Dear Congressman Murphy: Regarding HR 3717

American Enterprise Institute, AEI, a conservative think tank, held a panel on Fixing The Mental Health System, What Congress Can Do.  I posted the discussion above, the talking begins at 12 minutes.  The panel is introduced by Dr. Sally Satel, and the speakers include:

• Congressman/Psychologist Tim Murphy who talks about legislation in Congress, HR 3717.  This bill pushes the federal government to provide more services -- a good thing -- and it also ties in requirements for Involuntary Outpatient Treatment (also known as Assisted Outpatient Treatment or AOT).  The New York Times has discussed this in Mental Health Groups Split on Bill To Overhaul Care.  

• Dr. Jeffrey Lieberman, the President of the American Psychiatric Society
• Dr. E. Fuller Torrey of the Treatment Advocacy Center
• Former Congressman Patrick J. Kennedy

If you'd like to watch the event, the video is above, if you want to read about it, read Here. 

I don't want to dwell on the issue of involuntary treatments today, but instead, I'd like to make some comments on H.R. 3717 The Helping Families in Mental Health Crisis Act.  I've read about the bill, I have not read the full text, but if you'd like to, it's here. 

Dear Congressman Murphy,

I'm no fan of HIPAA, as a physician, I find it makes it more difficult to get information from other clinicians.  Your point, however, that HIPAA prevents a doctor from getting information from a family is not quite right and you were more on target when you said it was misunderstood.  Physicians can listen, and families can talk, but privacy laws mean that physicians can't release information without the patient's permission.  Actually HIPAA defines all sorts of entities that can get medical information, but there is nothing in it that says a family member can't tell a physician about their concerns or relay past history.  Sometimes, clinicians refuse to release information to families or even other physicians, citing HIPAA, when in fact, they haven't specifically asked the patient for permission.  Sometimes doctors or facilities are lazy, sometimes they are misinformed, and sometimes they are afraid of being sanctioned or sued so they err on the side of being overly careful about whom they communicate with.  For the most part, I don't believe that doctors should release psychiatric information unless a patient consents to this.  Lets hope that everyone's judgement on these issues gets a lot better. 

In talking about access to care and a shortage of psychiatrists, because psychiatrists are in such demand, many psychiatrists have chosen to opt out of participating with health insurance.  I've written about that Here.  Part of the access problem lies with the fact that insurance companies either restrict patients to seeing in-network psychiatrists, or reimburse less if patients go out of network.  At the same time, insurance companies will list psychiatrists as being in their network when they are not, creating the false impression that the network has plenty of providers: see this Wall Street Journal Article.   So what about increasing the number of available psychiatrists by requiring insurance companies to reimburse the same for both in-network and out-of-network treatment when access to care becomes difficult?  If a family is told that the next in-network appointment is 6 weeks away, but an out-of-network doctor can see them the next day, should the insurance company really be permitted to save money and reimburse less?  And should insurance companies be permitted to have "Usual and Customary" rates that are far below the community standard?  And perhaps if Medicaid and Medicare would reimburse for out-of-network services (they don't), the number of treatment options might open up. 

Finally, you talked a lot about the standard of "imminent danger" as being too high standard for hospitalization.  That's all well and good, and I agree with you that we shouldn't be waiting for metastatic disease (as your comparison mentioned) to begin care, on an inpatient unit if needed.  But it's not just about that standard of care for forcing treatment, it's about what insurance will reimburse for.  Have you ever tried to admit a patient to a hospital?  Insurance companies generally will not authorize treatment for psychosis alone.  The only level of illness that they will authorize inpatient care for is the same level that one needs for involuntary commitment: imminent dangerousness.  So you can drop the level of illness it takes to get a patient admitted -- and I presume you mean by allowing for involuntary treatment -- but does it matter if the law changes to a "need for treatment" standard if insurance companies don't agree that the patient needs treatment?  I asked a woman the other day why she didn't sign herself in voluntarily after a serious suicide attempt -- she was being transferred from an ICU and was distraught that she was being 5150'd (California lingo).  She told me the doctor said the insurance company wouldn't pay for the admission if she wasn't committed, otherwise she would have signed herself in.    One ER psychiatrist I know was asked by the insurance company if the patient's gun was loaded.  Does that matter?    If the Navy Yard shooter had been brought to the hospital by the police, as he should have been, they may well have let him go if it was believed that insurance wouldn't pay for an inpatient stay.  And while severely mentally ill people may have higher rates of violence, studies have shown that treatment deceases violence.  In fact, patients who are seen weekly after a hospitalization are half as likely to be violent as the general population -- voluntary treatment makes a big difference.  But getting that level of care for our patients in the public mental health system only happens with the few who get put with Assertive Community Treatment teams. 

