Saturday, December 27, 2014

Shrink Rap: Most Popular Posts for 2014

10.  Let's Keep Guns Out of the Hands of.....

9. How Hard Is It To Find a Psychiatrist? Tell me your stories!

8. Insurance (or Not), Flotation Tanks, and Involuntary Commitment.

7. The doctor will see you NOW!

6. Who are the Mentally Ill? Please take my Brief Survey!

(please note: the survey is closed but the results can be found here )

5. Does bad parenting cause mental illness?

4. Should it be a Crime for a Therapist to Have Sex with a Patient?

3. Are Psychiatrists Evil?

2. Why Psychiatrists Don't Participate with Insurance Networks 

1. Is it Ok to Shrink your Sister in an Emergency?


Friday, December 19, 2014

Written Off

Request from a friend.  I donated, if the cause sings to you, I hope you will too.

Hi Dinah,

I'm writing to tell you about the production of a feature documentary some good friends of mine (and extremely talented filmmakers) are producing. It's a compelling life and death saga of young opiate addict aimed at public enlightenment and destigmatization for which I am an advisor and supporter. I think it will have the power to seriously advance the conversations around prevention and treatment.

They are raising money to finish it as quickly as possible, and I wondered if you'd be so kind as to broadcast their Kickstarter campaign through SHRINK RAP. The link is below and contains lots of info and a short trailer.

Very best wishes and thanks,


Tuesday, December 16, 2014

Psychiatry or Bust?

Over on the Neurotransmitting blog, Dr. Joseph Andrews, a 4th year psychiatry resident, writes about Where Psychiatry Sits With Medical Students and What We Can Do About it
He writes, in a good deal of detail, about the finances of it all and about why someone who has taken on a lot of debt to go to medical school might not be able to afford to become a psychiatrist.  This isn't new -- I went to medical school knowing I wanted to be a psychiatrist, and there were medical schools I simply didn't apply to because I knew I would need to take on so much debt that my monthly payments would be more than I could afford on a resident's salary.  Ah, those schools were kind enough to provide that information in blunt terms, I remember pamphlets that said that if you needed to take out a HEAL loan at the high interest of the day, then you could expect to pay back $1700/month.  That assumed no college debt (which I already had) and at the time, residents made roughy $26,000/year.  Those applications went into the trash.

Dr. Andrews also talks about the stigma of psychiatry -- his friend's family would be shamed if she went into psychiatry, and he talks about how there are other mental health professions for those interested in the field.  It's a good post.  And I'm here anyway, though in college I did plan to be a psychologist.  I'm not sure what happened along the way, but suddenly psychiatry sounded better.

So I'm here to say it's still pretty good.  I still like being a shrink, and people get better much more than they ever told me in medical school.  I still talk to my patients and get to know them.  At the end of most days, I feel appreciated.  There is still a lot of variety to what psychiatrists can do -- research, teaching, brief contact practices (many many patients for brief med checks), or high contact practices (psychoanalysis, or less high contact with psychotherapy), administration, and blogging (warning: no pay).  I don't ever wake up and wish I was  a dermatologist.

So do check out Neurotransmitting -- it's one of very few blogs by a psychiatry resident and Dr. Andrews is just getting started. 

Thursday, December 11, 2014


I had a really interesting day yesterday.  I went to Richmond to learn about electroconvulsive therapy, or ECT.  Yes, shock treatments.  Now we have ECT in Baltimore, and all residents see patients on the inpatient unit who have ECT, and all residents do ECT.  I wanted to see it again because it's been a long time since I was a resident in an ECT suite, and thought perhaps something might have changed.  Nothing changed, except that now the psychiatry resident spends a lot of time looking at a computer. 

Why did I go to Richmond?  I'm doing research for our book on involuntary treatments, and in Maryland ECT is only used for people on a voluntary basis.  The only way around this for someone who is so sick that they are in danger of dying if their condition doesn't get treated, is to have a guardianship appointed, and this is quite rare and for quite extreme cases.  In Virginia, ECT is treated like any other involuntary treatment, a magistrate comes to the hospital to hear civil commitment cases, have medication review panels (I'm not sure what they call it there, that's the Maryland lingo) and involuntary ECT is considered another treatment.  Obviously, it's reserved for the very sick, who have not responded to other treatments, or where a quick response is imperative.  I heard about one patient who had been catatonic with a feeding tube and unresponsive to any treatments - a man in his early 50's -- the treating facility's plan had been to transfer him to hospice to die, and instead he was transferred for ECT treatments and he recovered.  

The doctors who do ECT regularly see it as a highly effective treatment, often life-saving, when all else has failed.  Clearly, this is the most controversial treatment we have in psychiatry, some might even say it's barbaric.  

I've hesitated to blog about the research I've been doing as I work on the book -- not because there's anything secretive about it, and it's been a fascinating project for me -- but because I'm not sure how are readers will respond.  Obviously, involuntary treatments make for a controversial and heated discussion.

And if you're interested in the latest on what Maryland's Department of Health and Mental Hygiene is planning to recommend to out state legislature on involuntary outpatient commitment, Here is an article in the Baltimore Sun to check out. 

Sunday, December 07, 2014

Did Adnan do It?

I figured I'd join the bandwagon of bloggers talking about The Serial Podcast.   I'm taking a break from psychiatry for the moment.  If you haven't been listening, Sarah Koenig is orchestrating a year-long investigation into a 1999 murder. 17-year old Adnan Syed was convicted of killing his ex-girl friend and there are a few things that have caught Koenig's attention about the case: an alibi witness was never interviewed, Adnan was a good kid who followed the rules and was no one's pick as a would-be murderer,  and there was no physical evidence.  Koenig has been hunting down every detail, interviewing Adnan (an inmate in the Maryland state penitentiary), his family, his friends and teachers, and making her way through all the records from the trials.  She plays tapes of her discussions with these people, and plays snippets of the trial.  The victim's family has not been heard from, and the story is tragic from every direction, and yet still somehow weirdly compelling.  The episodes get posted on Thursday mornings, and I believe each episode has over 2 million listeners.

Clink and I have been listening.  She is the only person I know who doesn't like it.  She says the crime is unremarkable and she's tired of Sarah Koenig's back and forth debate with herself of 'did he do it?' or 'Didn't he do it?'
    "She doesn't know.  We get it," Clink says.
I asked why she's continued to listen and Clink tells me that once she's started something, she has to finish, whether it's a book or a podcast.  If I had this issue, I'd be really picky about what I started.

I like Serial.  I really like it.  I discovered the series after 3 episodes had been posted, and I listened to all three at once -- strange for me, I'm not a binger when it comes to entertainment.  I look forward to Thursdays and the next episode, and I feel sad when the episodes are over.  I know that ultimately it's bound to be a letdown: the series will end in a few weeks with no definitive answer, or so I imagine.

