Should treatable schizophrenics be imprisoned?

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Re: Should treatable schizophrenics be imprisoned?

#21  Postby Darwinsbulldog » Mar 02, 2014 4:30 am

Shrunk wrote:
Scarlett wrote:Personally I don't agree it should be a criminal offence for you not to take your meds, let's face it, not all schizophrenics will become killers or even dangerous in any way.

It's not a topic I know a lot about. How do you ensure someone continues to take meds? Can they be found more culpable if they have chosen not to take meds that were proven to work? Surely not taking the meds could be a symptom of the illness?


The way the CTO law is written is quite clever: The order is incorporated as part of the treatment contract, and must be consented to by the patient. If the patient is not mentally capable of providing consent then, as in any other such situation, someone else consents on his behalf. So it's not a matter of making non-adherence a criminal offence. Enforcement of adherence becomes an aspect of treatment that has been consented to.

It is also only applicable if someone has a demonstrated history of deterioration severe enough to require hospitalization when not treatment, and of documented response to treatment. The goal is not necessarily to protect the public from the patient, but to allow the patient to remain out of hospital.

With injectable medication, it's easy to tell if it is being taken. It's a bit more difficult with pills, but not impossible (blood levels can be measured, or medications can be taken under observation at home or by coming in to the clinic daily.)


Schizophrenics relate/respond to their illness in different ways and at different times. Insight into their disease may be irratic indeed, or absent altogether, yet CYO's in Australia do not seem to be designed to acknowledge these simple facts. That is, medication must be administered for prolonged periods of time to improve quality of life, a reduction in psychotic episodes, the emergence of insight, and so on.
In my experience as a carer, the sufferer barely had time to recover before a CTO expired. It was pot-luck if the holy grail of insight appears. if it does, then of course the CTO can be lifted because the patient concerned realised the value of the medication. If insight did not recur, then the patient was deemed of sound mind, and discharged from the CTO, soon after which she stopped taking the medication.
There is also the question of this roller-coaster of meds-non-meds being of long term harm. After a crash the meds were usually of high dosage, and of course in non-insight period, no meds were taken at all. [We did find out that the meds given were often the highest doage in the state, calibrated for body mass.
While not wishing to return to the old horrors of life-time retention of mental patients, the revolving door system of CTO's does not seem to address concerns about the support of the chronically and severly ill. Their "legal rights" do not give them freedom from their disease, or necessarily an improved quality of life.
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Re: Should treatable schizophrenics be imprisoned?

#22  Postby Shrunk » Mar 02, 2014 1:44 pm

Darwinsbulldog wrote:Schizophrenics relate/respond to their illness in different ways and at different times. Insight into their disease may be irratic indeed, or absent altogether, yet CYO's in Australia do not seem to be designed to acknowledge these simple facts. That is, medication must be administered for prolonged periods of time to improve quality of life, a reduction in psychotic episodes, the emergence of insight, and so on.
In my experience as a carer, the sufferer barely had time to recover before a CTO expired. It was pot-luck if the holy grail of insight appears. if it does, then of course the CTO can be lifted because the patient concerned realised the value of the medication. If insight did not recur, then the patient was deemed of sound mind, and discharged from the CTO, soon after which she stopped taking the medication.
There is also the question of this roller-coaster of meds-non-meds being of long term harm. After a crash the meds were usually of high dosage, and of course in non-insight period, no meds were taken at all. [We did find out that the meds given were often the highest doage in the state, calibrated for body mass.
While not wishing to return to the old horrors of life-time retention of mental patients, the revolving door system of CTO's does not seem to address concerns about the support of the chronically and severly ill. Their "legal rights" do not give them freedom from their disease, or necessarily an improved quality of life.


Here in Ontario, CTO's have no expiry date. They do have to be renewed every six months, but there is no limit to how often this can be done, and if the patient does not actively challenge the order, renewal is usually a formality.

That said, at the moment there is little empirical evidence for the efficacy of such orders:

http://summaries.cochrane.org/CD004408/ ... -disorders
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Re: Should treatable schizophrenics be imprisoned?

