To those who consider patient autonomy one of the most important concepts in modern healthcare, being able to choose when to die is respected as part of that autonomy. However, euthanasia is a hotly contested issue and is especially debated with respect to mental illness. Euthanasia for untreatable psychiatric illness is currently permitted by law in the Netherlands, Belgium, and Switzerland. However, a recent study by the National Institutes of Health (NIH) has shown that many psychiatric patients euthanized in the Netherlands may have suffered from treatable mental illnesses, such as depression. In fact, of the patients whose case files were studied, more than half had previously refused at least one form of treatment with many of those patients citing “lack of motivation” as the reason for their refusal. Moreover, the study found that many of the psychiatric patients who requested to be euthanized were motivated by “loneliness” or “social isolation,” often symptoms of depression.
Although Dutch law requires that a “disorder be intractable and untreatable” to warrant euthanasia, the study also found that patients are able to seek out euthanasia after being refused, from other physicians, non-psychiatrists, and on-call mobile euthanasia clinics, sometimes on rather questionable grounds. As a result, the study questions whether the Dutch system “provides sufficient regulatory oversight” and casts doubt on diagnostic criteria that allow a symptom of an underlying, possibly treatable condition to determine whether the condition itself is untreatable. While the ethical use of euthanasia for patients suffering from mental illness will undoubtedly continue to be debated, the NIH study certainly makes clear that questions about the treatability of “untreatable” mental conditions must be resolved to protect an already vulnerable population from falling victim to its own self-fulfilling prophecy.
Several new companies have introduced genetic tests aimed at making treatment of psychiatric illnesses more predictable and effective. Test makers assert that psychiatric genetic testing minimizes patients’ risk of adverse side effects by enabling physicians to select appropriate medications with less trial and error. However, a recent investigative report conducted by the New England Center for Investigative Reporting (the “Report”) raises significant questions about the effectiveness of these genetic tests.
Among the concerns raised in the Report, the lack of independent oversight and financial conflicts of interest are the most serious. The Report suggests that test makers may be overstating findings and have failed to seek outside review of their unproven products. The Report also alleges that financial incentives may be causing improper referrals because test makers have been paying medical professionals to speak favorably about their tests, which have yet to be proven effective. Furthermore, as a result of a highly controversial FDA exemption, the majority of these genetic tests have been introduced into the marketplace without FDA review. Although the FDA recently announced plans to regulate these tests, no timeline has been established.
Despite the ethical concerns raised in the report, psychiatric genetics may still hold the key to unlocking a definitive approach for identifying the drugs most likely to be effective for individuals suffering from a multitude of psychiatric conditions. Only time will tell if the analysis of an individual’s genetic make-up can be used to effectively determine drug response.
A few days after Daniel St. Hubert was released from prison, he allegedly went on a stabbing spree resulting in the death of a 6-year-old boy. Hubert’s past is checkered with violence. In fact just before his release, he had been incarcerated for five years for choking his mother with an electrical cord. Moreover, Hubert’s time in prison was filled with violence against inmates and correctional workers. The correctional system would seem to have been aware of Hubert’s propensity for violence. Indeed, it took three years before he was deemed psychologically fit to stand trial for the assault on his mother.
While in prison, Hubert underwent years of therapy that resulted in improvement in his behavior including six months without any citations for violence. On May 23, 2014, after a psychiatric evaluation, Hubert was released without a structure in place to ensure the safety of Hubert and the public.
Currently, the criminal justice system focuses on ensuring that the mentally ill are competent to stand trial, but little has been done to combat mental illness once mentally ill prisoners are released. New York’s “Kendra’s law” gives the state the authority to order outpatient treatment for individuals who have had a violent past and have refused treatment. However, this law does not ensure thatmentally ill people released from prison will receive needed treatment. Hubert’s case forces us to ask whether or not six months without a citation for violence is enough time to deem a prisoner stable enough to re-enter society. Further, is there a better way to keep tabs on released prisoners with mental illnesses? Whatever the solution, there are civil liberty issues that must be balanced with public safety.
