Monday, August 27, 2012

Privacy please....

Over on Clinical Psychiatry News, I have a an article up on medical privacy, HIPAA, electronic medical records, routine dental care, compliance and regulation, and yes, fish.  Surf on over if you get a chance.

Mitch & Wendy: Lost in Adventure Land

My last novel (at least for now and probably forever) is now available as a Kindle book for 99 cents.
Mitch & Wendy: Lost in Adventure Land.  It's a kids' book, meant for the 10 year old set.  No psychiatry.  There is a bad guy and a two scary chase scenes (the chapters are labeled "This is the scary part") so if you have a youngster who is prone to nightmares, perhaps you should read it first, and it's not for very young children.

After all three of my books become available as paperbacks, I will offer free promotions of the Kindle books. 

Product Description

It's Wendy's tenth birthday -- double digits at last -- and she goes to an amusement park with her mother and her brother, Mitch. The day, however, gets off to a bad start. Her best friend has a fever and can't come. The day only gets worse when Mitch and Wendy get lost in the park, only to meet up with a strange man who seems to know all about them.

Two siblings struggling with major changes in their family find themselves in a scary situation.

Written for 4th to 6th graders, Mitch and Wendy are trying to renegotiate their relationships with their parents and with each other following their parents' divorce and remarriage. Mitch escapes to Facebook and a sports friend he meets there who seems to really understand, only to face disastrous consequences.

Thursday, August 23, 2012

Double Billing is Available as a Kindle e-Book

My novel, Double Billing, is now available as a Kindle e-book for $2.99.  The paperback version will be out in a couple of weeks.
A little less psychiatry than Home Inspection, which is also available as both an e-book and a paperback on Amazon.
Cover art by Natalie Adachi.

As always, if you read my books, I encourage you to put a review on Amazon.

Coming Soon --  Mitch & Wendy: Lost in Adventure Land.

Call the Police

What should you do if you believe someone is dangerous?  It's a sticky issue in psychiatry.  Here in Maryland, the requirements to have someone brought to an emergency room for evaluation by two physicians, include an imminent risk of dangerousness and the presence of a mental disorder.   If an emergency petition is signed by a judge, the police pick up the person in question and bring him to an emergency room for an evaluation.  In the ER, doctors can decide to certify the patient to an inpatient unit for further evaluation, or they can release the patient.  If admitted, a hearing must be held within 10 days.

Who else can file a EP?  Well, the police can.  If someone acutely agitated and violent and there is no time for a family member or interested party to obtain an EP, the police can be called and they have the option to fill out an EP and take the person to the hospital without a judge okaying the EP.  Depending on the circumstances, they also they have the option to arrest the individual and bring them to jail.   Finally,  a doctor can file an EP, but s/he must have seen the patient (--you can't get tell your rheumatologist-neighbor about your ill relative and get him to file an EP). 

So the police come -- either because they've been called in an emergency, or because a judge has authorized them to take someone to the hospital.  Most of the time, this goes smoothly.  But it doesn't always, especially since the person involved is presumably mentally ill and dangerous (the criteria for getting the evaluation).  Sometimes things get very upsetting, and sometimes they go very badly and someone gets hurt. 

In today's Baltimore Sun, there is an article by Justin Fenton that questions whether our police have the proper training to handle these crisis situations:

Baltimore Police have shot 10 people this year — eight of them fatally — leading some to question whether police are properly equipped to handle calls involving the mentally ill.

Only one of those shot was carrying a firearm, and several shooting incidents arose from calls to police about a disturbance involving someone with a mental illness. Relatives of some of those killed criticized police tactics, saying they shouldn't have lost loved ones after calling police to defuse situations that had ended peacefully in the past.

These are difficult situations, sometimes with no answer that will lead to a good outcome.   Fenton continues:

The director of the city's mental health organization praised the Police Department's training effort and said services for the mentally ill are lacking.

"If we don't do a good job getting people into treatment and something bad happens, we look to the Police Department and ask why did this person get shot," said Jane Plapinger, the president and chief executive officer of Baltimore Mental Health Systems. "Maryland is one of the best, but we unfortunately have an underfunded public mental health system everywhere in this country."