#23  Postby Darwinsbulldog » Mar 02, 2014 4:02 pm

Shrunk wrote:
Darwinsbulldog wrote:Schizophrenics relate/respond to their illness in different ways and at different times. Insight into their disease may be irratic indeed, or absent altogether, yet CYO's in Australia do not seem to be designed to acknowledge these simple facts. That is, medication must be administered for prolonged periods of time to improve quality of life, a reduction in psychotic episodes, the emergence of insight, and so on.
In my experience as a carer, the sufferer barely had time to recover before a CTO expired. It was pot-luck if the holy grail of insight appears. if it does, then of course the CTO can be lifted because the patient concerned realised the value of the medication. If insight did not recur, then the patient was deemed of sound mind, and discharged from the CTO, soon after which she stopped taking the medication.
There is also the question of this roller-coaster of meds-non-meds being of long term harm. After a crash the meds were usually of high dosage, and of course in non-insight period, no meds were taken at all. [We did find out that the meds given were often the highest doage in the state, calibrated for body mass.
While not wishing to return to the old horrors of life-time retention of mental patients, the revolving door system of CTO's does not seem to address concerns about the support of the chronically and severly ill. Their "legal rights" do not give them freedom from their disease, or necessarily an improved quality of life.


Here in Ontario, CTO's have no expiry date. They do have to be renewed every six months, but there is no limit to how often this can be done, and if the patient does not actively challenge the order, renewal is usually a formality.

That said, at the moment there is little empirical evidence for the efficacy of such orders:

http://summaries.cochrane.org/CD004408/ ... -disorders

Cheers Shrunk! :thumbup:

As I said, if the patient gets well enough to seem half-competant, they will not renew the CTO. :ill:
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Re: Should treatable schizophrenics be imprisoned?

#24  Postby Keep It Real » Mar 03, 2014 5:32 am

I'm on a CTO at the moment - I only wish it had been applied sooner. I was hospitalised 3 times and suffered life trashing fallout from my psychotic episodes before I was given a CTO. Nobody signed it as far as I can tell; it was just authorised by my consultant psychiatrist. I've been on it for 18 months now and have just recently come to view it as being unnecessary (I'm now sure I'd continue receiving treatment without it). I think the deciding factor in my being given a CTO was that, during my last psychotic episode, I assaulted a police officer (at the time I thought I had to fight for my right to eat excrement as an alternative to going to hell eternal - so decided to walk down a corridor in the police station I wasn't supposed to, and was held, and then I threw a punch). If only I had been given the CTO some three years before that, when my symptoms first presented, I wouldn't have trashed my life. Sure, I was prescribed meds, but at the time there was a strong desire to "be the real me" and so I frequently stopped taking them, and had another psychotic breakdown.

If I had known that there was a high risk of criminal behaviour whilst psychotic, and that I wouldn't be "let off" for punching that police officer (as I was - not so much as a slap on the wrist) perhaps I would have stayed on the meds without a CTO. Maybe not though, and so it seems to me a CTO is advisable until one becomes accustomed to permanently being on meds and realises the true dangers of a relapse.

For a first time occurance of schizophrenic behaviour with subsequent criminal acts, I don't think any long-term detention should be forthcoming - just a CTO (if they respond to treatment).

If somebody knows there's a high likelihood they'll suffer psychotic episodes without treatment then I don't see any reason they should receive a reduced sentence, or any leniency at all, as long as they'd been informed of the dangers. It would be interesting to know if the person who received 6 years in detention in Canada for murder knew he was a schizophrenic before he committed the crime - was he responsible for bringing on his psychotic episode through refusing to take medication?

I expect my CTO to be lifted at the next opportunity - and would consider myself fully responsible for any criminal acts I might commit if I stopped taking the meds prescribed. I reckon the law would be kinder to me than I would deserve, however.

ETA: my meds are 30mg depixol fortnightly intra-muscular injection - a fairly low dose I'm lead to believe - I've never been on anything higher. I don't relate to Darwinsbulldog's reference to high dosing following an episode or side effects being an issue.
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Re: Should treatable schizophrenics be imprisoned?

#25  Postby Shrunk » Mar 03, 2014 2:09 pm

That's an interesting point, Keep It Real, and one I hadn't thought of before.

It's a bit like drunk driving, in a way. The driver is not exonerated if he causes an accident on the basis that he was too impaired by alcohol to be able to competently handle his vehicle. He is held responsible because he knew the likely consequences of drinking before he drove. So should someone who has a mental illness be held responsible for the effects of that illness if he is able to appreciate the likely consequences for others of stopping treatment? I don't know if that question has ever even been seriously addressed in a legal context.
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Re: Should treatable schizophrenics be imprisoned?

