Like Dr. Steinberg, the anonymous psychiatrist urges tougher federal laws to make obtaining involuntary treatment easier for families and psychiatrists, a Health Law Court where doctors can serve as judges and psychiatric proceedings are streamlined, and of course, better insurance coverage. And finally, in recognition that most if not all of these shooters have been bullied, our anonymous psychiatrist wants to tell the popular high school kids “to stop being such dicks to the odd kids or the ones they don’t understand.”
These tragedies are dissected and the mental health of the shooters is endlessly parsed on the air by the media pundits. Yet psychiatrists, the most qualified to comment on the potential pathology of the shooters, are largely silent. According to Dr. Steinberg, psychiatrists are ethically bound by the APA to refrain from commenting on the mental health of someone whom they have neither examined nor been given permission to discuss. One unfortunate consequence of these unfounded speculations is the further stigmatization of patients with mental illness, making it less likely that some will actively seek out treatment for fear of discrimination in employment, housing, and or even their social circles. They will be left even further isolated.
Liza Long in her controversial blog asked us to begin a conversation in this country on mental health. Hopefully this conversation has finally begun and will continue, resulting in effective and obtainable treatment that will enable the mentally ill to maintain productive lives within their communities and among their loved ones and friends.