Investigates the illness schizophrenia. The deinstitutionalization movement; National Alliance for the Mentally Ill (NAMI) study; Numbers of schizophrenics on the streets; The case of Mark Sallee and others; Schizophrenic thinking. INSET: Treating schizophrenia, by D.H.; The search for model treatment.
By July 1, 1994 - last reviewed on June 9, 2016published
Today, there are twice as many people with schizophrenia living on the streets and in public shelters as there are in public mental hospitals. Episodes of violence by people with untreated serious psychiatric illness are on the rise.
Discharged from the Army after being diagnosed as schizophrenic, Mark Daniel Sallee returned to his hometown of country's homeless mentally ill. Sometimes he slept beneath a culvert that ran over one of the half-dry drainage ditches in the Louisville suburb. Other times he lived inside a makeshift lean-to in a wooded area, in the back of an abandoned school bus, inside an empty train car, or out in the middle of a field. Dirt and grease covered him so completely that a waitress at a local eatery took to calling him "black boy." He stole things from shopkeepers and spoke to no one, including his family, except to the threaten them. Once he promised to kill a police officer.
On January 10, 1989, he kept his promise. The story of that event presents a highly revealing picture of how the dangerous mentally ill slip through the cracks of American society.
Leaving his lean-to that morning, he carried a loaded, 22 caliber rifle and wore a one-piece insulated coverall, both of which he had bought two weeks earlier at a nearby sporting goods store. (Lisa Ludwig, the clerk who sold him the gun, is notable for being one of the only people in Sallee's voluminous court record to ever describe him as seeming sane.) By 10:30 A.M., he came across a man he had never met, Brian Madison, walking along a creek behind an apartment complex. Sallee raised his rifle and shot at him, but missed.
He was next seen less than an hour later standing on the east side of busy Smyrna Road. When a red Ford pickup truck passed close to him on the narrow shoulder, Sallee raised the rifle to his shoulder, pointed it at the truck and fired. Again he missed. But a passing motorist saw the incident and called 911 on his car phone. He said he thought Sallee looked "upset and angry."
Dispatched to the scene was 42-year Officer Frank Pysher, Jr., a grandfather and 16-year veteran on the Jefferson County force. That morning Pysher had told a fellow officer about his plans to retire in a few more years. "I'm going down to my house on Rough River, fish, and watch the world go by."
At 42 minutes past noon, Officer Pysher spotted Sallee walking south along Smyrna Road where it crossed over a freeway. He probably recognized Sallee from previous encounters, as did almost all the other police in the area. He pulled over and rolled down his window to speak. Without warning, Sallee allegedly turned, raised his rifle to his shoulder and fired two shots through the windshield, striking Officer Pysher twice in the forehead. At 1:58 P.M., Pysher would be declared dead, the first county police officer to die in the line of duty in three years.
Sallee ran from the scene through the semi-rural suburbs until he came to the backyard of Barry A. Mantooth, 35. "What are you doing?" asked Mantooth when he saw Sallee running. "What is the matter?"
"Who are you talking to?" asked Sallee, and allegedly fired his shotgun for a fifth time that day, this time striking Mantooth in the forearm. Mantooth would be treated and released from the hospital that afternoon.
By now, more than 25 police officers in helicopters cars, and on foot were chasing Sallee. He ran another mile or so until he was cornered in a yard next to the Deeper Christian Life Center. When Officer Dale Mobley ordered Sallee to drop his rifle, Sallee replied, "Fuck you. I am not putting it down!"
After a warning shot was fired, according to Detective Dick Brewer, Sallee "continued to talk and act as if he hadn't heard the shot." Sallee waved them away with his hands and shouted something many of the officers couldn't make out, but that "sounded as if he were talking about shooting," said Brewer. When he seemed to be lifting the rifle again, the police opened fire and struck Sallee once in the chest. Seriously wounded, he was taken by ambulance to the same hospital where Officer Pysher died.
"What did I do?" he yelled as police and medics struggled to restrain him. "I haven't done anything!"
His mother, Mrs. Donna Dalton, had reason to fear otherwise. Even before she heard his name on the television news later that day, she immediately thought, "It's Mark. Oh god, it's Mark."