The Behavioral Emergency Services Team, or B.E.S.T. training, was implemented in 2009 and teaches officers to de-escalate mental crises, minimize arrests, decrease officer injury and direct patients to the city's mental health crisis programs for help. It has become mandatory for recruits.

"The police have been such a steadfast partner — I don't know how many [other] police departments are devoting four full days to this kind of training," Plapinger said.

The patients aren't the only ones in danger.  Police officers, or others, can be injured in these struggles. While it's not like there is an obvious answer besides calling the police, if the situation does not involve immediate danger, I often suggest that family member work to de-escalate upsetting situations and  convince a patient to go for help voluntarily, or with coercion, because even if it's coerced, these situations are often less upsetting for the patient and less dangerous for everyone if they can be done without the police.  Of course, this involves 20-20 hindsight, and the use of a crystal ball, because if there is a bad outcome and someone is injured or killed, then calling the police would have been a better solution.

I do wish I had that crystal ball. 

Wednesday, August 22, 2012

Home Inspection is Now Available as a Paperback from Amazon

Home Inspection is now available as a paperback on Amazon. 

There is free shipping for Amazon Prime members, and Prime members can also borrow the book for free from the digital lending library.  Gift wrap is available.

Double Billing will be available shortly.  Maybe very shortly.

Monday, August 20, 2012

We Have An App

Just thought our readers might like to know that the Shrink Rappers now have their very own iPhone app! If you're tired of repeatedly checking iTunes to see if the latest podcast is up, you can now open this app and have us all right at your fingertips. It works on Android phones too. Just click on the link below and when it prompts you to "install on your desktop," do it.

How About a Little Inspiration?

Anyone who knows me as a therapist knows that I believe that change is difficult, and that for the most part, people come flawed.  We seem to spend an inordinate amount of time identifying and trying to fix our flaws so that we conform to some standard of how we're supposed to be, and this leads people to feel badly about themselves and have the infamous  Low Self-Esteem.  Or to feel badly that they aren't richer, prettier, smarter, tougher, whatever.  

I think people should come to terms with who they are and say Yup, I suck at this.  And then they should not spend much time thinking about what they are bad at and they should figure out what things they like and how to grow those aspects of themselves and make those characteristics work for them so they can live a more fulfilling life.  

Obviously, there are exceptions, and I don't think people should say, "Yup I'm a sociopath and I kill people, get used to it,"  Nor do I think people should embrace their mental illness without trying to get help.

That said, and with minimal relevance to what I really want to share, I really enjoyed this TED talk by Dan Gilbert on the pursuit of happiness, and I hope you will too.  I wish I could speak like this (maybe with a little bit more air exchange).  And I stole the Seuss cartoon from Kathy's facebook page.  Enjoy.

Sunday, August 19, 2012

Psychiatry Around The Web

I just thought I'd share a bunch of links with you, no specific theme.

The New York Times has a piece by a mom about Ritalin as a treatment for a disorder versus a academic enhancer -- I enjoyed this, and while some children really need the medication to make life work in any reasonable way, we should be questioning the use of medicine as treatment versus making someone the best they can be, at a cost.  Raising the Ritalin Generation

So psychoanalysis is big in Argentina.  Who knew?  I'll go have me a steak and get myself analyzed.  Do Argentines need therapy? Pull up a couch.

The media tells us that Jared Loughner is now competent to stand trial.  He has pleaded guilty to the charges against him for the Tuscon shootings, a life sentence, no death penalty.  So it's over, no trial, no insanity defense.  He still remains in a forensic hospital, but I assume he will be transferred to a prison at some point.  Here is a video on World News with Diane Sawyer.

Oh, and there was an article I wanted to comment on about a violent patient in a state forensic facility who was deemed incompetent to stand trial and one of the attorney's was quoted as saying they would keep the patient there for now, treating him with "aspirins" or whatever.  But I can't access the article without paying a fee, much less the quote, and I really just wanted to say that I think those involved in the prosecution or defense of people with major mental illnesses might like to know that we have new treatments now that sometimes work better than aspirins.  And even if they don't, the attorneys might sound  a little more sophisticated if they referred to treatments with psychotherapy and psychiatric medications, rather than aspirins.  I hear it does help headaches.  No link, I'm not sure I have my facts straight so I'm just rambling here.

