By Dr David Laing Dawson
Not only does medical science know how to treat psychotic disorders today, as Marvin points out in will we ever do the right thing, but it is also relatively straight forward. An experienced psychiatrist, when confronted by a psychotic patient, will make a tentative diagnosis within minutes, though it may take an hour to rule out other causes and decide on best treatment. And another hour to talk this through with the patient and family.
If admission to hospital is required this will cost on average about $13,000 for the full hospital stay. The investigations required and the actual medical treatment are relatively inexpensive. Medical followup and monitoring is also inexpensive, and can move fairly quickly from every day, to once per week, and then once per month. Add to this some counseling, some regular support, finding and securing adequate housing (if not living at home), and finding some meaningful daily activities, from attending groups and workshops, through to full employment.
When we have not done this and the psychotic person commits a crime and is sent to the Forensic Psychiatry Unit for assessment, a far more extensive assessment is embarked upon, involving multiple interviews and testing. The stay in the Forensic Psychiatry Unit will be much longer and more costly per diem. Then we have lawyers, courts, judges, reviews, hearings, taken all the way to the Supreme Court on some occasions.
The first question being asked at great and unnecessary expense is whether or not this person is “fit to stand trial”. This involves a basic level of competence and ability to “instruct counsel”. Often, what is really happening is the patient is being treated for his psychotic illness, and this treatment will render him “fit to stand trial”.
At trial we enter an adversarial system and, as we frequently read in the newspaper, or online, one psychiatrist spends the day in court arguing the subject does not qualify for the “guilty but not criminally responsible” conclusion (NCR), while another, both with lawyers of course, argues that the patient does satisfy the criteria for NCR.
In reality both psychiatrists would probably agree on diagnosis and necessary treatment, but find themselves having to parse the more difficult question of moral culpability, and, ultimately, punishment. The subsections of this being a “capacity to tell right from wrong” at the time the crime was committed and a capacity to “appreciate the consequences” of the act the subject was about to commit.
The answer to those questions will determine if the subject is confined in a prison or on the Forensic Psychiatry ward of the mental hospital. The cost to keep this person in prison per year in Canada will be about $120,000, plus medical, nursing care, and closer to $200,000 per year within the Maximum or Medium Security Forensic ward of a hospital.
Overall, my estimate would be that, apart from the human tragedy of it all, shifting apprehension, diagnosis, treatment and long term care from general psychiatric and mental health services, and mental hospitals, to Forensic Services, prisons, courts, lawyers, and Forensic Psychiatry Wards increases the cost of psychiatric care by a factor of at least 10.