Sunday, October 07, 2012

Capitated care, Young Brains, & Suicide Prevention Police

Thank you to everyone has been participating in our multi-post discussions of Capitated Care versus Fee-for-Service.  Based on the input of our readers,  I've come to the conclusion that in systems with capitated care (i.e., a national health system): 1) Our readers are pleased with that, feel it provides better blanket coverage to a large population and the emphasis is more on medicine and less on money.  2) Capitated care is less about service with a smile.  3) Capitated care does a better job with treating populations but may not be the best care for the individual with an outlier problem.  We've heard about systems in Canada, the UK, and Hong Kong, and of course, the USA.  I can't recall whether our Australian readers chimed in.

In today's New York Times, I wanted to give a shout out to a couple of articles about psychiatry. 

Robert Cantu and Mark Hyman have a book out called Concussions and Our Kids, and Dr. Cantu has an op-ed piece in today's paper, "Preventing Sports Concussions Among Children,"  talking about measures we should take to prevent brain injury during routine team sports for children under age 14.  The bottom line: children should not play tackle football, head the ball during soccer, body-check in hockey,  add chin-straps to batting helmets and eliminate head-first slides in baseball, and require helmets for field hockey and lacrosse players.  As psychiatrists, we're rather fond of intact brains.  The authors challenge us to re-think our approach to children's sports.  

The New York Times also has a nice article on the NYPD's Emergency Service Unit, an elite squad of 300 police heroes who talk people off bridges and rooftops.   So far this year, the NYPD has gotten 519 calls for people who are about to jump.   See Wendy Ruderman's, "The Jumper Squad."


Anonymous said...

Regarding the Suicide Prevention Police, there is an indisputable right to commit suicide. In serious chronic, unremitting brain disorders (mental illnesses), and after a decade or more of unsuccessful psychiatric treatment, suicide can be a personal choice. In such situations, people may not have many, or any, living family members. Everyday life presents unbearable emotional pain. Let these people end their lives without criticism or harsh judgment from others.

Anonymous said...

I don't think the suicide prevention police is critisizing or judging. I also think that if a person decides to end his/her life in a public place, then s/he runs the risk. I don't dispute chronic unrelenting mental illness, as I have one. However, tylenol is always available at any store and no one will be coming into your house to stop you. If you are choosing to end your place in a public location like a bridge you are more or less garaunteed that someone will see and call for help. One might even argue that making that choice is a cry for help -- if you really didn't want help or interference - bottle of tylenol plus the locked door of your house. Easy.

Anonymous said...

the tylenol will take much longer. I see the point in wanting a quick death. i would rather jump and not leave an intact corpse that will be manhandled.

Jane said...

Yeah...if you can't get your hands on a gun, jumping would probably be better than poisoning yourself with Tylenol. You could even potentially survive a gunshot wound if someone found you and you didn't die right away. With no silencer on the gun, everyone would be making a 911 call.
Jumping might actually be your safest best. Can't screw that up if your high enough.

I really do wish there was euthanasia available for people with severe mental disorders that have been resistant to treatment. It would make suicide so much easier and humane for them.

Dinah said...

Please take the discussion of how to kill yourself somewhere else.

Anonymous said...

My point wasn't how to kill yourself. My point was that if you choose to do so in a public venue, then the public most certainly has the right - obligation, even - to intervene.

Anonymous said...

I agree with Dinah. When you commit suicide, you have cut off any other future potential options. I have suffered from depression since I can remember and am now in my 50s. If I had had someone in my life who advocated for suicide I may have done it. Fortunately I am around people who value life and even if I need professional psychiatric support for the rest of my life, my life has value. That is what a person who mentally suffers needs to hear.

Jane said...

My point was more a response to the comment that attempting to jump off a public bridge is a cry for help and less real than other attempts because it is in a public place. There are probably people who are crying out for help (I highly doubt they ever jump...they may accidentally fall), but I don't think an attempt in a public place is necessarily any less of a real attempt because someone could intervene.

A good one I can think of, though it is fictional, is the George Baily character from It's a Wonderful Life. I didn't think his nearly committing suicide by jumping off the bridge so he would drown was written as a cry for help. Though in that instance George was saved because he had to rescue the guardian angel from drowning and not because someone was actively trying to pull him away from the bridge.

