Call the Police

What should you do if you believe someone is dangerous?  It's a sticky issue in psychiatry.  Here in Maryland, the requirements to have someone brought to an emergency room for evaluation by two physicians, include an imminent risk of dangerousness and the presence of a mental disorder.   If an emergency petition is signed by a judge, the police pick up the person in question and bring him to an emergency room for an evaluation.  In the ER, doctors can decide to certify the patient to an inpatient unit for further evaluation, or they can release the patient.  If admitted, a hearing must be held within 10 days.

Who else can file a EP?  Well, the police can.  If someone acutely agitated and violent and there is no time for a family member or interested party to obtain an EP, the police can be called and they have the option to fill out an EP and take the person to the hospital without a judge okaying the EP.  Depending on the circumstances, they also they have the option to arrest the individual and bring them to jail.   Finally,  a doctor can file an EP, but s/he must have seen the patient (--you can't get tell your rheumatologist-neighbor about your ill relative and get him to file an EP). 

So the police come -- either because they've been called in an emergency, or because a judge has authorized them to take someone to the hospital.  Most of the time, this goes smoothly.  But it doesn't always, especially since the person involved is presumably mentally ill and dangerous (the criteria for getting the evaluation).  Sometimes things get very upsetting, and sometimes they go very badly and someone gets hurt. 

In today's Baltimore Sun, there is an article by Justin Fenton that questions whether our police have the proper training to handle these crisis situations:

Baltimore Police have shot 10 people this year — eight of them fatally — leading some to question whether police are properly equipped to handle calls involving the mentally ill.

Only one of those shot was carrying a firearm, and several shooting incidents arose from calls to police about a disturbance involving someone with a mental illness. Relatives of some of those killed criticized police tactics, saying they shouldn't have lost loved ones after calling police to defuse situations that had ended peacefully in the past.

These are difficult situations, sometimes with no answer that will lead to a good outcome.   Fenton continues:

The director of the city's mental health organization praised the Police Department's training effort and said services for the mentally ill are lacking.

"If we don't do a good job getting people into treatment and something bad happens, we look to the Police Department and ask why did this person get shot," said Jane Plapinger, the president and chief executive officer of Baltimore Mental Health Systems. "Maryland is one of the best, but we unfortunately have an underfunded public mental health system everywhere in this country."

The Behavioral Emergency Services Team, or B.E.S.T. training, was implemented in 2009 and teaches officers to de-escalate mental crises, minimize arrests, decrease officer injury and direct patients to the city's mental health crisis programs for help. It has become mandatory for recruits.

"The police have been such a steadfast partner — I don't know how many [other] police departments are devoting four full days to this kind of training," Plapinger said.

The patients aren't the only ones in danger.  Police officers, or others, can be injured in these struggles. While it's not like there is an obvious answer besides calling the police, if the situation does not involve immediate danger, I often suggest that family member work to de-escalate upsetting situations and  convince a patient to go for help voluntarily, or with coercion, because even if it's coerced, these situations are often less upsetting for the patient and less dangerous for everyone if they can be done without the police.  Of course, this involves 20-20 hindsight, and the use of a crystal ball, because if there is a bad outcome and someone is injured or killed, then calling the police would have been a better solution.

I do wish I had that crystal ball. 

Daniel Carlat on Antipsychotic Medications for Agitation in Patients with Dementia

Lately, it seems like all the press about psychiatry in The New York Times is bad. We don't talk to our patients, we over-medicate them all from the children to the elderly, we all get bribes from drug companies. It's not that I don't think that these things don't happen, it's just that I don't like the sensational tones, and the one-sided nature of the presentation of psychiatrists as bad, the generalizations that it's "everyone," and the use of information taken out of context to make our practitioners look bad.

In a May 9th article Gardiner Harris writes:

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” Daniel R. Levinson, inspector general of the Department of Health and Human Services, wrote in announcing the audit results.

Mr. Levinson apparently feels the government should collect information on diagnoses so correct prescribing can be assessed.

On CNN today, Danny Carlat writes his own response in "In Defense of Antipsychotic Drugs for Dementia."

The story highlights include:

STORY HIGHLIGHTS

• Daniel Carlat: Report implies evil doctors are giving deadly drugs to nursing home patients
• But antipsychotics are most effective drug for calming agitation in dementia, he writes
• Carlat: No drugs are FDA-approved for this agitation, a terrible condition

Carlat writes:

But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.

The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

Collaborative Care: Fix It And Fix Mortality

I briefly scanned the Robert Wood Johnson synthesis report on mental and medical co-morbidity so I thought I'd summarize the highlights for the blog. If you'd rather watch the recorded web seminar you can hear it here.

The report relied on systemic literature review to look at the relative risk and mortality associated with co-morbid medical and mental health conditions. The looked at studies using structure clinical interviews, self-report, screening instruments and health care utilization data (diagnostic codes reported to Medicaid).