Her only son had been diagnosed as having paranoid schizophrenia back in 1978 when, at the age of 17, he shot and killed his stepfather, Mrs. Dalton's second husband, before her eyes. Yet despite Mrs. Dalton's repeated pleas to judges and psychiatrists over the years to help her deranged son, even after Mark had threatened to kill his sister and a police officer, he was simply allowed to wander about until he killed again. Now at last, the sick young man who everyone had done their best to ignore for 11 years had been catapulted into the top news story of the year in Louisville, with one TV news team even boasting in its commercials that it had been the first to reach the murder scene.
The story of Mark Daniel Sallee would be sad enough were it a rare instance of one dangerously psychotic person slipping through the cracks. But Sallee's case is just about business-as-usual in Kentucky and the rest of the United States in 1994. a recent story that grabbed national headlines broke on June 6, 1991, when a homeless man named Kevin McKiever fatally stabbed a 30-year-old former Rockette, Alexis Fichs, Welsh, with in 11-inch butcher knife near New York City's Central Park as she walked her two cocker spaniels. Fifteen months earlier, he had spent just 30 days in jail after stabbing another woman who lived in Welsh's apartment building. His mother told reporters that McKiever had been diagnosed as suffering from "schizophrenia and manic depression" as long ago as the mid-1970s, but that he had never gotten adequate treatment. "They system has absolutely failed him," she said.
In 1963, President John E. Kennedy announced a "bold new approach" to serious mental illness. With the development of anti-psychotic medications in the 1950s that were found to be at least partly effective in relieving symptoms for 90 percent of schizophrenics, Kennedy envisioned the opening of hundreds of community mental health centers, where people with schizophrenia could get day to day help in managing their lives. "When carried out," he declared, "reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability."
Hand in hand with the new federal policy, civil rights laws in all but a handful of states threw out all permissible reasons to institutionalize a person against his or her will, no matter how sick, save one: imminent danger. Unless a person was found to be in imminent danger of seriously harming himself or others--imminent as in the next few minutes or, in the case of malnutrition, days--that person would be free to go on living in the community.
The deinstitutionalization movement did succeed in bringing down the number of state mental hospital patients from a high of 552,150 in 1955 to 68,000 today. But despite $40 to $100 million in federal tax dollars given to community mental health centers beginning in 1965, according to a recent study by the National Alliance for the Mentally Ill (NAMI) and the Public Citizen Health Research Group, "It is clear that whatever was supposed to happen did not happen and that de-institutionalization was a disaster."
Many schizophrenics remained out of sight and out of mind until the flop-houses and single-room-occupancy hotels where they had found a last refuge began to disappear in the mid-1980s. Today, according to the NAMI-Public Citizen report, there are more than twice as many people with schizophrenia and manic-depressive psychosis living in public shelters and on streets than there are in public mental hospitals. In all, about 30 percent of the country's homeless--an estimated 150,000--are seriously mentally ill.
As a result, "It is clear that episodes of violence by individuals with untreated serious mental illnesses are on the increase," the report states. Although mentally ill people, when receiving treatment, are believed to be no more violent than average, when they are not treated "some of them will occasionally commit acts of violence," according to the report.
What spurs them on is the disease itself: paranoia may make them think they're being attacked, delusional thinking may make them believe their mother is really the devil, and auditory hallucinations may order them to kill. Since 1965, eight studies have found that violent acts by untreated psychiatric patients are on the rise.
Some of the most chilling rampages across the country in recent years were caused by people long known to the mental health system as dangerous schizophrenics, but who never qualified as being "imminent" dangers. In Berkeley, California, in the summer of 1990, Mehrdad Dashti stormed a bar, killed one man, wounded seven, and took 33 hostages before police shot him dead. Documents found in his apartment showed that he had recently been diagnosed as paranoid schizophrenic. Earlier that year, Calvin Brady shot and killed a man and wounded four others in an Atlanta shopping mall the day after he was released from a mental hospital. In his pocket was found a document describing him as having "homicidal and suicidal tendencies." In October, 1985, Sylvia Seegrist opened fire in a Philadelphia shopping mall, killing three and wounding 10. She had been committed 12 times to mental hospitals, had stabbed a hospital worker, and had repeatedly made violent, bizarre threats in the mall.
