Saturday, October 22, 2016

The Heated Battle Over Involuntary Committment

So often I write blog posts about topics I read about in the paper.  I take a few quotes and expand upon them.  Today I want to look at book review by Dr. Damon Tweedy, a psychiatrist at Duke University and author of Black Man in a White Coat: A Doctor's Reflection on Race and Medicine.  Only this is a little different. Dr. Tweedy is reviewing a book that We wrote!  And a fine job he did, if I do say so myself.

So from the Washington Post, to appear in print tomorrow, Tweedy writes about
 Committed: The Battle Over Involuntary Psychiatric Care 

Here, they explore forced psychiatric care, perhaps the most polarizing aspect of a controversial profession. The result is a highly informative and surprisingly balanced book that should be read by anyone with a personal or professional stake in how the mental health system provides care to those with chronic severe illnesses and those in acute crisis.

Miller and Hanson take us on a journey across America, where we witness significant variability in how states approach the issue of forced care. In some states, patients must be deemed imminently dangerous to themselves or others (i.e. high risk for suicide or homicide) for forced treatment, while in other states an inability to provide for basic needs due to mental illness is sufficient. The process of commitment also differs. California, for instance, does not require a formal psychiatric evaluation before patients can be involuntarily admitted to a psychiatric hospital, while in Maryland an evaluation must be done before admission and requires the input of two physicians or psychologists. Until recently, doctors in Virginia could not use the input of family members in assessing a person’s potential dangerousness.  

And finally:

Although “Committed” explores a complex subject, Miller and Hanson make a great effort to humanize this discussion. In each section, they introduce us to individuals — patients, family members, advocates, lawmakers, emergency-room doctors, psychiatrists, police officers and judges — involved in some aspect of forced treatment.

Thank you, Dr. Tweedy!

Thursday, October 20, 2016

Attend a Penn Conference on Ethics and Correctional Mental Health for Free

Ah, technology.  The Scattergood Foundation is having an all day conference on Ethics and Correctional Mental Health today in Philadelphia.  No the conference is not free, but I imagine there will be time to get a cheesesteak (whiz, please) and if you've lived in Philly, you'll understand the reference to Cheese Whiz.  

The Conference is being lived streamed, so you want to learn about ethics and mental health care in our jails and prisons, do consider attending, in your pajamas if you'd like.  

Here is the information:

Ethics and correctional Mental Health Conference live stream from 8:45 AM 
Watch the live stream of speakers:

 Follow tweets:

Sunday, October 09, 2016

Is Everyone's Experience of Mental illness the Same?

When I was in high school, one of my friends got mono -- infectious mononeucleosis or kissing disease.  He had a minor sore throat and, because his girlfriend was quite sick with mono, he went to the doctor and was tested.  He tested positive, but unlike his girlfriend, he never got sick and said, "Well, I haven't tried to run a mile, but I'm pretty sure I could."  Still, there is no doubt that both young people had been infected with the virus and one got sick while one did not.

One of the things I learned from the extensive research we did for our forthcoming book,  Committed: The Battle Over Involuntary Psychiatric Care  is that not every has the same experience of the same illness or the same treatments.  Okay, I didn't have to write a book to tell you that, I see it in my office every single day with every single patient.  Why does one person get a severe tremor to Wellbutrin while another with similar symptoms just gets better with no side effects? Why do some people need psychotherapy while others get better from a pill?  Clearly psychotropic medications don't agree with some people, and clearly they don't make everyone with psychiatric illness all better, but there is a contingency of people who feel that since medications were for bad for them, they are bad for everyone.  They are wrong. 

I wrote a blog post about a NY Times op-ed piece last week called "Medicating a Prophet" by Penn psychiatrist Irene Hurford.  She works with young people with psychosis, and I'm going to guess that she seen patients with a range of experiences.  In her op-ed piece, Dr. Hurford makes the point that there are people who like their psychotic symptoms, who gain some comfort from them, and who suffer when they lose their delusions and get smacked with the awful reality of their illness.  She doesn't say that there are not patients who are tormented by their psychosis and I'm going to make the assumption that she has met many paranoid, uncomfortable, and suffering patients -- psychosis is not fun for most people.  Dr. Hurford further makes the point that forced care can be traumatic-- and, as we write in Committed,  it can be for some people, even if it is appreciated by others.  I read from her article not that psychosis never leads to violence, but that rare, extreme acts of violence are rate and extreme and shouldn't be what sets public policy.  She is not the only psychiatrist I know of who is not gung-ho on making forced care easy policy, and I know several forensic psychiatrists who work with the most violent of patients on a daily basis, and still don't see involuntary treatment as the way to prevent these acts.