Thursday, August 16, 2012

Prognosis: Grave

Some of our readers would psychiatry to abolish diagnoses.  I would like us to abolish prognoses.  We don't know how patients will do.  We just don't. This is why.  

For ClinkShrink -- and all the Introverts I Know and Love

Our society values the qualities that go with extroversion.  You're supposed to be social, to get out, to collaborate, to gain energy from social events, and if you don't, damn it, well you're an introvert, or shy, or avoidant, or socially phobic.  "I wish Johnny got out more."  "I wish granny would go to the senior center."  We grow up believing that boys shouldn't wear dresses, that it's your fault if you're fat, and that it's of the utmost importance be outgoing.  Now introverts often do play well with others (Clink, in fact, plays very well, but don't ever try to get her to go out with you after she's in her pj's).  So I know several people who have gained some comfort from the book "Quiet: The Power of Introverts in a World that Can't Stop Talking" (that would be me, except of course on our podcasts where Clink just won't shut up).  So ClinkShrink enjoyed Susan Cain's book and even wrote a review of it HERE I found this TED talk by Susan Cain -- it's cute, funny, and insightful, so I thought I would share it. If you have other TED talks you've enjoyed, please do give me the links.  They don't need to be about psychiatry, but I enjoy funny and thought-provoking.  Thanks to Laszlo, I found this on his facebook feed.

Tuesday, August 14, 2012

Pink Boys

There was an interesting article in the Sunday New York Times Magazine on children who behave in ways that are inconsistent with the gender role expectations society holds for them.  The article starts by talking about a mom who e-mails the other parents in the  pre-school  to let them know their son is 'gender-fluid' and will be coming to school in a dress the first day.  

I spent a little more than a decade as a consultant to the Johns Hopkins Sexual Behaviors Consultation Unit (SBCU).  I also spent a few months working as a resident on an inpatient unit for people with sexual disorders-- though the two systems were completely different entities back then.  What differentiated whether a patient went to one versus the other was often a matter of legal involvement: someone who's sexual behaviors got them into legal difficulties (often people with pedophilia) were the domain of the Sexual Disorders group (they also had an outpatient component but I never worked there) and treatment sometimes included hormone injections to lower the patient's sex drive, along with individual and group therapy.  No one was admitted to this unit involuntarily, and no one was given hormones involuntarily.  The two units have since merged, but there is no longer an inpatient unit, it's all outpatient consultation.  Even back then, treating people with pedophilia was a logistically difficult thing: if a patient went to a psychiatrist and said "I've done this awful thing and I want to stop," it had to be reported (it still does) and there is no mechanism for getting help unless the patient requests it prior to acting on such urges, or after he's been caught and the assessment/treatment are part of his legal stipulation or defense. 

The SBCU  saw people with erectile dysfunction, couples with mismatched sexual drives, people who had troubles with all aspects of the sexual cycle (desire, arousal, climax, etc), those with fetishes,  and those with concerns about gender.  "Pink boys," a term I've never heard, would fall under that category.   Back then (the 1990's, early 2000's) the mentors of the unit felt that parents should encourage  their children to adopt gender-appropriate behaviors and play.  There was some thought that permissiveness around allowing Johnny to have a Barbie collection might encourage such things.  

In "What's So Bad About a Boy Who Wants to Wear a Dress"  Ruth Pawdawer, states:

Many parents and clinicians now reject corrective therapy, making this the first generation to allow boys to openly play and dress (to varying degrees) in ways previously restricted to girls — to exist in what one psychologist called “that middle space” between traditional boyhood and traditional girlhood. These parents have drawn courage from a burgeoning Internet community of like-minded folk whose sons identify as boys but wear tiaras and tote unicorn backpacks. Even transgender people preserve the traditional binary gender division: born in one and belonging in the other. But the parents of boys in that middle space argue that gender is a spectrum rather than two opposing categories, neither of which any real man or woman precisely fits. 

