Tuesday, June 06, 2006

Dangerous on the Outside

[posted by dinah, not ClinkShrink]

The Maryland Psychiatric Society Council Chairman writes:

A case currently working its way through the Maryland legal system may jeopardize our ability to treat involuntary patients who are refusing medications.

To go before a Medication Review Panel, a patient must have already been deemed psychiatrically ill and dangerous outside the hospital by an Administrative Law Judge. A lower court decision in Kelly v. DHMH changes the interpretation of the Medication Review Panel law to require dangerousness inside the hospital in order to justify forced medication. This creates a situation where a patient, committed to the hospital by an Administrative Judge because they are dangerous if discharged, cannot be treated because they are not dangerous inside the hospital. The patient would therefore have to remain in the hospital indefinitely without proper treatment and with little chance of safe discharge.

--bolding mine, letter excerpted with permission.

I'm not an inpatient psychiatrist, and I'm sure ClinkShrink will have volumes to add-- ah, the case in point is one of an inpatient at Patuxent, a forensic facility-- but I'm wondering how this works.

Let me try for a scenario. Patient is delusional about a neighbor, thinks the neighbor is implanting electrodes in his body while he sleeps, might need to kill neighbor (remember, I'm inventing this, please feel free to add a better fictional case). He's hospitalized, where he's free from delusional intervention, says he still might need to kill the neighbor, but is not violent on the inpatient unit, refuses meds, can't be forced to take them-- he's not dangerous in the hospital-- and can't be discharged because he remains delusional about neighbor and potentially is homicidal. For the sake of completeness in my fictional scenario, the neighbor exists and is not implanting any electrodes in anyone.

I would contend that since the patient's premise is delusional, his reality testing impaired, there is no guarantee that he is not dangerous in the hospital (actually, there is no guarantee that anyone is safe anywhere, but....). What is to say he won't suddenly become delusional about a nurse, or believe that the neighbor has entered his hospital room (delusions do tend to follow people) and what is to say he won't elope from a locked unit? I have worked in three different psychiatric hospitals where inpatients have committed suicide on the units-- if people are hospitalized to prevent suicide, it's not totally fool-proof.

Somewhere in here there is the assumption that psychiatrists and/or judges can predict violence and be certain of who is safe and in what setting. If only that were true. The Last Psychiatrist contends, "We spend a lot, a lot, of money and time hospitalizing people who are not going to die."*

So, eventually our fictional patient gets tired of years on the inpatient unit (I could make jokes here about withholding cigarettes, but I'll resist the urge), takes his meds, is quickly cured, and goes home. A few weeks go by, during which time he and the neighbor share herbs and tomatoes from their respective gardens, and finally, our fictional patient decides he doesn't need treatment and stops his meds, only to become delusional all over again. My point being that while we may want to involuntarily medicate dangerous, mentally ill patients for the safety of society, once they are back in "free society" they are free to stop their meds. Treating mental illness in people with dangerous behaviors continues to represent a delicate balance between the rights of the individual and the safety of others. I've nothing brilliant to add.

Quick closer-to-real life scenario and a link to a forced-medication tale:

When I was a newbie resident on an inpatient unit, I briefly had a patient who was mentally retarded with a psychotic disorder. He would stop his medications, have a few beers, and the voices would order him to kill children. He had no history of violence, no one knew if he really would kill children, but the family repeatedly got a bit anxious when he sat on the front steps with a machete. This was his tenth hospitalization for the same chief complaint. He'd come in, restart meds (including a shot of prolixin decanoate), and be discharged within a couple of days, only to repeat the pattern. So, if I'm thinking about Kelly v. DHMH, then I'll wonder if the rest of our laws make sense.

And finally, Tuboglacier, the psychiatrist who blogs at May Shrink or Fade, writes a story on a similar theme in Substituted Decision Making, with Clam Juice.

*(-- I might suggest that perhaps hospitalizing them worked and that's why they don't die, but that's another post for another day)