The drive to the hospital seems unusually long on this cold winter day as I travel to see a new patient admitted during this weekend call. You can never predict what the weather has in store for you. Winter is here in its full fury. The snow blows horizontally instead of falling and it seems as if the roads are smoking. I grab my steering wheel with both hands, as it helps me believe that I have full control over my vehicle, which is not always true. No cruise control for sure, as I learned from a recent, near-fatal spinout. I drive at the speed of a tortoise through this foggy weather. It seems that I am driving into space. I finally manage to see the exit leading to the hospital and welcome its coming into view. The hospital is located on the outskirts of this small town and is somewhat oblivious to what is happening around it, which is usually not much.
Dressed in hospital scrubs, disheveled, his long matted hair partly hiding his face which supports a long unkempt beard, Mr. Smith (not his real name) seems disorganized, confused, and perplexed. The smell of sweat suggests that he has not showered in a long time. He strips off some clothing, walks half-dressed in the hallway, and punches doors. He cannot hold a coherent conversation. He grimaces, sticks out his tongue, and makes sounds as if he is communicating in a language unfamiliar to me. My attempts to strike up a meaningful conversation fail.
“Mr. Smith, what brought you into the hospital?” He makes eye contact, looking intimidating, and just grunts. He utters a few words here and there, then mutters to himself.
“Mr. Smith, is there anything I can do for you?”
“I am cool,” Mr. Smith replies. He is in the time-out room.
“Do you want to go back into your room? It's kind of cold in here. You can go into your room if you want.” Mr. Smith starts pacing in the room.
“I have a lot of harm coming by my being.”
“Do you feel that it is not worth living?”
“I have no ‘confidention,’ ” he replies. When in a psychotic state, patients can sometimes make up new words or attribute new meaning to words.
This is Mr. Smith's second hospital admission. The first time, a few months ago, he was transferred from a nearby university hospital to this state psychiatric hospital for long-term treatment. Relatives reported that for about six months before his psychiatric hospitalization, Mr. Smith looked different. His thinking became “chaotic,” as he described it. He began contemplating suicide. He said that he kept having a dialogue with himself. He cut his wrist, only to repent later that it was not effective. He was scared of killing himself. He thought that the police might help if he did something illegal. He punched and broke his parents' mailbox, and when the police arrived, he told them to shoot him between the eyes. His thinking was scary. He wanted his energy to mix with that of the universe for, what he thought would be, the betterment of everybody. He was hospitalized and encouraged to take antipsychotic medication. He reluctantly took it, and his thinking became more organized. He still had much going on in his mind, but on the surface he seemed to be thinking more clearly. He did not want to talk too much and mostly kept to himself. He did not believe that medication was the answer and wanted to “try it without medication.” The process of commitment of Mr. Smith for psychiatric treatment was initiated in the university hospital, as he was unwilling to stay there and be treated. Government attorneys defended the need for psychiatric commitment and treatment, based on Mr. Smith's major psychiatric illness, his persistent symptoms, and his lack of insight. The independent evaluator also recommended psychiatric commitment for treatment, but Mr. Smith's attorney argued that many patients lack insight and it should not be a cause for commitment. Furthermore, Mr. Smith agreed to seek outpatient psychiatric treatment.
The court found that the most recent documented incident had lasted for a short time and that, in addition, the rendering of the diagnosis of schizophrenia was premature. It ordered that Mr. Smith be released immediately. After his release, he did not want to take his medications and did not allow us to set up psychiatric follow-up for him. He stayed with his friend for a few weeks after he left the hospital. He stopped taking medications. He started smoking marijuana and drinking heavily and tried mushrooms three times. His friend asked him to leave. He hitchhiked through several cities and finally came back to live with his parents. A few weeks later, they took him to the emergency room because he had not left his room for three days and was muttering to himself, eating and drinking little, and not taking care of his personal hygiene. I had been wondering how long it would take for him to cross this legal threshold or become a mature schizophrenic. The argument is not whether Mr. Smith has schizophrenia. It would have been all right if the judge had determined that, regardless of his diagnosis, Mr. Smith was doing well and did not need hospitalization for treatment. But that was not the case.
Schizophrenia is a brain disease, a difficult to treat but nevertheless treatable illness. We should look at individual patients and their need for treatment and not their diagnoses, regardless of whether we are legal or mental health professionals. We do not know everything about these complex psychiatric disorders, and it would be worthwhile if we reminded ourselves of our ignorance. Mr. Smith's lack of insight and his contained paranoia were not enough for our legal system. It had to see him cross that legal threshold, which unfortunately is high in many instances. He is now back in the hospital in a more decompensated state than before. He is an intelligent young man, but in the absence of treatment, his psychotic process is eroding his intellect like a moth feeding on a mulberry leaf. I hope that we can change our judicial approach so that we do not have to wait for patients to deteriorate before we can treat them.
- American Academy of Psychiatry and the Law