This is what they found:

• 68 percent of adults with a mental disorder had at least one general medical condition, and 29 percent of those with a medical disorder had a comorbid mental health condition
• These findings support the conclusion that there should be strong integration of medical and mental health care
• Psychiatric disorders were the most expensive conditions to treat among Medicaid beneficiaries, but also the most common when combined with cardiovascular disease
• Medical conditions and psychiatric conditions have a reciprocal risk relationship: having one disorder increases the risk for having the other
• Both medical and mental disorders are associated with low income, poor education, early childhood trauma and chronic stress
• Four modifiable risk factors are responsible for high rates of co-morbidity: alcohol and drugs, tobacco, poor nutrition and lack of exercise
• The treatments themselves may worsen co-morbidity (somatic meds cause psychiatric side effects, psychiatric meds may cause or worsen medical conditions)
• Public mental health clients die 25 years earlier than the average life expectancy (see Figure 4 above for the relative risk of six common psychiatric conditions)
• Multidisciplinary team approach to treatment is most effective: fully integrated medical, mental health and substance abuse services

So instead of having a public health care system that is fragmented between freestanding clinics, we should have integrated clinics that follow a collaborative care model and that provide a broad range of services. For me this means that we can no longer afford to have disjunction of care between state agencies: correctional facilities and public clinics need to coordinate care for both medical and mental health conditions. This study describes my typical clinic population: poor, poorly educated, sick, traumatized and under chronic stress. They are at greater risk of dying and the most costly to care for.

We're All Going To Die

I heard Irvin Yalom speak today. He's a psychiatrist/writer/ very famous shrink at Stanford, and he was at Johns Hopkins today to give the Jerome Frank lecture. The title of his talk was "Staring at The Sun: Overcoming the Terror of Death." It's also the title of his latest book. The auditorium was packed---no surprise here. When I heard Dr. Yalom was coming, maybe a month ago, I made a point to block off the time to be there-- I've never heard him speak and I was looking forward to this. Please let me share the experience with you.

Dr. Yalom is a gifted writer. He writes about his work in colorful and accessible ways, and he speaks about it this way as well. He lectures an audience of hundreds as though he is talking to a single friend. No notes, no hesitation, and he seems so at ease as he talks openly about work that is quite intimate. His specialties are group psychotherapy and existential psychotherapy, and he classifies the existential issues as death, isolation, freedom (as in freedom to make decisions and to steer the course of one's life, not political freedom), and meaning. "We are unfortunately meaning-seeking creatures heralded into a universe that has no meaning." Now he tells me!

Dr. Yalom started by talking about Dr. Jerome Frank (for whom the lecture is titled)--one of his mentors --and talked about a poignant visit with him near the end of Dr. Frank's life. Dr. Frank was also one of my psychotherapy supervisors, perhaps at a time in my training when I took such things for granted and had no true appreciation of what an amazing gift it was to be his student. Dr. Yalom talked about his memories, and I revisited my own.

Dr. Yalom talked about his own psychotherapy experiences: his three years in psychoanalysis in Baltimore "There was so much attention to the distant past and so little to the future and our death." Later in life, in California, he spent two years in therapy with Rollo May.

Death anxiety, Yalom contends, is an issue for many people--one patients won't necessarily bring up on their own, one they avoid if they sense the therapist is uncomfortable, one that, indeed, makes therapists uneasy as they, too, have their own death anxiety to face. Perhaps it's easier to avoid the topic; after all, there's nothing to do about it. We're all going to die. The therapist, he says, has a role in discussing death, and therapy can diminish the anxiety.

He talked a little about his work with cancer patients and how facing death can have a transforming effect; people get a better sense of priorities. "What a pity I had to wait until now to learn how to live," one dying patient told Dr. Yalom.

By far, the most interesting parts of the talk were when Yalom talked about specific examples of his own work with patients and the interactions that transpired. He talked about a patient--a psychotherapist--- who asked him about his own death anxiety (he responded) and who talked about his concerns about how Dr. Yalom might judge him. One nice thing about being Irvin Yalom is that you can get up in front of an audience of hundreds and talk openly about your work, boundary violations and all. He ended with the statement, "To become wise, you must listen to the wild dogs barking in your cellar." --a version of a quote by Nietzsche. I'm still thinking about that one.

It's been a while since I've heard a lecture like this. We've become so focused on psychiatry as the treatment of illnesses, of which drug at what dose, for how long, or which type of psychotherapy, and certainly we assume that what goes on in therapy includes talking about issues that having meaning to patients--including things that evoke anxiety, and the nuances of life that include meaning. We know we talk about these things behind closed doors--but we don't often talk about the process of such transactions.

