Guest blogger Dr. Jesse Hellman on Non-Compliance. Sort of.

I asked Jesse to blog about non-compliance, and at first, he was non-compliant, but now he's just being resistant.  Or oppositional?

Oh, truthfully, I don't like the term 'non-compliance' either.  It's a term I rarely, if ever,  use because I would never think of someone who stops a medication because it was too expensive, or  because they were having side effects, or because they felt better at a lower dose, or decided that a different medicine worked better, as being "non-compliant."  It is a pejorative term, and people need to be their own medical advocates, and the decision to take or not take a medication is a personal one where many factors come into play. 

Why I Don’t Want to Blog on Non-Compliance

I try to be compliant with most of Dinah’s requests, but this one threw me and it took me a while to realize why. The term is being, in my view, misused here when it come to psychiatry. Compliance is a term that is best used in the legal/governmental sense. It implies bending someone to one’s will. “The Office of Medicare Compliance” for example. They make the rules, or at least administer them, and those affected had better comply.

The word compliance is frequently used in medicine. If a doctor said, for instance, “I told the patient to take his penicillin twice a day for two weeks, but he stopped it after two days,” we would understand that he had not complied with the instructions but we would not know why. Patient non-compliance could be due to an unpleasant side effect, difficulty in following the instructions, expense of the medication, and so on. It does not imply disobedience or ill will, but only that the advice was not followed.

Yet in psychiatry, and particularly in the type of psychiatry that I practice, that of psychodynamically-oriented therapy with completely voluntary adult patients, the term itself seems particularly wrong. Certainly I have opinions and express them, prescribe medications, suggest intervals between appointments, and occasionally even give direct advice, but I have never thought of “compliance” in all the time I have been practicing and never think of patients as being “non-compliant.” A patient might come in for his session and, for reasons I might not understand that hour, sit the entire time without saying a word. That is his choice, and my job is to be sensitive to what is going on and try to help him, not superimpose my own values and expectations.

Do patients come late, or not at all? Of course. Not take medication or stop it without having called me? Certainly...

Wait! Let’s pause at that last one: If a patient does not call me in regard to a medication issue, and stops it, is he non-compliant? It is much more fruitful to try to understand, with him, what led him to do as he did. “I didn’t want to bother you over the weekend” he says. I could simply say that it would not have been a bother, or I might try to understand what he felt. “I thought you might be annoyed with me if I called.” “I felt it was my fault I ran out of the medication.” Or even “Perhaps your wife would have answered the phone and I would have felt like I was intruding into your private life.” 

One does not need psychoanalytic training to sense that there is a lot to be gained that could be helpful to a patient by being non-judgmental and thus being able to help him explore his thoughts and feelings, to see how they may be playing into his troubles.

So I find it much more useful in trying to understand and help my patients to be as non-judgmental as possible. And non-compliance is a judgmental term, better left to that Office of Medicare Compliance.

The Wicked Witch of the West, Behind the Scene

One week from now our legislative session will be over and we'll be left to sort through the wreckage of the new laws that hit us. Every year I do this I wish we had some way to limit the number of bills that could be introduced, to give the public a fighting chance to figure out what their representatives are trying to do to them.

The Shrink Rappers have been pretty busy with this particular session and I've written a short column about it over on Clinical Psychiatry News. Feel free to hop over there and read my piece "A Glimpse Under the Hood." The site doesn't require you to register anymore although there is one small annoying popup ad you have to click past first.

This afternoon is the big day. The House version of our governor's gun bill is going to a vote in a joint committee. If it passes, which everyone expects it will, that will be the final step before it joins the other version already passed by the Senate to become law. We've managed to keep psychiatry out of the decision to take guns away from people and to at least provide some education to the legislators about the limitations and dangers of policies based on categorical mental illness.

It looks like insanity acquittees, criminal defendants who are incompetent to stand trial and people under guardianship will be barred from purchasing weapons, as will be anyone under an active protective order. This addition is required by the Federal government to be compliant with their gun laws. People can petition to have their gun rights restored although the administrative logistics for this have yet to be hammered out, and legislators (in spite of their professed intent to get guns out of the hands of dangerous people) have shown a striking reluctance to enforce seizure of weapons from anyone who falls into one of these categories. And yes, they carved out certain assault weapons out of the list of proposed banned weapons.

The final piece is the Maryland version of the New York SAFE Act. The original bill has been dropped, but it bounced back in the form of an amendment to today's bill which will be voted on this afternoon. The last three days have been pretty intense with discussions about how to protect our patients from getting reported to police. Dinah has already written extensively about this in USA Today and in Clinical Psychiatry News, and I outlined the New York requirements here. We're hopeful Maryland is not going to skip down that yellow brick road. That yellow isn't gold.

Which brings me back to the Wicked Witch of the West. When crafting law, her advice "These things must be done carefully" is a good thing to remember. I thought of this often when looking at bills proposed to modify all of our involuntary treatment laws. Regardless of which way you fall on the issue, the worst outcome is to create confusion. I don't know if any of the changes will actually make it out of committee next week so I won't speculate here, but like most states following all these high profile shootings there was a rush to cobble together a lot of changes while the time was ripe. And it showed in the legislation.

