Book Review

Out of the Shadows: Confronting America's mental illness crisis

N Engl J Med 1997; 336:1331May 1, 1997

Article

Out of the Shadows: Confronting America's mental illness crisis
By E. Fuller Torrey. 244 pp. New York, John Wiley, 1997. $27.95. ISBN: 0-471-16161-6

Why are people with obvious psychiatric disease homeless on the city streets of America? Why are jails and prisons becoming de facto state hospitals? Why do there seem to be an increasing number of violent acts committed by people described as mental patients?

In this timely and very well written book, E. Fuller Torrey answers these questions. For over 35 years, treatment of the mentally ill has been provided in the context of a policy of deinstitutionalization, the shifting of the locus of treatment from large state hospitals to the “least restrictive alternatives” in community settings. The most obvious outcome of this policy is apparent on city streets and in jails and courts and is documented almost daily in the press, in articles about homelessness and violent acts by people with histories of psychiatric illness. The laudable goals of deinstitutionalization have been partially realized for many of the mentally ill, perhaps even the majority, but in the words of Dr. Torrey, “For a substantial minority . . . deinstitutionalization has been a psychiatric Titanic.”

Deinstitutionalization has resulted in homelessness for the mentally ill and the criminalization of mental illness. The policy has also led to a substantial rise in violence perpetrated by mentally ill people, even though only a small percentage of the mentally ill are dangerous. People with serious mental illness may live almost continuously in a cycle of homelessness on the streets, short-term hospitalization, and jail. In Dr. Torrey's eloquent words, “For such people, the cycle must be like that of medieval pilgrims who go on, year after year, enduring hardships in hopes of attaining grace. Within the public psychiatric care system as it is currently organized, grace is in very short supply.”

Mental illness can now be accurately diagnosed and treated. The ability to cure eludes psychiatry, as it does the rest of medicine in dealing with chronic illness. Furthermore, contrary to popular belief, violence in the mentally ill can be predicted. The predictors are previous violence, coexisting substance abuse, and failure to take prescribed medication. The reasons that persons with serious mental illness do not receive the treatment they need fall into three broad categories: economic, legal, and ideological. Each of these categories is well reviewed by Dr. Torrey in separate chapters.

On the economic side, the main problem is not that there is not enough money, but that the states — the traditional providers of care for persons with serious mental illness — have shifted the costs to the federal government, resulting in uncoordinated care in the community. After brief hospitalizations, large numbers of patients are placed in nursing homes, where they receive little more than custodial care, a process referred to as “transinstitutionalization.”

Legal factors involve the standard for commitment, which was changed in the 1960s from the need for treatment to dangerousness. Society should focus on the helplessness of persons with serious mental illness and their need to be protected from degradation, not just the danger they pose to themselves or others.

Complicating rational policy is American psychiatry itself, which for years focused on less disabling illness, a concept of the spectrum of mental illness compounded by a fuzzy concept of mental health, and a variety of social ills, instead of focusing as much as it could have on mental disease. The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (4th ed. Washington, D.C., 1994) is seen by some as making it possible to medicalize every human problem. The dominance of psychoanalysis in shaping the thinking of American psychiatry comes in for criticism from Dr. Torrey, who has plowed this ground before in Freudian Fraud: The Malignant Effect of Freud's Theory on American Thought (New York: HarperCollins, 1992).

Dr. Torrey offers several solutions. First, reestablish the states as the accountable agents, economically and clinically, by placing all public funds in their hands. Second, recognize that in at least half the cases, persons with serious mental illness must receive involuntary treatment, if they are to be treated at all, and that this necessity must be reflected by commitment laws. Third, divorce mental illness from mental health. One way to do this would be to replace, at both the federal and state levels, the focus on the spectrum of mental health and illness with a focus on brain disease, which the principal mental diseases (schizophrenia, major affective disorder, and bipolar disorder) clearly are. Dr. Torrey uses imaging techniques to establish the biologic nature of schizophrenia and bipolar illness. This approach is less than compelling. Responsiveness to medication is a more statistically sound measure of the organic nature of these diseases.

This is an important book on a pressing and vexing problem. Most psychiatrists would agree with Dr. Torrey's diagnosis. Some would argue that his remedies are too radical, but they are thought-provoking and deserve consideration.

Philip E. Veenhuis, M.D., M.P.H.
University of North Carolina, Chapel Hill, NC 27514