Quiet Tragedies

The major mental illnesses - schizophrenia, severe depression and bipolar disorder - used to be considered emotional disturbances, attributed to things like bad mothering or stress. But we now know that these conditions are biochemical illnesses affecting millions of people. With that knowledge have come better treatment methods, from more effective drugs to more comprehensive community-care programs. Still, thousands of people with mental illness are homeless, existing outside the mental-health system. Countless others represent the "quiet tragedies," as National Alliance for the Mentally Ill board member Carla Jacobs puts it, living isolated lives with little hope in their family homes, or in board-and-care facilities.We called together some of the county's most impassioned voices to discuss the situation in Los Angeles. Roundtable participants included: Christopher Amenson of Pacific Clinics Institute; Peter Chen, chief of Community Care Programs for the Los Angeles County Department of Mental Health; Susan Dempsay, founder and until recently director of Step Up On Second, a drop-in center for people with mental illness; Carla Jacobs, member of the board of directors of the National Alliance for the Mentally Ill; and Mark Ragins, psychiatrist at the Village Integrated Services Agency.

WEEKLY: I suppose any discussion of mental illness and its impact on society needs to begin with a discussion of what severe mental illness is.

CHRISTOPHER AMENSON: We don't properly differentiate between mental-health problems and mental illness. Mental illnesses, things like schizophrenia and bipolar disorder, are neurobiological illnesses. With physical problems we make the distinction better. Most severe physical illnesses are not called the same thing as the day-to-day experiences. Severe headaches are not called headache syndrome, but rather a brain tumor. But very severe biological depression has the same name we give to a mild case of the blues. So people get confused and think that the true mental illnesses are similar to everyday mental-health problems. But they're not, just as a sore leg is not the same as a broken leg.

MARK RAGINS: I only partially agree, actually. I work in a place where a lot of people have become seriously disabled or are homeless, and although I do see a number of people with biochemical disorders, with many of the people I meet it's less clear what's going on, less clear that it's a brain disorder. I meet the person who was that weird-looking kid in third grade who used to go in his pants and hit the girls. He has now grown up to be a homeless person. Society is saying, "You're a medical specialist, and that's not a medical disorder. He's got some sort of personality or social problem, so don't deal with him." Or if I meet someone whose mother was murdered by his father when he was 3 and he ran away and was homeless and using drugs by 9, I can argue that his problem really isn't a mental illness, that it's a mental-health issue and so he shouldn't be in the public system. But he's still homeless, still suffering. I think a lot of the people that we should be helping do not actually have biochemical disorders, or have other issues on top of their biochemical disorders.

CARLA JACOBS: Mental-health issues are social problems, but severe and persistent mental illness, such as schizophrenia or bipolar disorder, is a physical brain disease. And we have to accept that and start from that point before we can prevent the profound chronicity that occurs from spending your life in the streets eating out of dumpsters, being in jail, being scorned by society. And so while I understand exactly what Mark is saying, that there are all sorts of people that can be helped by mental-health treatments, severe and persistent mental illness starts as a neurobiological condition.

SUSAN DEMPSAY: I think so much of what we are discussing stems from the stigma attached to mental illness. In my retirement, I have started to volunteer at UCLA's Neuropsychiatric Institute, because I want to get involved at the time of the first break, at the time an 18- or 19-year-old is in the hospital for the first time suffering from delusions and hallucinations. The family is usually very confused about what's happening, and they've maybe put off hospitalizing the person for longer than they should have, because they didn't want to admit there was a problem. It's a time at which a lot of professionals hesitate to talk about a diagnosis, because they don't want to stigmatize the person. I think we have to get to the point where we say openly and early, "I think we're dealing with schizophrenia here." Only when we're honest and forthright and talk about symptoms and talk about treatment and medications - which can make an incredible difference - will the individual and the family get the kind of early help they need. Statistics show that only 50 percent of the people who should be in treatment for schizophrenia are in treatment. It's stigmatization, I think, that's behind that.

PETER CHEN: I agree. Roughly 1.5 percent to 2 percent of the population is afflicted with a major mental illness - that's a given across cultures. But for many years, our statistics indicated that the Asians don't utilize county mental-health services much. So the impression was that Asians don't have serious mental illness in the same proportion as the rest of the population. But then you look at the state hospitals and other hospital statistics, and you find that a lot of Asians end up in the hospitals for treatment. Because of stigma or other reasons, they did not get help in the very beginning, and so they end up at the end of the illness cycle needing hospitalization.