Maggie's Farm

Thanks for the plug. I came over to Maggies today after months away. Perhaps not an accident. Your summary of the difficulties is spot on.

I used to be an expert. I have been semi-retired since 2016, fully retired since 2020 and have not kept up with developments. New Hampshire, despite being the "Live Free or Die*" state, actually has the most comprehensive mandated outpatient treatment statute, and has since the late 1970s. The ACLU hates it, as they have too many people who like to conveniently pretend that the evil leviathan SoNH is locking up mere eccentrics and inconvenient people. I have read the old histories, and maybe that was true even up to the 1950s, but not that I have seen.

We use the term "Conditional Discharge." Other states require that someone have committed a crime, or limit treatment to medication, which can be a useless requirement if appts with a prescribing MD are not also required. I understand this is slowly improving nationwide. CD's are not magic, but they help.

* "Death is not the worst of evils" is the seldom-reported second half of Stark's quote.
I will continue in the next comment, replying to myself

The medications generally work to at least improve thinking or mood stability. The structure of the CD can be used with the most severe BPD's to get them past their many emergencies, but only if both the community and the hospital are agreed that this is a quick-in/quick-out-model. Without that, the mandate often makes things worse. The commenters who note that the subjective feelings of the sufferers on medications are unpleasant are quite right. The meds have side effects and patients can feel "like a zombie" or otherwise not fully in contact with the world. It is quite real. It does contribute to going off meds. The complicating factor is that they often do not accurately recall what they felt like when they were ill. They are comparing their feelings in a medicated state to what they felt like before they were ill, or when they were only slightly ill. They do not remember, or misremember their suffering. Also, mania feels rather like being on cocaine, with similar outcome, so it feels desirable even when it is objectively ruining your life. Three weeks ago you felt on top of the world, now you feel like crap. It's hard not to want to go back.

We seldom have to put depressed people on CD's. They want to feel better. Occasionally there are some who become discouraged and inactive so quickly that we have to set up the boundary.

The psychologist Xavier Amador has videos that are marvelous on the subject. He is a research psychologist, his beloved brother had schizophrenia - for which he became guardian - and he is a very good speaker.

You can only get a CD if you have been given an involuntary commitment, for which you have to have been shown to be "dangerous to self or others by reason of mental illness." The state has to prove both ends of that, the dangerousness and the mental illness. It is a complicated process - as it should be, taking away someone's rights like that. NH is a small state, and the judges and attorneys in these hearings know each other and are very clear what is going to fly and what isn't according to the statute. We have a strict State Supreme Court willing to occasionally overturn commitments that fell short of the standard, such as the woman in her 90s who became paranoid and let her heating fuel run out, wrapped herself in blankets in her old home for the winter and only ate what people dropped off for her - but was never in danger of freezing or starvation. We went for the commitment out of pity, but it admittedly did not meet the statute.

It is hard to get a commitment, as many families know to their misery. But all states decide where they want that freedom/safety line to be drawn. People go into mental health to relieve misery and so can slowly become controlling, wanting to make sure patients do "what is good for them" rather than what is necessary for safety. It can get away from even the people with good intentions.

One more reply.

So why don't we do more of it, if it works?

The whole process is expensive. The hospital is always overfull and discharging patients who would at least benefit, if not be "fixed," by a few more days, or even a longer definitive treatment. We are the most expensive item in the state budget. If we replicated the whole system, with another hospital and doubling the number of mental health centers we would do better - but not twice as well. There is a law of low-hanging fruit and diminishing returns. If you wanted to make things really solid for everyone, I figure it would cost about four times what we spend now.

On a related note. Halfway houses are a mixed blessing. It involves putting sick people in with other sick people, who are often street-skill manipulative, dangerous themselves, or even predatory. Families wish we could send their loved ones there because they could relax and not worry about where they were, but they carry their own problems - and the data suggests they do not reduce hospitalisation, even though every thinks they obviously do. "It just stands to reason" is not a good argument for gun control or drug enforcement or a dozen other things, and it doesn't hold up in mental health either.

I have been reflecting recently on the political difficulty of trying to fix things. It is usually liberals who believe that it should just be easy to fix society "We are the richest country in the world..." But on this subject (and education) conservatives are just as bad. We don't like to think about things too hard, I suppose, especially when we can't produce an immediate benefit. But the homelessness/drug/mental illness problem isn't simple, and simple solutions have mostly been tried - over and over again in some cases.

For those who made it this far, thank you for your patience. I just put up a post about The Problem of Good in the middle of the night because I could not sleep after corresponding with an old friend. I have posts on the growth of informal polygamy and the value of marriage coming up. I only say that because it's mostly light stuff on my blogspot page at present, and I wouldn't want you to think I've lost my touch.

Actually, I have lost my touch. I'm going for a long slightly depressed walk now.