I think there is more we should be throwing down here as long as were talking about newtown. Professional experience has taught me that the three most important symptoms are paranoia, hopelessness, and masculine identification with destruction. Theres a a reason why heterosexual males are the overwhelming majority of people carrying out mass killings. If we completely limit our consideration just as it is with guns, the idea of psychiatric illness were recognizing some of the quality. Ly also add that while medications are very effective for paranoia, were also dealing with a population that beyond those who fall in to the cracks, many and perhaps most mass killers, because its not an impulsive decision, its a decision which one deliberates and becomes determined. Once they become determined theyll do it. They crawl in to the cracks. They keep themselves from being appreciated for the risk they represent to others. The people that weve heard about today did not have the broad resentment of society to lash out. They killed themselves, they were violent within the family, and Research Demonstrates that the when a person lashes out at General Community dc a different individual with different pathology inspect is why beyond this, we can never, never with all good intention, all application and example of federal law and all well meaning states that pick it up, he will never resolve the issue of mass killings in the United States in particular with Good Mental Health care until we deal with the cultural forces of entertainment violence and video game detachment that the other rend influencing Vulnerable People to identify with destruction at the time when they are finding themselves as. Are they preventable. Can we prevent treatment of the identification treatment prevent some of the mass killings . The key thing is i think dr. Torrey brought up an important point. If you appreciate mass killers involve such a high concentration of folks who crawl to the cracks, you can build a best facility in the world and have the best staff. Theyre not going to come. So you to go to them and so you to engage them at the level and an dialogue that theyre willing to have with you whether youre informal, whether they dont appreciate you as a psychiatrist and caseworker. This is why the Assertive Community model has such promise for folks who either are in denial because a lack of insight or invested in destruction and have to be defused by the Mental Health seals that are specially capable as a Hostage Negotiator would be. Do you want to comment too . Yeah, i think the one thing i would add goes back to your come, doctor cassidy, these are treatable in the a sense that we know that the Robert Griffin iii risk of violation goes down 15fold with treatment. Doesnt solve all the problems. But that part of the problem is entirely treatable. Its getting them in to treatment which is youre suggesting is the trouble is. Struggle is. Its not a new conversation. We have been talking about how do you find the right balance between individual rights and safety for five decades. After big events like this, we went true the same thing with Virginia Tech. We rebalanced where we want to be. At the end of the day its a state by state decision. What i hope we can do is bring better and better science to that question. I think there are real opportunities through other Research Agencies to try to understand what has worked best and what hasnt worked well. We need to be careful about making policy decisions in the wake of rare effect like effort like this. As we rains rebalance this we dont want to go too far in one direction or the other. It has to be a careful conversation. Would you are you the Counter Point to from earleys, again, speaking for persuasively in the book the folks would say incompetent adult, not speaking majortively but technically, incompetent adult by nature of the illness should not have a right to make a decision saying no to a program therapy. I think mr. Earley brielgds against that from his personal experience. Someone mentally incompetent saying no, i dont want the therapy. Do you think they should have the right . Its i dont think its going to be a black or white call. You have you want to look at the unintended consequences. I accept that. At some point public law is a little bit moot. It is. Currently as i understand, and again theres a wall street jowrntd the wall street journal article are where a man kills his mother. And the family was never informed. It was a commitment issue because he was coached on how to get out of commitment and hipaa issue. I guess my question for you, doctor, is would you say no, that is the appropriate level of the law or i dont know where youre coming down. What im saying i think its the exact conversation to have. Im not going give you a direct answer because i dont think there is a direct answer. I think in every state there this is the conversation were trying to encourage. If we cant answer it on a federal. The answer is Public Policy makers then we are got to despair. I think this is a conversation, dr. Cassidy to have. As dr. Torrey said it does play out in every state. Your first question is not all the groups who weigh in on this, as tom said, are here today. There is a robust dialogue going on. My concern is we focus on Virginia Tech and focus on some of the newtown tragedy, and what have you. Smaller versions happen every day in this country. And it happens when people who have untreated have no insight to the illness and the families cant get access to the system. We need to have the dialogue, and tom is right. After every one of the tragedies we have a dialogue. Its an opportunity to i think, rethink, revision how we do this and how we get people in to treatment before they die under a bridge in the winter. Before, you know, something happens within a family this tragic. Im sorry [inaudible] i want to bring to the argument of the discussion too. Thank you very much, mr. Chairman, i do want to thank you for your outstanding leadership in cob convene convening these