Things That Make Me Crazy

I sometimes think I live in a tight little fantasy bubble where I want life to make sense and be fair.  I want it to be an uncomplicated place where, when resources are limited, we assess the problems and direct the dollars to things we know will efficiently fix the problems.  I'd like us to use our public health  dollars to feed hungry people, to house those without some place warm to stay, to help those in need learn strategies and get jobs so they can help themselves, and to provide health care to those who are ill.  In cases where there are big-picture items that lead to devastating consequences and enormous costs to society, I'd like us to target the causes with early interventions that are known to be effective: so measures to prevent drug/alcohol/tobacco abuse, better and more available drug treatments, and more resources dedicated to early education so that everyone gets the skills they need to earn a living and grow up to be a taxpayer.  

Instead, through some mix of politics and medicine, there are these untested (or poorly tested) ideas out there that cost billions of dollars and money gets diverted away from being used for the direct good of the people.  Maybe I'm wrong-- I'm sure there are plenty of people who disagree with me and think that these changes are important and will make the world a better place -- so by all means, feel free to comment. tell me why I'm wrong, or do add to my list.  It's a little of 'one guy unsuccessfully tried to blow up a plane with his sneakers so millions take off their shoes for screening every day.'  The cost is phenomenal, but I do have to  admit that no planes have been blown up with shoe bombs since, and if my child was on a plane that didn't explode, then the cost to society was worth it, but it's not a very "public health" way of thinking.  But you have to wonder what we're giving up when we put a lot of time, money, or resources towards low-probability events or towards paperwork for the sake of paperwork.  In no particular order:

Dinah's List of Aggravating Diversions from Productivity in 2013

• CPT codes that force psychiatrists to differentiate "medical care" from psychotherapy with rate changes depending on whether the psychotherapy component takes 52 minutes or 53 minutes or the session, and creates 15 different options for coding a single psychotherapy session.
• 68,000 ICD-10 codes for the purpose of diagnosis/billing. Really?  ClinkShrink will be thrilled, code Y92146 is for getting hurt at a prison swimming pool.  Prisons have swimming pools?  And Y92253 is for being hurt at the opera, so Clink and Jesse can both rest assured that injuries they may incur can be coded. This helps us how?  And, no, US prisons don't have swimming pools, but why should that stop us from having codes?
  
