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)


PsychPractice said...

Love the final line. I can't decide whether to laugh or cry. I think the only person on the planet not on that list may be the Dalai Lama.

Anonymous said...

""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.""

Sorry to spoil your satire and for what is about to a partially off topic post but this absolutely not true as many sleep problems are primary which cause psychiatric issues such as sleep apnea, UARS, and narcolepsy. Unfortunately, many people end up on apnea boards who were sadly misdiagnosed as having psych issues and wasted several years on meds.

Back on topic somewhat - I know you and many psychiatrists refuse to acknowledge this but many people with absolutely no history of mental illness or violence commit awful crimes once they are started on psych meds. Also, many crimes result because people suffer horrific withdrawal symptoms from being tapered too quickly including homocidality.

And before anyone thinks I always blame all violence on meds, no I do not and have gotten into debates with people who felt differently. But to consistently deny that meds cause serious adverse affects in vulnerable people is completely insane and doing so will just greatly compound the problem.

Definitely back on topic - Now that I have completely spoiled your sattire, I did want to commend you for it as it demonstrates perfectly how absurd the whole situation is in blaming gun violence on alleged mental illness.

Joel Hassman, MD said...

whether intended for subtle comedy or not, a very slippery

slope you are
treading here,
and I hope you can fill in the blanks.

This country again uses the black and white extremist commentary to define a gray issue. Owning a gun or other type of firearm is a privilege now that it is obvious that guns in this culture as of 2015 cannot be handled by anyone with a claim to citizenship.

Besides, per every firearm death by a legitimate psychiatric patient, how many numerous deaths have happened by other weapons, including an assailant's hands or feet?

You want to honestly play a role in minimizing violence and senseless deaths, it starts with holding people accountable, even if mentally impaired. Again, why we have prisons and graveyards, some here can dismiss that point of view until the cows come home.

Oh, to then be slaughtered???

Anonymous said...

Just add all men into the database, since they are statistically more likely to shoot up the place than women. Who cares if most would never commit a crime and are law abiding citizens, we must be pro-active! We should add Tim Murphy, Dr. Torrey, and others to the database. They, too, could be affected by mental illness at some point, what is it 1 out of 4 chance? and they're male so best to be safe rather than sorry.


Anonymous said...

The first half of the blog really had me boiling. Then I read the rest. It takes a certain courage to admit you have a mental illness and then to seek treatment. And by the way - a person with a mental illness is MORE LIKELY TO BE THE VICTIM OF A CRIME THAN THE CAUSE OF ONE. just sayin'

Dinah said...

I'll venture a guess that the Dalai Lama took an Ambien in 1997. Hold his gun at the door.

Please, no guns in the hands of narcoleptics.

"I know you and many psychiatrists refuse to acknowledge.." Just to be clear, you have no idea what I think. Trust me on this one.

Joel...again you leave me speechless.

P-K, Murphy is graded an A legislator by the NRA. I have suggested that the world would be safer if we kept guns out of the hands of men. Glad to hear you'll vote for me when I run.

Oh look, no more silly codes. Now I just have to check a box that says I'm not a robot. Some days I wonder if I am a robot. Is there some test for that?

ClinkShrink said...

Of course. It's called the Turing test. You don't read enough science fiction.

Joel Hassman, MD said...

My apology your satire escapes me for a point. I read it as a veiled effort to say that mental patients NEVER have a right to access a firearm, but, I hope I am interpreting wrong.

Again, I think access to firearms is now a privilege in this country, and letting gun rights advocates scream "everyone has a right" and gun control advocates scream "no one should access a gun" has no place in a responsible debate. Besides, firearms are just part of the risk for those with impaired insight and judgment, so what next after we get the guns??

What about patients who have been repeatedly victimized by assailants who seem to get an eternal free pass from the legal system to continue to assail away? You honestly do not think some victims who have the ability to show the responsibility to own a firearm for home protection should be denied if ever psychiatrically hospitalized or given a psych diagnosis?

I'll end on a psuedo-satire perspective: how many bodies do we have to pile up to prevent the antagonists and deniers of freedom and choice to get access to those still alive and with options? It seems to be a body count to me, but, I guess that is not living room discussion??

Working much of my 20+ years in community mental health sites has never made me speechless. Perhaps not so good at times, but, I have watched those who stay persistently speechless, and that is at least pathetic in my opinion. You are blogging, so I hope your efforts work for you.

I have to ask, although I note up front probably out of line, and not asking for an answer here, do you support the President as a Jewish person these days? I don't, and I hope readers who have an interest in the long term viability of Israel think about where the dialogue is going of late. How it fits here? Deny your allies weapons to fight an overt enemy. You decide if that is an honest analogy.

Be safe and well.

Joel H

Jen said...

