Devotion to Most Severe Cases Raises Risk of Personal Danger
Tuesday, September 5, 2006
Wayne Fenton knew better than most about the risk of treating people with severe mental illness.
He built a psychiatric career that focused on the most difficult cases and dedicated himself to trying to bring the insane back to the realm of normality.
"The average psychiatrist in the Washington area is on Connecticut Avenue and he's seeing . . . some executive who got passed over for a promotion and is having a midlife crisis," said Fuller Torrey, a local psychiatrist who often referred severe cases to Fenton. "Wayne was one of the few out here seeing the severely mentally ill. He was strongly committed to providing care and promoting research for the sickest people."
Vitali A. Davydov, the 19-year-old charged with murdering Fenton in his Bethesda office, had been referred to Fenton by another psychiatrist, according to court records. Davydov was charged last year with possession of marijuana, but the count was dismissed, records show.
People with mental disorders have a "modestly higher rate of violence" than the rest of the population, said John T. Monahan, a professor at the University of Virginia who studies the issue. "But only very rarely do people with mental disorder commit lethal violence."
If the person has been drinking alcohol or abusing drugs, the likelihood of violence increases significantly, several experts said.
Each year, people with serious mental illness commit about 750 murders, or five percent of homicides, in the United States, said Torrey, who just completed a manuscript about the consequences of untreated mental illness. In most of those cases, the victim is a family member. Police, mental-health providers, public figures, priests and strangers make up the rest, he said.
"This is not terribly common, but it is a known risk," said Steven E. Hyman, who recruited Fenton to the National Institute of Mental Health several years ago and is now provost at Harvard University. "It's clear that there is always risk and if you treat enough of these patients that someone is going to be violent."
According to charging documents prepared by Montgomery County detectives, Fenton had told Davydov's father that he was going to encourage him to take his medication for a bipolar illness.
Maryland is one of eight states that lack an outpatient commitment law, which would require a person with a mental disorder to take medication or receive therapy for an illness or else face court-ordered involuntary hospitalization. "So what options did the family have to force him to take the medicine?" asked Torrey, president of the Treatment Advocacy Center in Arlington, which is lobbying for commitment laws across the country. Virginia and the District of Columbia have such laws.
The fact that Davydov had been referred to Fenton could have provoked a misunderstanding, said Wayne D. Blackmon, a lawyer and psychiatrist who teaches at George Washington University Law School.
"We do handoffs all the time, when we go on vacation -- it's fairly common," Blackmon said. "But if a person is mentally unstable and feeling rejected, the person is more likely to commit an act of violence. Usually, it's against himself, but in case of someone delusional, you don't know how he's going to behave."
Many psychiatrists ignore the dangers of the job, said Blackmon, a former president of the Medical Society of the District of Columbia. "A lot of psychiatrists unfortunately operate in state of denial," he said. "The statistics indicate that by profession, the doctor most likely to be a victim of violence is a psychiatrist. You're dealing with people who are actively delusional, people who are in an agitated state who can misinterpret what another person is doing."
The issue is of such concern that several years ago, the medical society issued members a handbook on violence, Blackmon said.
Most say the best way to stay safe is to use common sense, said Torrey, who worked at St. Elizabeths Hospital, which provides inpatient mental-health care.
Torrey said that when he faced difficult cases in which the patient could become violent, he always made sure that there was another person in the room. Some psychiatrists have a panic button under their desk, which allows them to summon staff, he said.
"We can all make mistakes," Blackmon said. "The number one thing you can acknowledge is that you can always make a mistake. That's the biggest safeguard against making one."