Saturday, February 02, 2013

Put All Those Mentally Ill People Into An FBI Database, Stop Reimbursing Psychiatrists, Increase Access to Care, and Hey, Let's Decrease Stigma While We're At It!

Has anyone else noticed that there's a lot about psychiatry in the news, and all the messages are mutually exclusive?  In New York they've decided that a "SAFE Act" includes requiring shrinks to report anyone they believe is likely to be dangerous.  In Maryland, the proposed 2013 Firearms Act includes a provision to report all inpatients who are hospitalized for 30 consecutive days (voluntarily or involuntarily, dangerous or not) to an FBI database, and those who are found to be dangerous by a court are to be reported sooner.  And if the Firearms Act, as written now, passes and they take your gun, you can't get it back until a psychiatrist signs off by saying you are safe to own a gun -- a liability consideration few shrinks will be willing to accept.  And the Washington Post reported that another delegate plans to propose legislation that will require mental health professionals to report dangerous patients.  Funny, but only mental health professionals are required to report.  If you tell your urologist you're so pissed off you might harm someone, you still get doctor-patient confidentiality (and perhaps a specimen jar) with no obligation to report.  I'll limit my CPT code changes to a single sentence, but suffice it to say that many folks are having trouble getting reimbursed and are spending much more time on paperwork.  And yet as the media talks about rounding up all the dangerous mentally ill people, reporting them unknown community service director or to legal authorities or to an FBI database, all with the hopes that this will decrease their access to firearms so we don't have any more mass shootings, and in the same sentences we hear about the importance of increasing access to care and decreasing stigma so that people will want to go for help.  Does anyone else think this is all kind of weird?  It's like the left side of the mouth is saying "run" while the right side of the mouth is yelling "stop." 


George Dawson, MD, DFAPA said...

I don't think it is weird at all. I think it is internally consistent with long standing patterns to scapegoat people with mental illnesses and restrict access to psychiatrists. If anything, psychiatrists should have mass immunity from liability if they are making a good faith effort to treat potentially violent people. Putting psychiatrists in a position where there are mandated reporters of people who they are trying to help serves no useful purpose other than taking the heat off the gun lobby and making it seem that easy access to firearms is not really the problem.

I can't think of any more cynical legislation when it comes to mental illness treatment than the ACA, but I am sure than Congress and the White House can come up with more.

jesse said...

I agree with George here. The problem is that far too often politicians need to placate their base and suggest legislation accordingly with no interest in whether or not is is effective , and even harmful.

Removing liability from psychiatrists who do report or otherwise take action might actually help. The psychiatrist in the Aurora shooting notified authorities on campus - perhaps she might have done more if she felt protected in doing so.

Dinah said...

I only know what the media says, and that is, well, not always accurate.
I think the psychiatrist in aurora saw the patient once. She talked to campus police who checked his legal record (none) and offered to put him on a 72 hour hold and she said no. I'll guess that if the officer was able to easily access gun/ammunition registration information and had told the psychiatrist : no legal record but he owns a few assault weapons and a lot of ammo, she might have thought the 72 hour hold might not be a bad idea. Technically, and in hindsight, if you're asking about 'imminent' danger, she was right, he wasn't imminently dangerous, he didn't hurt anyone for weeks. Clinically, in hindsight, it may have been the wrong call-- if he'd been held for 72 hours it's possible that initiating treatment would have made a difference or that his psychosis and dangerousness would have been obvious and he'd have been kept longer. Or maybe he'd have said what he needed to say to get out asap and nothing would have been different.

I've had potentially dangerous people leave treatment. The 'potential' is based on a vague feeling, none of them have gone on to do anything that I know about (certainly not headlines stuff, knock on wood everyone). In psychiatry, we don't hunt down our patients. I make sure family knows how to find me, if I can, and if they tell me they're going to see a different shrink, I talk to the new shrink, But knowing how it turned out, I do like to hope I would have done more.

William said...