hearings. Thats a good segue. I would like to focus on what is working out there . What you can highlight that we need do more of because we have got to be as efficient and effective as possible with the scarce resources that we have. But first, id like to thank the parents on the panel who have shown great bravery in coming forward and telling their personal stories. You represent thousands, maybe millions of other physically abuse who have family members who have struggled with similar challenges. Im curious before we get to highlighting what is working and what question do better. When did when can d you notice the Mental Illness man manifesting itself . What it identified by others . A teacher in a classroom or someone on the Little League team or the scout troop . Maybe ill add mrs. Long is still available, i can ask her first. Did you notice it or was it someone else like a teacher . Its kind of a complicated process. My son is not my only child. I have three other children who do not suffer from mental disorders. I didnt notice Little Things such as behaviors that were a little different with this child compared to other children. We knew by kindergarten. We a clear the room face the order which, you know, seems like, yeah, thats what were going do. We worked with a variety of psychiatrists, therapists, diagnoses across the board, everything from oppositional disorder explosive disorder, right now were looking at autism factor and adhd, possibly bipolar. We struggled for a long time. Things became exacerbated when he went to middle school. Hes actually in a pull out program with children who suffer from emotional and behavioral issues. So hes not be able to main streamed with other children at this time in school. We noticed early and its progressed. Thank you. Yes, im probably get it wrong. My wife will correct me. It was in the early teens as matthew was addhd. We started having problems with that. But it just gradually got worse, and no matter, like i said, he was treated by one of the top psychiatrists . New orleans for many years different medication. Go back to the main issue of matthew, if he took the medication. Okay. When he was in trouble, and he took the medication, he was fine. So then it needs to be a mechanism that if patients arent taking their medication, what does a parent do . You cant make a 21yearold man who is living in your home take his medication. You cant got doctor, he wont talk to you. You just have no mechanism to fix the problem. When you know the medication helps. The obvious mechanism what we call assisted outpatient treatment. Louisiana has it but use it is rarely. 44 of the 50 states. Six states dont have it. Basically what it is, i used it in the hospital for eight years. The District Of Columbia has it. I would go to the the court and say this individual has been in the hospital 19 times. He has no awareness of the illness. I brought his mother and sister to explain whales what happens when we let him go. He never takes the medicine. We have seen him throw it away on the way out of the hospital. The judge put on assistanted vote partial treatment you have to get the injection, you dont we have a right to bring you back to the hospital. Thats assisted outpatient treatment it. There are six studies showing it decreasing hospitalization, studies showing that decreasing homelessness, decreasing victimization, deceases arrests, decreases violent behavior. Studies in new york and North Carolina specifically show the decrease in violent behavior by severely mentally ill individuals and staves money. The study in california saved 1. 81 for every dollar invested. North carolina found that people on it longer than six months the cost savings were 40 . We know its not used except in new york states where its not used as widely as it should be for kendras law. Theres been great resistance to using any kind of treatment that involves involuntary medication, which this does but youre dealing with people who have brain injury that impairs their ability to make those kinds of decisions. In answer to mr. Cassidys question, yes, some of the people need to be treated involuntarily. Can i ask you what to identify the early stages when you . My son was 22, he was a College Student and all the sudden he started complaining that food didnt taste good. I rushed up to see him after several months and he couldnt eat. We thought something was wrong. We took him to the psychiatrist, ill never forget the psychiatrist said if youre lucky your son is using drugs. If youre unluckily he has a Mental Illness. He gave my son medication. My son quit taking us. I thought its likes aspirin, you have a headache it goes away. A year later he was psychotic, like i explained. We looked back, you have to be careful because its easy to look back there were no signs. I note that the chairman wants to move on and come back to what works well. But i have to say what im hearing from families at home and educators and from doctors the last briefing was that the pruning of the brain early the identification of changes in behavior and activity we have got to figure out how to give educators and Mental Health professionals and families the tools as early as possible to identify and to treat. It does very well in defense of sampsa. They put outstanding tools in the hands of professionals at home, but im worried about disconnect now with the resources that arent available through schools at home. Especially, and then for you all who had health care coverage, you seem to be able to access greater treatment and there is a large segment now that are unensured that is going to change. How can we best impact the growing number of insured to make it meningful. Meaningful. Do you do you want to comment . I would. Thank you. I want to speak to the problem of lack of insurance or coverage for Mental Health. In my own case, my son racked up possibly the worlds most expensive library fine. I asked him to return over due library books. He completely went to a rage, threatened to kill me and himself. Pulled a knife i was able to get the police involved. They had to transport by balance blanks to emergency room. We didnt have coverage that covered Mental Health at the time. He was declared stable and sent home with the bill. Thank you. Doctor you want to comment too . This is actually in reference to what works. I would go back to dr. Torreys statement about the importance of thinking about options of assisted outpatient treatment. As he said, the Sciences Says to work to reduce violation. I think both of us and the other psychiatrist at the table would say thats a low bar. Thats really not where we want to end up. Important to do. But the real question is what do we have in place and what can we deploy to make sure that people finish their education. Get jobs, have families, contribute in some important way. Theres an entire package of interventions that help in that respect. They help people to work. And they help people to get back involved. You heard it from mr. Earley about some of the things that made a difference for his son. Theyre not available in many places and integrated in a package of care you would expect. Duo this pretty well for diabetes now. You know, we know a really good diet, supers, you need an exercise plan, and take your insulin. Theres a realm of people to make it happen. In this area, not so much. I think theres also [inaudible conversations] yeah, just to make a couple of quick comments. First of all, i think this issue that were hearing about now is compliance. I think there are two aspects. One is getting someone to comply to go on a medicine. The other is to get them to stay on. With involuntary treatment, you can get someone to take medicine for a certain amount of time, sooner or later you have to, as they say meet jesus. You have to get to a place where the person csh youre going have to bring somebody to taking that medicine they dont want to take. What i found is a clinician, which is much more difficult for younger people than it is for an older dependent, you must find your leverage within the relationship. For some people, that leverage is, hey, i know you dont believe that youre ill. You dont believe you need this, if you dont take your medicine, youre going lose your child because of certain complaints and issues that come up. For others, hey, i know you think its everybody else at the workplace, if you want to keep your job, you may want to consider taking this medicine that may actually make you more relaxed. And going back to dr. Torreys example i know you think im skits schizophrenic and for others the criminal Justice System works. A judge can say, you know, look, you dont have to be locked up. If youre not compliant, thats what is going happen. Its certainly what manifests in the insanity system that if people violate order and conditions they go back to a custodial environment. Finally, for those who are of age, who are adults, there is a perspective of homelessness. Say, look, youre in your 30s, im supporting you. I dont have to support you. So you to consider whether this lifestyle that you have where you are comfortable is something that is entitled to if you dont take your medicine. You have responsibilities in this just as i love you. So thats something that each family finds on their own. I can tell you not only from professional experience as treatment, i have had chronic Mental Illness in my family. I buried a siblings with illness. If you learn your leverage and use it right in a sensitive, loving relationship you get enduring compliance. Thats the holy grail here. You want to comment . Quickly. Thank you, mr. Chairman. Early identification and intervention in schools and primary care offices. Families and children are i think is something we need explore. Its a norm is dr. Insel said. There are a package of services and treatments available out there. If you can make them available and virtually all communities, it would make a difference and include sort of treatment teams, crisis stablization programs, supported housing, support employment programs for children certainly cognitive behavioral therapy. As he talked about earlier behavioral therapy and other interventions. Absolutely make a difference. The challenge we have we saw it in the 2009 the states report, hit or miss. You can go from one county to the next. One county the services exist. , the next county they dont. The recession comes and wipes out services, long waiting list. Taking families sometimes years and years and years to find the services we need. We know what works now. We are not there, e dont have the cure but we know can we no what the road to recovery is for most of the people with serious Mental Illness. There are those with the lack of insight. Thats another different conversation. To answer what works. There is a project impressive. One is the massachusetts child access project. You have pee proceed trisheses who get who problem. They are able to get telephonic consultation within that day as to how to help. It becomes a safety net not only for the patient but the peed pediatrician they understand what kind of interventions they do and know when they should reach for something more comprehensive like a hospitalization or a psychiatric consultation. Models like that developed, by the way, during governor romneys term and ron sign gaddafi who blank are effective. They take resources and say we can make the people there better than they are better. Because we give them more knowledge and take care. They the first line attack. Peed pediatricians could become better at eaching the warning signs. Thats who parents turn first. Go North Carolina who is also a nurse. To thank this panel and this is a very, very powerful discussion that were having here. And i want go back to the issue of hipaa, that is something at the federal level that we can intervene. I think one of the points or clarifications i want to make, mr. Chairman, you have mentioned that hhs in some instances uses hipaa as im going to say an excuse or relies on misinformation that is related is that correct . That was one of the things that we