Drendell Willis was burning alive.
Delirious with fever, he staggered through the streets of Albany, Ga., on a hot spring day. He found a doctor's office, but collapsed outside. At a nearby emergency room, a nurse recorded Willis' body temperature: 108 degrees, as high as the digital thermometer would register.
Minutes later, a doctor pronounced Willis dead. It was April 20, 2006.
Forty-eight hours earlier, Willis, 38, had checked out of a state psychiatric hospital, smiling and thanking doctors for getting his psychosis under control.
In five stays at Southwestern State Hospital in Thomasville, Willis had been nothing but trouble. He tried to hang another patient with a sheet. He toppled a piano. He exposed himself to patients and hospital workers.
He was so violent and so disruptive that doctors tried to transfer him to another state hospital for electroconvulsive therapy. That hospital refused to take him.
At one point, Willis' doctor prescribed an injection of an anti-psychotic medication "every time patient opens mouth."
Each hospital admission followed a pattern: Willis would act violently, doctors would subdue him with medications, and then, while he was still placid, they would discharge him.
Willis' death, too, followed a pattern, an investigation by The Atlanta Journal-Constitution shows.
Since 2002, at least 10 patients from Georgia's state mental hospitals have died after inadequate discharge planning, the Journal-Constitution found by reviewing medical files, court records, police reports, autopsies and other documents.
These deaths underscore twin failings of Georgia's mental health system: The seven state hospitals are chronically overcrowded and understaffed, forcing patients out into the surrounding community to seek treatment. But services in communities are hard to come by, and many patients --- particularly those like Willis, with mental illnesses that seem beyond control --- end up with no care at all or back in the hospitals again and again.
The way Georgia's state hospitals plan for patients' care after their discharge is among the topics on which the U.S. Justice Department will focus as it investigates possible civil rights violations in the facilities. The inquiry, announced in late April, began after the Journal-Constitution reported that at least 115 state hospital patients had died under suspicious circumstances from 2002 through 2006.
Few experienced as spectacular a collapse as Willis.
From an early age, trouble
By the time he was 14, Drendell Willis already was taking lithium, one of the earliest drugs used to treat manic depression. It didn't really help.
"He's been a mental patient as far back as I can remember, " said his aunt, Frances Judge, of Albany.
Willis first got into trouble as a teenager; he later told a psychiatrist he had been sent to a juvenile detention center for "breaking dishes." From an early age, Willis' medical records say, he had "an extensive history" of substance abuse: alcohol, marijuana, crack cocaine.
When Willis was 26, a jury in Wilkes County in eastern Georgia convicted him of burglary, shoplifting and other crimes. Willis entered Georgia State Prison, the maximum-security facility in Reidsville, on Valentine's Day 1994.
Willis later told a doctor that another inmate had sexually assaulted him. So he spent much of the next eight years there in solitary confinement, by choice.
"He was afraid of the other inmates, " his aunt said. "He would just do something to get them to put him in isolation."
Rather than release him when his sentence expired in 2002, prison officials sent Willis to the state psychiatric hospital in Augusta, East Central Regional. A review of his medical records indicates that the first of what would become repeated admissions to state hospitals did little to slow Willis' downward spiral.
In January 2004, shortly after he moved to Albany to be near his aunt, Willis entered a mental health crisis center in Albany. When he tore a sink off the wall and flushed keys down a toilet, the center's staff had him involuntarily committed to the nearest state hospital.
Southwestern State kept Willis for about five weeks. When he left on Feb. 23, 2004, a doctor assessed his prognosis: "fair."
Between hospital stays, Willis usually lived in a boardinghouse in Albany. There, owner Kenneth Price said, Willis was responsible for managing his own illness. Willis had barely lived on his own as an adult, and had shown little ability to cope with routine responsibilities. But whether he made appointments to see his doctors was up to him. So was whether he took his medicine as prescribed.
'Very shaky condition'
Southwestern and the other state hospitals routinely discharge patients like Willis to places where their chances for recovery --- or even survival --- are slim, at best.
A Journal-Constitution analysis of state records shows that about 5,000 times between 2002 and 2006, the hospitals released patients to homeless shelters, bus stations, motels, even streets and abandoned buildings.
Many leave the hospitals with no more than a week's worth of medicine and no more than a vague plan for continued treatment. They may have follow-up appointments with psychiatrists, but not until as long as two or three weeks later --- after their medication runs out. At Georgia Regional Hospital/Atlanta, for instance, departing patients may get little more than the address of a homeless shelter and a ride on MARTA.
"People tend to get released in very shaky condition, " said Janet Grayson, a former staff attorney at the Atlanta hospital. She now represents patients who have been involuntarily committed.
