Monday, January 26, 2015

A Quick Guide to Identifying the Mentally Ill for Puposes of Preventing Gun Violence.


I often hear people talk about how we have to keep guns away from the mentally ill.  A judge friend recently said it quite bluntly, "What's the issue with guns and the mentally ill?  They shouldn't have them." A cousin posted a link to a story about a man who killed his family and then himself.  Cousin commented, "We have to find a way to keep guns from the mentally ill."  The article mentioned nothing about a history of mental disorder or psychiatric treatment or distress in the man who killed his family and himself; people were shocked, there was no clear motive, the gun was owned legally.  Granted, by the time you kill your family and yourself, there may well be a mental illness leading you to this, but people say "Keep guns from the mentally ill" as though they wear signs indicating who they are.  Sometimes, the first clear indicator that mental illness is present is an act of violence, often a suicide attempt or worse, a completed suicide.  It's all awful.

So I thought I would help here with some guidelines as to how to identify those with mental illness so we actually can do a good job of getting their guns.  Here would be my criteria for labeling people so that we could prevent mass murders and other atrocities:

~Anyone who has a been civilly committed to a hospital for a suicidal or violent act.
~Anyone who has been civilly committed for threatening such things/ saying them/ or thinking them.
~Anyone who has been voluntarily in a psychiatric unit, even if not acutely dangerous right now, there is clearly a mental disorder present.
~Anyone who has seen a psychiatrist or therapist. To get reimbursed for these services, you need a DSM code to submit, so all these folks are mentally ill.
~Anyone on Social Security Disability for a psychiatric reason.
~Anyone who has gotten a psychotropic medication from a primary care provider, a psychiatric NP, or any other prescriber. Purchase of any psychotropic medication should immediately trigger notification of the FBI.  Remember, some anti-convulsants are prescribed for psychiatric reasons, so prescriptions will need to show clear indications for the medications.  The pharmacists will have a dedicated line.
~Anyone who has taken a sleeping pill, because sleep problems are often secondary to other psychiatric conditions, plus they slow reaction times and can cause cognitive issues.  We don't think people under the influence of sleep medications should be operating guns, do we? 
~Anyone who purchases over-the-counter sleep medications, or any medication that can induce drowsiness. If you need to be drugged with something that warns against operating heavy machinery, the FBI needs to know and you don't need to be pointing a gun at anyone.  Plus, do we really want people who are sleep deprived to be handling guns?  They can be very cranky.
~For the same reason, anyone who takes narcotics for pain, coughs, or recreation.  Or amphetamines for that matter -- they make people jumpier, not a good mix with a gun.  And testosterone makes people more aggressive, so that should be a no-no.  Need a mood supplement: St. Johns Wort or SAM-e?  The government needs to know.   
~Anyone who tells a health professional about mood changes, feeling sad or stressed.  This could be a warning sign that a mood disorder is present and you never know when someone might swing to being a killer. 
~Because many people with mental illness never seek treatment, we need a list of psychiatric symptoms to be made public, and all teachers and employers should be required to report when they hear of, or observe, any of these symptoms.  Voices, paranoia, moodiness, irritability, anxiety?  There should be mandatory reporting with stiff criminal sentences for any health care provider, teacher, coach, or employer who does not report the name of anyone with psychiatric symptoms to a federal gun database.
~Google searches should be monitored for those looking up mental disorders or psychiatric symptoms.  Facebook/Twitter/Instagram posts should also have identified phrases that are associated with mental illness.  Those teens who post song lyrics about existential angst or the end of the world -- the government needs to know. 
~Substance abuse is a mental illness, and guns and alcohol/drugs don't mix.  They are a recipe for disaster.  Liquor stores should have a threshold amount for purchases, along with requisite questionnaires to determine who is drinking too much.  Case of beer for the Superbowl?  List the names and addresses of who those who will be sharing with you and the predicted number of beers/person.  Unused portions along with accountability charts need to be returned so those who over-imbibe can be identified.The government needs to know.
~Reclusive and weird: absolutely no gun.  The government needs to know about anyone who isn't out of their house by 9 AM on weekdays.  Special dispensations could be issued for people who work at home or have unusual hours, provided they do leave their house for enough hours/week and have a threshold number of social contacts.