Okay, so it does feel odd to listen to the story of a real life murder as entertainment.  I worry that the victim's family might be injured by it.  If they feel that Adnan was guilty, then knowing that someone is out there revisiting the trial of their family member's murderer must be awful.    But, I'm going to rationalize this: we read books about murders and tragedies  all the time.  Is this different then say reading The Devil in The White City where part of the plot followed an evil serial killer? Or Truman Capote's In Cold Blood about a family that was killed? Maybe.  But what if Adnan didn't kill Hae, and what if this podcast inspires freeing an innocent man and perhaps even finding the person who actually did do it?  Koenig started investigating this at the request of a family friend of the Syed's. 

Issues of justice are compelling -- if you don't think so, check out the reaction people have had to recent police killings.  We want the bad guys to get what they have coming to them, and we don't want to see innocent people wrongly incarcerated.  And I've spent the last number of months doubling as a journalist researching involuntary psychiatric care; it leaves me in awe of Koenig's reporting.  She's a remarkable journalist, but even more, she's a truly wonderful story-teller.  She knows exactly how to rope a listener in, and how to keep them listening.  Honestly, I think if Sarah Koenig was talking about how to boil an egg, she'd have me transfixed.

Okay, so I want Adnan to be found innocent.  The series will be disappointing if he isn't.  Guy kills a girl  and there's a witness who helped bury the body.  Then a journalist  questions his guilt and reopens all the wounds and issues, and it turns out he really did do it; that doesn't quite make for a good story if you're telling it knowing how it ends.  Adnan is smart and personable --a model prisoner who is faring quite well on the inside-- and it would be nice for the story line if he didn't do it, though really tragic for the victim's family.  So far, though, I have to say that the evidence sounds like he may well have done it.  

Monday, December 01, 2014

So You Like To Write

 From my email, I'm passing this along.  This organization has no ties to Shrink Rap:

 Beyond Crazy

Deadline: February 9, 2015
Every year, one in four American adults will endure the trials of a diagnosable mental health disorder. But although many Americans have experienced a mental illness, either firsthand or through a family member, friend, or colleague, the stigma surrounding mental illness remains. We believe that the most important tool we have for defusing the power of this stigma is sharing true stories and revealing the real people beneath labels.
In Fact Books seeks original stories for an upcoming anthology tentatively titled BEYOND CRAZY: TRUE STORIES OF SURVIVING MENTAL ILLNESS. Stories should combine a strong and compelling narrative with an informative or reflective element, reaching beyond a strictly personal experience for some universal or deeper meaning.
We’re looking for well-written prose, rich with detail and a distinctive voice; writing should be evocative, vivid, and dramatic. All essays must tell true stories and be factually accurate. Everything we publish goes through a rigorous fact-checking process; editors may ask for sources and citations. Authors of accepted essays will be awarded a modest honorarium upon publication.
Guidelines: Essays must be previously unpublished and no longer than 4,500 words. Multiple entries are welcome, as are entries from outside the United States.
You may submit essays online or by regular mail:
By regular mail  Postmark deadline February 9, 2015
Please send your manuscript; a cover letter with complete contact information, including the title of the essay and word count; and an SASE or email for response to:
    In Fact Books
    c/o Creative Nonfiction Foundation
    Attn: Beyond Crazy
    5501 Walnut Street, Suite 202
    Pittsburgh, PA 15232

Online Deadline to upload files: 11:59 pm EST February 9, 2015
To submit online, click here. (Note: There is a $3 convenience fee to submit online.)
Creative Nonfiction | In Fact Books
5501 Walnut St | Ste 202 | Pittsburgh | PA | 15232
412.688.0304 | F 412.688.0262

Sunday, November 23, 2014

Questioning the Rules

Good morning.  I'm sending you to look at two articles today, both by or about people who have been on our blog before.

Over in the New York Times, Robin Weiss has a fabulous article about her work with a patient who wanted to know details of her personal life, "The 'rules' of psychotherapy."  Dr. Weiss talks about how revealing such information goes against the 'rules' of psychotherapy, and she discusses reasons why she decided that in this case, it made sense to break the rules.  She writes:
As therapy continued with her, I heard how flat and tinny I sounded whenever I attempted to analyze what was going on between us. When I lapsed into too clinical a mode, our connection would wobble, and her alienation became palpable.
In contrast, as I began, in the face of her challenges, to let down my guard, our alliance grew stronger, and she became open to treatment. We would laugh together about her bringing me just the right greeting card or a flower from her garden — exhibiting her need to challenge “the rules” and exposing my need to interpret her actions. These interactions helped develop her capacity to observe herself in action, as she courted me in her Sherpa style.
I may have been a slow student, but eventually I understood: I was the one who had to change. From then on, when she saw that look in my eyes, I said yes, I did have a migraine. We followed episodes of the TV show “ER” together, and I told her where I was going when I left for vacation.

I like the flexibility this articles conveys.  All patients aren't alike, they (and their psyches) don't all follow, or even know, the rules. It's good to question things when the treatment doesn't seem to be working.

And in the New Yorker, Jeff Swanson, a medical sociologist at Duke, is interviewed for an article by Maria Konnikova for "Is there a link between mental health and Gun Violence?"  Dr. Swanson has a wonderful idea: instead of preventing people from owning guns because they have a psychiatric diagnosis, we should prevent people from owning guns because they are violent.  Konnikova writes:

In all of his work, Swanson has found one recurring factor: past violence remains the single biggest predictor of future violence. “Any history of violent behavior is a much stronger predictor of future violence than mental-health diagnosis,” he told me. If Swanson had his way, gun prohibitions wouldn’t be based on mental health, but on records of violent behavior—not just felonies, but also including minor disputes. “There are lots of people out there carrying guns around who have high levels of trait anger—the type who smash and break things,” he said. “I believe they shouldn’t have guns. That’s what’s behind the idea of restricting firearms with people with misdemeanor violent-crime convictions or temporary domestic-violence restraining orders, or even multiple D.U.I.s.”

Friday, November 21, 2014

DJ Jaffe: The 4.2% (or the Us / Them Dichotomy)

Over on Pete Earley's blog, he gives the text of a speech by DJ Jaffe, a mental illness advocate.  Mr. Jaffe contends that those with serious mental illnesses constitute 4.2.% of the population and those people can be differentiated from the rest of the population, including the 20% of the population in any given year who have DSM diagnoses which are "mainly minor illnesses like anxiety." Jaffe would like to see those with real mental illnesses, who aren't the worried well, moved to the front of the line for services.  