Blogger's Block

Oh, not really, I'm almost never at a loss for words.
But this is the thing: For three years now I go through my days and when I see or hear something interesting, I think "I'm going to blog about that!" or....I think, "Oh, I wish I could blog about that" but I can't because it would reveal something about a patient.
So I get lots of ideas, but then I get to the computer and sometimes I've forgotten them. Last night, I was with Clink and Roy and we were having an animated (hmmm, is that the right word?) discussion about Richard the Internet Porn Fan (a fictional patient in our book) when one of them said something totally random and I thought "What a great blog post title." What ever it was, it was pretty random, but I wanted to use it, and it was gone. Neither of them remembered what they'd said. Sometimes, I make notes about ideas I've gotten, but ....

And I'm twittering now. Half-heartedly. Roy's been asking me to follow him, so I started. Actually, I'm a total failure. Someone has Un-followed me for being snarky about Twitter. I don't really get it, and being limited to 140 characters is my idea of suffocation. Plus, it's not like a blog were everyone has access to the same info: I twitter about someone's tweet and then realize he doesn't follow me, I just follow him. Or someone else responds to a tweet I never read. And there's really not so much to say in short bursts. But during dinner last night, we had a lengthy discussion on cremation and the interesting disposal of ashes (one friend helped scatter his uncle on the 14th hole where uncle had gotten 3 holes in one!) and I twittered that the temperature used for cremation is 3,500 degrees, per ClinkShrink. Why does she know all these random things.

My brain needs more coffee.

Family Passing

In our prison system we get blast emails. Dinah recently has listened to me rant about how much I hate random blast emails from the many organizations I belong to. I get blast email from my professional organizations (two of them), the local symphony, my car dealership, two academic institutions and any company I've ever done business with. I spend more time deleting email than I do reading and responding to email I really want.

But anyway, I get blast email from prison. The majority of it are press releases about various and sundry governer or secretary initiatives, but for some reason they also send out emails about deaths in the system. Not prisoner deaths, not anything work related, but the deaths of anybody who works in the system or is related to a DOC employee. These are called "family passing" notices, after the subject heading of the email.

Today I got three "family passing" blast emails. I don't know any of the people who died and all of them were relatives of DOC employees, and I didn't know the employees. They work in institutions on the opposite end of the state from where I am and it's unlikely I'll ever meet them.

I'm not sure why DOC officials decided I needed to know about these deaths. I'm not sure what I'm supposed to do with this information. I don't understand how they think it will help morale to know that people are dropping like flies right and left. I wonder if they realize that for most people this just reinforces the idea that when you die the majority of people will have no clue that you ever even existed.

I have my email rules set up now to automatically delete any message with "Family Passing" in the subject heading. I suppose I could send in a request to be taken off the notification list but in the bureaucratic world I live in, I know that would only last until the next employee comes in and takes over the death notification job. I'm sure I'll get a blast email to let me know when that happens.

Variations in Response to Stress-- from the NYTimes.

In "Down and Out-- or Up" New York Times write Benedict Carey (he likes to write about psych stuff) discusses suicide, psychological distress, and resilience in the face of the crashing economy. Carey writes:
----- Just as loss itself comes in different flavors, from the bittersweetness of divorce to the acid tang of public condemnation, so too do people’s responses to loss differ, sometimes wildly. There are people who fall hard and do not find their feet for a long time, if ever — a condition some psychiatrists call complicated grief. And the depth of this economic collapse has unceremoniously stripped thousands of far more than money: reputations have reversed; friendships have turned sour; families have fractured.
------
I agree-- some people grieve and move on quickly, others never go back to who they once were (even with therapy and anti-depressants). I wouldn't have put it, though, that they do not find their feet, I would have said they find different feet. They become a little of someone else, often someone who isn't quite so motivated to work or travel or run in the rat race as the person they were before, but someone who might eventually find a new and quieter life. It is as if their values and goals change. Sometimes, it seems, that's just the way it is.

Carey goes on to write:

--- In any group of people, moreover, there will be a handful who are exceptional, who find some release or hidden opportunity in a seemingly devastating loss — a kind of Zorba response. In one study in England, psychologists found a bricklayer who, after being paralyzed, became an academic and now says the injury was the best thing that ever happened to him. Other research has recorded significant improvements in the lives of some people after they lose a loved one.
---

I'll end with that. Oh, but in case you missed it, the Ravens won.

Here and After

One of the more---for lack of a better word-- "interesting" obituaries I've read: D. Carleton Gajdusek, a virologist who won the Nobel prize died. His obit in the New York Times details a life filled with adventure, discovery, and stomach-turning pedophilia. There's cannibalism and smeared human brains in the Amazon, 24-hour-a-day darkness near the Arctic Circle, prison time and sexual activity with children adopted in exotic places. Oh, and his biographer is a psychiatrist, so definitely worth a blog post.

-----

And while we're on morbid topics, apparently you can now buy a coffin from Major League Baseball, complete with the team logo of your choice....Go Red Sox?

Engage with grace: End of Life Discussions

Does your family know if you want to be put on a ventilator if needed? 

Kept alive with i.v. fluids and nutrition? 

For how long?

So you have a living will or advance directive?

Can your family find it?

