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Too often nowadays the very difficult task of recognizing mental illness in our neighbourhoods falls to police officers.1,2 In moments of crisis they must distinguish between psychiatric illness presenting as alcoholism, drug addiction, psychosis, suicidal depression or mania, for example, and reckless or antisocial behaviour resulting from exuberance or alienation. Occasionally they make mistakes — such as placing an obstreperous man (later diagnosed with paranoid psychosis) on a bus destined for NIMBY — and are criticized.
Such dramatic errors make the headlines but distract attention from the larger issues. Police in fact are involved with only a minority of acute psychiatric emergencies. The patients who are brought to emergency psychiatric services by the police tend to be male, intoxicated and aggressive.3 Because psychotic patients can be disruptive and combative, it's understandable that police are dispatched when they disturb the peace. But do we stop to consider the mentally ill patients the police may not be bringing in to hospital? In 1 month at the Timmins and District Hospital in Ontario, for example, only 32 (17.6%) of the 182 people referred to the psychiatric emergency department were brought in by police.4 According to a study in Tennessee, almost half come with relatives or friends and a quarter come by themselves.2
And what about the quiet, the hopeless and the paranoid who may not get to the hospital at all? Their illnesses can be more subtle and elusive. It takes time and stillness for their desperation to emerge and their mutterings to be heard.
With the closure of chronic psychiatric hospitals now virtually complete, patients with major psychiatric illnesses are living in inner cities, suburbs and small towns, often alone and marginalized, or worse, stigmatized. Deinstitutionalization of these patients has been called “the largest failed social experiment in twentieth-century America.”5 Far too often, their communities have few or no resources to help them. The World Health Organization has chosen to address this problem through a variety of efforts including the dedication of World Health Day (April 7) to the theme of improving the care of people with mental illness (see page 1013).
Medicine no longer meets its responsibility to diagnose and attend psychiatric illness in the community — to forestall the 911 call. Certainly, when a mental health emergency does occur, we can make it easier for police to drop off patients at the hospital by accelerating the transfer of care from police to physicians when they arrive in the emergency department. But we need to do more: we should join the police on the front line. Mobile community mental health teams reduce hospital admissions and prevent suicides,6 and a randomized controlled trial showed that volunteer befriending of chronically depressed women leads to reduced remissions.7
The enormous global burden of mental illness is largely ignored.8 As with most global issues, reclamation begins in our own backyard. — CMAJ