I've ranted before about how I still don't know who those mentally ill people are -- I did a poll on this on Shrink Rap and got results from 696 people and wrote about the results Here and Here.  I've been in private practice for over 20 years, and have worked at 4 different community mental health centers, including a stint volunteering at HealthCare for the Homeless.  Many of the people I see spend most of their lives doing very well, and for Catlover who commented on the post on The Violent Mentally Ill, I'll add that when they are well, they are indistinguishable from everyone else: they go to work, they care for their children and parents, they are doctors, lawyers, teachers, the heads of companies, and they do amazing volunteer work and give generously to charities.  And when they are sick, they suffer, can't get out of bed, miss work, stop eating, and feel suicidal.  Some of these very well people hear voices, have delusions, and shut down.  Some of the mentally healthiest people I know are also some of the sickest people I know -- it simply depends on what slice in time you catch them, and the sick part can be a very brief, but life changing, slice.  Many people I see have been hospitalized at some point, have attempted suicide, or have needed 4 or 5 medications at a time in order to be well.  

But Mr. Jaffe is right: there are some people who are chronically ill, who never get well, and who aren't going to work and contributing to society.  They cycle from the jail to the hospital to the street, and very frequently (as in almost always) this population includes people with substance abuse disorders.  Does it matter?  If someone cycles from the jail to the street and back again and they have a substance abuse problem which contributes, do they deserve less help than the person who also has a mental illness?  What if they have a personality disorder that destroys their ability to function, have relationships, hold a job, maintain housing, and live in a meaningful way in society?  And if you're in the midst of a terrifying panic attack, who decides if your problem is "mild?"  I don't like the Us/Them split with the idea that there is a clear divide.  We're all people, we all hurt sometimes, and some of us need more help than others : diagnosis is not the thing that determines that.    Nearly 40,000 people a year die from suicide; they aren't all obviously ill and sometimes we are left to be totally shocked.  400 physicians a year (the equivalent of an entire medical school) commit suicide and they probably weren't falling in Jaffe's listing of the severely mentally ill who cycle through jails and hospitals.  When people commit suicide, or school shootings for that matter, there were often subtle signs, but most of these people weren't in that 4.2% and weren't the obvious severely mentally ill. 

If you're suffering, you're suffering, and we need better services, available more readily, for everyone. The teenager who kills himself because he is distraught over a break up is just as dead as the man with chronic schizophrenia who dies on the street.  We need more and better treatments for substance abuse, and we need more and better treatments for those mental illnesses that are resistant to the medications that are available now.  We need more ACT teams, more housing (because it's hard to get your medicines if you have no address to get your check and no shelf to put them on), more peer support, more transportation.  Offering help to those who suffer but don't have severe, chronic, and persistent mental illness should not be equated with stealing services from those most in need.   

[This weather calls more for a snowy owl theme, I think. --Clink]


Tuesday, November 18, 2014

The Violent Mentally Ill

There's been lots in the news lately about forensic hospitals and the management of violence by psychiatric patients. Here's a short list:

1. Beyond the Gates of Gomorrah

A new book by Dr. Stephen Seager, a tell-all about his work in a California forensic hospital.

2. Broadmoor

A very rare documentary filmed within the walls of a British forensic hospital. In two parts, all on YouTube:

Ep 1 Ep 2

Friday, November 14, 2014

Abilify: It's Really Expensive!

Sometimes, I like to bother pharmacists.  They are the nicest people, and very patient about looking up medication costs for me.  Once, I wrote a post called The Co$t of Being Depressed, where I compared the cost of anti-depressants. Today,  I'm writing over on our Clinical Psychiatry News website about The Surprisingly High Cost of Abilify. 

Here's the short form, but do surf over there for details:
I called three pharmacies and compared prices on Abilify.
Please remember, this data is for three pharmacies only
  • A single 2 mg tablet cost between $30 and $33 dollars.  More don't cost appreciably less per pill so a 90 day supply ran $2700 at a local independent pharmacy to $2724.81 at Wal-mart.  If you do the math, you'll realized that at Wal-mart there was some discount for bulk : the pill price for 90 tablets is about 30 cents/pill less than for 90 pills. 
  • A single 30mg tablet runs $38-$47.  
  • A 2mg tablet costs the same as a 15mg tablet --which is the same as a 5mg and 10mg tablet
  • A 20mg tablet costs the same as a 30mg tablet.
  • It costs a whole lot less if you split the pills.
  • This stuff is expensive.
 You'll note the graphic above is an animated Abilify commercial.  I hope the pharmaceutical company appreciates the free advertising.

Tuesday, November 04, 2014

Out of the Hospitals & Into the Jails?

Over on Saving Normal, psychiatrist-blogger Dr. Allen Frances has put up a thought provoking article called We Should All Be Ashamed.    Frances asserts that closing the state hospitals was the wrong thing to do : those patients now live on the streets and cycle through the jails.  We haven't freed them, he says, we've abandoned them.  Frances goes on to say that Dr. E. Fuller Torrey is right: our society needs laws that allow us to force those who need help into care and Representative Tim Murphy is right: we need to pass the Helping Families in Mental Health Crisis Act -- one that mandates states to have programs for involuntary outpatient commitment.  

Frances concludes:
Is there any possible way to get this train back on track? First, implementing Tim Murphy’s Helping Families in Mental Health Crisis Act (H.R. 3717) would be a good start. Second, Congress should abolish the IMD (Institution for the Treatment of Mental Disease) exclusion. In fact, I personally believe that the federal government should get out of the mental illness treatment business altogether. They have been in this business since the passage of the CMHC legislation in 1963 and it has been all downhill. Let’s give the responsibility – and the federal money—back to the states and then hold the governors accountable for the results. They cannot do worse than we are doing now. Third, there needs to be further modification of state involuntary treatment laws and increased use of assisted outpatient treatment (AOT) and conditional release so that the small number of seriously mentally ill individuals who need these kind of services can be treated before they end up homeless or incarcerated. These three steps alone would go a long ways toward improving the treatment system."

Over the years, we've see lots of controversy about these topics on Shrink Rap and as you know, we are working on a book called Committed: The Battle Over Forced Psychiatric Care, so an article like this catches my attention.  

Surf over to Saving Normal, read the whole thing, and I'll invite you to return and comment here, if you'd like. 

Monday, November 03, 2014

What Happened to You in the ER?

I'm writing about what happens in the Emergency Room from the perspective of a psychiatry resident (the doctor who is training to be a psychiatrist).  I'd like to include  a couple of quotes from patients who have been through the experience of going to an Emergency Room with a psychiatric crisis. They would be short quotes -- though you're welcome to tell me the longer story.
~The ER visit needs to have been within the last 2-3 years
~Must be in the United States only
~I'd need the name of the state
~I might want to talk to you to verify that you are a real person
~I would not include your name or any identifying information, but you could make up a pseudonym. 
~Of interest would be how many hours were  you in the ER and who did you speak with there? Did they share with you their thought processes on disposition -- for example, "I'm afraid you're at risk so I'm admitting you,"  or "I'd like to admit you but there are no beds,"  or anything along those lines.
~Thank you for adding your voice!

