We're living in a time when quite a few professionals are coming forward and telling people about their mental illnesses. For example, on national TV a few months ago, a neurosurgeon lost his marriage and father in a couple of months time, went into a deep depression and had to quit work. He got help and is back doing neurosurgery. Here are other examples: I know of a physician who hears voices. I also know of a nurse who works all day but has suicidal thoughts each evening.

My guess is that most people would not want to be under the care of these health professionals. If I'm wrong, then we can all go home. In my opinion, these professionals have wonderful minds and brave hearts. I don't think they're coming forward completely for their own wellbeing.

The risks are there. I believe that these professionals put quite a bit of thought into their decisions and how coming forward might play out. I also believe that they came forward for the right reasons: Because they care. Or because they refuse to make the stigma a bigger deal than they believe it should be. If someone asked me if I would want to be treated by any of these professionals, I would say that I want the best. If they happen to have a mental illness, then so be it.

So then maybe the next question is: Can a professional really have the judgment and other needed skills to actually do the job of these professionals I mentioned? My answer is: Some can, and some can't. It would depend on the person, the skills needed, the
symptoms, the stability and the employer. Hearing voices has not prevented this physician from doing her job. For some, it might. I'm challenging you not to make assumptions.

There are some truly amazing professionals who can endure their difficulties and contribute brilliantly. We should applaud these people. Actually, we should applaud anyone for trying. We should encourage everyone to try. And if the job cannot be done, I would want that
professional to try for something else. This decision concerning job capacity should be made under the care and opinion of that professional's treatment team.

It is our ethical responsibility to avoid the “we and they” mentality, do away with outcome expectations based on diagnostics and exercise some open-mindedness. It isn't easy to be mentally ill, and it isn't easy not to be mentally ill. Better said, for many, life is not easy.

Hear what I'm saying: a person can have the same disorder as someone else, but due to individual differences, each person might aspire to vastly different levels of competence – even in the same job. If we do not consider individual differences, we are sending a wrecking ball through the very awareness and understanding we so desperately need to develop. . . . 

The truth of the matter is that, with the new drugs, the movement to reduce the stigma, the increased knowledge and understanding, the craving for awareness, and the people stepping out, there will be more and more people who will hopefully find better help, will get better help and will live more productive lives. Most importantly, we all might be able to do so without such worry about what people might think, say and do.

CAROLYN DOBBINS, PH.D.

Exceprt republished with permission of the author from What a Life Can Be: One Therapist’s Take on Schizo-Affective Disorder

Stigma is one of many consequences of nontreatement for mental illness. For more on this topic, see our "Consequences of Non-Treatment" backgrounder.

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Researchers at Feinstein Institute for Medical Research and Zucker Hillside Hospital say identification of the gene could help doctors better serve patients genetically predisposed to the negative side effects of antipsychotics (“Genetic link found to weight gain with antipsychotics,” Newsday, May 8).

"This is the first time that a genetic-association study has been this successful in identifying a gene that predisposes the weight gain," said Anil Malhotra, a physician and investigator at Zucker and the Feinstein Institute. "Some people carry the risk form of the gene and some people don't. It's that subset of patients with the gene who are at greater risk for severe weight gain."

An estimated 10-30% of people carry the gene called melanocortin 4 receptor.

Weight gain is among the side effects often cited as a reason that people with serious mental illness do not adhere to medications. For other reasons people do not take their medications, check out our backgrounder, “Why individuals with severe psychiatric disorders often do not take their medications.”

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Sexton looked at the roughly 1 in 6 jail inmates who receive psychiatric care in his jail, added the $300,000 a year his county spends on prescription drugs for its inmates to the $900,000 it spends on medical care for them and figured it was worth $28,000 to find out if a pilot mental health court could cut those numbers.

The County Commission on May 2 looked at the same figures and voted against a contribution of  $10,000.

The pilot program would divert inmates with mental illness who face misdemeanor charges from jail into treatment (“County to test mental health court; Sheriff’s Office contributes money to fund program after commission’s rejection,” Tuscaloosa News, May 17). Sexton says this would reduce jail overcrowding (currently 654 inmates in a jail with a capacity for 540), address mental illness treatment needs and diminish the likelihood that the county will be hit with a federal lawsuit.

The county’s mental health department and the county Circuit Court judge also support the program, set to start June 1.

