# Should there be mandatory treatment for psychosis?



## David Baxter PhD (Sep 19, 2006)

A Psychiatrist Is Slain, and a Sad Debate Deepens
September 19, 2006
By BENEDICT CAREY, _New York Times_

In the hour before he was killed, on Sunday, Sept. 3, 2006, Dr. Wayne S. Fenton, a prominent schizophrenia specialist, was helping his wife clear the gutters of their suburban Washington house. He was steadying the ladder, asking her to please stop showering debris on his clean shirt; he had just made an appointment to see a patient and wanted to look presentable. She said she would be happy to go along, to help control the patient. 

It was a running joke between them. For in this part of the country, Dr. Fenton was the therapist of last resort, the one who could settle down and get through to the most severely psychotic, resistant patients, seemingly by sheer force of sympathy and good will. An associate director at the National Institute of Mental Health, he met with patients on weekends, sometimes late at night, at all hours. 

“Absolutely the most nonthreatening person you ever, ever met,” his wife, Nancy Fenton, said in an interview last week.

At 4:52 p.m. that Sunday, the Montgomery County police found the 53-year-old psychiatrist dead in his small office, a few minutes’ drive from his house. They soon tracked down the patient he had agreed to meet that afternoon, Vitali A. Davydov, 19, of North Potomac, who admitted he had beaten the doctor with his fists, according to charging documents. When the young man left the office, “Dr. Fenton was on the ground, bleeding from the face,” the documents said. 

Dr. Fenton had known that the patient presented some risk: he was young, male, severely psychotic and struggling with a mental state that was frightening and unfamiliar. The psychiatrist was trying to persuade his patient to continue taking medication, Mrs. Fenton said. 

The killing, besides devastating the two families involved, has deeply shaken mental health workers around the country. In the days since, many have wondered about their own safety and about the dangers of allowing patients with severe psychosis to go without medication. 

Dr. Fenton’s death is not likely to change psychiatric practice, experts said, but it may become a touchstone for one of the most contentious debates in psychiatry: whether people suffering from psychosis should be compelled to accept treatment to reduce the risk of violent outbursts. 

“We have been thinking about all these things in the past week, that’s for sure,” said Dr. Thomas H. McGlashan, a psychiatrist at Yale and a close friend of Dr. Fenton’s, who worked with him decades ago at Chestnut Lodge, a renowned psychiatric hospital that closed in 2001. “Yes, there is a risk of violence with some patients, and no, it’s not black-and-white, like some would want you to see it. It’s not just that Wayne is dead, but that the kid’s life is ruined too.”

Violence is less common among those with mental illnesses than is sometimes assumed. Many people with schizophrenia are withdrawn, more likely to be targets of an assault than to commit one, said Bruce Link, a professor of epidemiology at Columbia.

But studies suggest that those with untreated psychosis — often characterized by intense paranoia and imaginary voices issuing commands — are at least two to three times as likely as people without mental disorders to get into physical altercations, including fights using weapons, Dr. Link said. 

An analysis published last month in The American Journal of Psychiatry found that people with severe mental illness committed about 5 percent of the violent crimes in Sweden, though they made up a small fraction of the population. The United States, which has higher crime rates, has a much smaller proportion of crime attributable to the mentally ill than Sweden, experts said. 

Yet the risk is real, if remote, for those who meet one on one with severely psychotic patients and try to negotiate difficult issues like medication. So-called antipsychotic drugs effectively blunt symptoms of psychosis and tend to reduce the risk of violent outbursts, psychiatrists say. But the medications are mentally dulling and often cause weight gain, among other side effects, and many patients either stop taking them or refuse them altogether.

In part to forestall violent episodes, several states, including New York and California, have tightened their treatment laws to compel some mental health patients to accept treatment, even if they have not committed a crime. The issue is divisive among former psychiatric patients, researchers and practicing psychiatrists. 

