Book Review

The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens

N Engl J Med 2008; 359:2401-2402November 27, 2008

Article

The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens
By E. Fuller Torrey. 265 pp. New York, W.W. Norton, 2008. $24.95. ISBN: 978-0-393-06658-6

Hardly a week goes by without a person who is alleged to be mentally ill committing some act of violence — and it is always covered by the media. What is the cause of the epidemic? E. Fuller Torrey, an indefatigable advocate for the adequate treatment of the seriously mentally ill, diagnoses the problem and prescribes a solution in this book. He focuses on violence that is committed by the seriously mentally ill and, to a lesser extent, the victimization of the seriously mentally ill. This book was difficult for me to read, but not because Torrey does not write well — he writes exceedingly well, adroitly weaving statistics with poignant anecdotes. The book was difficult to read because like other mental health professionals, I have lived through an era of the societal insanity of allowing the seriously mentally ill to reject treatment, a rejection that would not be tolerated if it were done by the seriously mentally retarded or by persons with dementia.

In chapter 1, Torrey reviews the origins of this social disaster. He cites deinstitutionalization of the mentally ill, which was made possible by the advent of effective psychotropic medications in the 1950s. He also blames members of the legal profession, who were helped along by the fact that state psychiatric hospitals “were inhumane on the best of days and often much worse.” In the 1960s, at the height of the Civil Rights Movement, a number of attorneys — some perhaps inspired by books such as The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: Paul B. Hoeber, 1961), by psychiatrist Thomas Szasz — began to advocate for the abolition of involuntary hospitalization. State legislatures began to severely restrict involuntary hospitalizations. The majority of state psychiatric hospitals were closed, and the patients were moved “from back wards to back alleys.” Currently, approximately 4 million people in the United States have serious mental illness; of those, about 400,000 are homeless, incarcerated, victimized, or violent. Most deny that they are ill, and most will not take medication; about 40,000 are very dangerous and — if they are not on medication — pose serious risks to their families or others. Torrey cites one study that shows that mothers represent “the largest single group to be targets for violence” by the severely mentally ill.

In several later chapters, Torrey skillfully presents cases that support his thesis, and he adds data from the psychiatric literature to further support his point. He postulates that anosognosia — which is essentially a denial of illness, often seen in stroke victims and in persons with Alzheimer's disease — is present in some persons with schizophrenia and bipolar illness.

In chapter 11, Torrey gives his prescription to fix the system. This consists of identifying the populations that are most at risk to commit violence: persons who have a history of violence, concomitant substance abuse, anosognosia, antisocial personality disorder, symptoms of paranoia, neurologic impairment, or a combination of any of these attributes. In each of these populations, men are at greater risk of committing violence than women. Torrey then proposes the creation of a national data bank to which people could be added only by judicial order; access to this data bank would be limited to health professionals and members of law enforcement agencies. Most of the treatment would be assisted outpatient treatment, with directly observed treatment — that is, the supervised taking of medication, as is done with patients with tuberculosis who refuse to take medication. There would be legal provision of involuntary hospitalization for those who refused. The vast majority of people in the United States with severe psychiatric illness receive monthly disability benefits through Social Security or the Veterans Health Administration. Courts would appoint representatives who would monitor compliance and would use the benefits as leverage.

The final chapter is the conclusion of a moving story that begins in chapter 2. It is the story of a family that was devastated by the murder of a man with schizophrenia. This man menaced his family for several years before his sister murdered him. She died in prison after she refused to continue treatment for her diabetes. This book should be required reading for all legislators and civil rights attorneys. I hope that Torrey continues his quest, and more important, that he has success.

Philip E. Veenhuis, M.D., M.P.H.
250 Turners Crossroad S., Golden Valley, MN 55416
pj.veenhuis@att.net