Virginia Tech tragedy renews focus on detection and care

Celeste Leizer, 19, sits in the rain next to a memorial stone for her friend Caitlin Hammaren, one of 32 people killed by gunman Seung-Hui Cho. (Jae C. Hong/AP)

By MATTHEW ROY AND CHRISTINA NUCKOLS

The court convened in a Portsmouth hospital conference room to decide whether the patient - wearing a Harley-Davidson T-shirt, his graying hair in a ponytail - should be committed to a mental hospital.

A uniformed security guard stood behind the man, who sat by his appointed attorney, facing two mental health professionals. This courtroom had no flags, spectators or deputies, nor a docket posted outside. A lawyer serving as a "special justice" presided.

Hearings such as this happen routinely across Virginia - mergers of the mental health and justice systems, with a person's freedom and mental state hanging in the balance.

A similar hearing was held in December 2005 for Seung-Hui Cho, the Virginia Tech gunman. A special justice determined he presented an imminent danger to himself but did not have him hospitalized, instead ordering outpatient treatment.

The shootings at Tech have reinvigorated the debate over mental health reform in Virginia among political leaders, mental health professionals, patients' relatives and others. Some say it should be easier to hospitalize people who don't want treatment. Attorney General Bob McDonnell is pushing to monitor court orders such as the one Cho received.

State spending on mental health - an area that some lawmakers acknowledge is underfunded - is also at issue, and reforms could carry higher price tags.

The Commission on Mental Health Law Reform, set up last year by Supreme Court Chief Justice Leroy R. Hassell Sr., has begun studying several issues, including access to treatment, the significant number of mentally ill people behind bars, services for children, and the commitment procedure. It is not expected to produce a full report until next summer, said commission chairman Richard Bonnie, who is director of the University of Virginia's Institute of Law, Psychiatry and Public Policy.

Some would like to make it easier for the state to commit people with mental illnesses who are refusing treatment.

The current standard - posing an imminent danger to self or others - can be interpreted to be very restrictive, said Mary Zdanowicz, executive director of the Treatment Advocacy Center, based in Northern Virginia.

Her group hears "the same story all the time," she said. "We tried to get him help; he wasn't dangerous enough yet." Tragedy can result, she said. The system is simply not adequately serving people who don't believe they need care, she said.

Dr. Richard Kaye, a local psychiatrist, said mentally ill people, because of their cognitive impairment, often don't believe they need help, even when they are quite sick.

Individual liberties also must be considered, said state Sen. Kenneth Stolle, R-Virginia Beach. "What we need to be careful about is not to come up with a knee-jerk reaction that will affect thousands of people who will never be a threat to themselves or others," he said.

At the Portsmouth commitment hearing, held early Monday at Bon Secours Maryview's Behavioral Medical Center, a community mental health worker told Special Justice Robert Bruce Jones about the patient's background. He had gone to another local hospital seeking treatment for chronic pain, then argued with and threatened staff.

A magistrate had issued a temporary detention order, which is generally in effect for up to 48 hours.

Christine Nogues, a licensed clinical psychologist, examined the man that morning for the court. She said he had been cooperative and showed no sign of acute mental illness. In short, he didn't meet the criteria for continued hospitalization.

Jones told the man he would be released, and recommended he see his doctor - for treatment for his pain. "I plan to," the man said.

After Cho's 2005 hearing, he was ordered to undergo outpatient treatment. To date, no evidence has been made public to indicate whether Cho followed through on those instructions.

McDonnell is calling for more oversight and follow-up with such patients. McDonnell said this week he wants Virginia to adopt a law similar to one in New York that requires monitoring of court-ordered treatment to ensure compliance. Developing such a system in Virginia would pose a "significant cost," he said.

Virginia ranks 30th among the 50 states in per-capita spending on mental health treatment, according to the National Association of State Mental Health Program Directors.

The national organization ranks Virginia ninth in spending for institutional care, but the state's community-based services are among the most cash-strapped, coming in at 39th place.

Virginia has reduced the number of state mental hospital beds in response to a 1999 federal court ruling that ordered states to offer more community-based services. States must offer treatment while ensuring that patients enjoy as much independence as possible.

The state has failed to invest sufficient money to ensure a smooth transition, some legislators said.

"When we went from a centralized service to a community-based service, we didn't adequately fund either one of them," Stolle said.

"It's a system that, ever since its inception, has never had the level of funding it needs," added Del. Phillip Hamilton, R-Newport News.

Both legislators sit on panels that oversee mental health spending.

Stolle and Hamilton predicted more legislators will support boosting spending for mental health services as a result of the Virginia Tech tragedy.

Dr. James Reinhard, Virginia's commissioner of mental health, said he hopes that any new money earmarked for monitoring and supervision does not result in reduced services for people who are voluntarily seeking care.

Legislators have been working to increase funding in recent years. The current two-year state budget includes $1.1 billion for mental health and mental retardation services, a 27 percent increase over the previous two-year budget.

Much of that increase went to mental retardation services and substance abuse treatment, but there also was new money for hospitals that provide inpatient psychiatric treatment.

Although he acknowledges the problems in Virginia, Stolle has expressed reservations about the work of the study commission established by Hassell. He said it is inappropriate for the judicial commission to advocate for increased spending on mental health because funding issues are the responsibility of the legislature.

"I told Chief Justice Hassell, 'The General Assembly studied this a hundred times,' " Stolle said. " 'We know what we need to do. We need more money.' "

Hamilton, however, said he thinks the commission can offer valuable advice. "If changes are warranted, it will be the legislature that will make those changes," he said. "Any information we can get is positive. All wisdom does not reside with the legislature."