DJ Jaffe has an article over on Policy Madness in response to Hurford's NYTimes article.  He writes in "Policy Madness: Serious Mental Illness is Not Enriching:"

The New York Times recently ran an op-ed declaring that being psychotic is “enriching,” and arguing against involuntary treatment of the psychotic. “The assumption that someone else’s reality is invalid can foster distrust; it sends the message that we don’t respect this person’s experience of his or her own life,” wrote Irene Hurford, an assistant professor of psychiatry at the University of Pennsylvania. This romantic, Pollyannaish, and false view of psychosis is rampant in the mental-health system, regularly parroted by the media, and dangerous to both patients and public.

Jaffe goes on to talk about people with psychosis who have killed, and how assisted outpatient treatment can be live-saving.  He talks about how nurses who treat psychiatric patients have emergency buttons, but those who treat psoriasis don't.  Well, there are several cases, at Harvard and at Johns Hopkins, where surgeons have been shot by disgruntled family members.  Maybe everyone needs emergency buttons.  

I want to borrow these articles to make the point that there is no single reality.  Some patients find their psychotic symptoms to be tormenting.  Some may find their private reality to be enriching, especially during a mania.  Some patients with psychiatric disorders are dangerous.  Some people get in cars after they've been drinking or using drugs and are dangerous.  And some people are just angry and dangerous.  Please, let's not assume that the experience or the needs of all people with mental disorders are the same.  And let's not even assume that psychiatrists are the same -- some are quicker to prescribe, and some are quicker to commit patients to hospitals.  Often studies of violence outcome look at acts like slamming doors or shoving someone.  While I have no doubt that psychiatric treatment, especially treatment done with with the doctor on the same team with the patient, saves or at least enriches lives, there is no evidence beyond the anecdotal that forced outpatient care prevents murders, mass murders, or even suicide, or that other, more collaborative methods might be more effective. 

And please, don't even consider reading this and thinking that I believe there aren't situations where the only option is to force a very sick patient to get involuntary care.  I just don't think we should assume all people with psychotic disorders have the same experience.  

Tuesday, October 04, 2016

More On Forced Psychiatric Care

For years -- over 10 to be a bit more exact-- we've had controversy here at Shrink Rap when we've talked about forced psychiatric care.  It's a controversial topic not just for patients -- some who have benefited from it and some who feel injured by it, but also for psychiatrists who vary in their own views about civil liberties and medical paternalism.  Ah, as I'm sure our regular readers know, it inspired us to write a book, Committed: The Battle Over Involuntary Psychiatric Care, and I do hope you'll read it.

 I was pleased to read "Medicating a Prophet," in this past Sunday's New York Times.  Psychiatrist Irene Hurford  adds to the idea that there is not a single truth about involuntary treatment as good or bad, and that this is a complex topic where there may be more than one reality.  Dr. Hurford writes:

Proponents of enforced treatment often point to horrific but rare events, like mass shootings, committed by people with mental illness. But psychosis alone is only a modest risk factor for violence. A 2009 study of more than 8,000 people with schizophrenia found that those who did not abuse drugs or alcohol were only slightly more likely than the general population to be violent.

There are several studies that demonstrate that assisted outpatient treatment can reduce the risk of hospitalization, arrest, crime, victimization and violence. Few, however, are based on high-quality randomized controlled trials. A 2014 meta-analysis of three randomized-controlled studies of more than 700 people found no statistically significant benefit of enforced outpatient care in reducing hospitalizations, arrests, homelessness or improving quality of life.

It can be devastating for families and doctors alike to watch psychosis seemingly claim the lives of those we love or care for. And in some situations, brief episodes of enforced inpatient or outpatient treatment may be necessary. But in my experience, weeklong inpatient stays, or yearlong outpatient treatment regimens, can do more harm than good when they engender distrust. Perhaps we must accept a new reality — to truly engage people in treatment we need to understand their own experience of psychosis and its treatment.

Thursday, September 22, 2016

Should Patients Have Rights?

We're getting ready for the release of our new book, Committed: The Battle Over Involuntary Psychiatric Care on November 1, 2016 (~great reading for after the election, if I do say so myself) and I found this to be very relevant. 

