Maryland lawmakers are moving to make it easier to medicate mental hospital patients against their will, while examining the idea of court-ordered therapy for mentally ill people who aren't hospitalized.
The legislation is based partly on recommendations from a panel convened by Gov. Martin O'Malley after the 2012 shootings at Sandy Hook Elementary in Newtown, Conn. That case prompted a national debate about the adequacy of care for mentally ill Americans.
But while some mental health advocates have long sought additional tools to better manage treatment — for the sake of the patient and public safety — the proposals have created a rift in the health care community. Some argue such measures are inhumane and unconstitutional.
"This is part of the dilemma in choosing between, on the one hand, necessary treatment, and having high respect for people's individual rights," said Del. Dan Morhaim, the General Assembly's only physician and sponsor of the medication legislation. "We are trying to strike the right balance and really help those who need it."
The state Department of Health and Mental Hygiene supports legislation that would expand the circumstances under which a doctor could medicate mental health patients without their consent. In those cases, as a check and balance, a review must be done by a clinical panel.
Health officials argue that the longer patients go without treatment, the worse their illness and chances for recovery become.
Some lawmakers want further study of a proposal that would allow patients to be forced to get outpatient treatment. They also want an outside panel to study other alternatives, such targeted outreach efforts called "assertive community treatment" that engage those with mental illnesses rather than forcing treatment.
Other measures that would make it easier to have people committed are less assured of passage. One bill would clarify the criteria needed to have somebody hospitalized when they have a psychotic break, but opponents warned the commitment process could be abused. A Senate committee voted against that proposal.
The state health department supports clarifying the standards for hospitalization of mentally ill patients, but it would rather see changes made through regulation, not legislation.
Under the law, patients must be deemed a danger before they can be hospitalized, but practitioners and institutions widely interpret the definition of dangerous.
The health department recently studied deficiencies in the state's behavioral health system that led to periods without care for those with schizophrenia, bipolar disorder, major depression and other conditions. Those breaks can on rare occasions lead to dangerous situations.
"There are some people that may not be in a position where they can make decisions about their treatment," said Dr. Gayle Jordan-Randolph, deputy secretary for behavioral health at the Department of Health and Mental Hygiene, who chaired the panel.
But balancing the need for treatment against individual rights is difficult, experts said.
Forcing people into treatment may not be effective, said Linda Raines, chief executive officer of the Mental Health Association of Maryland. She said it might be more effective to engage patients and help them understand they need help.
"Why don't we give people the option first to let them self-select what will make them better," Raines said.
She called some of the legislation proposed in the General Assembly a "substantial and frightening step backward" that would merely increase the number of people who are institutionalized.
Others say steps must be taken to ensure the mentally ill get the care they need before a crisis occurs. In fiscal year 2012, an analysis of Medicaid data found that 588 people, or less than 1 percent of the state's mental health population, accounted for one-quarter of all emergency department visits. Those patients visited the emergency department six or more times in a year. Many are believed to have a mental disorder called anosognosia, which causes them not to recognize that they are sick.
Some families of mentally ill patients say they can't afford to wait for more studies.
Dr. Steven Sharfstein, CEO of Sheppard Pratt Health System, supports mandatory treatment options because he has seen families desperate to help their loved ones. Doctors sometimes tell them the only way their relatives can get help is if they get arrested, he said.
"Families will tell you about how frustrated and frightened they are because their family member won't get care and how much havoc it creates," Sharfstein said.
Some mental health advocates back mandatory outpatient care as a way to ensure consistent care and fewer hospital visits. Many patients learn to manipulate the system, adhering to treatment while institutionalized but going back to their old ways once released, advocates said.
"There are people who cycle in and out and don't get stabilized in the community," said Kate Farinholt, executive director of the National Alliance on Mental Illness Maryland. "They end up getting released into the community with recommended treatment, with a history of not getting that recommended treatment, and becoming dangerous to themselves or others and getting hospitalized again. Or worse yet, picked up and put in jail or prison."
The Mental Health Association of Maryland and Maryland Disability Law Center support a community approach to treatment that provides basic services such as housing to improve the living conditions — and mental state — of the mentally ill.
"Assertive community treatment" programs have been successful in other states, but have proved expensive. New York has spent $2 billion on its program.
"As a general principal, we do not believe coercion is a benefit to anyone in the long run," said Laura Cain, managing attorney for the Maryland Disability Law Center. "We believe there are alternatives to engage people voluntarily. In the longer run, when a person becomes motivated on their own, that is where recovery actually begins."
Tonier Cane said she is an example of how forced treatment doesn't work. The 46-year-old Annapolis motivational speaker was in and out of jail and mental institutions for 19 years beginning in 1989. She blames her bipolar disorder, depression and drug addiction.
At one point, she was taking three medications for her mental disorder and was so drugged she drooled, could barely walk and couldn't hold her head up.
But she said she didn't get better until she got into a program that addressed the underlying trauma — sexual abuse as a child — that caused her illnesses. She now has coping mechanisms, such as reading, that help her adjust when she feels anxiety beginning to build.