Friday, December 28, 2012
Monday, December 24, 2012
The APA put out a statement in response to the NRA's recommendation to put armed guards in every school. Quoting from the statement:
“Only four to five percent of violent crimes are committed by people with mental illness,” said the APA’s president, Dilip Jeste, M.D. “About one quarter of all Americans have a mental disorder in any given year, and only a very small percentage of them will ever commit violent crimes,” he added.So Dinah sent me an email asking this question:
"So if 1/4 of all people have a mental illness in any given year, and 56% of people have a lifetime incidence, then why are only 4-5% of violent crimes committed by people with mental illnesses? It might seem that we'd all want to be mentally ill so we wouldn't be violent."My answer to that is:
Only 4-5% of crimes are committed by mentally ill people because most violence is due to personality disorders combined with substance abuse, and once you combine that trifecta the number of people at risk of committing violence drops quite a bit.
Here are the prevalence rates:
ASPD 15% prevalence (per ECA study)
MI 25% prevalence
SA 10% prevalence (per NIDA)
The population of the US at this minute is 314,996,054 (US Census Bureau). So, at any point in time now we've got:
|MI alone||79||314,996,054 x .25|
|MI + ASPD + SA||5.9||314,996,054 x .25 x .15 x .1|
|ASPD + SA alone||4.7||314,996,054 x .15 x .1|
In other words, very few mentally ill people commit violence crimes because most of them don't have the main necessary risk factors. And there are relatively few people with ASPD running around so that when you throw in the MI folks it doesn't increase the pool that much. And when it comes to violent crime, a disproportionately small number of people commit the majority of offenses. The relative risk of a small number of violent offenders outweighs the small number of mentally ill people who have the trifecta. Does that make sense?
Ugh, I just spent far too much time trying to get the table formatting right and then Blogger messed up my HTML code. I give up. And I can't believe I'm writing about this the day before Christmas.
Oh yeah, one more thing:
The APA response dings the NRA for conflating mental illness with "evil," and criticizes the NRA for using the term "lunatic." I'm going to ding the APA for referring to my prison patients as "evil." I'm going to object to that, big time. The people I treat may have poor judgement, may have substance abuse problems, may have done awful things during desparate times, but I have met very few truly evil people even in prison. Demonizing and dehumanizing criminals is a very very bad idea. These people are part of our society, they will be coming back to our cities and neighborhoods some day, and it does nobody any good to say that my correctional patients are evil people. Please.
Sunday, December 23, 2012
For the next 5 days, my three novels will be available as a free download to Kindle.
Double Billing is the story of a woman whose life changes when she discovers she has an identical twin she never knew existed. It's a short book and is intended to be a quick read. So I think it's my best shot at fiction.
Home Inspection is a story told through psychotherapy sessions in a format that is similar to the HBO series In Treatment. Dr. Julius Strand is a psychiatrist who plods along in his already-lived life until two of his patients inspire him through their own struggles to find love.
Mitch & Wendy : Lost in Adventure Land is about two siblings who are struggling with their relationships in the aftermath of their parents' divorce. The story takes place on Wendy's 10th birthday when the kids get lost in an amusement park, only to learn they are being followed by a man who knows all about them from Mitch's misguided Facebook life. Written for 4-5th graders, or the very young at heart.
If you don't own a Kindle reader, you can install a free Kindle app on your computer, tablet, or cell phone by going here and then you can read any Kindle book.
All three novels are also available as as paperbacks from Amazon.
Rather than giving different links to all these books and formats, there is a single link to my Amazon page with all the options here.
I'm more than happy to have people download my novels at no cost -- I'll be keeping the doctor day gig -- so please tell/tweet/blog/share the free promotions to anyone you think might be interested.
Finally, If you do read any of the books, please consider putting a review on Amazon.
Thank you so much and enjoy the season.
