“Mental health has been hidden behind a curtain of stigma and discrimination for too long. It is time to bring it out into the open. The magnitude, suffering and burden in terms of disability and costs for individuals, families and societies are staggering.” – Lee Jong-wook with the Department of Mental Health and Substance Dependence, Noncommunicable Diseases and Mental Health, World Health Organization, Geneva.
As the events unfold surrounding the attack of an apparently mentally ill young man on a small gathering in a shopping center in Tucson Arizona, killing six and wounding 13 others, including Congresswoman Gabrielle Giffords, questions have been raised about what appears to be the absence of adequate care with our mentally ill.
There has always been stress on the health system to accommodate those individuals of moderate and low means who can’t afford timely and prolonged treatment for their mental diseases, like schizophrenia. But the stress becomes amplified in economic hard times much like what we are experiencing today. State budgets are struggling to pay their bills and keep from sinking deeper into debt. As has always been our tendency in this country, social services are usually the first to feel the knife when it comes to finding ways to balance budgets.
Funding for behavioral health treatment in Arizona was cut by as much as 50% last year according to the National Alliance on Mental Illness, denying mental health service to nearly 28,000 Arizona residents. What are the repercussions of this and how might it have effected the outcome of Jared Loughner’s deadly actions.
According to Dr. H. Clark Romans with the National Alliance on Mental Illness (NAMI), the recent budget cuts in Arizona beginning in January 2010 have expelled some 2800 former mental health patients from the system because their mental health status was not diagnosed as serious. Beginning in July 2010 those who did have a serious diagnosis lost “virtually every service they were getting except generic medications” because they weren’t deemed not poor enough by state officials to qualify for the state’s run Medicaid program called ACCESS. This meant these people could no longer have access “to their doctor, case manager, support groups, out patient services, transportations subsidies and eventually housing subsidies” according to Dr. Romans.
The PhD representative with NAMI pointed out in an interview Monday that Arizona has laws in place that will allow some involuntary commitment for those who clearly need help. When the Pima County Community College administrators recognized Loughner’s erratic and strange behavior they could have used these options to have him committed, as could the Sheriff’s Department that had been aware also of Loughner’s spells of abnormal behavior. Romans says “it is not an arbitrary process, it’s a thoughtful process, it’s a tool that can be used” to help those like Loughner, who supposedly did not indicate an apparent danger to himself or others by these two institutions prior to his rampage on January 8th.
Will not only Arizona’s budget cuts but similar budget cuts in other states create a condition that may allow another unstable person to wreak havoc on society if not detected beforehand? It’s possible according to Dr. Romans. “The fact that people who are making more, at least for the moment, more than 100% of the poverty level, are now in a category that they have virtually no access to services, the public mental health services, so I think we have raised the barrier considerably higher than it used to be, so people who, you know, could be unstable are at risk.”
Dr. Romans further points out that “the fact is that most people who do have serious mental illnesses go through their life, undiagnosed and untreated. So any of those people could at any time be in a situation where the stress precipitates their symptoms, and the services are moving further away from that”.
In studying this issue we should consider some of the other cases where people who were mentally unstable and wound up killing others as a result of their disease that went undetected?
Seung-Hui Cho, the Virginia Tech shooter was diagnosed as early as the 8th grade for selective mutism, a psychological mental disorder … which a person, most often a child, who is normally capable of speech is unable to speak in given situations, or to specific people.” It can co-exist with severe forms of social anxiety. Cho was supposed to be treating his symptoms with medications and therapy and had been placed in special education classes under an “emotional disturbance” classification. After his junior year in high school he rejected any further treatment.
Eric Harris and Dylan Klebold, the Columbine High School killers, were not, as first portrayed as part of some “trench coat mafia outcasts”. They both suffered from mental instabilities. Diebold, the hothead, was depressive and suicidal. Harris, the kid everyone thought was “sweet-faced and well-spoken” was later diagnosed as a psychopath.
