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David Baxter

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Violence and schizophrenia
by E. Torrey Fuller
Schizophrenia Research 88 (2006) 3?4

The recent killing of Wayne Fenton by a patient with untreated schizophrenia reminds us of a fact that we too often ignore. A subset of people with schizophrenia and other psychoses are dangerous if their paranoid delusions and other symptoms are not treated, especially if they are also abusing alcohol or street drugs.

Eight major studies of violence among seriously mentally ill individuals have been reported in the United States since 1990. Together they show that 5 to 10% of such individuals commit acts of serious violence each year. The studies also show the importance of treatment in reducing this violence. For example in the CATIE study the incidence of violence was very low because all participants were receiving antipsychotic medications.

Similarly in the MacArthur Violence Risk Assessment study the incidence of violence among treated patients was much lower than among those not taking medications. Homicides are the best documented and supreme expression of violence. In the United States only one small study of homicides committed by mentally ill individuals has been carried out; in Contra Costa County in California from 1978 to 1980 there were 7 individuals with schizophrenia and 1 other with a drug-induced psychosis among 71 total homicides. In European and Commonwealth nations in recent years, 13 such studies have been done. Individuals with schizophrenia and other psychoses were found to be responsible for an average of 9.4% (range: 5.3 to 17.9) of all homicides. The United States has a higher total homicide rate than most other countries so the percentage of homicides attributable to individuals with severe psychiatric disorders will be somewhat lower. Thus it seems apparent that individuals with psychoses are responsible for at least 5% of homicides in America. The massive discharge of patients from state psychiatric hospitals, followed by the failure to treat many of them, was well underway by 1966. During the intervening 40 years in the U.S. there have been 742,691 total homicides, of which a minimum of 37,134 (5%) were attributable to individuals with severe psychiatric disorders, almost all of whom were not being treated. As such, almost all of these were preventable homicides.

The most common victims of such homicides are family members, especially mothers. Mental health professionals are not uncommon but not rare victims. For example, in Oregon two psychiatrists were killed by patients in a single year.

The violence issue among individuals with schizophrenia is a treatment issue, nothing more nor less. In virtually every case it has been found that the individuals responsible for such homicides, like the young man who killed Dr. Fenton, were not taking medication. The problem is that approximately half of all individuals afflicted with schizophrenia have moderate or severe anosognosia; they are neurologically impaired and thus unable to perceive their own illness or need for medication. Laws governing the treatment of mentally ill individuals in the United States ignore this fact and make involuntary treatment exceedingly difficult to carry out. Several studies have shown a correlation between anosognosia and noncompliance with medication and with violent behavior.

The solution is assisted treatment for individuals with schizophrenia who have anosognosia and are thought to be dangerous. This can be accomplished by conservatorships, conditional release, or by outpatient commitment. Maryland, where Dr. Fenton was killed, is one of only eight states with no provision for outpatient commitment. In most states the laws are written in such a way that the family of the mentally ill person and mental health professionals can do nothing until the person demonstrates dangerousness. Dr. Fenton paid the ultimate price for Maryland's inadequate laws.

Studies have shown that the use of conditional release and outpatient commitment reduce violence dramatically. In North Carolina outpatient commitment reduced the incidence of violence from 42 to 27% when the commitment was continued for at least 6 months. In New York, where the outpatient commitment statute is called Kendra's law, a recent study reported that its use reduced the incidence of those who physically harmed others from 15 to 8%.

However it is considered politically incorrect to promote outpatient commitment or other forms of involuntary treatment. As a consequence organizations like the two APAs and NAMI are largely silent on this issue. Others, like the Mental Health Association and the Bazelon Center even deny the link between untreated schizophrenia and violence despite overwhelming evidence to the contrary. The only organization actively trying to change state treatment laws to take into account the reality of anosognosia is the Treatment Advocacy Center.

Wayne Fenton was a friend and colleague for whom I had great respect. He was dedicated to improving the treatment for individuals with schizophrenia. As professionals, the most important thing we can do to honor his memory is to speak out on the issue of violence and to promote treatment laws that reduce it. As noted by Swanson and Holzer: ?No one is served by ignoring the evidence that mental illness is associated with some increased risk for assaultive behavior (Swanson and Holzer, 1991).?

REFERENCES
Swanson, J.W., Holzer, C.E., 1991. Violence and ECA data. Letter. Hospital and Community Psychiatry 42, 954?955.
 

HA

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Besides the issue of possible violence and the necessity for Community Treatment Orders (CTO's) or other forms to treat someone who is not aware that they have the illness (ana-sog-nosia) and are acutely ill, there is another problem that occurs, jails and prisons being used as treatment facilities. The story below points to one womans tragedy when the legal system becomes the treatment provider.

Another issue about violence and psychosis that I find hard to understand is that it seems to always be considered purposeful behaviour. It is difficult for us to willfully control our feelings of sadness, love or anger when we are healthy and for someone who is acutely psychotic, these emotions and their paired behaviours can be out of control and bizzare so why would the violence behaviour be considered differently?

10:02 AM CST on Sunday, November 12, 2006

Rosie's Journey

Day 1, The Voices Speak

A battle within
For the last 30 years of her life, Rosie Sims wrestled with a demon - schizophrenia. And in the end, a loving family and an inadequate mental health system coudn't save her.
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Day 2, What's Wrong, Mom?

Diagnosis and decline
Medication keeps schizophrenia in check for a while, but the disease still overpowers Rosie and her family

Day 3, A Brief Respite

Bullet to head sends illness into hiding[/COLOR][/B]
Mid-1980s bring the happiness of school and a job, but schizophrenia hovers
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Day 4, Her family tries to cope

Mom's mental illness weighs on kids
Her grown children take over as caretakers, facing anger, hurt and desperation
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Day 5, In the hands of the system

Needing a place to heal, she went to jail instead
Arrest warrant puts psychotic woman behind bars, not into treatment
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Day 6, "Bizarre behavior"

More time in jail, hospital
Schizophrenia retains its grip as woman slogs through legal system
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Day 7, Waiting, waiting


The trial that would never come

Schizophrenic ran out of time while delays kept her from court
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Day 8, Love You, Mom

In death, free at last
Rosie Sims succumbs to a quieter disease after her struggles.

READERS RESPOND: A sample of feedback that this series has generated
? Share your experiences or feedback

EDITORIAL: Texas must take mental illness more seriously

CHRONOLOGY: Significant dates in the life of Rosie Sims

SCHIZOPHRENIA: About 1 in 100 people suffers from this complex mental illness

RESOURCES: Where to find help for mental illness

Illustrations: MICHAEL HOGUE/DMN
About this series
The story of Rosie Sims is based largely on multiple interviews with members of Ms. Sims' immediate family, including daughters Tosha Lee and Melissa Lomack, son Archie Sims Jr. and former husband Archie Sims.

Other information came from interviews with officials at Vernon State Hospital and Terrell State Hospital, and with the paramedic who responded to the Dallas County Jail the night Ms. Sims was found dead in her cell.

Other interviews were conducted with an employee at Ms. Sims' bank and with several employees at the apartment complex where she lived. Dallas County Jail officials, officials in the Dallas County district attorney's office, the court-appointed lawyer who handled Ms. Sims' arson case and officials with the University of Texas Medical Branch at Galveston, which oversaw medical care at the jail when Ms. Sims was there, also were interviewed. Dr. Joel Feiner, a psychiatrist associated with UT Southwestern Medical Center, was consulted about the symptoms of schizophrenia and the medication used to treat the disease.

In addition, extensive legal and medical records were examined. The records include the files related to Ms. Sims' three legal cases, from initial police reports to transcriptions of competency hearings in which medical officials who had interviewed Ms. Sims presented their findings.

Also consulted were intake-screening forms filled out by Dallas County Jail officials each time Ms. Sims was booked and letters from officials at Vernon and Terrell describing her behavior while under treatment and the medication she received.

The Dallas Morning News also obtained medical records outlining Ms. Sims' medical care in the jail and the medical staff's actions the night she died, including UTMB employee clinic notes and medical briefs. The paper also relied on the Dallas County medical examiner's autopsy report, the state-mandated Custodial Death Report filed by the Dallas County Sheriff's Department and a Sheriff's Department supplementary investigation report.
 
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