One thing is clear, before we start forcing care, let's make sure there is even care to be had, and that those who want it, or can be encouraged to get it, have a means to do so. 

Book review: Viviane (a novel)

With thanks to Jed who thought I'd like this novel.

Take a deep breath before you get on this ride.  The twists and turns come fast, and the trip is short, but memorable, with moves that made me gasp.  So short, it's almost more of a novella, and that's good because a ride like this is compelling for hours; I'm not sure I'd want to be on long journey.  

Viviane is dark and mysterious, the psychologically-laden plot pulls the reader along quickly, and if that's what you're looking for, stop here before I move you to plot spoilers.  It's a first novel by Julia Deck, translated from the original French by Linda Coverdale.

Very quickly, we learn about Viviane.  She is 42 years old and she has a 12 week old daughter, a peaceful baby who seems to never want for very much.  Viviane is the public relations officer for a concrete company, and her husband Julien can no longer stand being married to her; he's having an affair and "it isn't even from love but from despair."  He wants to leave, he needs air, but instead, Viviane leaves and moves into her own apartment.  Then she goes to see her psychoanalyst and kills him.  We are now on page 8.

The circumstances that led up to the murder of the psychiatrist are described.  Viviane was struggling.  Something needs to be done, I can't take it anymore.  Doctor, you're not listening to me.  He is insensitive, he implies that her problems are her own fault.  You'll take these pills for a few months, you know, the antidepressants, plus the ones for when your nerves give way, they help stabilize the hysteria.  She stabs him and leaves, taking the knife with her.

Viviane then proceeds to stalk, meet, and talk with those suspected of murdering the psychiatrist: his pregnant lover, his widow (who lives with her own lover), a young patient with a history of violence.  She doesn't just stalk the patient, she sleeps with him.  We learn about how her husband's lover was the woman who took her job while she is on maternity leave, how jealousy strikes her, and how she can't let go of dead mother's apartment.  All the while, Viviane is searching, and the reader (or this reader, anyway) waits to understand what could have motivated her to commit murder.  She is not, it seems, delusional. But Viviane arranges to meet Julien, and she stands back and watches him, not letting him know she is there.  This is her end, her part from sanity, and she lands in a hospital, where she confesses to the murder.  She is moved to another facility, one for longer term care, and oddly, the baby goes with her.   Oh, but the end comes with a jarring twist, and all we thought we knew was not to be, the entire landscape shifts from under us. 

That is the thing with this novel, it is constantly shifting.  The language is dark and we feel a distance from Viviane who remains an unknowable person, even as we move closer to know more of her, then farther away to see she is truly a stranger.  As we move in and out,  the point of view constantly shifts: at one moment the story is being told in first person singular, and the next moment it shifts to third person, or even second person.  In French it must be more intriguing, because there is the second person pleural, or formal, tense, one that can't be bridged in the translation to English. (Reviewer's note: finally!  Those years of college French I sat through, that evaporated from my brain no sooner than I left the classroom, have finally served some purpose.)  This constant movement feels odd, quirky, and most unusual.  It parallels the ever-shifting sense of reality that the book creates, where we don't know whose story it is, what truth is to be had, or where it will all stop.  A truly unique ride. 

Thank You, Pete Earley

Lots of good stuff on Pete Earley's blog lately.  He has a blog post up today with a video of hours of Congressional testimony on the topic of "Where have all the patients gone, examining the psychiatric bed shortage. This will be taking up some of my free time over the next days as I plan to listen to it all. There's also a video of the talk Virginia Senator Creigh Deeds gave at the National Press Club about access to care and his tragedy with his son.

