Sentenced to the Max

Even if you're not interested in forensic psychiatry, I'd encourage our readers to wander over to The Crime Report to read an article by my esteemed colleague Dr. Erik Roskes. He has written an excellent piece entitled "Sentenced to the Max Without Benefit of a Trial", about the role of prosecutors in the continued confinement of incompetent and unrestorable criminal defendants.


I can't do it justice in a nutshell, but briefly it's about criminal defendants who will never be well enough to go to trial. Although the law requires that charges eventually be dropped in these cases, in Maryland prosecutors are pushing the limits of the law to keep defendants in the hospital as long as possible. Amazingly, public defenders do not oppose or question this. As a result, increasing numbers of state inpatient beds are tied up by forensic patients who would otherwise be released if non-dangerous. (Dangerous incompetent patients could still be civilly committed even if the charges were dropped.)

This practice has recently been criticized in a Justice Policy Institute report published last year. Still, the practice continues.

No Place To Go

There is a fantastic article up on the New York Times website, coming out in print this weekend in the NYT Magazine, called When My Crazy Father Actually Lost His Mind, by Janeen Interlandi.  The author tells the chaotic story of how her family tried to get help for her 69 year old father who was ill with a manic episode.  In it, he bounces from hospital to jail to ER, to homelessness, over and over. She talks about the catch-22's with the legal/psychiatric system with a father who is dangerous enough for a restraining order to keep him from his family, but not dangerous enough for civil commitment, and she talks about stories of others families where awful things have happened.  Her love for her father comes through, mixed in with her frustration that there is no place or mechanism to help such people.  Ah, but the story has a happy ending.  It reminded me a lot of Pete Earley's book Crazy: A Father's Search Through America's Mental Health Madness.


Interlandi writes:


And so for weeks, we had been locked in a game of chicken: waiting for my father to do something clearly dangerous; praying like hell that it would not be his suicide or accidental death or the death of someone else. In the meantime, my mother had all but stopped sleeping and had started hiding the car keys and the checkbook. She would tiptoe around their one-bedroom apartment at night, waiting for him to doze off, then call my sister or me to unload her despair in a flurry of whispers. 

Oh, I can't begin to  do this article justice in a blog post, you'll just have to read it.

Over on Clinical Psychiatry News....

Check out our CPN site where Roy is talking about Stage 2 Meaningful Use, and I've put down my final words (I hope!) on strip searching psych patients.  Do Check It Out if you'd like to see what we have to say, and to all those who helped me with this article, please accept my gratitude!  Roy and I would both love your feedback.


Lately, I feel like a moving obsession...I was preoccupied with medical marijuana legislation for a bit, then with how body searches are conducted of our patients, at the moment I'm reading Kaitlin Bell Barnett's new book Dosed: The Medication Generation Grows Up....my review is forthcoming.  What next?

Tell Me Your Psych Unit Search Stories

I'm planning to write an article on strip search policies at psychiatric hospitals and that's why I asked anyone who has been hospitalized in a psychiatric unit in  the last three years to take my Strip Search Survey.  Roy pointed out to me that I didn't define 'strip search' and that his hospital does not do this---they ask patients to change into a gown and search their clothes, but not their bodies.  I did assume that people would define strip search as the visual inspection of the skin after the removal of all clothes, and that being told to change with some sort of privacy --in a bathroom, behind a curtain, while a nurse of the same gender holds up a gown or a sheet but isn't looking-- is not a strip search. 


Will you help me with my article?  Can you tell your stories in the comment section and let me quote you?  I will not use 'names' but quote "one commenter said,"  and you are welcome to give your feedback as "Anonymous."  I would like to know what state the hospital you're talking about is in, and if you are a patient, a psychiatrist, a nurse, a family member.  I'm interested in stories of how being searched was handled well and how it was handled badly, stories by hospital personnel.  I know some of you have told your stories here before, but I didn't ask for permission to quote, so feel free to repeat yourself here if you don't mind being quoted.    Also, if you were strip searched, I'd like to know if it was because of a blanket policy at the hospital versus a specific concern the staff had about you and any danger you might pose to yourself or others.