• Legislation -- complete with the cost of databanks, means for reporting to such databanks, and the cost of enforcement -- to keep the poorly-defined 'mentally ill' from owning guns when there is no such effort to keep the family members or roommates of those people from owning guns, and there is no such effort to keep guns from those who are known to be dangerous if they are not mentally ill.  The laws in Maryland also include 'habitual drunkards,' -- but there is no provision to report those who goes to detox/rehab or have a second DWI/DUI from having a gun. 
• Continued support of the Second Amendment as interpreted rather widely, despite 40,000 gun deaths/ year, some of them innocent small children. "A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed."  I'm just not sure that the founding fathers foresaw a society of drug addiction, rampant suicide, and a country with a firearms death rate beyond any other country in the world.  There was slavery when the second amendment was written, and I don't think the amendment included slaves, so clearly the 'right of the people' did not mean all people, or include assault weapons that did not yet exist.  The second amendment has become an impenetrable devotion -- in Maryland's it's some state legislator's main forum -- as if it were a religious belief.  And people with mental illnesses have taken the blame for all inappropriate uses of guns.  See yesterdays Bloomberg Report for our President's pronouncement, and by all means, read the comments.   
•  Meaningful use -- a government/Medicare phenomena that creates a tremendous amount of work for physicians that does not seem to directly improve patient care (correct me if I'm wrong), and if it does, it doesn't improve patient care/outcomes in a way that warrants the time, and expense.  I don't really know what Meaningful Use is (such details never stop me from ranting), but I know the government will give me money if I'll convert to electronic records and use it in a particular way.  Otherwise, for every Medicare  patient I see, I must charge a lower fee if I don't use e-prescribing (which is not conclusively shown to improve patient outcomes) a certain percentage of the time, and that in 2013, to prevent an drop in my fees, I needed to put a PQRS code on one patient's insurance claim form.  I could not figure out what that meant, so I asked an APA assembly member who runs a hospital.  After two  separate half-hour phone conversations, one in-person meeting, and I have no idea how many hours of his time, he provided me a list of options which included things like "medications not reconciled, reason not given."  I opted to list on one patient's claim a code indicating he was not a tobacco user, and I'm told this was good enough to keep my fees from dropping 1.5% next year.  What's meaningful about this?
• CRISP/Government portals of patient records collected without patient knowledge/permission.  These may be very helpful for emergency care in crisis situation,  and perhaps they allow for data/outcome collection that will be used for outcomes research, but they cost a lot of money and after the NSA scandal, are we all comfortable with the government keeping our health records without our expressed permission?  Are we sure our health information won't bounce back at us in unwanted ways?
• Hospitals that spend HUNDREDS OF MILLIONS OF DOLLARS to replace existing, function, Electronic Medical Records when there are people sleeping on cardboard boxes outside their doors, and when such medical records increase the amount of time clinicians spend with computers and decrease the amount of time they spend with patients -- and don't necessarily decrease medical errors.  This feels wrong to me  on so many levels: there are shortages of physicians and we're diverting their attention to clicking through screens and checking off boxes that have nothing to do with the care of that particular patient, adding hours a day to physician workload, promoting physician burnout, and diverting funds to this project that could be used to pay for health care for human beings.
• Government-run health insurance exchange(ACA) websites that are basically unusuable and create too much frustration for the average person --especially the average person with medical or psychiatric issues-- to work efficiently.  One of my patients was blocked from signing up because he forgot his password, and the recovery question involved his pet's name, only he's never had a pet and was locked out of the system. 
• Hospital medical records that afford no privacy because thousands of people have access to them and patients can not opt out, other than to get care at another institution.  But if you want information about a patient from another institution, with the patient's permission, barriers are put in place to make this next to impossible.  I recently requested records from a local hospital ten minutes from my office, and two weeks later they sent me a form saying that the authorization my patient signed was not good enough, it had to be signed on their specific form.  How crazy is this?  Perhaps it's because that hospital's administrator was so busy looking up my PQRS codes that he wasn't updating their information release policies.
• That my state is proposing to spend money on programs to increase cultural awareness and competency on number of measures when people need food/housing/healthcare/job training.  I'm all for treating people respectfully, but maybe it would be cheaper to fire those who are demeaning to others rather than to set up training programs to make them 'culturally aware.' (Please forgive my cynicism, in a world where everyone is fed, housed, has healthcare, heat, education and jobs, I'm all in favor of programs to increase sensitivity to cultural issues).
• "That my state is proposing to add Assisted Outpatient Treatment (read: forced care) when we don't have enough information to know if this really works without other services in place.  We don't have  enough resources to care for people who want care, and this will entail forcing people to take medications that are known to have detrimental cardiovascular effects in some people,  distressing side effects in others, and may include forcing care on people when that care does not decrease their symptoms. If I thought the legislation was truly about getting care for the very sickest of people -- those 'dying in the streets with their rights on' -- I would be in favor, but I believe it's a "do something" measure to address spree shooters and has been tied to federal funding. 

Thank you for letting me rant.  That's what this was, and I appreciate it.  I feel much better now. 

What I Learned: Part 3

(Picture explanation to follow.)
Usually I write about the conference in the order that I hear things, but in this case I'm changing things around a bit to start with the topic I know most of our readers would be interested in. Involuntary treatment.

A Canadian nurse presented the results of a small but interesting study about the experience of being placed in a seclusion room. She developed a list of open-ended questions that she asked of both the nursing staff and secluded patients, 13 of each. Most of the patients who had been placed in seclusion had a psychotic illness, either schizophrenia or schizoaffective disorder. Five also had antisocial personality disorder.

Both groups were asked about the reasons for seclusion, their attitude toward the quality of care received while in seclusion, whether it was necessary and finally given the opportunity to describe the "ideal" seclusion room.

As expected, the nurses rated "safety" as the number one reason for use of seclusion, and none saw it as punishment. They emphasized that alternative interventions were always preferred and that extended negotiation was often used as a means of avoiding it. They emphasized the importance of having a good rapport in order to avoid escalation. Although the nurses were evenly divided on whether seclusion improved or impaired the quality of care given, most agreed that seclusion rooms could be beneficial in the short term for a patient's mental state. They reported feeling shaken and traumatized themselves when required to put someone in seclusion and said that debriefing with a colleague was helpful. They consistently emphasized the importance of a "QTIP" attitude ("quit taking it personally") when threatened or assaulted: "They could be cussing at you...spitting at you...hitting you. But you got to put all that aside because you know that's not the real person you were talking to the day before."

The surveyed patients had been placed in seclusion for an average of four or five days in the past six months. All but two patients had negative reactions to the experience and did not find the room beneficial for their mental states, although most understood the reason for the intervention. The experience was described in a wide variety of negative terms, but the most prominent theme was boredom. Two patients had positive reactions to the experience: relieved to avoid the stress of a potential confrontation with other patients, or even the opportunity to be "more creative" when left alone. The nursing protocol generally required the nurses to minimize patient stimulation and this meant that staff tried to minimize communication, and patients generally didn't like this. They were more likely to describe the experience as punitive, or used as an alternative to spending time with the patient. Lack of privacy, cold temperatures, difficulty with access to showers, soap and dental hygiene were also cited as a problem. Some patients were even served "finger food" rather than be trusted with utensils.

Both groups agreed that seclusion was a preferred alternative to physical restraints.

As a result of this study the group came up with recommendations to modify the physical conditions of the seclusion rooms, to provide more opportunities for interaction with staff while in seclusion, and to offer the option of listening to music.

This was the second presentation this week in which a project was organized and lead by a ward nurse, with resulting concrete recommendations to improve direct patient care. Nice.

Now to back up and discuss the poster presentations:

There was a survey of more than 600 Pittsburgh police drawn from all levels of service, including command staff and investigators. The purpose was to assess their attitudes toward the usefulness of mental health involvement in police matters. Most respondents rated crisis debriefing or personal counseling relatively low, but rated utility high for help with crisis or hostage negotiation. Interestingly, although most respondents weren't investigators (thus, had no direct experience with it) many rate "profiling" or investigative assistance as highly useful. About 25% of the respondents had been through CIT (crisis intervention training) and it was going to be made mandatory.

I'm a bit biased about the next poster since I know the investigator, but it's still a good one. It involved a battery of neuropsychology tests to look at which cognitive functions were most correlated with good or poor vocational outcomes. In other words, disability determination. Out of the entire battery, the strongest predictor was cognitive processing speed as measured by a simple paper and pencil test that took six minutes to administer. I thought this finding had intriguing potential for further study to look at correlations with general competence to stand trial.

There was a national survey of correctional mental health systems which tried to identify barriers to psychiatrist recruitment and retention. The most interesting part of this for me was the fact that anxiety or fear of the correctional environment was the biggest barrier to recruitment but the lowest factor for retention. That's consistent with my experience bringing new staff in to prison: after a few weeks you realize it's just not as horrible as everybody warned you it would be. (Or that journalists report.)

A poster about "Big Data" presented the results of a national survey of AAPL members regarding their use of Internet search data in clinical and forensic practice. About half regularly did Internet searches or reviewed social media related to their cases, and most have found useful information. Most thought there was a need for better guidelines for this practice given the ethical issues involved.

Today's session reflected ongoing concern about gun laws and firearm related violence. One poster presented the outcome of seven years of experience with a firearms seizure law in one Indiana county.  Court data from 2006 to 2012 was presented. During this time only 254 guns were seized. In the early years (2006 to 2007) most patients didn't bother to show up for their firearm retention hearing, or they voluntarily surrendered the weapon. In later years, courts dismissed the case and  returned the weapon in 80% of cases. The time to resolution of the case averaged 300 days. In two-thirds of cases, reason for seizure was threat of suicide and 3.5 weapons were recovered when the police transported the patient to the ER, voluntarily or involuntarily. In other words, the seizure law didn't take many weapons off the streets but it did make people more adamant about getting their weapons back. There was no data presented about suicide rates during this time.