Dinah said...

Suicide is illegal and against the teachings of many religions, so there is not an "indisputable right to commit suicide." And the issue of the "right" to kill yourself in public...well, I personally don't want to watch, to live with the nightmares, or to have the dead body land on my children.

If you all want to debate the right to commit suicide, that's fine. I was just uneasy with anyone offering the specifics of how best to do it here (even if just to illustrate some other point).

Anonymous said...

"suicide is illegal". How many people are in jail right now for having committed suicide?

Anonymous said...

A cry for help is not necessarily a bad thing - and I was not judging. However, if you opt to kill yourself in public, you are by definition more likely to encounter intervention.

And suicide being illegal is a moronic law. I don't think anyone disputes that, even Dinah.

Anonymous said...

It is legal to kill yourself if you do it slowly, like drinking yourself to death or smoking 3 packs a day. It is legal in a lot of places to murder. They call it capital punishment. The teachings of many religions have all sorts of nutty things in them, including when it is permissible to stone someone to death. The teachings of many religions forbid pre marital sex, extra marital sex and even sex with a spouse, at times. Not a whole lot of people seem to care.
I will bet you have seen people die in front of your eyes, over and over. Just turn on the news.

Anonymous said...

I made the original post and there was no intent to initiate a "how to commit suicide" discussion. I'm sorry that some responders took it down that path. My point was that suicide is a right and a valid choice. It's true that attempted suicide in public places will attract rescuers.

Suicide is NOT illegal in any state in the US. Assisting a suicide is illegal (physician -assisted suicide, rarely, may be an exclusion). If Police or Psychiatrists become involved, attempted suicide may legally land you on a Psychiatric ward.

It's important that discussions on mental illness and suicide are part of the comment process on Shrink Rap. Over 90% of those who commit suicide have a psychiatric diagnosis at the time of death. Psychiatrists must acknowledge that a good part of the practice of psychiatry necessarily involves suicide. It is a tremendous disservice to patients if clinicians are uncomfortable with talk of suicide.

Jane said...

I don't think people should have a right to commit suicide in public places...though I hope if people do try they don't get punished for it. I guess I understand someone bridge jumping to some extent because it is sooo "final" I guess? I would not recommend it.

Part of the reason I am for legalizing euthanasia for psych patients is because I thought that might actually save lives. Kinda like how no one actually wants an abortion, but if it's legalized and controlled it does give women access to counseling from a physician about whether that is the right decision (instead of adoption or keeping the baby). If someone wants to die, but doesn't want to involve psychiatric help out of fear of being coerced into hospitalization, they person might be more open to exploring options. If the shrink says,"Suicide is a personal choice. I see that you are planning to do it, but I would like to counsel you on your other options first. If you choose euthanasia, I understand and will refer you to the appropriate care" this might make some patients more likely to consider other choices? The patient has no fear of being locked up for being suicidal. And if he makes the decision to least he will not end up like the jumper who didn't die but instead mangled his internal organs and will be in a hospital bed the rest of his life.

Sometimes a failed suicide attempt is worse than suicide

Anonymous said...

Jane: I can appreciate your last couple of comments. You make some valid points.

rob lindeman said...

My father of blessed memory was an attorney. He taught me that suicide was the only crime for which you were criminally-liable if you failed to carry it out.

Pace Dinah and others, the right to kill oneself is indeed an inalienable right, in that the right inheres in the person. Government cannot grant inalienable rights, it can only take them away.

Suicide Prevention is a misnomer. A more accurate expression is Suicide Prohibition. No one can prevent suicide (we've had this argument before), but you can prohibit it.

The Church used to proscribe suicide by confiscating the property of the suicide. When it became clear that wives and children were harmed this way, church courts began excusing suicides by declaring the person insane, and therefore innocent. That was the first step that leads us to where we are today. Today virtually all suicides are absolved of sin by reason of insanity and may receive religious burials in consecrated ground.

Regarding rights, we consider birth control to be an unchallenged, almost inalienable right. Death control, however, seems a foreign concept. Sadly, governments have complete and unchallenged control over killing citizens.

Sheila said...

