Minutes before 11 p.m. on Oct. 18, 2010, two strangers sped toward a shared fate on a highway outside Seattle.
Behind the wheel of a Subaru wagon was Adam Knapp, 30, a schizophrenic 2,400 miles from home. Eighteen days earlier, he had slit his wrists and swallowed two bottles of pills in a suicide attempt. Three hospitals admitted him. None kept him, and now he had taken off in a car alone.
“He wasn’t ready to come home,” said his mother, Marcia Knapp, who wanted Adam to remain hospitalized.
Elisa Mefi, 31, was driving a Ford Explorer. She had just picked up her sister from work. They laughed and talked about new hairstyles until they saw the headlights of Adam’s car coming at them.
Adam had U-turned into oncoming traffic. On impact with his car, Elisa’s side of the Explorer crumbled. Once his car came to a halt, Adam climbed out, jumped over a guardrail into traffic and was hit by five vehicles. He died at the scene. Elisa succumbed to injuries three weeks later.
Their deaths lay bare continuing failures of the U.S. health care system in treating the seriously mentally ill. Adam’s parents, Dan, 58, and Marcia, 54, say he died because a series of hospitals sent him home too soon in the turbulent final months of his life.
The Knapps were at Midway Airport in Chicago, changing planes on their way to find him, when they received a cellphone message from his sobbing sister. Marcia phoned the Ohio State University Medical Center, which had last seen him.
“You killed my son,” Marcia told the nurse who answered.
Decades after antipsychotic drugs emptied many state psychiatric hospitals, fewer than 46,000 of the seriously mentally ill remain institutionalized in long-term care, vs. 559,000 in 1955. The decline was made possible by the discovery of one powerful drug after another — first, Haldol and Thorazine, then Abilify, Seroquel and Zyprexa, a trio in widespread use with $18 billion in annual sales.
Less noticed than the drug advances is the diminishment of acute care for the mentally ill — the kind of hospitalizations sought during times of crisis. The duration of these stays has dropped to 7.8 days in 2009, the last year of available data, from 12.8 days in 1993. Adam’s final stay, at Ohio State University Medical Center in Columbus, lasted a week.
“We were deeply saddened by Adam’s death and wish to express our sorrow and sincere condolences to his family,” the hospital said in a statement. Doctors declined to speak about the particulars of Adam’s care.
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Born in 1979, Adam grew up in Munroe Falls, north of Akron, Ohio. Dan was a mortgage banker; Marcia, an office manager and receptionist. He had a younger brother, Jason, and an older stepsister, Melissa.
Adam showed no early signs of a tortured mind. He was athletic and did well in school. He started college in Ohio, transferring to Washington State University in Pullman in 2001. The Knapps had vacationed in the state, and Adam nurtured a love for the outdoors. Jason planned to attend college in the Northwest, so Dan pursued a transfer and the Knapps moved to Federal Way, outside Seattle, following Adam’s junior year.
After graduation, Adam moved in with his parents and took a part-time job stocking shelves at Trader Joe’s. The first signs of darkness came about a year later, when he told his mother, “I don’t think I’ll live to be an old person.” One night, Marcia was watching television in the family room when Adam returned from a jog and pulled up a chair.
“I’m hearing voices,” he said.
Although her husband believed it was a case of depression that would fade, Marcia’s research discovered that imagined voices pointed at schizophrenia.
Dan’s company closed its Washington offices in 2003, so the Knapps returned to Ohio, where Dan found a new job. Adam refused to come.
He began living out of his car, and ceased contacting his parents. Then, in June 2004, he arrived unexpectedly in Ohio, beginning a six-year journey that pitted his erratic behavior against the efforts of his parents and doctors to help him. His seven hospitalizations rang up $142,000 in charges, and he used at least four types of antipsychotics and other prescription drugs.
When he told his parents soon after returning to Ohio that he was going to kill himself, their hopes actually rose. They already knew that those who could help wouldn’t act unless they had evidence of danger to himself or others.
At the Ohio State hospital emergency room, a doctor declined to admit him. Although he had told the police about the FBI following him, Marcia said, he wouldn’t talk about it in front of the doctor, who hadn’t read the police report.
“He had this doctor so buffaloed,” she said.
In October, he admitted himself to the Ohio State hospital. He was refusing medication, and the staff concurred with his parents’ wishes and obtained a court order to give him Haldol forcibly. He wound up taking it willingly during a 24-day stay.
The four years that followed encompassed some of the happiest memories of Adam’s adult life for friends and family. He got a job at a Trader Joe’s, gained weight, shaved his beard and dated again.
His reluctant parents relented when he pressed for a return to Seattle in 2007. He was now on Abilify, one of a class of “atypical” antipsychotics that cause fewer tremors and other side effects than earlier-generation schizophrenia drugs. He called home in the months that followed to talk about mountain hikes and fly-fishing.
Then came a call in June 2008 — at 4 a.m. Marcia’s heart sank. “He wasn’t making sense,” she said.