Pete was also kind enough to put up a post for me.  I'm interested in talking to families for my book, and I asked my colleagues who are active with NAMI if any of the NAMI families might be willing to chat with me.  Pete's post resulted in calls from all over the country.  I heard from several parents with children who have been terribly ill, in and out of hospitals and jails,  stories filled with heartache.  One woman spoke at length about her son who has been ill for decades, and then mentioned that she'd also committed her daughter for a post-partum psychosis.  She thought the daughter was still angry about it, but when she told the daughter she was going to talk to me about committing others, the daughter said, "I hope she's in favor of it," and this was the first she realized that the daughter was glad she'd been forced to get treatment.  The son is still struggling, the daughter is doing well, working and raising her children.  One woman called to tell me her distress about being committed, and as we talked for a while, I told her I didn't think she'd actually been committed as there had not been any court hearing.  By the time we hung up, she told me she felt better and maybe it was time to let go of some of her anger.  Another woman who was distressed about having been hospitalized was upset because she felt the doctors should have been more aggressive about looking for physical reasons for her psychosis, and they missed her exposure to toxic occupational chemicals.  One woman told me of her child's struggles with illness and treatment, and about how helpful Assisted Outpatient Treatment had been in keeping her well.  At some point the patient had come to realize how much better she felt without her delusions and hallucinations and now she gets treatment willingly.  Finally, a man called to tell me about his struggles with schizophrenia.  He was hospitalized once decades ago, has never missed a dose of medication, and has been able to enjoy a full life, but his brother, who also has schizophrenia has resisted treatment and has been in and out of the hospital (he guessed 40 times), jail, and has lived on the streets, and never able to work.

It's been helpful to me to hear these stories, they add to what I know from my own experiences, and to the stories that our readers have been writing in our comment sections for years.  I'll ask that if your story is different than those I described, that you respect  that someone else might have had a different experience than yours and that you not write in to criticize or question the story that someone else relayed.  I only spoke to these people for a little while, so I don't know every nuance of their care,  but what I do know is that some people found involuntary treatment to be helpful for themselves or their family members, and some did not.

 

Can You Make Docs Be Nice?

Today's post, called Legislating Kindness, can be found on our Clinical Psychiatry News column.  
Please surf over there for the post.   

They no longer have commenting ... I don't know why that is...but please come back here if you want to say something. 

In Their Shoes

There was an op-ed in the New York Times recently by the Executive Director of the Colorado Department of Corrections about the 23 hours he chose to spent in solitary confinement (ad seg, I think is what our forensic friends call it) --- see "My Night in Solitary Confinement."  

In a similar experiment, psychiatrist-blogger Simple Citizen spent a day going through the motions of being a patient on a Residential Treatment Unit where he is the psychiatrist.  He details his experiences in "My Day as a Patient."

I don't believe these experiences are anything like the real thing, nor do I believe they are meant to be.  For one thing, the person having them has not gone through the lifetime of events, traumas, distresses that led the inmate or patient to be in those places.  Or in the case of the patient, the doctor also is not experiencing both the internal discomfort that comes with the mental illness, or the side effects which come with the medications, or the emotional upheaval that comes from having been left there by their family, and the insecurities that come with being a teenager or any brand.  And they both get to go home.  Why, Dr. Simple Citizen, do the kids have to stand on line facing straight ahead without talking while they wait for breakfast?  What's wrong with talking?

Still, I like that these people did this, it's good that they want to try to understand what their charges are going through.  Even if it's not a complete understanding, it still acknowledges that the condition is different with a willingness to see and understand what the other is going through, for better or for worse.  

On a completely different note, Simple Citizen pointed me to his post by mentioning in our comment section that he used to work at an involuntary state hospital.  What's an involuntary hospital?  I ask because Clink has pointed out to me that the rates of patients in public facilities varies greatly, state by state, for involuntary hospitalization.  Wait, so there are facilities that only take involuntary patients?  In our state hospitals in Maryland, at this point, the vast majority of beds are for forensic patients-- you get there by way of a judge.  If you have a chronic, severe psychiatric disorder requiring long term treatment which you'd like to get voluntarily, you're out of luck, we don't do that.  Or if you have a chronic, severe, intractable condition which makes it so you can't live in the community, you may have no where to go.  But when we did have state hospitals, many of the patients were there voluntarily, and some got better and discharged in a matter of weeks.  So I'm perplexed about a hospital that only has involuntary patients, what if they want to sign in?  Help me out here, Simple Citizen and others.   

How Does That Make You Feel?

