Tuesday, February 17, 2004

Beautiful Minds Part 2: Legal Issues Regarding the Mentally Ill

Over the weekend, a news event perfectly illustrated the major legal issues faced by those that suffer from mental illnesses and by their families.

LEXINGTON, Ky. — A suspected gunman who told a reporter he was battling "alien clones" during a 6-hour standoff at his home was charged Saturday in the deaths of his wife and a female firefighter.

Patrick Hutchinson, 45, surrendered Friday night, hours after fire and police crews converged on his house in southeast Lexington following a report that a woman had been shot.

At one point during the standoff, a reporter from the Lexington Herald-Leader accidentally called Hutchinson while trying to reach his neighbors, officials said. An editor alerted police, who asked the reporter to end the call.
The reporter said Hutchinson made doomsday proclamations, calling the standoff "Armageddon" and rambling about the CIA and a conspiracy.

"We're going against the evil alien clones," the Herald-Leader reported Hutchinson as saying in its Saturday editions. "I started with my wife."

His wife, Elizabeth Fontaine Hutchinson, 60, died of multiple gunshot wounds, according to the Fayette County coroner's office.

Hutchinson also faces attempted murder and assault charges, and was being held at the Fayette County jail. Police have not commented on his mental status.

Clearly, unless this man is feigning insanity, he suffers from, paranoid schizophrenia or psychosis associated with bipolar disorder or schizoaffective disorder. The questions I have about this case are these:

1. How long had Mr. Huchinson exhibited symptoms of schizophrenia and how long ago was he diagnosed?

2. Had he been receiving treatment for his condition before this incident and if so, for how long and what was the treatment?

3. Had his wife attempted to get treatment for her husband’s condition before this incident and what was the result?

4. Was there any indication that Mr. Huchinson might act violently before this incident, and if so, what steps were taken by Mrs. Huchinson?

I tried to find more information about this case, including Mr. Hutchinson’s previous mental health history, but nothing has been released yet. Since the typical age of onset of schizophrenia for males is late teens or early 20’s, I’m guessing Mr. Hutchinson had a previous history of mental illness. Unless this was his first psychotic episode, most likely his wife knew about his condition.

To see what actions Mrs. Hutchinson could have taken to help her husband, let’s take a look at the Statutory Assisted Treatment Standards for the State of Kentucky.

For both inpatient and outpatient:

KY. REV. STAT. ANN. § 202A.026. No person shall be involuntarily hospitalized unless such person is a mentally ill person:
(1) Who presents a danger or threat of danger to self, family or others as a result of the mental illness;
(2) Who can reasonably benefit from treatment; and
(3) For whom hospitalization is the least restrictive alternative mode of treatment presently available.

KY. REV. STAT. ANN. § 202A.011(2). "Danger" or "threat of danger to self, family or others" means substantial physical harm or threat of substantial physical harm upon self, family, or others, including actions which deprive self, family, or others of the basic means of survival including provision for reasonable shelter, food or clothing;

It’s not clear what “substantial physical harm or threat of substantial physical harm” means. Does this include verbal threats or only attempts at physical violence? In the state of Utah, until the law was recently amended, the wording was “imminent danger” to self or others which pretty much meant that the person had to have the gun to their own head or someone else’s or have threatened violence in the presence of a police officer. Now the wording is “substantial physical harm” and takes into account past mental health history, and also whether that person will experience deterioration of his ability to function without treatment.

Also, what is meant by “basic means of survival?” Does that mean that the person must be employable or that they are at least able to walk over to their local homeless shelter and grab a meal?

According to Kentucky law any interested party, including family can petition the court for a 60 or 360 day involuntary hospitalization. So what evidentiary standard is used to determine whether a person present a danger or threat of danger to self or others? The statute says:
For preliminary hearing: § 202A.051(6). “probable cause”
For final hearing: §202A.076(2). “beyond a reasonable doubt”

So for the preliminary hearing which occurs within 6 days after a person is involuntarily committed, the standard is “probable cause.” This would include testimony of family, and friends regarding the behavior of the person in question and possibly his mental health history. The person may or may not be held in the hospital during this time, and if there is probable cause, then the person would be examined by 2 mental health professionals. The findings of this examination would then be used to establish “beyond a reasonable doubt” if involuntary hospitalization is necessary.

So the process for involuntarily committing someone seems pretty straightforward, but what happens at the end of the 60 or 360 days after the person is released? In Kentucky (and most states) there doesn’t seem to be an outpatient program that requires a patient to keep taking their antipsychotic medication without going through the whole petition process again and again. It can take weeks to days for the effects of antipsychotic medications to wear off. The newer ones can wear off faster because they have a higher off-rate (pharmacological term meaning they fall off their target receptors faster).