#26  Postby Keep It Real » Mar 03, 2014 7:06 pm

I too drew the parallel with drunk driving in an earlier post too - there're striking similarities. The thing is that people's ability to control whether they drink drive is dependant on the amount of alcohol they've consumed - if you're really pissed there's a chance you'll make a bad judgement call and drive. This is never given as a defence however - it wouldn't stand up in court. The same cannot be said for schizophrenics however - if they stop taking their meds for a week (the equivalent of having a couple of beers - no big danger perhaps) and then continue not to take their meds, if they committed a crime it would doubtless be suggested that their continued refusal to take meds following that first week was a result of their schizophrenia - and therefore beyond their control, and they would receive lenient judgement. The answer has to be that not taking meds for even a single day, for an effectively medicated schizophrenic, is the equivalent of drink driving, and should be dealt with as being a criminal act accordingly.

It's not just the risk they'll harm somebody directly whilst psychotic - there's also the financial cost incurred of detention and treatment. In countries with state funded healthcare this equates to squandering tax payer's money.
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Re: Should treatable schizophrenics be imprisoned?

#27  Postby Scarlett » Mar 03, 2014 7:10 pm

Shrunk wrote:That's an interesting point, Keep It Real, and one I hadn't thought of before.

It's a bit like drunk driving, in a way. The driver is not exonerated if he causes an accident on the basis that he was too impaired by alcohol to be able to competently handle his vehicle. He is held responsible because he knew the likely consequences of drinking before he drove. So should someone who has a mental illness be held responsible for the effects of that illness if he is able to appreciate the likely consequences for others of stopping treatment? I don't know if that question has ever even been seriously addressed in a legal context.


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Good thread, I'm learning a lot. Thanks guys :cheers:
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Re: Should treatable schizophrenics be imprisoned?

#28  Postby Mr.Samsa » Mar 04, 2014 5:53 am

Shrunk wrote: So should someone who has a mental illness be held responsible for the effects of that illness if he is able to appreciate the likely consequences for others of stopping treatment? I don't know if that question has ever even been seriously addressed in a legal context.


It's an interesting parallel but I imagine the problem would be that such a proposal would require us to effectively medicate people against their will or, at the very least, under the threat of coercion. It's a tough one.

EDIT: Nevermind, I think I misunderstood the line of argument.
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Re: Should treatable schizophrenics be imprisoned?

#29  Postby Keep It Real » Mar 04, 2014 7:55 pm

I can't imagine anybody saying a treatable schizophrenic who chooses to come off their meds should not be held accountable for their actions, because they might worry somebody might use that argument and persuade themselves it's OK to come off their meds. That's the prevailing view in the legal establishment however. I can see tumbleweeds....

The other thrust of this thread is that people who commit crimes whilst schizophrenic are:

a) not responsible for their actions
b) may pose no further threat to society as long as they take medication

Should not even a murderer who responds well to treatment be released almost immediately if meeting those criteria? Why 6 whole years detained?
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Re: Should treatable schizophrenics be imprisoned?

#30  Postby Shrunk » Mar 04, 2014 8:01 pm

I think it is largely a matter of the competing interests of respecting the person's rights and protecting the safety of the public. The latter demands a degree of evidence before it can be said with reasonable certainty that someone now presents a low risk. It might take years of observation to accumulate such evidence. But I wouldn't swear that political factors and matters of public perception don't also play a role. Look at how much pushback the decision to allow Li limited passes into the community is arousing as it is after six years. Imagine if it was after six months.
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Re: Should treatable schizophrenics be imprisoned?

#31  Postby Keep It Real » Mar 04, 2014 8:24 pm

Shrunk wrote:I think it is largely a matter of the competing interests of respecting the person's rights and protecting the safety of the public. The latter demands a degree of evidence before it can be said with reasonable certainty that someone now presents a low risk. It might take years of observation to accumulate such evidence. But I wouldn't swear that political factors and matters of public perception don't also play a role. Look at how much pushback the decision to allow Li limited passes into the community is arousing as it is after six years. Imagine if it was after six months.


Would you be outraged? It reminds me of the gay rights issue - just because homosexuality causes outrage to many doesn't mean it should impact the decisions of the wise law makers.

