American Psychosis (27 page)

But it is mental illness-related homicides that receive the most media attention. As noted in
Chapter 6
, there are two small, older studies in New York and California that
suggest that people with untreated serious mental illnesses are responsible for approximately 10% of homicides in the United States. A more recent study from Indiana supports this. Researchers examined the records of 518 individuals in prison who had been convicted of homicides between 1990 and 2002. Among the 518, 53 (or 10.2%) had been diagnosed with schizophrenia, bipolar disorder, or other psychotic disorders not associated with drug abuse. An additional 42 individuals had been diagnosed with mania or major depressive disorder. It should be emphasized that the study included only those individuals who had been sentenced to prison and did not include those who had committed homicides but were subsequently found to be incompetent to stand trial or not guilty by reason of insanity and therefore sent to a psychiatric facility rather than prison; thus, the 10.2% is an undercount. The authors themselves did not conclude that individuals with serious mental illnesses were responsible for at least 10% of the homicides, but given the data that seems an obvious conclusion. Studies from several other countries, including Sweden, Finland, Germany, and Singapore, have also reported that individuals with serious mental illnesses are responsible for approximately 10% of homicides.
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The homicides that receive the most attention are those in which there are multiple victims. As noted in the previous chapter, there are suggestions that these “rampage killings,” as they are sometimes called, are becoming more common. On January 8, 2011, Jared Loughner, suffering from untreated schizophrenia, killed 6 and wounded 13 in Tucson, Arizona. Because Congresswoman Gabrielle Giffords was among the wounded, this tragedy received wide publicity. What was not publicized was the fact that in the preceding 5 years, there had been at least 11 other “rampage killings” committed by seriously mentally ill people who were not being treated. They included Matthew Colletta in New York, who killed 1 and injured 5; Lawrence Woods in Pismo Beach, California, who killed 2; Omeed Popal in San Francisco, who killed 1 and injured 14; Jennifer San Marco in Goleta, California, who killed 8; Wesley Higdon in Henderson, Kentucky, who killed 5 and injured 1; Christian Nielsen in Newry, Maine, who killed 4; Naveed Haq in Seattle, who killed 1 and injured 5; Matthew Murray in Colorado Springs, who killed 4 and injured 5; Seung-Hui Cho at Virginia Tech, who killed 32 and injured 24; Isaac Zamora in Seattle, who killed 6 and injured 4; and Jiverly Wong in Binghamton, New York, who killed 13 and injured 4. Jared Loughner became a household name because he killed six and injured Congresswoman Giffords, whereas Isaac Zamora, who also killed six in Seattle in 2008, was quickly forgotten.

This phenomenon was also illustrated in July 2012, when James Holmes, with an untreated severe mental illness and dressed as the Joker, killed 12 and injured 59 at a Batman movie in Aurora, Colorado. Because of its bizarre nature, the killings received widespread publicity. By contrast, when Jiverly Wong, with untreated paranoid schizophrenia, killed 12 and injured 4 at an immigration center in Binghamton, New York, in April 2009, the killings were reported mostly as a local story. Within 1 month of the
Aurora tragedy, Laura Sorensen shot three shoppers near Seattle, and Thomas Caffall killed two and wounded four in College Station, Texas; both Sorensen and Caffall had an untreated severe mental illness, but these stories were not widely reported. It thus appears that homicides associated with untreated severe mental illness are more common than is generally realized. Unfortunately, the FBI does not keep separate statistics differentiating such cases from other homicides, so the true magnitude of the problem is not known.
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Public interest in the relationship between untreated mental illness and homicides reached a new high in December 2012, following a massacre of schoolchildren in Newtown, Connecticut. Adam Lanza, a mentally ill young man whose precise diagnosis has not yet been disclosed, killed 20 elementary school children, 6 school employees, his mother, and himself. The site of the massacre was ironic, as Newtown had been the site of one of Connecticut’s three state psychiatric hospitals, but the hospital there had been closed in 1996. It was in such hospitals that mentally ill individuals such as Lanza had been evaluated and treated in the past. Thus the Newtown tragedy was a symbolic coda to deinstitutionalization.