Twenty years ago I wasn't comfortable with the way psychiatry approached this topic.  I didn't believe that a child's gender role choices were necessarily 'choices' or that parenting styles (at least those those with-in some spectrum of "normal"), caused children to want gender-inappropriate dress/toys/identities.  The question remains, if this is who you are, shouldn't you come to some comfortable acceptance with yourself?  Unfortunately, our world is such that when a boy shows up at school in his princess outfit, other children might not want to play with him, and it can all make for a very confused, painful, and uncomfortable life, so professionals who encourage gender-appropriate roles aren't being mean or stupid or evil, they are just trying to figure out (with the benefit of a crystal ball) what will lead to the best result.  And this all occurs where both the individual involved may be fluid with their gender role (some pink boys turn blue), and society is fluid with it's acceptance of everything from left-handedness, to homosexuality, to it's stigmatization of cigarette smokers.  

 Around that time, my next door neighbor called me to ask if my son would like to take ballet lessons with her daughter (she was 2, he was 3 and they were best friends).  I asked my son, "Do you want to take ballet lessons with your friend?"  The 3-year-old considered this for a moment and said, "Is that a girl thing?  Do they have baseball lessons?" I don't think it was about parenting -- I would have sent him to ballet and assumed is was just another activity with a friend -- I think it was in his brain that made the girlthings-boythings distinction.

Interestingly, girls don't have these issues.  There are "girly-girls" with their interest in fairies and princesses, and there are tomboys who wouldn't be caught dead in a ballerina outfit.  We don't tend to worry about girls, and playgrounds  have the tomboys playing soccer on one side while the girly-girls play fairy princess on the other.  

The point of the article was that there are people who are struggling to deal with their children's gender issues -- it was more about the parents then the kids --  and while there are still no clear answers for what makes the happiest, most well-adjusted kid, there are those who believe that it's better to help a child accept who he is.

We now leave left-handers alone.  The Greeks were fine with their pedophiles.  Our society shuns them, more so then murderers.  Despite our growing rates of obesity, we still blame and ostracize those who are fat: shouldn't we teach people to eat and exercise in a healthy fashion, and beyond that to accept themselves with the awareness that people come in all sizes? And don't get me started on Presidential candidates.

I have no answers, I'll let you chime in.

Here's a link to the Hopkins Sexual Behaviors Consultation Unit. They list the conditions they treat and a phone number to schedule an assessment.  
Dr. Chris Kraft, their director of clinical services, has been a podcast guest with us on several occasions, see:
Podcast #21 Chris Kraft on Gender Issues
Podcast #41 Chris Kraft on Conversion Therapy 

Sunday, August 12, 2012

What Kind of Work is it I Do, Anyway?

I'm blogging during the closing ceremonies for the London Olympics.  As if there's not enough stimulation going on here....  

In Shrink Rap: Three Psychiatrists Explain Their Work, we talk about psychotherapy as a process that occurs over time where the talking is an integral part of the actual treatment; that is, it's the talking itself that facilitates the cure.  Traditionally, psychotherapy happens on at least a weekly basis -- sometimes twice a week -- and for psychoanalysis 3-5 times/week. Sessions are 50 minutes long and patients are often seen at a set time, for example, every Friday at 1pm. 

I think of myself as a psychotherapist because I see the majority of my patients for 50 minute sessions and people generally tell me about the events going on in their lives.  Unless someone is acutely symptomatic, very little of the sessions are devoted to symptoms, side effects, and medications, though certainly that is part of what gets discussed if there is a problem.  The assumption, however, is that there is more to the psychiatric treatment I'm doing then checklists of symptoms and medication adjustments that take place in a vacuum that does not include the patient's life events, past events (including childhood) and their emotional reactions to their world.  

Okay, so several readers and Amazon reviewers have commented on typographical errors in my e- novel, Home Inspection.  I recently got the paperback proof back, and with the help of one of our readers,  I've been re-reading it and going through the novel trying to see the words (and errors) my eyes (now on their zillionth reading) tend to simply not see.  