The hospitals are supposed to hold any patients deemed to be a threat to themselves or others or who cannot care for themselves. But when the hospitals are crowded, Grayson said, "the pressure to get rid of patients leads them to lower the bar on that standard."
Often in such situations, she said, "the person is pretty much alone in the world."
These patients frequently return to the hospital within a matter of days or weeks, records show.
The readmission rate to Georgia psychiatric hospitals is more than 50 percent higher than the national average, according to a state-sponsored study from 2005. State records and lawyers and advocates for people with mental illness describe patients who have come and gone from state hospitals 40, 50, even 70 times, with little or no improvement in their conditions.
Indeed, Willis was back at Southwestern State not even three months after his first discharge.
He stayed four days, until medications calmed his outbursts. Then he moved into the boardinghouse, using his monthly disability check to pay the rent. After exposing himself to other residents of the boardinghouse during a psychotic episode, he returned to Southwestern State on March 31, 2005.
In Willis' medical file, doctors reduced his behavior this stay to a single word: "bizarre."
He drank soap. He sometimes dropped to his knees to simulate sex acts.
And he turned violent. He struck a sleeping patient in the head with a chair; the man needed 11 staples to close his wound.
Willis' outbursts exasperated the hospital staff. About a week into his stay, one of Willis' psychiatrists, Dr. Pamela Carter, issued a standing order to give him a shot "every time patient opens mouth" or "exhibits sexually inappropriate behavior" --- as many as 10 injections a day. Those injections of an anti-psychotic medication formerly known by the brand name Thorazine would total 500 milligrams, triple the average daily dosage for patients with severe schizophrenia.
After Willis overturned a piano, doctors further increased his medication. The higher dosages sedated Willis enough to control his behavior; doctors said they no longer considered him a danger to himself or others, the key standards for involuntary commitment.
They discharged Willis on May 18, 2005. This time the doctors downgraded his prognosis to "guarded, " and a hospital van carried him back to the boardinghouse.
Not 'optimum placement'
Every two weeks or so, a white van pulls into the parking lot at MUST Ministries of Marietta, which operates the only emergency shelter for homeless people in Atlanta's northwest suburbs. Usually, one or two passengers, clutching a few papers and a plastic baggie containing several pills, stumble out before the van drives off.
This, according to MUST officials, is how the state hospital in Rome, Northwest Georgia Regional, discharges patients who have no home or no other place to go --- with little or no notice to the shelter and, apparently, with little or no plan for how the patients will cope with their illness on their own.
Like most others, the Marietta shelter has no mental health professionals on its staff, and barely enough workers and volunteers to manage the daily chaos of caring for nearly four dozen homeless people.
"It is an issue of being able to support them appropriately, " said Stephanie McKay, MUST's housing director. "We just are not able to do that."
Officials at the Georgia Department of Human Resources, which operates the state hospitals, said patients leaving in stable condition make their own decisions about where they go. Rather than telling former patients where they should live, "our job is to have services and resources in place to help them get better, " Dena Smith, a spokeswoman for the department, said Friday.
In an interview last November, Gwen Skinner, director of the agency's mental health division, said: "Do we think that a discharge to a homeless shelter would be an optimum placement? The answer to that is no."
Experts in psychiatric care say discharging patients into homelessness is an especially troubling practice.
"I can't conceive that a homeless shelter is a place where I could discharge a patient to, " said Dr. Sidney Weissman, a psychiatrist who teaches at Northwestern University's medical school in Chicago. "It's a place to sleep. . . . These are hard people to treat with everything in place. So when you don't have everything in place, it's much harder."
Weissman and others say patients should remain in mental hospitals until their conditions are stable. Discharge plans, experts say, should revolve around strong community-based services that make sure patients take their medicines and that assist them with housing, medical care and therapy, among other needs. In Georgia, though, budget cuts have made such follow-up services scarce.
In an April report on the state hospital in Atlanta, Virginia-based behavioral health consultant Diane Grieder wrote that its "discharge plans are not real, relevant or clinically or personally useful."
Off his medication
When Willis returned to Southwestern State on Sept. 10, 2005, he said he had been off his medication four or five months --- in essence, since his last discharge.
He was actively hallucinating, doctors noted. Willis told them he heard voices saying, "Behold, the Great Knight." He called himself "Black Lord" and announced, without prompting, that he did not "rape anybody."
This stay was his rockiest yet.
Sept. 14: With no provocation, Willis kicked and struck what a doctor described as a "vulnerable" patient. Hospital workers placed him in restraints.
Sept. 16: Willis trapped a staff member in a bedroom. Workers placed him in restraints again.
Sept. 19: After he injured two more patients "significantly, " medical records say, doctors tried to transfer Willis to Central State Hospital in Milledgeville for electroconvulsive therapy. Central State said it had no room for him.
Oct. 14: Willis ripped a pipe out of bathroom plumbing and used it to strike another patient.
