In the wake of several highly publicized crimes committed by the mentally ill, Maryland officials are studying ways to force patients outside the hospital to take medication that can prevent psychotic episodes.
A mental health task force is considering whether the state should permit courts to order patients to stay in treatment or face involuntary hospitalization. Similar measures have been adopted by 39 other states, often in the face of opposition from patients' rights advocates.
But the case of Richard K. Geier, the 23-year-old man accused of chasing and shooting a lawyer on a busy downtown street Tuesday morning, illustrates the difficulty of designing laws that will prevent violent acts by the mentally ill.
Bizarre and menacing talk is a common feature of schizophrenia, but few patients carry out their threats. Doctors say it can be difficult to predict which patients will turn violent.
Bill and Pat Geier feared their son might harm someone but found there was little they could do about it. They say the system should be changed to make it easier to treat patients whose very symptoms make them fear doctors and medication.
"If they're sick and are documented to be so, there has to be a way to keep them on medication," saidBill Geier, 60, who runs a woodcraft business with his wife from their Parkville home. "With someone over 21, the family is secondary to the patient's rights, and I think that's probably appropriate. But all we wanted to do was to get Richard the help he needed."
Last year, after a schizophrenic man fatally shot two policemen at the U.S. Capitol, the state Mental Hygiene Administration assembled a panel to consider the problem of noncompliant patients. In January, a disturbed man pushed a woman into the path of a subway train in New York, killing her.
The Maryland panel is considering whether to propose a system of "outpatient commitment" in which courts could order outpatients to take their medication. Patients who refuse could be picked up by police, evaluated at an emergency room and admitted to the hospital against their will.
"The Capitol shooting got people talking," said E. Lawrence Fitch Jr., a lawyer for the Mental Hygiene Administration and the panel's co-chairman. "People are concerned when these things happen, but at the same time the public doesn't recognize that thousands of people are in treatment all the time and these cases, when they happen, are pretty aberrant."
Each year, of more than 18,000 homicides committed across the country, mental health experts say about 1,000 are committed by the mentally ill.
The panel might propose a pilot program to test the effectiveness of outpatient commitment among a few hundred patients, Fitch said. They would be compared to others who would be offered the same intensive outpatient care -- but without the legal threat.
"The hope is that, just by the very fact that there is this legal scrutiny, they will comply with treatment," said Dr. Steven S. Sharfstein, head of the Sheppard Pratt Health System and a panel member. "But it's very difficult to force people if they don't want to take medication."
Among the 39 states with outpatient commitment laws, the record has been spotty. Many didn't provide the tools to enforce the law, such as caseworkers to track patients and visit them when they failed to show up for treatments. A pilot program in New York found lower rates of violent behavior and repeat hospitalizations among patients who were offered intensive outpatient care -- whether or not they were under court orders.
Mary Zdanonicz, director of the Treatment Advocacy Center in Arlington, Va., said the threat of a court order can persuade a disturbed patient to stay in treatment.
"Sometimes, the real specter of returning to the hospital is enough to convince someone to take medication," she said. "It also empowers the mental health workers to become more effective in working with clients."
Patients' support groups, however, have often opposed any effort to force treatment.
"There is definitely a question of individual rights: How do you put mechanisms in place to ensure that the system doesn't go out trying to commit anybody who doesn't show up for a clinical appointment?" said Mike Finkle, a panel member who is the director of On Our Own of Maryland, a patient advocacy group in Baltimore.
It is not clear that an outpatient commitment law would have affected a patient like Geier, who did not have a long history of psychiatric care.
In most states, said Sharfstein, "to meet the criteria you have to show you repeatedly failed to cooperate. There would have had to be three, four, five hospitalizations."
Like most people with schizophrenia, Richard Geier developed symptoms in early adulthood.
After graduating from Parkville High School in 1993, Geier worked in a series of low-skill jobs. He bused tables at the Parkville American Legion, hauled carpets for an Oriental rug company, worked construction and washed silk screens for a T-shirt maker.