Dan and Marcia booked a flight. Adam met them at the airport. His stare was cold. Hoping for diversion, they traveled to a lodge on an Indian reservation.
“He looked out the window and wouldn’t talk,” Dan said. “He just kept crying.”
His paranoia grew after he agreed to return to Ohio. His mother took him to the Ohio State hospital, whose records say he complained of “being watched” and told doctors he “has computer knowledge which could ruin the world.”
He refused medications and left after six days. Two weeks later, his father watched as he threw water at a mirror and began to utter a rapid stream of babble.
In a six-day readmission, Adam took his drugs and left with a prescription for Risperdal, later changed to Abilify. By the following year, he was independent again, living in an apartment near his parents’ house. He was seeing family and friends, and appeared to be supporting himself.
No one knew it then, but Adam had entered a critical phase. He was beginning to keep more secrets. He didn’t let on that he had stopped taking his Abilify somewhere around April 2010, according to his mother, based on records of prescription refills she examined.
Trader Joe’s called the Knapps on Aug. 31 and told them he hadn’t shown up the last two days. His car was found in a ditch at the Lake Placid Golf Club in New York three days later. Asleep inside, he woke up and told police he thought he was in Massachusetts.
At Champlain Valley Physicians Hospital in Plattsburgh, N.Y., Adam wouldn’t wash or attend group sessions. Dan and Marcia successfully urged the staff to get an order for forced medication, and Adam went back on Abilify. Psychiatrist Scott McMahon pushed Anthem Blue Cross & Blue Shield, Adam’s insurance company, to cover more time. The Indianapolis-based Wellpoint unit had agreed to previous extensions, but this time, 11 days after he went back on medication, it said no.
The hospital appealed the decision and lost, according to McMahon, who said Adam needed at least seven more days to get the drug dosage right.
“They just want to know if he’s killed anyone or tried to kill himself in the last 24 hours,” McMahon said. “No? Then he’s got to go. These people have no morals or conscience.”
Anthem said in a statement that the company “does not dictate when a patient should be admitted or discharged from care.”
The night after his release, Marcia pounded on Adam’s bedroom door when he ignored a call to dinner.
” I’m going to break this down,” she said.
“You’re not going to like what you see,” he warned.
Adam was bleeding from a gash on his left wrist and had a smaller wound on his right wrist. He had swallowed 30 Abilify pills and the remnants of a bottle of decongestant, and in the emergency room said he wanted to “leave my shell,” according to Dublin Methodist Hospital records.
After three days, he was transferred to Riverside Methodist Hospital in Columbus, an affiliated hospital with a psychiatric unit, for specialized care. He was discharged after four days.
The Knapps opposed his release because, they said, they believed he was still paranoid, and they pushed, unsuccessfully, for a powerful injection of medication like the one that had worked in his 2004 hospital stay.
At home that night, Adam feared an attack by unknown enemies. At dawn, he said he needed to go back to the hospital. Once admitted, he turned down an “injectable med,” according to Ohio State medical records. Dan and Marcia said their plea for a court order forcing medication was ignored.
Adam’s discharge meeting was Oct. 15. His “symptoms lacked any acute features that warranted continued inpatient treatment” and the Knapps “verbalized an eagerness to have the patient return to their home.”
“That’s nothing but a lie,” Dan said. “What I said is, ‘How can you send him home? He’s still paranoid.’ ”
At a restaurant after his release, Adam told his mother he was going outside to make a call. Instead, he jumped in his car and took off for Seattle.
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In 1977, Tina and Max Mefi came to Washington from Samoa. Elisa was their firstborn. To her parents, two younger sisters, and eight nieces and nephews, who all lived under the same roof, she was simply “E.”
After high school, she got a job and began helping support the family. Until 2010, when she was laid off as a medical records clerk, she contributed to the monthly rent and bills, using her leftover money to take her nieces and nephews to the movies and McDonald’s.
The night of the crash, Elisa and a cousin picked up Elisa’s sister Pookah from her job. Pookah said they were talking about her decision to get her hair colored “when I heard my cousin say, ‘What the hell?’ I looked up and it was a car coming toward us.”
Adam’s Subaru hit the Explorer and careered toward an Acura Integra, which struck the rear of Adam’s vehicle, according to the police report. Adam pulled himself from the wreckage and jumped over the guardrails into the southbound lanes, where five vehicles struck him.
Pookah, hysterical, called Tina. With traffic jammed, the Mefis couldn’t get close by car and parked on a side road. On foot, Max managed to get through to the mangled Explorer and saw Elisa pinned behind the wheel.
“Dad, my side is paralyzed,” she said. “I can’t move.”
“Be strong, E,” Max told her.
Suffering from head and neck trauma, and multiple fractures, Elisa had surgery four times before Nov. 6, when she died.
Adam’s funeral was Oct. 24, 2010. Elisa’s was four weeks later.
If she could do it again, Marcia said, she would fight harder to keep her son in the hospital.
“Honestly, you just have to scream,” she said. “You have to scream, you have to yell, you have to do whatever it takes to have your child medicated.”