Call the Police

What should you do if you believe someone is dangerous?  It's a sticky issue in psychiatry.  Here in Maryland, the requirements to have someone brought to an emergency room for evaluation by two physicians, include an imminent risk of dangerousness and the presence of a mental disorder.   If an emergency petition is signed by a judge, the police pick up the person in question and bring him to an emergency room for an evaluation.  In the ER, doctors can decide to certify the patient to an inpatient unit for further evaluation, or they can release the patient.  If admitted, a hearing must be held within 10 days.

Who else can file a EP?  Well, the police can.  If someone acutely agitated and violent and there is no time for a family member or interested party to obtain an EP, the police can be called and they have the option to fill out an EP and take the person to the hospital without a judge okaying the EP.  Depending on the circumstances, they also they have the option to arrest the individual and bring them to jail.   Finally,  a doctor can file an EP, but s/he must have seen the patient (--you can't get tell your rheumatologist-neighbor about your ill relative and get him to file an EP). 

So the police come -- either because they've been called in an emergency, or because a judge has authorized them to take someone to the hospital.  Most of the time, this goes smoothly.  But it doesn't always, especially since the person involved is presumably mentally ill and dangerous (the criteria for getting the evaluation).  Sometimes things get very upsetting, and sometimes they go very badly and someone gets hurt. 

In today's Baltimore Sun, there is an article by Justin Fenton that questions whether our police have the proper training to handle these crisis situations:

Baltimore Police have shot 10 people this year — eight of them fatally — leading some to question whether police are properly equipped to handle calls involving the mentally ill.

Only one of those shot was carrying a firearm, and several shooting incidents arose from calls to police about a disturbance involving someone with a mental illness. Relatives of some of those killed criticized police tactics, saying they shouldn't have lost loved ones after calling police to defuse situations that had ended peacefully in the past.

These are difficult situations, sometimes with no answer that will lead to a good outcome.   Fenton continues:

The director of the city's mental health organization praised the Police Department's training effort and said services for the mentally ill are lacking.

"If we don't do a good job getting people into treatment and something bad happens, we look to the Police Department and ask why did this person get shot," said Jane Plapinger, the president and chief executive officer of Baltimore Mental Health Systems. "Maryland is one of the best, but we unfortunately have an underfunded public mental health system everywhere in this country."

The Behavioral Emergency Services Team, or B.E.S.T. training, was implemented in 2009 and teaches officers to de-escalate mental crises, minimize arrests, decrease officer injury and direct patients to the city's mental health crisis programs for help. It has become mandatory for recruits.

"The police have been such a steadfast partner — I don't know how many [other] police departments are devoting four full days to this kind of training," Plapinger said.

The patients aren't the only ones in danger.  Police officers, or others, can be injured in these struggles. While it's not like there is an obvious answer besides calling the police, if the situation does not involve immediate danger, I often suggest that family member work to de-escalate upsetting situations and  convince a patient to go for help voluntarily, or with coercion, because even if it's coerced, these situations are often less upsetting for the patient and less dangerous for everyone if they can be done without the police.  Of course, this involves 20-20 hindsight, and the use of a crystal ball, because if there is a bad outcome and someone is injured or killed, then calling the police would have been a better solution.

I do wish I had that crystal ball. 

Florida Don't-Ask-Don't-Tell Gun Law Modified

Here's a follow-up to my March post about the Florida bill to outlaw physicians from asking their patients about access to firearms. Dinah later posted about the effects of the bill on pediatricians. The bill passed, though it was amended to remove the jail time and the potential $5M fine (a bit excessive?).

The Florida Medical Association originally opposed the bill, but now has expressed satisfaction with the compromise language. In March, Asher Gorelik, M.D., president of the Florida Psychiatric Society (FPS), expressed to Psychiatric News his membership's opposition to the bill, particularly “a great deal of concern about how this law would interfere with the ability of the healthy to properly assess a patient.” But in a recent follow-up interview, Gorelik stated that the new language in the bill “no longer interferes with the ability of a healthy to perform a risk assessment.

~Psychiatric Times

Those Privacy-Invading Pediatricians, Silenced!

A while back, Roy blogged about proposed legislation in Florida that would make it illegal for physicians to ask patients if they own guns. What the??? Since when do we legislate what people can ask each other, outside of discrimination issues for jobs? And is there any precedent for legislating the conversation that occurs between a doctor and patient? So apparently this is going to pass, and Greg Allen writes in "Florida Bill Could Muzzle Doctors on Gun Safety,"

Florida Gov. Rick Scott is expected to sign a bill that will make the state the first in the nation to prohibit doctors from asking patients if they own guns. The bill is aimed particularly at pediatricians, who routinely ask new parents if they have guns at home and if they're stored safely.

Pediatricians say it's about preventing accidental injuries. Gun rights advocates say the doctors have a political agenda.

Ah, it's not about us shrinks, it's okay to ask if there is a question of danger. It's about the pediatricians. Personally, I think the pediatricians should fight back: if they can't ask who owns a gun and target their gun safety remarks, they should give extensive gun safety instructions and literature to every parent at every visit. Perhaps as a statement of unity, all pediatricians in all states should discuss gun safety with every patient, no questions asked.

Doctors to Go to Jail for Asking Patients About Guns in the Home

Imagine the scenario where you are an ER physician, nurse, or social worker and a person is brought to the hospital by the police for making a suicidal threat.

"I want to die. My wife left me and our house is in foreclosure."--"Do you have any plans to harm yourself?""My dad shot himself when I was little. That's how I would do it."--"Do you have any firearms at home?""OFFICER! Can you arrest this social worker? He just asked me if I have guns at home."[officer]: "Come with me sir. You have the right to remain silent..."

This is the scenario that could actually happen if Senate Bill 432 passes in Florida. The bill makes it a felony to inquire about firearms access or to include any information about firearms access in the medical record, punishable by up to 5 years in jail and/or a $5 million fine. Excuse my French, but WTF?!

An article in the Psychiatric News by Bob Guldin explains that the bill was introduced in both the House and Senate at the suggestion of the National Rifle Association (NRA) to prevent intrusion into the constitutionally protected right to bear arms.

It has been shown that removal of firearms from the home reduces the risk of a completed suicide. So you'd think such a bill would get laughed out of the legislature? Florida child healthy and APA Assembly recorder said, "This bill is not a stunt... the financial power of the NRA in Florida will make it very difficult for sensible legislators to vote against this bill."

I note that a second version of the bill has been proposed, one that reduces the fine to a minimum of $10,000 for the first offense and a minimum of $100,000 for the third offense. It also reduces the offense from a felony to a "noncriminal violation" and compels the states attorney to pursue a possible violation or face professional misconduct charges. This version does permit certain health care providers to ask the question only in certain specific situations (e.g., an emergency "mental health or psychotic episode") but cannot tell anyone else other than the police. Apparently, a similar bill passed one house in Virginia five years ago before dying.

Next will be a bill that outlaws common sense.

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Clink comments: We've talked about issues related to guns before here, in Dinah's post "Guns and the Mentally Ill" and again when I mentioned a poster session that talked about gun ownership laws nationally. At my last American Academy of Psychiatry and Law conference I mentioned that 27 states have statutes with lifetime restrictions on gun ownership for people with mental illness. Other states have time limited restrictions on ownership, and some allow restoration of full rights contingent on a physician's documentation of recovery.

So now we have a dilemma: in states where you need a physician's certificate to buy a gun, how can that same physician then be banned from asking about ownership?? I can imagine the session in which a patient comes in to be "cleared" to buy a weapon.

MD: "Well, you're taking your medicine and your symptoms are all under control. You tell me you're feeling well and you'd like to buy that awesome weapon you've been dreaming about."

Gun buyer: "Yeah! I've done the research and I know exactly what I want."

MD: "I need to know whether you have cognitive skills and emotional stability to handle a responsibility like that. Tell me, have you ever owned a gun before?"

Gun buyer: "Awesome!! Now I can sue you for infliction of emotional distress for violating my Second Amendment rights. Those triple damages will really help me stock up my arsenal."

Bottom line: The NRA can't have it both ways. If they involve healthys in restoration of gun rights, they can't ban them for asking questions about ownership.

Guns and the Mentally Ill

On Facebook, I'm a fan of NY Times Reporter Nicholas D. Kristof

Mr. Kristof's status reads today:

Nicholas D. Kristof

Just in case Pres. Obama visits my FB page, what should we suggest for his State of the Union speech? My hope is that he calls for banning oversize ammo magazines, like the 33-round one used in Tucson. Even Cheney favors a ban on them. And gun serial numbers that are harder to scratch out. And tighter restrictions on the mentally ill obtaining weapons. Your thoughts? Other suggestions for the President?

I'm not an NRA member (this is my disclaimer here) and I've never had much use for guns. But I had thoughts about the issue of "tighter restrictions on the mentally ill obtaining weapons."
I wondered what that meant and how one defines "the mentally ill." Oh, and my second disclaimer here is that I don't know how current regulations work in determining who is mentally ill with regards to purchasing a weapon. I've never reported to any central source any information about who I'm treating so they can't buy guns and no one has ever asked me to sign off on a gun permit. I'm not sure how it's determined that someone has a mental illness and shouldn't own a gun.

It doesn't take very much to get yourself into the range of being 'mentally ill.' Knock-on-door community studies, known as the ECA studies-- meaning Epidimeologic Catchment Area-- show that over half of all people have an episode of mental illness at some point. This includes phobias and anxiety disorders. NAMI tells us that one in five people have a serious mental illness.

Some of the people who commit crimes with legal guns haven't sought treatment. If you haven't gotten a diagnosis, how can you be designated mentally ill for gun ownership? Does gun ownership get designated by diagnosis? Certainly, owning a gun is not a great idea for a person with brittle bipolar disorder who gets violent and impulsive. But we all know that the diagnosis of 'bipolar' disorder has become a bit loose and over-inclusive. An angsty teenager sees a healthy and is diagnosed with bipolar disorder. If he does well later, should he be forbidden from buying a gun at the age of 40? I believe one standard is a psychiatric hospitalization for over 30 days, but I'm not certain how--or if-- that's reported.

I suppose we worry about the Big Brother aspect here. Maybe instead of "mental illness" the standard should be that if college student is expelled, or an employee is fired, for certain behaviors then they are reported to a 'no-guns' data bank. Then you'd capture violent and threatening people who have not sought treatment but may well be dangerous. Oh, I'm just mouthing off here about something I admit that I know little about. But I hate finding one more thing to stigmatize mental illness over in a way that is not likely to effectively decrease gun violence.

Have a happy Facebook day, Mr. Kristof.

Any thoughts?