“This is an extremely important issue for psychiatry, and there are two sides of this story,” said Dr. William T. Carpenter Jr., the director of the Psychiatric Research Center at the University of Maryland and the editor of the journal Schizophrenia Bulletin. “As doctors, we think patients ought to do what we think they should do, and if someone needs to be on medication it’s difficult not to wish there was some way to do that.”

On the other side, Dr. Carpenter said, “you have a significant civil rights argument.”

In the wake of Dr. Fenton’s killing, some patient advocates cautioned against exploiting the tragedy to promote forced treatment. 

“The main concern is that we not let fear and stereotypes based on this case drive public policy” in support of forced commitment and drug treatment, said Will Hall, a mental health advocate in Northampton, Mass., who was hospitalized as a young man and treated with antipsychotic drugs for about four months after a suicide attempt. A better way to prevent violence, Mr. Hall said, “is to offer patients who refuse medication on any ground a much wider range of options, including psychosocial treatments.”

Yet alternatives to drug treatment are not yet widely available. And with the news of Dr. Fenton’s killing in their thoughts, some psychiatrists said they were thinking carefully about the precautions they take every day. 

“When a patient is revving up and paranoid,” Dr. McGlashan said, “instead of becoming imperious or dogmatic or rigid I might admit that I’m kind of nervous too. If you’re scared, you let the patient know that. Because a lot of their behavior is coming from their perception of being threatened. If you let them know that you are feeling threatened, vulnerable and not interested in controlling them, that can help defuse the situation.”

All of which, of course, Dr. Fenton understood.

But the need was urgent, Mrs. Fenton said. The need was urgent, the family was desperate, and that was enough for her husband, as long as she had known him. Someone wanted his help, so Wayne would go.


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## David Baxter PhD (Sep 19, 2006)

The sad case of Joe Martens
Monday, September 18, 2006

Police have been called to Joe Martens’ house 88 times in the past 5 years. Eight times he was actually arrested. The last time officers came to his home, it took three officers and a stun gun to subdue him.

Joe has been diagnosed with bipolar disorder and regularly goes off his medications, though family members say he is fine when he is on his medications. A loud public debate is raging in the community – neighbors want him arrested, but he has done nothing wrong. He isn’t dangerous, so he cannot be committed.

"When Joe (stops taking his medicine), I can't get him to go to Broadlawns," says [Joe’s father] Gary Martens, referring to Polk County's hospital. "So, I just sit and wait until he looks at someone cross-eyed. Then the West Des Moines Police Department comes and takes him away."Martens says he can't force his son to get help. The law says that Joe Martens is an adult, capable of making his own decisions.

Nobody can win this terrible standoff. 


Joe, as he describes it, is a prisoner in his own home. If he feels like the neighbors are watching him, it is because they are. 
The neighbors are afraid and feel unsafe in their own homes. 
Joe’s family can’t help their son stay on medication and are forced to watch him regularly deteriorate, worrying that the next encounter with police or neighbors might end Joe’s life.
Police are expending inordinate resources in responding to incidents caused by the symptoms of this one man’s untreated mental illness. 
And likely, people with mental illnesses in the area, probably others in that very neighborhood, are feeling stigmatized by the public reaction to Joe. 

Stories like this are infuriating precisely because this scenario is what many in the mental health community support. Their advocacy against tools like assisted outpatient treatment mean standoffs like these will continue. One wonders how they will react if Joe’s outbursts actually end up hurting a neighbor, or if police end up hurting Joe.


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## David Baxter PhD (Sep 19, 2006)

Kendra's law would help protect society
September 18, 2006
_Albuquerque Tribune_

Tonight the Albuquerque City Council could make history, adopting a city ordinance that would allow courts to order mentally ill persons into outpatient treatment programs if they are a threat to themselves or others.

The ordinance is sponsored by Councilor Michael Cadigan and as of early today had the support of a majority of council members, as well as Mayor Martin Chavez, who is among supporters irritated by delays in passing the measure.

While a state statute is the preferred option, Albuquerque shouldn't wait any longer. The Legislature considered but did not pass a state version of what is known as Kendra's Law, despite the strong support of Gov. Bill Richardson and other prominent politicians. New Mexico remains one of only eight states without such legal authority.

The council should adopt the ordinance, which balances individual rights and society's need to protect people from harming themselves or others. It provides for a court-directed, physician-monitored treatment programs that could include mandatory drug compliance through law enforcement.

Studies do suggest that such laws can go a long way toward helping the oft-forgotten mentally ill and in preventing the sad consequences of that neglect, including the tragic loss of life.

Opponents of such mandatory outpatient treatment say the ordinance is little more than a patch for a broken mental health system that desperately needs money and both outpatient and inpatient treatment facilities. They are right.

But until the country and the state get serious about mental health, this city ordinance is a responsible step toward helping those in need and protecting society from any harm they might inflict on others.

U.S. Sen. Pete Domenici, a longtime advocate of mental health and a critic of insurance companies and government failures in mental health coverage and treatment, supports the ordinance. He also pushed for the state law.

Patterned after New York's Kendra's Law, which was adopted after a young woman was pushed to her death in front of a subway train by a mentally ill man, the ordinance has been promoted in Albuquerque since resident John Hyde was charged with killing five people on a single day last year.

Hyde is in a state mental health institution, pending resolution of his case. Officials and members of Hyde's family say he was being treated for mental illness and had been seeking additional help in the days leading up to the shooting spree - in particular, a change of medication because the drugs he was given were not working.

Two of those killed that day were police officers acting on a medical directive to bring Hyde in for possible treatment.

But the Hyde case is not the only one that cries out for action. The Treatment Advocacy Center, which promotes mental illness reforms in the United States, lists more than 30 incidents in New Mexico involving mentally ill people over the last two years that ended in "preventable tragedies."

The people of Albuquerque - including those in need of, but who may not be getting, mental health treatment - deserve the help and protection this ordinance aims to provide.


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## ThatLady (Sep 19, 2006)

As I see it, civil safety has to come before civil rights. Having rights is no good to you if you're killed by somebody else whose rights allowed them to be out in the street with a weapon while they were unable to control, or even understand their actions. Neither do those civil rights do the poor, untreated mental patient any good when he/she is shot by police in order to protect another citizen. That's not to mention the untreated mental patients who must live in the streets because they have no place else to go and are unable to provide for themselves.

I can't imagine the horror to which the families of such individuals are subjected. Here's someone you love, whom you know needs treatment and medication; yet, you're unable to get them to understand the importance of said treatment and medication and must watch, helpless, as they flounder through life without the foresight to help themselves. It's the most vicious of vicious circles.

Somewhere, there has to be the application of common sense. Of course, people should be free to live their lives without the incursion of force by authorities; however, that's should be only as long as they are _able_ to do so without causing harm to themselves or others. Those who are ill need to be treated, particularly if their illness places themselves, or others, in danger. While the thought behind the laws that prevent forced treatment may be altruistic, it just isn't working in many cases. A line needs to be drawn compassionately, but realistically.


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## David Baxter PhD (Sep 19, 2006)

The question I ask repeatedly is this: 

How are we as a society supporting the civil rights of the mentally ill if, recognizing that one of the symptoms of their illness is impaired judgement and insight, and having the capability to make the quality of their lives better by any objective yardstick, we stand by and do nothing to help them?


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## ThatLady (Sep 19, 2006)

There's really only one answer to your question in my opinion, David. That answer is: We aren't. Lawmakers stand around and wring their hands, parents cry, siblings lament and victims proliferate, but little is done to change anything.

I think another factor that is too often overlooked is that it's very difficult to tell when an untreated mentally ill person will reach a breaking point and lose control. That sad soul living in the cardboard box on 3rd and Elm may have seemed harmless, lying there chittering to the voices in his head and picking at his clothing. With the right (or wrong) trigger, he could stop chittering and start killing. Yet, we leave him there in his cardboard box, alone with his voices. Nobody seems to want to take responsibility, and he can't.