For those of you who haven't read Home Inspection, it's a story told by a psychiatrist through the sessions of two of his patients.  Dr. Julius Strand's life is a bit of a disaster: he continues to mourn the death of his first wife, his second wife kicked him out, he's living with his cat in an apartment full of unpacked boxes, his career has a crisis, his health is not good, and his relationship with his daughters is strained.  Patient Tom is a cardiologist who is having panic attacks as he starts building his dream house with a woman who is certainly not his dream woman, and Patient Polly feels 'stuck' in her life.  She struggles in her relationship with the psychiatrist and talks about her past begrudgingly, asking repeatedly if it will set her free if she talks about those past secrets.    Through a series of coincidences, their paths all cross, and somehow, the patients help to cure the doctor.  

The therapy that Dr. Strand does is a very conventional, psychoanalytically-informed therapy.  His patients come at the same time each week.  They talk about how past events inform their current behavior, and he thinks a great deal about how their relationships with him are relevant.  

It occurred to me as I was reading my own account of treatment (fictional though it may be), that I don't do really do this type of therapy anymore.  I'm not sure I ever did.  When people start therapy and are feeling badly, they generally come weekly, but as soon as a patient's symptoms get better -- often a matter of weeks to months -- they ask to come less often, and most patients come every two to four weeks.  Some I see on an irregular basis -- they call when they have a problem and want to come talk.  Therapy is expensive, and in our harried world, most people don't have either the time, money, or inclination for sessions once or twice a week. While there are people I tend to see on specific days or at specific times, most patients don't have a fixed regular session -- I think this is because I like having some flexibility to my schedule.  And while people do talk about what is going on in their lives, and I often will ask about how past events and emotions have impacted them, I don't spend much time focusing on the therapeutic relationship.  I won't say never -- and certainly,  the fictional Dr. Strand thought about it much more than he talked about it -- but it is not a major focus of treatment for most people.

So I think of myself as a psychotherapist, and I think of psychotherapy as a crucial part of treatment, but if I don't see most people for weekly sessions,  then what exactly is it I do?

And if you don't feel like talking about psychotherapy, by all means, tell me what you think of the closing ceremonies!

Wednesday, August 08, 2012

Does it Help to be an Optimist in Psychiatry?

I am basically an optimist (I think).  I feel hopeful about most things, and I have this funny faith that people are basically good.  When people come to see me and they are severely depressed, I think they are going to get better.  Mostly, they are kind enough to humor me and they do get better.  The statistics seem to suggest that SSRI's work 40% of the time, and while that does seem to be true for the first go-around, I've found that if I fiddle with the medicines, augment, switch, augment, tweak, that many more than 40% of people get better.  If someone is doing well, and suddenly feels down, I encourage them to return soon, talk about it a bit, and don't rush to changing the medicines at the first sign of "the meds aren't working and I'm a little down."  Often (but not always), people get better without increasing or changing medications.  Clearly, though, my practice is not the stuff of double-blind-placebo controlled studies.  I tell people they will get better, I look for the good in them, and I encourage people to look for their strengths and try to get the good parts of who they are to work for them.  

Some people would say this is wrong: I shouldn't tell people they are going to get better.  How could I know that (? experience), and I may be offering false hope.  I may be.  And I've had at least one patient tell me that I try to normalize problematic behaviors.  Most patients, however, seem to feel encouraged by my optimism, and boosted by the good things I see in them.  Ah, remember my post from long ago: What I Like About You.

Another psychiatrist I know says he thinks you have to be an optimist in order to be a good psychiatrist.  Really?  I don't know about that.  I'm kind of optimistic that pessimists can also be good psychiatrists.  What do you think?

Ah, comment moderation is on for the time being because some of our commenters have been shaking my generally positive faith in humanity and I find myself feeling a bit pessimistic about blogging.  As always, it's not the message, it's the delivery.     

Please do listen to Podcast 68!

