MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Jared Loughner, the alleged gunman in the Tucson, Ariz. rampage, showed signs of mental instability months before Saturday's shootings. His community college suspended him, telling his parents he'd need clearance for -- from a mental health professional before he could return. Diagnosing and treating psychiatric orders -- disorders in young adults can be very difficult in the U.S. Joining me in the studio to talk about why, Pete Earley, he's author of "Crazy: A Father's Search Through America's Mental Health Madness," and psychiatrist, Dr. Lisa Dixon. She is at the University of Maryland School of Medicine. Joining us from the Harvard Medical School in Boston, Dr. Kenneth Duckworth, he's medical director of the National Alliance on Mental Illness.

MS. DIANE REHMI know many of you will want to comment. Feel free to join us by phone, 800-433-8850. Send us your e-mail to drshow@wamu.org. Feel free to join us on Facebook or send us a tweet. Good morning to all of you.

MR. PETE EARLEYGood morning.

DR. LISA DIXONGood morning.

DR. KENNETH DUCKWORTHGood morning, Diane.

REHMPete Earley, I want to ask you, first and foremost, how your son is. Having read the book, "Crazy: A Father's Search Through America's Mental Health Madness," I know your son went through a great deal of trauma as did you.

EARLEYYes, thank you for asking. He -- when he was in college, he had a major breakdown. He ended up being arrested after he broke into a house to take a bubble bath when I was unable to get him help. And we had a horrific time. It was one of four major breakdowns. At one point, he was tasered by the police. But, now, he's doing absolutely fantastic. Just as the system failed him initially, the system worked in Fairfax County. Three years ago, he had an episode.

EARLEYHe took off all of his clothes. He thought it made him invisible. But he was picked up by a crisis intervention-trained police officer, who got him to a hospital, insisted the doctors treat him, got a case manager in there who took control. She helped him get a job. She helped him get an apartment. And, today, he is working with persons with mental illness, and he's doing phenomenal.

REHMI'm so glad to hear that.

EARLEYAnd it's just -- it's an unusual success story when things go right.

REHMDr. Dixon, how often do things go right when young people behave in the ways that Pete Earley's son did?

DIXONWell, the time of adolescence, late teen, early 20s, is a very, very difficult time, and mental illness can be devastating as you've just heard. The challenges during that period of time are demonstrated by Pete's story and the story of his son. With the lack of knowledge and understanding of mental illness, considerable developmental tasks that make it difficult -- even for individuals and parents to know what's normal -- poor access to services and stigma really inhibit the delivery of obtaining good outcomes. How often people do well is hard to know, and what -- how to define doing well is hard to know. But I would say that what the story reflects is that, with good services, there can be a good outcome.

REHMAnd, Dr. Duckworth, turning to you, how do we define serious mental illness? What is it that constitutes it? Pete has talked about a series of actions on the part of his son, many of whom might seem to be just erratic behavior. But as we've seen in the case of the young man out in Arizona, that erratic behavior can turn violent.

DUCKWORTHOh, well, thank you, Diane. Serious mental illness is very commonly expressed in the college-age population. So if you look at a process like schizophrenia, the typical age of onset of that illness is about 18 to 25. Bipolar disorder has a similar age distribution. Substance abuse is at its peak in this period of time. Substance abuse is strongly correlated with violence, with or without a psychiatric illness. So when you look at the serious mental illnesses, you look at this late stage of adolescence as one of the periods of profound risk.

DUCKWORTHUnfortunately, in America today, we're sitting on a very profound public health crisis. It's very difficult for people to access care. It's not easy to find it. We don't have a culture where it's expected or supported that people will get help. And, at the same time, we're closing hospitals and building prisons.

REHMAnd his community college suspended him for his behavior -- this is Jared Loughner, of course. What can a school do when they suspect mental instability, Dr. Duckworth?

DUCKWORTHI don't know anything about this case, and it's not really ethical for me to comment on that. But I think one of the things we're learning is that there are emergencies that come up. And confidentiality, which is so important in mental care and in medical care, has to be trumped at times by contacting people in the person's lives and sending an alarm. People who develop serious mental illnesses often are not aware that they have a biological process going on. About half the people with schizophrenia, for example, can't appreciate that their experience of delusions or hallucinations are biological tricks their brain is playing upon them.

