Tuesday, February 26, 2013

Texas: Never Too Sick for Death Row

Oy, if you're very sick and very dangerous, Texas is not the place to be. Oh, it never was and maybe it never will be.  

In Maryland, if someone is in the hospital and wants to leave, the vast majority of the time, they get leave.  If the staff thinks they should stay, they get to sign a leaving AMA form --against medical advice.  In rare instances, if a voluntary patient wants to leave, but they are felt to be imminently dangerous, then they can be certified, and held on the floor until there is hearing.  At the hospital where I did my residency, hearings were held on Wednesday when an administrative law judge came in for that purpose, so how long a patient was stuck there without 'due process' depended on what day of the week this went down.  In Texas, you can be committed against your will, but apparently as I've learned from yesterday's New York Times, if you've signed in, you can't be held and committed, no matter how sick, psychotic, and dangerous you are.  Really?  I'm back to my original thought: oy!

From Advocates Seek Mental Health Changes, Including the Power to Detain:

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it. 

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him. 

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them. 

He was on a mission from God, he said, to free their hearts of demons. 

What a travesty.   And here in Maryland,  yesterday a court sent a 15 year old boy, tried as an adult, to prison for life, commuted down to 35 years, for a school shooting / attempted murder.  The boy took his step-father's gun, which fortunately,  was not a rapid fire weapon, but a shotgun (I think), and before he could get too many rounds fired, a heroic teacher tackled him and the single wounded victim survived.  The boy left a suicide note, but his plan to die that day was foiled.  He's reportedly been improving with treatment in a county detention center, and he pleaded guilty to the charges, no insanity defense sought, no trial necessary, just a hearing for sentencing.  I won't comment on whether I think it serves society to send a child to prison with adults for 35 years.  

To those who oppose involuntary hospitalization under any conditions at all, I have to ask, what do you think should be done if you become so psychotic that you believe it's necessary to kill your own children and eat your own eyeballs?  In Texas, it's clear: you're free to do so and the state will just kill you. 

Sunday, February 24, 2013

Psychiatrists Don't Certify People to Use Guns.

Legislation is being proposed  in Maryland --- and I assume in other states as well --  that would require patients who have have had psychiatric hospitalizations to get a psychiatrist to certify that they are safe to own a gun if they want to apply for a gun permit.

Psychiatrists don't certify that people are safe to own guns.

That's it. End of sentence.  The states legislators may have decided that this is part of our training or our job description or that this should be our role.  Can you imagine anyone in any career ever authorizing that anyone is safe to own a gun?  Sign your name to that with the implied promise  that any person won't get too angry, won't get too depressed, won't feel too threatened, won't use the weapon appropriately (for example, to shoot an intruder) but when less force might have sufficed.  Can you even begin to imagine the liability issues?  Or worse, the guilt when the patient certified as "safe to own a gun" then harms himself or someone else?  Psychiatrists diagnose and treat mental illness.  They don't certify that people are safe to own guns.

We should just say No, we don't do that.

Friday, February 22, 2013

Tell Me What To Do

Note: As I was writing this post, Pete Earley reran a post he wrote in 2010 about this identical topic. Spooky! Please go over to his blog and read what he has to say about it here.

Now that states are moving to create registries of involuntarily admitted patients, I think the time has come to reconsider an old idea, specifically the use of of psychiatric advance directives (PADS).

For those who have never heard of this idea, a psychiatric advance directive is a form of durable power of attorney. It's a document that a patient creates which states the kind of treatment the patient would like in the future, if he becomes ill and loses the ability to make treatment decisions. The document may designate a person the patient wants to make decisions on his behalf---a person known as a health care proxy---or may just list the patient's wishes about various things. Here is a partial list of the issues that get addressed in a psychiatric advance directive:

- the choice of hospital the patient would like to be admitted to
- an affirmative statement requesting admission
- the types, frequency and dose of preferred medication
- consent for use of seclusion or restraint
- designation for care of children, property or pets
- person to notify or next of kin designation
- consent for use of electroconvulsive or ECT treatment

Of course, the obvious thing about this list is that there is an assumption that the person is using it to request treatment when ill, but it can also be used to document which treatments, if any, the patient wants to refuse.