So if you look at it this way, it becomes pretty easy to identify the mentally ill.  You target treatment settings, medications used for their treatment, and observed or stated symptoms of psychiatric symptoms.  We still will miss a few people, but if we can identify these folks, and keep guns out of their hands, I guarantee the rate of gun violence will go down.  It's a sure fire thing.  
(Of note: Satire alert)

Wednesday, January 14, 2015

The lovely wife on the psych ward


I have one thing to say about Mark Lukach's essay, "My lovely wife on the psych ward."  That one thing is: Read it!  It's beautiful.  Mr. Lukach does a masterful job of describing his feelings as he plows through two months' long episodes of psychosis with his wonderful wife. When a friend gives him a copy of R.D. Laing's The Divided Self: An Existential Study in Sanity and Madness, Mr. Lukach learns about the world of anti-psychiatry and psychiatric survivors.  He struggles through with wanting to be a good husband, to help his wife get better, but he questions whether what he is doing is right, and he stumbles through with his own guilt.  And when his wife gets better, they struggle with the bitter aftertaste of what it meant to be her caretaker, to be in control.  The story isn't all pretty, but the writing and the description of the conflicts is beautifully done.

Yet Laing ripped through a conception I had of myself that I held dear: that I was a good husband. Laing died in 1989, more than 20 years before I picked up his book, so who knows what he really would have thought. His ideas about mental health and its treatment could have shifted with the times. But in my admittedly sensitive state, I felt Laing saying: Patients are good. Doctors are bad. Family members botch things up by listening to physicians and becoming bumbling accomplices in the crime of psychiatry. And I was an accessory, conspiring to force Giulia to take medication against her will that made her distant, unhappy, and slow, and that silenced her psychotic thoughts. That same medication enabled Giulia to remain alive, so everything else was secondary, as far as I was concerned. I never doubted the rightness of my motives. From the beginning, I’d cast myself in the role of Giulia’s self-effacing caregiver—not a saint, but definitely a guy working on the side of good. Laing made me feel like I was her tormentor.

Tuesday, January 13, 2015

And January 13th is.....

You guessed it: today is National Rubber Ducky Day.

Wishing the best National Rubber Ducky Day to all our Shrink Rap readers!

Thursday, January 08, 2015

Tweet Tweet


You may have noticed that I don't write on Shrink Rap as often as I used to.  Somewhere in there, I got busy with our book, and I also started to use Twitter more.   Instead of a real post, I thought I would put up a sample of things I've been Tweeting.

Saturday, January 03, 2015

The Jawbone's Connected to the ....


It's half-time and the Ravens are beating the Steelers by one point.  I thought I'd take this opportunity to tell you about my latest obsession.

      I spoke to Clink this morning.  I happened to mention that I was frustrated: among other things, my  Jawbone wasn't registering right; I'd have to reload.  Now Clink and Roy run circles around me when it comes to technology, but here, I had Clink. 
    "This is something technologic, right?  It's not a medical emergency?"  
    She may have offered to send an ambulance (or maybe I'm just making that up because it sounds good), but no, my choppers are fine and there's no problem at all with ingestion.  

So, followed by a few too many cookies over the holidays.  And some bagels, pizza, holiday meals, and too much everything, on New Year's Eve, I went to the store and bought a fitness tracker.  I got the Up Move, by Jawbone.  I don't even know what that means, or why someone would call a company Jawbone --it sounds very unfriendly and very aggressive -- but it was the cheapest one and it got decent reviews, and I figured less was probably better.  I want some inspiration to move more and eat less, and I don't care what my heart rate is when I'm swimming without Bluetooth.

    It says I should take 10,000 steps a day.  I'm trying.  It's a lot of steps.  I've done it 3 days in a row, and I'm definitely moving more -- it seems to take about 1 hour and 40 minutes of purposeful, non-strenuous motion.  The dog is very happy -- he loves walks.  We've done four trips around the block just to try to add steps.  The trick is that this is over the holiday week and I'm not working.  When life returns to normal on Monday, all bets are off, and I'll settle for moving a little more and eating a little less, without having to push for 10,000 each day.  For the moment, however, I'm enjoying my latest obsession.  No ambulance necessary.





Above: Kobe relaxing after 7,823 steps.  Can you guess which team he's rooting for?

  
 

Friday, January 02, 2015

Gun Owners & Mental Illness -- Is there a "chilling effect" on seeking treatment?


