Care, Not Incarceration, for the Mentally Ill


December 08, 2022

As a pathologist and medical editor, I know little about psychiatry. As a physician, a forensic toxicologist, and a broad observer, I know a lot. These are my personal observations of 70 years of American psychiatry.

In 1951, my first girlfriend in college was the daughter of a medical missionary who had moved from Africa to Tuscaloosa, Alabama, to work as a physician at the Bryce Hospital, built in 1851 as The Alabama Hospital for the Insane. The subliminal message from him to me, as a pre-med student, was: Stay away from there ("there" being not his daughter but the clinic).

As a medical student in Birmingham, my most vivid memory of psychiatry was a respected professor in Tinsley Harrison's great department of medicine telling us that psychiatry as a field was roughly like microbiology before Louis Pasteur discovered that microbes cause disease. Then, in 1954, came chlorpromazine, the first antipsychotic that allowed some patients with psychosis to reside in the community.

As a rotating clinical intern in 1957 and a 4-year resident in pathology into the 1960s, psychiatry hardly crossed my mind. In pathology practice in Texas, autopsying successful suicide victims was commonplace, as was autopsy of gay homicide victims. Where was psychiatry? I cannot recall ever seeing a psychiatrist in an autopsy suite.

I worked in the areas of toxicology and drug abuse in Los Angeles throughout the 1970s. Daily deaths from overdoses, rampant addiction, untreated alcoholism, a continuing epidemic of deaths from tobacco addiction, and street drug fairs defined the age.

When recruiting residents and faculty, in order to set realistic expectations, I would call LA County the "world's largest open-air insane asylum." The fact that Medicare and Medicaid did not treat mental illness on par with physical illness did not help. We often saw substance abuse (also not valued by mainstream medicine) and mental illness coincide.

When, in the 1970s, the University of Southern California started a Department of Human Behavior, I quipped that I did not know there was a science of human behavior; I was not even sure it was an art form. I lived and worked in San Francisco from 1962 to 1964 and encountered the emergence of speed freaks in the world's best city. I visited the area by choice many times over decades. I worked there again from 2012 to 2018 and it was still a great city whose streets were now blighted.

To understand why, we need to look at how the political history of California shaped the mental health of its most psychologically vulnerable residents.

When he was governor, Ronald Reagan was not the sole reason the state's mental hospitals closed, resulting in the long-term epidemic of homelessness. But in 1967, he took action to accelerate and sustain the movement.

By the time Reagan took office, California had already deinstitutionalized more than half of its state hospital patients. That same year, the California legislature passed, and Reagan signed the landmark Lanterman-Petris-Short (LPS) Act, which virtually abolished involuntary hospitalization except in extreme cases.

By the early 1970s, California had moved most mentally ill patients out of its state hospitals and had made it legally difficult to get them back into a hospital if they relapsed and needed additional care. California thus became a large test case for deinstitutionalization. This shift was made possible, of course, by the French discovery of chlorpromazine and the approval of the medication by the US Food and Drug Administration in 1954, launching the field of psychopharmacology.

The success of deinstitutionalization placed a great deal of faith in the science of early antipsychotic agents. But no medication is of value unless the person uses it. Furthermore, in the 1987 case of Riese v St. Mary's Hospital and Medical Center, the California Courts of Appeal declared that people had the right to exercise informed consent in regard to the use of antipsychotic drugs, except in an emergency. If they rejected medication, the ruling stated, then "a judicial determination of their incapacity to make treatment decisions" was required before involuntarily treatment could begin.

The case was a class-action suit, brought in the name of Eleanor Riese by the California office of the American Civil Liberties Union (ACLU). Riese's story is depicted in the movie 55 Steps. After this virtually absolute belief in patient autonomy and proper use of psychiatric drugs by physicians, huge numbers of psychotic individuals declined medication, thus facilitating their active public psychoses.

Adding to that movement, the abject failure of the "war on drugs" resulted in many people with untreated mental illness also becoming addicted to a variety of psychoactive drugs. This perfect storm of protected human despair flourished on the streets of the most economically successful and technologically advanced (that is, expensive) civilizations the world has ever seen. Homelessness is no longer consigned to invisible alleys and ghettos but has burgeoned in full flower along the avenues and greenspaces of most major cities.

Now California has a second chance. The gubernatorial career of Gavin Newsom will be remembered for many events and actions. But the Community Assistance, Recovery and Empowerment (CARE) Act of 2022 may have the greatest effect on health, safety, and economic prosperity of all his policies. It also serves as a bookend to the LPS Act in 1967. I have lived and worked in California for many years surrounding these two laws.

The CARE Act of 2022 and the CARE Courts mandate healthcare instead of jail or homelessness and street living for the most seriously mentally ill, those on the schizophrenia spectrum, and people with other psychoses — all of this while maintaining independence and community living for these citizens, to the extent possible.

But should Americans who are overtly psychotic be free to wander as they wish?

Psychiatry was once a field of listening to people, understanding them, helping them solve problems. Of course, electric or insulin shock therapy and involuntary institutionalization were the norms. I watched biological psychiatry and psychopharmacology emerge, develop, and burgeon, largely via the pages of the prestigious Archives of General Psychiatry, edited for many years by the great Daniel X. Freedman, whom I had the unenviable task of "supervising" in my role at the American Medical Association. I witnessed truly amazing evolution and achievements.

I wonder whether so many "normal" American children and adults experiencing the vicissitudes of life require their brains to be managed by externally prescribed chemicals? In or out of balance, does brain chemistry need to be titrated hourly? Roughly 20% of American adults reported receiving mental health care in 2020, more with medications than psychotherapy. Perhaps we all could benefit from a daily dose of mental health care.

It's possible that the implementation of the CARE Act in 2023 will provide Californians with some kind of middle ground betwixt pure patient autonomy and the interests of society. One can hope.

That's my opinion. I'm Dr George Lundberg, at Large at Medscape.

George Lundberg, MD, is editor-in-chief at Cancer Commons , president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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