The Treatment Advocacy Center applauds Sheriff Sexton for his compassion, pragmatism and ability to see that  $28,000 is a downright bargain if it even dents the nearly $1 million price tag for medical services.

Though it would be better yet  would be if Tuscaloosa used Alabama’s assisted outpatient treatment (AOT) law to keep mentally ill citizens out of jail in the first place, the Treatment Advocacy Center applauds Sheriff Sexton for his compassion, pragmatism and ability to see that  $28,000 is a downright bargain if it reduces the nearly $1 million annual cost of medical services to inmates.

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Ten patients with schizophrenia and anosognosia were compared to 21 patients with schizophrenia but without anosognosia (i.e., patients with good awareness of their illness) and also to 18 control individuals without schizophrenia.

All underwent testing to measure their cerebral blood flow. The patients with anosognosia were found to have significantly decreased blood flow to the precuneus region of the brain. The precuneus is part of the superior parietal lobule and is known to have functions associated with our ability to think about ourselves. Thus it is not surprising that damage to this area is associated with anosognosia.

Anosognosia, or unawareness of illness, is a common problem in several brain diseases including Alzheimer’s disease, Huntington’s disease, strokes involving particular parts of the brain, schizophrenia and bipolar disorder with psychotic features. The anatomical basis of anosognosia has been well described. Studies of anosognosia in schizophrenia have reported that the prefrontal and inferior parietal areas, and connections between these areas, are involved, especially when the disease is on the right side of the brain.

These pictures show the differences in blood flow in the precuneus in an individual with altered insight (anosognosia) compared with an individual with preserved insight (no anosognosia).

(Pictures courtesy of Dr. Eric Guedj, Dept. of Nuclear Medicine, Hospital de la Timone, Marseille, France).

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I constantly find myself reliving the past. Unable to distinguish reality from fiction, it's a labyrinth of memories and daily doubt. My mind is tormented by horrendous memories of endless harassment, espionage, grandeur, unspeakable acts of violence upon myself and loved ones.

At times I used to literally find myself in hell, face-to-face with the devil. Now medicated, I'm able to keep the demons (positive symptoms) at bay, yet I struggle with them at times. Being medicated comes with a price one is under a constant fog. Functioning in this "normal" world is difficult.

Along with the positive symptoms (hallucinations, delusions, thought disorder and speech disorder) come the negative symptoms (apathy, lack of motivation, social withdrawal, individual neglect and cognitive deficits) of schizophrenia, which make daily tasks a challenge. Paranoia is a continuing reminder of my illness. Yet something in the back of my mind won't let me break down into utter oblivion.

Acceptance of my life is a constant reality of a fortunate fate. Fortunate of warmth, coolness, laughter, sadness, breathe and much more, yet I ask myself who am I? What do I want? How can I help people?

At this moment, I struggle for the answers because my mind is in a chaotic struggle to process the information. Comprehending these questions is over whelming, but I've come to grasp that being self-aware, present, acknowledging achievements, not being attached to the outcome and just being is a step in the right direction.

It is my duty, my pleasure to help those in need by sharing my story to prevent future tragedies. So I type one button at a time with my gnarled hand, searching for the right word, lost in a sea of nothingness full of everything, the mind of a schizophrenic-quadriplegic.

Reny

(NOTE: Reny lives in California, where he is an advocate for the extension of Laura’s Law, the state’s assisted outpatient treatment (AOT) law. To learn how Reny became quadriplegic as a result of untreated paranoid schizophrenia, read ‘I Am a Victim of a Failed System.”)

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Sounds like a case for assisted outpatient treatment (AOT) to us.

“Psychiatric in-patient care and suicide in England, 1997 to 2008” (Psychological Medicine, May 17) attributed the 29-31% drop in suicide rates to “Increased awareness of risk, a safer ward environment and improved professional practice,” according to summary in MedicalXpress (May 16). The drop was greatest among young patients and those with schizophrenia and exceeded the drop in the general population.

But lead author Nav Kapur said, “(A)s in-patient services are now dealing with patients who may be more unwell than in the past, swift and effective support for people following discharge has become even more important. We also need to keep a careful watch on suicide in services and settings which are alternatives to in-patient admission.”