As you may be aware,  we are in the process of doing research for a book called Committed: The Battle Over Forced Psychiatric Care.  Our plan is to include a chapter on guns and mental illness, and I'm interested in talking to gun owners who believe they are suffering with mental health issues, but won't seek care because they are worried this will impact their right to own firearms.  I'm well aware that gun owners often say they'd never see a therapist, or never take psychiatric medications, but what one does for a theoretical problem may well be different then what one does while they are actually suffering.  So if you'd be willing to share your story of how you are avoiding treatment, or worked your way around your concerns, I'd love to hear from you, either in the comment section of this post, or by direct email to shrinkrapblog at gmail dot com.  Obviously, real names won't be used in a manuscript.  And, as always, thank you for visiting Shrink Rap today and for sending this post to anyone you know who might be interested in participating. 
----
ADDENDUM:  I'll take any interesting story about the intersection of guns and mental health.  Must be in the US, but from a patient, a doctor, a family member, someone afraid to get care, someone who did get care and had a happy or unhappy outcome...Just a guns and mental health story that's a little more involved then 'my shrink asked me to lock my gun away and I did.'  

Thursday, January 01, 2015

Happy New Year!



Happy New Year!
To you and yours
From the Shrink Rappers

Wishing you a joyous, prosperous
and healthy (mentally & physically) 
2015  

Thanks for reading and we look forward to entering our 9th year of Shrink Rap blogging this coming spring. 

Saturday, December 27, 2014

Shrink Rap: Most Popular Posts for 2014



10.  Let's Keep Guns Out of the Hands of.....

9. How Hard Is It To Find a Psychiatrist? Tell me your stories!

8. Insurance (or Not), Flotation Tanks, and Involuntary Commitment.

7. The doctor will see you NOW!

6. Who are the Mentally Ill? Please take my Brief Survey!

(please note: the survey is closed but the results can be found here )

5. Does bad parenting cause mental illness?

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

3. Are Psychiatrists Evil?

2. Why Psychiatrists Don't Participate with Insurance Networks 

1. Is it Ok to Shrink your Sister in an Emergency?

 


Friday, December 19, 2014

Written Off



Request from a friend.  I donated, if the cause sings to you, I hope you will too.

Hi Dinah,

I'm writing to tell you about the production of a feature documentary some good friends of mine (and extremely talented filmmakers) are producing. It's a compelling life and death saga of young opiate addict aimed at public enlightenment and destigmatization for which I am an advisor and supporter. I think it will have the power to seriously advance the conversations around prevention and treatment.

They are raising money to finish it as quickly as possible, and I wondered if you'd be so kind as to broadcast their Kickstarter campaign through SHRINK RAP. The link is below and contains lots of info and a short trailer.

Very best wishes and thanks,

Richard


https://www.kickstarter.com/projects/1928235665/written-off-the-short-sad-beautiful-life-of-matt-e?ref=nav_search

Tuesday, December 16, 2014

Psychiatry or Bust?


Over on the Neurotransmitting blog, Dr. Joseph Andrews, a 4th year psychiatry resident, writes about Where Psychiatry Sits With Medical Students and What We Can Do About it
He writes, in a good deal of detail, about the finances of it all and about why someone who has taken on a lot of debt to go to medical school might not be able to afford to become a psychiatrist.  This isn't new -- I went to medical school knowing I wanted to be a psychiatrist, and there were medical schools I simply didn't apply to because I knew I would need to take on so much debt that my monthly payments would be more than I could afford on a resident's salary.  Ah, those schools were kind enough to provide that information in blunt terms, I remember pamphlets that said that if you needed to take out a HEAL loan at the high interest of the day, then you could expect to pay back $1700/month.  That assumed no college debt (which I already had) and at the time, residents made roughy $26,000/year.  Those applications went into the trash.

Dr. Andrews also talks about the stigma of psychiatry -- his friend's family would be shamed if she went into psychiatry, and he talks about how there are other mental health professions for those interested in the field.  It's a good post.  And I'm here anyway, though in college I did plan to be a psychologist.  I'm not sure what happened along the way, but suddenly psychiatry sounded better.

So I'm here to say it's still pretty good.  I still like being a shrink, and people get better much more than they ever told me in medical school.  I still talk to my patients and get to know them.  At the end of most days, I feel appreciated.  There is still a lot of variety to what psychiatrists can do -- research, teaching, brief contact practices (many many patients for brief med checks), or high contact practices (psychoanalysis, or less high contact with psychotherapy), administration, and blogging (warning: no pay).  I don't ever wake up and wish I was  a dermatologist.

