Posted on Sep 19, 06
A Psychiatrist Is Slain, and a Sad Debate Deepens
By BENEDICT CAREY
Published: September 19, 2006
New York Times
In the hour before he was killed, on Sunday, Sept. 3, Dr. Wayne S. Fenton, a prominent schizophrenia specialist, was helping his wife clear the gutters of their suburban Washington house. He was steadying the ladder, asking her to please stop showering debris on his clean shirt; he had just made an appointment to see a patient and wanted to look presentable. She said she would be happy to go along, to help control the patient.
THE VICTIM Dr. Wayne S. Fenton was killed this month by a 19-year-old patient suffering from severe psychosis.
It was a running joke between them. For in this part of the country, Dr. Fenton was the therapist of last resort, the one who could settle down and get through to the most severely psychotic, resistant patients, seemingly by sheer force of sympathy and good will. An associate director at the National Institute of Mental Health, he met with patients on weekends, sometimes late at night, at all hours.
â€œAbsolutely the most nonthreatening person you ever, ever met,â€ his wife, Nancy Fenton, said in an interview last week.
At 4:52 p.m. that Sunday, the Montgomery County police found the 53-year-old psychiatrist dead in his small office, a few minutesâ€™ drive from his house. They soon tracked down the patient he had agreed to meet that afternoon, Vitali A. Davydov, 19, of North Potomac, who admitted he had beaten the doctor with his fists, according to charging documents. When the young man left the office, â€œDr. Fenton was on the ground, bleeding from the face,â€ the documents said.
Dr. Fenton had known that the patient presented some risk: he was young, male, severely psychotic and struggling with a mental state that was frightening and unfamiliar. The psychiatrist was trying to persuade his patient to continue taking medication, Mrs. Fenton said.
The killing, besides devastating the two families involved, has deeply shaken mental health workers around the country. In the days since, many have wondered about their own safety and about the dangers of allowing patients with severe psychosis to go without medication.
Dr. Fentonâ€™s death is not likely to change psychiatric practice, experts said, but it may become a touchstone for one of the most contentious debates in psychiatry: whether people suffering from psychosis should be compelled to accept treatment to reduce the risk of violent outbursts.
â€œWe have been thinking about all these things in the past week, thatâ€™s for sure,â€ said Dr. Thomas H. McGlashan, a psychiatrist at Yale and a close friend of Dr. Fentonâ€™s, who worked with him decades ago at Chestnut Lodge, a renowned psychiatric hospital that closed in 2001. â€œYes, there is a risk of violence with some patients, and no, itâ€™s not black-and-white, like some would want you to see it. Itâ€™s not just that Wayne is dead, but that the kidâ€™s life is ruined too.â€
Violence is less common among those with mental illnesses than is sometimes assumed. Many people with schizophrenia are withdrawn, more likely to be targets of an assault than to commit one, said Bruce Link, a professor of epidemiology at Columbia.
But studies suggest that those with untreated psychosis â€” often characterized by intense paranoia and imaginary voices issuing commands â€” are at least two to three times as likely as people without mental disorders to get into physical altercations, including fights using weapons, Dr. Link said.
An analysis published last month in The American Journal of Psychiatry found that people with severe mental illness committed about 5 percent of the violent crimes in Sweden, though they made up a small fraction of the population. The United States, which has higher crime rates, has a much smaller proportion of crime attributable to the mentally ill than Sweden, experts said.
Yet the risk is real, if remote, for those who meet one on one with severely psychotic patients and try to negotiate difficult issues like medication. So-called antipsychotic drugs effectively blunt symptoms of psychosis and tend to reduce the risk of violent outbursts, psychiatrists say. But the medications are mentally dulling and often cause weight gain, among other side effects, and many patients either stop taking them or refuse them altogether.
In part to forestall violent episodes, several states, including New York and California, have tightened their treatment laws to compel some mental health patients to accept treatment, even if they have not committed a crime. The issue is divisive among former psychiatric patients, researchers and practicing psychiatrists.
â€œThis is an extremely important issue for psychiatry, and there are two sides of this story,â€ said Dr. William T. Carpenter Jr., the director of the Psychiatric Research Center at the University of Maryland and the editor of the journal Schizophrenia Bulletin. â€œAs doctors, we think patients ought to do what we think they should do, and if someone needs to be on medication itâ€™s difficult not to wish there was some way to do that.â€
On the other side, Dr. Carpenter said, â€œyou have a significant civil rights argument.â€
In the wake of Dr. Fentonâ€™s killing, some patient advocates cautioned against exploiting the tragedy to promote forced treatment.
â€œThe main concern is that we not let fear and stereotypes based on this case drive public policyâ€ in support of forced commitment and drug treatment, said Will Hall, a mental health advocate in Northampton, Mass., who was hospitalized as a young man and treated with antipsychotic drugs for about four months after a suicide attempt. A better way to prevent violence, Mr. Hall said, â€œis to offer patients who refuse medication on any ground a much wider range of options, including psychosocial treatments.â€
Yet alternatives to drug treatment are not yet widely available. And with the news of Dr. Fentonâ€™s killing in their thoughts, some psychiatrists said they were thinking carefully about the precautions they take every day.
â€œWhen a patient is revving up and paranoid,â€ Dr. McGlashan said, â€œinstead of becoming imperious or dogmatic or rigid I might admit that Iâ€™m kind of nervous too. If youâ€™re scared, you let the patient know that. Because a lot of their behavior is coming from their perception of being threatened. If you let them know that you are feeling threatened, vulnerable and not interested in controlling them, that can help defuse the situation.â€
All of which, of course, Dr. Fenton understood.
But the need was urgent, Mrs. Fenton said. The need was urgent, the family was desperate, and that was enough for her husband, as long as she had known him. Someone wanted his help, so Wayne would go.
Here is the response from Bob Whitaker about the research presented in the NYT article:
-------- Original Message --------
Subject: Re: NYT, violence, psychosis studies
Date: Tue, 19 Sep 2006 09:31:41 -0400
From: Bob Whitaker <
To: Will Hall
When I looked at this while doing research for Mad in America, the evidence seemed to show this: Prior to the drug era (i.e. 1955), patients released from mental hospitals committed violent crimes at either the same rate or less than a corresponding population (age). Since then, they have committed violence at a higher rate than the general population rate.
This is a subtlety that is nearly impossible to discuss in the media. But the reason for the increased violence seems to be this:
a) It is intimately associated with akathisia. (In the Fenton case, it would be interesting to know if he was experiencing akathisia. Patients who experience this talk about it as a kind of torture, so when Fenton was talking about his needing to take an injection, it might have been experienced in that vein. Also, was the person who killed Fenton on or off drugs at the time?)
b) The cycling on and off the drugs, which is so common, does seem to lead to deeper psychotic symptoms than a person would otherwise have. That's the way to the worst outcomes imaginable (even worse than just staying on the drugs.)
c) The drugs do diminish and damage frontal lobe activity over time, and that's the part of our brain that helps monitor our own actions.
There seems to be increased recognition that the SSRIs can increase violence/suicide. It amazes me that the media won't explore this subject with neuroleptics, which are much more powerful, mind-altering drugs, and the akathisia they can cause, by all accounts, can be absolutely devastating.