It's the quintessential shrink question.  And what if you do if you don't know how something makes you feel? Is it really healthy to suggest that people spend so much time focused on their inner world, thinking about their mood, and how the events of their life make them feeeel?  Well there's good techy news, now there's an App to tell you how you feel!  No more introspection necessary, blow up those mood charts, just ask your phone and then you can report to your shrink!  From today's Wall Street Journal:
"App Tells You How You Feel," by Amir Mizroch.  

Mizroch writes:

TEL AVIV—Beyond Verbal Communications Ltd., a voice-recognition software developer here, is rolling out an app promising something Siri can't yet deliver: a readout on how you're feeling.
Called Moodies, it lets a smartphone user speak a few words into the phone's mike to produce, about 20 seconds later, an emotional analysis. Beyond Verbal executives say the app is mostly for self-diagnosis—and a bit of fun: It pairs a cartoon face with each analysis, and users can share the face on Facebook FB -0.34% or in a tweet or email.

Oh, but wait, no good thing comes without a cost, and with technology, we get to worry about privacy issues.  Mizroch goes on: 

These companies say the tools can also detect fraud, screen airline passengers and help a call-center technician better deal with an irate customer. And they can be used to keep tabs on employees or screen job applicants. One developer, Tel Aviv-based Nemesysco Ltd., offers what it calls "honesty maintenance" software aimed at human-resource executives. The firm says that by analyzing a job applicant's voice during an interview, the program can help identify fibs.

That's raising alarm among many voice-analysis experts, who question the accuracy of such on-the-spot interpretations. It's also raising worries among privacy advocates, who say such technology—especially if it is being rolled out in cheap, easy-to-use smartphone apps—could be a fresh threat to privacy in the digital age.

 Ugh, I may need to stick with the old introspection thing.  Hopefully your phone has told you that this post was written "tongue in  cheek."    

Pardon the Interruption

I've mentioned it before, but Clink and I are working on a new book.  Today, it the book-to-be is titled is "Committed: The Battle Over Forced Psychiatric Care."  I've started the process of meeting with people, interviewing, shadowing -- it's my mid-career crisis of being part-Shrink/ part-journalist.  Blogging, in the coming months, may be a bit less frequent, and may be more focused on involuntary treatments, because that's what I've been thinking about.  

So for yesterday's headlines here in Maryland, do read "Legislation Pushes Involuntary Mental Health Treatment" from yesterday's Baltimore Sun.  I went to listen to one of the Senate Committee hearings on some of the legislation -- the hearing room was packed with dozens of people there to give testimony and emotions running high. 

Should Insight (or "Anosognosia") be Considered in Involuntary Outpatient Treatment Orders?

Today's post can be found over on Clinical Psychiatry News where I address a NAMI member's concern's about anosognosia and forced outpatient care.  

You may want to read the article she was responding to first, and do check out the comments on that article:

Is Forced Treatment in our Outpatients' Best Interests?

 and today's post: 

Insight and Involuntary Outpatient Treatment

By all means, return here to tell us your stories about AOT. 

TED talks

In case you're interested, I hate to exercise.  I mean I really hate it.  I do it anyway, in what's hopefully not a misguided belief that this is good for me, but I will be very unhappy if they ever decide that exercise is bad for you, having already devoted so much of my time to something I dislike.  In any event, I've asked friends for suggestions for TED talks that I can listen to while I exercise, something to help the time pass as painlessly as possible.  I was told to watch Einstein the Parrot, and if you haven't, Einstein was very entertaining, and I'm told I was cackling on the elliptical today.  Here is a link for that short and amusing TED talk:

http://www.ted.com/talks/einstein_the_parrot_talks_and_squawks.html

The other TED talk I listened to today was given back in 2001 by surgeon/writer  Dr. Sherwin Nuland when he talked about his own experiences with Major Depression, psychiatric hospitalization, and electroshock therapy.  I've embedded the talk above, and I hope you find it as moving as I did. 

Finally, if you've never heard Elyn Saks talk about her struggles with schizophrenia, I highly recommend Elyn Saks : A tale of mental illness from the inside. 

And by all means, I'd love to hear which talks you enjoyed.  There are many more hours of exercise to come.

Are Psychiatrists Evil?

