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Book Review

The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens

Joe P. Tupin, MD

Published: June 15, 2010

The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens

by E. Fuller Torrey, MD. Norton, New York, NY, 2008, 265 pages, $25.95 (cloth).

In The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens, E. Fuller Torrey, MD, presents a lucid history of the impact of changes in mental health care beginning in the 1950s. Following World War II, a number of revelations of scandalous conditions in state mental hospitals came to light. These revelations were followed by legal initiatives designed to address problems of crowding, lack of treatment, obsolete facilities and equipment, and other conditions. At about the same time, the first effective psychopharmacologic agents were introduced, and community-based care emerged. Deinstitutionalization of patients followed, often to an unprepared community and minimal and often untrained professional staff. Dr Torrey notes that, in 1955, there were 558,000 mentally ill persons in public mental hospitals, while in 2006 there were only 40,000. So an old system collapsed, and within decades thousands of seriously ill patients were on the streets, often with little access to care or community or family support.

Legal challenges that reflected the 1960s’ preoccupation with civil rights produced radical changes in involuntary treatment laws. These new laws required court hearings to interpret and apply standards such as danger to self or others and gravely disabled. Involuntary hospitalization was measured in days, not weeks. In California, the standard was 3 days of initial hospitalization, followed by 10 more days if approved in a court hearing. Thus, treatment was focused on medication, and it relied on well-coordinated outpatient care and patient motivation. These processes made it almost impossible to treat poorly motivated patients who did not recognize that they were ill.

Dr Torrey estimates that there are 4,000,000 persons in the US who have serious psychiatric disorders.1(p5) And further, 400,000 of these are not aware of their illness. This lack of self-awareness, anosognosia, creates a significant group that often is untreated and resides in communities or spends time in jail and brief hospitalizations. Members of this group are often homeless, incarcerated, and victimized. A subset of 40,000, 1% of the total 4,000,000 severely ill, Dr Torrey declares are dangerous.

The book includes several detailed case studies that illustrate the failure of the current system in different states. In these cases, families were unable to access care, and clinics were unable to elicit or require cooperation of patients, thereby exposing communities to psychosis-driven killings. Legal and legislative advocates of civil rights protection for the mentally ill who do not recognize the need for treatment, sometimes on an involuntary basis, do serious harm to families, communities, and patients. These case studies are the backbone of Dr Torrey’s book, and they will ring true to all clinicians and families that have been unable to provide care to the patients. All of the cases presented resulted in killing as a consequence of poorly or untreated psychotic behavior.

Dr Torrey explores the consequences of a policy of unconstrained civil liberties in two chapters, 8 and 9, and he emphasizes homelessness, incarceration, victimization, violence, and homicide.

Change, in the form of legislation to authorize involuntary treatment of outpatients, has now been enacted in several states and, when implemented, as in New York State with Kendra’s Law, can substantially improve care of the mentally ill. However a similar action, Laura’s Law, passed in California but has failed to be widely implemented.

Thus, the problem continues in many states. I hope this book will be a part of continuing efforts to find a balance between patient civil rights and the right to refuse treatment, on one hand, and public safety for all of us on the other. Those in mental health advocacy groups, professionals and legislative bodies will find Dr Torrey’s book a useful resource that provides information on the current status of psychiatric care and its historical context.

Dr Torrey’s numbers and other details can be challenged, but the flow of events and the fact that patients are on the streets and sometimes dangerous are well documented and placed in a historical setting by him.

I recommend The Insanity Offense to clinicians, families, and those in judicial, legislative, and legal activities involved with care of the seriously mentally ill.


1. Torrey EF. The Insanity Offense: How America’s Failure to Treat the Seriously Mentally Ill Endangers Its Citizens. New York, NY: Norton; 2008.

Joe P. Tupin, MD

Author affiliations: School of Medicine, University of California, Davis, Sacramento, California.

Potential conflicts of interest: None reported.

Volume: 71

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