In Psychiatric Illness, Families Must Be Our First Responders

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No mental health system will ever be able to identify serious behavioral problems as early as family.

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Memorial tree in Newtown, Connecticut [CraigRuttle/AP]

Time is beginning to soften the shock of the Newtown massacre. As their community returns to the routines and rhythms of everyday life, much debate -- some reasoned and some polemical -- still rages around gun control.

There is no question that something must be done, but the answer is not to become an armed state. 

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I am a psychiatrist, a physician, and offer my ideas as a mental health professional. I believe there is one immediate action (among others that can be taken) that can reduce the risk of similar searing pain being rained upon families and communities in the future. W

.>e must employ an early warning system -- one that is already in place. I am referring to the families of people with mental illness.

These are families who see a loved one begin to become different from the child or spouse or sibling or parent that they knew: To isolate themselves from family and friends; to show persistent changes in sleep, eating and hygiene; to say or do odd things that suggest their thinking is off, maybe hearing or seeing things others are not; to be moody or irritable or intolerant of the slightest of questions or statements; or abusing alcohol and drugs. Families see these changes first, notice them subtlety, and it is they who typically call out for help particularly to mental health services that is seldom then provided them.

The plight of families that recognize a member is becoming mentally ill, and at risk to harm themselves or someone else, can be truly agonizing. Their loved one often will not accede to their entreaties to go for evaluation or treatment. Sometimes this is because the illness is so serious that it interferes with the person's ability to recognize they are ill -- often denying any difficulty and blaming others for their fears or anger. Sometimes it is hopelessness that erodes a person's capacity to take action on their own behalf, amplified by feeling unworthy and not wanting to be a burden; guilt and shame add to their psychic state; or they have had bad experiences with mental health care, or fear it. These are powerful forces to contend with, but families need help to manage them successfully.

Even when these families do reach out to professionals (medical, mental health, police, etc.), their calls are often rebuffed. They are told that professionals cannot speak with them because of HIPAA (federal privacy) regulations, or that no action can be taken to hospitalize a person with a mental illness unless they demonstrate "imminent" dangerousness, which is to say at that very moment (a moment in which many an ill person will manage to put on a good face for the doctor and promise to go to an outpatient appointment - -though they have steadfastly refused for months). This has been termed "dying with your rights on."

Family alarm calls often occur months before what become difficult to reverse setbacks in school or work accumulate. Their calls come at a time when early intervention could prevent crisis and the need for involuntary treatment or the assistance of police. Their calls come when there is greater likelihood of success and greater opportunity to avert disability and potential catastrophe. I meet these families all the time. I see their demoralization and outrage about how handcuffed they feel in trying to get help for their loved one.

No mental health system will ever be able to identify serious behavioral problems as early as a family. We have tried. But "random" acts of violence are not so random. In addition to privacy and civil rights requirements that limit how families can assist their loved ones, families have too often been led to doubt what they see, to attribute problems to phases in a life (like adolescence or being older) or to external events (like loss or disgrace). At other times, these families know very little about mental illness, or addictions, television notwithstanding -- or consider these to be problems others have, not them. Or they feel guilty, or ashamed, or just do not know where to turn. 

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Lloyd Sederer, M.D., is medical director of the New York State Office of Mental Health and adjunct professor at the Columbia University Mailman School of Public Health. His book, The Family Guide to Mental Health Care, will be published in early 2013.

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