Just what does a person have to do to be considered in imminent danger of harming himself or others?
"As soon as the bullet comes out of the gun, then we can arrest him;' says Herbert Pardes, M.D., former director of the National Institute of Mental Health and now chairman of the Department of Psychiatry at Columbia University in New York. "In an attempt to protect the rights of the patients, we have compromised the rights of society."
Says John Bell, M.D., who recently retired as director of the emergency psychiatric unit at Humana Hospital-University Louisville, and who personally treated Sallee for several years after he killed his stepfather, "There are 15 to 30 people out there in Louisville right now about whom the mental health workers at the hospital have said. This guy is going to kill somebody if we release him, yet we were powerless to do anything about it. I'm a very liberal guy, a long-term member of the ACLU. But when there are people who have already proven that they're dangerous, some of them murderers, I feel society has a right to protect itself.
According to E. Fuller Torrey, M.D., the psychiatrist who led the NAMI-Public Citizen report and who has devoted his career to researching and treating schizophrenia and advocating for better services, America's mental health system "exhibits more though disorder than most of the patients the system is supposed to treat."
"On the question of services for the severely mentally ill," says Senator Pete Domenici R. Arizona), "there's no question that were doing very poorly. Very few plans distribute services in a rational way."
Like most people who develop schizophrenia, Sallee was a normal, well-behaved, seemingly happy young man up until his midteens. (The disease affect equal numbers of men and women, but tends to strike men in their teens, and women in their twenties.) His younger-sister, Lisa, remembers him as "very sweet. He always helped me with my homework." His high school cross-country coach, John Sears, says, "Mark was a good kid around school. He didn't have any problems. He seemed sort of introverted, but most of the kids liked him. Kids who run cross country are usually you better kids, and Mark was no exception."
A first, the changes seemed to be little more than what many teenagers go through. By 1976, his parents had divorced and re-married, and Mark tried moving in with his father, a truck driver, in Elizabethtown, 43 miles south of Louisville. He started skipping school there after the first couple of months, however, and eventually returned to his mother and stepfather's home in Okolona. He re-entered Moore High School, but dropped out for good on March 20, 1978. As spring turned to summer, it became glaringly obvious that Marks wa suffering from more than teenage angst.
The once quiet, helpful young man was now sitting in his room for hours, refusing to talk to anyone or let anyone in. "We could hear him in his room giggling and talking to the radios as though someone was in there," says Mrs. Dalton. "I'd go in to talk to him and he'd look right through me, like I wasn't even there." When his sister Lisa asked him to turn his stereo down one day, he pushed her to the ground and choked her. He didn't let go until their other sister pulled him off.
Taken together, these are among the classic early sings of schizophrenia. Although no single symptom affects all schizophrenics, hearing voices is common, and they often have bizzare, irrational or paranoid delusions. How bizarre? Carol, a 31 year-old black woman living in Wisconsin who is now responding to medication but who spent a decade gripped by psychosis, tried to explain the thought process that made her thinks she was the devil.
"Something was going through my mind that everything in my past was negative," she said. "It wasn't godly things I'd done--it was all satanic. So I thought I was the devil. And I thought I was getting all these powers because I was the devil--the power to hear other people's thoughts. It was amusing at first to think I was chosen and special. But in the end it was terrible. I'd say, this can't be, this isn't right. I remember telling one of my brothers and his friends I was the devil, and they just said it was all in my mind. I didn't believe them. They couldn't tell me differently." Not until she attacked her mother with a knife was she involuntarily hospitalized and started on the road to recovery.
But schizophrenics' thinking is more than delusional; the hallmark of the condition is disorganized thinking--Torrey describes the schizophrenic mind as being like a blender. It jumbles all thoughts, making it hard for them to hold a conversation or follow instructions.
