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Although I'm IT, I happen to work in the mental health field, and we see a lot of Hassans on a semi-regular basis. I get the feeling that working with them would be extremely difficult, just because it'd be so fucking heartbreaking. I mean, I'd want to do everything I could for him, and I'd feel terrible that bare bones basics like medication management and linking him to help and encouraging him to use it would be the best that I could do for him, and that he probably wouldn't take advantage of any of the help because of the paranoia. It seems like bad choices all the way down when it comes to the question of when should these individuals lose their rights. I'm firmly on record as saying that the SC has erred on the side of turning the mental health problem into a law enforcement problem with the current doctrine of imminent danger of harm to self or others or chronic inability to care for self, but I also have no illusions that widespread institutionalization was worse. The reality of the law being a blunt instrument here really hits home with frequent flyer clients like the lady who is consistently hospitalized for abducting children off the streets which in her mind is for their own safety, treated with medication, then released, whereupon she promptly stops taking her meds, "because she doesn't need them," then goes back to her delusions and tries to protect another kid and starts the cycle all over again.
And the big kicker in all of this is that your example of Hassan is a great one in the sense that he seems to code to the classic, "would probably never even hurt a fly unless he is triggered in a highly specific fashion," sort of situation, which is, of course, the vast majority of schizophrenics. I know, I know, it's very trope-y to be busting out the, "less violent than normies," meme here but the other piece of this for me is that from what I've seen, the violent mentally ill throw many more red flags than just trying to protect themselves. Threats of violence and violent or even homicidal ideation are common and even then, the biggest single red flag is that they've been violent in the past, not that they threaten violence or fantasize about it. I'm sure this, in part, is why having a plan to harm someone or oneself is a prerequisite for involuntary commitment, lest we start locking folks up left and right for wanting to hurt or kill an antagonist or themselves.
Anyway, I really appreciate this post because it brings home the reality that absent a major breakthrough, schizophrenia in particular will remain a particularly poor fit for the lens of the culture wars. Even if we go with the metaphor of the spectrum for mental illness, there's a clear-cut difference between the Jared Loughners and the Lee Harvey Oswalds.
I know this is a big problem, but why does it happen? Is it that the meds don't really work, so patients are drugged and docile but still basically irrational? Is it that they work too well, so that patients think they're cured and therefore that they don't need the pills anymore? Or are the patients 'cured' but still basically too low-competency or erratic for their newfound sanity to make much difference?
I would have thought that after the first couple of rounds of 'didn't take my meds, got arrested', I would (being sober/sane because of the meds) spot the pattern and be very careful about taking the meds even when I'm feeling better.
To build on @Muninn's great explanation: Schizophrenia is in a way pattern matching in overdrive. What anti-psychotics do is dial the frequency in closer to the station that we call reality, but there is always still some fuzz. So a lot of people go on anti-psychotics for a while and because the fuzz is still there they don't really feel very different - or worse, they feel like they have traded the frankly fucking magical world they lived in for the grey lifeless slog all the zombies live in, because it has no effect on the symptoms like anhedonia.
And on top of that they also get to enjoy fun side effects like feeling dog tired all the time, constant headaches, weight gain despite constant vomiting, and the always delightful sensation of your muscles seizing of their own accord so you look like you have cerebral palsy because your jaw desperately wants to rest on your shoulder and your hands are doing their level best to retract into your elbows. On top of that, there is the widespread belief in the community that if you find yourself gurning you have been on anti-psychotics for too long and you are rolling the dice on involuntarily gurning for life.
Okay, I get this. So the fundamental delusions (the police want to hurt me / nobody's protecting these children / the CIA is watching everyone) are still there, just toned down and without the madder edges. They don't think, 'I was crazy before and now I'm sane', they think, 'I was basically right before, probably I was overreacting a bit but I'm better now'.
Pretty much. Sometimes it's easy to recognise when you have been crazy, but most of the time yeah it is 'oh I overreacted but I was basically right.' The confounder in all of this is the intelligence of the person being discussed of course.
I thought it might be. You need to be able to step back, look at yourself, and say, 'Even though I feel like I was obviously right, I got arrested, plus I know there is this disease called schizophrenia which everybody tells me I have and which does seem to make other people act this way. Maybe I should consider that my decision-making faculties aren't the best'. Not easy.
Makes me feel more impressed by deBoer than usual, although it's a shame he can't turn that self-awareness towards his Marxism.
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Combination of "I feel perfectly fine, I don't need this" plus the side-effects can range from not great to terrible, plus there may be a dash of "I'm not crazy, why are they giving me pills for being crazy?" denial in the mix.
Same general area as "why do people stop taking antibiotics half way through the course?" Because the immediate symptoms are gone, they feel way better, so why would they need medicine when they're not sick anymore?
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Sticking strictly to the antipsychotics, it's more that the meds help, but can only ease the symptoms and not actually rid most folks entirely of schizophrenia when they take them. If you've watched Reservation Dogs, the character of Maximus is a good example there. He knows he needs his medication when he's on it, and he tries to take it regularly, but he forgets sometimes and starts to spiral until his behavior catches up with him or he recognizes that he needs help. Either way, he gets treatment and can hold down his life again.
When it comes to not even believing that medication is needed, and with the caveat that I'm not a psychiatrist, etc. etc., my impression based on what I've seen is that for the most part is that there's a host of different justifications for that thinking, but the practicalities tend to boil down to a either a lack of insight or awareness that their behavior is even problematic in the first place, and/or an attachment to their particular flavor of schizophrenic ideation. On top of that, the side effects of antipsychotics tend to suck, too. More generally, kinda like how Hassan has the rigid belief that police officers want to have (homosexual) sex with him, in his world the police wanting to have sex with him is the problem, medication's got nothing to do with it! Or in my example above, of course the unaccompanied kids are in danger, there's no adult present to look after them! If the police were doing their jobs, they'd be either looking after the kids themselves, or going after the parents of the kids for not looking after their own!
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Psychiatric medication having side effects was mentioned below and is true, although less of an impact for patients like this who may not be "with it" enough to notice the problems.
"Anosognosia" can also be a core symptom of some disease - if you realize you are delusional....well you aren't really delusional, now?
Additionally many regular people struggle to take their medication for seemingly "benign" things (like high blood pressure or diabetes) and up to really bad stuff like "my anti-rejection medications for my transplant."
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Most people with schizophrenia eventually show some degree of cognitive deficits. The meds don't help with those, even if they reduce the risk of psychosis and some behavioral issues. (That is not the same as being sedated into compliance, if I could get away with that, my life would be much easier)
The best way to manage such situations is to provide long-acting depot injections. That way, when the patient is more or less in their right mind, they have fewer opportunities to just decide that they they can skip taking pills for a few days, triggering a relapse.
As hydro correctly states below, psych drugs are often unpleasant, and that's doubly true for antipsychotics. Nasty things, just better than untreated schizophrenia.
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Psych drugs are very unpleasant, for one thing. And having good days and bad days isn’t unusual for a crazy person.
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Exactly. To treat them, you have to drag them in against their will, medicate them against their will, and keep them locked up until they start responding to the medication. That's a horrible thing to do, but you might have to do it.
Then you let them out, and hope to God they maintain the medication regime instead of dropping it the second they're released and ending up back in the same rinse and repeat cycle.
We can ensure that TB patients take their meds. The cost is a fraction of the cost of allowing a well-controlled mental patient to relapse, waiting for them to start acting out, arresting them, re-institutionalising them, and re-stabilising them in an in-patient environment. Long-acting injectable mental health drugs make it even easier.
Why can't we do the same with mental patients? This is a serious question and I don't know if the answer is medical, practical or legal.
To be cynical, and invoking Freddie deBoer here, because there haven't been movies and TV shows and books all about how TB is ackshully a really wunnerful thing, not an illness, it's quirky! creative! unconventional! cool! people thing and it's only Big Pharma Medical Complex trying to force people to stop having TB. Nobody's made "One Flew Over The Magic Mountain" about wicked nurses torturing TB patients with mountain air and health regimes:
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Well, no, we can't. In the US, directly observed treatment would be cost prohibitive. $10 total for 6-9 months of observations? In the US it would be several orders of magnitude higher. Furthermore, even if we could, it doesn't transfer to mental health. One, people with mental illness tend to be more resistant to observation. Two, there's no "Short Course"; the meds are for life or at least for decades if burnout occurs.
NYC does TB DOTS, including by video call where appropriate. A quick google finds this paper giving costs of $5-10 per day per patient at 2015 prices (as far as I can see, NYS DoH eats the cost because most of the benefit is public). While expensive, that is a lot cheaper than a seriously mentally ill person going off meds twice a year.
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