It's a tough discussion to have, but even tougher to discuss when you have a feeding tube in your nose, a breathing tube in your throat, and are unconscious. So, while everyone's enjoying turkey at the table this week, someone bring up the topic so that everyone knows how aggressive to be if you are facing death. The website, Engage with Grace, can help.

What I Learned Part 3

The final installment in my conference series. Tomorrow I come home to my fellow bloggers! I miss them.

• In France they are doing an interesting project to look at the effects of incarceration. They are asking prisoners to spontaneously describe their incarceration experience and how they think it has affected them, then they are using computerized lexicographical analysis to define common domains of concern.

• There was a poster looking at the neuroanatomical basis of empathy, sympathy and moral reasoning. Highly theoretical and completely lacking in data, unfortunately.

• In 1895 Bridget Cleary was burned to death by her husband, who believed that she had been kidnapped by fairies and a changeling left in her place. It is possible that Michael Cleary suffered from a form of Capgras delusion.

• Someone tried to do a study looking at treatment compliance and motivation for change in sex offenders, but there weren't enough sex offenders motivated to participate in the research.

• Very few states have laws requiring mandatory reporting of impaired drivers to the MVA.

• One Russian psychiatrist proposed that the term "dependent behavior disorder" be used as a diagnosis for a broad range of compulsive behaviors.

• The first documented use of telepsychiatry was in 1959. In the U.K. a criminal justice statute required the installation of teleconferencing equipment throughout the courts and correctional facilities in the country. This is now being used to perform clinical and court-ordered psychiatric assessments. Free society studies have shown patient satisfaction to be similar between telepsychiatry evaluations and face-to-face interviews. In the U.S. there are a number of undefined legal issues with regard to telepsychiatry and computer-assisted treatment. These including licensing issues for practice across state lines, informed consent for remote clients/patients and malpractice coverage across state lines.

• Directors of forensic fellowship training are working to create measurement tools and procedures to meet the core competency requirements of the American Council for Graduate Medical Education (ACGME). There was a very nice workshop that presented a "toolbox" of techniques for documenting residents' competency as well as a discussion regarding how to prepare for an accreditation visit. The workshop also discussed the challenges of funding a forensic fellowship program.

THE END

Thank you for reading

What I Learned Part 2

Here's the second installment in my conference ramblings:

• The Supreme Court decided in Sutton vs. United Airlines that for the purposes of the Americans with Disabilites Act the disability must be assessed only after attempts have been made to correct the impairment.
  

• Liability in medication-related tort claims is best reduced by well-documented informed consent (Duh. But that came up a lot this year so I mention it.)

• In states that allow for outpatient commitment, only 20% of pretrial detainees who are referred for commitment actually end up getting commitment orders. This is because most of them are either sent to prison prior to a commitment hearing or because they are committed to a hospital for restoration to competence prior to an outpatient commitment hearing.

• Death Penalty

In 2006 there were 53 people executed, 32 were white and 21 were black. In 2005 there were 1805 whites and 1372 blacks on death row. One out of 12 death row inmates had committed previous homicides. Death penalty aggravating and mitigating factors are set by state statute. Aggravating factors include victim characteristics (law enforcement or firefighting personnel, children, pregnant women), defendant characteristics (previous violent offenses), and offense characteristics (murder committed during the course of a felony, contract killings). By law all possible mitigating evidence is allowed to be heard during the sentencing phase of a death penalty proceeding. Although mental health issues are statutory mitigating factors, sentencing juries actually consider them as aggravators and they are more likely to result in a death sentence. The main purpose of expert mental health testimony in a death penalty hearing is to humanize the defendant and to change the focus of the hearing from the crime to the defendant. It also serves to give the defendant an opportunity to communicate to the jury through the expert. Surveyed death penalty defense attorneys usually prefer psychiatrist rather than psychologist expert testimony. They prefer forensically trained experts with an area of expertise that is relevant to the case, with good testifying skills.

• Risk Assessment in the U.K.

The U.K. has a relatively new law that allows for the indefinite detention and/or community supervision of violent offenders. This led to the creation of the Risk Management Authority, an administrative body that trains, supervises and regulates official risk management assessors. The assessments are quite exhaustive and includes a minimum 6 hour interview over three days. It is primarily a clinical assessment although it does require the use of at least one "official" approved actuarial tool. There were only 7 orders for assessments filed in 2006. Some offenders refuse to cooperate since they know it could result in a lifetime of supervision and mandatory treatment.

Another development was the creation of a Dangerous and Severe Personality Disorder Service, which essentially is a tool for civil commitment of psychopaths. This has led to 150 referrals a month and an increased number of non-mentally ill sociopaths in forensic hospitals. (One presenter's quote: "The system is swamped.") They are treated with cognitive-behavioral therapy at a cost of $500,000 per inmate per year. Remarkably, there have only been three minor inpatient assaults involving these patients over five years.