My friend, blogger buddy, and mental health advocate Pete Earley went to India recently for a few days.  That sounds tiring -- but Pete is full of energy and so what's  not to like about a few days on the other side of the world? He's been blogging about mental health in India, and the first of his 3 part series is called Patient Rights is a New Concept in India, I learned.  Pete talks first about how little psychiatric care there is in India: 6,000 psychiatrists for 1.3 billion people.  It's an unthinkably low number, and there are roughly the same number of total beds there as the public system has in our country.  What a disaster.  And patient rights?: unheard of.  It's a different culture, one in which patients don't question doctors, but also one in which the mentally ill are chained, abused,  or left to starve on the streets (ah, tragically we do that part here, too).  Pete was the keynote speaker at a conference on Rights of Homeless Persons with Mental Health Issues.

In his post, Pete talks about his own experiences with his son and involuntary care and his belief that this is a band-aid, not a solution, and that it helps to come to view the world of the patient through his eyes for a longer-term solution.  So it won't surprise you if I mention that Pete wrote the foreword for our book.  His few pages are an amazing piece of writing, and they draw you in and  round out the book because he really does a wonderful job of capturing the desperation of a family member watching helplessly as his beloved son became so desperately ill. 

 I wanted to tell you share our excitement over the upcoming release of Committed, and I also wanted to send you over to Pete Earley's blog to read his stories about India. 

And of course patients should have rights, what kind of nonsense is my title?

Tuesday, September 20, 2016

Why Professional Sports Should be More Like Psychiatry

Okay, so we all have our strengths and our weaknesses.  I get calls from people all the time and they tell me their problems over the phone, but sometimes we don't end up scheduling or they don't end up coming, so at this point, the story isn't the story until the patient is in front of me.  But once there is a real live person in my office, often in pain, with a unique personal history, parts of which I hear over and over with time, the story gels.  I remember sons and daughters and mothers and fathers and spouses, and deaths and pets and who cheated and who left someone feeling so very badly.  Sometimes I have to hear it twice or I forget the precise details, or I cheat and look at my notes between sessions, but the big picture stuff: I get it and I remember it.  It comes naturally, there's not much trying.

I live in a family where everyone is really excited about sports.  My kids played sports.  I went to their games.  I had no clue what was happening, kids who all looked alike in uniforms and helmets ran around the fields.  Sometimes someone hit a home run or scored a goal and that was exciting (if I was even paying attention) and sometimes I knew the other kids, so that helped a little, if I could tell which kid was which in rapid motion in all their gear.  Whole games went by where I watched my kid only to discover, oops, not my kid.

Okay, so my family isn't just a little into this.  Season's tickets to the Ravens games and my son writes for a fantasy sports website (this is a real job).  My daughter went to every college football game and also loves the Ravens (and particularly ex-Raven Torrey's Smith's baby).  They all know the rules.  They all wait for Sunday.  And Monday night. And Thursday. And college football on Saturday.  They know all the players.  They dress in purple.  It's fun.  Fun?  I know a few of the players, but these big guys in funny looking costumes are hard to keep straight.  Flacco, I got you.  Ray Lewis, #52, but he's no more a Raven.  Suggsy...T-sizzle...are you even still here?  And it's not quite the game...I know the basic rules: the purple guys run one way to a goal and the other guys run the other way.  4 downs to get 10 yards, and then it resets to the next first down.  MOVE THOSE CHAINS!! (I'm good, right?). To get a goal, you get to the end zone and have the celebration dance.  If you don't get far enough by the third down, you can try for a field goal or punt to the other team and hope that you get it down far enough on the field that they start with a lousy position.  Time outs, hail Mary's, I mean I'm golden.  Still, I have no idea, and if I know the score and which team has possession, I'm doing well.  The details of every play, might as well be speaking Swahili to me. And those yellow flags everywhere-- the calls and the penalties all seem so random.

So by some family quirk, we root for the Ravens and we root for the Red Sox.  This is serious business.  Today we went to a Red Sox -Orioles game.  Both teams vying for first place and the stadium was empty.  Big Papi, Mookie Betts (did you know he's a professional bowler too?).  Xander Boegarts, now there's a great name. The rules, I have down, but again, I'm doing well if I know the score and who's at bat.  Sometimes I remember who hits a home run.  But unlike my family members, I don't remember each player's performance on the field and at bat for each inning.  Someone slid into second and he got his uniform very dirty.  The Red Sox won, my family was happy.