At a panel discussion about gun laws since the Virginia Tech shooting I learned that in 1999, the first year that NICS (the background check system) went live, 81,000 firearms applications were denied (only 1.8%) and fewer than 0.1% were denied due to mental illness. By 2012, still only about 1% were denied but mental illness was the basis for 22% of the denials. I also learned that in order to take possession of a revoked weapon, police can only knock on the door and ask for the weapon. Apparently revocation does not serve as a basis for a search warrant. I hadn't thought about that issue.

Last but not least, there was a presentation on national laws related to zoophilia. (Thus, the turkey.) If you feel a need for dinner party trivia, I can tell you that 31 states have laws against zoophilia and that it could be either a felony or a misdemeanor. A LexisNexis search of cases using the term "zoophilia" turned up 26, usually in relation to an appeal of a sex offender commitment. The disorder was cited as a sign of generally more serious psychopathology in connection with other paraphilic disorders. I also learned about the practice of people known as "furries." If you want to know what that is, I will only tell you if you retweet a link to this post ten times:

Day 3 of the American Academy of Psychiatry and the Law, summaries here: http://t.co/ahtZbOfFeh #forensic #psychiatry #AAPL2013

— Clink Shrink (@clinkshrink) October 27, 2013

The Wicked Witch of the West, Behind the Scene

One week from now our legislative session will be over and we'll be left to sort through the wreckage of the new laws that hit us. Every year I do this I wish we had some way to limit the number of bills that could be introduced, to give the public a fighting chance to figure out what their representatives are trying to do to them.

The Shrink Rappers have been pretty busy with this particular session and I've written a short column about it over on Clinical Psychiatry News. Feel free to hop over there and read my piece "A Glimpse Under the Hood." The site doesn't require you to register anymore although there is one small annoying popup ad you have to click past first.

This afternoon is the big day. The House version of our governor's gun bill is going to a vote in a joint committee. If it passes, which everyone expects it will, that will be the final step before it joins the other version already passed by the Senate to become law. We've managed to keep psychiatry out of the decision to take guns away from people and to at least provide some education to the legislators about the limitations and dangers of policies based on categorical mental illness.

It looks like insanity acquittees, criminal defendants who are incompetent to stand trial and people under guardianship will be barred from purchasing weapons, as will be anyone under an active protective order. This addition is required by the Federal government to be compliant with their gun laws. People can petition to have their gun rights restored although the administrative logistics for this have yet to be hammered out, and legislators (in spite of their professed intent to get guns out of the hands of dangerous people) have shown a striking reluctance to enforce seizure of weapons from anyone who falls into one of these categories. And yes, they carved out certain assault weapons out of the list of proposed banned weapons.

The final piece is the Maryland version of the New York SAFE Act. The original bill has been dropped, but it bounced back in the form of an amendment to today's bill which will be voted on this afternoon. The last three days have been pretty intense with discussions about how to protect our patients from getting reported to police. Dinah has already written extensively about this in USA Today and in Clinical Psychiatry News, and I outlined the New York requirements here. We're hopeful Maryland is not going to skip down that yellow brick road. That yellow isn't gold.

Which brings me back to the Wicked Witch of the West. When crafting law, her advice "These things must be done carefully" is a good thing to remember. I thought of this often when looking at bills proposed to modify all of our involuntary treatment laws. Regardless of which way you fall on the issue, the worst outcome is to create confusion. I don't know if any of the changes will actually make it out of committee next week so I won't speculate here, but like most states following all these high profile shootings there was a rush to cobble together a lot of changes while the time was ripe. And it showed in the legislation.

And now for something completely different:

Well, not completely. I listened to a presentation yesterday by Dr. Jeff Swanson, a sociologist and epidemiologist who studies the impact of certain public policy decisions and programs. He was part of a summit meeting on gun policy recently at Johns Hopkins. I listened to 90 minutes of impressive outcome data on gun violence and mental illness. His research provides strong support for the futility of reducing gun-related violence by singling out people by diagnosis. Unfortunately, as we've already seen with the sex offender registries, futility and costly ineffective public policies are not mutually exclusive.

So that's where I've been disappeared to lately. I hope to come up for air soon.

My Day With Our State Legislature

It was a long day in Annapolis yesterday.  I was one of an estimated 1,300 people who showed up to give testimony on gun legislation.  For details, see The Baltimore Sun article.

On the public testimony, I was #162  and I went at nearly 9 pm, they were estimating 16 hours of testimony and it didn't start until 4:30 pm. My quick demographic estimates: 99% white, over 90% Male, & over 95% or those who came to testify opposed the governor's bill. The supporters, including busloads of school children, were outside rallying in the morning.

There were 4 hours of expert testimony, then I heard  4 hours of  public testimony with the same handful of messages : civil rights, why I need an assault weapons, statistics on how gun control doesn't decrease violence, I'm gonna move to another state if this passes, you're going to make me a criminal, go after the criminals and the mentally ill,  all of these measure prevent straw purchases but no one is ever prosecuted for straw purchases, this won't fix anything, and my personal favorite: the little girl who testified that if the law passed she'd have to move away from her friends, her school, and going to McDonald's.  Where were the victims of gun violence? Where were the mental health advocates?  They were part of the expert testimony -- I'll talk more about this below--but I was the only one (of those I heard) who was not giving public testimony on the Firearms Act.  I left after I testified, but it went on until early the next day --I've heard 3 AM and 6 AM. 

I got to testify around 9 pm, maybe a little earlier, thanks to our kind psychiatric society lobbyists who signed me up, even though I wasn't the designated speaker for the expert testimony. It fast-forwarded me out of a long line to get into the building and I got me a much better number than I'd have gotten myself, being that I'm not a "morning person."  I was psychologically prepared to stay until 10 or 11, so being heard by 9 was good.  I'd brought a peanut butter and jelly sandwich, a pear, and some carrots.  I resorted to water from a faucet in the rest room, and at one point, I was sitting on the floor of the hearing room with my phone charging while I tweeted, and a kind staffer offered me a chair.  I didn't want a chair, but I did ask if he could get me a cold beer. 

I had prepared three minutes of testimony, but given the numbers, they cut the time to one minute. Everyone ran over, and the Chairman, Delegate Pete Hammen, sometimes let people ramble on, and other times, cut them off.  I thought he was incredibly rude and dismissive to me.  I seem to remember going to meet with him years ago, and that he was dismissive then --not to me specifically but to our psychiatrist group.  Is this my imagination or does he not like psychiatrists?  I think I felt like our readers feel when they talk about being dissed because they are psychiatric patients; I felt dissed because I was a psychiatrist.  I pointed out to him that I was the only person there not testifying on the Firearms Bill, I was talking about HB810 --mandatory reporting of dangerous patients.  He'd been more patient listening to  gun-owner after gun owner make one of the same 4-5 points about why they oppose the legislation.  Me, as the only one giving testimony on a different bill, he cut off repeatedly and was quick to dismiss.  In all fairness, it was nearly 9 pm and everyone was fading, some of the legislators had left, and  I can't imagine what they were like at 3 AM.  I did go over my allotted time and I did give my testimony as a story, not as bullet points, something I knew might be risky. The bill's sponsor had been in and out of the hearing room, but during my testimony, he was gone. 

There was on ob-gyn who testified in favor of the bill --one of only 3 pro-gun control advocates I heard --  and they were much nicer to her.  I guess on the positive side, someone in the room applauded me -- no one else was applauded while I was in the hearing room -- and one of the legislators said, while I was speaking, "That's why we shouldn't pass this."  So I guess it was worthwhile.  No one had any questions for me, but Hammen phrased it as "Any questions? Next." And they were all understandably a bit zoned out by that hour.  One person gave testimony that she'd been mistakenly diagnosed with a mental disorder and could never get a gun because no one would say the doctors at the hospital were wrong, and this was part of the Firearms Act.

By the way, when someone (? I think it wasn't one of the bill's sponsors, but I missed the introduction) described HB810, he described the three Tarasoff options and said this bill would require mental health professionals to tell the police if there was a specific threat against someone else. He proposed it as a tightening of the Tarasoff requirements, while the HB810 actually undermines Tarasoff.   In fact, the bill requires mental health professionals to report to the "Director of Mental Hygiene" : a nonexistent agency.  Perhaps they meant MHA or DHMH.  The Direct of Mental Hygiene then decides whether to tell the State Police for the purpose of preventing gun sales (so reporting to the FBI NICS database, I assume?), who then decides if they should contact the local police. 