Excuse me... please help me understand. I am getting a bit confused here.
Suicide is not illegal in my territory as far as I know (as many of my patients failed attempting suicide and got brought in by police, none of them were charged). Is attempting suicide illegal in the USA (in a sense that police can charge you and a Judge can convict you of committing a crime called "suicide")?

rob lindeman said...


Like many laws, it's on the books, but never enforced. The failed-suicide nevertheless ends up incarcerated, except without due process, in a mental hospital.

Anonymous said...


Never fear. The failed suicide ends up incarcerated for as long as it takes to stabilize medically. There is not enough cash in the system for anything beyond that. Has the activated charcoal worked? You are gone? Was there organ damage? You will stay longer but not a very long time. The suicidal person does not wish to stay very long in a hospital and the hospital matches this by not wanting to play host longer than necessary. To those who fear discussing suicide, please do not. Talking about it does not make anyone suicidal if they were not already. Suicidal persons have many sources of information when it comes to methods.You will not be sued for comments made here. In the words of someone fictionally famous: the law is an ass.

Dinah said...

I stand corrected. Per Clink, suicide is not illegal. It's good I have her.

I'm told suicidal people don't want to die, they want to be out of their pain. It's unfortunate that suicide inflicts so much damage on those who survive.

Anonymous said...

"I'm told suicidal people don't want to die, they want to be out of their pain. It's unfortunate that suicide inflicts so much damage on those who survive." - Dinah

The above is insulting and demeaning. You minimize the amount of genuine suffering people wiht real mental illness live with. Your last sentence reads as an off the cuff reference to the selfishness of suicide. Of course every suicidal person has considered carefully, long and hard, the effect his or her suicide will have on his loved ones. The implication that they have never thought such a thing is really offensive.

Yet again, I wonder if this is how you interact with your patients. How do you maintain a practice? Or do you perhaps see only the very mildly mentally ill, the slightly neurotic.

Anonymous said...

Anonymous, not every person thinks long and hard about the repercussions of their suicide on others. Some commit suicide impulsively. Some are experiencing delusions, and some think they are punishing someone else by killing themselves. With a mood disorder you can emotionally cycle very rapidly and act impulsively. Substance abuse can put someone in a dark place where they can not think rationally. I hope Dinah you can address that issue. Thanks!

Sarebear said...

"I'm told suicidal people don't want to die, they want to be out of their pain. It's unfortunate that suicide inflicts so much damage on those who survive." - Dinah
"Of course every suicidal person has considered carefully, long and hard, the effect his or her suicide will have on his loved ones. "

UGH. This may be opening myself up to criticism, but when I'm suicidal, I am not thinking about my family (unless it's that they'd be better off without me). You say Of course every person has etc. etc., but I'm part of "every", and I do not "of course" think about that.

If I did, it would have some chance of pulling me out of it, and when I'm suicidal, I WANT to be as serious about it as I can, which means not distracting me from my goal with anything else. My thinking and state of mind is all twisted, though.

So don't speak for "every" suicidal person. There's a whole spectrum of behavior, motivations, thoughts, feelings, reasons, etc.

Dinah has likely seen most of those, I'd guess (don' know for sure though). Just because she says something ONE way doesn't mean other things can't be a different way; she can't be expected to cover the full range of experiences, motivations, all contingencies, every time she speaks on a subject, no matter how much some readers of this blog EXPECT her to, or wish she would.

This is a blog, and it's often written in an informal style. The other thread about reading while depressed and people's attitudes about how depressed you are, how functional you are or not, what things you like to do, even when depressed, or if depression has taken it away . . . well, there's a whole spectrum there, too. Some people can or do or like to read when lightly or moderately oreven I'd imagine there's some who might manage it when severely depressed; the range of human behavior, motivations, reactions to illnesses is huge. Just because it's not YOUR experience, doesn't mean it isn't valid as someone else's. Just because your experience isn't THEIR experience, doesn't make yours invalid either.

There is a wide range of stuff, and trying to expect that what someone says will cover everything, or whatever, is not realistic. Granted, some posters' comments are presented in a manner that leads one to think they are tring to say experiences different from their own aren't valid; I'll argue against that. As I'm arguing your "every" statement here . . . it does not apply to ME; perhaps "every" one you've known who's been suicidal has fit your statement, but it would be better if you would say THAT instead of telling all of us how we think and feel.