Speaking in a kind of "word salad," as psychiatrists call the mixed-up language that flows from schizophrenics' disordered thinking, a sturdy-looking young man named John, also from Wisconsin, tried to tell a visitor why he likes taking the antipsychotic medication Clozapine. "It's better than antidepressants," he began, sounding reasonable enough. And then he went on, "They're made of crushed spiders. Arachnids. A voice told me to cut myself open today. I thought a vampire was behind me." As if in afterthought, he added, "I could look at a point in the floor and just crawl right into it."
Perceptions of colors, sounds, heat, smells, and pain might also be distorted. In the early 1980s, Beatrice Phillips' sister--once a svelte, meticulous fashion model and dancer who toured Europe--began wandering outside her mother's Philadelphia home in the middle of winter in jeans ripped all the way up to her crotch and shoes without soles. She stopped bathing, wore the same urine-soaked rags for months at a time, threw all her possessions in the garbage, and spent hours in her room with a sheet over her head.
Often schizophrenics' emotions are strikingly inappropriate to what's going on around them. "These inappropriate emotions produce one of the most dramatic aspects of the disease--the victim suddenly breaking out in cackling laughter for no apparent reason;' writes Torrey. One patient told him, "It must look queer to people when I laugh about something that has nothing to do with what I am talking about, but they don't know what's going on inside and how much of it is running round in my head. You see I might be talking about something quite serious to you and other things come into my head at the same time that are funny and this makes me laugh." Eventually, though, the emotions of schizophrenics tend to flatten as the disease progresses, so much so that Torrey tells of one patient who set his house on fire and then sat down serenely to watch TV.
As serious a medical illness as schizophrenia is, thousands of psychologists, social workers, and even psychiatrists cling to the myth, popularized in the 1960s, that schizophrenia is caused by "bad mothers" or "crazy families."
Such was apparently the view of psychologist A.P. Tadajewski, Ph.D., to whom Mark's mother took him at a local child guidance clinic beginning in the summer of 1978. "He wanted to know about the relationship between Mark and us, to find a reason for the behavior," she says. "We were made to think it was our fault. I told him, 'Hey, what are we going to do? This can't go on.' And he said, 'Mark's very rebellious. He has a lot of anger.' I don't even know if this man knew what schizophrenia was."
On the night of Friday, September 1, 1978, the family had some friends over and by 10 o'clock, two of Mark's sisters were walking a neighbor home. Mark's mother and her husband, Patti Hicks, had just gone into their bedroom when Paul said, 'Hey, where is my Baretta?" The gun case on the bedroom wall, he noticed, was missing one of the shotguns he used for hunting. "I don't know," said Mark's mother. "Mark's been home all day. Maybe he knows."
She walked across the hall and knocked on Mark's door, closed as usual. When no answer came, she opened it and found him lying in the darkness. She walked over to his bedside lamp to switch it on, but the lamp remained dark. Mark fumbled with it and knocked it onto the floor. As she stooped down to pick it up, she saw Mark rising from the bed with something in his hands. Suddenly three gunshots broke the silence. She turned to see her husband in the doorway fall with three wounds to the chest.
"I just stood there," Mark's mother recalls, her voice shaking with sobs. "I didn't know what to do. I didn't scream. I just closed my eyes and thought, 'I'm dreaming this. I'll wake up in a minute.' Then I opened my eyes and Paul was just lying there."
Realizing she needed to get the Baretta, she quietly yet firmly said to her son, "Mark, give me the gun." She reached toward him, he pulled back, and then he handed it over.
After calling the police, she went back to her husband as he lay on the floor, gasping for air. By midnight, Paul was dead. Eight hours later, after hiding out all night from police and neighbors, Mark was found curled up under shrubbery next door, and arrested.
The official line from schizophrenia researchers and foundations is that schizophrenics are no more violent on average than ordinary people. And surely it would be an injustice to perpetuate the groundless fears that many people have of the seriously mentally ill. Most schizophrenics, in fact, are said to become passive, listless, nearly mute. Of those who do become violent, most become their own victims: fully one of 10 schizophrenics die at their own hands.
Even so, in a three-month investigation including interviews with over 100 people across the country and visits to homes and institutions in Wisconsin, Florida, Louisville, New York, and New Jersey, it was impossible to find a parent living at home with a schizophrenic child who wasn't afraid of him or her.