Assisted outpatient treatment is a vital strategy for providing "swift and effective support" following discharge. As an increasing number of US states shutter or shrink state hospitals and increasing numbers of psychiatric patients are left with more limited inpatient care or no inpatient care at all, the use of AOT as a means of maintaining stability in psychiatrically fragile individuals becomes more urgently needed.  

There’s no reason to think the English trend would not hold in the US as well. Let’s hope it doesn’t take former patients taking their own lives to drive home the point that court-ordered outpatient treatment can play a lifesaving role in recovery from psychiatric crisis. 

(A copy the paper is available upon request from the University of Manchester.)

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The principle reason we reject Big Pharma support is that – as an organization which advocates for the passage and implementation of laws that can result in individuals with severe mental illness being ordered to adhere to medication orders – it would be an unacceptable conflict of interest to take money from the companies that make the drugs.

But the case of Abbott reveals another pitfall we are delighted to avoid: linking ourselves to corporations accused of committing criminal acts in their selling of psychopharmaceuticals.

Depakote is an approved treatment for mania, epilepsy and migraine prevention. Abbott allegedly marketed it for non-approved uses and gave doctors illegal kickbacks to talk about off-label uses in order to boost sales (“Abbot Labs agrees to pay $1.6 billion to settle Depakote cases,” Los Angeles Times, May 7, 2012).

As the only national nonprofit dedicated to reforming treatment laws that affect individuals with the most severe mental illnesses, our support for the appropriate use of medication when needed in treatment is just that. We certainly do not condone improper/illegal/hiding side effects or other tactics that put profits above health. In the same class: Eli Lilly & Co., fined $1.4 billion in 2009 for concealing the side effects of Zyprexa, an antipsychotic drug.

Big Pharma currently grosses an estimated $14 billion a year from antipsychotics alone. These are the top-selling class of therapeutic prescription drugs – far outstripping pills for much more widespread conditions like high cholesterol or heart disease – even though only an estimated 3.6 million Americans suffer mental illnesses with psychotic features that these medications are approved to treat.

For more on “pharmaceutical funhouses,” read Dr. E. Fuller Torrey’s essay, “The going rate on shrinks: Big Pharma and the buying of psychiatry” on our website.

With its ban on pharmaceutical contributions, the Treatment Advocacy Center relies entirely on private individuals and foundations for its support. To make a contribution that supports our mission of eliminating barriers to the treatment of severe mental illness, please visit Donate now and make a gift of any size.

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Douglas Franklin Jones, a homeless man with mental illness, entered St. Peter’s Episcopal Church in Ellicott City on May 3 and shot and killed the Rev. Mary-Marguerite Kohn, 62, and the church’s administrative assistant, Brenda Brewington, 59. Police said Jones then retreated to nearby woods and turned the gun on himself.    

Three deaths. All without reason. All of them preventable.

In their grief, the local Episcopal churches responded with love: They offered to host Jones’ funeral. The Rev. Carol Pinkham Oak – who served as co-rector alongside the Rev. Kohn – told the Baltimore Sun that it’s a simple matter of forgiveness:

"From St. John's point of view, we see this as a tragedy, and we also see this as a homeless man who was suffering with mental illness, so with our Christian understanding, we have offered him forgiveness. There is still grief and sadness and anger, but that doesn't mean there can't be forgiveness" ("Churches offer to host funeral for alleged St. Peter's shooter," May 9).

The churches found a way to forgive. But forgiving shouldn’t mean forgetting. What we can’t forget is that untreated serious mental illness brings unncessary loss. Lives are lost. Churches lose their leaders. Parents lose their children. Friends lose their dearest friends.

The churches are showing compassion by offering a final act of forgiveness. As advocates, we need to help our communities and policy makers not to forget that treatment works and that those too ill to seek treatment deserve an opportunity to benefit from it. Maryland is one of only six states without an assisted outpatient treatment (AOT) law. Other states have laws that need improvement or better implementation. When it comes to preventable tragedies, forgiving without forgetting is key.

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Through all of this, I have been impressed by the uncompromising quality of anosognosia. Formal training did not teach me what subsequent clinical experience did ... that among those with serious mental illnesses, blindness to the illness itself is a neurological agnosia (anosognosia), the mitigation of which is cause for genuine celebration.