Sarebear said...

The second quote in my comment above is from the Anyonymous two comments above mine, just to makje it clear it's not Dinah.

My keyboard is screwing up again, sorry for typos.

Anonymous said...

Suicide is about many things, as Sarebear writes. Yes, there are many motivations,thoughts, feelings, reasons. I can only speak to suicide as related to mental illness. The belief that suicide is a selfish act is highly insulting, and is made by those who don't comprehend or fully understand mental illness (though they like to think they do). Unfortunately and amazingly, a few clinicians hold this ignorant view.

It is not true that suicidal people don't really want to die. It is true that they usually want to be free from emotional pain. Not every suicidal person has thought out the damage to those left behind, because unspeakable, unbearable psychic pain can be the decision-maker here. It's not realistic to expect all suicidals to ignore their psychic pain. Protection from emotional pain is paramount and suicides will happen.

Dinah, it sounds like you've never treated suicidal people. If true, it is surprising. Clink, your post makes it seems like you're uncomfortable with the continuing comments relating to suicide. It's also surprising that both of you claim enough knowledge of suicide to present at a conference.

As uncomfortable as it is, maybe the blog comments on suicide can enlighten the public, patients and clinicians.

I love the Shrink Rap blog and don't mean to insult the blog owners, but I do mean to provide information on certain issues.

Anonymous said...

So now we have established that people have different opinions and experiences. Seppuku, sati, senicide, and suicide bombings were and sometimes (rarely) are still practiced. You can still see a crucifixion in the Philippines on Good Friday, though most survive and some do it on a yearly basis. We aren't all the same.

ClinkShrink said...

"It's also surprising that both of you claim enough knowledge of suicide to present at a conference."

Oh my, for someone who doesn't mean to insult the bloggers you did a good job.

My clinic consists of a high volume, high acuity and risk practice. Suicide risk assessment and prevention is the bread and butter of what I do in prison. I've treated suicide attempters as well as the loved ones of the dead (including some patients who witnessed their loved ones' suicide). So yes, I think I'm qualified to speak at a suicide conference.

My discomfort at the ongoing discussion was a reflection of my concern that, at least in traditional media, detailed discussions of suicide methods have been associated with short term increases in suicide rates. That, and the fact that the blog (for me) is generally a fun and interesting place to hang out and I prefer to think about fun and interesting topics. While suicide assessment and prevention is certainly important, it's a serious business that I think about with a fair amount of gravity.

I do enough of this on my day job, that when I'm off-duty on blog time I'd rather think about other things.

Jane said...

I really don't think that we can call suicide bombings the same thing as suicide. That's murder/suicide. And it is definitely selfish. I have never met a Muslim who felt it was not a selfish act. I have met some who believe that some of the bombers (if not the majority) were brainwashed and Allah will have mercy on them for their sin and punish those who brainwashed them.

I can remember walking into a women's halaqa (Islam discussion thingy) once, and the topic was about intentions. The halaqa leader shared a story with us. There was a Muslim man who fought many battles on the side of the Muslims, and his dream was to die a martyr. He was very respected in his community and seen as a righteous man. Eventually he did die in battle. He was considered a martyr and the thought was that this man obviously went straight to Jannah with the rest of the martyrs when he died. He was destined for the highest level of Paradise.

However, when he was brought before Allah, he was rejected. He said, "Allah, I died for you! How could you turn me away?" And Allah replied, "No. You did not die for me. You died so that other people would call you a martyr. So there is your reward..."

Suicide bombers die for glory, and so they can be honored as martyrs. It is the definition of selfishness.

I exclude those who have been indoctrinated and/or coerced.

Anonymous said...

We also cannot call senicide suicide because it is actually murder. My point was not about intentions, it is that at different times in different places, some acts are considered differently than they might be considered at other times and in other places but what remains true is that humans have a long history of killing themselves and/or others and that how one judges it has a lot to do with culture. Suicide bombers are not always coerced and certainly seti was not always an act carried out willfully by the woman who self immolated.

Anonymous said...

Being uncomfortable with debating suicide on an open blog is not the same as being uncomfortable with talking about suicide in one's practice. Posting on a blog is not the same has a conversation, and I agree with those who find this discussion problematic, including the worry that some readers might find it triggering.