When mentally ill make threats, can we afford to call their bluff?

“I am desperately pleading for your help with an urgent matter,” read an email sent to KIRO Radio in early July.

“I could die on July 13th,” the subject line read.

The sender was a 44-year-old Seattle woman named Marcia who believed she was at risk of a psychotic break.

“If I have a psychotic break, that means that I may not know what I’m doing and I may injure someone else unintentionally and that is my worst fear,” said Marcia, as she fought back tears at the public library in Northgate. “I do care about my own life, but I really care about everyone else’s safety more than my own and I don’t want to hurt anybody else.”

Marcia, who said she suffers from a long list of mental illnesses, had just been notified that she would be dropped as a patient by Northgate Family Medicine, a University of Washington neighborhood clinic where she had been seeing a primary care physician for seven years.

As a result, she said, her prescription medication would run out on July 13. Without it, she feared she would end up hurting herself or others and, if she did, wanted the public to know why it happened.

“So often we are left wondering how and why such senseless tragedies occur,” she said.

In the city of Seattle, two high-profile events in particular have raised awareness of serious mental illness and the dangers that can arise when it is left untreated.

In May 2012, a man named Ian Stawicki opened fire inside a cafe in Seattle’s Roosevelt neighborhood, killing four and injuring another. He went on to fatally shoot a woman in a downtown parking lot before killing himself as police surrounded him on a sidewalk in West Seattle. In the media, Stawicki was painted as a troubled man whose family said he suffered from a mental illness that was never diagnosed.

In August, a King County bus driver was shot multiple times at Third Avenue near University Street. The gunman, 31-year-old Martin A. Duckworth, was shot and killed by officers as he boarded a different bus near Second Avenue and Seneca Street. Police said Duckworth had a documented history of mental illness.

An estimated 400,000 people in King County suffer from a mental illness, according to numbers provided by the county’s mental health division. Of those, roughly 100,000 have a mental illness that is considered serious in that it affects their ability to function normally.

Marcia is one of those people.

According to medical records she provided, Marcia suffers from generalized anxiety disorder, depression, prolonged post-traumatic stress disorder, borderline personality disorder and agoraphobia – a condition that she said causes her to panic in unfamiliar environments. She had been stabilized for years on Alprazolam – a generic form of Xanax – and Vistaril, which is an antihistamine that helps to treat her anxiety.

“My depression and my overall symptoms have improved,” she said. “I’ve seen a significant ability to live my life, essentially.”

Which is why she was concerned when UW Medicine informed her that she would no longer be allowed at the Northgate clinic – or any other UW neighborhood clinic, for that matter.

Dr. Peter M. McGough, chief medical officer of UW Neighborhood Clinics, told KIRO Radio that he signed off on Marcia being dropped as a patient, but was prevented by law from discussing why. He said UW Medicine drops several patients each month, sometimes a few every week, many of whom suffer from a serious mental illness.

According to a letter the clinic sent to Marcia in June, her case was being terminated as a result of “non-compliance with proposed health care plans and threatening behavior.”

KIRO Radio learned that Marcia had refused to submit to random urine analysis samples that would have let doctors know if she was taking any drugs that could interfere with her prescribed medications. It was also discovered that Marcia had been recording visits with her doctor without his knowledge, which is something that Marcia admitted to.

“It’s difficult with patients who refuse the help they need, and all they want is the drugs they want,” Dr. McGough said. “In this case, it was my sense that we gave her additional options which she then refused.”

When asked why UW Medicine would not have ensured that Marcia had continued access to care and medication prior to dropping her as a patient, Dr. McGough said she was referred to the Harborview Adult Medicine Clinic, but refused to go. He said Marcia had been given a month’s notice of her termination; plenty of time to find another provider if she were willing.

Marcia refused to find another doctor. She said she “had done nothing wrong,” and that her agoraphobia would make it difficult to get treatment in an unfamiliar place.

“They put me in this situation,” she said of UW medicine. “And if they’re not going to remedy it, then things will have to take their course.”

So, in mid-July, Marcia said she ran out of medication.

As the weeks went by, she became increasingly agitated.

In a voicemail on July 30, she explained that she had to cancel an afternoon interview with KIRO Radio because she thought she would be dead by then.

“I don’t think I’m going to be around this afternoon,” she said. “I’m not doing very well. It doesn’t look like I’m going to make it much longer. Anyway, thank you for your kindness and everything.”

During a phone conversation on August 1, her mood shifted from sadness to anger. In between sobs, she threatened to confront her old doctor.

“Do you think that if you knew where he was and you weren’t stable, you might go try to find him?” she was asked.

“To hurt him,” she said. “To make him know what it feels like to feel all of this. To be in agony.”

Acting on advice from UW Medicine and law enforcement officials, KIRO Radio placed a call about Marcia to King County Crisis and Commitment Services, a hotline that receives thousands of calls each year about people who have expressed suicidal or homicidal ideation.

Crisis and Commitment staff are part of King County’s Mental Health, Chemical Abuse and Dependency Services Division and are responsible for evaluating people with mental disorders for possible involuntary detention in psychiatric facilities in accordance with state law.

“It’s very difficult. It’s a very stressful job,” said Amnon Shoenfeld, director of the county’s mental health division.

In 2012, mental health professionals in King County visited and evaluated 5,907 individuals for potential commitment. According to Shoenfeld, roughly 60 percent of those individuals met the standard for involuntary commitment. He said the county’s commitment rate has gone up 50 percent over the past five years.

Marcia did get at least one visit from mental health professionals following statements she made to KIRO Radio, but the threats she made were apparently not enough to meet the standard for commitment.

“Because someone says something, doesn’t mean that they have intent. Part of the difficult job of the mental health professional is to figure that out,” Shoenfeld said. “Is this person serious? Is this a cry for attention?”

Marcia told KIRO Radio in an email that when Crisis and Commitment staff came to her door she denied being homicidal or suicidal.

Shoenfeld acknowledged that Crisis and Commitment staff have made mistakes, but they have to rely on the information they have at the time.

“Mental health professionals have to make difficult decisions every day, knowing that if they make a bad decision or make a wrong decision there could be some serious repercussions,” he said. “That’s the reality that we have.”

Shoenfeld said state law does not give mental health professionals the authority to force someone like Marcia to see a doctor on an outpatient basis, which means that Marcia could be without medication indefinitely if she does not decide to seek out a new primary care physician.

“It is very important to understand the distinction between somebody who has a mental illness and somebody who is incompetent and can’t make any kind of decision,” Shoenfeld said. “The idea that we kind of stigmatize people with mental illness as people who can’t do anything, can’t make decisions for themselves, is really insulting.”

Marcia stopped returning phone calls and emails for this story in mid-August. Recent attempts to check on her at her apartment in the Maple Leaf neighborhood were unsuccessful.

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