DUCKWORTHSo when you have a person who doesn't have awareness that they're becoming ill, the family, the community, have to create conditions where it's okay to seek help. It's not the worst, most low social status thing that you can have because as we learned from Pete and from thousands of people that I've worked with in my career, treatment works for people. This is a very important point. While we're weak on the preventive end, once a person gets into services, they do find much of the time, although not always.

REHMDr. Dixon.

DIXONI agree with what Dr. Duckworth said. I think, also, that the institutions that encounter people with mental illnesses, like schools, can try to provide access to services, for example, within school-based mental health programs or campus counseling that can provide information to students. They can provide information to parents on what's available. And they can also give information to, again, create this -- create an environment in which seeking services is not an embarrassment.

REHMBut, Pete Earley, providing that information doesn't necessarily mean anybody is going to use it.

EARLEYThat's exactly right. You know, when my son got sick, I took him to -- it's interesting, Diane. We have family doctors. Most families don't have psychiatrists. I mean, they don't have a family psychiatrist you just run to. But I -- one of the times, I took him to a psychiatrist. Now, my son was an adult. He took his chair. He turned it around. He folded his arms and refused to face or talk to the psychiatrist. Another time, he got angry. I was telling him he had to take his medication. I said, okay, I'm going to practice tough love. If you don't take your meds, I'm throwing you out of the house. He said, fine, and left. You know, what, you're going to allow your son to be homeless? This is what you face as a parent.

EARLEYAnother time, he and I got in an argument. I felt threatened. I called the police. They showed up, barged in and shot him with a Taser. So there he is, twice tasered, and he's angry at me. Interestingly enough, Diane, all three of those incidents would not have been enough in Fairfax County for me to get my son forced into treatment.

REHMWhat could you have done to get him into treatment against his wishes?

EARLEYWell, I would -- in Fairfax County, it's almost impossible. It's very, very difficult because the three administrative law judges who hear the cases are die-hards on a person has to be a danger to themselves or others, even though we recently changed the law. And this is most states. Now, Arizona, I checked this morning their law, and it does have a dangerous criteria, although it's not -- it's more of a need for treatment. But danger still remains the key role, and proving someone is dangerous or going to be dangerous is extremely difficult.

REHMHow do you get to prove that someone is potentially dangerous before he commits a dangerous act, Dr. Dixon?

DIXONIt's impossible to prove. But what you can do is look at risk factors. You look at someone's history. Have they themselves been victims of violence? Have they committed violent acts before? Or do they have a substance use problem? Substance use definitely puts people at risk for violence. People who -- it tends to be males tend to be at greater risk for violence. So what we can do is just really look for risk factors, but we cannot predict with certainty.

REHMDr. Duckworth.

DUCKWORTHYeah, this is a challenging area, but I think the idea that there are risk factors that are correlated with violence is what the statutes are typically based upon. And when a person has an untreated psychotic illness, for instance, or manic illness, typically their judgment is impaired when it's wildly out of control. And often they can't appreciate that they're ill. So there is a role for a paternalistic intervention at times. And I've had patients say that, you know, the intervention saved their lives, to be put into the hospital, for instance, against their will, although they still have bad feelings about it. So they don't often thank you for that moment. But that is a part of the art of the field of psychiatry, is trying to figure out how to enroll a person into services, woo them, and at times, if it needs to be, to use the commitment criteria.

REHMPete.

EARLEYWell, I -- as a parent, I'd like to point out something else. We see on TV someone like this as the incident or the Virginia Tech incident would show. And we sit back, and we say, what is wrong with those parents? I mean, this guy obviously had something wrong with him. Why didn't they get him help? But what you have to understand is psychosis isn't always acting out in that way. There are times when my son could be perfectly fine and talk to you. It's only in emergency situations that he might get upset.

REHMPete Earley, he is author of "Crazy: A Father's Search through America's Mental Health Madness."

REHMAnd as we continue our discussion about what Pete Earley calls mental health madness, we're joined now by phone by Dr. E. Fuller Torrey. He's president of the Treatment Advocacy Center. Good morning to you.

DR. E. FULLER TORREYGood morning, Diane. Nice to hear you again.

REHMAnd good to have you with us. I must say what happened in Arizona seems to happen all too frequently around the country. Do you see any difference in this case from those that have gone previously?