And now for something completely different:

Well, not completely. I listened to a presentation yesterday by Dr. Jeff Swanson, a sociologist and epidemiologist who studies the impact of certain public policy decisions and programs. He was part of a summit meeting on gun policy recently at Johns Hopkins. I listened to 90 minutes of impressive outcome data on gun violence and mental illness. His research provides strong support for the futility of reducing gun-related violence by singling out people by diagnosis. Unfortunately, as we've already seen with the sex offender registries, futility and costly ineffective public policies are not mutually exclusive.

So that's where I've been disappeared to lately. I hope to come up for air soon.

Guns & Legislation: I wish the world made sense

The school shooting in Newtown three months ago has ignited state legislators to propose lots of new legislation.  What it did not ignite legislators to do is to think about what goals they wished to achieve and how to go about making meaningful changes. 

The first question that should be asked before writing gun legislation is this:

Who is it you want to protect and from what?

  

If you want to prevent spree shootings in schools you create different laws than if you want to prevent suicides, than if you want to prevent violent murders.  If you want to prevent violent murders, then the issues are different if you want to drop the gun deaths by domestic violence versus drug-deal related gun deaths.  

Suppose you want to prevent spree killings.  These are rare events, with very similarities.  It's really hard to target legislation at rare events.  We know a few things about high profile spree shooters: they tend to be young --mostly under 30, but not exclusively-- and all are male.  There has been no legislation proposed that would target males, but keeping guns away from men might stop spree killers.  

Okay, so there are dangerous mentally ill people and we know this.  Legislators in Maryland have decided that anyone hospitalized for 30 days or more should be reported to the FBI's database to prevent future gun purchases and to revoke current firearms.  I don't believe any of the high-profile mass murders have been committed by anyone who has been hospitalized for 30 days, so I'm not sure where that idea comes from. And I am opposed to reporting voluntary patients to an FBI database because I worry this will discourage people from getting care.

In Maryland, we can add to our knowledge the fact that a high school student came to school on the first day prepared to kill a cafeteria full of kids. He used a parent (or step-parent's) firearm, and was tackled by a faculty member.  He shot one student, a boy with Down's syndrome, who survived and has since returned to school.  The shooter was reportedly depressed, told other kids he was going to do this, and posted on his Facebook page that this was the first day of school and the last day of his life.  He did not  have access to a high-velocity firearm, he used a shot gun, and perhaps that fact limited the number of wounded.  The 15 year old shooter, by the way, was sentenced as an adult to life in prison, eligible for parole in 35 years.  I, for one, think we need to use this an example to chip away at teenager's "code of silence" that keeps them from talking to adults about dangerous behaviors in their friends, whether it be drunk driving or school shootings.   

So we know that some shooters have used assault weapons (Newtown and Aurora, for starters).  In Maryland, the legislature has backed down on banning assault weapons.  We know some shooters, including the one in Newtown, used legal weapons owned by a family member.  None of the legislation proposed addresses guns owned legally by family members of those we don't want accessing guns.  And all of the legislation that targets people with mental illness targets those who have been in treatment, even though the majority of shooters have not been in on-going psychiatric care or have ever been hospitalized. 

It's like our legislators have walked into a room with  blindfolds on and just randomly started shooting, hoping they hit some target.

Guest Blogger Dr. Jesse Hellman: Why Can't We Be Friends?

Back when we discussing The Basic Treatment Plan, I asked Jesse if he would write a blog post on Non-compliance.  Jesse, however,  was non-compliant and he wrote a guest blog post on how we dialogue here on Shrink Rap.

Was St. Bernard right? 

Qui me amat, amat et canem meam

 "Who loves me, loves also my dog."  --St. Bernard, 12th century

  

St. Bernard quoted this Latin saying in a sermon, and it led me to consider whether it applies to much of what we discuss on Shrink Rap. Granting that St. Bernard had a very big, and most likely unwashed and untrained, dog, which would have tried the patience of many homeowners of his time, may we apply his principle beyond retainers, followers, and family to equally speak to our possessions, words, actions, and beliefs?  If you love me, you'll also love all that I think, say, and say.

How often do we see here on Shrink Rap dialogue which is heated rather than restrained, opinions which are held ex cathedra, invectives thrown with careless disregard, and individuals attacked quite casually? Shrink Rap is not unique, but a rather educated example of what we see commonly in the news, on talk shows, in editorials. 

What I am positing is that St. Bernard's adage is often taken in the reverse: if you do not agree with what I say, you do not love me, and I will respond accordingly. There is a failure of empathy, and hurt feelings, the sense of not being loved, leading to an exaggerated response.

Shrink Rap is a psychologically attuned blog with a thoughtful community. Do others see  what I do, or disagree? Do you see that when an opinion is presented a disagreement may lead to a nuclear response rather than to a thoughtful reexamination of whatever argument is present? Do you think that hurt feelings are frequently underneath this?

Lost in history is the housewife who did not want Bernard's big unwashed dog on her couch. How do you imagine the conversation went?  

Moral: if you disagree with an adversary, it is best said in Latin.

Guest Blogger Dr. Allen Frances on the Dangers of Premature Diagnosis

 
We've talked before about psychiatric diagnoses and whether the label can be part of the problem.  See Diagnostic Labels that Change Lives, for starters.   