Dr. Robert Hare, who authored Without Conscience, considered the authoritative work on psychopathic behavior and was one of the psychologists consulted by the FBI about Columbine, says “Unlike psychotic individuals, psychopaths are rational and aware of what they are doing and why. Their behavior is the result of choice, freely exercised.”
It appears their illnesses had not manifested themselves to a level that those close to them saw it as a potential threat. No one, not even their parents seem to pick up on these symptoms because as David Cullen points out in his Slate magazine article on these findings five years after the 1999 incident, “Both killers feigned regret” to a previous robbery and avoided prosecution for the robbery by engaging what Cullen says “was a ‘diversion program’ that involved counseling and community service.” Perpetual deceitfulness is a classic symptom of the psychopath.
Timothy McVeigh, the Oklahoma City bomber, seems to fit Dr. Robert Hare’s description of a psychopath. He was a product of parents that underwent a painful divorce when he was 10. There are no records of his mental condition leading up to the bombing of the Murrah Building bombing but clearly he developed a neurosis that is typical of someone who was raised by a unaffectionate father, was bullied in school, read anti-government literature (McVeigh read William Pierce’s neo-nazi tract, The Turner Diaries), couldn’t hold a steady job and was never able to develop a stable relationship with women he dated.
He served in military combat but no record exists that shows he suffered PTSD. After showing a keen interest in the United States Army Special Forces he later became discouraged after entering the program and soon left, with a military psychological profile that catergorized him as very unsuitable for SF. A 1995 Washington Post article cited that “McVeigh complained that the Army had implanted him with a microchip into his buttocks so that the government could keep track of him.” McVeigh, unlike the others who killed innocent victims from some mental imbalance, was never around others long enough to diagnose his building schizophrenia.
Does society pay a higher price in monetary terms and human suffering when they fail to address mental health issues early?
As I indicated above, the costs to assist those in our communities who suffer debilitating mental illnesses are high. Most people who need the services are those least likely to afford them or encouraged to seek out what is made available through state and federal funding. What are the social costs when treatment is delayed?
According to NIMH “Suicide is a major, preventable public health problem. In 2007, it was the tenth leading cause of death in the U.S., accounting for 34,598 deaths. The overall rate was 11.3 suicide deaths per 100,000 people. An estimated 11 attempted suicides occur per every suicide death.” Globally we rank 40th out of 106 nations studied that have suicide rates per 100,000 people per year.
One in four families has at least one member with a mental disorder, with other family members often serving as the primary caregivers, according to the World Health Organization (WHO). Out of pocket expenses are often not revealed in statistics on mental health care coverage. Also not revealed is the human toll that victims of mental illness suffer , including family members, in the form of “human rights violations, stigma and discrimination, both inside and outside psychiatric institutions.”(WHO)
In their study on the issue, WHO has estimated that “The cost of mental health problems in developed countries is estimated to be between 3% and 4% of GNP. However, mental disorders cost national economies several billion dollars, both in terms of expenditures incurred and loss of productivity. The average annual costs, including medical, pharmaceutical and disability costs, for employees with depression may be 4.2 times higher than those incurred by a typical beneficiary. However, the cost of treatment is often completely offset by a reduction in the number of days of absenteeism and productivity lost while at work.
Clearly their is a need to address our growing dilemma with dysfunctional members of society. When they fail to get the help they need with their disorders, they become a deadly threat to themselves and others in their community. The Affordable Care Act, that was repealed by the House Republican majority in Congress yesterday, attempts to mollify this crisis by preventing insurers to regard substance abuse or mental illness as a condition to deny coverage as a “pre-existing condition”; nor will they be able to use those conditions to raise premiums. Furthermore, “mental health and substance use disorder services will be part of the essential benefits package, a set of health care service categories that must be covered by certain plans, including all insurance policies that will be offered through the Exchanges, and Medicaid.” (The Affordable Care Act & Mental Health: An Update)
The tragedy in Tucson should not become a missed opportunity to get all of us involved at a level that could hopefully prevent any similar reoccurrence. Next time it may be our own communities that experiences the public apathy that in part allows this to happen.