I Need Your Help

If you've been admitted to a psychiatric hospital in the last three years, please take my survey by clicking HERE. It will only take a moment, and I'd like to use the responses to write an article.  Thank you!

Strip Search Survey

Okay, if you've been reading our blog for long, you know that there are some sensitive issues here, and strip searching patients upon admission to psychiatry units is one of them.  I'm a psychiatrist and I didn't know this was routine.  Of course, I assumed it happened if someone was presumed to be dangerous, so if they have a weapon taken from them in the ER, a history of violence, or are being admitted to a locked unit for their own safety.  But grandma with her agitated depression?  Or a high school student with an eating disorder?   One thing that's changed since I was a resident (the last time I worked on an inpatient unit) is that admission criteria has changed significantly.  There are few elective admissions, and pretty much the only way that insurance will pay for admission is if the patient is an imminent danger, so this means that the patients on the inpatient unit are, by definition, more likely to be dangerous and acutely ill.  When I was in medical school, people were admitted for depression for weeks, they'd go out on passes to see how they did at home or away from the unit, and admissions were planned for "next Wednesday."  I remember one patient was admitted for chronic insomnia.  On the Sexual Behaviors unit, people would be admitted for evaluation-- was the old guy who touched his niece when he was drunk a pedophile, or was this an unusual behavior inspired by the fact that he was drunk?  Was he a danger?  And someone could be admitted (electively) for urges to commit sexual offenses.  Things have changed.  So maybe it's not that outrageous to strip search someone who's admitted because they are imminently dangerous, or maybe it is---our readers comment about the trauma of it, how it deters them from being hospitalized when they should be, about feeling violated and having old sexual traumas evoked.  


If hospitals have different policies and they don't have different rates of violence with weapons/ problems with smuggled drugs, then changes should be made.  Some readers have written in about more sensitive means of searching patients, and Clink now thinks hospital should employ trained, cute, dogs to sniff out contraband.  I'm all for it.  What about those with dog allergies?

Strip Search

A while back, one of our readers wrote a comment discussing the distress of being strip searched upon admission to a psychiatric facility. The reader felt this was particularly egregious because she had been a victim of sexual abuse and this insensitive treatment, unnecessary in her case, caused her to relive the distress of past sexual abuse and psychiatry should be about healing, not opening wounds and causing pain and suffering.


I felt badly for our reader.  In fact, I felt badly for anyone put through such a practice, but I suppose I understand that outrageous and dangerous things happen in psychiatric hospitals and this could be a no win situation: what about the person who is assaulted by a patient who had a razor taped to their inner thigh that went undetected...wouldn't that patient feel it was awful that no one had searched the perpetrator?  And staff on psychiatric units are not uncommonly assaulted, shouldn't they have the right to do what's necessary to protect themselves?  I'm not sure that includes strip searches, but I suppose if there's a couple of stories of contraband or weapons or drugs being sneaked in, then policies change.  One guy has an explosive in his sneakers 9 years ago, and millions of people are taking off their flip-flops every day in airports.  I can't say that particular practice ever made me feel safer.


Okay, I also didn't know that psychiatric units strip search patients.  I haven't worked on an inpatient unit in many years, and if this occurred, I imagine it was done by the nurses, if at all.  Back then, I never heard a patient complain about this or even mention it, and in the years since, I've never had a patient mention being strip searched during an admission.  I'm guessing that it's not a universal phenomena?  Actually, I'm guessing that most hospitals don't strip search psychiatric patients, and really, if they do, I'd be pressed to know why just psychiatric patients, many people in hospitals have histories of unsavory behavior.  


Okay, so just in case I'm not appalled enough, yesterday the Supreme Court, in  Florence v. Bd. of Chosen Freeholders  voted that anyone who is arrested, for even the most minor of crimes-- walking your dog without a leash,  jay-walking, you name it--can be strip searched before being placed in jail.  The court says that even minor violators can be dangerous, and note that Timothy McVeigh was arrested for driving without a license and one of the 9/11 terrorists was stopped for a traffic violation.  Would strip searching them have stopped their terrorist attacks or prevented any future bad events?  As doctors, we think in terms of risk, evidence-based medicine, best practices, statistical events, not anecdote, but I'm convinced that anecdote is much more powerful than science.  And I don't think this supreme court decision bodes well for treating psychiatric patients any more humanely-- if it's no big deal to strip someone who didn't pay a traffic fine (for example, Mr. Florence in the above named case, but oops, he actually did pay the fine years earlier and there was a computer error, oh my), then I can't see why there would be sympathy for the dignity of anyone else.