Tuesday, August 07, 2012

Podcast #68: Supermax, Health Exchanges, Statins, and e-Novels

Here's what we talk about:

  • Clink talks about the burning issues in corrections, including a class action suit against a federal control unit prison in Colorado, filed by a civil rights organization.  Allegations include the idea that correctional officers were abusive and that mental health services were inadequate.  You can read more about this in Clink's article here.
Clink provides the following links:

  • Roy talks about the Supreme Court decision to uphold the Affordable Care Act (aka ObamaCare) and talks about the Mental Health Parity Act and the delay in getting this clarified.  Roy believes there will be increased access to mental health care.   
  •  Roy talks about Network adequacy and whether providers are actually available.  Here is his link to his article on Health Information Exchanges. 
  •  Dinah talks about statins and depression and and reads from Emily Dean's blog on Evolutionary Psychiatry where she discuss statins and depression and violence and cholesterol.  The guinea pig pictured above has a fine lipid profile.

  • Dinah  talks about her new novel : Home Inspection.                
This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from

Thank you for listening.
Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post.
To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Sunday, August 05, 2012

Run Faster, Jump Higher

Tonight (at least 'tonight' in Eastern Standard time in the the US), McKayla Maroney slipped on her second vault, and surrendered the gold medal to the Romanian competitor.  She was expected to win the Gold, and her distress and disappointment were obvious as the cameras zoomed in on her.  As someone who is neither athletic nor coordinated, I am in awe of all the Olympians, and I find it sad that a young woman would be so disappointed after winning a silver medal in a very competitive and difficult sport.  She was, I might add, no where near as gracious as Oscar Pistorius, the South African runner with the double leg prostheses who finished last in the 400 meter semi-finals.

Maroney reminded me that years ago, I published a short piece in the American Journal of Psychiatry, an Introspection piece titled "Going for the Gold." If you can't get in to the site, try here. (It's short, I promise).  

I suppose we all are left with the question of how good is good enough?  

Revisiting Normal

A couple of years ago, I wrote a post about how patients often ask me if they...or something they are feeling...or something they are Normal.  I went on to ramble about how Normal is Boring, and why would anyone want to be Normal.  IQ = 100, tuna fish for lunch, you name it.  

People still ask me if they are normal. I've taken to responding: "I have no idea what 'normal' means."  I still have no idea why anyone would want to be normal. 

 In psychiatry, we often ask "Why now?"   Why are you seeking help for your problem today?  You may want to know why I'm blogging about Normal today.  Ah, the answer to that is easy.  My friend Patty put the above cartoon on her Facebook Page and what better graphic for a Shrink Rap post?  Is it normal to blog about Facebook cartoons?

Friday, August 03, 2012

Baby We Were Born To Run

Check out David Remnick's story on Bruce Springsteen in The New Yorker.  The Boss and his wife, Patti,  talk candidly with Remnick about their struggles with depression:

You begin to see that something is broken. It’s not just a matter of being the mythological lone wolf; something is broken. Bruce is very smart. He wanted a family, he wanted a relationship, and he worked really, really, really hard at it––as hard as he works at his music.”
I asked Patti how he finally succeeded. “Obviously, therapy,” she said. “He was able to look at himself and battle it out.” And yet none of this has allowed Springsteen to pronounce himself free and clear. “That didn’t scare me,” Scialfa said. “I suffered from depression myself, so I knew what that was about. Clinical depression—I knew what that was about. I felt very akin to him.”

Over On CPN and Novel Updates.

It's been all over the news that the psychiatrist who allegedly treated the alleged Aurora shooter had been disciplined by her state medical board for an infraction that occurred over a decade ago.  Is that relevant to this case?  I wrote my thoughts about this in an article for Clinical Psychiatry News.  If you're interested, please surf over there and read The Deep Dark Past of Dr. Lynn Fenton.   And while you're there, if you haven't already checked it out, read Clink's thoughts on Why the Mental Health Community Must Show Restraint


On a cheerier note, I received the proofs yesterday for the paperback edition of Home Inspection.  There are a few issues, but the paperback should be available shortly.  And Double Billing is in the works.  If you've read it, please leave a review on Amazon.  And the Kindle edition is available for $2.99.  I'm taking Roy's advice and going with the cheapest price for now. 