On a related note, there has been a lot in the news recently about "boarding" in psychiatric ERs and you may be interested in this article about ER boarding in The Orange County Register by Bernard J. Wolfson: Psych Patients Pack Emergency Rooms
Wolfson writes:

Once they get to the ER, patients with mental health disorders are are often held without treatment for many hours, or even days, while they wait for a psych bed to open up – or for an assessment to determine they don’t need one. In an ideal world, those patients would be seen much more quickly, by qualified professionals, in a setting intended specifically for handling urgent psychiatric cases.

Sunday, November 02, 2014

Brandon Marshall: Football Player with Borderline Personality Disorder

This is a short post to send you over to Clinical Psychiatry News where I wrote an article on an television special "A Football Life" special about Brandon Marshall, the Chicago Bears wide receiver, who struggles with borderline personality disorder.  It's not often that I get to write about football and psychiatry in the same post, and I always like it when successful people are public about their psychiatric disorders -- what better to help de-stigmatize conditions that are erroneously associated with people who have been marginalized? 

Saturday, October 25, 2014

What I Learned Part 3

Today I enjoyed the presentation about the role of the Academy and of the American Psychiatric Association in appellate litigation. Both organizations work together to file amicus curiae ("friend of the court") briefs for court cases that have relevance to psychiatry and the care of the mentally ill. The APA has participated in 127 cases since 1962, and AAPL has participated in 16 cases since 1985. Most briefs are written by the APA counsel (all of whom have been former Supreme Court law clerks). Most of the cases were criminal rather than civil cases, and several were cases that went before the U.S. Supreme Court. AAPL wrote briefs for cases involving intellectually disabled defendants facing the death penalty, and in the California prison case regarding overcrowding and access to mental health and other services. The AAPL brief was cited in the appellate opinion in 10 of the 15 cases, so the organization apparently does have some influence.

A panel presentation on the New York Safe Act was interesting, since the work on it was done long before the New York Times story came out on the subject. A group of forensic people tried to obtain data from the New York Office of Mental Health as well as the New York Division of Criminal Justice Services regarding the number of reports made, the professional training of those filing reports, the treatment settings the reports were made from, and the ultimate outcome of the reports. Both agencies refused to release data for a variety of reasons, either because "it was an election year" or because the statute was in litigation. In rare cases, the agency expressed concern over potential privacy issues where a report was filed in a county so small that the individual could easily be identified. Both agencies said that the only way to determine the number of guns actually seized would be to contact each law enforcement agency in every county---not a small feat for the state of New York. The only definitive statements given by OMH was that no reporter had ever been sued to date for making a report, and that there were some cases where reports were made by someone other than a mandated reporter (a psychiatrist, psychologist, social worker, or psychiatric nurse). None of these reports were acted upon or forwarded to local law enforcement. The implication appeared to be that if the information was coming from someone other than a mental health professional it might not meet the standard for requiring that dangerousness be due to a mental illness. This is speculation on my part; still, I'm not sure why a lay assessment of potential dangerousness---regardless of cause---wouldn't be taken seriously by someone. More evidence that common sense and public policy do not always go hand-in-hand.

The final session of the day was a panel presentation on consultation to law enforcement, easily the most testosterone-laden of any talk this week. The presenters were people who provided peer support, counseling and fitness for duty assessments on police officers. There was a lot of emphasis placed upon the need to slowly develop trust both with the department and the individual officer. In addition to post-incident counseling, mental health providers were involved in substance abuse and domestic violence counseling as well as crisis and hostage negotiation. I was impressed by some initial data they presented: that a police officer is two to three times more likely to die by suicide than to be killed in the line of duty, and that the life expectancy for an officer is 10 years less than the rest of the population (average age 66). This seemed like such a dramatic statistic that I figured I should do a little research about it myself, and I did. I found this article which contradicted the ten year number. In this 2013 study I found, the life expectancy of a police officer in Buffalo NY was actually 20 years shorter! Yowza.

Tomorrow's topics: Guns and the mentally ill, and research done on prisoners (ethics and barriers).

And a thank you as well as a shout-out to D.J. Jaffe for taking the time to tweet with me today. I'm trying to encourage the organization to have a more real-time social media presence during future conferences and your input was a great example of how the organization can broaden our discussions.

What I Learned Part 2

Day Two of the American Academy of Psychiatry and the Law Conference

I picked up a number of tidbits from the poster sessions:

-250,000 juveniles a year are sent to the adult criminal just system
-3/4 of all juveniles serving life without parole were sentenced in five states
-Louisiana uses an assertive community treatment program to supervise and restore  incompetent, nondangerous criminal defendants. This sounds like a good way to get people out of the hospital, or avoid having to send them there in the first place
-In Indiana, a survey was done of judges who have dealt with defendants claiming to be “sovereign citizens.” Most appeared in court for traffic violations or fraud rather than violent offenses. Tax evasion was least common charge.
-In a survey of PGY4 general psychiatry residents, most felt confident in their ability to perform sanity and competency assessments. Fewer felt confident in their ability to assess malingering or to participate in civil commitment hearings. This is concerning.
-Specialized processing centers (SPC) have been built for ICE detainees. They have 24/7 psychiatric coverage and freedom of movement, but no clinical review or medication over objection procedures.

The Bazelon Center has filed suit with the Department of Justice over the American Bar Association requirement to disclose disabling conditions like psychiatric disorders on the bar application, and over the requirement for some lawyers to work provisionally under supervision solely due to  a history of psychiatric treatment. Proposed language to restrict questions about psychiatric issues is being considered.

The APA is updating its resource document on assisted outpatient treatment. The final document is not available at this time and the organization's position has also not be finalized.

There was an interesting talk by one of the people working on the development of the Stalking Risk Profile, a new instrument designed to predict the relative risk of continued stalking of one victim, the risk of stalking a new victim, and the risk of violence posed by a stalker. It has shown good interrater reliability based on the stalker typology, and good predictive validity between high and low risk offenders. (The overall recidivism rate was 15%, but almost all of that was due to stalking the same victim.)

The final session of the day was a panel presentation, with pro and con arguments, regarding whether involuntary non-emergency medication should be administered in a correctional rather than a hospital setting. The "pro" side noted that in some jurisdiction the waiting time to hospital transfer can be months long, and that appellate courts have upheld the use of these "Harper procedures" (after the SCOTUS case Washington v Harper) for pretrial detainees. The most creative argument on the "con" side was by Michael Perlin, who suggested that involuntary medication of prisoners was a violation of the Convention on the Rights of Persons with Disabilities (CRPD), an international human rights agreement which the United States has signed on to. He suggested that any kind of involuntary treatment or detention based solely on the presence of a mental disability was discriminatory and a violation of that document. A creative but not persuasive argument.