So I have tried to memorize the line up, to make the players real so they would come to life and maybe I'd remember their stories.  But they are like the people on the phone who may or may not show up, and the truth is it's hard to find much personal information about them.  I want each each player to do a YouTube discussion, a few minutes of "here is my life," with some stand out things, interactions with their family members, parents who helped them become pros, what they aspire to, and maybe then, if football was more like psychiatry, I could feel invested in the players and their professional performance.  

I mean really, what could be more exciting for pro sports?

Sunday, September 04, 2016

Shrink Rap Embraces the Politically Incorrect (because this is kind of funny?), just for a moment.

Oh, I have to say, last week I was away for the week and saw a T-shirt that said, "Please, Lord, help me to be the person my dog thinks I am."  I thought of buying it.  But actually, I'm not that sure my dog thinks that well of me, and he's not the most articulate of persnickety and temperamental little creatures.

Today, I saw the sign above on Facebook, and I chuckled.  It's probably not the most politically correct of things to smile at, and I am not always the most politically correct of people, though it seems  important to at least try on a psychiatry blog, so here, I at least try.  I thought I'd give it up for a day and share this with you.  If you hate it, please forgive me.

In other news, 64 days until the election is over.

And there is an important article in The Washington Post on why more middle aged white women are dying of accidental drug overdoses -- not surprisingly part of the reason is that people get sleeping pills or anxiety medications (benzodiezapines) and take them together with opiates for pain -- a deadly combination.  So please, warn your patients about the dangers of respiratory depression with this combination like you would warn them not to drink alcohol with benzos. And know that if you're striving to be the person your psychiatrist medicates you to be, that person is alive and thriving.

Sunday, August 28, 2016

Dear Boston Globe Spotlight Team: Access to Care is About So Much More than Public Safety

The Boston Globe Spotlight Team -- the investigative reporting team featured in the Oscar-winning, best picture Spotlight -- is doing a six-part series on the shambles the mental health system has become in Massachusetts.  And make no mistake, their system is a shambles.  The series is called The Desperate and the Dead, and while I understand that journalism involves sensationalism to get people to read, the emphasis on violence in these articles is striking, and unnecessarily provocative.  It's stigmatizing and distracts from the real issues.  This from an author who has a book coming out shortly about psychiatry's role in preventing violence.

So the first article came out in late June, about people who can't, don't, or won't get care and kill their parents. It was written about desperate and dead family members.  The second came out 10 days later and focused on police interventions, and the third was published today.  In the meantime, the Spotlight team has set up a Facebook page for commenters and there are over 1,100 members and even with a 6 week hiatus between articles, the commenting and bickering is incessant, it has become pro-versus-anti psychiatry, do meds work anyway? And the tension over forced care is enormous.  150 People demonstrated outside the Globe one day to protest the series.

Today's article starts out well -- a man is talking to his therapist about his grief after his son has died by an overdose, and during this heartfelt session where both men are in tears, there's a knock at the door with the announcement that the clinic has declared bankruptcy and the therapist has an hour to get himself and his belongings out-- the desperate patient helps him pack and transport his books and belongings.

 There are statistic about how many promised clinics never opened after the national movement to close the state hospitals, and about how reimbursement is so low that mental health facilities often lose money on every patient they see.  State hospitals were disasters --harboring people for decades and there are descriptions of people without clothes, withering in horrible conditions -- and as the article says, we don't want this back.  But still, there are not enough beds and sometimes people need to say in the hospital for a little while to heal (simply put: we don't do that anymore; we treat people but their on their own for healing).  And some people are so sick and so dangerous that they really do need someplace to live with nursing care, close medical supervision, and safety measures for a long time, and it should be somewhere clean and comfortable with good food, interesting activities, and knowledgeable and compassionate staff.  But I've digressed.

So this morning's article on Community Care makes the point that care is very hard to find in Massachusetts, and people simply go without.  Violence among those with mental illness is uncommon, but certainly exists.  They go on to highlight a story of a woman who repeatedly repeatedly stabs people, including children,  who is found to be not guilty by reason of insanity, spends time in a hospital, gets released, does well, then falls through the cracks and leaves care because of warps in the system, stops her medications, gets sick, and in her delusional state, stabs some and the cycle repeats.  And if that isn't bad enough,  the exact same cycle happens a third time!  This isn't about forcing people who've committed no crime to get treatment, it's about a totally broken system, and please note that our book, emphasizing respect for civil rights, is about civil commitment: forced care for those who have committed not crime in a 'treatment before tragedy' concept.   Forcing care on people with a history of committing  violent crimes when they become delusional belongs in a different ballpark.  But again, I'm digressing.