The Accessible Psychiatry Project
Saturday, December 22, 2012
Okay, so today was my first day of vacation. I baked cookies, watched TV, cooked a gourmet meal, saw my family. I tried moving the laptop to another floor so I wouldn't be attached to it, but within an hour or two, it made it's way back downstairs. I didn't leave the house, didn't do any work, have my voicemail set to send callers to a covering doctor. Ah, but here it is, Saturday night, and what am I doing? Yup.... blogging.
So what do you do to unwind? Do you have trouble disconnecting?
Wednesday, December 19, 2012
Please, please, I must beg your forgiveness before posting this. Sometimes, I just wish the world made sense, and it doesn't. I should get over it.
There is the story of a psychiatrist in France who was criminally charged with murder because a patient left and then, 20 days later, killed someone. The psychiatrist was found guilty and I believe she paid damages. I think ClinkShrink may write about this on Clinical Psychiatry News in the coming weeks, but for now, I just couldn't resist the sarcastic pull that overtook me when I saw this...the psychiatrist guilty for another person's murder, the horror of our gun laws, and the ridiculous new CPT codes we will all soon be using. If you are touchy about satire, please don't read anymore.
French psychiatrist jailed for patient who committed murder
Sunday, December 16, 2012
Like many, I have been drenched in sadness this weekend. In honor of ClinkShrink's wisdom that media coverage of tragedies leads to more such atrocities, I will talk in generalities.
When a public tragedy happens, it gives us reason to relate it to the issues we naturally advocate for. I am no exception, and I've been posting articles on my own Facebook page in support of gun control. I especially like this article by Nicholas Kristof, "Do We Have The Courage to Change This?"
Mass shootings bring up the issues of gun control, adequate treatment of the mentally ill, and the combination of the two, as President Obama has put it, oh so in-eloquently, “Enforce the laws we’ve already got. Make sure we are keeping the guns out of the hands of criminals… Those who are mentally ill." And finally, there are what I'll call the Out-in-Left Field assumptions.
Let me take it systematically:
The Out in Left Field Assumptions:
It seems to me that sometimes people are quick to make assumptions, to fill in the blanks using their own stories. On Friday, someone I follow on Twitter posted that the perpetrator's mother (at that point, thought to be a school teacher), was probably bullied at school and the son was doing her "dirty work." I was floored at the assumptions that were made there, with no evidence whatsoever, and I no longer follow that person's tweets.
The Problem is The Mentally Ill People and the Care They Are or Are Not Getting:
On a blog called The Anarchist Soccer Mom, a woman posted about her own son's problems. Her 13-year-old is violent, unpredictable, and sometimes dangerous. He has been hospitalized and she's had to hide sharp objects and call the police. Treatment with many medications has not helped, and she's been told by a social worker that unless he gets into the legal system -- presumably by her pressing charges-- little more can be done (note that this is a child who is in treatment, not an adult refusing care) and she finds that answer inadequate (it is). I don't know enough to comment on the quality of her son's care and whether or not there is more that could be done if only the resources were available --she does say she has health insurance. But what troubled me is that the Huffington Post reprinted it with a title asserting that she is the shooter's mom, naming the gunman in the most recent tragedy. I understand that she worries terribly that her child could do something awful and that she is frustrated by the inadequacy of a system that has been unable to help her child, but so far, we don't know that the shooter in question was anything like her son. We've heard he was smart, quiet, withdrawn, and may have had a diagnosis on the autism spectrum. So far, we've heard nothing about violence or hospitalizations. And since I'm asking people not to make assumptions, I will tell you that I am making the assumption that the Huffington Post renamed her piece with a provocative title.
As of this writing, we know little about the mental health history, or care, that the most recent gunman requested or received, and we have reason to believe that his family may have had resources to obtain care for him. In other instances, shooters have been in active treatment, or have had a history of a single, or a few, visits to student mental health centers, sometimes in the remote past. In retrospect, on any case with a mass shooting of strangers, it's obvious that the mental health care rendered was insufficient, but whether there is something that can learned to prevent future such events remains unclear. These shooters tend to be male and isolated -- that would be a lot of people to round up in preventative measures. While I certainly believe that our mental health services are inadequate, we aren't hearing that shooters were people trying desperately to access care but were unable to do so. Sometimes they are people that a mental health professional or an educational institution was concerned about. And while some gunmen have sought treatment at some point and then fallen through the cracks, it's not always clear that having laws that would make it easier to commit someone would make a difference, or that we want to become a society where people can be forced into treatment because they fit a profile. Nevertheless, Newser linked to the Huffington Post anarchist soccer mom's Huffington Post title with the statement,"It's time for a meaningful, nation-wide conversation about mental health. That's the only way our nation can ever truly heal."
