10. Let's Keep Guns Out of the Hands of.....
9. How Hard Is It To Find a Psychiatrist? Tell me your stories!
Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen. All patient vignettes are confabulated; the psychiatrists, however, are mostly real. --Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)
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.
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.”
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.
Sometimes, I like to bother pharmacists. They are the nicest people, and very patient about looking up medication costs for me. Once, I wrote a post called The Co$t of Being Depressed, where I compared the cost of anti-depressants. Today, I'm writing over on our Clinical Psychiatry News website about The Surprisingly High Cost of Abilify.
Here's the short form, but do surf over there for details:
I called three pharmacies and compared prices on Abilify.
Please remember, this data is for three pharmacies only
Over on Saving Normal, psychiatrist-blogger Dr. Allen Frances has put up a thought provoking article called We Should All Be Ashamed. Frances asserts that closing the state hospitals was the wrong thing to do : those patients now live on the streets and cycle through the jails. We haven't freed them, he says, we've abandoned them. Frances goes on to say that Dr. E. Fuller Torrey is right: our society needs laws that allow us to force those who need help into care and Representative Tim Murphy is right: we need to pass the Helping Families in Mental Health Crisis Act -- one that mandates states to have programs for involuntary outpatient commitment.
Is there any possible way to get this train back on track? First, implementing Tim Murphy’s Helping Families in Mental Health Crisis Act (H.R. 3717) would be a good start. Second, Congress should abolish the IMD (Institution for the Treatment of Mental Disease) exclusion. In fact, I personally believe that the federal government should get out of the mental illness treatment business altogether. They have been in this business since the passage of the CMHC legislation in 1963 and it has been all downhill. Let’s give the responsibility – and the federal money—back to the states and then hold the governors accountable for the results. They cannot do worse than we are doing now. Third, there needs to be further modification of state involuntary treatment laws and increased use of assisted outpatient treatment (AOT) and conditional release so that the small number of seriously mentally ill individuals who need these kind of services can be treated before they end up homeless or incarcerated. These three steps alone would go a long ways toward improving the treatment system."
Once they get to the ER, patients with mental health disorders are are often held without treatment for many hours, or even days, while they wait for a psych bed to open up – or for an assessment to determine they don’t need one. In an ideal world, those patients would be seen much more quickly, by qualified professionals, in a setting intended specifically for handling urgent psychiatric cases.
This is a short post to send you over to Clinical Psychiatry News where I wrote an article on an NFL.com television special "A Football Life" special about Brandon Marshall, the Chicago Bears wide receiver, who struggles with borderline personality disorder. It's not often that I get to write about football and psychiatry in the same post, and I always like it when successful people are public about their psychiatric disorders -- what better to help de-stigmatize conditions that are erroneously associated with people who have been marginalized?
Day Two of the American Academy of Psychiatry and the Law Conference
I picked up a number of tidbits from the poster sessions:
-250,000 juveniles a year are sent to the adult criminal just system
-3/4 of all juveniles serving life without parole were sentenced in five states
-Louisiana uses an assertive community treatment program to supervise and restore incompetent, nondangerous criminal defendants. This sounds like a good way to get people out of the hospital, or avoid having to send them there in the first place
-In Indiana, a survey was done of judges who have dealt with defendants claiming to be “sovereign citizens.” Most appeared in court for traffic violations or fraud rather than violent offenses. Tax evasion was least common charge.
-In a survey of PGY4 general psychiatry residents, most felt confident in their ability to perform sanity and competency assessments. Fewer felt confident in their ability to assess malingering or to participate in civil commitment hearings. This is concerning.
-Specialized processing centers (SPC) have been built for ICE detainees. They have 24/7 psychiatric coverage and freedom of movement, but no clinical review or medication over objection procedures.
The Bazelon Center has filed suit with the Department of Justice over the American Bar Association requirement to disclose disabling conditions like psychiatric disorders on the bar application, and over the requirement for some lawyers to work provisionally under supervision solely due to a history of psychiatric treatment. Proposed language to restrict questions about psychiatric issues is being considered.
The APA is updating its resource document on assisted outpatient treatment. The final document is not available at this time and the organization's position has also not be finalized.
There was an interesting talk by one of the people working on the development of the Stalking Risk Profile, a new instrument designed to predict the relative risk of continued stalking of one victim, the risk of stalking a new victim, and the risk of violence posed by a stalker. It has shown good interrater reliability based on the stalker typology, and good predictive validity between high and low risk offenders. (The overall recidivism rate was 15%, but almost all of that was due to stalking the same victim.)