So that was Day Two.

Thursday, October 23, 2014

What I Learned Part 1

Hello from Chicago and the 45th Annual Meeting of the American Academy of Psychiatry and the Law!

One of the Shrink Rap traditions is that I blog tidbits that I picked up at various sessions of the forensic psychiatry conference. This year's conference was preceded (for me, anyway, not for all attendees) by a three day review course in preparation for my mandatory recertification exam next year. This is another way of saying that I'm starting the conference in "listener overload" mode, so my notes may be a little light this year.

As usual, the conference started out with a keynote address by current president Dr. Richard Weinstock. He gave a thoughtful presentation about forensic ethics as it pertained to consultation to the courts. He covered the essential ethical imperatives, the mandate to maintain impartiality and respect for persons, the presented several situations where these issues come into play along with a few other secondary considerations. This was good basic ground to cover for early career forensic psychiatrists. Of course, forensic psychiatrists do more than consult to the courts and I think in this post-9/11 age we need to think about broader potential role conflicts, particularly for those involved in consultation to law enforcement and national security agencies. But there's only so much you can cover in an hour.

Ethical issues---the theme of this year's conference came up again in a session about competency assessments of immigration deportees. I wrote about the dilemma of mentally ill detainees for Clinical Psychiatry News in my column "ICE and the Inpatient Psychiatrist." The challenge with these evaluations is that you have to determine whether the respondent is mentally capable of acting as his own attorney at a deportation proceeding. Never mind that even most lawyers have no knowledge of immigration law, and we expect a mentally ill non-English speaking person to be able to do this? What ethical issues? The good news is that steps are being taken and a policy is in place to provide qualified representation to these folks.

There was a panel debate on the indefinite civil commitment of psychopaths. This is more of an issue in the UK where they have a law which allows for this, but here in the US we have commitment laws for sexually dangerous or sexually violent individuals. There was no one in the packed conference room who was truly in favor of the "pro" side of this; even the lawyer on that side of the debate panel was careful to qualify his presentation so that people would know he was presenting a theoretical viewpoint which was not his own.

Last but not least, there was a panel presentation on the ethics of involvement in traditional media. There was a talk on the history, content, and implications of the Goldwater Rule and the extent to which television and talk show appearances could be used for public education without crossing certain boundaries. Again, a pretty basic talk covering issues I've written about before on this blog but it was good to cover again for the trainees and early career docs in the audience.

So that was the first day of the conference. For those of you interested in a more real-time data feed you can follow me on Twitter at using hashtag #2014AAPL.

Sunday, October 19, 2014

Update on the NY SAFE Act and Keeping Guns from the Mentally Ill

There's an article on the front page of the New York Times today titled "Mental Health Issues Put 34,500 on New York's No Gun List."  Anemone Harticollis was able to get data that I was unable to obtain when I wrote about this for Clinical Psychiatry News last November.  It doesn't sound like she got that information easily.

Harticollis writes:
The way the law has played out, local officials said, frontline mental health workers feel compelled to routinely report mentally ill patients brought to an emergency room by the police or ambulances. County health officials are then supposed to vet each case before it is sent to Albany. But so many names are funneled to county health authorities through the system — about 500 per week statewide — that they have become, in effect, clerical workers, rubber-stamping the decisions, they said. From when the reporting requirement took effect on March 16, 2013 until Oct. 3, 41,427 reports have been made on people who have been flagged as potentially dangerous. Among these, 40,678 — all but a few hundred cases — were passed to Albany by county officials, according to the data obtained by The Times.

She further notes:
Despite the breadth of the law, significant loopholes remain. Outside of New York City, permits are not required to buy long guns, so nothing would stop someone in the database from buying a shotgun, for example, after being released from a hospital. Also, it is unclear exactly how the process for confiscating someone’s guns is enforced. And law enforcement officials may not even be aware of all of the guns someone owns.

Of the 36,500 people who've been reported to the database, only 278 had gun permits.  

I'm going to point out a few things:
--While the database does not prevent the ownership of long guns, it also does nothing to address the gun ownership and access in family and friends.
--None of this relates to illegal guns.
 --We don't have data to confirm if taking these guns or preventing certain people from purchasing guns has resulted in lower homicide or suicide rates.

Tuesday, October 14, 2014

My Emotional Support Alpaca Will be Arriving Shortly!

This one couldn't go unnoticed.  If you're a long-time Shrink Rap reader, you know we enjoy emotional support animals --  ducks in particular -- so I must send you over to The New Yorker to read "Pets Allowed" by Patricia Marx.  

Marx starts by letting us know how she likes her animals: medium rare.  She talks about Emotional Support Animals versus Service Animals and what about the rights of those without a disability, citing a plane that had to make an emergency landing on a cross-country flight when an emotional support dog repeatedly relieved himself in the aisle and people were getting sick.  Like a scare for Ebola virus, this required a hazmat team.  

So Marx on a journalism endeavor that I would have loved to have done: she goes around town -- New York City to be precise -- with 5 different Emotional Support Animals. She starts at the Frick Collection with a turtle, and later in the day gets the critter a manicure in anticipation of its attendance at a Bar Mitzvah.  (Really, is that necessary? I'm guessing the turtle didn't get to pick out the color.)

Marx then takes a snake around town.  Let me quote:

Here’s what happened at the Chanel boutique: “Hello. I’m looking for a pocketbook that will match my snake,” I said to a salesman. “Maybe something in reptile.” I shuffled Augustus from one hand to the other as though he were a Slinky.
“I’m sorry, Ma’am, I have a thing against snakes, so let me get someone else to assist you,” he said, as if he were telling the host at a dinner party, “No dessert for me, thank you.”
A colleague appeared. “Wow,” he said, leading me to a display case. “We do have snakeskin bags back here. Is he nice? Does he bite?” The salesman handed me a smart, yellow python bag marked $9,000. “I think this would work the best. It’s one of our classics. I think yellow. Red makes the snake look too dull.”

 Marx proceeded to take a 26 pound turkey named Henry on a bus ride and out to lunch at a deli, then there was the very cute alpaca (pictured above) who accompanied her to CVS, and then on a train ride from Hudson to Niagra Falls where they went to an art exhibit.  Finally, Marx flew to Boston with a one-year-old pig named Daphne, where they went to The Four Seasons for tea. 

 All I could think was that I want a job where I could be paid to drink tea with a pet pig and write about it.  


