Mental Health Gaps Jeopardize Public Safety

This is part I of a three-part article on mental health and severe mental illnesses in North Carolina.

Almost unheard of before 1966, mass shootings like the Newtown massacre have become more and more frequent in modern American life. Pundits and politicians alike have been unable to identify the root cause of these atrocities. In the aftermath of Sandy Hook, the Left called for sweeping gun control measures, while the NRA suggested hiring armed guards in schools. Both proposals are far off the mark. They are directed at the symptoms of a much greater problem: untreated severe mental illness.

In almost every recent mass shooting, the perpetrator suffered from some sort of untreated or undertreated mental illness or disorder. The Virginia Tech shooter, Seung Hui Cho, had a long and well-documented history of mental illness. Jared Lee Loughner, who killed six and wounded 13, including Congresswoman Gabrielle Giffords, had untreated paranoid schizophrenia. So did James Holmes, who murdered 12 people in a Colorado movie theater. And Adam Lanza, the Sandy Hook killer, had been “coded” as someone who might have a mental or developmental issue.

It is no coincidence that the spike in mass murders committed by people with severe mental illness coincides with the national trend of deinstitutionalization. Before the 1950s, mentally ill people were treated in state psychiatric hospitals. This was in many ways an effective system: patients could receive treatment and medication in a safe and controlled environment. It was not perfect, however. A number of high-profile abuse cases – like the sort dramatized in One Flew Over the Cuckoo’s Nest – sparked outrage about the state hospital system. At the same time, the advent of new and powerful anti-psychotic drugs led some health officials to believe that state hospitals had outlived their usefulness.

The result was deinstitutionalization, the decades-long process by which state hospitals were closed and patients moved back into society at large. In many ways, deinstitutionalization was a good thing. It gave a great number of people with more treatable conditions a much greater degree of freedom and dignity. But for people with severe mental illness, deinstitutionalization was an unmitigated disaster. E. Fuller Torrey, one of the nation’s foremost authorities on schizophrenia, calls deinstitutionalization a “psychiatric Titanic” that “[discharged] people from public psychiatric hospitals without ensuring that they received … any psychiatric treatment.”

In North Carolina, deinstitutionalization was a gradual process that reached its conclusion in 2001. In that year, Gov. Mike Easley signed legislation that closed many of the last remaining mental hospitals, including Dorothea Dix Hospital in Raleigh. The state handed responsibility for mental health care to “local management entities” (LMEs), which were supposed to contract with private providers for mental health services. But many of the private “community services” that were supposed to pick up the slack from the hospitals never materialized. Those services that did emerge were often not directed at the severely mentally ill, since those services were more complicated and costly to provide. The shift to LMEs also created a major legal gap, since local providers could not provide involuntary treatment.

As a result of North Carolina’s mental health reform, the state reduced the number of emergency inpatient beds available, while making it harder for severely mentally ill people to receive follow-up outpatient care. In 1992, North Carolina had over 2,800 public inpatient beds. By 2001, that number had fallen to 1,755 beds. This February, North Carolina had only 866 inpatient beds. That number actually exaggerates the resources available: Many beds are taken by dangerous long-term patients, while others are reserved for insured patients or nonviolent patients. Of course, the severely mentally ill people who used to reside in the state hospitals have not simply gone away. Nor have they recovered. Today, the severely mentally ill increasingly end up homeless or in prison.

The gap in the state mental health system has major implications for North Carolinians. Today, there are thousands of people living among us who are not getting the treatment that they gravely need. Some of these people may pose a risk to public safety. So far, North Carolina has largely been spared the tragedy of Newtown and Virginia Tech. But there have been close calls: in 2006, Alvaro Castillo shot and killed his father before driving to Orange High School. He opened fire, wounding two students before he was subdued and arrested. Castillo suffered from an untreated schizophrenic disorder.

The best way to prevent future mass shootings is not to post more guards in schools. It is not to outlaw guns. The best way to prevent mass shootings is to attack the problem at its source: severe mental illness.