Oct. 24: Willis threatened to incite a riot on his hospital unit. He calmed down after talking to a therapist about his childhood --- then, unprovoked, punched a young mentally retarded patient.
Nov. 14: Willis became aggressive again after doctors reduced the dosage of his anti-psychotic medication.
Nevertheless, they prepared to discharge him.
By then, a physician wrote in Willis' file, "he would threaten staff only when his demands were not immediately gratified. Likewise, he argued with peers over snacks and cigarettes but not over delusions. . . . He had reached maximum hospital benefit."
His prognosis: "guarded because of his anti-social behavior."
Willis returned to his boardinghouse in Albany, with predictable results.
He got into a dispute with the owner over his disability check. They scuffled in the street, the police came, Willis struggled with the officers, and he wound up in the Dougherty County Jail. Thirteen days later, he was back at Southwestern State.
In his medical file, doctors described Willis as "difficult to stabilize" and "extremely psychotic." If anything, his violent behavior had escalated since his last admission.
Two days after he entered the hospital, he tried to hang another patient with a sheet. About a week later, he bloodied a technician's lip. He struck a patient in the head with a deodorant can. Then he punched a technician, breaking the man's nose.
"From that point on, " said Judge, his aunt, "it was just a downhill slide."
Willis' father, Ralph, who lives near Chicago, said a hospital social worker told him that because of the attack on the technician, she would no longer get within 20 feet of his son.
The doctors, meanwhile, again increased Willis' medication. The effect, records show, was to sedate him so heavily that his blood pressure dropped to 114/50, and his pulse rate soared to 142.
Hospital employees stimulated and hydrated Willis, and his vital signs improved.
"It sounded like they had doped him up and wanted to get him out while he was under the influence, " Willis' father said.
Two of the physicians who treated Willis, Drs. Pamela Carter and Gary Carter, a married couple who both practice at Southwestern State, declined to comment.
By mid-April, doctors had decided Willis was responding well to therapy. No psychosis was evident, they wrote in his medical chart.
They discharged him on April 18, but with a warning, records show: Two of the medicines they had prescribed would make him unusually sensitive to sun and heat.
Willis smiled, the doctors wrote. He told them, "Thank you for all you've done."
A hot spring day
April 20, 2006, was hot for a spring day. Albany recorded a temperature of 89 degrees, the highest yet of the year.
Willis had been back at his boardinghouse for two days. Already, a doctor from a community mental health provider had prescribed new medications for him, state records say. It isn't clear, however, whether he actually had begun taking them.
Shortly after lunch on April 20, wearing a plaid short-sleeve shirt and long green pants, Willis left the boardinghouse on foot. No one knows where he was headed. But he apparently wandered for at least three hours in the hot sun --- exactly the kind of activity his doctors say they had warned him against.
Late in the afternoon, his temperature spiking, Willis collapsed on a ramp outside a doctor's office. At the emergency room, nurses packed him in ice. He died anyway.
An autopsy determined that Willis died from neuroleptic malignant syndrome: a heatstroke induced by his anti-psychotic drugs.
The medicine that was supposed to control his behavior ended up killing him.
At Southwestern State, Drs. Gary and Pamela Carter signed a report summarizing Willis' last hospital stay. The report detailed their decision to discharge him despite their doubts about his potential for success on his own.
Willis, they noted, had a "history of noncompliance" with medication orders and a "history of polysubstance dependence." They described his prognosis as "guarded."
By then, he had been dead five days.
Where do they go?
About 5,000 times from 2002 through 2006, Georgia's state psychiatric hospitals discharged patients to places where continuing treatment and other services were most likely unavailable. Total discharges over that period numbered about 70,000.
Here's a look at how the questionable discharges break down among categories listed by the hospitals:
3,567 to homeless shelters
408 to boardinghouses
351 to bus stations
250 to hotels/motels
38 to streets ("public park, bridge, etc.")
6 to public buildings
3 to "car or abandoned house/building"
393 to unknown
Source: AJC analysis of data from the Georgia Department of Human Resources.
ABOUT THIS REPORT
This is the sixth in an occasional series of reports on Georgia's state psychiatric hospitals. Previous articles reported on the suspicious deaths of at least 115 patients from 2002 through 2006, on more than 190 substantiated abuse cases, on patient suicides, on escapes and on the prevalence of patient deaths from bowel obstructions and similar conditions.
Future articles will examine how the state deals with mentally ill defendants from the criminal justice system.
Today's main article on Drendell Willis is based on a review of his voluminous medical chart from Southwestern State Hospital, which was obtained by attorneys for his family; state reports on his death; an autopsy report; and interviews with family members.
Articles in this series were reported by staff writers Alan Judd and Andy Miller. To contact the reporters, call 404-526-2640.