As far as "respecting the person's rights" goes, I don't see the same ideals afforded to drink drivers - they have no rights about this; it's just illegal. I might sound like a proper authoritarian right wing douchbag, but I don't think diagnosed schizophrenics should be let off the hook if they commit a crime whilst off their professionally prescribed meds - they're rolling the dice where there's a very strong likelihood they'll be sectioned again (costing $1000s) and a reasonable probability they might injure somebody.
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Re: Should treatable schizophrenics be imprisoned?

#32  Postby Shrunk » Mar 05, 2014 6:21 pm

Keep It Real wrote:
Shrunk wrote:I think it is largely a matter of the competing interests of respecting the person's rights and protecting the safety of the public. The latter demands a degree of evidence before it can be said with reasonable certainty that someone now presents a low risk. It might take years of observation to accumulate such evidence. But I wouldn't swear that political factors and matters of public perception don't also play a role. Look at how much pushback the decision to allow Li limited passes into the community is arousing as it is after six years. Imagine if it was after six months.


Would you be outraged? It reminds me of the gay rights issue - just because homosexuality causes outrage to many doesn't mean it should impact the decisions of the wise law makers.


Personally, no I wouldn't. In fact, I will quite often discharge people to the community a matter of a few weeks after they presented a risk to public safety, if they have now stabilized enough that they no longer pressent such a threat. There does seem to be a degree of randomness as to whether someone ends up in prison or in hospital.

As far as "respecting the person's rights" goes, I don't see the same ideals afforded to drink drivers - they have no rights about this; it's just illegal. I might sound like a proper authoritarian right wing douchbag, but I don't think diagnosed schizophrenics should be let off the hook if they commit a crime whilst off their professionally prescribed meds - they're rolling the dice where there's a very strong likelihood they'll be sectioned again (costing $1000s) and a reasonable probability they might injure somebody.


The issue is a bit more complicated due to the difference between intentionally ingesting an intoxicating substance, and choosing not to ingest a foreign substance which can have its own undesirable effects. People generally have the right to decide for themselves whether they take medication, so to make an exception in the case of people with mental illness needs a strong justification. Not that such a justification might not exist. Like I say, it's complicated and I'm not sure where I stand on the issue myself.
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Re: Should treatable schizophrenics be imprisoned?

#33  Postby monkeyboy » Mar 05, 2014 7:08 pm

In the UK, someone found guilty of a crime who is deemed to have been suffering from a mental illness at the time of their offence can be handed a hospital treatment order in lieu of a custodial prison sentence.

They are then detained under the Mental Health Act under section 37, which has no limit of time attached to it but does have regular reviews and the right to appeals. If the crime is serious enough, the judge may also add a restriction order under section 41 of the act which can also be without limit of time and may include such provisions as ensuring that on discharge, the person has to notify authorities where they live, may have restrictions imposed on where they live, be compelled to attend outpatient appointments, accept medication and other treatment etc and can be recalled into hospital at any time there is felt to be a deterioration in their mental health or increase in their risk.

There are a variety of assessment/treatment orders a court can order covering from the time of arrest right through to sentencing in lieu of remand or accompanying remand. Sentenced prisoners can also be sent to hospitals if they become ill during the course of their sentence. If they remain ill on completion of their sentence and still require treatment, they can be detained either under section 37 of the mental health act or under a civil sentence.

Hope this helps clarify the UK position.
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Re: Should treatable schizophrenics be imprisoned?

#34  Postby monkeyboy » Mar 05, 2014 7:18 pm

Sorry, I didn't explain what happens next after being detained.

As I said above, the treatment orders after sentencing are without limit of time. The reason for this is that people's response to treatment varies. During treatment, the individual will be constantly assessed in terms of their symptoms and response to treatment. They will also be risk assessed throughout their stay in hospital.
They can discharged by their responsible clinician when their symptoms are stable and their risk is deemed to be acceptably low. With people subject to a restriction order, there is the extra hurdle of satisfying the Ministry of Justice that these criteria are satisfied and some people can only be discharged following a successful Mental Health Tribunal which is essentially a judicial review by a Judge, Independent Psychiatrist and a Lay person.

Lengths of stay in hospital vary and are in response to criteria as above. Hence, some people who are considered to have comitted serious offences may appear to be released "early" in some people's opinions whereas others can end up being detained for lengthy periods for apparently more minor crimes. It's not always a perfect system by any means but I'm not sure what would suit everyone's needs.
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