Yes, we need better mental health care. And I do think that if we had a kinder and gentler system of involuntary treatment that didn't upset and traumatize people, then there might be a lower threshold to getting help for people, but I'm not sure that would prevent all these tragedies. It's one way we can begin the process of healing, but it's not the only way. Do we ever really heal from something like this?
Keep the Guns Away from the Mentally Ill
On Pete Earley's website, he talks about how troubling it is when a mentally ill person commits a heinous crime because it further stigmatizes his son who is not violent, but has suffered from a psychiatric condition. I'll let you read his post, because I'm not sure I'll do it justice.
Unfortunately, Mr. Obama, I'm not sure how one goes about keeping arms away from the mentally ill. I'm not even sure who those mentally ill are, given that a gazillion people take psychotropic medications and door-to-door surveys show that over half of all people suffer from a psychiatric disorder at some point in their lives. It seems that disturbed people sometimes obtain guns legally because they aren't ill enough to be identified by the system (for example, if they haven't been hospitalized or criminally charged), or they are related to someone who has legal guns and they use those. And people who are well can buy guns and then later become mentally ill, if you think it's an issue of "those people," think again.
It sounds good -- obviously suicidal or homicidal people shouldn't have guns -- but I don't know how it translates into something useful in terms of legislation.
Okay, you can fly a plane into a building, knife multiple people in China, blow up a federal building with fertilizer, or jump off a bridge. We are never going to prevent all murders and suicides, but gun possession allows for a level of lethality that isn't seen in such numbers when people have impulsive violent moments, have had a little too much to drink, or leave their guns where children can play with them, or disturbed people can take them. We probably can't round up every young man who is isolated and distressed, but we probably can question everyone who purchases large amounts of ammunition, or make it illegal to own high-velocity weapons.
Dr. Erik Roskes, a forensic psychiatrist, notes about the astounding number of gun deaths,"Those victims far outnumber the victims in Connecticut, Colorado, etc on an annual basis, and many would not be dead were it not for easy access to handguns. Many more people die due to impulsive shootings than due to the planned acts of the perpetrators of the mass tragedies - yet because they happen one at a time, there are no headlines. It is not too soon - it is never too soon - to rethink our antisocial national approach to weaponry."
I don't know if we'll find out what happened last week, whether this tragedy was planned or impulsive, the result of anger or psychosis, illness or evil, or whether this, or other similar tragedies, are preventable in a society that values the right to bear arms and the right to refuse psychiatric treatment in the absence of stated imminent dangerousness. Making assumptions is not helpful.
~Yes, we need better access to mental health care, whether or not such care helps prevent tragic, senseless acts that effect many people or one person.
~Perhaps we want to re-think our threshold for involuntary treatments, but that certainly will not capture every potential mass murderer. If we do so, we want a system where accessing treatment is fast, easy, non-stigmatizing, humane, and respectful.
~We need to re-evaluate our gun laws, now.
I'll go back to my sadness now.
Thursday, December 13, 2012
I will be one of the two experts, tweeting from @HopkinsMedicine.
@SharecareNow is hosting an expert-led Twitter chat to help you stress-less this holiday. Join the community discussion, bring your questions and concerns and connect with experts who can help you clear the noise and stay calm and cool this holiday season.
Join the chat Friday, 12/14, 1-2 PM Eastern Time (US) on Twitter.
Follow hashtag #Calm&Cool.
Oh, and if you'd like to tell me how you deal with your holiday stress, I'd love to have you comment!