What I Learned Part I

Regular readers know that every year I tweet and blog from the conference of the American Academy of Psychiatry and Law. This group of forensic psychiatrists consists of about 1800 of the country's practitioners. Topics are quite diverse and sometimes rather unusual. It's a lot of fun. Here's just a small smattering of factoids I picked up yesterday:

• The "sovereign citizen" defense can prompt a competency eval, but is not a delusion. The sovereign citizen movement is a recognized subculture of people who believe the government has no jurisdiction over them.
• Of 200 defendants cleared by DNA, one-fourth had confessed to the crime.
• According to FBI uniform crime reports, between 2001 to 2009 2.2% of police murders took place while responding to calls involving a mentally ill person.
• The collection and selling of serial killer memorabilia is also a venue for potential fraud.
• President Peter Ash gave an interesting and useful Presidential address about juvenile violent offenders. Persistent juvenile offenders tend to become more impulsive with age, not less. They commit an average of 30 to 70 previous offenses before they are caught for the index violent offense. They differ from adult violent offenders in that they tend to act in groups rather than alone, they commit impulsive rather than planned violence, and their criminal activities tend to be more diverse than adults. There is a .3 correlation between juvenile psychopathy scores and later adult psychopathy, but this only accounts for ten percent of the variance. Translation: most violent juvenile offenders do not become violent adults. Nobody knows for sure why.
• There was frequent discussion of the hazards and pitfalls of involvement in social media, including discussion about using it to impeach or undermine witness credibility. So far though, when questioned nobody had actually seen this happen to an expert witness. Concern seems to be out of proportion to reality.

HIGHLIGHT OF THE DAY:

My favorite part of this first conference day was the luncheon speech by Pete Earley. Mr. Earley is a former Washington Post report and New York Times bestselling author who's son has a serious mental illness. His book Crazy is required reading in my training program. The book is a description of life inside of one state's broken forensic mental health system. He is passionate and compassionate, and a vigorous and outspoken advocate. The audience was clearly captivated by what he had to say, and at sometimes it was frankly hard not to stand up and shout 'amen'! when he made his points. (Take home quotes for me: "Never give up hope! People get better!" and "A single person can change the system.") I was thrilled to finally meet this very warm man whom I admire. And I'm not just saying this because he wrote a blurb for our book!

SUB-HIGHLIGHT:

I attended a presentation about psychiatrists in the media. The panel presented an interesting categorization of activities: psychiatrist as scientist (presenting and interpreting studies), educator, storyteller, celebrity commentator and curbside therapist. I was surprised and flattered to see the home page of Shrink Rap, and the cover of the book, as an example of "psychiatrist as educator" in the media. I'm glad to see we seem to be accomplishing something helpful.


So that's the first day. You can follow me on Twitter (see the sidebar). If you're here at the conference and want to #OccupyAAPL, drop me a note!

Suicide, Free Will, and the Shrink's Magical Ability to Predict Violence

I'm posting over my fellow co-bloggers today.  So what else is new?

Please visit: Hot Grand Rounds-- The Summer Solstice medical blog posts with the pretty pictures, including a pink urinal with teeth.  One could ask for anything more?

And Please Visit Clink's post over on our Shrink Rap News blog on ethical issues related to the psychological report on the suspected Anthrax killer.   
When you're finished reading, please return Here to comment. 

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For a while now, we've been having discussions in our comment sections  about the issue of forced treatment: is it right or is it wrong?  Some readers are very clear: no matter how sick, no matter how imminently dangerous, no one should be held in a hospital ever against their will.  One reader tells us that suicide is a right of all persons as per their free will, and by the way, psychiatrists can't predict acts of violence and have no right pretending they can.  They should stand up to the legal system and say so, and not go along with the charade.