It's a sad and frightening realization that our compassion often goes right out the window when dealing with the mentally ill. So many seem to prefer to look the other way. Insurance companies don't want to pay for treatment. Most of the psychiatric hospitals have been shut down for lack of funds. Acute care hospitals are too busy, and not properly equipped, to deal with the issues of the mentally ill. The government has far more important matters to attend to than to see to its less fortunate citizens. It's not a very pretty picture when you really start to look at it.


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## foghlaim (Sep 19, 2006)

> A line needs to be drawn compassionately, but realistically.


who is gonna be brave enough to draw this line tho?? i wonder.. 

I believed that if a doc, psych or even parents thought that a person was a danger to others they could actually have that person committed anyway.. is this gone??? 



> The government has far more important matters to attend to than to see to its less fortunate citizens.


 like spending billions on space programs or weapons etc. 


i think that the majority of the worlds governments have their priorities up their you know what. as long as they as individuals are not touched by this then it doesn't really exist... or it's not as bad as some ppl wuld have them believe. 

it's a global shame.. and for some countries it's us the ppl who have put these governments in place.. maybe us the ppl can take them out again.. i don't know.


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## ThatLady (Sep 19, 2006)

nsa said:


> I believed that if a doc, psych or even parents thought that a person was a danger to others they could actually have that person committed anyway.. is this gone???



In most states, if a person is deemed by a qualified mental health professional to be a danger to themselves, or to others, that person can be involuntarily committed. However, as the article said, in eight states, this is not true, as those states have not yet adopted a law allowing a person to be forced into treatment against that person's will, no matter how sick that person may be. It's sad, but it's true.


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## David Baxter PhD (Sep 19, 2006)

nsa said:
			
		

> I believed that if a doc, psych or even parents thought that a person was a danger to others they could actually have that person committed anyway.. is this gone???


No, but the key criterion there is *imminent danger to self or others*. Failing to meet that criterion does not mean a person is not a long-term danger, although that is admittedly difficult to predict accurately.

_<edit> I just read TL's comment that there are 8 states that do not currently permit this. My comment above applies to those areas that do have such legislation in effect. </edit>_

But the more important issue to me is not danger per se but quality of life. The question is how to balance that issue with the issue of personal freedoms and choice. There are people who at a certain point or under certain circumstances can be declared "mentally incompetent" to manage their own affairs or make their own decisions. It seems to me that this issue is related - at what point do we have the right to say that an individual's capacity for rational and informed decision is sufficiently impaired that medicine or the state has the right or duty to intervene?


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## ThatLady (Sep 19, 2006)

David Baxter said:


> But the more important issue to me is not danger per se but quality of life. The question is how to balance that issue with the issue of personal freedoms and choice. There are people who at a certain point or under certain circumstances can be declared "mentally incompetent" to manage their own affairs or make their own decisions. It seems to me that this issue is related - at what point do we have the right to say that an individual's capacity for rational and informed decision is sufficiently impaired that medicine or the state has the right or duty to intervene?



That's an interesting point, David. When dealing with a person's financial well-being, if the family feels that their aging parent/uncle/aunt/whatever is no longer mentally competent to handle his/her affairs, the family can retain an attorney and have the aging person declared mentally incompetent, thereby allowing the family (or the attorney) to take over control of the person's estate. Yet, if a family feels that their relative is mentally ill to such a degree as to not be able to provide for their own needs, or present a danger to themselves and/or others, they can do nothing. They cannot hire an attorney and expect to succeed in getting mandated treatment unless the mentally ill individual is an imminent danger to self or others. So, we can do it for the purpose of "saving" the person's estate but we can't do it to provide that person with a safer, healthier environment?

There's something kinda scary about that.


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## HA (Sep 20, 2006)

This article about the loss of Dr Fenton.....makes me cry. My sincere condolences go out to his family and friends.

One thing that really bothers me is the stigma. Stigma of people with mental illness by other people with mental illness has to be the worst kind. When you have people with mental illness writing letters about how they have schizophrenia or bipolar and they have never committed a "criminal" act as a way to defend their illness....this just increases stigma by 100 fold. Not only that but they turn their back on their peers who are the most ill and need the most support at the most difficult time they will ever have in their lives....when it involves the loss of a life.

Imagine waking up from a vivid dream where you had killed someone. Personally I can't imagine how that would feel but think it must be similar to what happens when someone with a severe psychotic illness kills another person. Most often this happens to family members......not the general public. Then imagine realizing that it was not a nightmare after all but something that you actually had done to your mother, sister or other loved one.

The person then has to live the rest of their lives with this. People with schizophrenia who commit these acts are NOT EVIL or have character flaws. They don't purposefully commit these acts because of revenge, anger, and pleasure or for lack of caring. They commit these acts as a result of untreated psychosis. It is because of hallucinations, delusions and disorganization of the brain. They are sick and most of the family members I have talked to tried very hard to get them the help they needed and it was in an untreated state that these acts occurred.

Some of them die by accident as a direct result of their psychosis but we never hear about this and it is most likely just deemed accidental death by drowning, hit by car, train or a fall or perhaps malnutrion/dehydration or a result of hypothermia or heat stroke. Some commit suicide. If it were my relative I would know that it was a direct result of their illness being untreated but there is no record of that! Coroner’s reports don't say.... death due to lack of treatment for psychosis.

I have had to sit many days and hours wondering if it would be this time that my son may die and not know where he was but knowing that he was too sick and disorganized to eat or drink and could quite easily have an accidental death. He was 21 yrs old. I would also pray and hope that if anything was to happen that it would be to him and not anyone else. The time he got the best treatment was when he broke the law. We were lucky...no one got hurt.

No family member should ever have to go through such a thing. No family member with any other brain disorder would ever have to go through such a thing. The public would be up in arms if people with Alzheimer's and autism were left to the street because they did not want to be at home or in the hospital or be with family. Not so with schizophrenia......it is their human right to choose and this comes above all else. It is the law. 

Some still believe in Thomas Szasz a psychiatrist who supports the beliefs of Tom Cruise and believes that schizophrenia does not really exist. That they are just people with a difference and society makes them sick. He believes that people with mental ilnness who committ a crime such as this should all go to prison as they are just criminals. How sick is that. It's certainly not what I have witnessed with my eyes and ears. 

With treatment of antipsychotic medication the effects of psychosis is diminished for many people. Unlike Alzheimer's and autism where there is no medication to bring their loved one back. I have seen my son return from the depths of psychosis only to be gone again when he stops his medication....many times. People who live, struggle and care for loved ones with other brain disorders don't have such a gift like this medication and I hope one day they do. But, to see their loved one not have an opportunity with such treatment even if it exits...could be the plight of thousands more than the thousands of families living with schizophrenia who suffer as a result. If we can help it...this won't happen to others.

There are two perspectives on treating those with psychosis when they don't want treatment. One is the *civil libertarian perspective* where the right to chose comes above all else as it is a human right under the mental health law. The other is the *human needs perspective* where the right to treatment comes above all else. The later is non-existent in practice and people suffer greatly as a result.

I do believe the day will come when we will look back on how we *do not treat *people with schizophrenia today and be shocked that we had done such a thing.


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## David Baxter PhD (Sep 21, 2006)

NY Times on violence and mentally ill
Wednesday, September 20, 2006

Would that everyone would talk about violence and mental illness as cogently as Dr. Bruce Link.

Dr. Link highlights the problem in the _New York Times_' careful coverage of the tragic death of Dr. Wayne Fenton ...

Violence is less common among those with mental illnesses than is sometimes assumed. Many people with schizophrenia are withdrawn, more likely to be targets of an assault than to commit one, said Bruce Link, a professor of epidemiology at Columbia.

But studies suggest that those with untreated psychosis - often characterized by intense paranoia and imaginary voices issuing commands - are at least two to three times as likely as people without mental disorders to get into physical altercations, including fights using weapons, Dr. Link said.​


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