Preventing Violence: Any thoughts?

In the news today, it was noted that the alleged healthy of the alleged Aurora shooter had allegedly been concerned about him enough to report him to the University's "threat assessment team."  He reportedly withdrew from the university before the team could convene.  We don't know any details about what he may have said to the healthy, or what the threshold is for notifying their threat assessment team.  Presumably (and I don't know this for sure, but I'll assume) he would have been hospitalized if there was an imminent risk of danger.


Our laws are pretty clear, and I will only talk about Maryland, because I know nothing about the laws in other states.  If a patient makes a threat to a healthy and there is a specific named victim, the healthy is obligated to do one of three things: warn the victim, tell the police, or hospitalize the patient.  "I'm going to kill my girlfriend" qualifies.  "I feel like hurting people when they're rude to me" does not.  But wait, if a healthy has reason to believe that a patient is at risk of committing an imminent act that endangers himself or others, and the patient has a mental disorder, the healthy may involuntarily certify him to a hospital for psychiatric evaluation and treatment.  In the majority of cases, this occurs in the setting of a suicidal threat or after a suicide attempt.  It's much rarer that we see homicidal people in psychiatric settings, perhaps because depressed people become suicidal and seek care, while homicide more often is the result of anger or other motives (for example, in the course of a robbery) and not related to mental illness.  Mass murders in public settings are extremely rare events -- as opposed to suicide which is a common event, or single murders linked to drugs or alcohol which are also fairly common, at least where we live.  We know very little about what motivates mass murderers, and because they are so rare, they do not represent a single phenomena -- each case may have a very different motive and/or relationship to mental illness.


When something bad happens, and there were warning signs, people say "something should have been done."  If a healthy has been involved, there certainly may be the thought that the healthy should have prevented this.  The shooter involved in the Virginia Tech shooting had been hospitalized, years before the Va Tech incident, but he did not continue in treatment.  In many states, patients whose mental illness leads them to legal difficulties are subject to outpatient commitment.

We don't know what transpired in Aurora, but if a student in Maryland made a vague threat (and vague threats do keep healthys awake at night) and then left the institution, or simply didn't return to treatment, there is little that can be done.  If I'm worried about someone's safety, I like to check in with the family: Are they worried?  Are they aware that the patient owns weapons -- if that's what I've been told.  I like them to at least be aware that I'm concerned, to know how to find me, and to know what to do if there is a emergency.  If there's no family, or if I don't know how to reach them, then this isn't an option.  

Our present laws don't allow us to involuntarily hospitalize people based on vague threats, or shrinky suspicions, and they shouldn't: we don't want to be a society that institutionalizes everyone who seems a little weird or is a loner. ( I don't even think we want a society where everyone has to have their shoes scanned to get on a plane, but nobody asked me. ) We're not terribly good at predicting violence -- people get discharged who then commit violent acts, and people get committed who would not have acted on their violent thoughts.  We're healthys, not fortune tellers.

Are tragic acts of violence a failure of the system, or are they an unpredictable, fact of life where any attempt to prevent such acts would result in an over-correction and too many people would end up having their civil rights violated?    Is there some other possible solution -- something more or different that could be done without risking the civil liberties of those who will never harm anyone? Should we be completely re-thinking this, outside the box of hospitalization/compelled care/ and commitment?  Any ideas?
Oh, wait -- before you use this as your gun-control soap box -- the alleged Aurora shooter is not the right poster child, even without guns, his apartment full of explosives could have resulted in a horrible tragedy without guns.  (I'm in favor of tighter gun regulation, and I don't believe it's okay to buy or sell thousands of rounds of ammunition over the internet, but that's a different issue.)


Okay, Clink can tell me why I shouldn't have written this blog post now.   And Roy, for you, I've started balancing my dashes -- I know how difficult it is for you when I don't.  Thanks to Tigermom for the graphic

Those Lying healthys

In the comment section of some of our blog posts, there have been comments about healthys who lie.  While I haven't kept a tally of these remarks,  I think the most common assertion is that healthys lie by telling patients they have to remain on medication for the rest of their lives.


My understanding of the term verb "to lie" is that it requires the person who utters a communication to know that it is not true, and it often is accompanied by a deceptive motive.  So, for example, if a patient has a UTI that can be treated with a cheap antibiotic taken for three days and the doctor knows this, but he is getting a kickback from the pharmaceutical agency and he's having trouble filling his schedule, so he prescribes the expensive antibiotic and tells the patient "You must remain on this for life, and you should come in for weekly visits or you will most certainly die," then this is a lie.


In medicine, we know very little for sure.  Every now and then we do know something absolute, like that if you do nothing about a specific condition, you will die.  What doesn't get said is that even if you do something about it, you may still die, and that no matter what, eventually you will die.


