It is tempting to expand court ordered treatment for mental illness because it seems like such an obvious, rational and simple solution. Why not round folks up in a kind way, have benevolent judges order them to do what we know is best and make them take their meds? They will no longer suffer and neither will their families, who love them and also suffer greatly from the effects of these debilitating illnesses.
This would be a wonderful solution if it worked. But we do not have a cure for mental illness, and despite dramatic treatment advances, we do not have treatment that works for all. The euphoria of the 1980s, when new psychiatric medications seemed to be sprouting like daisies in fields, has been replaced by a stark reality check with respect to the limitations of pharmaceutical treatments. And sadly, recent scientific analysis of medication effectiveness is rarely covered by the press or considered when policy is made.
As the leader of the world's largest mental health research organization, National Institute of Mental Health Director Dr. Thomas Insel is well qualified to offer insight on this point. In an August 2013 article, he shared results of a recent study examining outcomes for two groups of individuals with schizophrenia. One group received medication over the long term and another discontinued medication treatment. After seven years, the group that discontinued medication had achieved twice the functional recovery rate — 40.4 percent vs. only 17.6 percent among the medication maintenance group. He summarized by stating that "Clearly, some individuals need to be on medication continually to avoid relapse. At the same time, we need to ask whether in the long-term, some individuals with a history of psychosis may do better off medication."
The results should give pause to all who press for the increased use of forced medications. And frankly the results cited in the above study are not new. Within psychiatry the experts are debating whether the short term symptom relief provided by medications is causing permanent disability for some individuals with serious mental illness. Is this the time to increase forced administration of medication, and if not, what is the answer during these intervening years while we wait for science to catch up with sickness?
Given the limitations of our knowledge and the life altering consequences of treatment decisions, the following issues warrant attention as the Department of Health and Mental Hygiene's involuntary commitment approach is considered:
First, coercion must be the last resort, and individuals should not be forced into treatment before they have had the opportunity to voluntarily choose the most effective array of care that is currently available to treat their illness. This is not the case today, particularly for those who are commercially insured and lack access to the system of care that is funded by their tax dollars for Medicaid recipients.
Second, oversight of care must be strengthened. While we commend DHMH for launching the Maryland Consumer Quality Team, a program of unannounced site visits to state psychiatric facilities and community programs; it was a wake-up call to learn last year that no consistent data are collected across state and private facilities to document whether those forced into treatment are getting better, worse or staying the same. In addition to implementing an outcome monitoring system using a valid and reliable tool, the department should expand its program of unannounced site visits to private as well as public facilities serving publicly funded patients, with the initial focus being on patients who have no choice in the care they receive.
Third, we should ensure the approach to care for forcibly treated individuals is evidence-based, holistic and not limited to a singular focus on medication. Given the impact of managed care on clinical practice in mental health, there would likely be overwhelming support within the clinical community for a return to the days when providers were free to select the best care for their patients with the tools at their disposal, rather than being forced to do the best they can in a brief medication management visit that insurance will pay for. With the move toward outcome driven health care and the implementation of proper metrics, better safeguards can be put in place today to ensure that care is appropriately and not overly rendered.
Finally, we need a race for the cure on par with the investment in breast cancer research and other disabling somatic illnesses. None of the solutions to "the mental illness problem" will be efficient or effective if clinicians lack effective treatment options, as they do today, and individuals and their families have few options from which to choose.
Laura Cain is a senior attorney with the Maryland Disability Law Center; her email is laurac@mdlclaw.org. Linda Raines is chief executive officer of the Mental Health Association of Maryland; her email is lraines@mhamd.org. Mike Finkle is executive director of On Our Own of Maryland; his email is mikef@onouronwmd.org.