Thursday, October 09, 2014

What Gives Your LIfe Meaning?

Perhaps this is more of a question for a philosopher, and not one for a psychiatrist.  But people talk about the same thing in psychotherapy:  everyone focuses on the things that give their lives meaning, whether they talk about it head on -- for example, by talking about occupational strivings or relationships gone awry -- or less directly, perhaps by discussing things other people do that they don't approve of, or a book or movie that resonated for them.  It's clear to me that people find meaning in a variety of things.  

Me?  I like being busy, feeling useful and having a purpose-driven goal.  Being a blogger has been meaningful to me.  At the same time, I feel best if I can sleep late, linger over coffee, talk with friends, win at Words With Friends, eat good food, and start my day slowly -- all things that go at cross-purposes with being busy and purpose-driven.  The simple answer is that family, work, and friends give my life meaning, but the more complex answer is ....well, that it's more complex.

Okay, so I thought I would ask: What gives your life meaning?  Do tell....

Wednesday, October 08, 2014

Euthanasia for "Intractable" Mental Disorders?

Today's post is by ClinkShrink and is over at our  Clinical Psychiatry News site.  She discusses the case of a Belgium prisoner who wants to be euthanized for his intractable psychiatric illness, and she wonders if that might Antisocial Personality Disorder. 

While I'm sending you places, let me also suggest PsychPractice where there's a discussion about an App called "Pager"  in New York that lets you get instant home visits --within two hours -- from a doctor.  Being one to push the envelope, PsychPractice asked about gynecology and psychiatry home visits.  Personally, I think it's a great idea -- quick, in home consult to get someone started in care rather then waiting weeks for an outpatient appointment with a psychiatrist,  or sitting for hours in an ER.  Could we prevent hospitalizations this way?  Or would there just be more when very sick or very dangerous people who might otherwise let it pass, instead called for a consult? 

Friday, October 03, 2014

On Faxing Forms. May I Rant, please, Just a Little?

I'm trying to be more duckish, to let things roll off me and to slow life down, just a little.  There are so many people with so many problems, and so many bad things going on in the world, it seems I shouldn't get bent out of shape about things that really don't matter.

Having said that, I snapped at someone today over one of those little things that just shouldn't matter:  Getting pre-authorization for a medication for a patient.

First, let me say that some of this is my fault.  I hate my fax machine and I just haven't bothered to replace it.  It spams me with roofers and $99 Disney World offers, and repeat requests for medication refills when the patient long ago stopped taking the medicine.  The memory empties if the machine gets turned off or the power blinks, and it often prints the same document repeatedly. It prints documents one at a time and I often need to stand over it to get them.  The day I stood there waiting for it to print out 11 requests from the same pharmacy, for a refill for the same medication,  I had a revelation:  I could become a doctor who won't fax.  I turned off the fax machine and it is no longer a part of my daily life.  On rare occasions, when there is no option, I turn it on. But mostly it's been a big relief.  Other people don't return phone calls.  I don't fax. We can email pdf files, and if I need to get a document to a patient, I take a photo with my phone and text it to them.  If that doesn't work, the phone has a scanner and I can email documents.  Why would I need to stand over a fax machine?  It's also my fault because I don't have a secretary to do these things for me, but that would come with it's own set of things to take care of.

So today I got a call from a pharmacy.  I wrote for a high dose of a medication, it needs preauthorization. I'd need to call an 800 number to get that preauthorization.  They forgot to leave the patient's  insurance number.  I called back, got the insurance ID #, then called the insurance company and began the arduous process of voicemail menu hell to get the right authorization form.  Somehow, I was led to a live person, who kindly offered to do the pre-authorization over the phone, but then said it couldn't be done for this medication.  It had to be faxed.  They'd fax the form, I'd fill it out and fax it back. There were no options.

I went to the dreaded fax machine, during which time the insurance company put me on hold.  I waited.  Then I waited for the fax and it didn't come. She tried again and it still didn't come.  I figured my machine just wasn't working and I asked if they could email it to me. They can't.  Why?  It has patient information on it, sending it on email would be a HIPAA violation.  I asked about sending the blank form that I could fill out (I now had the insurance ID number).  They don't do that.   It's a HIPAA violation to send email, but faxes to a office where who-knows-who might see it, or wrong numbers might get dialed, or the wrong doctor with the same name could get sent the information (..with my last name, I get other people's faxes), happen all the time.   I asked if the blank form was on a website.  It was and she gave me the insurance company's general website.  I knew -- from previous experience-- that I'd never be able to find it from there and asked for the exact URL.  She couldn't give me that and instead offered to give me another 800 phone number where I could call to ask for the URL of the form.  We were at 20 minutes of this -- in a time where there is no excuse for not being able to easily transmit a form to someone -- and I snapped at her and hung up.  I'd deal with it on Monday.  And then, of course, the form came through.  

The form was already filled out.  There were check boxes for the indications why one might need a higher dose.  I check one.  There was a question about whether a specific other medication had been tried.  It had been, do I checked yes.  And I faxed it back.  Two check marks -- now why couldn't they take this information over the phone?  Or why couldn't the form automatically have been sent to me when the patient handed in the prescription, without the pharmacy intervening to call me to tell me I had to call the insurance company to request the form be faxed to me?  Oh, never mind, that would not have worked because my machine was off. 

I suppose it bothers me because it feels like an unnecessary waste of time that is purposely engineered to be that way. 

Sunday, September 21, 2014

You are at RISK!

Open a newspaper or read a medical journal or look at your Twitter feed and you'll learn a sad fact: something you're doing -- and probably something rather fun -- puts you at increased risk of some bad disease.  It sounds very ominous and you should stop doing those fun things.  Sometimes, I have to scratch my head and say 'Really? What does that actually mean?"  And while I've decided that my Diet Coke habit probably isn't particularly healthy and have mostly, sort of, cut way back, it caught my attention when I saw that one diet soda a day increases the risk of stroke by 16%.  Actually, it caught my attention because it was in my social media feeds about a zillion times tweeted by the Cleveland Clinic then retweeted by countless others.  Really?  How can anyone know that?  

So the first thing I wondered was how common is stroke?  I mean, a 16% increase is not huge, it's not like it makes you 5 times (a 500% increase) likely to have a stroke, and I didn't know how common stroke is.  A small increase for an unlikely event (stroke, for any given person for any given year) caused by a common habit (diet soda ingestion -- or actually any soda ingestion as I would soon learn) would seem like a difficult thing to quantify and measure.  And then you might wonder if 2 diet drinks/day increase the risk by 32% and if 6 diet drinks/day double it, and what about adding artificial sweeteners to coffee or tea? 