 

I want to point you to a psychiatry blog I happened upon not long ago, In White Ink, written by psychiatrist Dr. Maria Yang.  There was a post that moved me, and I went to comment, but there was no place to do so. 



Now, Dr. Yang is in the process of moving her blog and she's put up a post about My Brief History on the Internet.  My favorite part of the post is where she marries one of her blog readers!

Dr. Yang writes:

I started meet­ing peo­ple who read my writ­ing online. The inter­net was a dynamic and excit­ing place.
I started feel­ing ambiva­lent about writ­ing online. I closed down com­ments because anony­mous peo­ple left state­ments like, “ALL PSYCHIATRISTS SHOULD DIE” and “YOU’RE A PSYCHIATRIST, YOU KILL CHILDREN”. A physi­cian who wrote a blog under a pseu­do­nym was revealed in court. I wor­ried that my writ­ing wasn’t fic­ti­tious enough, that maybe my sto­ries weren’t purely coin­ci­den­tal. My mind gen­er­ated cat­a­stro­phes: Some­one might read a story and think I was talk­ing about them! They would sue me and I would lose my license! Other doc­tors would judge me! I would never recover! Even if I did, one of those com­menters who hate psy­chi­a­trists would then kill me!
So I shut down that blog. The inter­net was a scary and dan­ger­ous place.

At Shrink Rap, we've been to all those places, since we started blogging in Spring of 2006.  We do have the best of readers, who are bright, articulate, and thoughtful, and we don't get death threats or personal accusations, but part of this post resonated for me.

What we do see a lot of in our comment section are stories about people who are, from their point of view only (the psychiatrist's side is never solicited) who have been mistreated by the mental health system.  I like getting the links, because I do like to know that these issues are out there.  What I don't like, is the insistence that the patient is always the victim of the evil psychiatrist, that they played no role and if they behaved in an aggressive way that provoked unwarranted treatment, then it's obviously because the evil psychiatrist was not listening to their concerns and any reasonable, mentally well, human being would respond in such a fashion.  

If that's not enough, then commenters go on to talk about how psychiatrists are all about "power trips." Trust me on this, any day a psychiatrist calls the police for an out-of-control patient, it's BAD day.  There's no, "Honey, what a great day, I got to call the cops and commit someone." It's traumatic, upsetting, and draining for the psychiatrist.  And, I'm well aware that it's traumatic, upsetting, and draining for the patient, and no doctor likes to upset their patients.  It's a much better day when things are congenial and patients like the ways we have of helping them.

Personally, the psychiatrists I know -- who are all just people with the same types of flaws and imperfections that all people have -- really care about their patients, respect them as human beings, and are interested in working with them collaboratively.  I get insulted when readers insist my career is about power trips and that I'm wrong to say we shouldn't revel in the stories of patient victimization without knowing the full story.   I'm not saying that psychiatrists don't make mistakes, or that their aren't bad psychiatrists, and I'm certainly not saying that there are not bad laws out there, but I am saying that our field is not about evil people (they are the exception, not the rule), and power trips. One should reserve judgement when all sides can't weigh in.  A psychiatrist simply can't tell his side of the story to the media.  "I was hospitalized unjustly!"  can't be countered in the media by a psychiatrist saying, "He insisted he was going to kill his family."   

What I'm lost for is why the "Psychiatrists are Evil" crowd congregate here at Shrink Rap.  Do they think that the incessant drumbeat of "psychiatry is evil" in the comment section of a blog changes the world?  It doesn't, it just annoys the bloggers and adds to this odd notion that a therapeutic relationship with one's doctor is adversarial, when we see it as being collaborative.  It's exhausting and eroding.  I believe that if the commenters want to change the world, they should start their own blogs for like-minded readers, and when they believe someone has been victimized by bad laws, they should write the newspapers and legislators in those states and protest the bad laws.  The comment section of Shrink Rap does nothing, nada, zilch. 

Jeffrey Swanson, PhD, Lecture on Assisted Outpatient Treatment as Crisis-Driven Law

Outpatient Civil Commitment: Coming to Maryland Soon?

Today's blog post is over on Clinical Psychiatry News.  See Dinah's article summarizing a lecture on outpatient commitment, guns, and more, by Duke sociologist Jeff Swanson: Here.