TORREYUnfortunately not. This is just another episode. And the only reason, I think, we're talking about it today is because this young man shot six people, including a congresswoman. But these kinds of episodes, caused by people with untreated severe mental illness, are, unfortunately, happening in many places. In terms of Dr. Duckworth's comment on the laws, I think it's very important to realize -- and he's absolutely right -- the laws vary state by state. And so if you are a family and you have a family member who is severely mentally ill or becoming severely mentally ill, you want to check and find out what your options are. The laws are all listed, state by state, on the website of the Treatment Advocacy Center, which is www.treatmentadvocacycenter -- all one word -- .org.

TORREYI think the other point that's important to realize is that there are, as Dr. Duckworth mentioned, many of these people. About half of them are not aware that they're sick so that there are people out there who have severe illnesses, like schizophrenia, who have to be on some kind of mandated treatment, or they deteriorate. And some of them -- a small number, 1 percent -- do become dangerous again.

REHMNow, Dr. Torrey, I want to raise with you a point that Pete Earley raised earlier. Even in a household with parents, as this young man had, what can those parents actually do?

TORREYWell, the law in Arizona, actually, is quite liberal compared to many states. They could go to the mental health authorities, to their local mental health center, and say, we need an evaluation of our son. We think he is becoming severely mentally ill and, perhaps, dangerous on it. And in some states -- and I don't know exactly how the law is written in Arizona -- but in some states, he could then be picked up and taken to the mental health center and evaluated. And, obviously, in this case, that would have prevented the tragedy.

REHMAnd what about the question of involuntary commitment, Dr. Torrey?

TORREYWell, about half of the people, as Dr. Duckworth mentioned, are not aware that they're sick. So in these instances that they have to be treated involuntarily, that has been a major problem because some libertarians say nobody should be treated involuntarily. But, in fact, some of these people are like people with Alzheimer's disease. They're not aware of their illness because of the way the damage to the brain caused by the illness. So we have things called outpatient treatment, assisted outpatient treatment, which basically says, yes, you could live in the community as long as you're on your medication. But because you have demonstrated dangerousness and failure to take medication in the past, we're going to require you to take medication as a condition for living in the community.

REHMAnd, Pete Earley, you had a comment.

EARLEYWell, I'd like to comment on what Dr. Torrey said. Yes, the parents could have said -- gone to the authorities and said, look, we're really concerned. We want this person to have an evaluation. But that does not guarantee that anything will happen. And you take, for instance, here in Fairfax County, one of the wealthiest counties, one of the best mental health care system. Let's say you actually get through the system, and you show that the person is dangerous -- and in Arizona, dangerous is a requirement -- so you get someone to commit someone.

EARLEYYou're talking about three to five days at best. You're talking about -- Fairfax County, a two-week wait to get into a treatment program if you want to go voluntarily, a six-month wait to get a case manager, an 18-year wait to get in kind of housing. So, yes, even if you get them over the hurdle and say, look, we have a problem. You've got to have services there.

REHMDr. Dixon.

DIXONI want to echo what Pete said about services, that much of the research that's been done shows that the real key is getting people services that we know work and that involuntary treatment may have a role, at times, in the life of a person with mental illness. But when people have available to them, services, psychosocial treatments, housing, then they will not need outpatient commitment.

REHMDr. Torrey, I want to come back to you on the question of parents. We truly have no way of knowing whether the community college's message about their son's behavior actually got to them, do we?

TORREYNo, we don't. And we obviously don't know the details of this case, other than the fact that the young man clearly was severely disturbed and almost certainly has schizophrenia, but we don't know what information was conveyed to different people. In retrospect, we have lots of information because a lot of people have been interviewed. But how much the parents knew, how worried they were, is still to be determined.

REHMDr. ...

DUCKWORTHDiane, I'd like to...

REHMSure.

DUCKWORTHI'd like to jump in on this. This is kind of...

REHMGo right ahead.

DUCKWORTHIt's a very difficult position parents are in because most people with mental illnesses are not violent. And nobody has done the preparation to anticipate this possibility. That is to say, it falls into your lap at a certain time. I'd encourage people to go to the NAMI website, www.N-A-M-I.O-R-G, to look at information about different mental illnesses and also about the treatment, strengths and weaknesses in your state, how much bed...

REHMTell me how -- in your practice, how do young adults come to you, Dr. Duckworth?

