Thursday, September 19, 2013

Guns, Again (--another broken record shrink rapper)

Apparently,  if the shooter is dead, I can talk about it (a little).  I don't know any facts except what I've seen in the paper, and I've interviewed absolutely no one, so I'm not going to say much, but I am going to use what I've read to write a post on the on-going issue of the role of mental illness and gun control.

Per today's New York Times:

But several senators, like Senator Richard Blumenthal, Democrat of Connecticut, who has pushed for tougher gun laws since last year’s elementary school massacre in Newtown, Conn., see mental health policy as a way forward.
Mental health is really the key to unlocking this issue,” Mr. Blumenthal said. “I’ve become more and more convinced that we should establish the mental health issue as our common ground.”

  So you know, I have read approximately eight news articles, mostly in the New York Times, a couple in the Wall Street Journal, and I listened to the transcript of the interview with Dr. Ritchie and Dr. Torrey on PBS.  And ClinkShrink already wrote about this in Speaking Ill of the Dead, because she's a broken record.

Here are the "facts" I have seen reported.  Note that some of these "facts" are conflicting:
--the shooter went to the VA ERs twice in the past month and got medicine for insomnia.  He was reported not to be suicidal, depressed, or anxious, and was given Trazodone, an antidepressant used for sleep. Trazodone is not an SSRI, and I say that because there have been questions about whether SSRI's can cause violent or suicidal thoughts.
--he had a "decades long history of mental health problems" with no clarification as to what that meant or consisted of.
--the VA has no history that he ever sought mental health treatment
--on August 7th, he was in Rhode Island and called the police because he was paranoid that people were following him and there was something to do with microwaves.  (Sounds psychotic, but the psychosis is due to what? No clue but possibilities might include ?schizophrenia, ?delusional disorder, ?DTs, ?bad drug trip, ?mania, ?brain tumor, ?malingering, ?psychotic depression, ?neurosyphillis, ?hypothyroidism aka myxedema madness --I have no clue, though Dr. E. Fuller Torrey calls this "classic paranoid schizophrenia" and he may be smarter than me.).  
--The police faxed a report to his employer
--The police did not fax a report to his employer .
--The police did not take him to the ER (that we know of).
--Nothing has been said (that I saw) about any offer to take him for a psychiatric evaluation, so we don't know if he 'refused' care that day or any other day.
--His father said he had PTSD from being a first responder on 9/11
--There is no record that he was a first responder
--There has been no mention of psychiatric hospitalizations
--He had VA benefits and access to care and was actively employed and working, rehired by a prior employer this summer and had a security clearance.  To me, this implies that his work for that employer during the previous stint was satisfactory.
--His discharge from the military was honorable.
--His discharge from the military was not dis-honorable.

So with regard to mental health issues being the key to gun control, I ask:
--What's the line?  You hear a voice and everyone's head is wired such that the voice goes directly to a databank so that your guns are removed and a magical shute pops up to wisk you to a state hospital bed?
-- You tell a doctor you are having trouble sleeping and you can no longer own a gun? This would be a huge help in either keeping guns from people or cutting down on sleeping pill prescriptions.  And it would be fun to watch the drug companies go bonkers.
--Everyone who sees a therapist is exempted from owning a gun?  Or just people who see psychiatrists?  What about people who get psychotropic medications from their family doctors?  Or do we weed people out by their psychiatric diagnoses?  Or specific symptoms?  And how do gun-limiting databanks and law enforcement agencies discover those symptoms or diagnoses?  Insurance forms?  Mandatory reporting by therapists?  What about self-pay patients?  Perhaps we should require anyone with psychiatric symptoms to self-report to a database?

With regard to looking at behavior, instead of imprecise labels like "the mentally ill," I've seen the following reported (again, just what I saw in the press):
--two weapons violations for discharging a gun, no convictions.
--the shooter reportedly claimed he had an anger-induced blackout (not an official diagnosis) as an explanation for firing shots
--two days in jail for a bar fight 
Legal records are not confidential, so it might be much easier to ban people with a history of criminal impulsive behaviors from owning guns and cast a wider net.  