Initially uncertain of my own conceptual footing, I began to label this frequent and frustrating illness blindness "anosognosia," especially after seeing the strong similarity of this to the anosognosia seen in other neurological disorders, such as Alzheimer’s disease or stroke  I was relieved to see others in my profession also begin to use the label.

The ramifications of accepting anosognosia as a feature of serious mental illnesses are important. For example, can a person truly give informed consent for treatment of an illness that he cannot see?  How is legal competency affected? What should state laws, policies and resources look like in addressing this? Should it be a DSM diagnostic criterion? Somehow the answers seem clearer when a radiologist can point on a film to a discrete cause for such an agnosia (e.g., a stroke.)

Though serious mental illness, such as schizophrenia, is as serious a neuropsychiatric disorder as Alzheimer’s disease or stroke, our current service delivery systems ignore this and the associated anosognosia with tragic consequences.

Though I'm guilty of sampling bias, I believe that anosognosia is over-represented among those with genuine serious mental illnesses in correctional settings and in the forensic hospital in which I’ve worked over the past four years. Due to the manner in which civil mental health services are delivered, anosognosia appears to be a powerful predictor of criminal incarceration.

I'm amazed by the novelty of this information to the mental health clinicians with whom I've worked over the years. "Denial" is supposed to respond to therapy and education. This kind of "denial" is a neurological brick wall.

Also amazing is some of the resistance I’ve met among psychiatric colleagues, who downplay the significance of this, or who simply don’t respond.

When I know I’m not mentally ill, why would I take onerous medications and keep clinic appointments? It is a legal/policy fantasy that people who suffer from anosognosia are uniformly able to make informed decisions re: their care and to rationally conduct their own affairs. As such, those in the active throes of illness are “empowered” to make their own decisions without interference from others, including parents. Many of those who advocate for people with serious mental illnesses seem do so in full naivety of anosognosia, with predictably bad results.

David Hager, MD

Click to view a short video that includes footage of a patient exhibiting anosogosia. Dr. E. Fuller Torrey's 2011 backgrounder, "How unawareness of illness (anosognosia) increases violent behavior in individuals with severe mental illness" is linked from our Reports/Studies/Backgrounders page. 

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This latest concern about an age-old problem has resulted from a number of fatal shootings involving the police and people with mental illness in Toronto. The usual response in the past has been to convene a Coroner's Inquest into these incidents. After months and sometimes years, the inquests all come up with a list of recommendations which are mostly ignored.

But, contained in the Globe and Mail report on this latest move by Ontario may be the reason these altercations between police and mentally ill people happen in the first place. The Globe stated

"the closing of beds and the move away from institutionalized mental-health care in Canada has put the responsibility of responding to people in crisis more and more in the hands of the police, who have limited access to health-care experts in these crucial moments."

That was 2010 and this is 2012. We're all waiting.

The police are not mental health professionals and they should not be expected to spend as much time as they do dealing with sick people. In fact, the Vancouver Police Department issued a report in 2008 called, "Lost in Transition: How a Lack of Capacity in the Mental Health System is Failing Vancouver's Mentally Ill and Draining Police Resources." On page 9, the report states that during a sample period, 31 per cent of police calls involved at least one mentally ill person.

In a study done for the London, Ontario Police Department, it was found that between 1998 and 2001, contact with people who suffered mental illness cost the city between $1.5 and $2.4 million.

The Globe article also quoted psychologist, Dorothy Cotton, who is or was a member of a group called Psychiatrists in Blue, part of the Canadian National Committee for Police/Mental Health Liaison. I mentioned this group in my own book on schizophrenia. The primary goal of the organization is to try to ensure that individuals with mental illness are not criminalized.

In the U.S., this concept was expressed very eloquently by Seminole Florida County sheriff, Donald S. Eslinger who said that "sheriffs are not medical professionals," and yet his officers are called on more and more to deal with dangerous situations involving those with serious untreated mental illness.

Our police should not be put into this role and the role would be considerably lessened if we provided proper treatment and resources to those who are ill.

My comment to the concerned cabinet minister in Ontario is to put the money to be used for this study into resources, and to resurrect the task force recommended to look into the laws on involuntary treatment.

MARVIN ROSS

Writer, publisher and producer of "The Brush, The Pen and Recovery," a documentary exploring "the very issue of schizophrenia, the lives of the people it affects and the role of artistic expression in their recovery."

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