• Liability and risk management in forensic practice

Case law is still defining areas of liability for forensic clinicians. Most liability seems to arise as a result of independent medical evaluations (IME's). The 2006 case Harris v. Kreutzer determined that there was a limited physician-patient relationship created during the IME. The three duties created as a result of this are: 1) to cause no injury during the evaluation (read the Harris case), 2) disclose significant findings to the evaluee (eg. an orthopedic surgeon doing an IME who incidentally discovers a tumor), 3) maintain confidentiality (eg HIPAA compliance)

Most states have limited civil immunity for expert testimony but this is not absolute & varies with jurisdiction. Experts appointed by medical boards for peer review have been sued with varying degrees of success by their evaluees. A forensic expert could face discipline from the AMA, the state medical board, or a specialty organization. In general psychiatric practice most liability comes from suicide or from medication-related injuries.

• Ethics of Forensic Psychiatry

In 1982 Harvard professor Dr. Alan Stone gave an address in which he suggested that it was unethical for psychiatrists to be involved in expert testimony. The last panel today was an update by Dr. Stone on his position and a response from a number of illustrious colleagues. I can only give this topic pitiful recapitulation here. Stone argued that psychiatry has no absolute truths to offer and that professional consensus is dangerously misleading. Panelists Ezra Griffith, Stephen Morse and Paul Appelbaum responded that it is ethical for professionals to aid the court's search for truth and to promote justice. While acknowledging potential ethical pitfalls, there was a consensus that evolving standards of science provide something to offer.

(Incidentally, in Podcast #14 (No April Fool) I talked about the New York Times article, Brain On The Stand, which quotes Dr. Morse's views on the use of neuroimaging in forensics. Now that I've had a chance to listen to this guy speak it is clear that he is someone to keep an eye on. Interesting things are going to be coming out of U. Penn, particularly with his involvement in the recent $10 million MacArthur grant for neuroscience and the law. This is probably worth a blog post all on its own, when I get the chance. Right now I'm off to dinner.)

What I Learned Part 1

This is my second annual blog post that summarizes my experiences at the forensic conference I attend every year. Last year I put up a three part "What I Learned" series, which I occasionally go back to when questions come up and I know I heard something about it once but can't remember the details.

So here goes:

• The Atlantic ocean is surprisingly warm for October.
• There are approximately 5000 women murdered every year in honor killings. Syria and Jordan still have laws on the books for men to kill their wives without consequences if they are caught in the act of adultery.
• There is evidence that the Slater method may be effective for restoring developmentally disabled defendants to competence to stand trial.
• Only two states in the country (Connecticut and Indiana) have laws that allow police to seize legally owned weapons from dangerous individuals.
• Violence predictions instruments, even the PCL-R, has not been validated for use with women and it is not recommended to use them as a predictive tool for female defendants or prisoners.
• Vaginal plethysmography exists but has not been validated for use in evaluating female sex offenders.
• In recent years the number of women found Not Guilty By Reason of Insanity (NGBRI) has increased. This may be due to increased awareness of post-partum psychiatric illness.
• Culture-bound syndromes can be seen in immigrant populations and it is necessary to understand these phenomena in order to distinguish them from delusions. Ashanti witchcraft, "root workers" and others may lead to commonly held cultural beliefs.
• A woman named Marti Ripoli was an infamous serial killer in the nineteenth century. She was thought to be responsible for the deaths of 25 children, whose blood she used to make magical remedies that she sold on the streets. Belle Gunness had nothing on this lady.
• Alan Felthous gave an amazing Presidential Address in which he reviewed the religious and philosophical underpinnings of free will from Aristotle up to the neuroanatomy of decision-making as shown by functional MRI's. All in less than an hour. Wow.
• There was a great panel presentation about cults. They discussed the difference between a religion, a sect and a cult. They described characteristics of cult leaders and followers and cult dynamics including recruitment, retention and deprogramming. They presented case law regarding deprogramming practices and risk management issues for psychiatrists. Finally, they presented the satanic cult abuse issues of the 1980's and the lessons learned from this. (I enjoyed the tutorial about the Church of Satan and what to ask your Goth patients. Also the Church of Satan tattoos. Personally, if I saw a 'Satan Rules' tattoo I don't think I'd need to ask too many more questions.)
• In Germany forensic experts are always the agents of the court rather than agents of an adversarial attorney. The goal is a neutral and impartial evaluation. (We could learn something from that here in the States. I bet their malpractice costs are significantly lower.)
• The concealed information test is the most commonly used experimental deception paradigm. It has been used in functional MRI lie detection studies, the first one of which was published in 2001. The number of fMRI lie detection studies has increased quickly since then, but a number of the authors are partners in two companies that do commercial fMRI lie detection, Cephos and No Lie MRI. (We discussed this topic in Podcast 5: Sex, Lies and Neuroeconomics.) Functional MRI's cost about $1800.
  