So do check out Neurotransmitting -- it's one of very few blogs by a psychiatry resident and Dr. Andrews is just getting started. 

Thursday, December 11, 2014

Shocking!



I had a really interesting day yesterday.  I went to Richmond to learn about electroconvulsive therapy, or ECT.  Yes, shock treatments.  Now we have ECT in Baltimore, and all residents see patients on the inpatient unit who have ECT, and all residents do ECT.  I wanted to see it again because it's been a long time since I was a resident in an ECT suite, and thought perhaps something might have changed.  Nothing changed, except that now the psychiatry resident spends a lot of time looking at a computer. 

Why did I go to Richmond?  I'm doing research for our book on involuntary treatments, and in Maryland ECT is only used for people on a voluntary basis.  The only way around this for someone who is so sick that they are in danger of dying if their condition doesn't get treated, is to have a guardianship appointed, and this is quite rare and for quite extreme cases.  In Virginia, ECT is treated like any other involuntary treatment, a magistrate comes to the hospital to hear civil commitment cases, have medication review panels (I'm not sure what they call it there, that's the Maryland lingo) and involuntary ECT is considered another treatment.  Obviously, it's reserved for the very sick, who have not responded to other treatments, or where a quick response is imperative.  I heard about one patient who had been catatonic with a feeding tube and unresponsive to any treatments - a man in his early 50's -- the treating facility's plan had been to transfer him to hospice to die, and instead he was transferred for ECT treatments and he recovered.  

The doctors who do ECT regularly see it as a highly effective treatment, often life-saving, when all else has failed.  Clearly, this is the most controversial treatment we have in psychiatry, some might even say it's barbaric.  

I've hesitated to blog about the research I've been doing as I work on the book -- not because there's anything secretive about it, and it's been a fascinating project for me -- but because I'm not sure how are readers will respond.  Obviously, involuntary treatments make for a controversial and heated discussion.

And if you're interested in the latest on what Maryland's Department of Health and Mental Hygiene is planning to recommend to out state legislature on involuntary outpatient commitment, Here is an article in the Baltimore Sun to check out. 

Sunday, December 07, 2014

Did Adnan do It?




I figured I'd join the bandwagon of bloggers talking about The Serial Podcast.   I'm taking a break from psychiatry for the moment.  If you haven't been listening, Sarah Koenig is orchestrating a year-long investigation into a 1999 murder. 17-year old Adnan Syed was convicted of killing his ex-girl friend and there are a few things that have caught Koenig's attention about the case: an alibi witness was never interviewed, Adnan was a good kid who followed the rules and was no one's pick as a would-be murderer,  and there was no physical evidence.  Koenig has been hunting down every detail, interviewing Adnan (an inmate in the Maryland state penitentiary), his family, his friends and teachers, and making her way through all the records from the trials.  She plays tapes of her discussions with these people, and plays snippets of the trial.  The victim's family has not been heard from, and the story is tragic from every direction, and yet still somehow weirdly compelling.  The episodes get posted on Thursday mornings, and I believe each episode has over 2 million listeners.

Clink and I have been listening.  She is the only person I know who doesn't like it.  She says the crime is unremarkable and she's tired of Sarah Koenig's back and forth debate with herself of 'did he do it?' or 'Didn't he do it?'
    "She doesn't know.  We get it," Clink says.
I asked why she's continued to listen and Clink tells me that once she's started something, she has to finish, whether it's a book or a podcast.  If I had this issue, I'd be really picky about what I started.

I like Serial.  I really like it.  I discovered the series after 3 episodes had been posted, and I listened to all three at once -- strange for me, I'm not a binger when it comes to entertainment.  I look forward to Thursdays and the next episode, and I feel sad when the episodes are over.  I know that ultimately it's bound to be a letdown: the series will end in a few weeks with no definitive answer, or so I imagine.

Okay, so it does feel odd to listen to the story of a real life murder as entertainment.  I worry that the victim's family might be injured by it.  If they feel that Adnan was guilty, then knowing that someone is out there revisiting the trial of their family member's murderer must be awful.    But, I'm going to rationalize this: we read books about murders and tragedies  all the time.  Is this different then say reading The Devil in The White City where part of the plot followed an evil serial killer? Or Truman Capote's In Cold Blood about a family that was killed? Maybe.  But what if Adnan didn't kill Hae, and what if this podcast inspires freeing an innocent man and perhaps even finding the person who actually did do it?  Koenig started investigating this at the request of a family friend of the Syed's. 