As far as the expert testimony went -- the first 4 hours of the proceedings --Dr. Brian Zimnitsky from the Maryland Psychiatric Society did a great job, and an internist testified who also did a wonderful job-- he described that 1/4 of his patients have psychiatric issues and how hard it is to get people in to see psychiatrists, how many don't take insurance and how clinics aren't open late for people who work, and the long waits.  And he was very articulate about how the process to get your gun back doesn't/won't work because psychiatrists  won't certify people to use guns, either because they are liberal urbanites against gun ownership, or because they won't accept the liability.  Dr. Zimnitsky did a good job of re-iterating that with a little more detail about what it is we can do.  It was very confusing because the Firearms Act was the focus of attention, yet there were other mental health issues which got no space for discussion.  And most of the testimony was about the details of guns and assault rifles and statistics about how gun control effects morbidity and mortality.

Overall, Dr. Zimnitsky was the only psychiatrist, and there were 2 psychologists and 1 lawyer from the Maryland Disability Law Center -- in 4 hours of expert testimony, and the 4+ hours I watched of public testimony.  Is there anyway to get a stronger psychiatrist presence at the table?  These lawmakers clearly don't understand the issues, and I think it's hard because they seem to have their minds made up about psychiatric patients and either they are not open to learning, or we're not doing a good enough job explaining.  Even with the Emergency Petition issue that came up, it sounded like EP's happen when a doctor files one, and there was no mention of the fact that a family member or neighbor can easily obtain one, and then if the professional in the ER doesn't have enough information, they may want to hold a patient for a day or two to observe and clarify whether they are safe. In this case, a person will be deprived of a civil right without any due process. This was an 11th hour amendment that was brought into the Firearms Act on the night it passed the state senate.

There was nothing mentioned about doctor-patient confidentiality and how this is necessary for psychiatric treatment to ensue.  The point was made they times that using a 30 day cutoff for reporting would affect eating disorder patients who aren't dangerous, but I think the point should be that reporting voluntary patients forces physicians to violate the doctor-patient confidentiality that is necessary for psychiatric treatment it and  deprives people with mental illness of a civil right and that this singles out psychiatric patients as the only group of people who can be deprived of civil rights without any legal due process.  It's all terribly stigmatizing and may well serve the opposite of the intended effect: to leave people fearful of psychiatrists and less willing to get help.  And it's striking that HB810 only applies to mental health professionals and no other health care provider is being asked to report dangerousness.  I wasn't really sure by then end of all of it if the 30 day voluntary inpatient reporting was still part of the bill passed by the senate; it was twice mentioned that this had been removed.  We need to move the terminology from "the mentally ill" to "those who are dangerous" for any reason.

It's amazing that there is nothing about substance abuse, that you can go for eight rehabs, and still have your arsenal. 

In terms of actual safety issues, I think it might be helpful, though I imagine it's too late, to have a  process by which all physicians are "allowed" (as opposed to required) to violate confidentiality and the police are "required" to investigate and confiscate weapons then have a quick legal process that would ensue to return such weapons if they were confiscated in error.  This could be used for psychiatric patients, substance abusers, or simply angry, mean people who are making threats or behaving erratically.  And because it wouldn't be about just reporting to a database, it might serve as a mechanism to get guns out of the hands of those who have them illegally, something none of this legislation addresses.

If you read through all this, thank you.  Eleven hours yesterday and I needed to vent.  It was really fascinating and I'm so glad I went.

Now is the Time: Sebelius, Hyde, and Insel Begin National Dialogue on Mental Illness

HHS Secretary Sebelius held a public phone call on Jan 16 regarding the expansion of mental health (MH) treatment, especially for kids. This was the day after President Obama's "Now is the Time" [pdf] plan was released. The recorded 30-minute phone call is available until Feb 15 and can be listened to by calling 888-568-0013 (no codes or anything).