But what if a patient uses an advance directive to refuse all treatment? Here likes the conundrum. What if the patient becomes violent or threatens someone else? What if the patient's condition deteriorates to the point that his life is in jeopardy? For example, someone who is catatonic and unable to eat or drink fluids? What if the patient is not dangerous or doing anything violent, but just needs supervision and nursing care (help bathing or dressing or eating) and can't live outside an inpatient unit? Should this person be allowed to stay in a hospital indefinitely (when there is a huge demand for psychiatric bedspace for voluntary patients) when a short course of involuntary medication might make them better enough to live independently, outside a hospital?

And what if the patient wants treatment, but the advance directive dictates a treatment that is experimental, ineffective, or even potentially harmful? Should an advance directive be allowed to contain a patient's request for medical marijuana? In some states, the treating psychiatrist is bound by law to follow the instructions in an advance directive and there are civil penalties for not following them.

Also, in certain cases an advance directive can be overridden by the court if the patient becomes dangerous to other patients. Depending on how the directive is written, it can also be revoked by the patient once he's in the hospital which makes the whole document rather pointless. Finally, many patients and doctors have either never heard of PADS or are not familiar enough with them to use them.

This is why I'm putting up this post now. I think the PADS have potential utility and are certainly better than the outpatient commitment laws that many states have (and that our state is considering). To keep things simple, let's start with the assumption that the patient actually wants to be treated when they are sick but loses the ability to make that decision. (In other words, the patient agrees with the treatment in retrospect---ie. "I didn't like it, but I know it had to be done.")

I'd like our readers to discuss this so we can figure out better ways to make them useful. Have you ever written or used a PAD (from either a psychiatist or patient standpoint)? What worked, what didn't? What would you like to see changed? How could it be improved? Do you have a better idea than a PAD?

If you want more information before commenting, here's a one-stop-shopping site for PAD information.

Thursday, February 21, 2013

How a Psychiatrist Predicts Violence

I am not a forensic psychiatrist.  I am a general adult psychiatrist, and ClinkShrink may have much more to add about such things. But with all this talk about potentially violent people and likely-to-be-violent people and legislation suggesting that psychiatrists should be the ones to determine if psychiatric patients are safe to own guns (no, no, please no...we treat mental illness, we don't certify people to use guns....) I thought I would try to demystify the process by which we determine if someone is dangerous.

For the routine, day-to-day shrink, we use two main measures of dangerousness:
~ History of violence
~ The patient's stated intent

If someone has never been violent and says they are not thinking about hurting themselves or anyone else, we assume they are not dangerous.

Are there other factors, or innuendo here? Of course, and other considerations may include:
~Substance abuse.  Substance abuse.  And substance abuse.  Substances dramatically increase the risk for violence.  Stay away from intoxicated people with weapons.
~The presence of factors that distort someone's ability to accurately assess reality, such as psychosis, dementia, or delirium. 
~ The patient says they have no thoughts about hurting anyone, but there are indicators that they are not being truthful about their intent.  Usually this is in the form of information presented by other people and we realize that the other party may be presenting information that has been misunderstood or distorted or meeting their own agenda, so we do our best.
~How well the evaluating psychiatrist knows the patient.  In an Emergency Room, there may be the tendency to err in favor of over-stating dangerousness because the doctor has no history with the patient and needs to make an admit vs. release decision fairly quickly and often with limited information.   They may decide to admit a patient and let an inpatient team observe the patient and gather more information.
~The patient's tendency to behave impulsively.
~Sometimes family history is considered, especially in patients with mood disorders and a family history of suicide.

The most common dilemma is that people will say they are having thoughts about hurting themselves (much more common then thoughts about hurting others) and they are uncertain about whether they will act on them.  If the psychiatrist knows the patient and knows that such thoughts are fairly common for this person, and that historically they have not acted on such thoughts, they may be more comfortable deciding the patient is probably not imminently dangerous than if the patient has a history of serious suicide attempts.