So Joe Schmoe could be released from the hospital after 60 days of treatment and then decide to stop taking his meds and suffer a full blown psychotic episode in days or weeks. I would guess that this might have happened in this case in Kentucky. And then before Mrs. Hutchinson can get him some help and get him back on his meds, he’s killed her and a firewoman. I’d be interested to know if Mrs. Hutchinson had filed a petition for involuntary commitment of her husband or if she had previously called the police or his doctor asking for help in dealing with her husband. I hope the papers in Kentucky will keep tabs on this case, so it can be determined if this tragedy could have been prevented by pre-emptive action.

This is going to sound harsh, but people with schizophrenia or similar disorders must take their medication for the rest of their lives, unless they have a lengthy remissive period and their medication has been tapered off. It’s too dangerous to them and to the public to allow individuals with schizophrenia to go unmonitored. About 1000 homicides a year are committed by people with severe mental illnesses and this is a tragedy because these illnesses are treatable. Antipsychotic medications work, and when someone with a severe mental illness commits murder or suicide, it is almost always because they stopped taking their medication. Severe mentally ill individuals that are taking their medication are NOT more dangerous than the general population, but those that go untreated are MORE dangerous.

Civil rights advocates are always protesting that no one should be forced to take medication involuntarily and propose that more education and outpatient services will help . The problem is, people suffering a psychotic also exhibit impaired awareness of illness or anosognosia. They do not know they are sick and thus cannot make proper decision regarding their own medical care. They can’t choose to not be sick! About 40-50% of all people with severe mental illness go untreated. And the number one reason for this is anosognosia.

The irony is our society lets people with severe mental illnesses wander around homeless or severely impaired where they can commit petty crimes or become victims of crimes themselves, while Alzheimer’s patients are cared for so they can at least die with some dignity. But both groups suffer from diseases that affect the same organ, the brain, where our memories, reasoning, and personality are housed. The city of San Francisco hands out $300 every month to their homeless and calls that compassionate. For those of the homeless that are mentally ill, it would be more compassionate to help them get treatment so they could find a job, draw a salary, and live in their own home with their families.

Another big problem is that our prison system has become the dumping ground for the severely mentally ill. One group estimates that 16-20% of the inmate population are severely mentally ill. Most do not receive adequate treatment and are repeat offenders. It’s also 2-3 time more expensive to treat the mentally ill in prison than in a mental health facility.

One answer to this problem is a new system being tested by various states, mental health courts. When a mentally ill person commits a petty crime, instead of being incarcerated, the individual is brought before a judge and a treatment plan is worked out. The individual is then released on bond with the stipulation that the treatment plan must be followed. Figures in Atlanta, where this program was introduced showed a 60% drop in recidivism. A similar program known as “drug court” also works well for non-violent drug offenders.

Timely intervention and increased funding for outpatient mental health treatment are needed to prevent tragedies like the murder of Mrs. Hutchinson. If you are interested in helping make treatment more available to the mentally ill, contact the National Alliance for the Mentally Ill, and the Treatment Advocacy Center.

Next: Beautiful Minds Part 3 - Religion and Mental Illness

Update: Thanks to my husband Randy for clarification of some of the legal terms contained in this article.

Evidentiary standards (or standards of proof) from weakast to highest are:
-reasonable suspicion;
-probable cause;
-preponderance of the evidence;
-clear and convincing evidence; and
-beyond a reasonable doubt.

Some lawyers will quantify the standards to give an idea of how strong the evidence must be to meet the standard. One quantification of each of the five standards might arguably be: 10%, 30% >50%, 80% and 90% respectively.

For a principal to check a student's locker, he must have reasonable suspicion. For police officers to get a warrant or arrest someone they must have probable cause. In a civil trial if the evidence supports the plaintiff's case (a preponderance of the evidence) over the defendant, the plaintiff wins and vice versa. In most states, a petitioner must prove by clear and convincing evidence that a person is incapable (e.g. schizophrenia or alzeheimers) in order to take over their personal and financial affairs and involuntary commit them to a hospital. Prosecutors must prove beyond a reasonable doubt that the defendant is guilty in order to convict the defendant of a crime. The standard for convicting some one of a crime used to be clear and convincing evidence but that changed over time.

For whatever reason, the standard of proof is harder to commit a mental ill person in Kentucky than in other states. Its preliminary standard (probable cause) to bring some one in, however, is the norm.

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