When someone has committed a tragic, senseless crime and has complained, ever, of a psychiatric symptom, it's easy to say mental illness is the common denominator and that's where we should target our gun control.    If you shoot strangers, we don't understand that behavior (at least I don't), so we say someone is severely mentally ill, and in retrospect, they may well have been.   But until that time, it may not have been obvious that they were dangerous and the question is how big a net should we drop?  Mental health professionals  see people every day with psychiatric symptoms, insomnia, violent thoughts, and sometimes psychotic symptoms.  It is so easy to see the 'red flags' in hindsight, but so many people have these symptoms who never go on to hurt anyone, that our predictive powers are sometimes limited.  I certainly think there should be a mechanism to report someone who a therapist is clearly concerned about as being at high risk for violent behavior, and in our state, there is a mechanism to get someone in the hospital, but not to keep them from owning or purchasing a gun.  I think we need to base such gun control on actions -- people who've been violent or people who have had suicide attempts serious enough to require medical admission, or those with stated intent.

Finally, at this point, we don't know for sure that mental illness was the motive for this action and maybe we should wait to hear if anything indicates that it was before jumping to that conclusion.


Unknown said...

Realistically, I think something needs to be done regarding gun control. These mass shootings have to stop. However, I can just see the negative stigma towards mental illness and psychiatric help becoming more and more of an issue. So, this begs the question, what are we going to do when people who need psychiatric care will not seek it out, for fear of retribution in terms of their ability to own guns?

Anonymous said...

Great post Dinah. In looking at the comments sections, I thought the one that pointed out that alot of the shootings are by sane people was excellent such as domestic argument escalating or stickups gone wrong.

Also, as I have previously mentioned, many of the shooters were already in the mental health system. James Holmes psychiatrist apparently had some concerns about him but was blown off. Anyway, instead of looking at those possible breakdowns, it is alot easier to just stigmatize a group of people by blaming the shootings on MI without any evidence as you wonderfully pointed out.

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Je Suis said...


" I want to move that responsibility to those who deal with the repercussions of troubled behavior and let the patient see a psychiatrist without fears of repercussions for what they say."

" I think we need to base such gun control on actions -- people who've been violent or people who have had suicide attempts serious enough to require medical admission, or those with stated intent."

Both of those are your statements. So, which is it - no repercussions for what they say or repercussions for something they say in the form of loss of rights (A.K.A. gun control) for a "stated intent" (basically, something they said)?

Cassara is right, and I've been saying it all along: people needing psychiatric care are in jeopardy for seeking that care. Best not to do it at all. The risk of being turned into a second class citizen for what you say is too great.

Hmmm, it appears that we are living in East Berlin circa 1975 after all..

Joel Hassman, MD said...

You know what, even though the shooter's treatment probably was the best that could be offered, someone is going to want a person to be accountable. Hey, Dr M, didn't you see that bulls eye on your back when you committed to being a psychiatrist?

I ask every single provider who reads here, do you think the general public really cares what we honestly and realistically can do as psychiatrists or other mental health care providers in identifying people who are at risk to themselves or others at the end of the day?

I wrote a rather sarcastic piece about this issue the other day, and had someone tell me today I was ridiculous in what I wrote. Well, sometimes you have to be a bit outrageous to get people to really think hard about an issue. It is what I do at times, ask people to think hard.

There is a lot of hate and negative passion out there, folks. We as providers can't control it, we can only ask you as patients to step back and rethink it so it can be resolved, not dissolved. I think as a start, you need to make your alleged leaders and politicians do their jobs right, or make them step away and stop leading by poor example.

Next week in DC will be very interesting, and I ain't talking 'bout gun control issues. PPACA will finally be front and center, and those who want it, well, I hope you are right in your passionate support. Because if you aren't, and my perspective is in fact more likely right, worrying about these q6month shootings are the least of our worries.