Here are some of the points I noted while listening:

• 60% of people with mental illness and 85% of people with substance use disorders do not receive help
• failure to receive help is largely due to stigma and people not asking for help [umm, what about failure to access help due to insurance barriers and inadequate and inaccurate provider directories?]
• Project AWARE to train 5000 MH professionals to help identify MH problems in school age kids
• to help eliminate stigma, she will be initiating a year-long "national dialogue" about mental illness, focusing on young people
• mentioned a Healthy Transitions program for young adults

Then SAMHSA Director Pam Hyde entertained questions from callers. My telegraphic notes are below:

• peer specialists (Pam called them "peer professionals")
• surrogate parents and their MH needs
• workforce issues
• correlation of violence w psych meds; toxic practices w/in MH; stigma of coercive treatment; fear guns removed w/o reason 
• veterans' advocate in Michigan: how do we determine who is at risk and who is not; removing vets' guns; how to reach people in gangs
• APRN public health nurse: expanding nurses' scope of practice to treat people with mental illness can improve access
• hope for expansion of voluntary, and not involuntary, treatment; "open dialogue" concept from Finland
• ACLU: training police to deal better w MH symptoms, esp in kids, so they don't enter the justice system
• NFFMH: concerns about cuts to existing programs for families

NIMH Director Tom Insel was also present, and said additional questions and comments can be sent to this email: externalaffairs@hhs.gov.

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. 

Florida Don't-Ask-Don't-Tell Gun Law Modified

Here's a follow-up to my March post about the Florida bill to outlaw physicians from asking their patients about access to firearms. Dinah later posted about the effects of the bill on pediatricians. The bill passed, though it was amended to remove the jail time and the potential $5M fine (a bit excessive?).

The Florida Medical Association originally opposed the bill, but now has expressed satisfaction with the compromise language. In March, Asher Gorelik, M.D., president of the Florida Psychiatric Society (FPS), expressed to Psychiatric News his membership's opposition to the bill, particularly “a great deal of concern about how this law would interfere with the ability of the psychiatrist to properly assess a patient.” But in a recent follow-up interview, Gorelik stated that the new language in the bill “no longer interferes with the ability of a psychiatrist to perform a risk assessment.

~Psychiatric Times

Those Privacy-Invading Pediatricians, Silenced!

A while back, Roy blogged about proposed legislation in Florida that would make it illegal for physicians to ask patients if they own guns. What the??? Since when do we legislate what people can ask each other, outside of discrimination issues for jobs? And is there any precedent for legislating the conversation that occurs between a doctor and patient? So apparently this is going to pass, and Greg Allen writes in "Florida Bill Could Muzzle Doctors on Gun Safety,"

Florida Gov. Rick Scott is expected to sign a bill that will make the state the first in the nation to prohibit doctors from asking patients if they own guns. The bill is aimed particularly at pediatricians, who routinely ask new parents if they have guns at home and if they're stored safely.

Pediatricians say it's about preventing accidental injuries. Gun rights advocates say the doctors have a political agenda.

Ah, it's not about us shrinks, it's okay to ask if there is a question of danger. It's about the pediatricians. Personally, I think the pediatricians should fight back: if they can't ask who owns a gun and target their gun safety remarks, they should give extensive gun safety instructions and literature to every parent at every visit. Perhaps as a statement of unity, all pediatricians in all states should discuss gun safety with every patient, no questions asked.

Doctors to Go to Jail for Asking Patients About Guns in the Home

Imagine the scenario where you are an ER physician, nurse, or social worker and a person is brought to the hospital by the police for making a suicidal threat.

"I want to die. My wife left me and our house is in foreclosure."--"Do you have any plans to harm yourself?""My dad shot himself when I was little. That's how I would do it."--"Do you have any firearms at home?""OFFICER! Can you arrest this social worker? He just asked me if I have guns at home."[officer]: "Come with me sir. You have the right to remain silent..."

This is the scenario that could actually happen if Senate Bill 432 passes in Florida. The bill makes it a felony to inquire about firearms access or to include any information about firearms access in the medical record, punishable by up to 5 years in jail and/or a $5 million fine. Excuse my French, but WTF?!

An article in the Psychiatric News by Bob Guldin explains that the bill was introduced in both the House and Senate at the suggestion of the National Rifle Association (NRA) to prevent intrusion into the constitutionally protected right to bear arms.

It has been shown that removal of firearms from the home reduces the risk of a completed suicide. So you'd think such a bill would get laughed out of the legislature? Florida child psychiatrist and APA Assembly recorder said, "This bill is not a stunt... the financial power of the NRA in Florida will make it very difficult for sensible legislators to vote against this bill."