Today,  Dr. Allen Frances joins us to talk about whether a diagnosis with a poor prognosis can become a self-fulfilling prophecy.  I'll leave you to decide.
_________________________
 The Dangers Of Premature Diagnosis 
 
  Psychiatric diagnosis is a serious business. Done well, it can significantly help a life, sometimes save it. Done carelessly, it can lead to disaster, even to premature death.
  I have been witness to many thousands of patients who benefited greatly from psychiatric diagnosis and treatment. But I have also seen many hundreds who have been harmed by it.
  When you lose a son partly as the result of a premature and wrong diagnosis, it ignites in you a painful and prolonged search for answers. Suzanne Beachy shares her deep and heartfelt perspective here. 

  Ms. Beachy writes: 

  I, along with a growing number of fed-up mental health consumers and family members, believe that disability and loss of hope can often be made worse by premature diagnosis that highlights weakness, ignores strengths, and predicts a dire prognosis based on meager evidence.
   Jumping to a diagnosis of schizophrenia and starting long-term pharmaceutical treatments can turn a potentially temporary problem into a chronic one. In the not-too-distant past, a person reacting strangely to extreme distress was said to have a “nervous breakdown.”  People who “broke down” were expected to become well again. Today, the diagnostic names are scarier and the prognosis is expected to be much grimmer- in a way that can become a self-fulfilling prophecy.
  At age 21, my son Jake landed in the psych ward of a teaching hospital because he was having a 'psychotic episode.' Although he had no prior history of mental problems, the psychiatrists immediately emphasized that he had a life-long and serious 'mental disorder' with no hope of recovery. Among the staff, there seemed to be absolutely no interest in the possibility that his problem could be brief and temporary.
  On only his second day on the psych ward, he was told that he probably had 'schizophrenia.' The next day, his doctors were leaning toward a diagnosis of 'bipolar disorder.' Why not the much less discouraging and more accurate 'brief reactive psychosis?' It was never even suggested as a possibility.
   Jake was told that the stresses in his life (the potential loss of his home and his best friend, capped off by 9/11) would not bother a “normal” person. None of the clinicians expressed any willingness to help Jake reclaim his life. They were all laser focused on which chronic DSM diagnosis might best 'fit' him so they could assign him to a long-term drug protocol."
  In hospital, a low dose of olanzapine helped him to finally sleep at night (for the first time in weeks), and he was steadily improving. But that was not good enough for the white coats. They insisted on titrating the dosage immediately to the 'therapeutic level' and adding lithium. Jake was told he needed these drugs like a diabetic needs insulin.
  Alarmed by the staff’s refusal to engage in any sort of dialogue about the situation, Jake and I fought for his discharge (A.M.A), and he left the hospital with a diagnosis of 'Psychosis, NOS.' His outpatient psychiatrist, aptly named Igor, told us that Jake’s brain was 'just like a broken bone' and the drugs were 'like a cast.'
  Unlike a broken bone, though, Jake’s 'broken brain' would need to be immobilized by the 'cast' of medication for AT LEAST a year in order for his brain to heal. And even though the drugs almost completely incapacitated Jake, and he requested a reduced dosage, Igor refused.
  A doctor friend of mine says that when a psychiatrist tells a young adult he/she has a life-long mental illness, hope crumbles. Being told that mental illness is like diabetes is misleading and discouraging. This is not a fair comparison.
  Diabetes is due to a well understood defect in a body part, the pancreas. Mental illness, on the other hand, literally means that your mind is sick. Your mind, unlike your pancreas, is not just a body part. Your mind enables you to relate, set goals, dream, and have hope. If you and the people around you believe that your mind will be defective and sick for the rest of your life, you are left without hope of ever having the agency to build a life.
  The dire prediction of chronic disorder became a self-fulfilling prophecy for my son Jake. Being told he needed to 'set more realistic goals for himself' presumably because of his 'chronic mental illness,' Jake gave up on his goals and decided he might as well be homeless. And that’s the way he died in April of 2008, two weeks after his final birthday. (Happy Birthday, Jake).
  What I have learned in the wake of Jake’s tragedy is that psychosis, mental breakdown, going bonkers – whatever you want to call it – need not be a self fulfilling prophecy of permanent illness.
  We need not burden distressed young people with hope-sucking labels of chronic mental defect. There is a better way.

  Thanks so much, Suzanne, for sharing with us your tragedy and your grief. Surely, your experience will be helpful to others faced with a similar situatIon.
  Young people are particularly difficult to diagnose accurately. Their track record is so short; the future course is impossible to predict; developmental factors unpredictably affect the clinical picture; and substance use is so common.
  We should preserve uncertainty when it is the most accurate prediction of the future. The most common mistake in psychiatry is to prematurely jump to conclusions and to mislabel someone with a inaccurate diagnosis that has a terrible prognosis.
  It is much safer to under-diagnose than to over-diagnose and much better to encourage realistic hope than to shoot from the hip with unrealistically gloomy predictions that can become self-fulfilling prophecies.
  Diagnosis most often helps, but sometimes hurts. The loss suffered by Suzanne Beachy reminds us just how high are the stakes. We must get it right and first do no harm.