DUCKWORTHYoung adults sometimes are willing to come. Sometimes parents come quite vexed by their behavior. As you know, adolescence is a time of separating from adults and developing your own identity at a time when your body is undergoing tremendous changes, and you're trying to figure out who you are. So many of us parents are trying to figure out what is normal adolescence and what is not. And what I find is when the parents are waking up early in the morning, anxious about their child, they should talk to their general practitioner and figure out if there's a mental health assessment. Don't ignore that kind of basic human anxiety that you have about your child.

REHMDr. ...

DUCKWORTHYou may not be -- yeah, go ahead.

REHMDr. Torrey, I want to ask you about the college and whether you think there was anything more the college itself could have done.

TORREYI think if all of the information that everybody had about this young man was in the hands of an administrator, yes, I think that they should have, number one, gone to the family, probably put it in writing, said, this is a disturbed young man. He needs some help. Now, if the family then said they're not going to do anything, I guess I'd have to go back and see exactly what was available then. But at what point do you go to the authorities and say, this fellow is potentially dangerous? Clearly, his classmates felt he was.

REHMWhat about treatment in Arizona? Could he have gotten anything that would have really helped him, Dr. Torrey?

TORREYArizona has one of the worst treatment systems in the United States. A study we did with the Treatment Advocacy Center two years ago, they were next to last in terms of number of available beds -- public psychiatric beds on it. So in no state is he likely to get good treatment -- in Arizona, even less than that.

REHMAnd, of course, you've had many mental hospitals around the country closing down. Those people, many of them, now, ending up in prison.

TORREYIn jails and prisons and homeless and on the street. The system has failed completely, and that, I think, Pete Earley described very clearly. We're dealing with a broken system, and the tragedy that you saw this week is simply one more evidence of a broken system.

REHMDr. ...

DUCKWORTHDiane, this is -- can I...

REHMSure.

DUCKWORTHI'd like to jump into this, if I could, briefly. NAMI did a whole thorough review of each state mental health system for people with serious mental illness, and that's available on the NAMI website, as I mentioned. Arizona, the comments we got from people was that they couldn't get into a psychiatric visit. So even if the community college behaves optimally, the family behaves optimally, the ability to find a psychiatrist on a quick basis to do a thoughtful evaluation is very limited in many places around the nation, but in Arizona in particular.

REHMDr. ...

DUCKWORTHThere's no equivalent of going to Walmart and finding a mental health assessment.

REHMDr. Dixon.

DIXONI wanted to raise the additional point about communication to parents when the individual in question is an adult. In my own situation with my family, one of my brothers developed a severe mental illness, and, at that point, even though he was an adult, he -- I'm sorry, even though he was young, he was an adult. And he -- no information was provided to the family in order to protect his confidentiality. And that becomes a very serious obstacle to engaging the individual support system and their families, friends to get them help.

REHMDr. Torrey, I know you have to leave us. But last comment about that whole question of confidentiality, embarrassment, the kind of social stigma.

TORREYConfidentiality is very important, as Dr. Duckworth said. However, we go overboard at times. I think the most important thing I'd like to leave is the last comment -- because I do have to go -- is the fact that the vast majority of people with these severe mental illnesses are not dangerous. They're not violent. It is a very small number -- about 1 percent -- who are causing all of the problems. These are the ones who often need to be on some kind of involuntary treatment.

REHMDr. E. Fuller Torrey, he is president of the Treatment Advocacy Center. Thank you so much for joining us.

TORREYThank you very much for having me.

REHMAnd we have many callers. I'm going to open the phones now, 800-433-8850. First, to Jackson, Mich. Joshua, good morning to you.

JOSHUAGood morning. How are you doing?

REHMI'm fine. Thanks.

JOSHUAI've heard the views of all the doctors and stuff, and I, myself, am going to school for psychology here in Jackson, Mich. I think that what has been left out is society's impact on these individuals. When you look at the case of Ted Kaczynski and all these other people, if you read his Unabomber manifesto, you'll see that he has a lot of problems with the way society is. And it seems as though we're wrapping up psychology and training these doctors on what society wants them to instill into the society of people. And I just -- I don't know. It's -- society is -- it's a broken system, like one of the other doctors said, and I think that needs to be addressed.

REHMDr. Duckworth.

DUCKWORTHI do think the mental health care system is broken, but we also do live in a free society, you know, with many protections. I noticed, on NPR, there has been a lot of discussions about improving the quality of our public discourse, which I think any sound citizen is in favor of, but these illnesses also exist in cultures that don't have the sort of open society. One percent of the people around the planet have schizophrenia, regardless of the culture. But I do think the culture can influence a person who is troubled.