As mentioned, Delegate Murphy in Maryland has proposed a bill legislating Outpatient Civil Commitment here in Maryland.  The text of the HB 767 is here.  In it's current form, the bill is not likely to pass.  Please remember, before you comment, this bill was written by a legislator, it is not coming from psychiatrists. 

On another note, there is another editorial by Dinah on Psychology Today's website about defining mental illness.  It's not much different than the piece on Clinical Psychiatry News a few weeks ago, and with this, the topic of the Who Are the Mentally Ill? survey is now done.  

Should it be a Crime for a Therapist to Have Sex with a Patient?

Currently, there is a bill before our state legislature [video testimony] that would make it a crime for a therapist to have sexual contact with a patient.  I wondered what our readers think of the idea of criminalizing sexual contact between a therapist and a consenting adult patient.

• As it stands now, we all agree that it is unethical for a therapist to have sexual contact with a patient.  Therapists are licensed to practice by professional boards (medical, social work, nursing, psychology), and all of these Boards handle complaints about sexual contact.  They are difficult cases, because often the cases are one person's word against another's in a setting where there are no witnesses and no "proof."  The sanctions include the loss of professional license, either permanently or temporarily, sometimes requirements for counseling and/or supervision, and a record of disciplinary action in a professional newsletter and details of the proceedings on the internet.  The process includes a hearing, and the standard to sanction a therapist is lower than the standard of guilt for a crime.  And finally, therapists are sanctioned for behaviors that are not generally considered "crimes," including any type of physical contact inappropriate to the therapist-patient relationship, even if the patient has been the one who requests the contact.  So a therapist can be sanctioned for letting a patient sit in their lap or hold them if the patient insists this is what they really need, and the psychiatrist can permanently lose their license if a patient seduces them -- and we all agree that this is how it should be, the therapist is the one who is supposed to hold the boundaries. The ethics of the situation are dictated as such because the therapist-patient relationship involves an imbalance of power. 

• There have been references to patient-therapist contact as "sexual assault."  Any type of forced sexual contact is a crime.  The new law would extend the issue of criminalization would include contact with to competent, consenting adults.  (I don't know the legal code, but I do assume it is already a crime to have sex with a compromised patient-- one who is psychotic, delirious or demented, just as it illegal to have sex with a "consenting" adult who is compromised at a frat party).

• Obviously, sexual contact between an adult therapist and a minor is already a crime.

• A patient who feels injured by a sexual relationship with a therapist can also file a civil malpractice suit against the therapist. 

Here are my thoughts, and then I'd like to hear yours:

• Using patients for sexual gratification is absolutely unethical.  To deem such behavior with a competent, consenting adult to be a crime seems to me to say that the patient is not capable of any role in making the decision.  It feels like it infantilizes the patient and I wonder what else this means that psychiatric patients are incapable of deciding?  
• Do we extend this to other situations where there is an imbalance of power-- so does it become a crime, punishable by jail time, to have sex with an employee ?  Or an adult student?   What about a patient who is not in therapy? (It's unethical and a cause for Medical Board investigation for any doctor to have sex with any patient).  What if a surgeon has sex with a patient he knows has a psychiatric disorder?  Should that be a crime, rather than an ethical violation?
• It's a tougher standard to put someone in jail then it is to remove a professional license.  In settings where "proof" may be difficult, especially since patients often come forward years later, will therapists be found "innocent" (because the evidence is not strong enough for criminal guilt), only to go unsanctioned? 
• The patient needs to testify in these hearings and such testimony in a closed hearing before a professional board may be easier for patients than hearings in an open court with an aggressive cross examination.  Are there patients who would file a complaint with the board (this can be done on-line) who would not come forward if it entailed a police investigation and all the scrutiny that entails?  Again, might unethical therapists go without censure?  Will the police simply shrug, say there's no evidence if the event happened years before with no witnesses, and not prosecute?

What do you think? I understand that some states already criminalize sex with therapists.  How is that going?  How do these states divide what is matter for the police from what is a matter for their professional boards?

In the Public Interest

When does some public good override psychiatric confidentiality? Dinah's post yesterday outlined the recent issue in the Navy's public release of the shooter's psychiatric treatment information. I wrote about this issue before following the release of the expert behavioral analysis panel's report on the suspected anthrax mailer, Dr. Bruce Ivins. In both cases, the rationale for releasing detailed information about the decedent's psychiatric care was cited as being a need to ensure that the government was taking appropriate steps to safeguard public safety. Following release of the EBAP report, the government---without admitting fault---agreed to pay 2.5 million dollars to the widow of the first anthrax victim.