-------------
Dr. Allen Frances was the Chair of the DSM-IV Task Force.  He hasn't been so happy with the DSM-V.  He is author of Saving Normal: an Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.

Shrink Links: Guns & Suicide, DSM-V, and the Evolution of NAMI

Here are some links to some thought-provoking articles about psychiatry.

Our colleague and friend,
 Dr. Steven Sharfstein writes in the Baltimore Sun that keeping guns from the mentally ill will decease suicide rates.  I'll agree with him, and add that keeping guns from everyone will decrease suicide rates even more. See Mental Illness and Guns: Suicide is the Issue.

The Invitation to a Dialogue editorial in the New York Times once again features a psychiatrist who has been a guest blogger on Shrink Rap.  Dr. Ron Pies talks about the value of psychiatric diagnoses and the new DSM-V.  Among those who responded are Dr. Allen Frances, the chairman of the DSM-IV Task Force who has been railing against the DSM-V, a member of the DSM-V committee who quit, and a number of people with psychiatric diagnoses, including a recovery movement advocate.  I think you'll enjoy Sunday Dialogue: Defining Mental Illness.

And over on Pete Earley's blog, he takes us through the history of NAMI and how it's moved from being parent-focused to including a strong patient voice.  This year's convention will include speaker Robert Whitiker, author of several books which demonize psychotropic medications.  Do check out: The Changing Face of NAMI.   

As always, we'd love to hear your thoughts. 

 

Survey Results: Guns & Mandatory Reporting of Dangerous Patients. Is there a Difference in Perception of Willingness to Seek Care?

Here are the responses of the mandatory reporting survey.  Please note that this is not a scientific study and it has not been validated in any way.  The survey was done of Shrink Rap readers, plus I tweeted it a put it on Facebook briefly.  

 

Response indicate a person's perception of what they would do in a hypothetical situation.  Responses might vary if the respondent were actually confronted with a real-life situation.

 

100responses

Do you own a legal firearm?
	Yes 19 20% No 78 80%

----------------------------   Yes: Answer this if you own a legal firearm   If you answered Yes: Would you seek help if you were feeling urges to harm yourself or others?(If you already are in treatment, would you tell your doctor/therapist?)
	Yes 9   50% No 9   50%

------------------------------- No: Answer this if you do not currently own a legal firearm   Would you seek treatment if you thought you might be dangerous to yourself or someone else? (If you're in treatment already, will you tell your mental health professional if you feel dangerous?)
	Yes 58   73% No 21     27%

The Basic Treatment Plan

There's a lot of discussion going on in the comment section of the post where I asked people to take a survey on mandatory reporting of dangerousness.  Our favorite commenter, Anonymous, mentioned a therapist who refused to treat him/her unless s/he got rid of her gun.  Then Jesse and Clink got into it over whether it's reasonable to ask patients, on the first appointment, to get rid of their guns.  Clink said, "Jesse, the problem with the approach that you're suggesting is that the therapist has then taken on the responsibility of caring for a patient who has announced at the outset that they will not follow the most obvious treatment recommendation."  Clink later noted that a therapist would not likely take on a patient who announced at the outset that he'd be late to every session and pay the bill late.  This all made me think.

So enough with guns, I want to discuss treatment plans.  Clink would be appalled: some of my patients are late to every session, and some take their time with paying the bill.  I don't really press people on the payment issue, I just like to be paid eventually.  I'd say it's because I don't have a dollar-to-dollar cash flow need, but when I was younger and my lifestyle was limited by cash flow, I didn't hassle people about paying in a timely fashion either, so I think it's me and my distaste for discussing money issues, not my generous spirit.  

It occurred to me that I frequently take on patients who 'announce' at the outset that they will not follow the most obvious treatment recommendations.  They don't want to take the medications I suggest.  I can live with that, so long as they aren't demanding I prescribe medications I feel are  not indicated for their condition, or that will do them more harm than good.  Then I say no, and yes, I do screen patients quickly before I see them, so that if their only reason for seeking care is to come in briefly every three months to get a specific controlled substance (for example, Adderall or Xanax), then I can say that I'm not the doctor for them.  Not because I won't prescribe those medicines, but because I don't like to see someone who is looking for a very specific service that I don't feel comfortable providing.  

I often suggest that people work on putting more structure into their lives, exercise, eat healthy foods, experiment with different diets to see if that has an impact on their psychological state, drink a little coffee, don't drink a lot of coffee, and don't drink alcohol if that seems to be adding to their problems.  If they taking sleeping pills at night and sedatives during the day, I suggest this might be a reason why they feel tired all the time, and perhaps they should come off.  I always recommend that people stop smoking.  I often recommend a frequency for therapy visits at a rate that is more often than some patients want.

So what's my success rate with getting people to follow my most obvious treatment recommendations?  Honestly, it isn't so good.  Most people take the medications I recommend and nearly everyone pays their bills, eventually.  The people who like exercise anyway will exercise.  It's not unusual for people to call me in a crisis, in which case I usually see them within a day or two.  During those periods of distress, we will formulate an immediate treatment plan.  During those episodes, people generally follow my recommendations for about two days.  Every now and then, someone is so resistant to following any recommendation at all despite continued difficulties, or they change the dose of their medicines so often without consulting with me, that I wonder if they are really patients, because the state of patient-hood does require at least the willingness to collaborate and consider treatment recommendations.

