How does the system deal with violent mentally ill persons?

[Socrates25]

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Case scenario: 55 year old man with paranoid schizophrenia is picked up by the police for assaulting someone with a baseball bat. He is promptly put on meds, and "stabilized" over the next 2 months. He has a history of 20 violent assaults in his background. He has a history of refusing to take his medications once discharged.

He currently denies any intent to harm himself or others. He denies hallucinations and exhibits no paranoid tendencies currently. For the past 3 weeks he has been very "stable," taking his medications daily without incident and getting along well with the other patients.

Your case manager comes to you and says they need his bed and he needs to be discharged.

What is your response?

A. D/C with a date/time/phone number for outpatient clinic follow-up
B. D/C only with direct transportation to a group home or other "monitored" environment
C. D/C with case manager follow-up who will check on him weekly
D. Deny discharge; pt has violent tendencies and is highly likely to come off medication once discharged, despite the fact that he is currently "medically stable"

 

[OldPsychDoc]

Case scenario: 55 year old man with paranoid schizophrenia is picked up by the police for assaulting someone with a baseball bat. He is promptly put on meds, and "stabilized" over the next 2 months. He has a history of 20 violent assaults in his background. He has a history of refusing to take his medications once discharged.

He currently denies any intent to harm himself or others. He denies hallucinations and exhibits no paranoid tendencies currently. For the past 3 weeks he has been very "stable," taking his medications daily without incident and getting along well with the other patients.

Your case manager comes to you and says they need his bed and he needs to be discharged.

What is your response?

A. D/C with a date/time/phone number for outpatient clinic follow-up
B. D/C only with direct transportation to a group home or other "monitored" environment
C. D/C with case manager follow-up who will check on him weekly
D. Deny discharge; pt has violent tendencies and is highly likely to come off medication once discharged, despite the fact that he is currently "medically stable"

In my state, hopefully and most likely B, unless C is an ACT team that can visit daily with eyes-on meds. And this will be happening with the enforcement capabilities of commitment--a court order from a judge. At least that has been my experience with patients we've had with similar histories of violence and non-compliance.

 

[Socrates25]

In my state, hopefully and most likely B, unless C is an ACT team that can visit daily with eyes-on meds. And this will be happening with the enforcement capabilities of commitment--a court order from a judge. At least that has been my experience with patients we've had with similar histories of violence and non-compliance.

Lets assume you have never treated this patient before and know him only from his current hospitalization.

What is the feasibility of actually getting a court order for forced medication? Doesnt he have to prove his "unworthiness" yet again before a judge will issue one? Or will judges issue them based on previous episodes of "bad behavior"?

Also, how available are ACT services? Are they around for everyone who has compliance issues? Or are their resources stretched so thin that they arent available to cover all the people who refuse meds?

 

[OldPsychDoc]

Lets assume you have never treated this patient before and know him only from his current hospitalization.

What is the feasibility of actually getting a court order for forced medication? Doesnt he have to prove his "unworthiness" yet again before a judge will issue one? Or will judges issue them based on previous episodes of "bad behavior"?

Also, how available are ACT services? Are they around for everyone who has compliance issues? Or are their resources stretched so thin that they arent available to cover all the people who refuse meds?

Well you told me he had the history of previous assaults and non-compliance, so I will assume that the judge knows this too, that we filed the paperwork properly, and that he's not leaving the hospital without that order. And realistically, in our system, this order was already issued in the first 2-3 weeks of this hospitalization, when he is acutely paranoid and assaultative--not after 3 weeks of "stability" in the 2nd month--and it will be enforceable (by pick-up order and forced rehospitalization) for 6-12 months.

I suppose there are a minority of cases where a patient like this agrees to hospitalization and medications, and the team admits him as a voluntary patient and fails to file for commitment when he's most acute. In that case, I'm sure the county would be telling us "good luck!" if we tried for the court order at this late date (after your hypothetical 3 weeks of "stability"), and we would have to discharge him.

You are right, the ACT services will vary tremendously from state to state and county to county. I am fortunate to live in a fairly progressive "blue state", so for high priority threat-to-public-safety types like this, we could probably get him on an ACT team.