The mass killings in Connecticut were followed closely by several other homicides committed by individuals with untreated severe mental illnesses. These included a man pushed to his death beneath a subway in New York by a mentally ill woman with at least 10 past psychiatric admissions, a history of violence, and a history of failing to take medication. Coming so soon after the massacre of theatergoers in Colorado, the Newtown tragedy, and subsequent homicides elicited an unprecedented volume of calls, from President Obama down, for gun control and improved mental illness treatment laws. Whether this public outcry will results in any meaningful change remains to be determined.

Yet another indication that mental illness-related violence is increasing is the apparent increasing incidence of repeat acts of violence committed by the same person. Such acts are often eerily similar in character, suggesting that little learning is taking place among mental health officials:

• In Detroit, Paul Harrington, diagnosed with depression with psychotic features, stopped taking his medication and killed his wife and 3-year-old son. Twenty-four years earlier he had killed his wife and two daughters, ages 4 and 9 years.

• In Everett, Washington, Steven Well, diagnosed with paranoid schizophrenia, stabbed to death his landlady, who he thought was sending electrical signals into his brain. Thirty years earlier he had attacked another landlady with a knife, but she had survived. In the intervening years he had attacked a man with a hammer.

• In suburban Washington, D.C., Antoinette Starks, diagnosed with paranoid schizophrenia, stabbed a woman shopper outside a department store. Six years earlier she had stabbed another woman shopper outside a different department store.
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Such repeat acts of violence by mentally ill individuals were occasionally reported in past years, but they now appear to have become common. The following, for example, all took place during a 12-month period in 2007 and 2008:

• In Virginia, Johnny Hughes, diagnosed with schizophrenia, stabbed to death an elderly woman as she walked her dog. In the mid-1990s, Hughes had been found not guilty by reason of insanity of attempted murder.

• In Washington State, Daniel Tavares, diagnosed with schizophrenia, murdered a young couple. In 1991 Tavares had killed his mother.

• In Texas, Darrell Billingslea, diagnosed with schizophrenia, killed a woman he had met through the Internet. In 1989 and 1990, he had killed two men.

• In Washington State, James Williams, diagnosed with schizophrenia, killed a young woman on the street. In 1995 he had shot a stranger at a bus stop.

• In Colorado, Audrey Cahous, diagnosed with bipolar disorder, stabbed a man to death. In 1987 she had stabbed her third husband.

• In Iowa, Richard Mutchler, diagnosed with bipolar disorder, stabbed to death a man and woman. In 1991 he had killed a man.

• In California, Ofiu Foto, diagnosed with schizophrenia, beat to death an elderly woman who worked in his group home. In 2005 he had severely beaten another elderly woman and had additional charges of assault.

Such incidents, in which seriously mentally ill individuals who have proven dangerousness are not followed up and properly monitored, suggest a widespread failure of the mental illness treatment system.
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If, as studies suggest, seriously mentally ill individuals who are not being adequately treated are responsible for 10% percent of the nation’s homicides, then how many homicides is that? In 2009, there were 13,636 total homicides in the United States, so approximately 1,300 of these might have been prevented if the mentally ill perpetrators had been adequately treated for their illness. Since 1970, there have been a total of 765,270 homicides in the United States, so approximately 76,000 of these might have been prevented. These 76,000 individuals, their families and friends, and the perpetrators of these tragedies are all victims of our failed mental illness treatment system.
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In summary, homicides and other violent acts committed by individuals with serious mental illnesses who are not being treated have emerged as the most visible symptom of the failed mental illness treatment system. The situation was summarized by Keith Ablow, a psychiatrist who has written a book about such cases:

We are not facing an epidemic of gun violence. We are not facing an epidemic of first-degree murder. We are facing an epidemic of mental illness, improperly triaged and treated, leading to killings with no apparent motive. They will stop when we decide to stop them—by providing robust mental health care services, targeted to those individuals whose mental illnesses include a component of violent or psychotic thinking.
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WHAT ARE THE FINANCIAL COSTS?

