Even 6 months after the tragedy at Shady Hook Elementary
School, we’ve all been asking what may have caused the horrific shooting. We may or may not agree that the ready
availability of assault weapons and the playing of violent video games may have
contributed to the rampage, but we can surely agree that failures in the mental
health system also played a significant role. We don’t know if his mother struggled to
obtain mental health services for her son, although we know that she had home-schooled
him for a time. What we do know,
however, is that for many families, providing mental health services for their
desperately ill children is an extraordinary challenge. And many, many children, as well as adults,
are falling through the cracks. I see the struggle for mental health services occur on a daily basis.
According to the National Alliance on Mental Illness (NAMI), 4 million children and adolescents in this country suffer from a serious mental disorder that causes
significant functional impairments at home, at school, or with peers. Additionally, 21% of children between ages 9
and 17 have been diagnosed with a mental or addictive disorder that causes at
least minimal impairment. Despite this
high prevalence rate, NAMI reports that in any given year, only 20% of children
with a mental disorder are identified and treated. That’s a lot of kids to not
receive treatment, and the consequences can be tragic. Suicide is now the third leading cause of
death among youth aged 15 to 24. Of
those children who commit suicide, over 90% have been diagnosed with a mental
disorder. Additionally, 50% of teens
with a mental disorder will drop out of school.
Many of these youth will wind up in the criminal justice system. The National Institute of Mental Health found
that 65% of boys and 75% of girls in juvenile detention have at least one
mental disorder.
And why are these children so underserved? Well one reason is that we continue to cut
funding for mental health programs. In
the last three years, states have cut a combined $1.8 billion for mental health
care from their budgets. Additionally, in
the last five years, we have eliminated 4,000 inpatient hospital beds. Dr. Denise Dowd, who authored a paper on
firearm-related injuries on behalf of the American Academy of Pediatrics,
stated, “We have plenty of beds for kids with gunshot wounds, but a kid with a
mental health problem, that’s another issue.
We don’t have beds for those kids.”
In addition, we have a woefully inadequate number of child and
adolescent psychiatrists. The federal
government estimates that we will need 12,624 child and adolescent psychiatrists
by the year 2020. The projected number
is just 8,312. Currently, we have only
6,300 nationally. Nebraska has only 30
child psychiatrists in the entire state, or one for every 11,000 children.
Liza Long, in her controversial blog “I am Adam Lanza’s
Mother,” asked for a national conversation on mental health. One anonymous psychiatrist responded in a
blog titled, “I am Adam Lanza’s Psychiatrist:
A Response from the Mental Health Trenches to ‘I am Adam Lanza’s
Mother.’” The unknown psychiatrist acknowledges psychiatry has limitations in
judging when a patient could become violent.
It is hard to predict when a patient who is a ticking time bomb (characterized
as chronically dangerous) becomes acutely dangerous (in need of immediate hospitalization). Sometimes patients are missed, and we wind up
hearing about them on the evening news after yet another rampage. The anonymous psychiatrist in his blog quotes
the APA Council on Law and Psychiatry:
“The ‘absolute risk’ message is that the vast majority of people with
mental illness in the community are not violent. The ‘relative risk’ message is that people
with serious mental illness are, indeed, somewhat more likely to commit violent
acts than people who are not mentally ill.
And the ‘attributable risk’ message is that violence is a societal
problem caused largely by other things besides mental illness (ready
availability of guns, for example.”
We would never know from watching the 24/7 news coverage
after these shootings that most persons with mental illness are far more likely
to be the victims of violence rather than the perpetrators. Yet some patients are dangerous and need
involuntary treatment; they fail to grasp how desperately ill they are or how
disordered is their thinking. Dr. Paul
Steinberg, in an editorial in The New
York Times states that in our squeamishness to impose treatment on the
seriously mentally ill, we are in fact neglecting the rights of ordinary
citizens, particularly since pharmacologic treatment of schizophrenia, can be
“remarkably effective.”
Within the field of psychiatry there appears to be
disagreement on the types of involuntary treatment which should be imposed and
under what circumstances, topics clearly beyond the scope of this blog. However, both Dr. Steinberg and the anonymous
blogger have wish lists of what they feel should happen. Among other things, Dr. Steinberg asks for reasonable
restrictions on semi-automatic weapons; criminal penalties for those who sell
weapons to individuals who are clearly mentally ill; better insurance coverage,
including longer hospital stays; more hospital beds; and a “greater
willingness” to impose treatment on those who are threats to themselves or
others. Like Dr. Steinberg, the
anonymous psychiatrist urges tougher federal laws to make obtaining involuntary
treatment easier for families and psychiatrists, a Health Law Court where
doctors can serve as judges and psychiatric proceedings are streamlined, and of
course, better insurance coverage. And
finally, in recognition that most if not all of these shooters have been
bullied, our anonymous psychiatrist wants to tell the popular high school kids “to
stop being such dicks to the odd kids or the ones they don’t understand.”
These tragedies are dissected and the mental health of the
shooters is endlessly parsed on the air by the media pundits. Yet psychiatrists, the most qualified to
comment on the potential pathology of the shooters, are largely silent. According to Dr. Steinberg, psychiatrists
are ethically bound by the APA to refrain from commenting on the mental health
of someone whom they have neither examined nor been given permission to
discuss. One unfortunate consequence of these unfounded speculations is the
further stigmatization of patients with mental illness, making it less likely
that some will actively seek out treatment for fear of discrimination in
employment, housing, and or even their social circles. They will be left even further isolated.
Liza Long in her controversial blog asked us to begin a
conversation in this country on mental health.
Hopefully this conversation has finally begun and will continue,
resulting in effective and obtainable treatment that will enable the mentally
ill to maintain productive lives within their communities and among their loved
ones and friends.