Is there magic?  No.  Are we right?  Sometimes.   

Tuesday, February 19, 2013

Registries and Registries

Gun Registries
Over on Pete Earley's blog yesterday, he had a guest post by Jessie Close who talks about her fears that some of the new legislation being proposed to keep guns out of the hands of the mentally ill may compromise her privacy.  Our readers have also expressed fears about what such legislation may bring, and some have said that if psychiatrists are mandated to report dangerous patients to authorities for the purpose of preventing or ending their gun ownership, they will drop out of treatment.  I wanted to respond to the post, but oh, registering and proving that I'm not a robot and waiting to see if I was moderated in or out were too much, so instead I shot Mr. Earley an email, and today I'm the guest poster on his blog.  See A Psychiatrist Speaks About Gun Laws on PeteEarley.com.

Bed Registries
And over on The Baltimore Sun's website, you'll note that another Shrink Rapper is talking about bed registries that would allow ERs to figure out where psych beds are available and to shorten how long patients get stuck waiting in ERs while the staff call around trying to find beds.  Our own photogenic Roy can be seen and heard in Hospitals Team to Find Beds for Psychiatric Patients.     And just in case that's not enough, Roy is also mentioned in a second article on proposed legislation to require hospitals to participate in the registry.  His quote of the day, "That kind of freaked everybody out."  

And in case you're wondering, the baby pictured above is looking for a toy registry, he is not interested in either owning a gun or occupying a psychiatric bed. 

Sunday, February 17, 2013

It's Not So Bad, Hon

Here in B'more, it's not uncommon for people to call each other "hon," especially strangers.  So the checkout person at the grocery store may well say, "Have a good day, hon."  It's kind of endearing.

So here at Shrink Rap we've been discussing some difficult things going on in psychiatry -- major changes in the way we code appointments -- I'll avoid the 3 letter acronym we've all come to dread -- and gun legislation that targets, and therefore stigmatizes, those with mental illnesses.  I, for one, have been among those ranting, and it's for that reason that I have a blog: I like to rant.

Our commenters have joined me in kvetching about changes and possible changes.  I have to say, though, that I don't think things are so bad, hon.

So I've learned how to use the new codes and I've learned to incorporate this into my practice so that I'm doing nothing different when I see patients, which is good, because I was worried that the new coding would force me to derail part of the session to ask questions or do things that are irrelevant to the individual patient's care, and so far they haven't.  I've computerized my progress notes, and the first couple of weeks were very painful. I was in the office hours longer each day, but now I have a rhythm.  What still hasn't been sorted out is how to code so that insurance companies will reimburse patients, and at this point it seems that some insurance companies are reimbursing significantly better, some are disallowing psychotherapy, and some don't even have prices assigned to the codes and have all claims as "pending."  Through our state listserv, we've engaged with the Insurance Commissioner's office, and at least they know there are problems.  But I do think that in a few months it will just be what we do and psychiatry will move on, hopefully with sustained and improved reimbursements.  At this point, I still think it was a bad move to do this -- more paperwork with unclear gains -- but it is what it is and I don't think this will be a devastating change for psychiatry.  If you're still confused, my YouTube tutorials have had over 2800 views, and when once it falls out as to what insurers will reimburse, I may do a quick and easy synopsis. 

Regarding upcoming legislation, I remain annoyed at the quick response of our legislators.  I've rejoined our psychiatric society's legislative committee, and I wrote an op ed piece in our local paper.  One commenter noted they didn't think it would do any good, but I remain optimistic that these efforts have some meaning.  Of course, no one wins all the time in going against a system, but last year Clink and I wrote a joint op ed piece opposing legislation to make marijuana legal, it was run the day the legislature voted, and it was defeated.  When my op ed piece ran last week discussing why it's a bad idea to mandate that psychiatrists report patients, I got a lot of emails, including one from one of the governor's appointees asking how I thought the Firearms Bill should be changed.  I may not win on my issues, but I'm planning to go down making a lot of noise, and I'm not at all hopeless. And if you have a cause or an issue, please, please: DO SOMETHING.  People who say "you can't fight the system," don't fight the system.  It's not always fun and it's not always gratifying, but at least you can say you tried and you might just make a difference.