LOL - the dalai lama on ambien!

Are private practice psychiatrists who don't accept insurance (patients submit for out of network benefits) still bound by HIPAA?

Dinah said...

Joel, Oh my, this was in no way intended to say that people diagnosed with mental illnesses should never own firearms. It was meant to poke fun at the idea that we can divide those with mental illness into 'us' versus 'them' categories and to highlight how pretty much everyone (except, apparently, the Dali Lama) has problems, issues, moments of needing medication, therapy, support, or moments of expressing psychic suffering. I think I've been pretty clear that I don't think we can clearly identify who does and doesn't have a mental illness (now, before, in the future), or that designating people as mentally ill should be the criteria for banning people from gun ownership. I think, instead, we need to look at behaviors for impulsive/violent behaviors.

I am definitely not a violent robot

joel hassman, md said...

sorry I missed your intent. Hope you think about my question at the end of my last comment, and this one my last one at this thread.

Iran wants to assassinate Ben Netanyahu's children, and our President wants to ostracize the leader of Israel while negotiate with assassins. Lovely, eh?

Joel H

Anonymous said...

Jen, my understanding is if you are submitting for insurance reimbursement you are giving up some of your right to privacy. You can ask the psychiatrist to withhold information from the insurance company, but the insurance company can also refuse to reimburse you if they don't get the information they want.

That's my take on it anyway.

If you read the informed consents we sign and the privacy policies we are given you will see how we are pretty much giving health care professionals the freedom to hand our information all over the place (e.g. outside EMR vendors, etc). I think HIPAA actually made things worse. Privacy in health care is pretty much a joke these days.


Anonymous said...

I won't even say what I think about the "patient centered medical home" nightmare, because that would be a little off topic.


Anonymous said...

Joel: I recommend that you read "A Modest Proposal" for another example of this kind of satire...

Jen said...

Surprise. If you are a self-pay psychiatrist (don't accept insurance (patients submit for out of network benefits) and don't use electronic transfer of information) then you are not bound by HIPAA. I am blown away.

Isn't patient privacy a cornerstone of psychiatric treatment? What privacy strictures are binding, then?

Anonymous said...


If doctors can access information through electronic medical records that includes psychiatric diagnosis' (that may not even be accurate), in my opinion, privacy doesn't exist at all. So much for confidentiality. Anyway, that is why when you go to any doctor, you need to consider carefully what to disclose regarding past medical history, particularly if it may not be relative to the reason you are seeing the doctor.

Yes, I understand that ideally, you shouldn't hold anything back. But then there is reality.

ClinkShrink said...

Jen, state medical confidentiality laws still apply and take precedence when they provide more protection than HIPAA. Nevertheless, there are still a lot of exceptions as well as mandatory reporting laws.

Anonymous said...

Yeah, it's the exceptions that are the problem and particularly at large institutions they have written all kinds of very general exceptions to your right to privacy. When I read the consent and privacy policy of my dermatologist who is part of a university system it is clear that HIPAA is a joke. All they have to do is say they are sharing it with all these people who are HIPAA compliant which means EMR vendors, the state/federal health care exchanges, etc. Don't you worry everyone under the sun is HIPAA compliant these days. I don't tell my dermatologist much of anything, because they share my information all over the place. Glad my shrink still uses paper or he wouldn't know jack.


Dinah said...

I'll post about this later this week if I have time.
Doctors were obligated to confidentiality before HIPAA and psychiatrists didn't share information without consent, that's not new. Confidentiality came first. HIPAA created a group of entitites that information would be shared with without the patient's consent (not really applicable to your average shrink in an office) and they predated EMRs. HIPAA and EMRs have nothing to do with each other, but that the existance of EMRs means that doctor-to-doctor sharing within an institution can happen without a patient's expressed permission and may save lives, especially in an emergency setting.
So a self-pay psychiatrist in a private office is not bound to give you a list of organizations that can have his information but he is still obligated to keep your information confidential and is very unlikely to be giving your information to research companies. Ask. But not being a HIPAA-covered entity doesn't mean a self-pay psychiatrist can share your information without your consent, it may mean it's more confidential.

I am not a HIPAA-covered-entity Robot

Jen said...

Clink - most states (including mine - NY) have state laws that match fed HIPAA laws.

Dinah - but what is there to enforce that confidentiality - beyond a nice thought? I'm dealing with an MD psych who who broke confidentiality knowingly and repeatedly (I don't want to get into specifics but essentially shared lab reports with individuals not related to me or involved in the treatment or in a consultation in any way shape or form by using a shared fax in a hospital unit in order to avoid paying for a second phone line in her private practice where I was a patient. There was never a consent to this and I knew many of the employees there, all of whom had access to the faxed reports.) It's a clear HIPAA violation, except she's not bound by HIPAA. So I have no form of redress? I'm back to - what regulations are binding on psychiatrists for confidentiality? Just the idea? That doesn't really hold up....

