The Charlotte Light-Rail Murder Exposed the Cracks in Our Mental-Health System

The senseless murder of Iryna Zarutska on a Charlotte, North Carolina, light-rail train has reignited discussion of the connection between serious mental illness and crime. That discourse has come in two parts—one helpful, one less so.

The helpful part of this debate is the recognition that the connection between crime and mental health is real. Untreated psychosis and schizophrenia of the kind afflicting Decarlos Brown Jr. is associated with much higher risks of violence and criminal activity (especially when the sufferer also uses illegal drugs).

The less helpful part is the treatment discussion, which is often founded on false assumptions and a deep misunderstanding of the historical structure of our mental-health system. Too often, raising the question of treatment serves as political cover for public policies that aim to reduce accountability and limit the state’s authority to incapacitate criminals or the chronically ill.

Insofar as rehabilitation of the mentally ill or criminals should be a policy response to public-safety crises, we need a better understanding of the assumptions and safeguards associated with it historically—and how they were dismantled over the past 50 years.

Serious mental illnesses like schizophrenia or bipolar disorder occur in about 6 percent of American adults. Many of these individuals willingly accept psychiatric treatment for their illnesses, usually in the form of anti-psychotics. Some do not. This population, “the untreated,” is at much higher risk of criminal activity, homelessness, and forced hospitalization.

Our psychiatric system has limited tools to help this population access treatment. A strict legal framework governs coercive medical interventions, such as involuntary administration of anti-psychotic medication. Even in the few cases where the untreated do receive involuntary treatment, courts require that patients be released to less restrictive environments as soon as their symptoms abate sufficiently, regardless of their likelihood of further deterioration or treatment refusal. This cycle, which often involves emergency rooms, psychiatric holds, jails, and preventable crises, is a typical one for people with serious mental illness who are resistant to treatment.

Those who favor using psychiatric treatment to prevent crimes within this subset of the seriously mentally ill population operate on two core premises. First, they assume that medical interventions work consistently. Second, they assume that the lack of treatment is the result of a lack of resources or access.

Neither of these suppositions is entirely accurate. Anti-psychotics don’t always work. Consistent antipsychotic treatment can achieve positive results in as much as 87 percent of patients after one year, but most studies find a much lower efficacy rate, around 50 percent. Even assuming the highest efficacy rate, at least 13 percent of people with serious mental illness will have symptoms that do not improve with long-term medication. Pharmaceutical interventions are an important tool, but our legal and psychiatric systems are predicated on overestimates of their efficacy, especially given the need for patients to take their medication willingly and regularly.

Idealism about pharmaceutical interventions was a primary motivator behind the reckless deinstitutionalization that occurred over the past 50 years. Pharmaceutical companies and psychiatrists promised policymakers that drugs were cheaper and more humane than large institutions. These promises proved too optimistic.

This context is important because so much of the discussion of mental-health treatment among the seriously mentally ill focuses on the issues of resources and access to medication. The reality is that most Medicaid patients have no out-of-pocket costs for antipsychotics. The larger problems are getting patients to take their medications as prescribed, ensuring long-term compliance with treatment plans, and responding appropriately to medication-resistant mental illnesses.

When individuals repeatedly refuse medication or their symptoms fail to improve even with consistent dosage, psychiatrists need broader latitude. That includes sequestering the patient in a psychiatric institution. The current system is organized around stabilizing and releasing patients from psychiatric hospitals, but it has far less capacity to respond to those who may never stabilize or who will deteriorate once released into the community.

Here, however, there is a resource constraint: we have lost upward of 90 percent of our psychiatric bed capacity over the past few decades. At the same time, we have designed a system that fails those at highest risk and least likely to recover because it is built around the assumption that recovery is possible for every patient. Empirically, that is not the case.

For this high-risk population, we should get more comfortable with the idea of long-term, indefinite institutionalization. But given the high costs of the recovery-oriented psychiatric hospital system—in the range of $180,000 per person per year—we must also create lower-cost, long-term environments for people who for one reason or another do not recover from mental illness. To reduce costs, these facilities should be less medically focused.

Abandoning the “recovery” paradigm will be uncomfortable for psychiatrists, courts, and the public alike, but it is clearly necessary. Such a shift is also likely to save and improve the lives of mentally ill people currently left to suffer in a helpless cycle that too often results in preventable crimes like the one that led to Zarutska’s death.

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