Is it me?  My impression from how people react, is that I'm not particularly intimidating.  No one seems to shy away from telling me they never filled the prescription I gave them or they aren't going to stop drinking.   I sort of figured it was the nature of the work, and that part of the job entails treating people as they come, and respecting the fact that not everyone is willing or able to do what I might think is best, and most people get better anyway.

But I don't need to ask people to give up their guns to know that I'm fine to work with people who won't follow the most obvious of treatment recommendations.  What about you?

Please take my survey on mandatory reporting of dangerous patients

Oh, you know I love surveys. 

The NY Safe Act's requirement that mental health professionals report dangerous patients goes into effect on March 16th.  New York has released a video and slideshow for mental health professionals explaining who must report, to whom they must report, and there's a website to enter the information.  A Director of Community Services reviews the information and decides if it goes to the FBI's NICS database to prevent such individuals from purchasing guns or to revoke a firearms license if the patient already owns a gun.  The Director can also decide to have the patient brought in for emergency evaluation, though presumably the treating clinician might do that if there is an imminent threat.  The information is used only for gun permits, and is not accessible for other reasons. 

In Maryland, lawmakers are considering a similar measure, currently as House Bill 810, but it may get rolled into the Governor's Firearms Act which has already passed the Senate.  
Legislators are aware this may have "a chilling effect" and deter people from getting care.  I'm wondering if that's true. 

So I'm asking you to take a quick survey for me.  Two questions.  If you've never felt dangerous, or you've never been in therapy, try to imagine.  Obviously, I'm wondering if gun owners would feel differently than those who don't own a gun and who may never wish to own one.  Comments are welcome as well.  Thank you so much.

What Happened to Science?

Over on the New York Times Sunday Dialogue, our colleague, friend, and former guest blogger Dr. Robin Weiss has an conversation on Science and Politics.  What happened to science, Dr. Weiss ponders? 

But a disturbing trend threatens future public health initiatives. At the heart of successful public policy lies a shared, bipartisan assumption that science is trustworthy. Lately, politicians unashamedly issue proclamations tantamount to declaring, The world is flat. Climate change is a hoax. Vaccines cause autism. Intelligent design should be taught in biology class alongside evolution. The United States has the best health outcomes in the world.

In public health, knowledge is truly power. If politicians no longer agree that sound scientific knowledge is valid, our nation’s health will suffer for decades — or centuries — to come.

Readers wrote in with a variety of thoughts: it's the almighty dollar that corrupts politicians and blinds them from the truth, scientific research is underfunded, it's those damn Republicans (you can always blame the Republicans), if not them, then the religious extremists.  Science is wrong, and sometimes just evil.  And Dr. Weiss then responded, I'll let you surf over there to read.

I think one of the issues that makes it hard to rely completely on science is that such truths are hard to come by.  For every set of numbers, we have a set of anti-numbers, not to mention the science du jour-- whether it be hormone replacement therapy (oops) or what type of diet we should eat.  Low fat diets seem to have made us fat, unless of course, the fat people aren't the ones eating the low fat diets.  At any rate, we learned that the 'science' of the food pyramid wasn't science at all, but the thoughts of a group of committee members, just as our DSM diagnoses are agreed upon by consensus and debate, not clear scientific studies.   One day it seems that multivitamins are associated with an earlier age of death (cause, effect, coincidence, or those who are sicker are more likely to take vitamins?) and the next day we read that male physicians who take vitamins are less likely to die of certain cancers.  Calcium supplements --pushed on us for so long -- may be the cause of your kidney stones.  And stay out of the sun, it's bad for you, but oh no, your vitamin D levels are too low.   There are too many numbers and they are too easy to manipulate, which every side seems to do.  And even when the numbers play out again and again and are indisputable -- wear your seat belt and drop that cigarette, now -- the numbers are about populations, not individuals, so there will be that person who smokes to 100 and if you're very allergic to nuts, that Mediterranean diet make make for a much shorter lifespan.  

Okay, I just had to argue with Dr. Weiss a little bit.  It's like making her an honorary Shrink Rapper without the screaming. 

Writing With Style

I thought people might be interested to know that the Associated Press just updated its style manual to give guidance to journalists writing about people with mental illness. Besides the obvious advice like "don't use words like 'crazy' or 'nuts'" (and it's sad they'd really have to tell someone not to do that), they also advise journalists not to automatically attribute the behaviors they're covering to mental illness: "Avoid interpreting behavior common to many people as symptoms of mental illness. Sadness, anger, exuberance and the occasional desire to be alone are normal emotions experienced by people who have mental illness as well as those who don’t." Writers were advised that violence alone is not solely a sign of mental illness and to avoid relying on bystanders' statements that the subject of a story is mentally ill.

 This is good. Now the American Psychiatric Association needs to put together a style manual for talking head mental health types. If you go in front of a camera or behind a microphone (or keyboard) to comment on someone in the news and their alleged mental problems, you should know your professional and ethical limits. I've written about the problem of mental health professionals in high profile cases before over on Clinical Psychiatry News.

 This is not to say that mental health professionals shouldn't be involved in the media. They can provide a broader context for a story, correct inaccuracies and give an 'insiders' view of a story that may help the people get a better handle on what's going on. But, this should be done responsibly.

My Patient Is Not A Peanut Butter Cup

On CBS news yesterday I saw this report about mentally ill people who end up in jail. The sheriff of the Cook County jail complained that psychiatric patients who don't take their medication become criminals and added, "We're not a mental health facility. These people should not be here.''

Simultaneously this week in the Baltimore Sun we have this story, where hospital workers complained because malingering criminals were being held at their facilities.

This week's news is a terrific example of what I call the Reese's Peanut Butter Cup problem of forensic patients. (I put up the old commercial for reference.) Each side is basically complaining that they have to provide care for someone. Nevermind that people can't be cleanly divided between the "mad" and the "bad," or that people who "only" have personality disorders can still die from those disorders. We waste a lot of time and energy arguing about who should be where and who should be doing what.

The bottom line is that we have to figure out how to deliver the right care to the patient regardless of the setting. Forensic patients require treatment as well as security. That sheriff needs to realize that his facility will always require a psychiatric infirmary and mental health services and that he's not going to be able to "clean house" off all the psych patients. Similarly, hospital workers can't write off every assaultive patient as being "just a sociopath."

We need to beef up hospital security so everyone, patients and staff alike, can feel safe. And jails need to be given enough mental health staff so the administrators won't feel like they're being overrun with chaos.

Getting rid of the patient is never the right answer to a health care system problem.

Dear Legislator

Over on the Clinical Psychiatry News website,  I  have posted the testimony I gave at the legislation hearings in Annapolis on Friday.  It's a open letter to any legislator, in any state, who is thinking of following suit after New York's SAFE Act which requires mental health professionals to report patients who may be dangerous. 

Break a Leg, Pete Earley!

Tomorrow, our blogger friend, Pete Earley, will be giving testimony to Congress about mental health and public safety.  A tireless mental health advocate, author of Crazy: A Father's Search Through American's Mental Health Madness, and a fabulous writer in many genres, Mr. Earley will be one of three parents speaking.  He's been asking his readers for suggestions about what to say in his 3 minutes of testimony, and ClinkShrink devoted one of her posts here to making suggestions, and Mr. Earley plans to use the input he's gotten in the written testimony he submits.

We've had a bunch of back and forth discussions on proposed gun legislation and mental illness.  Mr. Earley was kind enough to put my op-ed piece from the Baltimore Sun on his blog.  One of our readers, SunnyCA, said we needed a bigger audience for this, and ironically, that comment was made on the day that Mr. Earley and I were writing an editorial to submit to USA Today.   If you'd like to read that article, which was published today,  click HERE. 

 
I want to wish Pete the best tomorrow. I'm sure he'll do a wonderful job, an ho, it's so tempting to suggest that when Mr. Earley testifies in Congress, we know he won't be late.  I'll stop now.  It's hard to keep up with ClinkShrink when it comes to puns, and I'm not sure why I even try. 

 

What This Shrink Rapper Would Tell Congress

Recently one of our readers posted this comment:

“If any Shrink Rapper ever has the time and inclination it would be interesting to read about what you would do to fix the mental health system, particularly the issue of involuntary hospitalization, if you had unlimited funds and political resources. You've been in the trenches, it would be great to hear your thoughts.”

Simultaneously, over on Peter Earley’s blog I see that he is planning to testify next week before a U.S. house subcommittee regarding issues related to violence and severe mental illness. He is asking for people to contribute responses to six specific questions he expects to be asked. Please go over there and contribute your ideas---this is your chance to make a difference.

Meanwhile, I have my own thoughts about this which may or may not be directly relevant to the six questions, but I want to bring this to the attention of the subcommittee if Mr. Earley would be kind enough to include it. For those of you who want the "bottom line," I've underlined my main ideas.

First, a bit about why I think my experience and ideas are relevant.

As a forensic psychiatrist, I evaluate and treat severely mentally ill people who are or have been violent. I see the rare exceptions, the people who as a result of their disease commit acts that seriously injure or kill others. As a correctional psychiatrist I have also evaluated and treated thousands of prisoners, many of whom also have serious psychiatric disorders.

I will emphasize, as you've already heard from others, that violent offenses due to psychosis are the exception to the rule. Almost all crimes of violence are not committed by people with schizophrenia or other psychotic disorders. Drug and alcohol abuse is the culprit in most violent crimes and we must vigorously address this and do more to provide treatment to people with substance abuse problems at the time that they are willing to accept treatment.

From evaluating insanity acquittees, people who are found not criminally responsible for  their crimes due to mental illness, I’ve learned that one significant systemic problem is the lack of public awareness about psychosis and how to recognize prodromal symptoms. Often the early symptoms get written off as attributable to some other life stressor: the breakup of a relationship, the stress of a young adult's transition to college or some other understandable life event. Sadness, withdrawal from family, loss of interest in hobbies or friendships can be explained in this context. However, as the illness gets worse and the patient's personality changes, there is more recognition that something serious is going on. Friends, neighbors and teachers recognize psychosis only when there is increasing disorganization, inability to complete tasks, or eventual bizarre behavior and unusual statements.