Soon, Congress will hear testimony concerning the Helping Families in Mental Health Crisis Act. Republican representative, Tim Murphy, from Pennsylvania, sponsored the bill, and, though many agree that the mental health care system requires revamping, some provisions in the bill have sparked controversy. Among the more controversial provisions is one that supports the increased use of involuntary outpatient treatment—via court-ordered therapy for “certain mentally ill people with a history of legal or other problems.” Detractors of this provision claim that it will erode trust in doctor-patient relationships, and that it presents a civil rights issue. However, 45 states have compelled treatment programs already, one of which is New York.
New York’s compelled treatment program, Kendra’s Law, was passed in 1999. Since the implementation of Kendra’s Law, studies show that the percentage of patients returning to the hospital or getting arrested has greatly decreased. The statistic is significant, as “about 350,000 Americans with a diagnosis of severe mental illness…are in state jails and prisons” and the availability of psychiatric beds meets only 10 percent of that need.
The Joint Behavioral Health and Firearms Safety Task Force of Rhode Island approved a final report for submission to the General Assembly, which concerns how Rhode Island should submit mental-health records to the National Instant Criminal Background Check System (NICS). Ultimately, the Task Force recommends that Rhode Island submit only the names of patients committed involuntarily because a judge deemed them a danger to themselves or others. Sen. Frank Lombardi, D-Cranston, believes that the Task Force’s determination strikes the correct balance between: the right to privacy; public safety; and, “the recognition of mental health as an illness and not as a stigma.”
The Supreme Court of the United States barred the execution of intellectually disabled individuals in 2002. Soon the Court will address the standard that a State should use to determine whether an individual is intellectually disabled. There are ten states that use IQ scores to assess the intellectual competence of convicts, including Florida. Typically, in these states, a person with an IQ of 70 or higher is considered intellectually competent. Some psychologists maintain that using such a bright-line standard is scientifically outdated, and that IQ tests are not precise enough to make such a determination. The Court will hear arguments on the issue in Hall v. Florida, on March 3, 2014.
The bill to streamline the involuntary commitment process for mental health patients in Vermont is not finished yet. However, some are concerned that the bill does not sufficiently protect the rights of patients committed involuntarily under the new, streamlined process. The head of Vermont Legal Aid’s Mental Health Law Project, Jack McCullough, requested that the Vermont Senate Judiciary Committee add language to the bill that would preclude a patient’s name from being added to the federal registry’s list of individuals who should not own firearms, at least until a preliminary finding of mental illness was adjudicated fully. Lawmakers indicated that they would not add the requested language in this bill, and would rather deal with that issue in separate legislation.
Recently, Vermont Senate committees conducted hearings regarding the involuntary administration of psychiatric medication for some psychiatric patients who pose a danger of harm to health care providers. Proposed legislation would “streamline the process” of involuntary commitment and would allow the state simultaneously to request authority to require a patient to take psychotropic medications against his or her will.
On January 22, during the hearings, Dr. Gordon Frankie, Chief of Psychiatry at the Rutland Regional Medical Center, offered anecdotal evidence regarding a patient who assaulted two of the Center’s staff members—leaving one member brain damaged. Dr. Frankie indicated that the staff awaited a court order before it could medicate the patient. The lawyer who directs Vermont’s Legal Aid’s Mental Health Law Project, Jack McCullough, claims that the commitment process operates appropriately and requires no intervention.
On October 18, 2013, the National Alliance on Mental Illness (NAMI) hosted a forum at Fort Hays State University (FHSU) regarding the mass shootings at Columbine, Virginia Tech, Newtown and Aurora. The forum is part of NAMI’s effort to disentangle the public’s conception of the mentally ill from the violence of the tragedies. The executive director of NAMI Kansas, Rick Cagan, stated that though the perpetrators of those tragedies were mentally ill, other factors contributed to their rage. Professor of psychology at FSHU, Dr. Patrick, said that the men responsible for the mass shootings had exhibited signs of their potential for violence, and that those signs were unheeded.
Recently, a clinical faculty member at Tufts Medical School uncovered a connection between gut bacteria and mental health. More neurons surround the GI tract than the spinal cord, and the bacteria in the gut communicate to the brain in various ways, such as through the nervous or immune systems. Health professionals suggest that patients with GI disorders may improve their mental health status via probiotics.