Are the mentally ill falling through the cracks?

Experts struggle to prevent patients' violent crimes


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The Kia Johnson case -- in which a Wilkinsburg woman with mental illness was charged with killing a pregnant teenager and stealing her baby -- drew worldwide news coverage this summer.

That startling homicide, though, was just one of at least 10 serious incidents involving local residents with mental illness that have occurred in Allegheny County neighborhoods in less than a year. Known as sentinel events, they are tracked by the state Department of Public Welfare. Officials here and around the country are struggling with how to prevent such violence or other problems.

In one case, Shadyside resident Terrence Andrews was arrested in the stabbing death of culinary student Lisa Maas. In another, Nang "Ricky" Nguyen was shot dead by police in Oakland after he brandished a meat cleaver. And Anthony Fallert drowned after he apparently walked away from a community mental health program on the South Side and jumped or fell from the Birmingham Bridge.

Andrea Curry-Demus, charged with the Kia Johnson homicide, had a history of mental illness and previous arrests for other crimes, including stabbing a woman and kidnapping a baby.

The series of sentinel events here, as well as incidents elsewhere such as the killing of 32 people at Virginia Tech in April 2007 by a gunman with a history of mental health problems, have left officials, grieving families and others to ask: Are people falling through the cracks of the community mental health system? And what might be done to prevent such problems from occurring?

Flawed system

"What we're seeing, in tragedies large and small, is what happens when we fail to make the investment in mental health services," said Dr. Robert Bernstein, executive director of the Judge David L. Bazelon Center for Mental Health Law. "There are fundamental flaws in mental health service delivery across the board."

Experts disagree, however, on what changes should be made to prevent violence or other serious problems. Some measures that might help are controversial because they restrict patients' rights.

Officials also emphasize that only a fraction of violent crimes are committed by people with mental illness. And it's unclear whether the recent rash of sentinel events in the Pittsburgh area represents a trend.

But concerned about the safety of patients and the general public, the state has taken steps to prevent more problems.

Following Ms. Johnson's death, the welfare department imposed a temporary moratorium on some referrals to the University of Pittsburgh Medical Center's Western Psychiatric Institute and Clinic pending a review of agency services and procedures. The department said Western Psych provided outpatient services to adults involved in six of the 10 community sentinel events.

In announcing the lifting of the moratorium, beginning Sept. 1, officials noted a new policy that requires the state and county to approve proposed discharges of clients from local case management programs. The state also wants to improve outreach and take other measures to keep high-risk people involved in community care -- a challenge when some stop taking anti-psychotic medicines or otherwise drift from services.

"Finding better ways to keep people engaged in treatment is the Holy Grail," said Dr. Jeffrey Swanson, a professor at the Duke University School of Medicine.

Close contact a must

Officials at Mercy Behavioral Health believe frequent contact is essential.

Most of the agency's 278 local residents served by community treatment teams -- mobile groups of psychiatrists, nurses, case managers and other professionals -- have a psychiatric diagnosis and at least one other health problem, such as a substance abuse disorder, said Dr. Brenda Freeman, a team psychiatrist. Many are former Mayview State Hospital patients and nearly all live in unlocked facilities in the community.

The treatment team meets every weekday to discuss patients' status. At least once a day, team members make face-to-face contact with most patients, who also can call for help 24 hours a day.

Even with that level of support, some refuse treatment or other assistance and end up hospitalized or in jail, Dr. Freeman said. Team members have tracked down patients under bridges, in bars or even other states.

Despite such challenges, most patients improve, said Christine Gregor, the program's clinical director.

Carl Graczyk, who has schizophrenia and depression, was incarcerated for years, then in Mayview and other treatment facilities, before getting involved with the team about six years ago.

Now Mr. Graczyk, 47, of Mount Oliver, lives in his own apartment and attends group sessions at Mercy Behavioral. He attributes much of his recovery to the caring attention of the program's staff.

Case managers may be able to moderate a key concern -- violent behavior -- by providing "careful monitoring and clear identification of 'no violence' as a goal," along with help in accessing services such as mental health care, job training and housing, said Dr. Kirk Heilbrun, professor and head of the psychology department at Drexel University.