Therefore, my first suggestion to address violence due to mental illness would be to provide better public education to recognize emerging psychosis.

Once the psychotic episode is recognized for what it is, the challenge for families then becomes figuring out what to do. Finding a psychiatrist and getting prompt evaluation and treatment is a tremendous challenge particularly in rural or underserved areas. In southwestern Minnesota where I was raised, there is only one fulltime psychiatrist serving a seven county area of 70,000 people. Our local Baltimore City Detention Center has a higher per capita number of psychiatrists than my hometown. That has to change.

My second recommendation is this: the government needs to provide increased funding for medical education, particularly the training of psychiatrists. There should be additional incentives, beyond Federal public health service commitments, to work in underserved regions or state facilities.

All of my patients are institutionalized but most will return to the community eventually. Insanity acquittees typically are hospitalized for substantially longer than they would have been incarcerated if convicted. The majority of my mentally ill offenders are convicted of misdemeanor property offenses that are drug or alcohol-related, and return to the community within months to a few years. Regardless of the length of confinement, we need better programs to transition patients from a public institution to the community. Insanity acquittees and mentally ill offenders need housing, transportation, educational and vocational programs in addition to addressing their medical and mental health needs. Lack of adequate community services and transition plans are a key factor in unnecessarily prolonged hospitalizations.

Many recent high profile crimes have lead the public to demand looser civil commitment standards and easing of laws for involuntary treatment. In my opinion, this creates an adversarial atmosphere and unnecessarily sets families in opposition to their mentally ill loved ones. People with psychiatric illnesses have legitimate reasons to oppose confinement, and we should examine these reasons thoroughly and address them.

Some public psychiatric hospitals, of the few that remain, are antiquated and dilapidated. We need to improve environmental conditions of these facilities and address the poor ventilation, bad plumbing and faulty infrastructure. The inpatient unit should emphasize treatment plans that respect a patient's educational level, skills and interests rather than focussing solely on disability. Inpatient safety and security are increasing concerns, leading some patients to be strip-searched arbitrarily. We must improve hospital security to protect both patients and staff from physical assault. As a recent story in our local newspaper indicates, concern about violence is not limited to free society and must be addressed within facilities as well.

Finally, we need to reinvigorate collaborative treatment planning through the use of psychiatric advance directives. Make them meaningful and useful. Currently patients don't trust them because they know doctors can override them. Ironically, doctors don't trust advance directives for exactly the same reason---because they can be revoked by patients. We need to update psychiatric advance directive laws to make them binding, effective and safe, then make sure treatment providers are educated about their use.

Thank you for reading this far. We can’t make the system perfect, but I’m sure we can make it better.

My Day With Our State Legislature

It was a long day in Annapolis yesterday.  I was one of an estimated 1,300 people who showed up to give testimony on gun legislation.  For details, see The Baltimore Sun article.

On the public testimony, I was #162  and I went at nearly 9 pm, they were estimating 16 hours of testimony and it didn't start until 4:30 pm. My quick demographic estimates: 99% white, over 90% Male, & over 95% or those who came to testify opposed the governor's bill. The supporters, including busloads of school children, were outside rallying in the morning.

There were 4 hours of expert testimony, then I heard  4 hours of  public testimony with the same handful of messages : civil rights, why I need an assault weapons, statistics on how gun control doesn't decrease violence, I'm gonna move to another state if this passes, you're going to make me a criminal, go after the criminals and the mentally ill,  all of these measure prevent straw purchases but no one is ever prosecuted for straw purchases, this won't fix anything, and my personal favorite: the little girl who testified that if the law passed she'd have to move away from her friends, her school, and going to McDonald's.  Where were the victims of gun violence? Where were the mental health advocates?  They were part of the expert testimony -- I'll talk more about this below--but I was the only one (of those I heard) who was not giving public testimony on the Firearms Act.  I left after I testified, but it went on until early the next day --I've heard 3 AM and 6 AM. 

I got to testify around 9 pm, maybe a little earlier, thanks to our kind psychiatric society lobbyists who signed me up, even though I wasn't the designated speaker for the expert testimony. It fast-forwarded me out of a long line to get into the building and I got me a much better number than I'd have gotten myself, being that I'm not a "morning person."  I was psychologically prepared to stay until 10 or 11, so being heard by 9 was good.  I'd brought a peanut butter and jelly sandwich, a pear, and some carrots.  I resorted to water from a faucet in the rest room, and at one point, I was sitting on the floor of the hearing room with my phone charging while I tweeted, and a kind staffer offered me a chair.  I didn't want a chair, but I did ask if he could get me a cold beer. 

I had prepared three minutes of testimony, but given the numbers, they cut the time to one minute. Everyone ran over, and the Chairman, Delegate Pete Hammen, sometimes let people ramble on, and other times, cut them off.  I thought he was incredibly rude and dismissive to me.  I seem to remember going to meet with him years ago, and that he was dismissive then --not to me specifically but to our psychiatrist group.  Is this my imagination or does he not like psychiatrists?  I think I felt like our readers feel when they talk about being dissed because they are psychiatric patients; I felt dissed because I was a psychiatrist.  I pointed out to him that I was the only person there not testifying on the Firearms Bill, I was talking about HB810 --mandatory reporting of dangerous patients.  He'd been more patient listening to  gun-owner after gun owner make one of the same 4-5 points about why they oppose the legislation.  Me, as the only one giving testimony on a different bill, he cut off repeatedly and was quick to dismiss.  In all fairness, it was nearly 9 pm and everyone was fading, some of the legislators had left, and  I can't imagine what they were like at 3 AM.  I did go over my allotted time and I did give my testimony as a story, not as bullet points, something I knew might be risky. The bill's sponsor had been in and out of the hearing room, but during my testimony, he was gone. 