"I think the national leadership greatly underestimates the level of violence," says Barbara Rankin, forensic coordinator for the Kentucky Alliance for the Mentally Ill and a member of the forensics committee of the national alliance. "They think the violence adds to the stigma. But I don't know of one family in my support group in Lexington whose schizophrenic children don't get violent when they're delusional. I can't think of anyone who hasn't had at least very real threats--and usually worse than that. With appropriate treatment, they're no more dangerous than other people. But untreated, you never know."
Rankin's schizophrenic son, James, was in and out of mental hospitals three times in the year leading up to June of 1985. Even then, though, no law required him to continue taking his medications once he was back home, and soon he was talking about killing Rankin's second husband. On June 27, 1985, James walked out to his truck, picked up a compound bow and arrow, came into the kitchen and shot her husband through the heart. He was found "guilty but mentally ill" on charges of manslaughter, and is now serving a 10-year prison sentence.
Although only a month and a half from his 18th birthday, Mark Sallee was still technically a juvenile and not legally required to stand trial for the killing of his stepfather. A coroner's jury did find that he had killed him, but due to Mark's age and a diagnosis of schizophrenia, he spent only a few months in a private psychiatric hospital, Our Lady of Peace. His symptoms soon controlled by antipsychotic medications, he was released into his father's custody shortly after Christmas, less than four months after the shooting.
For two and a half years, Mark did fairly well. He took his medications, earned a high school diploma, enrolled at a local community college, and worked at a few jobs. Then he complained of being unhappy living with his father and moved in with his grandmother. Eventually, he stopped taking his medication.
"He was exhibiting strange behavior again," recalls his mother. "He'd be laughing at nothing, sitting with a blanket over his head and giggling." This time Mark voluntarily agreed to return to Our Lady of Peace. One day, after about a month, his mother came to visit.
"He was standing there with his bags packed," she recalls, "and they were waiting for me to sign the papers. They said he could go home. I had told the doctors I couldn't handle him, but I didn't know what else to do. So I took him home."
Sallee's mother and her three daughters lived in fear that Mark would become violent again. Although he had stopped taking his medication and was becoming increasingly menacing, his mother could get no advice from his doctors, or even any information on what treatments he had received while in the hospital. That information was confidential, they were told.
"I couldn't go anywhere," she says. I had a six-year-old and two teenage girls. I was afraid to leave them with Mark. We were sleeping all in one room with the door locked. He'd walk around the house, giggling and throwing things. Our lives just stopped. My daughters quit school, they couldn't stand it." Routinely Mark made violent threats. Once he tried to kill the family cat. And now he had taken to smoking marijuana, a common problem among many schizophrenics as their disease progresses. (There is no evidence that drug abuse can cause schizophrenia. But when schizophrenics abuse drugs, in an apparent attempt at self-medication, the drugs can make the symptoms worse.)
Finally, Mark's mother de tided she had to involuntarily commit him to the state mental hospital. But at his commitment hearing, the judge ruled that none of his actions constituted an imminent danger and declared him free to go. At that point, his mother raised her hand and said, "Am I allowed to say anything?" The judge said she was. "Please, please keep him;' she begged. "I know that he needs long-term help. He has never had really long-term therapy anywhere."
The judge turned to Mark and said, "Are you sick?"
"No," said Mark
And that was that. Mark wanted to go home with his mother afterward, but she had to refuse for the safety of her family.
"Most people felt sorry for Mark," she later told a Louisville radio station, WHAS. "And I think a lot of people thought, you know, what kind of person is she? She knows her son is in this shape. Poor thing's out,there digging in garbage cans to eat. Out in the cold." At that point, she broke down crying on the air. "That's the choice you have to make," she continued. "After society, the system fails, and they're pushed out by them, you keep them as long as you can, until you know it's gonna be them or the rest of your family. So you have to push them out."
After that, Mark broke off all contact with his family. Then, on May 29, 1984, he enlisted in the Army. In less than two years, however, a mental status evaluation found him to be depressed and delusional, with a bizarre thought process. At one point during his evaluation, he told the Army psychiatrists that President Carter had recently mentioned him in a speech and told "peanut jokes" about him. The psychiatrists diagnosed him as suffering from "schizophreniform disorder" and "schizotypal personality disorder." He was discharged on July 28, 1986.