At the end of the day, I still like my job, hon.

Tuesday, February 12, 2013

Bang Bang: I'm thinking about Gun Legislation and the Mentally Ill

The figure I've heard is 40.  Forty pieces of new legislation brought before the Maryland General Assembly this year pertaining to firearms.  Some of them specifically address issues of gun ownership and those with mental illness.  Others don't, but simply conflict with one another.  There's a bill that would make it a crime (yes, a crime) to ask someone who purchases ammunition for identification.  Another bill requires that those purchasing ammunition must present identification.  Nothing like having our legislators on the same page.  Please don't quote me on that 40 number, I could be wrong.

Personally, I wouldn't flinch if they repealed the second amendment and did away with guns for everyone.  I've got my curare darts ready to shoot at the bad guys, who needs a gun?  And really, who needs a high velocity assault rifle? People who buy guns may have the best of intentions: shoot Bambi for dinner, protect their families, be ready for that government-overthrowing militia.  No one buys a gun thinking the bad guy will wrestle it from them, they'll shoot themselves while cleaning it, they'll use it when they get into a drunken brawl, their kid will play with it and shoot a friend, their kid will take it to school and shoot someone, they'll fly off the deep end and go postal when their wife has an affair or a boss fires them.  And those mentally ill folks, they aren't "us," the gun owners would never get depressed and kill himself, that stuff happens to "other people," those mentally imbalanced folks who shouldn't own guns.  And of course, the onset of mental illness is predictable, to one can know at the time of purchasing a gun that they or someone in their family won't be affected.  I do hope you'll forgive my sarcasm.

I'm not sure why the Newtown killings spurred this.  Nothing we've heard indicates that these laws would have prevented that (I could be wrong, maybe the shooter was telling a psychiatrist about his plans and the psychiatrist did nothing).  The college student in Colorado had seen a school psychiatrist once (?) and then dropped out.  Do we want every kid who goes to a mental health center to be reported to the FBI?  If you wanted a poster child for gun control and mental illness, then the college student in Arizona who shot the Congresswoman and innocent bystanders may have been the right one-- his behavior was reported to be flagrantly unusual and he was banned from campus.  Perhaps if there were easily accessible databases of people who purchased ammunition, then when these people came to the attention of mental health professionals, they could have run a check to see if they owned guns and were stockpiling ammunition, and maybe that would have spurred preventive action.  But for the most part (and there are exceptions), our spree killers have not been people who would be captured by the current proposals: people who've been hospitalized for more than 30 days, who've informed a mental health professional of plans to kill, people who've been involuntarily hospitalized for being dangerous.  So why now?

Take away everyone's gun, it's okay by me, so why do I feel so strongly that we shouldn't pass laws that use mental health professionals as agents of the state to fill databases?  Because it stigmatizes those with mental illness. Because it may deter people who are dangerous from getting much needed help.  Because we're bad at predicting who is dangerous in the absence of a specific threat.  Because we have measure to deal with specific threats (we can warn the victim, notify the police, hospitalize the patient).  Those requirements don't bother me because they leave me as the agent of the patient -- as far as I'm concerned, it's never in my patient's best interest to do nothing if they tell me they are going to kill someone.  Bad for the victim, and bad for my patient to rot in prison for years.  But mandatory reporting of people I think might be dangerous for the sake of putting them in a database, well, I've told you, I'm not good at guessing. 

 If you wanted to pass a law that says that if a psychiatrist calls the police with concerns that a patient has a gun and might be dangerous and the police are obligated to follow up on this, that would be okay.  As is, we can request involuntary evaluation (we can't demand hospitalization here in Maryland), but sometimes there is little else the police can do.  But mandatory reporting of our suspicions for act that have not occurred?  And even though this year's mandatory reporting law includes an immunity clause, we've seen mandatory reporting laws in other states turn into criminal acts: if you don't report, you can go to jail.  Specifically, there are states where it's a crime for a doctor to not report suspected child abuse. It's a law that get proposed nearly every year in Maryland.