Thursday, August 02, 2012

Preventing Violence: Any thoughts?

In the news today, it was noted that the alleged psychiatrist of the alleged Aurora shooter had allegedly been concerned about him enough to report him to the University's "threat assessment team."  He reportedly withdrew from the university before the team could convene.  We don't know any details about what he may have said to the psychiatrist, or what the threshold is for notifying their threat assessment team.  Presumably (and I don't know this for sure, but I'll assume) he would have been hospitalized if there was an imminent risk of danger.

Our laws are pretty clear, and I will only talk about Maryland, because I know nothing about the laws in other states.  If a patient makes a threat to a psychiatrist and there is a specific named victim, the psychiatrist is obligated to do one of three things: warn the victim, tell the police, or hospitalize the patient.  "I'm going to kill my girlfriend" qualifies.  "I feel like hurting people when they're rude to me" does not.  But wait, if a psychiatrist has reason to believe that a patient is at risk of committing an imminent act that endangers himself or others, and the patient has a mental disorder, the psychiatrist may involuntarily certify him to a hospital for psychiatric evaluation and treatment.  In the majority of cases, this occurs in the setting of a suicidal threat or after a suicide attempt.  It's much rarer that we see homicidal people in psychiatric settings, perhaps because depressed people become suicidal and seek care, while homicide more often is the result of anger or other motives (for example, in the course of a robbery) and not related to mental illness.  Mass murders in public settings are extremely rare events -- as opposed to suicide which is a common event, or single murders linked to drugs or alcohol which are also fairly common, at least where we live.  We know very little about what motivates mass murderers, and because they are so rare, they do not represent a single phenomena -- each case may have a very different motive and/or relationship to mental illness.

When something bad happens, and there were warning signs, people say "something should have been done."  If a psychiatrist has been involved, there certainly may be the thought that the psychiatrist should have prevented this.  The shooter involved in the Virginia Tech shooting had been hospitalized, years before the Va Tech incident, but he did not continue in treatment.  In many states, patients whose mental illness leads them to legal difficulties are subject to outpatient commitment.

We don't know what transpired in Aurora, but if a student in Maryland made a vague threat (and vague threats do keep psychiatrists awake at night) and then left the institution, or simply didn't return to treatment, there is little that can be done.  If I'm worried about someone's safety, I like to check in with the family: Are they worried?  Are they aware that the patient owns weapons -- if that's what I've been told.  I like them to at least be aware that I'm concerned, to know how to find me, and to know what to do if there is a emergency.  If there's no family, or if I don't know how to reach them, then this isn't an option.  

Our present laws don't allow us to involuntarily hospitalize people based on vague threats, or shrinky suspicions, and they shouldn't: we don't want to be a society that institutionalizes everyone who seems a little weird or is a loner. ( I don't even think we want a society where everyone has to have their shoes scanned to get on a plane, but nobody asked me. ) We're not terribly good at predicting violence -- people get discharged who then commit violent acts, and people get committed who would not have acted on their violent thoughts.  We're psychiatrists, not fortune tellers.

Are tragic acts of violence a failure of the system, or are they an unpredictable, fact of life where any attempt to prevent such acts would result in an over-correction and too many people would end up having their civil rights violated?    Is there some other possible solution -- something more or different that could be done without risking the civil liberties of those who will never harm anyone? Should we be completely re-thinking this, outside the box of hospitalization/compelled care/ and commitment?  Any ideas?
Oh, wait -- before you use this as your gun-control soap box -- the alleged Aurora shooter is not the right poster child, even without guns, his apartment full of explosives could have resulted in a horrible tragedy without guns.  (I'm in favor of tighter gun regulation, and I don't believe it's okay to buy or sell thousands of rounds of ammunition over the internet, but that's a different issue.)

Okay, Clink can tell me why I shouldn't have written this blog post now.   And Roy, for you, I've started balancing my dashes -- I know how difficult it is for you when I don't.  Thanks to Tigermom for the graphic