By Robert Freedman, M.D.
DENVER (May 27, 2009) – The recent killing of a Denver convenience store clerk by a mentally ill patient raises issues of the risk for violence in some mentally ill persons, the ability of psychiatrists and psychologists to predict and prevent such violence, and the effectiveness of the Colorado system of care for mentally ill persons who have committed violent acts.
Most violent criminal acts are committed by individuals who are sociopathic, intoxicated, or socially disadvantaged. These individuals are not considered to be mentally ill. Most mentally ill persons are not violent, and our society should not stigmatize them as potentially violent when they are not. However, a small group of persons who are mentally ill do commit violent acts.
Violence in mentally ill individuals arises from their delusional thinking about other people, including strangers whom they may see as threatening. Eruption into violent assault on others occurs when there is a sudden loss of self-control, usually triggered by an upsetting event. Medications and psychotherapies are highly effective in decreasing rumination and in preserving self-control. However, patients may stop taking them when they live outside supervised settings.
Persons with mental illness who commit violent acts most often understand that what they did was wrong. They are then convicted as criminals and incarcerated in state penitentiaries, where they also receive psychiatric care for their mental illness. If they are too ill to understand, then they cannot be tried in court and instead they are hospitalized at the Colorado Mental Health Institute at Pueblo to assess whether treatment will allow them to recover enough mental function to be able to stand trial. Under Colorado law, they cannot be held indefinitely at the Institute. If they are not imminently dangerous, they must be released back to their community. The legal paradox that a patient may be too severely mentally ill to stand trial and too well to remain in the hospital arises from the different laws that govern courts and hospitals.
Public attention is directed to the psychiatrist or institution that made the decision to release a patient before the violent act occurred. In fact, it is inevitable that a few recently released persons will commit acts. A change in setting, from a prison or hospital to a halfway house or a halfway house to a family home, often occasions a lapse in medication compliance and an increase in social stress, which increase the risk that violence will occur. In Colorado, prisons and mental hospitals are State institutions, whereas community mental health centers are non-profit independent entities, with different clinical personnel and procedures. Thus, at the critical juncture of release into the community, there is a poorly timed change in the treatment program.
What is needed is a seamless treatment system that delivers effective, monitored care over many years to severely mentally ill persons living in our community who are potentially violent. Psychiatrists have not historically done a good job of developing plans for these programs and then convincing policy makers of their effectiveness and value, when they are adequately funded. Such programs need to include required frequent visits, checks for compliance with medication and avoidance of illicit drugs and alcohol, and support for the family homes and residential settings where patients live. Model programs are now being developed, but their effectiveness needs to be rigorously tested and verified.
Violence in adulthood is frequently preceded by violence in childhood, when the first signs of mental illness appear. Mental illness researchers have charted the developmental course of these illnesses through childhood, and now we are beginning to find treatments that can arrest or reverse them. Mental illnesses are now recognized to be severely disabling to individuals, but the killing of a store clerk reminds us that these illnesses affect the entire well-being of our community as well.
Robert Freedman, M.D. is Scientific Director of the Institute for Children’s Mental Disorders and Chair of the Department of Psychiatry at the University of Colorado Denver School of Medicine. Faculty of the Department are psychiatrists at the Colorado Mental Health Institutes at Pueblo and Fort Logan and the Colorado Department of Corrections.