Okay, so I rant at Shrink Rap readers.  Today I also ranted in the Baltimore Sun in the hopes that our legislators might read it and think about the implications of these proposed laws.  Do visit the Sun website and read my article.  You'll note that I titled it "Reporting the Mentally Ill: Will this Really Halt Gun Violence?"  Somehow, the op ed editor was inspired to change the title to one that looks like I'm against any legislation that would keep guns from the mentally ill, and that's not true.  I just don't think the treating clinicians can be agents of both the patient and the state, and I believe that doctor-patient confidentiality is necessary for medical treatment. People may be safer if they're not afraid to get help, and the less barriers the better.

You'll tell me what you think, here, or better yet, on the Baltimore Sun's website where our legislators might see your thoughts.

Sunday, February 10, 2013

Why Am I Still Here?

It's a question I hear from time to time: "I've been in therapy for years.  How come I'm not better by now?"  

Okay, so psychiatric conditions are not like infections, at least not for some people; you can take a week of antibiotics and your urinary tract infection is all gone.   Your bipolar disorder may take a wee bit longer to stabilize.

~ Not only that, but this is something that's different for everyone, some people seek treatment for a single episode of depression, for a help coping with a stressful life event, or for help to change a maladaptive pattern, and they come for a short time, figure out what they want to figure out, and they're done.  In this case, it is kind of like a taking a round of antibiotics.

~Some people have intermittent problems and come to treatment for a while then stop, then return when the problem comes back.  It's kind of like seasonal allergies.  Or maybe like the infectious disease model, but the infection recurs.

~Some people have chronic psychiatric problems, along the line of "think of it like diabetes or another illness" and treatment continues for a very long time. For some, there's chronic titration of both medication and therapy to cope with life's issues when the psychiatric condition waxes and wanes but never totally recedes, or at least not for long.

~Some people have a chronic problem that requires medication, but they find they just do better if they keep up with some degree of regular therapy.  Therapy either gives them an outlet or a degree of support that makes it so the psychiatric problems don't relapse, or the relapses are more manageable.

~And finally, some people, whether or not they need medication, find that it's helpful to have someplace to process what goes on in their emotional lives.  If the patient doesn't have a psychiatric disorder, then you're welcome to raise questions such as to whether this is an appropriate use of treatment or whether it should be reimbursed by insurance, but I would contend that if having a place to process one's stuff makes it so that someone is a more productive, less distressed member of society, then should a decision to see a therapist be judged by others?  A variant of Socrates' thought that "The unexamined life is not worth living." (This is not to say everyone needs a shrink to examine their life in a thoughtful manner.)

Ah, you might say that our resources are scarce, that no treatment should be offered without "medical necessity" whatever that may mean -- it's a term invented by insurers to justify denying payment for a problem.  So let me put it this way: our sickest members are often our least productive members, even with treatment.  They take the most expensive medications, often get government disability payments, and may require expensive hospitalizations repeatedly, not to mention case managers and placement in day programsThey are clearly ill and one would would deny them careSo what about a rocket scientist or a neurosurgeon or a school teacher, who simply finds that talking to someone once a week or once a month, or whenever a problem arises,  enables them to be more emotionally comfortable, to understand and manage their interpersonal motivations in a way that gives them more control and makes life smoother and more productive -- might it be okay for therapy to continue without a definite endpoint?  What if insurance is paying?  Is this really "medically necessary?" and do we ask "medically necessary for what?" For optimal functioning and emotional comfort? What if the patient is paying out of pocket?  Or should psychiatric care go only to the sickest members of our society, a form of rationing to make sure the needs of our sickest members get met?

No, I don't encourage patients to stay forever, but I do believe that most people talk with their feet.  If they want to come less often, or call when there is an issue, I'm usually good with that unless there is a reason not to be, for example if they are still in the middle of an episode and notably symptomatic or having trouble functioning.  If they're well but want to stay in treatment and feel they are getting something out of it, I'm good with that, too. And I end most sessions with "When should we meet again?" just to be sure that the agenda belongs to the patient, and not the doctor.