It might be useful to think of it like this:

1. Demand that psychiatrists put to use the power to know who is dangerous and who is not to ensure that nothing bad happens in the future.


2. Grind down payments to same psychiatrists for services rendered WHILE complaining that "access" is limited (implying psychiatrists should work harder.)


Does this remind anyone of certain traits seen in the office periodically?

HarrietMD said...

I simply do not understand this way of thinking because in my judgment there is absolutely nothing that psychiatrists can do to diminish societal violence in America without examining the ways in which violence permeates the culture at large.

Joe Nocera of the NY Times had a very sobering and upsetting column last weekend, and may again this week, in which he simply lists all of the gun-related murders in America, case by case, during the previous 7 days. The point made, among many, is that Americans are extraordinarily indifferent to an astonishing amount of violence in this society.

America spends incomprehensible amounts of money on its military; at the same time it also spends billions of dollars on a 'security apparatus' "intended" to "protect" its citizens from violence. We are the greatest purveyor of munitions on earth; we have tens of thousands of nuclear weapons and thousands of military bases throughout the world armed with nuclear warheads. On and on and on; we are a culture that depends on violent solutions to conflict and on violence as a means of economic survival.

What about discussing the idea, as psychiatrists, that Americans are filled with paranoid projections and fears because we are so sadistic; what about proposing the idea that we have reasonable expectations of terrifying "blow back' scenarios from our enemies in response to foreign policies in which we have become well-known for torturing and terrorizing helpless civilians.

If we are going to be psychiatrists, can we please start talking about violence in a way that can perhaps do some good, rather than becoming part of the political machinery that spins a mass delusion about how only "some" "bad" Americans are violent: nope, it is the whole culture and thus transcends our preoccupation with "guns."

Joel Hassman, MD said...

Umm, isn't the best predictor of violence a history of violence? If so, why aren't politicians going after lenient judges who just pass lame, nothing sentences on convicted people guilty of violence on others.

Case in point TODAY is the slimeball who has kidnapped a 5 year old after shooting the bus driver. Didn't the perpetrator have another court date on Wednesday for menacing issues? Note from what little I know it was ANOTHER case involving this man?

Oh, sorry to note this as well, but having talked with a colleague who works for the VA system, now following the Baltimore Sun expose last Sunday about the dearth of disability claim verdicts for alleged disabled vets, and this colleague telling me she has been threatened in the past by patients who EXPECT the colleague to sign off on their claims, what will lead from this? Vets have access to firearms, true? You think this population will want their names in a database?!

But hey, we are not just like priests anymore, having to take a vow of poverty to do our jobs, now we wear the hat of glorified janitors, cleaning up everyone else's messes, oh, and not being told of the hazards to the job.

And George Dawson above hits it squarely on the head at the end there: "I can't think of any more cynical legislation when it comes to mental illness treatment than the ACA, but I am sure than Congress and the White House can come up with more."

Nicely said!

doccupy said...

"Ain't it awful?"

All you shrinks do is complain. Until you get mad enough to actually TAKE ACTION it will continue to get worse.


Dinah said...

Actually, I think 'complaining' in a public forum is taking action, it's a way of increasing awareness and pointing out the issues with the hopes of articulating what does and doesn't make sense about the issues (from the writers' perspective, anyway).

I've submitted an op-ed piece, let members of the APA assembly know my feelings, and offered to testify at the state legislative hearings. I've re-joined our psychiatric society's legislative committee and the other two Shrink Rappers are also involved on that committee.

ClinkShrink said...

Doccupy: Umm, you don't have to get mad to take action. You don't even have to get mildly annoyed. You just have to care enough to be aware of what's going on, and be willing to be involved with other people enough to join together to act.

I will join your snipe, however, when it comes to physicians who complain about "X" issue but who refuse to join professional organizations. (Or who drop out of them.) If you won't do something yourself independently then at least support the organization that will.

