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.