There are many disturbing aspects to the breakdown of public psychiatric services in the United States. Not the least of these is the fact that the chaotic, unplanned system that has emerged is not only very dysfunctional—it is also very expensive. It is doubtful if there are many other areas of public services in which so much money is being spent with so little effect.

Begin, for example, with the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) payments. These are federal entitlement programs intended to provide living support for the aged, blind, and disabled. As noted previously, SSI is the product of President Nixon’s decision in 1972 to standardize and federalize welfare and disability payments that previously had been the responsibility of the states. Nixon had no intention of making SSI into a major mental health program, but over the years it has become so. In 2009, 41% of all SSI and 28% of all SSDI recipients qualified for benefits because of their mental illness, not including mental retardation. Their total number was 4,741,970 individuals; by comparison, in 1977 the total number of mentally ill individuals receiving SSI and SSDI was estimated to be between 225,000 and 425,000. In 2009 the annual SSI and SSDI payments to mentally ill individuals was
$45.7 billion
.
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As a federal entitlement, the SSI and SSDI money is given to qualified individuals with no requirements. Thus, although some recipients might be able to work if they were to receive and adhere to treatment for their mental illness, there has never been any requirement for SSI or SSDI recipients to participate in a treatment program. The SSI and SSDI programs also operate independently from all other government programs for mentally ill individuals. It was the SSI and SSDI programs that spawned the board-and-care home industry, with mentally ill individuals trading their monthly stipends for “three hots and a cot” in largely unregulated facilities.

The government programs that finance mental health services are Medicare and Medicaid. These were products of President Johnson’s 1965 Great Society initiatives and were originally intended to provide medical care for elderly and poor people, respectively. Medicare is funded exclusively by federal funds and pays hospital and other medical costs for people ages 65 years and older. Medicaid is funded jointly by federal and state funds and covers hospitalization in general hospitals (but in most cases not in psychiatric hospitals), outpatient services, nursing homes, medications,
and a variable list of other services, such as case management, depending on the coverage offered by that particular state.

As noted previously, the architects of Medicare and Medicaid had no intention of creating mental health programs, and in fact Medicaid specifically excluded coverage for psychiatric hospitals under a provision called the institutions for mental diseases exclusion. Nevertheless, Medicaid has become “the largest payer of mental health treatment services” in the United States, with mental health costs now constituting more than 10% of the entire Medicaid program. By covering hospitalization in the psychiatric units of general hospitals but not in psychiatric hospitals, Medicaid has encouraged states to empty state hospitals, thus effectively shifting the costs of psychiatric hospitalization from exclusively state funds to a mix of federal and state funds. An analysis of deinstitutionalization in the early 1970s reported Medicaid funds to be “very strongly associated with the amount of deinstitutionalization.” By covering nursing home care for mentally ill individuals, Medicaid and Medicare together acted as an additional impetus to deinstitutionalization and spawned the for-profit nursing home industry. Indeed, as economist Richard Frank and colleagues noted, “the creation of the Medicaid program in 1965 began a process that fundamentally changed the rules governing a US public mental health care system.”
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In the almost 50 years since Medicaid was instituted, states have become increasingly sophisticated in finding ways to shift mental health costs from state funds to federal Medicaid. Widely known as “Medicaid maximization,” it has been characterized by the phrase: “If it moves, Medicaid it.” Medicaid now covers 55% of all state-controlled mental health costs, and for some states, such as Arizona, Alaska, Vermont, Rhode Island, and Maine, the percentage of Medicaid funds is 80% or higher. In total, based on 2005 data, Medicaid and Medicare contribute approximately
$60 billion
a year to mental health costs in the United States.
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