What The Washington Post Got Right...And Wrong

Two days ago, the second of two police officers shot by a psychotic young man with an assault rifle died. It's yet another tragic part of an already tragic event. Two cops and the young man are now dead. There is plenty of blame to go around.

In an editorial yesterday, the Washington Post made all the appropriate points about the tragedy, especially that the young man should have been able to get treatment or have been forced into treatment at several points prior to his going on a rampage. Then, in making its point about schizophrenia and violence, the Post's editorial board over-stepped a bit. I'll get to that part in a minute.

First, I agree with the paper that the outpatient commitment statute in Virginia is flat-out impractical. It says that someone can only be forced into outpatient treatment--translation: be required to take meds--if they are in "imminent" danger of harming themselves or others. In practical terms that means someone would have to be fully psychotic in front of a doctor or mental health professional in order to hit the trip wire for treatment. Psychosis is so transient that it can be gone within minutes, except in more extreme cases. In Washington State, the outpatient commitment threshold is lower: "If the court finds that a person, as the result of a mental disorder, presents a likelihood of serious harm, or is gravely disabled, but that treatment in a less restrictive setting than detention is in the best interest of such person or others, the court shall order an appropriate less restrictive course of treatment for not to exceed 90 days." The order can be extended another 90 days.

I've been reporting on mental health in Washington State for 3 years and known of no cases where this law has been used unreasonably against patients. The law here is similar to that in many other states. Why Virginia's is so weak is beyond me.

I have no trouble with short-term outpatient commitment and 180 days doesn't seem like too much to ask, at least as far as I understand the law's application in this state.

Where I part company with the Treatment Advocacy Center crowd, clearly behind much of the media push around this issue of late, is when it comes to forcing patients into long-term (ie, forever) outpatient commitment. If treatment isn't working after 180 days and the patient is still psychotic or delusional, then society either needs to step up and put the patient in a long-term hospital setting or it needs to let the patient make their own choice.

I'm not comfortable saying any of this, but we do need to strike an appropriate balance between individual liberties and rights and society's demands to protect itself against extreme anti-social behavior. Not many people in the psych world like hearing this, but the psych meds we have at our disposal these days are not the slam dunk solution that you'd think, and they are very damaging to patients' bodies, minds and souls.

There will never be a perfect trade-off.

As in Pete Earley's WaPost op-ed last week, there is an inherent assumption that the mentally-ill are prone to violence and that meds work all the time. We know the last part isn't true. So what about violence?

I demolished Earley's data on that point in an earlier post. And that negated his entire argument there. He later admitted to me that he was embarrassed about using the flawed data he did.

Yesterday, the Post used evidence from a recent paper on schizophrenia and violence, which I have dissected in another post. While the WaPost was careful to point out that the study's findings were based on 1,400 patients (3.5 percent committed acts of serious violence and 15.6 percent committed low-level assaults), that's not the message that the public will take away. You put the words violence and schizophrenia together and suddenly heads begin to nod, an old assumption reinforced.

What the newspaper missed were two key points. One, it's not unusual for violence, serious or not, to occur even when patients are medicated. The presumption made in the editorial and by Earley and TAC is that violent outcomes--rare though they are--are always preceded by patients not taking their meds. Not true. Especially with low-level assaultive behavior I have seen exhibited by patients, they were almost always on meds. It is also not uncommon for patients to assault staff members (and vice-versa sadly) at state hospitals--where the patients sure as hell are medicated.

What's more, in the study cited by the WaPost, the patients who committed these alleged acts of violence--none of them proven in court mind you--were medicated. That ought to make you wonder what the fuck is going on in our culture of treatment. That singular fact should tell everyone that the treatment we are offering schizophrenics isn't have such swell results. And make them skeptical enough to start asking some questions about how well meds are working.

In addition, the editorialists assumed that the 1,400 schizophrenics in the study were pretty much like other schizophrenics. Not true. As I've noted elsewhere, the CATIE study, from which the smaller study came, is comprised of schizophrenics who either come from homeless shelters or the most hardcore public hospitals in the country. That's not your average schizophrenic. In that audience, I am not surprised at all that 3.5 percent of them committed acts of serious violence. If they did so while on meds, then I think we all need to take a deep breath.

Take a deep breath. According to the paper on the study, all of the patients were medicated and all of them had been in treatment of some kind, on average, for 16 years.

Why didn't the WaPost either tease that out of the study itself or contact one of the authors? Or is it presumed that violence in schizophrenia must be tied to med non-compliance? (Although I am clear from re-reading the study that the patients were medicated at the time of their violent acts, I am going to double check this with one of the study authors.)

I have asked the nice people at TAC to tell me, if in their database of delusional folks committing violent acts, how many of those people were on meds at the time of said delusional act. Because since they are using them as the basis to argue for expanded outpatient commitment laws, then you'd think they'd want to be upfront about how many were on meds and how many weren't.

To date, I've gotten no answer from them. If they don't step up soon, then I'll publish the last email they sent me the other day as well as my reply to them.

Finally, I had an email exchange the other day with the lead author of the schizophrenia and violence paper. He assured me that, in terms of absolute risk, schizophrenics were not more violent than the rest of the population. He said he's troubled to see how the TAC people and others are using his results. "They know better," he wrote. He also passed along two other studies on the same subject which found the same thing.

For those of you who follow my blathering here, I have put off submitting an op-ed to the WaPost until after the second officer's funeral. I won't disrespect his memory, his family or his colleagues by going against the emerging consensus until next week.

Here's a list of outpatient commitment laws around the country.

Posted by Philip Dawdy at May 19, 2006 12:06 AM
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