As I commented on Dinah's post, in Maryland there is an extensive list of statutory execeptions to medical confidentiality:

• with a patient's written consent
• upon receipt of a valid court order or subpoena
• in emergency situations
• when a patient is dangerous
• in cases of child abuse
• during civil commitment proceedings
• when the clinician is under investigation for fraud, abuse, or other criminal activity
• when the patient puts his mental state at issue in a civil or criminal case
• during hospital review, for quality control
• when billing for payment, with patient's written consent
• in case of an HIV-positive patient's high risk behavior
• when the patient is incarcerated in an adult or juvenile correctional facility
• when an involuntary patient elopes from a hospital
• if an interested party files a missing persons report on a patient
• if a patient is being served legal notice (process servers)
• as part of a death investigation (release to medical examiner)

That last bit, death investigation, is what allows a facility or institution (or government branch in the case of the Navy shooter) to access postmortem records in most cases. Internal quality control and quality assurance are necessary processes that any health care system has to have. That being said, the results of a morbidity and mortality conference are not typically public documents.

In the case of the anthrax investigation, the EBAP report was originally sealed which meant that the report could not be read or redistributed by anyone without an explicit order from the court. The FBI, through the Department of Justice, was able to have the report unsealed. The results of the investigation were announced at a press conference and the report was put up for sale on the internet. Although the panel was careful to state that information drawn from medical records was redacted, the report gives explicit descriptions of Dr. Ivins' treatment history and psychiatric issues and strongly implies he had several motives to commit the crimes, although he was never indicted or convicted.

The parallels to the release of the Navy shooter records are a little uncanny. In both cases, the rationale for releasing the information is to address public concern that any preventive steps that could have been taken, were taken. However, there is also a strong whiff of CYA in both cases. After incorrectly accusing Dr. Steven Hatfill as the anthrax mailer the government was under pressure to close the case. After the EBAP press conference many media outlets published stories that Ivins was, in fact, the perpetrator.

Postmortem review is a necessary part of any health care system. However, I think we need to be clear that public release of that review should be subject to more stringent limitations.

Should Medical Records be Released to the Public Online?

With the adoption of electronic medical records and the advent of CRISP, Maryland's centralized collection of health information (it's an opt-out, if you haven't, you're in it, and if you opt out, they still get your info, they just don't release it), I'm coming to accept that there is no medical privacy.  Before you get distressed, the system does not include physician notes -- it's tests per the labs, medications per the pharmacies, radiology reports, and perhaps hospital discharge notes.  I'm  not aware of any psychiatrists who are feeding information into the system, but if you're in Maryland and you're filling a prescription for a psychotropic, or getting a lithium level done, it goes into the system.  Most doctors still can't access it, and the Emergency Rooms says the information is invaluable,  in situations where people don't know what medications they take or what tests they've had, the information can be lifesaving.  I, personally, wish that the system included patient consent, and some type of first-visit access grant, such as a ATM card with a PIN number, so that patients could be certain that only the people treating them have access to their records.  Among the thousands of authorized users, misuse of the information is limited only by the honor system, and the fear of repercussions if caught. 

With that as a prelude, The VA has posted the medical records of the Navy Yard Shooter on line, with the names of the doctors redacted.  The VA or AP did not feel inspired to redact the shooter/patient's name in the statement that was made in their release statement, but I have redacted it for our blog in abiding by our Shrink Rap policy to not use the names of mass murderers for fear that the publicity they receive creates a reason to commit such atrocities.

"The Veterans Affairs Department agreed that the public interest in the mass killing outweighed [the Navy Shooters’] privacy rights in keeping his treatment records secret after his death."

The shooter is dead, his actions destroyed the lives of many, the tragedy is obvious. But is "public interest" (meaning 'curiosity')  a reason to reason to forgo the usual ethical requirements established by the AMA  before scanning someone's medical/psychiatric records onto a public website and releasing them to the Associated Press? What do you think? Perhaps the public has a right to know, but perhaps a summary? Where is the precise line for public interest versus personal health privacy?  What other lines might be drawn?