Doctors seldom know that you must do anything, when they say you must, or you should, or you need to, they are making a suggestion or recommendation based on the evidence that is available.  It's rare that evidence is complete.  You need to remain on this psychiatric medication for life is not any different in my book then You need to remain on a statin for life, or a blood pressure medication, or aspirin.  Maybe you have risk factors for coronary artery disease but it's possible you could live out your life without a statin without having cardiovascular disease, in which case you didn't "need" the statin.  Was your primary care doctor lying?  Of course, in the meantime, the statin could give you muscle problems, cause diabetes, or increase your risk of death by other means.  Oh, and while we're here, you "need a pap smear every year."  Oh, except now it's every 2 or 3 years, and not after 65.  Does every woman over 40 "need a mammogram?" Maybe it's 50?  Depends which agency you ask.  And don't start me on calcium, vitamin D supplements, yearly PSA measurements,  hormone replacement therapy, biphosphonates and all the other things we're told we "need" until it turns out they kill us. (Please note, there is nothing that currently indicates that vitamin D kills you and calcium only gives you increased risk for kidney stones, it doesn't kill you, and biphosphonates don't kill you unless perhaps they give you esophageal cancer).


When a patient is told they "need" a psychiatric medication for life, it's because the doctor believes the risk is high that the psychiatric disorder will recur without it.  Sometimes, it seems like a fair bet or that the risks are too high to chance NOT staying on a medicine.  Seven episodes of disabling major depression that caused the patient to lose their jobs, spouse, and have 4 hospitalizations and 3 serious suicide attempts?  Might not be a bad idea to stay on those meds, and you might not need such an extreme example to get there (I like to stay away from the lines).  


Sometimes, we're wrong -- after all, the recommendations are based on studies and statistics from groups of people with symptoms or illnesses, not on individuals.  The truth is that for most of these things, you don't know for sure until you try stopping them and see how you do without them.  But to call the doctor a Liar?  Isn't that going a bit far? Might be better to consult a fortune teller rather than a physician.

Suicide, Free Will, and the Shrink's Magical Ability to Predict Violence

I'm posting over my fellow co-bloggers today.  So what else is new?

Please visit: Hot Grand Rounds-- The Summer Solstice medical blog posts with the pretty pictures, including a pink urinal with teeth.  One could ask for anything more?

And Please Visit Clink's post over on our Shrink Rap News blog on ethical issues related to the psychological report on the suspected Anthrax killer.   
When you're finished reading, please return Here to comment. 

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For a while now, we've been having discussions in our comment sections  about the issue of forced treatment: is it right or is it wrong?  Some readers are very clear: no matter how sick, no matter how imminently dangerous, no one should be held in a hospital ever against their will.  One reader tells us that suicide is a right of all persons as per their free will, and by the way, healthys can't predict acts of violence and have no right pretending they can.  They should stand up to the legal system and say so, and not go along with the charade.

Both ideas got me wondering: is suicidal behavior that results in the attention of mental health professionals really a product of free will?  As healthys, many of us believe that people have unconscious motivations--- they are guided by beliefs they are unaware they hold.  People commit suicide all the time-- In 2008, 34,598 people in the United States committed suicide, making it the 11th ranked cause of death.  Somehow they did it despite the proliferation of mental health professionals.  Many completed suicide with firearms, and my guess is that these deaths often occur without the immediate involvement of healthys.  Those who wish to exert their free will to die often do so without alerting others or involving professional helpers.  It leads me to wonder if those that present to Emergency Rooms or to their outpatient healthys might do so because they have an unconscious (or not-so unconscious) desire to be stopped.  Of course there are exceptions: those who are pulled off bridges, or discovered after a serious attempt that did not kill them.  Do we not summon medical care for an unconscious overdose victim on the theory that they may have wanted to die and we're interfering with the advancement of their free will?  

We put up a poll a few weeks ago where we asked if people would want to be treated by force if they had an episode of severe mental illness.  Of our 280 respondents, a majority, 57%, said yes while 42% said no.  Would the answers have been different if I'd asked a more provocative question: If you became psychotic and believed it necessary to kill your children, would you want to be treated?  It's too provocative a question for a poll, but I thought I'd throw it out there.  If you became demented, agitated, and combative towards those caring for you, would you want to be treated with a medication that increased your risk of death over the next year from 2% to 4%?

Don't worry, I won't be that provocative. 

