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Out of the Shadows: Confronting America’s Mental Illness Crisis, 2nd ed.
Am J Psychiatry 1999;156:961a-962.
View Author and Article Information
New York, N.Y.

by E. Fuller Torrey, M.D. New York, John Wiley & Sons, 1996, 244 pp., $27.95; $16.95 (paper, published 1998).

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Whenever the plight of families of individuals with serious mental illness who refuse treatment has reached our national consciousness, it has been in the context of blatant tragedy. Reluctantly, we see our patients and their families in the headlines. We also see our own predicament in that of the Kaczynski, Laudor, and Hinckley families, who tried desperately to get their loved ones to accept treatment. Far more common than the tragedies that make headlines are the ones that test the bonds of families and the moral resolve of physicians and therapists who are entrusted with the care of the seriously mentally ill.

In Out of the Shadows, E. Fuller Torrey compiles cases such as that of a man brought to the hospital with acute symptoms of manic depression who rejected the advice of the doctor on call and the pleas of his family to stay and be treated. He walked out of the emergency room and several hours later hanged himself. Dr. Torrey also tells the tale of a woman with chronic schizophrenia who walked into a shopping mall and opened fire with a gun, killing three, and the story of a homeless woman in New York who roamed the streets conversing with the president until the day she was found raped and stabbed to death.

What these tales have in common with the cases that make the headlines is the seriously mentally ill person’s refusal to be treated. Citing such cases and the societal barriers that keep such people out of treatment, Dr. Torrey offers us a provocative indictment of how we in the United States treat people suffering from serious mental illness. He writes with passion and combativeness, and the crisis he describes should stir even the uninitiated to anger. This book should be required reading for every psychiatrist, psychologist, social worker, nurse, and therapist treating patients with serious mental illness. It will also appeal to a much wider audience with an interest in civil liberties, medical ethics, and social policy.

The crisis is spelled out in tragic detail at the outset, We learn that in a given 1-year period, approximately 5.6 million people 9 years old or older have a severe mental illness, such as schizophrenia or bipolar disorder, and that approximately 2.2 million of these people are untreated. Of these, 150,000 are homeless and 159,000 are incarcerated, mostly for crimes they committed while refusing treatment. Dr. Torrey argues that homelessness, repeated incarcerations, episodes of violence, and premature death are not necessary because we know what to do, but we fail to do it because of economic, legal, and ideological reasons.

Dr. Torrey provides a detailed and concise history of deinstitutionalization in the United States. Included in this account is the startling revelation that approximately 763,400 severely mentally ill people are living in the community today who would have been hospitalized 40 years ago. This number is startling when we consider the author’s observation that "deinstitutionalization has helped create the mental illness crisis by discharging people from public psychiatric hospitals without ensuring that they received medication and rehabilitation services necessary for them to live successfully in the community." In many respects, this statement is the heart of this book. Most mental health policies and laws affecting the mentally ill were drafted in an earlier era, he argues. Reflected in them is an immature understanding of the nature of mental disorders. We now know that these are disorders of the brain and that about half of the victims typically refuse treatment. The policies and laws were also based on the principle that severe mental illness should be treated in the least restrictive setting. However, the least restrictive setting "frequently turns out to be a cardboard box, a jail cell, or a terror-filled existence plagued by both real and imaginary enemies."

A more evocative, moving, and informative discussion of this country’s treatment of the seriously mentally ill would be very hard to find. Tens of thousands of mentally ill people end up homeless and in jails. How they get there and what happens to them on the streets and in prisons are topics of several chapters. Dr. Torrey’s description of the degree of trauma and injustice that the mentally ill suffer will impress even readers who have extensive knowledge of the topic. He describes in exquisite detail the economic factors that he believes are the single largest cause of the mental illness crisis and the failure of deinstitutionalization.

Dr. Torrey then addresses a controversial topic that is no less vital for our tendency to shy away from it. He reviews the relevant statistics and research to bolster his statement that many of the seriously mentally ill are "walking time bombs." The claim that the mentally ill are no more dangerous than the general population was true before deinstitutionalization because most potentially dangerous patients were kept in the hospitals. Now studies show a higher rate of violent crimes among the severely mentally ill. Studies also suggest that the three primary predictors of violence are a history of past violence, drug and alcohol abuse, and a failure to take medication.

Dr. Torrey highlights poor insight into illness, one of the most powerful predictors of medication refusal; specifically, he cites research showing that about one-half of patients with schizophrenia do not believe they are ill and that this type of unawareness is often linked to frontal lobe dysfunction. In this context, the belief that one is not ill is considered a symptom (or sign) of schizophrenia, another manifestation of the brain disorder. Such research begs the question of whether a person with schizophrenia who cannot see that he or she is ill can make an informed decision about medical treatment.

As an outspoken advocate for the mentally ill and a clinical scientist unafraid to test novel hypotheses, Dr. Torrey is no stranger to controversy. In the later pages of his book he takes on the controversial question of whether our involuntary commitment laws have enough teeth to meet the needs of the mentally ill and of society. He argues for reinstituting a "need-for-treatment" criterion in state commitment laws, for modifying the standard of proof required by courts for commitment, and for interstate reciprocity of commitment and other safeguards to ensure that the seriously mentally ill who refuse treatment get the medical attention they need. To further such goals, he believes that we should "divorce mental illness from mental health" by merging severe mental illnesses, or brain disorders as many prefer to call them (e.g., schizophrenia, manic depression, autism, and severe forms of depression, panic disorder, and obsessive-compulsive disorder), with neurological illnesses (multiple sclerosis, Parkinson’s, and Alzheimer’s). For example, research on mental illnesses would be carried out by a National Brain Research Institute instead of a National Institute of Mental Health, and commitment laws for the mentally ill would more closely mirror the laws that exist for neurological illness.

Out of the Shadows is an informative, important book that reveals the human suffering and tragedy stemming from our society’s mishandling of the treatment needs of the seriously mentally ill. Some will enthusiastically agree with the solutions to the mental illness crisis that Dr. Torrey proposes; others will vehemently disagree, but everyone who reads this book will likely come away convinced that a crisis does indeed exist and that the time has come to reevaluate our treatment of seriously mentally ill people in America.




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