The final session of the day was a panel presentation, with pro and con arguments, regarding whether involuntary non-emergency medication should be administered in a correctional rather than a hospital setting. The "pro" side noted that in some jurisdiction the waiting time to hospital transfer can be months long, and that appellate courts have upheld the use of these "Harper procedures" (after the SCOTUS case Washington v Harper) for pretrial detainees. The most creative argument on the "con" side was by Michael Perlin, who suggested that involuntary medication of prisoners was a violation of the Convention on the Rights of Persons with Disabilities (CRPD), an international human rights agreement which the United States has signed on to. He suggested that any kind of involuntary treatment or detention based solely on the presence of a mental disability was discriminatory and a violation of that document. A creative but not persuasive argument.
So that was Day Two.
The way the law has played out, local officials said, frontline mental health workers feel compelled to routinely report mentally ill patients brought to an emergency room by the police or ambulances. County health officials are then supposed to vet each case before it is sent to Albany. But so many names are funneled to county health authorities through the system — about 500 per week statewide — that they have become, in effect, clerical workers, rubber-stamping the decisions, they said. From when the reporting requirement took effect on March 16, 2013 until Oct. 3, 41,427 reports have been made on people who have been flagged as potentially dangerous. Among these, 40,678 — all but a few hundred cases — were passed to Albany by county officials, according to the data obtained by The Times.
Despite the breadth of the law, significant loopholes remain. Outside of New York City, permits are not required to buy long guns, so nothing would stop someone in the database from buying a shotgun, for example, after being released from a hospital. Also, it is unclear exactly how the process for confiscating someone’s guns is enforced. And law enforcement officials may not even be aware of all of the guns someone owns.
Here’s what happened at the Chanel boutique: “Hello. I’m looking for a pocketbook that will match my snake,” I said to a salesman. “Maybe something in reptile.” I shuffled Augustus from one hand to the other as though he were a Slinky.
“I’m sorry, Ma’am, I have a thing against snakes, so let me get someone else to assist you,” he said, as if he were telling the host at a dinner party, “No dessert for me, thank you.”
A colleague appeared. “Wow,” he said, leading me to a display case. “We do have snakeskin bags back here. Is he nice? Does he bite?” The salesman handed me a smart, yellow python bag marked $9,000. “I think this would work the best. It’s one of our classics. I think yellow. Red makes the snake look too dull.”
I'm trying to be more duckish, to let things roll off me and to slow life down, just a little. There are so many people with so many problems, and so many bad things going on in the world, it seems I shouldn't get bent out of shape about things that really don't matter.
Having said that, I snapped at someone today over one of those little things that just shouldn't matter: Getting pre-authorization for a medication for a patient.
First, let me say that some of this is my fault. I hate my fax machine and I just haven't bothered to replace it. It spams me with roofers and $99 Disney World offers, and repeat requests for medication refills when the patient long ago stopped taking the medicine. The memory empties if the machine gets turned off or the power blinks, and it often prints the same document repeatedly. It prints documents one at a time and I often need to stand over it to get them. The day I stood there waiting for it to print out 11 requests from the same pharmacy, for a refill for the same medication, I had a revelation: I could become a doctor who won't fax. I turned off the fax machine and it is no longer a part of my daily life. On rare occasions, when there is no option, I turn it on. But mostly it's been a big relief. Other people don't return phone calls. I don't fax. We can email pdf files, and if I need to get a document to a patient, I take a photo with my phone and text it to them. If that doesn't work, the phone has a scanner and I can email documents. Why would I need to stand over a fax machine? It's also my fault because I don't have a secretary to do these things for me, but that would come with it's own set of things to take care of.
BRFSS is a state-based, random-digit_dialed telephone survey of the noninstitutionalized, U.S. civilian population aged >18 years and is administered by state health departments in collaboration with CDC. In 2005, the median response rate among states, based on Council of American Survey and Research Organizations guidelines, was 51.1% (range: 34.6%--67.4%). This rate accounts for the efficiency of the telephone sampling method used and participation rates among eligible respondents who were contacted. A total of 356,112 respondents from all 50 states, DC, Puerto Rico, and USVI participated in the survey. State (including DC) and territory sample sizes ranged from 2,422 (USVI) to 23,302 (Washington). The racial/ethnic national sample sizes ranged from 5,535 (AI/ANs) to 279,419 (whites). All prevalence estimates in this report have a numerator >50 and a relative standard error <30 are="" ensure="" estimates="" stable.="" sup="" that="" to="">†30>
Survey respondents answered the question, "Has a doctor or other health professional ever told you that you had a stroke?" Differences in prevalence were assessed by age group, sex, race/ethnicity, education level, and state or territory of residence. Data were weighted to reflect the population aged >18 years in each state and territory and were age adjusted to the 2000 U.S. standard population to allow for more meaningful comparisons between states and between demographic groups. The weighted state prevalence values were used to estimate the number of persons with a history of stroke in various demographic groups and in each state or territory. Respondents provided racial/ethnic identification; those who identified themselves as multiracial were included in a separate category.