Both ideas got me wondering: is suicidal behavior that results in the attention of mental health professionals really a product of free will?  As psychiatrists, many of us believe that people have unconscious motivations--- they are guided by beliefs they are unaware they hold.  People commit suicide all the time-- In 2008, 34,598 people in the United States committed suicide, making it the 11th ranked cause of death.  Somehow they did it despite the proliferation of mental health professionals.  Many completed suicide with firearms, and my guess is that these deaths often occur without the immediate involvement of psychiatrists.  Those who wish to exert their free will to die often do so without alerting others or involving professional helpers.  It leads me to wonder if those that present to Emergency Rooms or to their outpatient psychiatrists might do so because they have an unconscious (or not-so unconscious) desire to be stopped.  Of course there are exceptions: those who are pulled off bridges, or discovered after a serious attempt that did not kill them.  Do we not summon medical care for an unconscious overdose victim on the theory that they may have wanted to die and we're interfering with the advancement of their free will?  

We put up a poll a few weeks ago where we asked if people would want to be treated by force if they had an episode of severe mental illness.  Of our 280 respondents, a majority, 57%, said yes while 42% said no.  Would the answers have been different if I'd asked a more provocative question: If you became psychotic and believed it necessary to kill your children, would you want to be treated?  It's too provocative a question for a poll, but I thought I'd throw it out there.  If you became demented, agitated, and combative towards those caring for you, would you want to be treated with a medication that increased your risk of death over the next year from 2% to 4%?

Don't worry, I won't be that provocative. 

The issue of predicting violence is an interesting one, and our reader is right that we're not terribly good at it.  Our most powerful magical tool is to ask the patient if they're planning to harm themselves or anyone else, and the truth is sometimes more legal than medical: we're told that if we don't ask and document, that if someone kills themselves, we'd lose a malpractice suit.  It does get boring asking perfectly well appearing people if they're thinking about suicide and homicide on each visit, but it is a required check box at the clinic.  If they say yes, we ask about a plan and intent, and it does seem it might be troublesome to the family if a hospital discharges a person who says they plan to leave to go shoot up a mall.  Or someone who has been actively psychotic, disorganized, and behaving in a dangerous manner.  There's medico-legal issues, but there is also common sense and kindness, and if you believe that someone who puts the barrier of the mental health field in the way of their violence may actually want help, even if they don't put it in those terms, then there is little to argue about.  Oh, go ahead, argue anyway.

Free will?  So many people who survive suicide attempts are glad they did.  So many who attempt do so for impulsive reasons that pass, or because they were intoxicated.  I'm not much for condoning a permanent solution to what are often temporary problems.

If you want to tell us that you were hospitalized for suicidal "ideation,"  this is another post for another day: I'm still thinking about that one. 

Guest Blogger Dr. Gerald Klee on Martin Luther King Jr., Riots and Psychiatric Hospitalizations

Oh, I so wanted to put this up yesterday! A day late, but....

Dr. Klee writes:

Today, April 4, 2008, is the 40^th anniversary of the assassination of Martin Luther King, which was immediately followed by widespread rioting in cities throughout the US . Baltimore was one of the cities most seriously affected by riots. This tragic situation provided an opportunity to study how admissions to public mental hospitals would be affected by such an emergency. The following 1998 article from The Maryland Psychiatrist summarizes a report by Klee and Gorwitz in Mental Hygiene, Vol. 54, No. 3, July, 1970. The findings, though limited are quite interesting and counterintuitive. For example, psychiatric admission fell during the days of crisis, while General hospitals reported increased admissions of patients with delirium tremens during the same period.

It occurs to me that this story may still be relevant. How well prepared is our present health care system to handle the effects of future civil emergencies.

Riots and Mental Illness

by Gerald D. Klee, M.D. Editor

The Maryland Psychiatrist [Spring/Summer 1998; Vol. 25 No. 1]

Psychiatric Hospital Admissions During The Baltimore Riots of 1968

How would a widespread civil emergency affect psychiatric hospital admissions? Would they go up or down? Would there be differences in demographic characteristics or diagnoses of those admitted? Our efforts to make predictions may be more successful if we have access to biostatistical data from previous events.