Returning to Okolona, Sallee appears to have gone quickly downhill. Reports in his police file chronicle his run-ins with local residents and shopkeepers: stealing a car radio, shoplifting from a Majik Mart, throwing rocks at cars passing beneath abridge, yelling at people who happened to walk by his lean-to, threatening a mall security officer, rummaging through garbage bins behind restaurants, walking down the highway collecting bottles and cans.
On April 24, 1987, Sallee was jailed after he rushed at a police officer who was questioning him. The officer had to hold Sallee down on the ground until other officers arrived, and Sallee was still so agitated when put into the car that, according to the police report, he damaged the police cat's back seat as he was driven to the station. Yet based on only a single interview, without any check into his 10-year history of violence and psychosis, a staff psychiatrist at Central State Hospital in Louisville concluded on May 4, 1987, that Sallee "is not a danger to himself or others."
Eighteen days later, on May 22, Sallee was arrested again, this time for stealing a shopping cart. (Jailing of severely mentally ill people for seemingly minor offenses is common across the country, in an apparent attempt by police to get them off the streets on whatever technicalities they can find. As a result, there are now about 100,000 people with schizophrenia and manic-depressive psychosis in U.S. prisons and jails--more than in public mental hospitals.) After a Winn Dixie manager had reported seeing Sallee take the cart, Officer William E. Brough found him near the corner of Preston Highway and Chateau Lane, where he was living in a ditch. Sallee told Officer Brough, "I gave you a break. If I wanted to, I could have killed you. I will kill you when I get out:
He was out again within days. For the next 20 months, he threatened anyone who dared go near him. When his own sister, Sandra, approached him on the street in the 1988 to offer him some warm clothing and money, he threw a large rock at her and told her to go away or he would kill her. The family's only recourse was to find out from police what his normal roaming area was and stay dear of it. Hearing how bad things had gotten, his father drove up from Georgia, where he had moved, to try and find his son. He found him on the side of Preston Highway. But Mark didn't even seem to recognize him.
On November 30, 1988, Mark walked into a branch of the First National Bank, set down a piece of paper with his name, address, and a number on it, and said to a clerk, "C.D." She asked if he wanted to buy a Certificate of Deposit. Mark replied, "No, cash it." Checking the bank records, she found that Mark had indeed bought a $5,000 C.D. two years earlier (probably with money he had earned from the Army). The next day, she gave him $5,478.76 in cash and change, representing the interest he had earned.
Two days after Christmas, Mark took his money and went to a nearby Herman's sporting goods store. He bought a Marlin 60 rifle, a red wooden box of .22 caliber cartridges, and some rifle-cleaning equipment. A few days later he returned and bought the blue snowmobile jumpsuit that he would be wearing when he allegedly shot and killed Officer Pysher. Of course, selling a gun to a mentally ill person is against the law in Kentuck. And of course, had the federal Brady Bill been in effect in 1988, a police check during the required five-day waiting period would have easily picked up Sallee's record of violence. Instead, it was up to the Herman's employee to satisfy herself that Sallee was mentally fit.
No one can say for certain where Mark was heading when Officer Pysher stopped him on the Smyrna Road overpass, but this much is fact: He had already walked more than two-miles from his campsite and was then just one block from the house where he grew up, the same house where he shot and killed his stepfather, the house where his sister Lisa now lived with her husband and daughter. Officer Pysher might well have given up his own life to save theirs.
In the absence of effective community mental-health programs, over 100,000 friends and family members of schizophrenics have organized themselves into the National Alliance for the Mentally Ill, with chapters now located in every state.
Ultimately, the real solution to the tragedy of schizophrenia is to find a cure. "Research is progressing at an accelerated pace," says Sam Keith, M.D., former director of NIMWs schizophrenia research branch and now head of psychiatry at the University of New Mexico. Even he admits, though, that "many of our very fine treatments turn to trash when they're not administered appropriately, either due to overtreatment with a medication or undertreatment."