[Oh yeah--and with this history, the meds he's going out on WILL include long-acting injectibles!]

 

[PikminOC]

I know the way that OPsychDoc said...

The judge has the information regarding the pt..it should not be his first committment with outpt fup also.

I used to testify in these cases at the county hospital.

 

[toothless rufus]

E. Molecular deorganizer

 

[Socrates25]

I frequently hear that out of all the schizophrenics and others with mental illness, that only a small percentage of them are violent. I'm assuming that is true.

I'd like to get your opinion on a related topic.

Question #1: A mentally-ill person who has done violence against humans previously is likely to do so again, provided that he stops taking his medications. True or False?

Question #2: Many/most people who are mentally-ill and arrested for violent crimes are likely to have a prior record of violence. True or False?

 

[OldPsychDoc]

I frequently hear that out of all the schizophrenics and others with mental illness, that only a small percentage of them are violent. I'm assuming that is true.

I'd like to get your opinion on a related topic.

Question #1: A mentally-ill person who has done violence against humans previously is likely to do so again, provided that he stops taking his medications. True or False?

Question #2: Many/most people who are mentally-ill and arrested for violent crimes are likely to have a prior record of violence. True or False?

My opinion is that both are true--but equally true if you remove any reference to mental illness and meds, etc. (#1: A person who has done violence against humans previously is likely to do so again... #2: Many/most people who are arrested for violent crimes are likely to have a prior record of violence.) Previous violence is the best predictor of future violence.

 

[toothless rufus]

My opinion is that both are true--but equally true if you remove any reference to mental illness and meds, etc. (#1: A person who has done violence against humans previously is likely to do so again... #2: Many/most people who are arrested for violent crimes are likely to have a prior record of violence.) Previous violence is the best predictor of future violence.

Excellent point.

 

[loveoforganic2]

In my state, hopefully and most likely B, unless C is an ACT team that can visit daily with eyes-on meds. And this will be happening with the enforcement capabilities of commitment--a court order from a judge. At least that has been my experience with patients we've had with similar histories of violence and non-compliance.

This is my understanding of how it works in my area too (although C may be the go to choice, as we have fairly sparse [understatement] outpatient treatment options for these populations). For court-ordered observed tx, are the repercussions just recommitment? At a point, if the individual is well managed on medication (psychosis/mania/paranoia/etc wise, not necessarily side-effect wise) and they have recurring failures to adhere to tx, I start to look at it from more of a personal responsibility perspective and wonder if a more punitive option than commitment isn't appropriate (if violent behavior occurs secondary to discontinuing tx)

 

[Anasazi23]

I'm just in shock that a patient was stable for three weeks in the hospital and had no discharge plan.

Now they want the bed and everyone is scrambling?

Does he have pending criminal charges? Sounds most likely like "yes." In that case, the answer is "none of the above" and he is discharged to jail via direct pickup.

 

[nitemagi]

I frequently hear that out of all the schizophrenics and others with mental illness, that only a small percentage of them are violent. I'm assuming that is true.

I'd like to get your opinion on a related topic.

Question #1: A mentally-ill person who has done violence against humans previously is likely to do so again, provided that he stops taking his medications. True or False?

Question #2: Many/most people who are mentally-ill and arrested for violent crimes are likely to have a prior record of violence. True or False?

1. Depends on the nature of the violence, and which medications. If they are paranoid and feel trapped and the violence is viewed as self-defensive, then quite possibly. If they have depression (technically a mental illness) and are violent because they also have some psychopathy, meds ain't gonna matter.

2. Depends on locale and prior crimes. If it's a progressive are they may have no record since no charges would be filed.

These true/false are false dichotomies in complex questions.

Violence is not itself a mental illness. Mental illness may disinhibit some people, or motivate some to be violent, or make them erratic or unpredictable (such as in a disorganized state), but most mental illness is not associated with violence.

A much better target would be substance abuse if you really want to change the prevalence of violent behavior. Lot more bang for the buck there.

 

[zappeuse]

this is how
http://www.npr.org/2011/09/04/140167676/nations-jails-struggle-with-mentally-ill-prisoners