Oh, so much to talk about, but let me begin by sending you over to Clinical Psychiatry News to read ClinkShrink's latest article on Suicide and Sunshine.
Other things we could talk about are the op-ed piece in the New York Times about how in areas where there are trace amounts of the element Lithium in the water, there are lower suicide rates. See "Should we all take a bit of lithium." The article suggests further study, and perhaps adding lithium to the water supply. Before you jump to discuss kidney disease, let's be clear, these are trace amounts, around 1/1000 the starting dose when used as a pharmaceutical agent. My sister-in-law, Meg, was kind enough to inform me that there is a tiny bit of lithium in San Pellegrino water, but I'm not sure how that measures up to the amounts that occur naturally in places with lower suicide rates. We add fluoride to the water, and iodine to salt, why not lithium to the water?
And, finally, there's a study linking benzodiazepine use to a higher risk of getting Alzheimers' Disease, with a specific cut off of 91 pills is what it takes to raise the risk. I'm guessing there may be other factors here, but this may be yet one more reason not to use these medications.
Please surf over to the Clinical Psychiatry News website to see my post on Psychiatry and First Amendment Rights as they Pertain to School Violence and Cannibalism.
Also, blogger Pete Earley wants to know how to find a good psychiatrist. Please read his post here.
I went to post a graphic and decided that nothing was quite right when it comes to cannibals.
Maybe it was the shock of meeting with a D.U.I. lawyer, or the point after sentencing when I realized I’d be forced to make a daily call, first thing in the morning, to find out if I would have to pee in a cup that day. Maybe it was the fact that I’d need someone else, mainly my mom, to drive me anywhere for the next year. Or perhaps it was the consistent Saturday morning drug and alcohol therapy group or Wednesday and Thursday afternoons of community service that kicked me into a groove.
The groove of it eventually turned into a routine, one that wasn’t marked by indulgence but instead by forced commitment that eventually I would grow to respect.During that time, I quit smoking pot, I quit drinking and I got some of the best sleep I’d gotten since my diagnosis. Trips to the bar on Monday afternoons turned into extended hours at coffee shops where I finished my first novel.
For some reason, it gave me joy to recite my routine to whoever asked. I would wake up at 7, get coffee and a bagel with plain cream cheese, check Facebook, write until I had 1,000 words, get lunch, do errands in the afternoon, return home, get dinner, take my pills (with food), watch TV and get to bed around 9.
Maybe it's not just for people with schizophrenia or for people with substance abuse problems. Routine is comforting to all of us, and clean living helps. I almost missed this one and I'm glad I didn't, it's was worth passing along.It might all sound tremendously boring. But this regimented series of events was always there; they’d always carry over. And with time, it gave me great comfort to not have to deal with the unexpected. I had a set plan for most days, and there was already too much chaos in my head.
In Washington, patients who are involuntarily committed must be brought before a judge after 72 hours. The judge then makes a decision whether to continue to detain the patient in the emergency department. Some of these patients may then be returned to the same ED.
Such patients may remain in less than ideal locations such as hallways, administered psychiatric medications, but having no formal access to psychiatric evaluation and care. Staff members including nurses and administrative staff have in some cases faced verbal or physical threats from such patients, with their safety being a concern.
“While we respect the state court’s decision, federal law (Emergency Medicine Treatment and Labor Act) still prevents hospital emergency departments from discharging unstable patients — for example suicidal or homicidal patients — back into environments where they could cause harm to themselves or to others. This ruling does not provide guidance for hospitals and physicians regarding resolution of the conflicts among federal law, this state ruling, and the medical liability risk of discharging patients based on a time limit rather than based on reaching a stable condition,” added Rosenau.
“The ruling is a call to action, and our main objective must be to get every patient the right level of care. The next challenge is directed to hospital and community leaders to find the resources to care for them,” concluded Rosenau.