• SPECT scans are very sensitive but completely nonspecific. They are abnormal in a broad variety of conditions but there is a lot of overlap between conditions. When using SPECT to evaluate mild traumatic brain injury, it is important to first rule out the confounding variable of clinical depression.
• Problematic Internet use covers a broad range of behaviors: cyberstalking, cyberbullying, excessive surfing, excessive online gaming and inappropriate work behavior.
• When evaluating a building for Sick Building Syndrome it is important to do a visual inspection first, then take samples if necessary. Sampling includes measurements of wall and room humidity, temperature, carbon monoxide and carbon dioxide levels and surface swabs. A normal carbon dioxide level is 1000 parts per million. Normal building temperature is from 68-72 degrees in the wintertime with less than 60% humidity. Some plaintiffs alleging sick building syndrome are actually suffering from somatization disorder so it may be necessary to involve forensic psychiatrists in these evaluations.

PHEW. And that's only the first day. Here's the other thing that I learned:

I love eating lobster while watching the ocean. Beats the heck out of working in prison.

What I Think About Paris Hilton

I'm really not one for celebrity gossip but this news (and I use the term loosely) item had some good correctional teaching points so I thought I'd address it. Besides, it's just a matter of time before somebody drops a question to My Three Shrinks asking my opinion about Paris Hilton and her jail status.

So here goes:

Looking at this from the Sheriff's viewpoint, I can imagine what was going through his mind. He's got a new inmate who is:

1. a high profile case
2. a previously upstanding citizen
3. crying, distressed and not eating
4. has a known mental disorder (in treatment at arrest)
5. has an active substance abuse problem
6. is in isolation in a single cell
7. is serving a relatively short sentence
8. is within 24 to 48 hours of incarceration

Egad. The next thing this Sheriff is going to imagine is Paris Hilton hanging dead in a jail cell. She has eight separate risk factors for a correctional suicide and it is not good to have a dead celebrity in your facility. Ideally, the proper intervention would be to get her referred for crisis intervention services as quickly as possible. Educate her about what to expect and how the incarceration will run. Get her referred for psychiatric evaluation and pharmacology, if indicated. If all else fails, use suicide observation to preserve safety. I don't know the LA jail or what resources they have; given her relatively short sentence the Sheriff may have felt the more efficient alternative was to release her to home detention.

Home detention is a good tool used to reduce institutional crowding but it is limited to people with relatively short times left on their sentences and to non-violent offenders. Given that she only had less than a month to serve, keeping her in jail was a waste of space. In Charm City she probably would not have been incarcerated for a first probation violation; I think she probably was treated more harshly than the average defendant. Maybe this was because of her celebrity status or maybe she didn't present herself well in court. In our prison system the decision to put someone in home detention is made without judicial input; it's the institution's perogative to assign someone there.

She was being kept in a single cell because of her celebrity status, but she was seen crying and not eating there. Most completed correctional suicides are done by inmates in single cell status. The facility would have had a reasonable concern about maintaining her safety under these circumstances. One option would have been to put her on suicide watch involuntarily, but again this involves a fair amount of embarrassment and discomfort to the person you're doing this to. I understand she is now housed in a special needs unit where she is being monitored, another reasonable alternative. The term "special needs unit" refers to a specific tier or placement within a facility for vulnerable inmates who require therapeutic monitoring. It is not the same as protective custody in that a special needs unit is controlled and regulated by mental health staff. People with chronic serous mental illnesses or developmental disabilities may be housed on a special needs unit. Every facility does not have a special needs unit; they usually just exist in larger (over 500 beds) facilities so your average small local county jail may not have one.

So that's what I think. I'm sure she'd be welcome back at the Charm City zoo or the local television station anytime. As long as she doesn't drink.

Moral and Ethical Choices

Dr. Richard Schloss posed the following conundrum recently:

The following 2 vignettes are sometimes used to illustrate that there
are universal moral standards that transcend religion, culture, and
ethnicity, because everyone, regardless of background or belief system,
always gives the same answers. See what you think.

Suppose there is a runaway trolley car that is about to mow down and
kill 5 people. Now suppose that there is one observer standing next to
the track watching this, and he realizes that, by throwing a switch, he
can divert the car onto a different track so that it will kill only one
person, but spare the other 5. Virtually everyone says that the morally
correct thing to do is to throw the switch and sacrifice one person to
save 5; most even go so far as to say that it would be morally
reprehensible for him just to stand there and do nothing, once he
realizes that throwing the switch is an option.

Now, a different scenario: there is a hospital with 5 patients who will
die very soon if they do not receive organ transplants, and there are no
donors immediately available. (They all need different organs.) Now,
suppose someone is brought into the emergency department of that
hospital after having suffered a life-threatening, but easily
repairable, injury -- and he has and organ donor card in his wallet.
Would it be ethical for the ER staff to deliberately withhold treatment
and let him die so that his organs can be used to save the other 5
patients? Everyone says "no" to this question. Why? How is it different
from the trolley car scenario? Aren't they both cases of sacrificing one
to save 5? Why is it right to do so in the first case, but wrong in the
second? And why does everyone, regardless of background, give the same
answers to these two illustrations?

