"Whenever I go into a restaurant, I order both a chicken and an egg to see which comes first"

Friday, October 11, 2013

Institutionalize The Mentally Ill And Reduce Crime

In recent years there has been an unfortunate spate of mass murders committed by the mentally ill.  Time after time the shooter has either been treated for a serious mental disorder or has exhibited psychotic symptoms. Unfortunately the phenomenon of mass killings has been polarized – i.e. those who think guns are the problem and those who think wackos are the problem – but it is only the gun control issue which has gotten serious attention.  Get the guns out of the hands of the insane, the argument goes, and there will be less violent crime committed by them.  Yet the other side of the argument – removing the insane rather than the guns – goes without notice.

If mental illness is a disease; and if it is a disease with social implications like polio or HIV – that is,if the illness of one person affects many others, unlike cancer or diabetes – then it should be treated as such.  In the past doctors were obliged to report all seriously infectious diseases to the Department of Public Health which would then take appropriate steps to protect the wider community.  Quarantine was not unusual, and public measures were adopted to stop the spread of the disease.  During the summer polio epidemics of the 50s, for example, municipalities routinely shut down public pools and other commonly-used and heavily-trafficked spaces.  Although disease could strike anyone, an infected person was justifiably considered a threat to society. 

Mental illness should be treated the same way.  Doctors should be obliged to report cases of mental disorder to the Department of Public Health or the Centers for Disease Control.

Why are infectious diseases and social diseases no longer reported? Part of the answer lies in Political Correctness.  Although HIV/AIDS is one of the most serious infectious diseases of any era, it was never treated as such, nor was it treated as an epidemic and subjected to normal, established epidemiological procedures.  Although it was known early on in the epidemic that the epicenter was the gay population of San Francisco, there were no aggressive attempts to track, target, or control this group.  “AIDS is everyone’s disease” became the motto as the powerful gay lobby succeeded in deflecting attention from itself hoping to reduce discrimination if not exclusion.  As a result billions of dollars were spent on convincing the public that that their risks were just as high as gay men.  While this campaign certainly did accomplish its social goals, and promote social equality and acceptance of homosexuals, it did not address the more serious issue of infection and spread. 

Over 40 years ago, vast numbers of mentally ill patients were released from public and private institutions.  In an article in the New York Times (10.30.84) Richard Lyons explains why:

Many of the psychiatrists involved as practitioners and policy makers in the 1950's and 1960's said in the interviews that heavy responsibility lay on a sometimes neglected aspect of the problem: the overreliance on drugs to do the work of society.

According to health experts interviewed at the time of the article the policy was a major failure:

THE policy that led to the release of most of the nation's mentally ill patients from the hospital to the community is now widely regarded as a major failure. Sweeping critiques of the policy, notably the recent report of the American Psychiatric Association, have spread the blame everywhere, faulting politicians, civil libertarian lawyers and psychiatrists.

Yet there was no move to re-institutionalize former inmates, and they were allowed to roam free and often homeless. In a study done in 1995, Psychiatric Services found that:

Homeless mentally ill persons appear to be grossly overrepresented among mentally disordered defendants entering the criminal justice and forensic mental health systems and to have a higher base rate of arrest for both violent and nonviolent crimes than domiciled mentally ill persons.

Despite mounting evidence showing the high incidence of mental illness among the homeless population, little or nothing was done to re-institutionalize them or to track their behavior in any meaningful way.  As the 90s progressed, influential ‘progressives’ insisted on the rights of the homeless; and they should be treated no differently than any other American.  If they suffered from a mental disorder, so did millions of their fellow citizens, and no government surveillance or control was ever contemplated for them.

As a result, some cities – most notably San Francisco – has a very high number of homeless people living on the streets.  Shopping carts loaded with the blankets, plastic containers, ragged clothes, and the odd bits and scraps of a life on the streets are everywhere.  Worse is the smell of urine and feces.  San Franciscans seem not to notice or choose to accept this public nuisance as part of the cost of living in an open, tolerant city; and ignore the menace of the unhinged homeless wreaking havoc.

Although no state or municipality feels it has the funds to provide new institutions for growing homeless populations, it would be cost-beneficial in the long run.  First and foremost it would take potentially dangerous citizens out of circulation.  Second, it would lead to a cleaner, more civilized city. Everyone who visits San Francisco complains about the homeless and the trash, litter, and excrement they generate.  Third, it would offer the help that mentally ill the mentally ill homeless require.  Surely a regimen of anti-psychotic drugs would be cheaper than the social costs of the homeless on the streets.

Admittedly, this very targeted approach to crime and mental illness will only capture a small proportion of those sick enough to become violent; but at least it makes epidemiological sense.  Doctors are in a perfect position to diagnose, treat, and report serious mental illness.  Public health officials can be instrumental in adopting a TB-style DOTS program whereby trained health workers directly supervise and observes the administration of the anti-psychotic drugs.  State governments can expand public mental institutions; and the public health community at large can work to change the tolerant and counter-productive community norms of no-treatment.

Finally municipal authorities can assume a more aggressive but legal role in rounding up and institutionalizing homeless people.

In conclusion, while there is no way to preventing the inward wacko from going postal, there are ways to focus directly and unashamedly on the disease aspects of crime.

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