Friday, February 08, 2013

Wednesday, February 06, 2013

On Publishing the Psychiatric Records of Those Who Can't Say No







Sunday, February 03, 2013

Happy Purple Thoughts

Happy Super Bowl Sunday!!!

For the first Ravens haven't been in the Super Bowl for 12 years, and so today is an exciting day in Baltimore and purple lights are up everywhere. 

My family members love football.  I love my family, and I'm sort of getting the hang of some of the football after years of exposure.  I know some of the player details, and the big ones for the day include the fact that the coaches of the competing teams -- The Baltimore Ravens vs. The San Fransisco 49ers -- are brothers.  A first ever for the Super Bowl and in psychiatry we call this the ultimate in sibling rivalry.  Ray Lewis, #52 (big guy on defense who tackles a lot of people) is playing his final game today, so winning a Super Bowl would be a nice way to end his 17 year career.  Joe Flacco's, the quarterback, father was quoted in the paper saying he's "dull" and I was shocked that a parent would publicly say this, but everyone else (including Joe, apparently) thought it was funny and it's rumored that Papa Flacco was quoted out of context.  Hoping Joe won't be dull today. 

For me, it's about the family and the tailgating.  The menu here will be tortilla chips with topping options: guacamole in large quantities, cheese (shredded and sauce), chili, lettuce, salsa, sour cream, beans, sauteed onions and peppers, and chicken wings with carrots/celery and bleu cheese dressing.  I think I've perfected the purple drink: prosecco or champagne with pomegranate juice and half a drop of blue food coloring served in a champagne glass.  The debate here is whether you can drink this before they win, and I say it's fine to celebrate the accomplishment of making it to the Super Bowl but apparently there is some superstition around this idea

The guest list is limited: we have a bitter Patriots fan visiting from New England.  The Shrink Rappers were not invited because I was limited to hard-core football fans who will keep quiet, concentrate, and respect the high-anxiety tension in the air.  "No psychiatrist asking if they got a home run."  The kids are scattered, but I'm expecting photos and texts during the game, and two of our guests have husbands and sons who will be at the game. 

Finally:  Go RAVENS!  (okay, I'm off to paint the dog purple)

Saturday, February 02, 2013

Put All Those Mentally Ill People Into An FBI Database, Stop Reimbursing Psychiatrists, Increase Access to Care, and Hey, Let's Decrease Stigma While We're At It!

Has anyone else noticed that there's a lot about psychiatry in the news, and all the messages are mutually exclusive?  In New York they've decided that a "SAFE Act" includes requiring shrinks to report anyone they believe is likely to be dangerous.  In Maryland, the proposed 2013 Firearms Act includes a provision to report all inpatients who are hospitalized for 30 consecutive days (voluntarily or involuntarily, dangerous or not) to an FBI database, and those who are found to be dangerous by a court are to be reported sooner.  And if the Firearms Act, as written now, passes and they take your gun, you can't get it back until a psychiatrist signs off by saying you are safe to own a gun -- a liability consideration few shrinks will be willing to accept.  And the Washington Post reported that another delegate plans to propose legislation that will require mental health professionals to report dangerous patients.  Funny, but only mental health professionals are required to report.  If you tell your urologist you're so pissed off you might harm someone, you still get doctor-patient confidentiality (and perhaps a specimen jar) with no obligation to report.  I'll limit my CPT code changes to a single sentence, but suffice it to say that many folks are having trouble getting reimbursed and are spending much more time on paperwork.  And yet as the media talks about rounding up all the dangerous mentally ill people, reporting them to...an unknown community service director or to legal authorities or to an FBI database, all with the hopes that this will decrease their access to firearms so we don't have any more mass shootings, and in the same sentences we hear about the importance of increasing access to care and decreasing stigma so that people will want to go for help.  Does anyone else think this is all kind of weird?  It's like the left side of the mouth is saying "run" while the right side of the mouth is yelling "stop."