Schizophrenic man beheads innoscent man on bus

A man on a bus beheaded his fellow passenger.  The witnesesses say they still suffer the trauma of seeing this.  No doubt the headless man, had a problem with his own fate.
Now the court decided in Canada that the man who did the beheading was schizoprhenic. After a few years of being in custody he was allowed to go to a group home where the fellows says he is planning on changing his name.

My concern as a psychiatrist who has treated violent schizophrenics in the United States and Canada is whether or not the man will be required to remain on injectable medication.  The 'non compliance with medical regimen' runs up to 80% with schizophrenics.  I was in charge of a dangerously insane ward in a provincial asylum.  One day my patients would hear a command hallucination, "kill " and it was no different than I might hear myself say, 'go outside'.  The trouble is that a schizophrenic hearing such a command hallucination may well follow the internal or externally perceived 'advice'.

One of the principle problems I have had treating schizophrenic patients is the commonly misperception that "if I stop my medication my disease will go away".  Non adherence to medical regimen occurs roughly 30% of the time for most people with medications at some time. We can forget a pill or taken three in stead of 4 or stop our antibiotics on day 7 instead of 10 or 14 'because we're feeling better" .  The schizophrenic patient on medications 'feels normal' and on medication those around him after a while think he is normal.  However without the medication the psychosis returns usually in weeks or months.

One dangerously insane patient I remember well stopped taking his medications having chopped off someone's arm with a machete and was then seen a while later wandering about with a machete all set to do it again.  Outreach mental health nurses are a good send in the world of psychiatry.  With a nurse I went out and brought this fellow in with the help of the police assistance.  So often police are required in such cases and often as we've seen in the news these are the cases where the police  are attacked by a sad sick tragic schizophrenic man who off his medication will and do kill policemen believing they're aliens from another planet.

Now I've weighed in on this discussion simply because in the articles that I've perused in the papers I've not seen that the man will be mandated to be on injectable antipsychotic medication for life.  Injectable medications are given monthly and are more effective than pills generally. The critical matter is that if a patient doesn't show up for his intramuscular injection we know t hat the patient is at increasing risk for psychosis and can alert the police.  There's no 'mouthing' of medication or 'spitting out' or 'throwing up later' with injectable medications.  It's done.

In all enlightened forensic settings this is the standard.  I agree that schizophrenics who have been violent don't need to be incarcerated.  However, when a person has killed another human being, especially in such a heinous way,   the risk of another psychotic episode is too great to trust to anything but injectable medications.   I have been happy following schizophrenic patients on injectable antipsyhotic medications and felt that individual and community are safe. However, too often I've been faced with non compliant schizophrenic patients who have not been taking their oral medications and many times I've been faced with near catastrophic consequences.  It's difficult enough to "find" schizophrenic patients who "escape' between injections given every 2 to 4 weeks.  I've had to "return' a dangerous Toronto schizophrenic patient from Vancouver where they escaped to.  Fortunately no one was hurt.

And the vast majority of schizophrenic patients are the least likely to be violent.  Further on medications the vast majority of schizophrenics are safe in the community. Very very few need to be in psychiatric asylums. However I now work in the DTES where I see schizophrenics with histories of violence on crystal meth or crack cocaine, or drinking. all of which counteracts medications and increases risk of violence. If they are on injectable antipsychotic medications even abusing drugs is unlikely to cause a recurrence of violence. Off anti psychotics 'street drugs' exponentially increase the risk of further offences.

The Injectable anti psychotics today are highly superior in patient tolerance than the old medications of the 'One Flew Over the Cuckoo Nest " era.  No longer do patients do the "Thorazine Shuffle" or feel like they are in the Haloperidol 'chemical straight jacket.'  While some patients liked Haldol, even, with the introduction of Flupenthixol there was a breakthrough in well tolerated medications. Today my patients tell me how much they like the Paliperidone Intramuscular monthly mediation and the Long Acting Abilify and even the every 2 week Long Acting Rispiridone.  The safety to the individual and the community is central.  I hope for this man's sake and for others as well that he will be on an Injectable Antipsychotic for life.  Otherwise, frankly, knowing what I do about the disease and violence, I won't be taking buses anytime soon.