That being said, we've got specific actions, language and statutory changes on the table to hopefully make this legislation meaningful and potentially even useful. Ultimately it will be up to the legislators, but I'm pleased what we're bringing to them. It's too early to talk specifics but it will be blogworthy once the session is over.

Joel Hassman, MD said...

Support the organization that will, what? Continue to give mixed messages? How much money has the MD chapter alone made on those CPT seminars?! That will get psychiatrists what, 70 cents on the dollars they got last year?

Thank you for the example of why being a member of an organization that is not interested in helping a profession, but just crony members will make a difference.

Gimme a break. Oh, and when one of you three take a stand against real inappropriate actions by other colleagues, be it file a complaint with the Board of Physicians against an impaired colleague, or perhaps against a hospital who mistreated one of more of your patients, or perhaps speak at a meeting and voice dissent with the status quo, can't wait to hear how you are treated.

I've walked the walk, don't tell me to just join an organization that is not representing what psychiatry needs, but just wants and conveniences.

You are welcome for my rebuttal!

ClinkShrink said...

Joel, as Dinah can probably tell you I don't give a turkey buzzard's tailfeather about what the APA does about psychiatrist reimbursement or CPT codes. If all you're interested in is what the organization does for your pocketbook, then I have no further response to your rebuttal.

As far as taking "real" action against colleagues, that's truly just not something that would get broadcast in a blog is it?

Anonymous said...

Sorry....I would guess that it might make a difference for some to know the "ridiculous" comment was left by an "anonymous" psych. RN or Oregon, but wasn't sure about the "open ID" et. al. settings to post the comment....

Anonymous said...

A little over a year ago, my therapist convinced me to see a psychiatrist. She had been encouraging this for years, and for years I said no thank you for a whole host of reasons. I doubt she would have been successful in getting me to see a psychiatrist had I known what was coming in terms of the legislation, mass hysteria in the media, and so on. I do not want to hand over more of my civil liberties just because someone who I share nothing in common with decides to unleash his hatred on the world. I find the whole thing nauseating.

Unfortunately, it seems the media turns to the psychiatrists and other mental health professionals who are the more extremist types who wish to take away more of our rights. This only increases the stigma of seeing a psychiatrist, and will cause people to avoid it altogether.

I find it almost comical that the media talks about reducing stigma even as they talk about taking away more patient rights. If they want people to seek care, this is not the way to do it.

Anonymous said...

Addendum to my last post:

I hope the media pays attention and realizes that extremists like TAC do not speak for people with mental illness like myself. The media, if they truly want to decrease stigma, could start by interviewing less reactionary mental health professionals and stay away from the extremists like TAC.

Joel Hassman, MD said...

To Clinkshrink, I find your replies to what I write to be fairly disingenuous at best, just trying to deflect from the points I make here at the least. People who know me know I am not about money, and my comments reflect that is solely what the APA is about these days. So, to defend the APA by the way I read your last comment seems to be either a projective comment, or just a tort dismissal of my points.

If you belong to the APA and think they are doing a fine job helping psychiatry, I just want to know how limited you are in paying attention to what is going on in psychiatry these days. Oh yeah, forensic work is so marginally profitable for most in the specialty, what do your forensic colleagues charge per hour, what, 250-400 dollars? And do you want readers to know that little fact?

Let me finish by telling readers about my first forensic psychiatry lecture in residency back in 1992, when the lecturer came in and asked the class what was the most important thing about forensic psychiatry. People guessed things like "represent clients who are innocent", "be sure to maximize as best an honest interview to know the client", I even offered something of the sort of "make sure the law backs up your position on the case."

Nah, you know what this "psychiatrist" came back with as a reply? "Make sure you get paid in advance." Think that attitude is off base with the majority of forensic psychiatrists in this country even today?

Just the court appointed psychiatrists! 'Cause you are public defenders.

Tell me I am wrong!?

Oh yeah, that last comment about talking about taking action against colleagues, that is totally out of line? Sorry, that last comment of yours was just lame! Because noting to readers you have been a whistleblower and been ostracized and harassed is not what the APA really wants the public to know, eh?