Just for fun, I'd like to throw a few qualifiers into the second
scenario. Would your answer change if the potential organ donor who can
be easily saved, but will die without treatment, had been driving drunk?
Would it change if he were a paroled murderer? What about if he had been
speeding at the time of his accident and had killed a family in another
vehicle?

Discuss.

Tarasoff Overview & Inservice

Dinah's post Johnny Get Your Gun generated a lot of interest in and comments about public safety and the mental health professional's duty to warn or protect. Some readers commented and cited the Tarasoff case, which made me think a quick inservice was in order. Many of our readers aren't mental health professionals or aren't American, so it's not really fair to leave them without any context for the discussion. Also, many American mental health professionals have heard of Tarasoff but may not really be aware of the limitations or extent of this decision.

First some background:

In 1969 a Berkeley college student, Prosenjit Poddar, became enamored of co-ed Tatiana Tarasoff. He pursued her to the extent that police got involved. They detained Poddar and referred him to the college counselling center where he was seen by a psychologist. The psychologist consulted with his superior at the center, and both decided that Poddar did not need to be hospitalized. Poddar later shot and killed Tarasoff.

Tarasoff's family sued the university, the police, and the mental health professionals for failing to hospitalize Poddar. The suit was originally dismissed by the California Supreme Court (in a case now known as Tarasoff I) because all of the defendants were government employees who were acting within their discretion regarding the hospitalization decision. Thus, they were covered by government immunity. Also, at the time no mental health professional had any duty to a third party---the clinician's only duty was to the patient. The suit was dismissed without prejudice, meaning that the plaintiffs were free to refile the suit on other grounds. The California Supreme Court hinted in their opinion that if the suit had been filed on the grounds of failure to warn or protect the defendants would not be immune from suit. The plaintiffs took the hint and refiled on these grounds.

This led to the case known as Tarasoff II, in which the California Supreme Court found for the first time that mental health professionals had a duty to protect (not just warn) third parties of danger from their patients.

Now the thing to remember about case law is that opinions are only binding on the regions that the appellate court has jurisdiction over. The Tarasoff cases were decided by the California Supreme Court and were binding only in California. Only the U.S. Supreme Court can issue opinions that apply to the entire country. So how did this idea spread across the country?

If I were a complete cynic I'd answer: Blame it on the lawyers. Being only a partial cynic, my answer is that the creation of this new duty created a new fertile ground for recovery in case of injury. A flurry of cases in other states followed the reasoning in Tarasoff and laid the groundwork for mandatory warnings in other jurisdictions. A nice overview of the current state of national Tarasoff laws can be found here.

Fortunately, the Shrink Rappers live in Maryland. Our professional organization took a proactive approach to this impending issue and crafted a Tarasoff duty by statute rather than waiting for it to be created through a lawsuit. It was designed thoughtfully and narrowly so the duty for our clinicians is not as broad as that which is implied in the California cases. It can be found in Courts and Judicial Proceedings (granting immunity for certain actions) and it states:

§ 5-609. Mental health care providers or administrators.

(a) Definitions.-

(1) In this section the following words have the meanings indicated.

(2) "Mental health care provider" means:

(i) A mental health care provider licensed under the Health Occupations Article; and

(ii) Any facility, corporation, partnership, association, or other entity that provides treatment or services to individuals who have mental disorders.

(3) "Administrator" means an administrator of a facility as defined in § 10-101 of the Health - General Article.

(b) In general.- A cause of action or disciplinary action may not arise against any mental health care provider or administrator for failing to predict, warn of, or take precautions to provide protection from a patient's violent behavior unless the mental health care provider or administrator knew of the patient's propensity for violence and the patient indicated to the mental health care provider or administrator, by speech, conduct, or writing, of the patient's intention to inflict imminent physical injury upon a specified victim or group of victims.

(c) Duties.-

(1) The duty to take the actions under paragraph (2) of this subsection arises only under the limited circumstances described under subsection (b) of this section.

(2) The duty described under this section is deemed to have been discharged if the mental health care provider or administrator makes reasonable and timely efforts to:

(i) Seek civil commitment of the patient;

(ii) Formulate a diagnostic impression and establish and undertake a documented treatment plan calculated to eliminate the possibility that the patient will carry out the threat; or

(iii) Inform the appropriate law enforcement agency and, if feasible, the specified victim or victims of:

1. The nature of the threat;
2. The identity of the patient making the threat; and
3. The identity of the specified victim or victims.

(d) Patient confidentiality.- No cause of action or disciplinary action may arise under any patient confidentiality act against a mental health care provider or administrator for confidences disclosed or not disclosed in good faith to third parties in an effort to discharge a duty arising under this section according to the provisions of subsection (c) of this section.

[1989, ch. 634; 1997, ch. 14, § 9; 1999, ch. 44.]