There was on ob-gyn who testified in favor of the bill --one of only 3 pro-gun control advocates I heard --  and they were much nicer to her.  I guess on the positive side, someone in the room applauded me -- no one else was applauded while I was in the hearing room -- and one of the legislators said, while I was speaking, "That's why we shouldn't pass this."  So I guess it was worthwhile.  No one had any questions for me, but Hammen phrased it as "Any questions? Next." And they were all understandably a bit zoned out by that hour.  One person gave testimony that she'd been mistakenly diagnosed with a mental disorder and could never get a gun because no one would say the doctors at the hospital were wrong, and this was part of the Firearms Act.

By the way, when someone (? I think it wasn't one of the bill's sponsors, but I missed the introduction) described HB810, he described the three Tarasoff options and said this bill would require mental health professionals to tell the police if there was a specific threat against someone else. He proposed it as a tightening of the Tarasoff requirements, while the HB810 actually undermines Tarasoff.   In fact, the bill requires mental health professionals to report to the "Director of Mental Hygiene" : a nonexistent agency.  Perhaps they meant MHA or DHMH.  The Direct of Mental Hygiene then decides whether to tell the State Police for the purpose of preventing gun sales (so reporting to the FBI NICS database, I assume?), who then decides if they should contact the local police. 

As far as the expert testimony went -- the first 4 hours of the proceedings --Dr. Brian Zimnitsky from the Maryland Psychiatric Society did a great job, and an internist testified who also did a wonderful job-- he described that 1/4 of his patients have psychiatric issues and how hard it is to get people in to see psychiatrists, how many don't take insurance and how clinics aren't open late for people who work, and the long waits.  And he was very articulate about how the process to get your gun back doesn't/won't work because psychiatrists  won't certify people to use guns, either because they are liberal urbanites against gun ownership, or because they won't accept the liability.  Dr. Zimnitsky did a good job of re-iterating that with a little more detail about what it is we can do.  It was very confusing because the Firearms Act was the focus of attention, yet there were other mental health issues which got no space for discussion.  And most of the testimony was about the details of guns and assault rifles and statistics about how gun control effects morbidity and mortality.

Overall, Dr. Zimnitsky was the only psychiatrist, and there were 2 psychologists and 1 lawyer from the Maryland Disability Law Center -- in 4 hours of expert testimony, and the 4+ hours I watched of public testimony.  Is there anyway to get a stronger psychiatrist presence at the table?  These lawmakers clearly don't understand the issues, and I think it's hard because they seem to have their minds made up about psychiatric patients and either they are not open to learning, or we're not doing a good enough job explaining.  Even with the Emergency Petition issue that came up, it sounded like EP's happen when a doctor files one, and there was no mention of the fact that a family member or neighbor can easily obtain one, and then if the professional in the ER doesn't have enough information, they may want to hold a patient for a day or two to observe and clarify whether they are safe. In this case, a person will be deprived of a civil right without any due process. This was an 11th hour amendment that was brought into the Firearms Act on the night it passed the state senate.

There was nothing mentioned about doctor-patient confidentiality and how this is necessary for psychiatric treatment to ensue.  The point was made they times that using a 30 day cutoff for reporting would affect eating disorder patients who aren't dangerous, but I think the point should be that reporting voluntary patients forces physicians to violate the doctor-patient confidentiality that is necessary for psychiatric treatment it and  deprives people with mental illness of a civil right and that this singles out psychiatric patients as the only group of people who can be deprived of civil rights without any legal due process.  It's all terribly stigmatizing and may well serve the opposite of the intended effect: to leave people fearful of psychiatrists and less willing to get help.  And it's striking that HB810 only applies to mental health professionals and no other health care provider is being asked to report dangerousness.  I wasn't really sure by then end of all of it if the 30 day voluntary inpatient reporting was still part of the bill passed by the senate; it was twice mentioned that this had been removed.  We need to move the terminology from "the mentally ill" to "those who are dangerous" for any reason.

It's amazing that there is nothing about substance abuse, that you can go for eight rehabs, and still have your arsenal. 

In terms of actual safety issues, I think it might be helpful, though I imagine it's too late, to have a  process by which all physicians are "allowed" (as opposed to required) to violate confidentiality and the police are "required" to investigate and confiscate weapons then have a quick legal process that would ensue to return such weapons if they were confiscated in error.  This could be used for psychiatric patients, substance abusers, or simply angry, mean people who are making threats or behaving erratically.  And because it wouldn't be about just reporting to a database, it might serve as a mechanism to get guns out of the hands of those who have them illegally, something none of this legislation addresses.

If you read through all this, thank you.  Eleven hours yesterday and I needed to vent.  It was really fascinating and I'm so glad I went.