Will look forward to your post on this.

Dinah said...

I could be wrong, but I don't think that's a HIPAA violation. The psychiatrist isn't willingly releasing your information, she's using a fax machine in a HIPAA-compliant facility, and this is an issue with anyone who works in more than one site -- pharmacy's often fax my office machine about patients I see in a clinic, and sometimes stuff went to the clinic about my private practice patients who had nothing to do with my practice. I hear she's not even trying to make this separation, but even if she did, it might not go perfectly. There's not a guarantee that someone you know won't take a job at the pharmacy or the lab, that someone you know won't have an appointment the next hour with the same shrink, or if there is a shared waiting room that you won't know someone there. I have a shared waiting room and sometimes my patients know someone, and sometimes I see my friends waiting for another psychiatrist.

There are some things that don't have great answers. You could complain your confidentiality was violated, but if it's a fax machine in a medical facility, HIPAA would not make a difference.
Unless I'm wrong, of course.

Maybe I am a robot.

ClinkShrink said...

It looks like you've got case law that sets the NY medical privacy laws as more stringent than HIPAA (from the footnotes of NY CLS Men Hyg § 33.13 on Clinical Records):

"As N.Y. Mental Hyg. Law § 33.13 is more stringent than the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C.S. § 1320d et seq., when the records in question are clinical psychiatric records, § 33.13 is not preempted by HIPAA and is the prevailing standard under which to evaluate the confidentiality and maintenance of clinical psychiatric records in New York. Midgett v Beth Israel Med. Ctr. (2010, Sup) 30 Misc 3d 224, 916 NYS2d 888."

I don't see any specific civil penalties in the statute, but that doesn't mean somebody wouldn't have cause of action for a breach of confidentiality. I'm not a lawyer, but an injury caused by failure to maintain confidentiality seems like the most clear answer to your question about what patient's redress would be.

Jen said...

You could be right - it may not be a HIPAA violation, but it was a definitely unprofessional, and still a confidentiality violation.
Which still begs the question - what patient privacy standards are psychiatrists held to if not HIPAA in states where state law IS HIPAA?

Jen said...

Clink - thanks. I'm relieved to hear there are laws binding psychiatrists regarding patient privacy.

Unfortunately, unlike with HIPAA where the violation itself is the crime, and has clear penalties, it seems like causal damage needs to be shown for this and I suspect humiliation and stress from disclosure just won't do it.

So this psychiatrist will get away with it. It's really too bad.

Jen said...

On second look - this only looks to apply to OMH operated facilities and providers. Once again, private practice shrinks who are non-covered entities (very common in NY) are not obligated by confidentiality laws.

Anonymous said...

People seeing physicians in a large institution should read the privacy policy and informed consent very, very closely. Some psychiatrists in large institutions also share records with other physicians in that institution, you really don't have much privacy. Physicians in some of these hospital and university systems will also start sharing your personal medical health information in state and federal health information exchanges - making your records available to anyone who joins the exchange and takes care of you - including your optometrist. You want your optometrist receiving your pap smear results, I don't. But, this is already starting to happen in my city. The sheriff's dept has also joined the health information exchange. Fabulous. I'm going to avoid physicians who partake in this. No thank you.

These university or hospital systems also share your name with Press Ganey. I saw a dermatologist who is in a university system and later received a survey from Press Ganey. I received the survey by both mail and by email. So, this university system didn't give a hoot about my privacy. They thought it was just fine to give Press Ganey my name and email address and let them know I saw a dermatologist. I don't appreciate that, but they are able to breach privacy like this because they wrote this into their stupid privacy policy. To heck with what patients think about this organization receiving their personal information. I would be livid if a psychiatrist ever did something like that. See a psychiatrist in private practice if you can. You have more privacy. Meanwhile, as much as I like my dermatologist, I'm about to find another one - one outside of a university system. My optometrist doesn't need to know I had a mole removed.


J said...

P-K -
If you read what I wrote, you'd see that I was talking about a psychiatrist in private practice. She inappropriately used the fax at a hospital, where she was employed part time, as she did not have a fax in her private practice office. While the hospital fax was inappropriately used, at no time did any information enter into the hospital system.

Press Ganey surveys are sent to all hospital inpatient and outpatient services of many major university hospitals as a means of quantifying and improving service. This is not news and when you sign the release, you are permitting it. Your health details are not shared.

Anonymous said...


I understand. I wasn't really speaking to you in the last post. I was just thinking out loud. And, you're right about hospitals which is why in the future I'm going to see outpatient doctors at places other than a hospital system or university system setting.