Diagnosing danger in the mentally ill

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Early on a summer morning in his Vernon, B.C., apartment, Kenneth Barter gave in to his delusions.

Foreign agents were warning him that the man smoking a cigarette on his couch, a good friend with whom he had been drinking the night before, was plotting to kill Kenneth's father. So he rose from his bed, and struck Nathan Mayrhofer with a hammer.

Then he chopped his friend's body up with a meat cleaver (as he learned on the TV show Dexter, he later said) and shoved the parts in his fridge. His mother and his father, a former police officer, discovered the remains two days later - after their son, in a bizarre confession, told them he had been hypnotized.

The killing happened in August, 2010. At the time, Kenneth, 37, had been on a six-month wait list to see a psychiatrist. His appointment was scheduled for October.

Two weeks ago, he was found not criminally responsible for murder and sentenced indefinitely to a secure mental hospital. It was justice, bluntly administered, leading to the old, frustrating question: Why didn't the system step in earlier and save two lives?

Mental-health advocates have fought the stereotype that mental illness leads to violent crime, aware of the stigma this creates for already-isolated patients, most of them much more likely to be hurt than to hurt another. When the most bizarre crimes occur, mental illness comes as an automatic explanation, deduced in hindsight from ranting Facebook posts and odd behaviour - as with Jared Lee Loughner, charged with killing six in a shooting spree in Arizona, and Richard Kachkar, accused of killing a Toronto policeman in a snowplow rampage.

Those men have yet to be diagnosed as mentally ill by trained professionals. But for most crimes, expert says, that would be looking in the wrong place. Research has found that less than 15 per cent of mental-health patients ever commit a criminal offence of any kind.

'It's not The Shining we're talking about," says Christian Joyal, a neuropsychologist at the University of Quebec, Trois-Rivières. Yet while crimes such as the ones Jared Loughner and Kenneth Barter are accused of are rare, new research is showing that with the right mix of symptoms and circumstances, the link between mental illness and violent crime is stronger than advocates might like to admit.

"The vast majority will not be violent. But who will be?" Dr. Joyal says. "If you don't want to stigmatize everyone, you should know who is at higher risk."

Under pressure to identify high-risk patients, psychiatrists are working to develop better screening tools and build on the early findings of brain scans. But as they do, medical staff will need resources, hospital beds and time to make diagnoses - three things in short supply in Canada's mental-health system.

They mainly hurt the ones they love

"You probably have more chances of winning the lottery than of being killed by a psychotic person you don't know," says Dominique Bourget, a clinician in the forensic psychiatry and schizophrenia program at Royal Ottawa Hospital.

People with schizophrenia - a disorder estimated to affect .5 to 1 per cent of the population that often brings on powerful delusions and hallucinations - may indeed have a higher risk of homicide or arson.

By analyzing 20 international studies, Seena Fazel, a senior psychiatrist at Oxford University, calculated that the homicide rate among male patients with schizophrenia was about five times higher than in the general population. (For women, the risk was about eight times higher, though the sample size was smaller.) He found a similar correlation with bipolar disorder, in which patients typically cycle between depression and mania.

But people with a mental illness rarely harm strangers. More often, the victims are people they love - family, friends, caregivers. A Quebec study of 64 cases in which offspring killed parents found that about 67 per cent had a psychotic disorder.

But substance abuse is the big risk factor. In Dr. Fazel's research, when drug or alcohol addiction was involved, the homicide risk among people with schizophrenia rose to 12 times greater than the general population's. People with mental illness, especially schizophrenia, are more likely than others to suffer from alcohol and drug addictions.

But the homicide rates were no lower among addicts without an underlying mental illness. "If you were thinking about it from a public-safety strategy, you would actually target substance abuse everywhere you could find it," Dr. Fazel says.

Dr. Joyal agrees: "I'd rather have, by far, a person with schizophrenia as my neighbour than a person who abuses alcohol or drugs."

But psychiatrists have begun to identify some other foreboding characteristics.

Patients with a history of violence - their own, or in their families - are more likely to continue the pattern, though for many, aggressive behaviour begins only with their illness. Patients with paranoid delusions, who believe someone is threatening them, show higher risks than those with delusions of grandeur (who believe they're famous or god-like). But if patients are aware of the illness, it decreases the risk of violence, and increases the chance they will follow treatment and stay on their medication.

More red flags go up if a patient shows signs of additional illnesses, such as antisocial tendencies. Dr. Joyal did brain scans of homicide offenders with schizophre-nia and discovered that, unrelated to their mental illness, their orbital frontal lobes - the impulse-control area of the brain - tended to be less developed.

These offenders often committed angry, unpredictable assaults in bars: Being schizophrenic may not have factored in.

However, Dr. Joyal says, "Today we still don't have really sensitive instruments to say that Person A will be dangerous and Person B will not be dangerous."

The revolving door to disaster

But that's a solution when patients have actually seen a doctor to be tested - and then get the treatment they need. What happens when they can't?

Michelle Huot's son, Haldane, is two years into a 13-year sentence for randomly stabbing a 77-year-old stranger to death on an Edmonton street in 2008.

For years, she watched doctors pile on the diagnoses - schizophrenia, bipolar disorder, depression - and a varying cocktail of medications. The longest he ever spent in hospital was three weeks; most of the time, he went in with his delusions, stayed for 48 hours, and came out no better.