So I went to look for the prevalence of stroke and what I discovered was 2.6% for adults over age 18 have had a stroke.  But what surprised me was how the data was collected, per the CDC website:

BRFSS is a state-based, random-digit_dialed telephone survey of the noninstitutionalized, U.S. civilian population aged >18 years and is administered by state health departments in collaboration with CDC. In 2005, the median response rate among states, based on Council of American Survey and Research Organizations guidelines, was 51.1% (range: 34.6%--67.4%). This rate accounts for the efficiency of the telephone sampling method used and participation rates among eligible respondents who were contacted. A total of 356,112 respondents from all 50 states, DC, Puerto Rico, and USVI participated in the survey. State (including DC) and territory sample sizes ranged from 2,422 (USVI) to 23,302 (Washington). The racial/ethnic national sample sizes ranged from 5,535 (AI/ANs) to 279,419 (whites). All prevalence estimates in this report have a numerator >50 and a relative standard error <30 are="" ensure="" estimates="" stable.="" sup="" that="" to="">†
Survey respondents answered the question, "Has a doctor or other health professional ever told you that you had a stroke?" Differences in prevalence were assessed by age group, sex, race/ethnicity, education level, and state or territory of residence. Data were weighted to reflect the population aged >18 years in each state and territory and were age adjusted to the 2000 U.S. standard population to allow for more meaningful comparisons between states and between demographic groups. The weighted state prevalence values were used to estimate the number of persons with a history of stroke in various demographic groups and in each state or territory. Respondents provided racial/ethnic identification; those who identified themselves as multiracial were included in a separate category.

Ok, so first off,  half the people don't answer.  Are those who refuse to participate more or less likely to have had strokes?  The survey requires that someone answer the phone, so all the people who were too disabled to answer the phone are excluded from the survey results.  People with lower educational levels were more likely to have had strokes.  Could it be that people with lower educational levels were less likely to understand the question, or to confuse a doctor's warning "you could have a stroke" with "you have had a stroke?"   And could it be that people who have had strokes don't understand the question or have anosognosia so they don't know they've had a stroke?  I'm so confused. In the study below, the incidence of stroke was also self-reported but the report of a stroke was then verified by review of medical records.  I suppose they still might not capture those who have fatal strokes or those who don't know they've had a stroke.

And back to the Cleveland Clinic Study -- actually it's diet soda and sugar containing soda that increases risk. Switching to skim milk apparently decreases risk by 11%.  Go figure.  In this study, the participants were asked for a self report with forced choice responses (none, up to one/week, one per week up to one/day, more than one per day, etc).  Coffee consumption, by the way, lowered risk, but I couldn't figure out if drinking coffee and skim milk would counteract the risk of drinking soda.  Before I wash away....

Tuesday, September 16, 2014

Sunshine, Lithium, and Xanax --Which ones are good for your mental health?

Oh, so much to talk about, but let me begin by sending you over to Clinical Psychiatry News to read ClinkShrink's latest article on Suicide and Sunshine

Other things we could talk about are the op-ed piece in the New York Times about how in areas where there are trace amounts of the element Lithium in the water, there are lower suicide rates.   See "Should we all take a bit of lithium."  The article suggests further study, and perhaps adding lithium to the water supply.  Before you jump to discuss kidney disease, let's be clear, these are trace amounts, around 1/1000 the starting dose when used as a pharmaceutical agent.  My sister-in-law, Meg, was kind enough to inform me that there is a tiny bit of lithium in San Pellegrino water, but I'm not sure how that measures up to the amounts that occur naturally in places with lower suicide rates.  We add fluoride to the water, and iodine to salt, why not lithium to the water? 

And, finally, there's a study linking benzodiazepine use to a higher risk of getting Alzheimers' Disease, with a specific cut off of 91 pills is what it takes to raise the risk.  I'm guessing there may be other factors here, but this may be yet one more reason not to use these medications. 

Tuesday, September 09, 2014

Psychiatry and First Amendment Rights as they Pertain to School Violence and Cannibalism

Please surf over to the Clinical Psychiatry News website to see my post on Psychiatry and First Amendment Rights as they Pertain to School Violence and Cannibalism.  

Also, blogger Pete Earley wants to know how to find a good psychiatrist.  Please read his post here.  

I went to post a graphic and decided that nothing was quite right when it comes to cannibals.

Sunday, September 07, 2014

Eliminating Stigma with Psychiatric Disorders: Is it Even Possible?

It's almost a mantra in advocacy circles: we need to get rid of the stigma associated with mental illness.  Fear of being stigmatized keeps people from seeking treatment, so it leaves people to suffer from the symptoms of these disorders.  Stigma keeps employers from hiring people with psychiatric problems. Stigma makes people not want to be friends with someone with a psychiatric disorder. Stigma is part of ignorance -- it leaves society to blame the person for their problems.  There's no stigma to having a medical illness such as hypertension or diabetes or cancer.  There should be no stigma to having a psychiatric disorder.

If you read the above paragraph and you agree with every sentence there, then please let me warn you: what follows is not going to be what people want to hear.  You may not like what I have to say.

First, I don't agree that medical illnesses don't have stigma attached to them.  I suppose it depends on what exactly "stigma" means to you -- oh, what exactly does "stigma" mean?-- but I would contend that if you have hypertension and you're not overweight, you eat a low salt diet, and you exercise regularly, then there's no stigma involved.  If you have any medical problem associated with being overweight, poor dietary habits, smoking, alcohol, drug use, or lack of exercise, then others will look upon your illnesses as being your fault.  The truth is that in our society, poor self control is stigmatized, and obesity in particular, is very stigmatized.  Fat people are the last people (even after the mentally ill) that it's okay to openly discriminate against for everything from jobs to love.  And many people think that's okay, because after all, many believe that obesity is the result of gluttony and laziness, or if not, then of poverty (oh, we stigmatize the poor as well) because they lack access to high quality food and athletic facilities. But if there's a way that society can blame you and your less-than-ideal behavior for your health problems, it will happen, and it's not all stigma-free.

One of the things we never discuss when talking about the need to reduce stigma is that psychiatric disorders sometimes lead people to behave in ways that are embarrassing or disturbing to others.  People in the throes of an acute psychotic episode have been known to go outside naked, or to react in odd and alarming ways in response to things other people don't see, here, or understand.  Sometimes ill people don't attend to their personal hygiene and they wear dirty clothes and smell badly.  Other times, psychiatric disorders can cause people to be belligerent, to act in troubling impulsive ways, or to be unreliable and to miss work. Yes, cancer makes people unreliable and they miss work as well, but I would contend that an employer who has two equal job candidates in front of him might well choose the one who won't need to miss work regularly for any type of illness.