After being arrested for the killing of Officer Pysher, Mark Sallee spent more than a year at the Fayette County Jail, without any treatment whatsoever. On December 13, 1989, psychiatrist Robert P. Granacher, Jr., M.D., examined him in his cell and found him huddled nude, with a sheet and blanket over his head. For 11 months Mark had sat psychotically mute and motionless.
Within weeks of being ordered to begin antipsychotic medication at Kentucky Correctional Psychiatric Center, Mark improved dramatically enough to dress and dean himself, talk with guards and fellow patients, and even show interest in watching television and having a cup of coffee. Although he is not yet well enough to stand trial, if that day does come, he will be prosecuted for murder in the first degree, and could end up on death row.
This, then, is the ultimate irony of Mark Daniel Sallee's story: the only reason a Kentucky court ever forced him to take his antipsychotic medications was to make him well enough that they might one day execute him.
"Its too late for my son," says his mother. "But there's so many more out there."
Whatever the causes of schizophrenia may be--genetic, obstetric, viral, or environmental--the primary treatments is with any of more than a dozen types of antipsychotic medications, including Thorazine, Clozapine, and Haldol.
Studies have shown that about 70 percent of schizophrenics clearly improve on these drugs, with 20 percent improving minimally at best, and 5 percent getting worse. But over the course of a lifetime, improvements are more limited; while one-fourth do recover fully from their first psychotic episode and never experience a relapse, and another fourth recover well enough to live and work independently, the remaining half need help in taking care of themselves the rest of their lives, especially when their illness flares up, as often happens with this notoriously cyclical disease.
But medications don't work when schizophrenics don't take them. And experts estimate that half to three-fourths of schizophrenics stop taking their medications within one year of walking out the hospital door. Most are unable to understand that they need the drug to get better most, in fact, can never see past their delusions to realize they're sick in the first place.
Many drugs also have a harrowing array of side effects. A schizophrenic who takes antipsychotics for years might find that his hands shake, his tongue pokes and curls out of his mouth, his emotions feel numb and flat. Or he might feel unbearably agitated. New hope has come with the recent introduction of the drug Clozaril, which can produce seemingly miraculous recoveries in about one-third of people for whom no other medication worked. And in mid-1993, the FDA approved yet another antipsychotic, risperidone, which appears to be as effective as Clozaril with fewer side effects.
THE SEARCH FOR MODEL TREATMENT
Balancing the civil rights of the severely mentally ill against society's right to safety.
Many experts have come to the conclusion that the aggressive use of so-called outpatient commitment laws may be the best answer. Already in place in a handful of states but used regularly in only a few progressive counties, outpatient commitment permits schizophrenics only about three visits to the psychiatric emergency room before they are put on long-term court-ordered medication as a condition of leaving the hospital or avoiding a jail term. The counties soon find that keeping a close eye on each patient, making sure they're followed up and taking their medication--and not standing around naked in the middle of an airport, as was a man I recently saw--is a lot less expensive than waiting for them to get so sick they must return to the hospital.
Some psychiatrists argue, however, that outpatient commitment laws are beside the point. What's really needed are good community programs that put care-givers in close, regular contact with schizophrenic patients. Such programs which amount to the community mental health centers envisioned by President Kennedy, are seen as the missing foundation of what should be the country's response to the crisis of homeless, violent schizophrenics.
Two fundamental models have been developed:The clubhouse model was first pioneered by Fountain House in New York City. About 400 severely men tally ill people each day come to socialize with fellow patients, develop work skills, and get ongoing help in finding housing, finding a job, managing money--and taking medications.
Says Jim Schmitt, Fountain House director, "The biggest thing is not just housing. They have to have a life--something to do during the day--or life becomes oppressive."
The second model, based on the Program of Assertive Living Treatment (PACT) in Dane County, Wisconsin, has the doctors and social workers go to the schizophrenics, by making weekly, sometimes even twice-daily, house calls.
The federal Substance Abuse Mental Health Services Administration has put $20 million toward creating a model program in one city. In New York, meanwhile, the governor and legislature agreed late in 1993 that five of the state's all-but-empty psychiatric hospitals will be closed with the $210 million in savings dedicated to community treatment programs--an estimated 20 to 25 percent increase in the state's spending on such programs.