The key points compared to the Tarasoff cases are that the statute requires imminent danger to an identifiable victim. Clinicians are not required to foresee danger to the general public, nor are they required to predict dangerousness into the indefinite future. Clinicians are given the discretion either to warn the victim or to carry out a protective plan; hospitalization is not mandatory. Regardless, a decision to break confidentiality is shielded from liability if the clinician is acting in good faith.

In Memoriam

[Posted by ClinkShrink]

I lost a great officer last week and I'm sad.

Correctional Officer X** was assigned to work in the psychiatric infirmary. He had been there for years and he was good at it. CO ("Correctional Officer") X was build like a sumo wrestler, only bigger. He had a soothing, mellow, story-telling voice like Garrison Keillor. I swear he could have hypnotized a rabid dog with that voice. Whenever any situation came up on the unit that looked like it could have gotten out of control, he was there. If any of my patients got loud during rounds, he'd poke his head in: "You OK in there, doc?" When he moved down the unit it was like watching an ocean swell move toward a tropical beach. But more than his size, his demeanor set the tone for the milieu. He approached patients in a way that made them feel safe.

He was the ideal physician recruiter. Whenever I brought applicants through the unit I'd introduce them to X. "In case you're nervous about working here," I'd tell them. "Don't you worry," X would say. "You come work here, I got your back."

He was a big (pardon the pun) reason why we never needed to use physical restraints.

And now he's gone.

He got promoted to sargeant and moved to a different tier. Gotcha!

But I'm still sad.

**********************

**Not his real name. Duh.

Facts & Figures

[Posted by ClinkShrink]

While studying for the recertification exam I came across some interesting relevant facts and figures. In a 1990 mortality study of Maryland prisoners, male inmates had a 39% lower all-cause death rate than the Maryland general population. Correctional deaths from AIDS and other causes have also dropped significantly over the past twenty years, according to the Bureau of Justice Statistics. Not coincidentally, this decline occurred over the twenty years since the U.S. Supreme Court mandated medical care for prisoners in the landmark Estelle v. Gamble decision. Makes you wonder how much mortality rates could drop in free society if people made their minds up to commit to broader access to health care.

Death & Hot Fudge Sundaes

I’ve been thinking a lot about death and hot fudge sundaes.

Yesterday, there were no blog entries because I spent most of the day on a train, traveling to and from the funeral for a member of my extended family. His death was tragic and completely unexpected—a healthy man who should have lived for decades more, he died at work from a cerebral hemorrhage.

A few weeks ago, I also lost a patient to a chronic and incapacitating illness. The death was horrible, culminating in pain and cachexia, but it was not unexpected, and perhaps there was, at least for the patient, some sense that death would yield relief.

At any rate, death has been on my mind lately.

So, we try to live life right: there is a list. The list is fairly long, though I think I can summarize at least some of it. Low fat (or, this week, low trans fat), diet, regular exercise, lots of calcium (oops, that may have been last week), no smoking, drink only in moderation—and, please, red wine. Seat belts. No illicit drugs; caffeine (sorry, Clinkshrink), and aspartame are a little lower down on the list but still there. Smoke detectors, definitely, and remember to check the batteries once a month. Multivitamin and baby aspirin, perhaps. Sunblock. And finally there’s the medical screenings: mammogram, Pap smear, PSA, colonoscopy, to name just a few. Hormone replacement therapy is out, fish oil supplements are in. I’m sure you can add to the list.

We grow up listening to directives on how we should live as determined by the medical community, or perhaps by the medical community in concert with the pharmaceutical industry and unclear political agendas. The Food Pyramid, as taught to all our children and described on the back of every cereal box, was never a scientifically-determined recipe for good health, it was voted on by a committee, and it sure sounded good.

The pretext of how to live life right is that if you follow the directives, you get to live a long, healthy, and fruitful (pun intended) life-- if all that exercise doesn’t destroy your joints, that is. The subtexts, however, are ones of guilt, fear, and social ostracism. We live in a society that praises “taking care of yourself,” where foregoing hedonist pursuits and rigid self-discipline are something to aspire to. Of course our neighbor had a heart attack, didn’t you see him chowing down that chocolate éclair the other day? Do you know how many grams of fat are in that thing? And if you aren’t on a low-fat, high-fiber diet, exercising a minimum of four hours a week, then perhaps you deserve to have that recurrence of your breast cancer. We fool ourselves into thinking other people get what they deserve and if only we do it all exactly right, we won’t die. While, as a physician, I won’t encourage anyone to smoke or drive after drinking-- or even to skip the next dose of lipitor-- the truth, I believe, is that we live until we die and we have much less control then we think.

People have many anxieties, as a psychiatrist I get to hear them. Terrorists, bird flu, violent criminals, shark attacks, plane crashes-- we all have things we worry about, many of them are things beyond our control.

I am worried that I will miss a hot fudge sundae. I carry this fear that I will do it all right, follow all the rules, say No to yet another hot fudge sundae—all in the name of healthy living and the pursuit of longevity-- and what if, in the end it doesn’t matter?