I note that a second version of the bill has been proposed, one that reduces the fine to a minimum of $10,000 for the first offense and a minimum of $100,000 for the third offense. It also reduces the offense from a felony to a "noncriminal violation" and compels the states attorney to pursue a possible violation or face professional misconduct charges. This version does permit certain health care providers to ask the question only in certain specific situations (e.g., an emergency "mental health or psychotic episode") but cannot tell anyone else other than the police. Apparently, a similar bill passed one house in Virginia five years ago before dying.

Next will be a bill that outlaws common sense.

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Clink comments: We've talked about issues related to guns before here, in Dinah's post "Guns and the Mentally Ill" and again when I mentioned a poster session that talked about gun ownership laws nationally. At my last American Academy of Psychiatry and Law conference I mentioned that 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.

So now we have a dilemma: in states where you need a physician's certificate to buy a gun, how can that same physician then be banned from asking about ownership?? I can imagine the session in which a patient comes in to be "cleared" to buy a weapon.

MD: "Well, you're taking your medicine and your symptoms are all under control. You tell me you're feeling well and you'd like to buy that awesome weapon you've been dreaming about."

Gun buyer: "Yeah! I've done the research and I know exactly what I want."

MD: "I need to know whether you have cognitive skills and emotional stability to handle a responsibility like that. Tell me, have you ever owned a gun before?"

Gun buyer: "Awesome!! Now I can sue you for infliction of emotional distress for violating my Second Amendment rights. Those triple damages will really help me stock up my arsenal."

Bottom line: The NRA can't have it both ways. If they involve psychiatrists in restoration of gun rights, they can't ban them for asking questions about ownership.

Guns and the Mentally Ill

On Facebook, I'm a fan of NY Times Reporter Nicholas D. Kristof

Mr. Kristof's status reads today:

Nicholas D. Kristof

Just in case Pres. Obama visits my FB page, what should we suggest for his State of the Union speech? My hope is that he calls for banning oversize ammo magazines, like the 33-round one used in Tucson. Even Cheney favors a ban on them. And gun serial numbers that are harder to scratch out. And tighter restrictions on the mentally ill obtaining weapons. Your thoughts? Other suggestions for the President?

I'm not an NRA member (this is my disclaimer here) and I've never had much use for guns. But I had thoughts about the issue of "tighter restrictions on the mentally ill obtaining weapons."
I wondered what that meant and how one defines "the mentally ill." Oh, and my second disclaimer here is that I don't know how current regulations work in determining who is mentally ill with regards to purchasing a weapon. I've never reported to any central source any information about who I'm treating so they can't buy guns and no one has ever asked me to sign off on a gun permit. I'm not sure how it's determined that someone has a mental illness and shouldn't own a gun.

It doesn't take very much to get yourself into the range of being 'mentally ill.' Knock-on-door community studies, known as the ECA studies-- meaning Epidimeologic Catchment Area-- show that over half of all people have an episode of mental illness at some point. This includes phobias and anxiety disorders. NAMI tells us that one in five people have a serious mental illness.

Some of the people who commit crimes with legal guns haven't sought treatment. If you haven't gotten a diagnosis, how can you be designated mentally ill for gun ownership? Does gun ownership get designated by diagnosis? Certainly, owning a gun is not a great idea for a person with brittle bipolar disorder who gets violent and impulsive. But we all know that the diagnosis of 'bipolar' disorder has become a bit loose and over-inclusive. An angsty teenager sees a psychiatrist and is diagnosed with bipolar disorder. If he does well later, should he be forbidden from buying a gun at the age of 40? I believe one standard is a psychiatric hospitalization for over 30 days, but I'm not certain how--or if-- that's reported.

I suppose we worry about the Big Brother aspect here. Maybe instead of "mental illness" the standard should be that if college student is expelled, or an employee is fired, for certain behaviors then they are reported to a 'no-guns' data bank. Then you'd capture violent and threatening people who have not sought treatment but may well be dangerous. Oh, I'm just mouthing off here about something I admit that I know little about. But I hate finding one more thing to stigmatize mental illness over in a way that is not likely to effectively decrease gun violence.

Have a happy Facebook day, Mr. Kristof.

Any thoughts?