REHMAll right. To Dallas, Texas. Jessica, good morning to you.

JESSICADiane, good morning. Our son had a severe psychotic break this past August. He is 18 years old in three weeks and had to be hospitalized. Actually, we lost control of him to the state. And when we finally were able to stabilize the situation, we started speaking to his friends. And all his friends said, oh, well, yes. You know, we did notice that he started to hear voices and that he was hallucinating. And as a parent, you say, well, why didn't you say something? That's not normal. There was drug use, so that sometimes is the explanation amongst the friends. But, you know, the behavior patterns were also -- things like sleep deprivation and, you know, things that are not normal.

REHMJessica, how is your son now?

JESSICAHe is, right now, in a rehab center. I'm -- we -- you know, we are fortunate. We have health care. It is very, very difficult. He now has to go to a long-term residential rehab. And I would ask your panel of doctors if they could recommend something because, you know, when you're faced with something like this, Diane, you -- we're not educated on this. We're lay people, and we are...

REHMOf course. I don't think anyone of us is educated at a time of something as serious as this, Pete.

EARLEYYes, exactly. Well, first of all, as a parent, it's hard to understand what's going on. These do typically happen the college years. My son never drank. All of a sudden, when he developed his mental illness, he wouldn't go anywhere without a beer in his hand. He had, in itself, medication. It made him feel better. And so you're torn. Well, is this just normal college behavior or not? And it's frustrating in dealing with the system. These are hard -- my son's been diagnosed with bipolar disorder, schizoaffective disorder, early-onset schizophrenia. And, as a parent, you sit back and you go, I don't care what it is. Just help me. Help me, please. Help me fix this.

EARLEYAnd then you're told things like, well, he's had one breakdown, but he may never have another one. He may be fine. Or he may have many, and he may get worse. I mean, these are difficult diseases to deal with. The thing that frustrates me the most is the parent always gets a lot of blame, and you become the enemy. If you do take your child and try to get them involuntary committed, they're angry at you. The system suspects you. And if you can't get the person committed, then the person is turned loose to who's care? Yours, and they're mad at you. So the -- it's not a parent-friendly system.

REHMDr. Dixon.

DUCKWORTHI wanted to underscore a couple of things that Jessica said. First, when -- before the onset of psychosis, which Jessica describes, about three-quarters of young people do have prodromal kinds of symptoms, indicators that something may be going wrong, problems with attention, problems with thinking, problems with mood and a decline in functioning. And those are the kinds of things, even if you don't know that your son or your child is hallucinating -- if you notice problems, a falloff in their behavior, that might be the time to think about trying to get help, to talk to them before the illness becomes more severe. And...

REHMGo ahead, Dr. Duckworth.

DUCKWORTHSorry about that. Jessica, I wanted to add some resources for where you can get more information. I think you're spot on, that absolutely no one is prepared for this, and we don't have a very good public health preventive mindset when it comes to serious psychiatric conditions. There are three places I would suggest people look. One is to call your state mental health authority. This would be the Department of Mental Health in your state. They are charged with having a master plan with what's happening for serious mental illness in their state. The Substance Abuse and Mental Health Services Administration, samhsa.org, has a list of all substance abuse treatment centers.

DUCKWORTHAnd, finally, at the National Alliance on Mental Illness, www.nami.org, you can find out what's happening in different states, including are all the hospitals accredited. Have there been citations for abuse and neglect within the service system? These things have to become transparent for people to use the system. You know, this is a big problem we have in the mental health field. And NAMI is very invested in taking as much information and handing it to these parents who are placed in a very difficult situation.

REHMDr. Dixon.

DIXONI also wanted to take the opportunity to discuss two NIMH initiatives, the RAISE project -- Recovery After Initial Schizophrenia Episode. The NIMH has funded two large studies to try to test whether intervening early and optimally in young people with psychotic disorders will improve outcome. And these studies are being done in different parts of the country. You can get information from NIMH.

REHMAnd is there -- you got two programs going on.

DIXONMm hmm, yes.

REHMThat's great. Dr. Lisa Dixon, she is professor of psychiatry at the University of Maryland School of Medicine, director of the Division of Services Research within the Department of Psychiatry.