So how do we de-stigmatize psychiatric disorders when they are associated with disturbing behavior as a direct result of the illness?  It seems it would be impossible, but I can think of one disorder where that seems not to be true: Attention Deficit Disorder comes with little stigma.  I've often wondered why this is.  ADD causes people to be inattentive, their lack of focus can be annoying, or disruptive in a classroom.  They often had difficulties with executive functioning which means they forget things, are late, and come off as being scatterbrained (how's that for a scientific term?).  They may forget they have appointments or forget to meet friends.  In schools, they get more time for exams (does real life confer that as well?), and they may get all sorts of other accommodations such as front row seats or testing in quiet rooms.  In addition, the treatment may include medications that have many side effects, including tics, agitation, insomnia, and addiction.  In college, I hear this makes people fairly popular before exams -- it's not uncommon for those who have the diagnosis to share (or sell) their stimulants with those who just want to use them to study more intently, even though giving one's controlled substances to someone else constitutes a felony. 

So here we have an illness that may make include symptoms that are often obvious, impair functioning, may infringe on the rights of others at times, include treatment with an addictive and dangerous medication, and yet ADD is not stigmatized.  Why isn't that the case for bipolar disorder or schizophrenia?  This issue of stigma is all very perplexing.

I welcome your thoughts here.

Saturday, September 06, 2014

The Importance of Routine (and Clean Living)....

There's a great essay in The New York Times that I'm sure you'll like -- it's written by Michael Hedrick, a journalist/photographer who discusses the difficult time he had in the year after he was diagnosed with schizophrenia.  Tormented by his symptoms, he spent his days at work and his evening drinking and smoking pot, until he lost his job then landed in court with a DWI charge.  Mandated to treatment (for substance abuse) and drug testing, Hedrick writes in Living With Schizophrenia: The Importance of Routine:

Maybe it was the shock of meeting with a D.U.I. lawyer, or the point after sentencing when I realized I’d be forced to make a daily call, first thing in the morning, to find out if I would have to pee in a cup that day. Maybe it was the fact that I’d need someone else, mainly my mom, to drive me anywhere for the next year. Or perhaps it was the consistent Saturday morning drug and alcohol therapy group or Wednesday and Thursday afternoons of community service that kicked me into a groove.

The groove of it eventually turned into a routine, one that wasn’t marked by indulgence but instead by forced commitment that eventually I would grow to respect.
During that time, I quit smoking pot, I quit drinking and I got some of the best sleep I’d gotten since my diagnosis. Trips to the bar on Monday afternoons turned into extended hours at coffee shops where I finished my first novel.

For some reason, it gave me joy to recite my routine to whoever asked. I would wake up at 7, get coffee and a bagel with plain cream cheese, check Facebook, write until I had 1,000 words, get lunch, do errands in the afternoon, return home, get dinner, take my pills (with food), watch TV and get to bed around 9.

It might all sound tremendously boring. But this regimented series of events was always there; they’d always carry over. And with time, it gave me great comfort to not have to deal with the unexpected. I had a set plan for most days, and there was already too much chaos in my head.
Maybe it's not just for people with schizophrenia or for people with substance abuse problems.  Routine is comforting to all of us, and clean living helps.  I almost missed this one and I'm glad I didn't, it's was worth passing along.  

Monday, September 01, 2014

Boarding Psych Patients in the ER

It's no secret that over time, the number of available beds in psychiatric hospitals and on psych units of general hospitals have decreased.  When the states moved patients from long term beds in state hospitals back into the community (a mostly good thing if you ask me), the promise was for more services in the community, and oops, that never came to be.  With time, there are fewer and fewer services available, it's harder to get care with people often waiting weeks to be added to the overburdened caseloads of staff in outpatient mental health centers -- especially those who have no insurance or Medicaid/Medicare -- meaning the people most likely to have the biggest problems seem to have to wait the longest.  If you need help now, there's often only one answer: go to the Emergency Room.  

This is thing about going to the ER.  They often have no miracles.  In the hospital where I worked in the clinic, there were a few perks -- the ER had some reserved clinic slots so that they could refer people for outpatient appointments within a few days.  Often, however, this isn't the case, and often delaying treatment means that the situation is so bad that the patient needs to be admitted. Because I was at a facility with 84 psych beds, this generally happened fairly quickly, but it many places, this just isn't the case.  People can wait for beds for hours (okay, that's life in an ER), days (ugh) or even weeks.  Weeks?  A psychiatrist in Vermont (where the state hospital had been destroyed in a hurricane) told me they kept patients in the ER for 6 weeks.  Six Weeks.  I have no idea how they did that and I didn't ask.  Did the patient stay in a seclusion room?  What if the room was needed for another aggressive patient?  Did they get a cubical? A gurney in the hall?  A curtained area?  Most psychiatric hospitalizations last about 7-12 days.  Were they getting medications and therapy in the ER?  This is crazy, and I use that term to describe the insanity of our system, not the patients.

This summer, the Department of Health and Mental Hygiene here in Maryland held work groups to discuss the delivery of outpatient care and recommendations for legislation for outpatient civil commitment -- we are one of only 5 states that has no provision for mandating outpatient treatment.  The work groups were ordered by the state legislature.  I went to some, and at one, an ER physician (not a psychiatrist) made a comment that sometimes patient were held in the ER for days "and they describe those days as the worst days of their lives."  This just shouldn't be -- no hospital experience should be horrible because of the setting --granted, it may be horrible if you're in the middle of a panic attack, a heart attack, you've just been shot, or you've lost a limb --but it should be a place to be stabilized, then discharged or admitted, without physical discomfort.  

This was my long-winded way of pointing you to an article in Forbes about ER psych boarding.  Do read: "Boarding" of Psychiatric Patients Unconstitutional in Washington State by Robert Glatter, M.D.  Glatter writes:

In Washington, patients who are involuntarily committed must be brought before a judge after 72 hours. The judge then makes a decision whether to continue to detain the patient in the emergency department.  Some of these patients may then be returned to the same ED.
Such patients may remain in less than ideal locations such as hallways, administered psychiatric medications, but having no formal access to psychiatric evaluation and care. Staff members including nurses and administrative staff have in some cases faced verbal or physical threats from such patients, with their safety being a concern.

The ruling leads to some obvious concerns:

“While we respect the state court’s decision, federal law (Emergency Medicine Treatment and Labor Act) still prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients — back into environments where they could cause harm to themselves or to others.  This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition,” added Rosenau.
“The ruling is a call to action, and our main objective must be to get every patient the right level of care.  The next challenge is directed to hospital and community leaders to find the resources to care for them,” concluded Rosenau.

Glatter goes on to discuss some possible solutions: better outpatient services, case management, crisis beds and mobile crisis units, more beds, and elimination of out-of-network barriers that keep some patients out of some available beds.  All good ideas.