Committing to outpatient psychiatric commitment

Most of you are going to blow off this column once you realize it has to do with mental illness. You can prove you are smarter than your coon hound, however, by sticking with this column to the end. It has everything to do with you even if you are not mentally ill, because one in five of us is, because you have family members who suffer from mental illness and because some day mental illness may visit its pall on your mind.

This column has to do with you because it is about basic human freedoms, about dignity and self-determination and about your tax dollars. If all of that does not make this column about you, then you are probably a house plant. So read on, or go get repotted.

Somewhere in the pile of proposed programs waiting to get funded in the new state budget is one for which Maine state legislators should just write the check. It is the outpatient commitment program (OCP) that allows a judge working with mental health professionals to require some patients with severe mental illness to comply with a community-based treatment program or face involuntary treatment in a psychiatric hospital. Maine was one of only eight states in the country without an OCP law until the Maine Legislature passed one overwhelmingly this year.

However, in order for the law to go into effect Maine legislators must appropriate $520,000 to staff a pilot OCP in the Augusta area, provide housing for the mentally ill patients in the program and monitor program effectiveness. The OCP program would be focused on patients who have been hospitalized frequently because their mental illness was poorly controlled, often in part because the patient was not taking his or her medications.

The involuntary treatment law has been very controversial in Maine and elsewhere because it takes away from certain mentally ill patients the right to decide whether or not they will participate in their treatment program, including whether or not they will take their medications. Prior to such laws, mentally ill patients could be involuntarily committed to a psychiatric hospital if they were a danger to themselves or others, but forcing those patients to then take medications which might clear their disordered thinking was usually prohibited.

Many advocates for the mentally ill have bitterly opposed involuntary treatment laws, saying such laws deprive patients of the freedom to control their own bodies, serve as an excuse for government to avoid paying for better outpatient treatment programs as alternatives, pick on a weak and often disenfranchised population and may not be effective.

Opponents’ arguments are countered, however, by evidence of the success of OCP programs in other states. Patients in such programs appear less likely to be hospitalized, to commit crimes or (much more frequently) to be the victims of crimes and their care costs less as a result. Legislators in most states have now found such arguments compelling; Maine is finally going as the nation has gone.

The OCP debate has turned on the issue of the rights of the patient, since much of the weight of medical decision-making in this country is based on the patient’s right to determine treatment. However, patients with severe mental illness weaken several fundamental underpinnings of this model of patient autonomy.

First, patients with severe mental illness often have little insight into their illness, and reject treatment because they do not believe they are ill or are suspicious of the treatment. In other words, they reject treatment of their illness because of their illness, not because they are exercising the reasoned judgment of a sound mind thoughtfully protecting its free will. Second, some of them already have their freedom abridged frequently because this lack of insight and judgment causes them to be a threat to themselves or others, and that trouble gets them jailed or involuntarily committed.

Third, mental illness is unique among diseases in the amount of mayhem the patient’s illness causes others, including family, police, emergency medical care providers, hospital staff and society at large. In this regard the patient with untreated mental illness clearly differs from the patient with untreated lung cancer.

This spillover effects to others elevates society’s right and need to intervene beyond the right it would have to intervene in a disease with little or no immediate adverse impact on others. Finally, the freedom to be imprisoned by the mental jail of profoundly disturbed thoughts and terrible quality of life is not freedom.

Those who would err here on the side of patient autonomy often do so for one of two reasons; they do not fully understand the consequences of untreated, severe mental illness, or they are fundamentalists for patient autonomy no matter what the cost.

Severe mental illnesses, especially schizophrenia and so-called manic-depressive illness, are deadly, debilitating, ruinous diseases that preclude good judgment and reasonable quality of life when uncontrolled. These diseases kill patients, ruin careers and families and spread chaos beyond the patient the way a tsunami spreads from an earthquake. Assuming such a patient can have the insight and judgment to make treatment decisions about their care while in the grips of psychosis suggests a failure to understand mental illness as real and serious disease.

Fundamentalists for autonomy of the mentally ill, while well-intentioned and understandable, can only protect that autonomy in totality by sacrificing the many for the few. The many are the large number of mentally ill patients who will improve if they get treatment and who, when surveyed, say they prefer to be treated (and feeling better) even if the treatment is mandated. The few are those patients who would sacrifice themselves in a state of uncontrolled illness to the goal of total autonomy.

Maine and other states have few options but to try well-designed OCP programs. The states need to put the taxpayer dollars that OCP programs save into better community treatment programs for the mentally ill, and the states don’t have enough psychiatric hospital beds to keep admitting these patients to the hospitals instead of taking care of them well in the communities. Nor do they have enough jails.

The states also need to do something other than abandon the severely mentally ill to tragic and debilitating cycles of the streets and the jails, emergency departments and the psychiatric hospitals. They need to treat psychiatric illness as real disease that does not fit the traditional model of patient autonomy, disease that wastes patient lives and taxpayer dollars. And in Maine they need to sign the damn check for $524,000 to fund a pilot OCP project. People are certainly dying for the chance to try it.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region.