Haldane made no secret that he was worried that he might hurt someone, Ms. Huot says. "He expressed that to doctors - it's not like they had to do dig very far to find out." She and Haldane's father (her ex-husband), both schoolteachers, spent hours on the phone and with doctors trying to get him help. They would call in a crisis team, only to have Huldane hide his symptoms when they arrived.

He fit all the high-risk characteristics: paranoid, smoking pot, off his medication and living, for a time, on the streets. He has been aggressive with his family, even throwing a punch at his mother. They kept trying: In the months before the killing, on his second-last hospital stay, Ms. Huot took his clothes home to make sure he would not be discharged without her knowledge.

"Every time, going from the doctors to the psychiatrists to the hospital, it was like watching him disintegrate. You'd think, 'This time they are going to figure it out,' and every time it was the same."

That is, until a man died, and her 27-year-old son went to jail: Despite his history, a judge found him responsible for the crime.

A slowly creeping calamity

Kenneth Barter is also easy to recognize in Dr. Joyal's list of warning signs. He was first diagnosed with schizophrenia in 2003. An only child, he stopped calling his parents, and when they went to his apartment he refused to open the door. Inside, the fridge was filled with mouldy food, and he looked, his mom recalls, "like a street person."

His parents took him to the hospital, where he was admitted for about three weeks, and then sent home with a prescription. For a time after that, a nurse came daily to make sure he took his pills, and a caseworker checked on him. He tidied up and went back to his good job at a local brewery.

But when the monitoring ceased, he stopped taking his meds, which had made him gain weight. Six months later, rambling about mysterious forces out to get him and his family, he was back in the hospital.

After that, he lived on his disability pension and refused to stay with his parents. He mostly held it together, but he drank too much, rarely took his medication and, when the paranoia set in, locked himself away in his apartment. Afterward, his mother would clean up, and they would start over.

"There were times when he was very bad, but most of the time he acted perfectly normal," Dorothea Barter says. She doesn't know how many times she called the hospital and doctor on her son's behalf: "I always felt like a pest."

But last spring, his symptoms began to grow worse. Like many patients, he had not kept up with his appointments, his lawyer, Juan O'Quinn, explains, so he was being treated like a new name in the system when he was wait-listed in the fall.

But his delusions grew more intense. He ranted that there were plots to kill his family. One day, he accused his mom of being a spy in disguise. By August, his parents were urging him to get an earlier appointment.

Two days after the killing, he appeared at his parents' home and told them a barely comprehensible story of how he had seen "in a mist" a hand holding a hammer and beating Mr. Mayrhofer. At his apartment, they found the evidence of what he had done.

Until then, his only encounter with the police had been when a neighbour made a noise complaint in July.

What can the system do?

Schizophrenia, like mental illness in general, is difficult to treat, requiring doctors to experiment with different medications and therapies. Those treatments are most effective when the disease is caught early, but often early stages of psychosis are confused with bad behaviour and drug use, especially because so many first-time patients are young men.

Dr. Bourget, the Royal Ottawa Hospital clinician, says she has seen too many examples of parents turned away in Emergency after seeking help for their son, only to arrive at her office after the patient has committed a crime. "There's an idea that because the person has abused drugs, they are responsible for their own behaviour," she says, a bias that traps patients who are more likely to be drug users because of their mental illnesses.

Even in psychiatric facilities, Dr. Bourget often sees patients making a constant round of short-term stays and treatment, only to leave without proper support and return a month later. "There is certainly a lot of pressure to free up a bed for someone else."

But the Huot and Barter stories are supported by research that suggests certain mental-health patients merit closer attention. It indicates keeping such people in hospital for longer stays when required, and developing community support that makes sure they stay on their medication.

Certainly, Ms. Huot suggests, a better approach would mean listening to families more, especially since they are the most at risk.

In these severe cases, it may also be that the system has swung too far toward patients' rights, making it too hard for families to get them committed to hospital against their will and forced to comply with treatment, or for caregivers to get access to medical records.

Similar recommendations were made in an Ontario Legislature report released in the fall, including clear follow-up after emergency-room visits, and broadening the criteria for involuntary admission.

And what about the school authorities, friends and other community members who may see the signs of trouble?

In Jared Lee Loughner's case, he was expelled from school for his strange behaviour, told not to return reportedly without a psychiatric note confirming he was not dangerous - but not given any help to find medical treatment or a mental-health consultation. As the Ontario report found, schools and police need to have specific protocols to follow through.

As well, most people with mental illness will make first contact with a family doctor, if they have one. So the report also suggested a standardized screening tool so that physicians will know who can be treated in their practice and who should be referred for more intensive care. And it called for more public education to raise general awareness and help people navigate the patchwork of services.

Ontario has set up a task force to report by spring with plans to implement the recommendations. Such changes, experts point out, would improve care for everyone, not just high-risk patients. "I don't think all these cases can be prevented. Some of them will happen unpredictably," Dr. Fazel says. "But I think you can reduce the likelihood."

Instead, too often they end up spinning in the system until the worst happens, and everybody wonders how it could have been prevented.

Every weekend, the Barters drive five hours to see their son at a secure facility in Coquitlam, thinking about that question. Ms. Barter says her son "is not some product of a ghetto somewhere who was abandoned on the street somewhere by his parents and had nowhere to turn. This is a boy who was in sports all his life. He had a job he loved. He had a college education. He was very charming. And he was totally abandoned.

"I phoned, I bugged, I pestered and I couldn't get help for him."

Erin Anderssen is a feature writer for The Globe and Mail.