Issues of justice are compelling -- if you don't think so, check out the reaction people have had to recent police killings.  We want the bad guys to get what they have coming to them, and we don't want to see innocent people wrongly incarcerated.  And I've spent the last number of months doubling as a journalist researching involuntary psychiatric care; it leaves me in awe of Koenig's reporting.  She's a remarkable journalist, but even more, she's a truly wonderful story-teller.  She knows exactly how to rope a listener in, and how to keep them listening.  Honestly, I think if Sarah Koenig was talking about how to boil an egg, she'd have me transfixed.

Okay, so I want Adnan to be found innocent.  The series will be disappointing if he isn't.  Guy kills a girl  and there's a witness who helped bury the body.  Then a journalist  questions his guilt and reopens all the wounds and issues, and it turns out he really did do it; that doesn't quite make for a good story if you're telling it knowing how it ends.  Adnan is smart and personable --a model prisoner who is faring quite well on the inside-- and it would be nice for the story line if he didn't do it, though really tragic for the victim's family.  So far, though, I have to say that the evidence sounds like he may well have done it.  

Monday, December 01, 2014

So You Like To Write

 From my email, I'm passing this along.  This organization has no ties to Shrink Rap:

 Beyond Crazy

Deadline: February 9, 2015
Every year, one in four American adults will endure the trials of a diagnosable mental health disorder. But although many Americans have experienced a mental illness, either firsthand or through a family member, friend, or colleague, the stigma surrounding mental illness remains. We believe that the most important tool we have for defusing the power of this stigma is sharing true stories and revealing the real people beneath labels.
In Fact Books seeks original stories for an upcoming anthology tentatively titled BEYOND CRAZY: TRUE STORIES OF SURVIVING MENTAL ILLNESS. Stories should combine a strong and compelling narrative with an informative or reflective element, reaching beyond a strictly personal experience for some universal or deeper meaning.
We’re looking for well-written prose, rich with detail and a distinctive voice; writing should be evocative, vivid, and dramatic. All essays must tell true stories and be factually accurate. Everything we publish goes through a rigorous fact-checking process; editors may ask for sources and citations. Authors of accepted essays will be awarded a modest honorarium upon publication.
Guidelines: Essays must be previously unpublished and no longer than 4,500 words. Multiple entries are welcome, as are entries from outside the United States.
You may submit essays online or by regular mail:
By regular mail  Postmark deadline February 9, 2015
Please send your manuscript; a cover letter with complete contact information, including the title of the essay and word count; and an SASE or email for response to:
    In Fact Books
    c/o Creative Nonfiction Foundation
    Attn: Beyond Crazy
    5501 Walnut Street, Suite 202
    Pittsburgh, PA 15232

Online Deadline to upload files: 11:59 pm EST February 9, 2015
To submit online, click here. (Note: There is a $3 convenience fee to submit online.)
Creative Nonfiction | In Fact Books
5501 Walnut St | Ste 202 | Pittsburgh | PA | 15232
412.688.0304 | F 412.688.0262
www.creativenonfiction.org

Sunday, November 23, 2014

Questioning the Rules


Good morning.  I'm sending you to look at two articles today, both by or about people who have been on our blog before.

Over in the New York Times, Robin Weiss has a fabulous article about her work with a patient who wanted to know details of her personal life, "The 'rules' of psychotherapy."  Dr. Weiss talks about how revealing such information goes against the 'rules' of psychotherapy, and she discusses reasons why she decided that in this case, it made sense to break the rules.  She writes:
As therapy continued with her, I heard how flat and tinny I sounded whenever I attempted to analyze what was going on between us. When I lapsed into too clinical a mode, our connection would wobble, and her alienation became palpable.
In contrast, as I began, in the face of her challenges, to let down my guard, our alliance grew stronger, and she became open to treatment. We would laugh together about her bringing me just the right greeting card or a flower from her garden — exhibiting her need to challenge “the rules” and exposing my need to interpret her actions. These interactions helped develop her capacity to observe herself in action, as she courted me in her Sherpa style.
I may have been a slow student, but eventually I understood: I was the one who had to change. From then on, when she saw that look in my eyes, I said yes, I did have a migraine. We followed episodes of the TV show “ER” together, and I told her where I was going when I left for vacation.

I like the flexibility this articles conveys.  All patients aren't alike, they (and their psyches) don't all follow, or even know, the rules. It's good to question things when the treatment doesn't seem to be working.