Hey, if you get care from the Cleveland Clinic, bet you are happy to read what they are doing after this week's announcement!

You know me, just shooting my mouth off again! Yeah, bad pun, so was this week!

Oh, the irony, the "prove you're not a robot" for the comment was "painably". Happy Sukkos and first Fall weekend!!

Sunny CA said...

This topic has been on my mind again, since the recent shooting. The NRA viewpoint is "It is not law abiding gun owners that are the problem, the problem is criminals and crazy people". The legislature seems to be picking this up from the NRA.

Criminals: Don't they mostly shoot people with unregistered guns they buy illegally on the street? If you plan to shoot people, would you register the gun and buy it legally?

Crazy People: How do you find the people-shooting crazy people? It strikes me that if you take the right of gun ownership away from people who have contact with the psych community, the group you are trying to identify will not be seen.

This particular shooter would not have been identified, yet hundreds of thousands of calm, peaceful people would lose their rights.

Anonymous said...

Uh, the reality can have all the gun control in the world...if you want one, you'll find one. Kind of like drugs!

Anonymous said...

One thing the U.S. has always done really well is mass hysteria. This push toward targeting a group of people for the sins of a few is disgusting. When you have supposedly reputable news organizations like CNN (which is increasingly becoming more like a tabloid) asks questions like, "How do we better track the mentally ill?" I want to hide.

I read the comments on the New York Times' website and other websites and the hatred of those with mental illness comes through loud and clear.

The fact is most people with untreated mental illness don't kill people. Some do. Most men don't beat their wives, some do. It makes no sense to target a group of people for what a few have done. It's wrong.

We did this with the Japanese. We rounded them all up. Why? Irrational fear. We've done this with African Americans. We have done this with people who are different, simply because they are different. When is this going to stop?

I'm beginning to think those in positions of power have more issues with paranoia than folks with mental illness.


Anonymous said...

I wish when I heard psychiatrists interviewed on t.v. they talked about things like how to reach out to patients, collaboration, listening, rather than force, force, force. If my only experience with psychiatrists was what I saw on television, I would be too afraid to see one.

The media's over the top way of dealing with these issues not only does not help, it makes things worse. My plea to the media would be to interview some different psychiatrists, find the ones who will reassure the public that treatment doesn't have to be this scary thing, that it can be done in a positive, collaborative way.


a psychiatrist who learned from veterans said...

As far as commenting/ speculating on some psychiatric aspect of the individual. HIPAA protections are less stringent in dealing with the deceased. Not that anybody you reported commenting knew the individual, but I think the implication does loosen the required modesty in talking about what one knows or thinks. This weekend an APA task force released a report saying that 'antipsychotic drugs' are overused*. The comments at USAToday had a delighted group of psychiatry bashers. My specific gripe is that, reviewing the literature, I find that other adult bipolar drugs are just not found useful in Adolescents. Thankfully from a criticism standpoint the spokesman, Joel Yager, MD is from the same Medical School that treated the man found armed to the hilt at the scene of the Aurora Colorado movie shooting. Are we to be speculatively happy that he wasn't about to develop diabetes from Risperdal?


Anonymous said...

a psychiatrist who learned from veterans,

I am perplexed by your remarks as in looking at the comments, I recall a specific one that based psychiatry. There were a few who extolled the virtues of the benefits of the meds. Many of them criticized medicine in general and psychiatry for over prescribing these drugs which is the truth.

I think what you may thinking of that wasn't reflected in the comments in my opinion is many of us who have been very critical of the overprescription of these drugs have been frustrated that we have blown off for many years. So when there is finally acknowledgment from your colleagues that we were correct, of course we take delight in that as anyone who was finally acknowledged in that manner.

Anyway, if psychiatry wants respect from people, it has to stop falsely attributing legitimate criticism to folks being anti psychiatry and truly begin to what is being said.