But the real interests of the quiet, lanky young man were music and drawing, his family says. He taught himself to play guitar and piano and joined occasionally in jam sessions with friends. He drew elaborate, fantastic scenes in pen and pencil.
At age 21, Richard began to behave strangely, worrying his friends and family. He shared houses with a series of roommates but rarely stayed anywhere long. He grew argumentative and was evicted from one apartment.
At first, his father said, "we couldn't separate it from just boisterous behavior that young men have." They only linked Richard's problems to mental illness after a call from his boss at Down Under Design, the T-shirt company, in November 1996, who said his conduct had become steadily more bizarre.
"He'd be talking and laughing or smiling, and no one would be there," said Leeann Slaysman, the manager. "He was increasingly weird, but nobody was afraid of him -- just a little uncomfortable."
After Slaysman's call, Richard called to quit.
By mid-1997, his visits with family were becoming more and more stressful. He would curse his parents and interrupt holiday gatherings with his mutterings.
"I'd be afraid to make contact with him, because he'd say, 'What the hell are you looking at?' " recalled his sister, Jean Dellman, 30. "I felt threatened."
On several occasions, Richard told his mother he "could kill" his father. His parents discovered a notebook in which he had scribbled lists of unrelated phrases. Amid incoherent words was scrawled, "I AM JESUS CHRIST."
Alarmed, Richard's mother coaxed him to seek help, but he refused. Finally, in August 1997, the Geiers drove to District Court in Towson and filed a petition for an emergency evaluation of their son. A judge signed it, and police took Richard to Franklin Square Hospital Center.
What happened during the 11 days he stayed there is unclear, because hospital officials will not comment, citing privacy laws. There may have been a hearing before an administrative law judge on whether to commit Richard, or doctors may simply have decided he did not need to stay. The Geiers say they were frustrated that doctors, bound by confidentiality rules, wouldn't discuss their son's case with them.
In any case, Pat Geier picked up her son after he had been discharged and drove him to a pharmacy to fill a prescription for an anti-psychotic medication called Zyprexa.
Inside, "he started looking around suspiciously," Pat Geier, 56, recalled. "He pointed at the pharmacist and said, 'Everyone here's crazy!' " He refused to sign a necessary form, and they left without the medication.
Like many people suffering from schizophrenia, he was adept at evading treatment he feared. "He said to me, 'I'm a smart paranoid,' " his mother remembered.
In October 1997, the Geiers tried again. Richard had wrecked his apartment, bashing holes in walls with a machete, before hop- ping on a bus to Phoenix, Ariz. Days later, he called to say he was out of money. The Geiers paid for a ticket home and met him with another emergency petition. Police took him back to Franklin Square.
"Within two or three hours, I got a call saying they didn't think he needed any treatment," Bill Geier said.
Again, the parents retrieved their son, allowing him to spend one night at their house. But they were frightened enough by his continuing threats to insist that he sleep on a heated porch, locked out of the house proper. The next day he moved in with friends.
Busy with their own medical treatment -- Bill Geier has colon cancer, and his wife has breast cancer -- the couple lost track of their son, who moved several more times and found construction work through a temp agency.
Last spring, a friend called the Geiers to say Richard was talking about getting a gun. In July, records show, Richard bought a .38-caliber revolver at Baltimore Gunsmith Co. on South Broadway. Because he had never been involuntarily committed to a mental institution, the purchase was legal under state and federal law.
In August, the Geiers spotted their son standing at a bus stop on Harford Road. They pulled over, and Pat approached him. "I said, 'Richard, please get help, please.' " He moved away, saying, "Do I have to move to the next bus stop?"
The next time the Geiers heard news of their son was after he was arrested Tuesday for the shooting of Jeffrey Yeatman, 29. Bill Geier, who had seen the first television news reports, already had a feeling the strange gunman might be Richard.
Now the Geiers wonder what else they might have done. They say they support outpatient commitment, though they know it might not have helped their son.
"We were reaching out," Pat Geier said. "If they had listened to us then, that man wouldn't be lying in Shock Trauma, and Richard would have gotten help."
Pub Date: 2/07/99