And in the New Yorker, Jeff Swanson, a medical sociologist at Duke, is interviewed for an article by Maria Konnikova for "Is there a link between mental health and Gun Violence?"  Dr. Swanson has a wonderful idea: instead of preventing people from owning guns because they have a psychiatric diagnosis, we should prevent people from owning guns because they are violent.  Konnikova writes:

In all of his work, Swanson has found one recurring factor: past violence remains the single biggest predictor of future violence. “Any history of violent behavior is a much stronger predictor of future violence than mental-health diagnosis,” he told me. If Swanson had his way, gun prohibitions wouldn’t be based on mental health, but on records of violent behavior—not just felonies, but also including minor disputes. “There are lots of people out there carrying guns around who have high levels of trait anger—the type who smash and break things,” he said. “I believe they shouldn’t have guns. That’s what’s behind the idea of restricting firearms with people with misdemeanor violent-crime convictions or temporary domestic-violence restraining orders, or even multiple D.U.I.s.”


Friday, November 21, 2014

DJ Jaffe: The 4.2% (or the Us / Them Dichotomy)

Over on Pete Earley's blog, he gives the text of a speech by DJ Jaffe, a mental illness advocate.  Mr. Jaffe contends that those with serious mental illnesses constitute 4.2.% of the population and those people can be differentiated from the rest of the population, including the 20% of the population in any given year who have DSM diagnoses which are "mainly minor illnesses like anxiety." Jaffe would like to see those with real mental illnesses, who aren't the worried well, moved to the front of the line for services.  

I've ranted before about how I still don't know who those mentally ill people are -- I did a poll on this on Shrink Rap and got results from 696 people and wrote about the results Here and Here.  I've been in private practice for over 20 years, and have worked at 4 different community mental health centers, including a stint volunteering at HealthCare for the Homeless.  Many of the people I see spend most of their lives doing very well, and for Catlover who commented on the post on The Violent Mentally Ill, I'll add that when they are well, they are indistinguishable from everyone else: they go to work, they care for their children and parents, they are doctors, lawyers, teachers, the heads of companies, and they do amazing volunteer work and give generously to charities.  And when they are sick, they suffer, can't get out of bed, miss work, stop eating, and feel suicidal.  Some of these very well people hear voices, have delusions, and shut down.  Some of the mentally healthiest people I know are also some of the sickest people I know -- it simply depends on what slice in time you catch them, and the sick part can be a very brief, but life changing, slice.  Many people I see have been hospitalized at some point, have attempted suicide, or have needed 4 or 5 medications at a time in order to be well.  

But Mr. Jaffe is right: there are some people who are chronically ill, who never get well, and who aren't going to work and contributing to society.  They cycle from the jail to the hospital to the street, and very frequently (as in almost always) this population includes people with substance abuse disorders.  Does it matter?  If someone cycles from the jail to the street and back again and they have a substance abuse problem which contributes, do they deserve less help than the person who also has a mental illness?  What if they have a personality disorder that destroys their ability to function, have relationships, hold a job, maintain housing, and live in a meaningful way in society?  And if you're in the midst of a terrifying panic attack, who decides if your problem is "mild?"  I don't like the Us/Them split with the idea that there is a clear divide.  We're all people, we all hurt sometimes, and some of us need more help than others : diagnosis is not the thing that determines that.    Nearly 40,000 people a year die from suicide; they aren't all obviously ill and sometimes we are left to be totally shocked.  400 physicians a year (the equivalent of an entire medical school) commit suicide and they probably weren't falling in Jaffe's listing of the severely mentally ill who cycle through jails and hospitals.  When people commit suicide, or school shootings for that matter, there were often subtle signs, but most of these people weren't in that 4.2% and weren't the obvious severely mentally ill. 

If you're suffering, you're suffering, and we need better services, available more readily, for everyone. The teenager who kills himself because he is distraught over a break up is just as dead as the man with chronic schizophrenia who dies on the street.  We need more and better treatments for substance abuse, and we need more and better treatments for those mental illnesses that are resistant to the medications that are available now.  We need more ACT teams, more housing (because it's hard to get your medicines if you have no address to get your check and no shelf to put them on), more peer support, more transportation.  Offering help to those who suffer but don't have severe, chronic, and persistent mental illness should not be equated with stealing services from those most in need.   

[This weather calls more for a snowy owl theme, I think. --Clink]