Let me borrow some statistics from the article.  One in 10 homicides in this country are thought to be committed by people with mental illness.  It's a number we hear consistently.  What does that mean?  Are those people with psychosis or does it include people on an SSRI for anxiety? Because 1 in 5 people are affected each year by a mental disorder, and half of all people will suffer from an episode of some type of mental illness during the course of their lifetime.  Some people do kill because they are delusional, and if we are aware that someone is delusional and dangerous, we are obligated to help them, but I can't imagine that is one of 10 killers (and I admit, I could be wrong).  It's possible that statistic includes people with mental disorders that have nothing to do with their decision, or impulse to kill, and that much more violence is about substance abuse and anger, and if you kill someone during an argument, does the fact that you were once treated for a mental disorder necessarily have anything to do with it.  With those statistics, if not limited to severe and active psychiatric disorders (and I'd include all murder/suicides in there, even without psychosis), then I'm going to say that you're safer in a community of people with mental illness than in a community of people without mental illness.

Another statistic: From 2011-2015, 52 people were killed by assailants with known or suspected mental illness and 17 people with mental illness were killed by police.  Maybe it's not relevant, but may I mention that in a single weekend this June, 64 people were shot in Chicago and one person is shot by the Chicago police every 5 days?  In those four years, there were at least 100,000 suicides in this country.  Obviously, we're talking apples and oranges, and obviously we should be making sure that people with a known history of violence due to their illnesses are getting care, but I think the important point here is missing.

All three articles talk about violence.  They quote a psychiatrist as saying that if we care about public safety then we have to do something. They don't talk about the difficulties people have all over the country, and likely in Massachusetts in particular, in accessing care they need and want.  They talk about mental illness as a safety issue.  Mental illness is not generally a public safety issue (and yes, there are obvious exceptions), but for the average person, mental illness is about suffering and getting care is about seeking relief.  Why don't these articles highlight the pain and suffering of someone who wants care and can't get it even if they won't kill anyone?  Maybe they just ache, can't enjoy their kids, can't get out of bed, don't work and live on the street or from government disability payments? It  all seems to be about how the state is lax in trusting patients to take their medications (hmmm, and how hard is it to get those medications, and have you ever tried to get Abilify for a Medicaid patient in Maryland -- it isn't fun and the state wants the patient to fail two cheaper meds first, even if she has a history of a good response to an expensive med).  

From the Spotlight piece today:
Unlike nearly every other state, Massachusetts has refused to adopt a so-called assisted outpatient treatment law allowing court-ordered treatment for people with severe mental illness. Opponents fear it would be misused, forcing treatment on people whose behavior is merely disruptive or inconvenient, not dangerous.
Maybe there are times when court-ordering people to treatment is appropriate, but why would a state spend resources on that when your average person with schizophrenia, bipolar disorder, depression, OCD, anxiety, and PTSD has a really hard time accessing voluntary care?  When someone who wants to be in the hospital can't be because the state has cut their beds by 97%.  When the article also mentions that the state doesn't have adequate mental health courts (where patients agree to treatment and are diverted from incarceration and the state follows them closely and helps them get services), where the police are not specifically trained to work with people with mental illness, which may lower the rates with which they shoot them, and help divert people from jail to treatment (~oh, but they have so little treatment available).  There is this odd assumption that only people who don't want help are dangerous and that we should funnel resources to them first.  

Finally, I'd like to add one more form of perspective here: despite the fiasco of the MA public mental health system, the murder rate is at a 10 year low.  In the entire state, in 2015 there were 133 murders.  6.8 million people live in Massachusetts.  In Baltimore City, we have 600,000 people and years when we exceed 300 murders.  How can the claim be that declining access to public mental health services and the lack of outpatient commitment is a safety hazard when the homicide rate is dropping?

Can we change the conversation? Psychiatric care and substance abuse treatment should be available to those who want it because it's the humane thing to do.  We want to lessen human suffering for everyone, not only the victims of violence, and we want a kind and humane system that helps people to be mentally well members of society who achieve to their potential.  Highlighting the few disasters does just that, but it's stigmatizing.  Hopefully it wakes up the legislation in Massachusetts and gets increased funding and treatment  that is easy to access.

Article number one in the series
Article number two in the series
Article number three in the series
The Spotlight mental health Facebook page

Friday, August 26, 2016

What's up here and our CPN Posts

Oh, my -- it's been nearly a month and that is the longest I have ever gone without posting on Shrink Rap in 10+ years.  Just busy, to the point of being a little overwhelmed at moments.  And the nice part is that some of busy is time with family and time down the ocean, hon (as they say in B'More).  So lots of good busy, and lots of work busy, too.   

I just submitted two abstracts to the APA --proposals for symposia for May's meeting in San Diego.  One is based on the subtitle of our forthcoming book: The Battle Over Involuntary Psychiatric Care and the other is called Outpatient Commitment: A Tour of the Practices Across States.  I do hope they get accepted because there is an amazing group of people who have agreed to speak at these sessions.  I do think this will be the first time a member of MindFreedom International -- a group that traditionally demonstrates outside the meetings in opposition to organized psychiatry -- would be present as an invited speaker.  I do hope our symposia make the cut.  More in the months to come.

Over on Clinical Psychiatry News, I have two recent articles up and Roy has a new column as well.

My editor, the lovely Gina Henderson, asked me what I thought the five most important issues for psychiatry are and here is my post on The Top 5 for Psychiatry.  If you want the short answer: access to care, a need to stop di-chotomizing people into mentally ill versus mentally well,  better treatments, less distracting red tape and paperwork for an overstretched/undersupplied profession, and a more thoughtful look at involuntary care.  

I also wrote an article on Why Psychiatrists' Opinions of Political Candidates Shouldn't Matter and I do hope you'll read this.  I've gotten some nice feedback on the piece so let me know what you think.

And Roy has a new techy column in the last hard copy of CPN, but due to technical issues, it's not up online yet.  I'll let him update you soon.

Finally, 73 days until the damn election is over.  I was ready for it to end 8 months ago.

Thursday, July 28, 2016

Murphy Bill --Now With Guns?

Pretend there's a photo of the U.S. Capitol here.  Blogger is not cooperating.

Let me first send you to Pete Earley's blog to read about the Murphy Bill, HR2646, which was passed by the House of Representatives with a vote of 422-2.  The Helping Families in Mental Health Crisis Act had bipartisian and broad support, but not until it was sanitized of it's controversial issues: patient advocacy groups remained funded, outpatient commitment was de-emphasized, and the right of a  patient with a psychiatric disorder to refuse release of their health information to family/caregivers remained intact (at least for now).

Honestly, as a psychiatrist I was perplexed that these things would hold up the bill.  Access to good -- or any-- psychiatric care is a huge issue in our country.  Civil rights are important, psychiatry has a history of abuses, and patients should have access to advocacy.  HIPAA rights and outpatient commitment pertain a few patients  and while these may be pressing issues in the lives of the parents of the sickest of the sick, they are issues that don't come up everyday for your average psychiatrist.  So was I pleased when the Act was sanitized of some of the more controversial issues and I've deemed the newest version of HR 2646 the Vegetarian Version : not enough meat for the carnivores and too much for the vegans.  And P.S., none of these issues were going to prevent mass shootings anyway.  I just hope that if the legislation goes through, it leads to meaningful change in access to good care for the patients.

So a vote of 422 to 2; It seems we have a pizza bill with bipartisian support and little opposition -- all but two vegans knocked off the cheese and voted in favor.  Surely, such a bill will pass in the Senate, but if you read Pete's blog post, you know that the bill has hit a wall because Senator John Coryn of Texas wants to tack on a gun issue to the legislation.  Pete has gone into the details of the gun legislation Coryn wants to add, and I won't, because really, does it matter?  It's a mental health care bill;  it's not a gun bill.  It's time to separate these issue, and it's not the time to throw a bunch of controversial pepperoni on legislation that  has finally gotten agreement after three years of debate.  

Can we go home now? Oh, wait, Congress left already.

Wednesday, July 27, 2016

Boy or Girl and Are You Sick?

First, let me send you to an article in the New York Times: W.H.O. Weighs Dropping Transgender Identity from List of Mental Disorders.

There are lines we've drawn in medicine: a fever above a certain degree is not normal and indicates a pathological process.  A tumor that will spread and debilitate you is not normal and indicates a pathological process.  To be pervasively sad, uninterested in the things you enjoy, and want to kill yourself is not normal and indicates a pathological process.  And to hear voices and believe that someone is monitoring you when no voice or stalker or agency is there, is not normal and indicates a pathological process.  

