When it comes to dealing with the mentally ill, treatments are difficult to administer and are very often controversial. All too often, psychiatric patients end up in the hospital over and over again because they do not self-administer prescribed treatments.
"You see patients revolving in and out of a hospital and it's demoralizing," said Dr. Marvin Swartz, head of Duke's Division of Social and Community Psychiatry.
A recent study has found an effective but controversial approach that teams law enforcement with doctors: Having a judge order a patient to stick to his treatment can achieve promising results.
The study's results, published in the April issue of the British Journal of Psychiatry and the December 1999 issue of the American Journal of Psychiatry, found that treatment encouraged by the force of law can reduce the number of violent acts committed by psychiatric patients as well as reduce their rate of hospital readmission.
But the issue at the heart of the matter has to do with the limits of this approach, called involuntary outpatient commitment programs. Mary Zdanowicz, executive director of the Treatment Advocacy Center, said nearly half of individuals diagnosed with schizophrenia and manic-depressive illness suffer from an inability to recognize that they are ill. Consequently, they do not take their medication.
Under the laws suggested by the recent studies, if a patient is unable or unwilling to seek treatment, a physician may request a hearing with a judge. The patient is then assigned a course of treatment; if the patient does not comply with the treatment, the physician may request that law enforcement officers transport the patient to a clinic-but at no time can patients be forced to take their medication. Swartz said this approach is used frequently but not abundantly by Durham judges.
Professor of Law and Philosophy Martin Golding said this strategy of involuntary outpatient commitment should be carefully weighed against basic human rights. "It's a hot pistol because the person in question hasn't done anything yet," he said.
Last summer, New York enacted an outpatient commitment program called Kendra's Law, named after Kendra Webdale, who was pushed to her death by a schizophrenic who neglected to take his medication.
"The Kendra Webdale case is tragic, but also rare," said Swartz, pointing out that the violence rate of the severely mentally ill, when separated from substance abuse, is relatively minor.
However, Zdanowicz believes that Webdale's tragic death was generally representative of real problems that need to be addressed. "New York had more than its share of similar tragedies which resulted in large part because the state did little to ensure treatment compliance for individuals who need medication to live safely in the community," she said.
But balancing effectiveness of treatments and societal safety with preserving patients' autonomy makes this such a tricky issue. Elizabeth Kiss, director of the Kenan Institute for Ethics, emphasized the need to respect people's autonomy. "On one hand, we're moving toward a more draconian, punitive approach," said Kiss, citing a decrease in clemency and trying minors as adults as examples. "But there's also a greater understanding of mental illness."
She added that it is hard to know why certain treatments may work. In her mind, the real challenge is in creating "a community framework which sustains the treatment of mentally ill...," she said. "In the best of possible worlds, there should be someone other than a judge telling them to take the medicine."
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