REHMWelcome back. As we talk about care for the mentally ill in this country, we'll go right back to the phones to Cape May Court House, N.J. Good morning, Kevin.

KEVINGood morning. Yes. I have worked in health care professions. And one thing I've seen is that once a chronic -- a person with chronic schizophrenia or something gets treatment through medication, which has its own issues in many ways -- it's a blunt instrument. But once their head starts to clear and they come out of the cloud, they see a lot of the wreck that possibly the illness has caused in their life. And actual legitimate depression sets in, and it's very difficult to fight that in many ways. And it's through the services of the community that's really getting them...

REHMHmm.

KEVIN...to feel motivated about themselves.

REHMPete Earley.

EARLEYWell, I think you're addressing an important issue there, but you're also talking about stigma. What we have to understand is bipolar disorder and schizophrenia and major depression are illnesses, and there should, really, be no shame in having them. The shame should be in not doing something to help somebody who does.

REHMDr. Dixon.

DIXONThat is a very common situation that occurs. And it's very important, as a provider, to provide hope and always to communicate hope. And Pete Earley's son's work as a peer provider or a peer counselor is another great way to combat that problem of hopelessness, that by working with a peer who has gone through it and survived, it really gives people with mental illness an example to aspire to.

REHMHere is a message posted on Facebook by Patty who says, "The fact that we cannot force someone to seek mental health is unfortunate, but we cannot afford to turn the clocks back to the days when people could be held against their will. One would think, however, that with the advances in psychiatry over the past 40 years, we could devise a system where something more proactive could be done when we see obvious signs of psychosis in people, especially children." Pete Earley.

EARLEYWell, nobody wants to turn back the clock. But why do we have to accept the idea that we only intervene when there's dangerousness? That's what I have the issue with. Why can't we see when somebody has a need for treatment? Why can't we consider? Right now, in Virginia, if you have a history of breakdowns, you can't introduce that at a commitment hearing because that's unfair. So that is prejudicial. You can't judge somebody on the past. That's ridiculous. You should be able to take a person in and have a more holistic approach, in my opinion, and say, does this person have a history of it? What helps him? What hasn't helped him? And are they obviously having a relapse? And waiting for dangerousness is just a waiting for these kind of situations.

REHMDo you agree with that, Dr. Dixon?

DIXONI think that the tools that we now have in our toolbox allow us and encourage us, as providers, to try to engage people. The key is not to present and say, oh, hi, you have a mental illness. Here's my treatment for you. That doesn't work. What does work and what we know works is by trying to engage people to try to figure out what they need and what they want. And even if someone doesn't believe that they have a mental illness, they may need something, and that is the key to getting them engaged.

REHMLet's take a caller here in Washington, D.C. Good morning, Julia.

JULIAOh, good morning, Diane. Thank you so much. This is such an important issue, and my -- what I'd like to say is that my son has been a paranoid schizophrenic since he was 16 years old. He's now 29. He's doing pretty well. He's in the system here in Washington, D.C. And I can tell you that I have tried so hard to get housing and residential care. It wasn't there. It isn't there. Their -- the health insurance does not cover residential care. I found a fantastic place in North Carolina where the people with paranoid schizophrenia are doing so well, and I don't have the money.

JULIAI just don't have the money. And I see very wealthy people, and they maybe could send their son there. I can't. And I don't understand why we worry about how much social services cost when schizophrenia is dangerous. We have seen that it is dangerous. We need to provide for these people who are suffering and killing themselves because they cannot bear the delusions.

REHMJulia, I'm so sorry for the illness that your son is experiencing. Pete Earley, what is available through Washington, D.C.?

EARLEYWell, what you have to understand, Diane, is that we know how to help most people with mental illnesses. We really do. We know the medication works in some cases. We know that if you add peer-to-peer, if you add housing, if you have different kind of job programs, if you add a mixture of these things with good case management, you can actually help most people, not all, but most people with mental illness. It's always -- comes down to the money. But what we've learned recently is that many of these programs are cost-effective and, in fact, will save money over the long haul.

EARLEYIf you look at housing first, which is a program that takes chronic people, chronic schizophrenia, chronic homelessness, puts them in an apartment with no questions asked, back in services to them, it has an 80 percent recovery rate. And that helps turn someone into a taxpayer, somebody who, actually, is doing better. So it's shortsightedness on our part, thinking that people can't get better, that they won't get better and, you know, our refusal to set up programs that work.

REHMSo what would you recommend that Julia do right now?

EARLEYWell, I'd recommend that she raise hell. No. I mean, look for a housing program in D.C. There's Pathways. There's a number of housing programs that might be able to get you in and try to get you help. I'm involved in the Corporation for Supported Housing. It's a big push -- advocate of Housing First. Look for Pathways homes. See if they have some kind of program that you can get your loved one into.

REHMDr. Duckworth, any suggestions?

DUCKWORTHWe know that supported housing is the preference of most people with serious mental illness, and we know that it is effective, cost-effective and supports people in their recovery. I would encourage you to contact people in the State Mental Health Authority or in the District of Columbia, whoever the responsible authority is. Find out what the wait list is. See if you can push it. See if you can become an advocate. Join the National Alliance on Mental Illness. You'll meet half a million people who wake up every morning and try to figure out how to make this system work for a group of people that our society tends to want to ignore or hope that go away.

REHMAll right.

DUCKWORTHNAMI needs you. And we are interested in fighting for services every day.

REHMAnd, by the way, all of these websites are listed on our website, drshow.org. Here's an e-mail from Christine in Chapel Hill, N.C. "Why do we never see girls in the headlines committing these acts of violence? Is the rate of mental illness that much higher in boys?" Dr. Dixon.

DIXONThe rates of mental illness -- different type of mental illness differ in the genders. So women tend to be at greater risk for depression. Men tend to be at greater risk for substance use, although women also suffer from substance use. I think, in terms of violence, it is the case that men are at greater risk for committing acts of violence, and that's why they make the news more.

REHMAll right. To Elizabethtown, Ky. Good morning, Carmen.

CARMEN CALLER)Hi. Good morning. I'm a community psychiatrist for the last 20 years in central Kentucky. And my comment is that we don't have good integration between the legal system, the mental system and the disability system. I really would like to see all illnesses that give -- you know, all people that qualify for disability to be -- have a requirement to be involved in treatment. We realize that people have incapacities, and we say, okay, we're going to pay you. We shouldn't pay people to be sick. We should pay them to be in treatment.

REHMPete Earley.

EARLEYWell, I think that he's raised an excellent point here. One of the problems I ran into, when I did my research in Florida, was that persons had high medication cost. One of my son's medications is $500 a month. The only way to get that paid for was by him or someone going on a disability. Well, if you go on a disability, then there are rules about when you can and can't work. And so this is part of what he is talking about. We create this situation where people sit in their rooms and smoke cigarettes and watch TV and watch their lives being wasted away.

REHMDr. Dixon, any comment?

DIXONIt's a very interesting question. Again, it gets to a fundamental point of human rights and autonomy. If someone is getting -- has been declared disabled and is getting a federal subsidy, it's an interesting question as to whether they should be required to get treatment. And, I think, it's something that probably deserves some debate.

REHMPete Earley.

EARLEYWell, I was just going to say something about the jobs and having people with disabilities who can work. There's a wonderful program in New York called Fountain House. It's been around for 60, 70 years. And it takes somebody who has a mental illness and says, okay, you can only work for two hours. But, guess what, you get to work for those two hours. And we pay you, and we support you. And we don't take away your medication payments. And then somebody else fills in at your job. So it takes creative thinking to want to help an individual move forward.

REHMHere's an email from David in Kendall, Fla., who says, "The real question is, where does the mental health system actually work? Does Canada have the same process to deal with insanity? How long will it take the U.S. to get humble enough to copy a system that works?" Dr. Duckworth.

DUCKWORTHWell, I think one of the things that you can take a look at is the fact that we still have millions of Americans who do not have insurance. And it's as difficult to get mental health care as it is with insurance. It's even more difficult without insurance. Health care reform has an interesting subtext to this. Mental Health Parity is finally a potential reality. The first thing that happened after Mental Health Parity was passed is the managed care industry filed a lawsuit to prevent it.

DUCKWORTHAnd, now, health care reform, the entire thing is up on the blocks to be taken away, so I think that there are some progressive thinkers, in terms of how mental health is part of health, how the brain gets sick. It's all part of the same biological process as a human being. But we need to fight for things like Mental Health Parity, which we are close to achieving in our country if health care reform can go forward.

REHMPete Earley.