In psychiatry, the line gets blurry at times: to be sad, fatigued, and uninterested is normal if you're grieving.  And even with that tumor -- suddenly, as ClinkShrink will tell you -- there is this funny question of whether doctors should remove your tumor or just kill you with physician-assisted suicide.  In some cultures, those voices you hear, or those seizures you have,  may not indicate pathology but visitations from God that hold you not as ill, but as superhuman and special.  You prefer your intimacy with little boys?  In Ancient Greece, it may have been fine,  but in modern America, if you act on it you spend time in prison and get labeled, stigmatized, and restricted as a sex offender for life.  And homosexuality with a consenting adult-- who even notices anymore?  Unless of course you live in Saudi Arabia or a variety of other middle eastern countries where they just execute you.

When I was in training (oh, that was a while ago), Gender Identity Disorder was considered rare and pathological.  Even before that, I remember a lecture in my college Abnormal Psychology class.  The professor was Martin Seligman, well known for his book, Learned Helplessness, and in discussing gender disorders, he mentioned that he traveled a lot and when he woke up disoriented in strange hotel rooms he always knew two things: Where the bathroom was and that he was a man.  Okay.   It was his introduction to his lecture on disorder of gender: it's not normal and you're not supposed to feel like something you're not. I have no idea if Dr. Seligman's ideas have morphed with the decades.

In my clinical experience, it seems that gender identity issues came with a slew of distress.  People with these problems often have other issues as well: problems regulating their mood, self-injury, and a host of emotional and interpersonal issues.  Are these issues part and parcel of Gender Identity Disorder, or are they the result of societal disapproval?  If we just accept transgenderism (is that a word? It should be) as being perfectly normal --or at least not pathological -- would the distress that accompanies it just go away?  Can we create a world where people choose their gender, or where they lie along a spectrum of male-femaleness, and their parents and society are completely open to the idea that one can choose and this is fine?  At what age would we allow for hormonal treatments?  For irreversible surgeries?  Does health insurance pay for these treatments if it's not a disorder?  I have no answers for this, but I find it fascinating that illness --and criminality-- are things of flux that change in time and with culture.  Funny to grapple with in a world where we make such a big deal out of which bathroom you choose to use.

Sunday, July 10, 2016

News. News. And Too Much News.

Oh my, time has been getting away from me  and it's been a bit since I've written a blog post on Shrink Rap!  

First let me steer you over to Clinical Psychiatry News where ClinkShrink has written an article called "New Mexico High Court States that Assisted Suicide is not a Right."  If you surf over, you'll also note that Clink has a lovely new head shot up next to her article.

As I've mentioned before, the Boston Globe's famed spotlight team is doing a series on the trouble public mental health system in Massachusetts.  The second installation went up on July 7th and discusses the roll of the police, and police training, in handling psychiatric emergencies.  It read just a little like the chapter from our forthcoming book, Committed, only I liked our chapter on the police and Crisis Intervention Training much better (perhaps I'm biased?).  In writing our chapter, I was privileged to have the help of Montgomery County PD officer Scott Davis and he is a treasure.  Also, our chapter had more meat to it,  so you can check out the Globe's piece and when Committed is available, let me know which you like better.

Otherwise, I have to say that the news is leaving me rather despondent.  I tend to be an optimist, to have at least a little trust in the system and in the goodness of people, and it's all being tested.  341 million people in this country and we can't find two smart, honest, kind, capable and energetic people to run for president.  The stories of police officers shooting people leave me ill, and the mass murders in Orlando (which now seems to be old and forgotten news) and Dallas, are just horrific.  Baltimore has always been a dangerous city, and the Freddie Gray trials are wearing on us all.  There are protests, sink holes, random murders of children.  In the last two days, a former Hopkins professor was murdered while walking her dogs (the assailant remains at large) and a 21 year old young man in the suburbs was shot and killed while walking his girlfriend home.  Between the election and the crime, I may be due for a social media vacation.  I'm sad.  Can't we make America Kind Again?

Monday, June 27, 2016

Guns and Violence

Oh there is so much to say and so little time.
I'm sending you to two different sites today:

My post on Guns & Mental Illness over on Clinical Psychiatry News.  It never fails to amaze me that suspected terrorists get due process before losing their  constitutional rights to own a gun, but law-abiding people with psychiatric disorders have no such rights.   Please do read my article and share you own thoughts here.

And the famous Spotlight group of the Boston Globe is taking on the failures of the mental health system in Massachusetts. They start with an article about mentally ill people who murder their families.  Oy.  The article was good,  and access to care is an enormous problem.  And unfortunately, the sensationalism is stigmatizing at a time when we are trying to get rid stigma so that people will not hesitate to seek the help they need.  But if you show up for help, you may be forced into treatments you don't want, lose your gun or your career, and be looked at as a potential mass murderer and family killer.  And at least some of the people with mental illnesses kill family members for reasons unrelated to their mental illness -- like others who kill, they are angry &/or intoxicated but not necessarily psychotic.  Most end up in prison, found to be responsible for their acts.  And some are actively in treatment at the time they commit violent acts, so psychiatry may not be everyone's answer.  There is a facebook group for those who want to comment, so I'll send you there for a rich conversation with input from everyone with an opinion.

Monday, June 13, 2016


No, not again.  I looked at my Twitter feed and learned about yet another mass shooting.  

I can't even imagine what it's like to feel the kind of fear the people in that nightclub felt, to die in such a horrible way, to live with the aftermath, or to be a family member and know that someone viciously targeted my loved one and purposely inflicted such horror on them.  My heart goes out to the victims and their loved ones, and I'm so sorry they are going through this unnecessary tragedy.

I heard on the news that the gunman's ex-wife said he was physically abusive and mentally unwell, but I don't know if there was a clinical diagnosis or simply the observation that he was an angry and violent person.  She also has not seen him in 7 years, and if he mentally ill, he has been able to hide that fact from his employer.  The press reported that he was steadily employed for nearly nine years and his employer, a security firm, did not see this coming.  I say this only because the initial news reports seem to imply that the gunman was a radical extremist, twice investigated by the FBI as a terrorism suspect, he obtained a military-grade assault weapon legally, and he called 911 during the event and pledged his support to a terrorist group.  What does this have to do with psychiatry?  If the facts are as they now appear (and they may change or be slanted by the press),  but the answer is Nothing.  The Orlando terror/hate mass murder, as currently reported, does not seem to be about something in the realm of psychiatrists.    People who sign on may be angry --I believe it takes anger to kill innocent people -- but so far, we're not hearing that there is something here for psychiatrists to treat, or that if only he'd sought help, this never would have happened.  But these days, we talk about mass murders as defined by the number of victims in a public place, and terrorists get lumped together with those who commit such acts because of delusional states.  

And just in case you missed it, an Indiana man was arrested in LA with a car full of assault weapons and explosives, perhaps enroute to a Gay Pride parade, on that same day.  The horror of the day could have been even worse than it was.

It's no secret that I believe gun control measures would help.  I don't believe they would prevent all the deaths that guns cause, and there are certainly other ways that terrorists have of killing people.  We saw that on 9/11 and we saw that with the Boston Marathon bombing.  But I find it strange that we allow for the manufacture of firearms that enable one person to kill dozens of people within minutes, we allow for the easy access of these weaponsby civilians  (even a previous terror suspect with a history of domestic violence)  and then we're surprised when people buy these weapons and use them for exactly what they were made to do: kill lots of people quickly.   Should we ban them? Of course.  They are not a household item that anyone needs, and while we will still have terrorism and hate crimes, there is no reason to hand terrorists or haters the easy means to their evil end. 

It's funny, because after the fact, there is blame, finger-pointing, and questions of who missed what and how could we not have known.  Who should have seen it coming?  Yet know one says, when someone buys an assault weapon with lots of ammunition, maybe a flag should be raised. Maybe someone should go ask this person why they need such a weapon, check up on their history, look at whether the weapon is being kept securely and whether someone else in the household who should not have a gun might have access to it.  Or maybe we simply shouldn't have assault weapons as legal machines to be owned by any citizen who wants one, short of felons.  

No, I'm not suffering the way the victims and their families are, but each one of these events takes just a little out of all of us.  Whether it's a an act of terror, an act of hate, an act of violence perpetrated by someone who is very ill, or routine gang violence that we see in our city everyday, it touches us all.  I hope this does not leave you afraid, because if it does, the terrorists win.  

Saturday, June 04, 2016

Book Review: Ordinarily Well: The Case for Antidepressants by Peter Kramer

My post for today is a review of Peter Kramer's new book over on Clinical Psychiatry News.  You may remember him from Listening to Prozac, and he's back now with more on the science that supports the use of anti-depressants.

The review of Ordinarily Well can be read here: