Emotion versus Mental Illness

My favorite commenter, "Anonymous," wrote in to my Duckiness post to say that it was good I could post something totally silly without being told I need more meds. Oh, if life were that simple. And it is true that once someone has a diagnosis of bipolar disorder, not only does the world question their emotions in a black & white "are you sick again?" kind of way, but patients don't trust themselves to feel for it's own sake.

If you're not sick, then being asked if you took your meds is insulting and degrading. And so I thought I'd put together some guidelines for Emotion versus Mental Illness. I'm inventing this as I go, with no evidence-based anything, so take my suggestions at your own risk.

• If you are ultra-successful, rich, brilliant, gorgeous, famous, and comfortable with your diagnosis, you may want to consider telling people you have a mental illness because it decreases stigma and people like being with the ultra-successful rich, famous, brilliant and gorgeous and won't care that you have a mental disorder. It helps even more if you're charming.

• If you're not ultra-successful, you may want to pick and choose who you tell that you've been ill and are on medications. This isn't always possible, especially if your illness is evident to others or if the presentation of your symptoms resulted in a hospitalization. It's good to tell close family members.

• If multiple people are looking at you strangely, or commenting on your behavior, or saying you need medications, you might want to at least entertain the option that you could be sick. Unfortunately, poor insight and judgment are symptoms of mania.

• Tell the people close to you not to make medication jokes. It confuses the issue if you seriously do need medication changes, and it's rude, degrading, dismissive, and disrespectful. There, I said it.

• If you want to be silly, go for it. Be silly when you're well so that being silly is part of your baseline personality and no one equates this with being out-of-character. You'll note the duck invaders did not come after me, rather they said, "There's Dinah posting yet another stupid duck post." If I'd posted about why chocolate should be outlawed and made into a controlled substance, those same duck invaders would be asking "What's wrong with Dinah?"

• Mental illnesses come as constellations of symptoms. There is no "Sending out silly duck stuff" as a symptom. People think about mania when the ducks are combined with more energy, racing thoughts, a decreased need for sleep, increased mood OR irritability, and other symptoms of mania. Know the list and if someone bothers you, say, "I posted about ducks, I do not have any other associated symptoms." Recite them if necessary. If you do have the other symptoms, refrain from posting about ducks. I don't want Posts Duck Blog Posts to show up anywhere in DSM-V and these days you just never know.

• No one controls how any other person thinks of them or judges them and it's not reasonable to live life ruled by a desire to be perceived in a certain way . It's another form of poultry, but Don't Let the Turkeys Get You Down. There are a lot of turkeys out there.

Moods happen on a spectrum. Some people have large variations in their mood---large enough or severe enough such that it causes suffering, and we call it an illness. Some people don't have much variety to their moods and live in a calm, even-keel place, and it's great that we have such people. But, I absolutely promise you that if we lived in a world where everyone had a very narrow range of mood, this would be one terribly boring planet. We should celebrate our diversity, not condemn those who like ducky stuff.

Flower for Patients

A group of internet friends (what do you call people you know only via the net? peeps? tweeps? there have to be better words) have been talking over the last couple weeks (via Google Wave and also on Posterous and Skype about what we've been calling "Flower" or #hcflower on Twitter) about the changes that need to occur to reform health care.  One of the revolutionary -- and critical -- changes needed is the recognition that patients need access to their health data.  They not only have a right to access it, but should own it and be able to license access to it.  For a particular purpose.  For a particular period of time.  To particular individuals or organizations (my doctor, my hospital, my insurance company, my wife, my tweeps).

But that is not being much discussed in Washington.

One of these friends is Gilles Frydman, who also founded ACOR.  Click on his post on Open Streams and Fax Machines below.

-via Gilles Frydman on e-patients.net

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"Close to $2.5 trillions have been spent on health care since President Obama announced his decision to reform the health care system. A year later, as expected,  all the talk in Washington remains about:

• the end/restart/end-again of the public option
• the expected final/interim/temporary definition of “meaningful use”
• the amount of savings/taxes/additional expenses
• move from FFS (I really mean Fee-For-Service) to PFP and
• comparative effectiveness/death panels/healthcare rationing

Have you heard ANY politician talk about patient/individuals empowerment in relation to health care reform? I have not! Health care reform is still 100% about reimbursement reform and 0% about social innovation. No surprise when individuals so often experience dehumanizing events when they interact with the medical system."  [more]

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[photo credit: bestrated1 via Flickr]

Chinese Psychiatry and Internet Traffic for Blogs and Podcasts

I've been noticing lately that we get a lot of traffic from China. I guess that makes sense... it is only the most populous country on the planet. But, it is now clear that the internet has hit China in a big way. And opened its borders.

Above is a list of our podcast traffic for the first week in June. China is our #1 international source of hits. Most of these hits are image files (our logo) but there are quite a few podcast hits (though most are not completely downloaded). Most of the traffic comes from Baidu, which is China's version of Google. Baidu is, in fact, a competitor to Google, and is now China's Number One Son, accounting for 62% of all searchs in China.

While our podcast gets 500 hits per week from China, our blog gets no traffic from China. Zero. Not one single hit.

This suggests to me that China censors all Blogspot sites (or at least all the ones which might use the word psychiatry or mental), but they have no mechanism for blocking our audio content.

Of course, Psychiatry has had a difficult past in China. It has been used as a government tool for social and political control (I'm sure there are some in the anti-psychiatry movement who feel this way about American psychiatry). This 2005 article points out that raw capitalism may now be the dominant force in Chinese psychiatry now.

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.

Public Psychiatry and Free Speech

For those of you working in public institutions in this country, the United States Supreme Court ruled three days ago that you have no First Amendment right to job-related free speech.

In Garcetti v. Ceballos the majority opinion stated:

"When public employees make statements pursuant to their official duties, they are not speaking as citizens for First Amendment purposes, and the Constitution does not insulate their communications from employer discipline."

In this case an employee of the California district attorney's office, Richard Ceballos, came to believe that a sheriff had presented false information in order to obtain a search warrant. Ceballos prepared a memo and presented it to his supervisors, who decided to procede with the prosecution. Ceballos was later demoted and transferred in retaliation. He filed suit against the district attorney's office (one of the defendants was Gil Garcetti, supervisor of the O.J. Simpson prosecution).

Eventually the case wound its way up through the 9th Circuit Court, which ruled that his speech was protected under the First Amendment. The state appealed, and the Supremes argued the case twice, once on October 12, 2005 and again on March 21, 2006 after Samuel Alito was appointed. The opinion was split along the lines of the usual suspects: Kennedy, Roberts, Scalia, Thomas and Alito ruled against the employee protection while Souter, Stephens, Ginsburg and Breyer dissented. In his dissent, Justice Breyer recognized that certain professions have ethical standards which compel them to speak out under certain circumstances. For example, prosecutors have an obligation to disclose exculpatory evidence. He also cited a case familiar to correctional psychiatrists:

"So, for example, might a prison doctor have a similar constitutionally related professional obligation to communicate with superiors about seriously unsafe or unsanitary conditions in the cellblock. Cf. Farmer v. Brennan, 511 U. S. 825, 832 (1994). There may well be other examples."

Breyer favored constitutional protection for government workers under specific circumstances:

"Where professional and special constitutional obligations are both present, the need to protect the employee's speech is augmented, the need for broad government authority to control that speech is likely diminished, and administrable standards are quite likely available. Hence, I would find that the Constitution mandates special protection of employee speech in such circumstances."

The majority of justices ruled against this. They felt that constitutional protection was unnecessary given the existance of Federal and State whistle-blower laws, various labor laws and professional standards that mandate certain speech.