And you wonder why we read of more corrupt police officers getting no real punishment for their transgressions as cops against the public. Sort of like the same for psychiatrists!!!

ClinkShrink said...

Joel, you're wrong. Here's the post I wrote in response the last time you brought this hackneyed old topic up. You're interpretation of that lecture tells me you completely missed the point of it. But I already know that you hate forensic psychiatry and you don't want forensic patients in your clinic so I doubt I'll change your mind about any of that.

You commented on this post to accuse the Shrink Rappers of being all blogtalk and no action. I'm at a loss to understand how you know that if you're not a member of the district branch yourself.

HarrietMD said...

Well, to make another unwelcome political analogy I just want to comment that the argument between Joel and Clinkshrink is as demoralizing as the intractable standoff between Dems and Republicans. At a certain point, you have to question the institutions that maintain such polarization and anger in people who have much more in common than not.
I spent a lot of the day reading comments about yesterday's front page NY Times article about the death of a young man from amphetamine abuse.
One more nail in the proverbial coffin; psychiatry looks pretty bad here.
We have a great deal that is more interesting to talk about than to fight amongst ourselves and call each other names. But the war between psychopharmacologists and psychotherapists in psychiatry has been waging for a long time; it has been bad in every conceivable way, in my judgment, for the field31 and led to very poor decisions and an anemic and minuscule lens by which to understand our subject-matter.
If we stopped fighting amongst ourselves, what would we be talking about? Can't we just get there?

roblindeman said...

I'm with George and Jesse on this, partially. I'll add this: Current events fit perfectly in the history of the way the so-called mentally ill have been demonized, marginalized, and incarcerated since the days of the mad-houses.

Hmmmm said...

...Joel called Clink a whore?

Hmmmm said...

Just thinking about translating guy talk: A slut is someone who sleeps with everyone. A whore is someone who sleeps with everyone except you.

I wonder if Joel has a little crush on Clink. She's cute and smart and a doctor...and yet she's not into him and doesn't seem to like him very much.

Joel Hassman, MD said...

My sincere apologies to HarrietMD for this follow up comment, but I am compelled to reply to someone who has said 2 things that are just as equally arrogant and rude to how Clink Shrink seems to interpret my comments.

1. My interpretation is wrong, because you do not agree? Ah, you were not in the class that day, that I know of at least, and isn't experience of some value in forming interpretations? And we are to totally disavow first impressions, is that what you tell people? And if you do any psychotherapy, do you tell patients directly their interpretations are "wrong"?

2. Major violation of the point in allowing anonymous comments. You didn't think about linking to your prior post when it was clearly noted I was "anonymous clinician", because I did not want to identify myself over a charged issue that this is. Your site posted it, kept it, and then wrote a post about it. You have basically told readers that their anonymity is only respected as long as it is convenient and serves the site's benefit. I hope readers note this flagrant transgression of trust!

I agree with your point that I have not worked, much less know anything about the district branch's role and impacts on other elements in Maryland. But, isn't the hypocrisy just dripping with irony that we are to believe that since you were not in the class that day, your interpretation trumps mine, yet the roles reversed now with my not in the district branch still makes your interpretation trump mine again.

Sorry, that is plain arrogance to me! Doesn't really tell me my opinion about forensic psychiatry is completely off. I wonder what Jonas Rappaport would say to both of us being a third party to this difference of opinion. He was quite the mensch in the field during his days. There are fine, outstanding people in the specialty of forensic psychiatry, and then there are whores.

People can take whatever interpretation to what I said before and now, but to sell your expertise to the highest bidder, irregardless of whether the agenda is right or wrong, please give me a better word as analogy, and I will use it hereon.

On thing is for sure, I will never comment at a Clink Shrink post in my life hereon. And it does frighten me that this violation of alleged trust has happened. I hope all the authors here think about it.

It is just my interpretation.