Monday, December 10, 2012
Behind all the anxiety of new CPT codes-- because change is hard-- there is not just the angst of more paperwork, or the question of whether gathering specific data distracts from the work of caring for the individual patients. We wonder whether the burden of new billing systems and more documenting for the sake of being able to code like "real doctors" will actually translate to higher reimbursements. More than that, though, there is the fear, which lately does not go unspoken: the fear of doing it wrong and being accused of insurance fraud. Our presenter at a CPT training seminar warned that down-coding is just as fraudulent as up-coding, and my feeling is that we should accurately code the work we do within the confines of the very complex Evaluation and Management schedule, such that our services do get higher reimbursement --- it's difficult to follow but it's either about collecting the right number of bullet points in each category or it's about spending more than 50% of time counseling and coordinating care. Funny, now psychiatrists have to talk more than they listen. Yet everyone I've spoken to says they code low because they don't want to draw attention to their work and don't want to be accused of fraud. I suggested that this is wrong when the doctor is paid a salary and so the hospital collects lower fees. I also think it's wrong when the doctor is out-of-network and the patient's reimbursement, from their health insurance company with those very high premiums and very low reimbursement for expensive psychiatric services, depends on the code.
Some docs are just trying to ignore the upcoming changes, especially those in small private practices. Insurance companies don't typically audit charts of solo practioners who are not in their networks. It's likely rare that Medicare does either, unless perhaps something looks fishy? So some say, "they won't bother me." Others say, they're coding low to stay off the radar, and at least 2 docs I know are opting out of Medicare, because Medicare audits are scary with their $10,000 per claim fines. (Am I right about this?)
Emailed to me today, with the actually title, "They'll Come Knocking":
Of course this company is selling their services and they are doing it through scare techniques, but still.
Friday, December 07, 2012
(note, I corrected a zillion typos and added a little)
Thursday, December 06, 2012
The way mental health clinicians code their services for insurers is changing on January 1st. A minor thing, a really boring & tedious thing, but I decided I'd learn about it to write about it (oh, I have, but instead of writing, I call it Ranting) and make YouTube how-to videos on how to do the new coding.
Only the new coding takes something that was simple and self-explanatory and makes it really complicated -- it requires courses, manuals with more layers of charts and graphs and algorithms then you want to imagine, and it's all done in a way that has nothing to do with how psychiatry is actually practiced (it's about asking questions to get enough bullet points on your template). I'm seriously considering resigning from the APA over this-- they wanted and supported these changes that make something so simple into a pain, and could potentially be yet one more distraction from taking good care of patients. There are now 21 ways to code a psychotherapy session. However, if you want to learn about the new coding, I'm pleased to report that after hours of technologic hell involving PowerPoint, iPhoto, GarageBand, and iMovie, I now have 4 videos on YouTube about CPT codes for psychiatrists. Thanks to Clink for emailing me a brief how-to list, but in the end I did it all by myself!
It's not looking like the insurance companies have changed their coding for next month, and many people don't know how to do the new coding, so if you're a patient waiting reimbursement, you might want to make sure your therapist/shrink knows to code the new codes (which might not work) and you might want to stay on top of the insurance company. And if you're a mental health professional who gets reimbursed by insurance, you may want to make other plans for that mortgage.
I will tell you that Roy is all in favor of the changes and thinks it's going to lead to much better reimbursements for psychiatry now that we'll be billing like the real docs do.
If you watch these, coffee first. They are really boring. And I think they are only of interest to psychiatrists.
Please do write in the comment section if you find other errors, I will correct them.
Tuesday, December 04, 2012
Monday, December 03, 2012
Note from Dinah: This looks like something Roy would draw on his iPad.
Sunday, December 02, 2012
You know how ClinkShrink writes to us about the AAPL (the Amercian Academy of Psychiatry and the Law) conference every year? Our friend and colleague, Dr. Judith Kastenberg in Philadelphia has offered to do a similar guest post about what is going on at the American College of Neuropsychopharmacology (ACNP). From Florida, Judy writes: