The article “Dangerous Cases: Crime and Treatment“, by in the December 1st edition of Time, is the best damn thing I’ve ever read about violent crime and the mentally interesting. I can’t remember reading anything in the mainstream press, other than the BBC’s website, the stats I’ve been quoting for the last 12 years:
People with a serious mental illness are also nearly 12 times as likely as the average person to be the victim of a violent crime, like rape, and as much as eight times as likely to commit suicide. People with symptoms of mental illness account for as much as 30% of the chronically homeless population.
She also dug into the same studies I’ve been throwing around every time I have to write the same damn essay in response to the same over-reaction to annual tragedies. She’s the first sane reporter to see the light:
As a total population, the millions of Americans who suffer from a mental illness at some point in their lives are no more likely than anyone else to commit a crime. But narrow that population to only those with the most serious mental illnesses, like schizophrenia or bipolar disorder, who do not receive treatment, and it appears to be a different story. A widely cited 2005 study based on NIMH data found a violent-crime rate of 8.3% among those with a “major mental disorder,” compared with 2.1% among those without disorders. A 2008 peer-reviewed analysis that surveyed 31 academic studies found that 12% to 22% of inpatients and outpatients with serious mental illnesses “had perpetrated violence in the past six to 18 months.”
Only 3% to 5% of violent crimes in the U.S. can be attributed to mental illness, according to Duke medical sociologist Jeffrey Swanson. But such tragedies–like Cukor’s death or the 2007 Virginia Tech shooting, in which a student with a mental illness killed 33 people–tend to have a disproportionate impact. They earn headlines, anger the public and motivate politicians to action in a way that the mundane suffering of the homeless or convicted criminals does not.
I never liked the 2008 meta analysis to which she refers, but that’s just quibbling over dueling studies. I think she gives her readers a bit too much credit by not pointing out that such events earn more headlines than when the dangerously sane do the same thing, but that would have been beyond the scope of the article. Which is actually about the question of broadening the rules for involuntary commitment of the severely crazy.
On the article’s core issue – it’s well worth reading for that too. It raises important questions. If someone is unable to tell that they are ill (anosognosia – lack of insight – a condition about half of the schizophrenic and a third of the bipolar have, I think, because stats on this are hard to come by), thinks the meds are making them worse, or are pressured by the general stigma and/or their family to stop taking their meds, should they be forced to stay in a psych hospital before they wind up dead on the streets? As someone who has been homeless due to brain cooties and in the locked ward of a psych hospital I’d much rather be locked up in a loony bin than living in an abandoned building and eating mystery meat or oatmeal soup at a church. And I don’t think there are that many abandoned buildings left in which it’s safe to for a lone nutjob to be living, let alone something like the palace of a condemned thrift shop that I found over 30 years ago. Trying to get someone with anosognosia to determine if they need to check themselves into a hospital, or even if they need to take meds and other treatments, is the same as telling someone with bipolar disorder to try really hard to not have mood swings. Which, as we all should know, is the same as asking someone with type-1 diabetes to try really hard to produce the correct amount of insulin. It’s basically Christian Science psychiatry.
I hate to quote a bunch of hippies, but “Freedom’s just another word for nothing left to lose.”
Lack of insight – easier to remember than anosognosia – is a physical condition you can see on a brain scan. It looks the same in Alzheimer’s as it does in bipolar disorder and schizophrenia. If we don’t expect someone with Alzheimer’s to decide for themself if they belong somewhere they don’t want to be, should we expect the same of someone with schizophrenia or bipolar who is similarly clueless?
Like lots of things in life there is no easy, simple answer. Who determines how crazy someone needs to be to get checked into what sort of facility for how long? What sort of treatment options will be available? What prevents them from being gulags where inconvenient, but not particularly crazy people are dumped? Does everyone get a brain scan, or do we just rely on something like the Beck Cognitive Insight Scale? What if someone knows they’re batshit crazy but just doesn’t want to take their meds? What if the only thing that works has really bad quality-of-life, but not health-endangering side effects?
Whatever the answers are they need to be determined by people with real experience in the world of mental illness, not politicians. And it needs to be done before the next over-publicized killing, not immediately after. No matter what steps are taken nothing, absolutely nothing will prevent another mass killing by someone with a mental illness. It certainly won’t prevent the ones carried out by the dangerously sane. Designing something with calmer, clearer minds will be like the really good meds: it will work better and suck less.