For people with or without mental illness, certain factors can contribute to violence risk, including substance abuse, anger problems, a history of violence and specific personality traits, Dr. Heilbrun said. But he noted that with the exception of those with co-occurring substance abuse, people with mental illness are no more likely to be violent than their neighbors without mental illness.

Better funding and services, along with use of assessment tools -- basically, appraisals of risk factors and protective factors, such as having a supportive family or a job -- may help optimize care and better protect communities, he said. The risk assessment tools, some of them available for years, are reasonably good at identifying people at higher risk for violence, he said. But outside the criminal justice system, which has more leverage to order treatment and other measures, "people tend not to want to take them voluntarily," he said, noting many may not want to have such results made part of their health record.

Risk factors for suicide include past attempts, a family history of suicide, hopelessness, thoughts or plans of suicide, substance abuse, or a recent loss, said Dr. Robert Simon, director of the program in psychiatry and law at Georgetown University School of Medicine. Those factors and others, he said, are typically evaluated in a clinical assessment by a psychiatrist.

Funding problems

In Allegheny County, officials hope to strengthen the system of care through an overhaul of the case management system. The five-year project began earlier this year.

Part of the idea is to upgrade pay and training, improve retention and make case managers -- renamed service coordinators -- more accountable for keeping in touch with their clients and taking action if problems arise.

"We've got a long way to go," said Stephen Christian-Michaels, who is working to put the new system in place.

One challenge is that community mental health funding often does not keep pace over time with inflation, said Mr. Christian-Michaels, who is also chief operating officer for Family Services of Western Pennsylvania. Another is that funding may not be allocated to best serve people at the neighborhood level.

Estelle Richman, secretary of the state welfare department, acknowledged some basis for those concerns, while noting that mental health funding tends to be higher in Pennsylvania than in many states.

In a more controversial move to improve care, officials are exploring greater use of outpatient commitment -- turning to the courts to force people to take medication or adhere to other stipulations of a treatment plan.

Some communities in the state rely on the practice more than others, Mr. Christian-Michaels said. In his agency's service area in Westmoreland County's Allegheny Valley, it appears to work well, he said.

The process usually involves patients who are in a hospital's inpatient psychiatric unit and show signs of not complying with treatment once they are released, he said. Typically, an initial hearing is held at the hospital, with a hearing officer presiding and testimony from a psychiatrist and the patient or a patient's representatives.

If outpatient commitment is approved, the patient will likely face scrutiny in the community from case managers or other personnel to ensure compliance with the terms of the commitment, such as taking medication.

In Allegheny County, outpatient commitment is used infrequently, officials said.

The key question is whether "this is really necessary -- not just that it might be helpful -- when you're talking about infringing on someone's rights," said Patricia Valentine, deputy director of the county's Office of Behavioral Health.

In Pennsylvania, people must be found dangerous to themselves or others to be placed on outpatient or inpatient commitment, officials said. But some states have different standards that allow broader use of outpatient commitment, also known as assisted outpatient treatment, said Kurt Entsminger, executive director of the Treatment Advocacy Center, a national group that favors that approach.

Kendra's Law

New York, for example, has enacted Kendra's Law, which allows court-ordered outpatient commitment "to prevent a relapse or deterioration which would be likely to result in serious harm to the person or others." To be eligible, adults must have a history of noncompliance with treatment that has led to certain acts of violence or threats of serious harm to self or others, or to prior hospitalizations or stays in correctional facilities.

The 1999 law was named after Kendra Webdale, a young woman who died that year after being pushed in front of a New York City subway train by a man living in the community who was not receiving treatment for his mental illness.

A 2005 report by the state indicated that those committed under the law had improved functioning and a reduction in harmful behaviors.

"I've seen Kendra's Law be very helpful," said Deborah Ashline, criminal justice program director for the National Alliance on Mental Illness -- New York State. She called the law a last resort for seriously impaired people who might otherwise be victimized, harm themselves or others, or end up homeless or incarcerated.

But not everyone agrees.

The focus on outpatient commitment "misses the point of what will make people more safe: The hard work of improving our system," said Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services, which promotes the recovery and rights of people with psychiatric disabilities.

He suggested that system improvements in the state have come primarily from other factors, such as increased community mental health funding.


Joe Fahy can be reached at jfahy@post-gazette.com or 412-263-1722.


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