The Baltimore Riots of 1968 provided an unusual opportunity to conduct such a study in Maryland.¹ Following the assassination of Dr. Martin Luther King, Jr. in April of 1968 there was rioting in more than 130 cities in the U.S. Baltimore was one of those most seriously affected, with widespread rioting, looting, and burning during the four-day period from Saturday, April 6th to Tuesday, April 9th. The National Guard was mobilized and a curfew was imposed in the city and adjacent areas. Many arrests were made. Daily life was affected in many ways for nearly all residents of the area, black, white, and others.

Events of this magnitude were bound to have many effects on mental health. Soon after the riots occurred, Klee and Gorwitz studied the effects they had on mental hospital admissions.¹

Summary of Methodology and Findings

Our data were obtained from the Maryland Psychiatric Case Register, a ten year (1961-1971) joint project between the Biostatistics branch of the National Institute of Mental Health and the Maryland Department of Mental Hygiene. I was the psychiatric consultant to the project. There was an active psychiatric advisory board with representation from the Maryland Psychiatric Society (MPS). With the exception of office visits to private psychiatrists, all psychiatric admissions and discharges in the State were reported to the Case Register. In this investigation, admissions from Baltimore City to the three state hospitals serving the area were studied. In addition to the four days of the riots, periods of two weeks preceding and following the riots were examined. The number of Baltimore City admissions during the two-week period before the onset of the disorders and after their conclusion did not differ markedly from comparable figures for the prior year (1967). There were distinct differences in admission patterns during the four-day emergency, however, both as compared with the preceding and the following time periods and also with the comparable period of 1967.

At that time, Maryland ’s psychiatric hospitals had been experiencing a consistent increase in admissions of approximately 10% per year. (The revolving door was already in motion.) While this pattern continued during the pre and post riot periods, there was a sharp drop in admissions during the four days of crisis. In 1967's comparable Saturday-Tuesday period, there was a total of 65 admissions to these hospitals. Adding the noted 10% increase brought the number of expected admissions to 71, but the actual number of admissions dropped to 50. Further variations were found on the basis of race and diagnosis as well as place of residence. While there were 27 black admissions for the four-day period in 1967, this decreased to 18 in 1968. The comparable figures for white residents were 38 and 32. Thus, while a drop in admissions was noted for both races, this decline was more marked for blacks. In 1968, 31 of the 50 patient admissions were diagnosed as alcoholic as compared with only 26 of the 65 admissions in the prior year.¹ Concurrently, there was a sharp decline in admissions with psychotic diagnoses (9 in 1968 versus 24 in 1967; statistically significant, using Chi-square test).

In 1967's comparable Saturday-Tuesday period, two thirds of the 65 admissions were from inner city areas where much of the rioting occurred in 1968. During the 4 days of disturbances, however, only half of the 50 admissions were from this part of the city. Some of the admissions were related to the civil disturbances. For example, some patients were picked up by the National Guard for violating curfew and were found to be mentally disturbed.

The data presented are one-dimensional and represent only a fraction of psychiatric episodes that may have occurred during this period. We have no information on the number of cases dealt with solely by the police and the jails. We did not examine short- and long-term mental health effects that did not result in treatment episodes.

While the sample in this study was small and not all of the comparisons were statistically significant, the results show interesting trends and are counterintuitive.

Comment

The study provides an interesting vignette of a major historical event in Maryland history. One would expect to observe changes in psychiatric admission rates during a widespread civil disturbance affecting nearly every aspect of life within the city. It is unlikely that anyone could have predicted a drop in admissions and the other changes that occurred. In hindsight, there are many possible explanations for the findings. For example, the rise in admissions of alcoholics was thought to be related to sudden curtailment of supplies of liquor as liquor stores and bars were closed. General hospitals reported increased admissions of patients with delirium tremens during the same period. Other civil emergencies may occur in the future. How well prepared will the psychiatric system be to deal with them?

1. Effects of the Baltimore Riots on Psychiatric Hospital Admissions; Gerald D. Klee, M.D. and Kurt Gorwitz, Sc.D.; Mental Hygiene, Vol. 54, No. 3, July, 1970