EARLEYThe question you were asked about other countries -- and I've been to several -- and I found in Iceland and Brazil and Portugal and New Zealand has more better laws, as far as I'm concerned, about commitment. But what you find is that a lot of these countries are socialistic, so the cost is not the driving force. But the main thing is that I found in my travels overseas is that other countries don't have the fear we have of state hospitals. If somebody gets sick, you send the person to the hospital. But because of our history, because of these dreaded asylums, because of "One Flew Over the Cuckoo's Nest," we have a cultural anger and animosity and reluctance to put anybody in a state hospital. And you just don't see that in other nations.

REHMDr. Dixon.

DIXONI think, though, that the real key here is providing access to outpatient services and education of the community. If you look in, say, countries like Australia or Holland, there's a lot of community education. People learn about what the signs of mental illness are, and they also have access -- ready, available access to services.

EARLEYYeah, I wasn't pushing for return to state hospitals.

REHMYeah.

EARLEYI'm just saying that that was part of our history, and that adds to the stigma, of fear, that people need to be put away locked up.

REHMAnd you know what bothers me? This same discussion went on after 9/11. It went on after Oklahoma City. It went on after the shootings at the University of Virginia. Where are we, Dr. Dixon? Have we made any progress in our understanding at all?

DIXONWell, I think that these kinds of incidents focus our attention on the negative, on the failure, and there are failures. And, frankly, there probably always will be, and it's multi-determined. However, many, many systems -- many, many people do get good care. Many people receive good housing services, good employment services, good medication, and so, I think, it would be a mistake to sort of denigrate the whole mental health system.

REHMAnd I'm sorry. I misspoke. I meant shootings at Virginia Tech and not the University of Virginia. You're listening to "The Diane Rehm Show." And one last caller in Boston, Mass. Good morning, Andy.

ANDYGood morning. Diane, I wanted to bring a different perspective to the conversation. I'm a 37-year-old male who is -- that has been diagnosed with bipolar disorder. I will point out that I was diagnosed this year. I've clearly been struggling with depression and other issues since adolescence. I was diagnosed with major depressive disorder at 30. And in those seven years and multiple professionals, it still took a lot of work to get to the root cause, the root diagnosis. But -- so we talk about diagnosis.

ANDYWe talk about, you know, how we can begin treatment, but we sort of avoid -- well, how do people live with this, you know, both prior to getting treatment and once they've had treatment, you know? Because there are massive repercussions of this, relationships, pain that people have experienced, messes, financial messes created, the difficulty of maintaining employment. And I'm just interested to know what your guests have to say about, you know, the adult predicament of (unintelligible)...

REHMSure. Andy, let me just ask you one question. Are you on medication now?

ANDYI am. And it has changed everything dramatically.

REHMI'm so glad. Dr. Dixon, do you want to comment?

DIXONMany, many things are help -- are available to help people live with mental illness -- treatment, medication, psychotherapy, family support and peer support are very, very important. And those are the kinds of tools that we have at our disposal.

REHMDr. Duckworth.

DUCKWORTHThe National Alliance on Mental Illness is here to tell you, you're not alone. There is more than a thousand groups of people who are living with this predicament and all of the negative social attitudes and prejudices that our society has towards people who are trying to live successfully with mental illnesses. My experience is that we have a lot to teach each other and a lot to learn from each other, but these illnesses can make people feel alone and isolated. There's an old expression called pain shared is pain halved. And so I would encourage people to look at a NAMI Support Group nearby, both for the support of it, the realization that you're not alone, and also to figure out how to improve this system.

REHMAll right. And last word, Pete Earley.

EARLEYWell, I'd just like to reemphasize that most people with mental illness are not a danger. They are more likely to be victims of crime than to commit crimes. And, now, the face of mental illness is the shooter in Tucson. But the real face of mental illness is Mike Wallace. It's Terry Bradshaw. It's people who are recovering and doing well.

REHMPete Earley, he is the author of a book titled, "Crazy: A Father's Search Through America's Mental Health Madness." Dr. Lisa Dixon is professor of psychiatry at the University of Maryland School of Medicine. Dr. Kenneth Duckworth is the medical director for the National Alliance on Mental Illness. Thank you all so much. Thanks for listening. I'm Diane Rehm.

ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture and Monique Nazareth. The engineer is Tobey Schreiner. Dorie Anisman answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our e-mail address is drshow@wamu.org. And we're on Facebook and Twitter. This program comes to you from American University in Washington. This is NPR.