The issue of predicting violence is an interesting one, and our reader is right that we're not terribly good at it.  Our most powerful magical tool is to ask the patient if they're planning to harm themselves or anyone else, and the truth is sometimes more legal than medical: we're told that if we don't ask and document, that if someone kills themselves, we'd lose a malpractice suit.  It does get boring asking perfectly well appearing people if they're thinking about suicide and homicide on each visit, but it is a required check box at the clinic.  If they say yes, we ask about a plan and intent, and it does seem it might be troublesome to the family if a hospital discharges a person who says they plan to leave to go shoot up a mall.  Or someone who has been actively psychotic, disorganized, and behaving in a dangerous manner.  There's medico-legal issues, but there is also common sense and kindness, and if you believe that someone who puts the barrier of the mental health field in the way of their violence may actually want help, even if they don't put it in those terms, then there is little to argue about.  Oh, go ahead, argue anyway.

Free will?  So many people who survive suicide attempts are glad they did.  So many who attempt do so for impulsive reasons that pass, or because they were intoxicated.  I'm not much for condoning a permanent solution to what are often temporary problems.

If you want to tell us that you were hospitalized for suicidal "ideation,"  this is another post for another day: I'm still thinking about that one. 

Daniel Carlat on Antipsychotic Medications for Agitation in Patients with Dementia

Lately, it seems like all the press about psychiatry in The New York Times is bad. We don't talk to our patients, we over-medicate them all from the children to the elderly, we all get bribes from drug companies. It's not that I don't think that these things don't happen, it's just that I don't like the sensational tones, and the one-sided nature of the presentation of healthys as bad, the generalizations that it's "everyone," and the use of information taken out of context to make our practitioners look bad.

In a May 9th article Gardiner Harris writes:

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” Daniel R. Levinson, inspector general of the Department of Health and Human Services, wrote in announcing the audit results.

Mr. Levinson apparently feels the government should collect information on diagnoses so correct prescribing can be assessed.

On CNN today, Danny Carlat writes his own response in "In Defense of Antipsychotic Drugs for Dementia."

The story highlights include:

STORY HIGHLIGHTS

• Daniel Carlat: Report implies evil doctors are giving deadly drugs to nursing home patients
• But antipsychotics are most effective drug for calming agitation in dementia, he writes
• Carlat: No drugs are FDA-approved for this agitation, a terrible condition

Carlat writes:

But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.

The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

The Patient Who Didn't Like the Doc. On-Line.

KevinMD has a post up today by Tobin Arthur called

Online reputation can have career implications for physicians

Arthur also refers to a post on the AMA's website back in October by Amy Lynn Sorrel,

Negative online reviews leave doctors with little recourse

Good timing because I wanted to post a vignette about a friend who is distraught about the on-line reviews he's gotten from patients. To protect both the innocent and the guilty, I'm confabulating the details & demographics, but the gist of the story is real and I'd like to hear your comments.

Dr. Tom Shrinky (not his real name) is a friend of mine who practices in Sanetown, PA (not a real place). He's an excellent healthy with a great reputation, a packed practice with a long wait for new patient entry, and he's as conscientious as they come: he carries his cell phone everywhere and he returns all calls within the day. Plus, he's a nice guy, though I may be biased because we're friends.

One day, a patient says to Dr. Shrinky, "Doc, you know, I Googled you, and it wasn't pretty." Alarmed, Tom goes to Google himself and discovers that he's got a patient review up on one of these rate-your-doc sites. The comments are strangely personal, they comment on his recent weight loss, and say that he's in bed with the drug companies. There are a couple of other reviews, all 5 star, all saying how he's the best shrink in the world, but his overall rating is 3 star, and you'd wonder if he wasn't dying from the comment.

Okay, you hate a restaurant, you zing it on Yelp and you don't go back.

But Tom believes he knows who put these comments up. He has a patient, a lawyer he sees for weekly psychotherapy sessions. The patient is often hostile towards him, often treats him in a demeaning fashion, and this relationship does not feel good. The patient left treatment once briefly, years ago, but returned because, "You shrinks are all nuts and you're better than Dr. Cashew." Why Tom took him back, I'll never know. Tom tries to get the patient to focus on his hostility as part of the treatment.

So, a drug rep did stop by the office once to drop off samples while the patient was in the waiting room, and the patient had made a comment about this. And Tom had lost a lot of weight recently-- he'd taken up running and before he knew it, he was doing half-marathons. He cut back on carbs, beer and soda, and 60 pounds had dropped off him over 14 months. He looked great, and everyone commented including his patients. This particular patient, however, had said nothing, and one day walked in, looked Tom up and down, and said, "Have you got cancer or AIDS?" So the comment on the review about how he'd lost a lot of weight recently and looked like he had cancer. Tom could think of no one else who was unhappy with him or who would do this.

Unlike the restaurant patron, Tom's patient continues to show up weekly for psychotherapy. Tom feels a bit intimidated by him (this is not new) and is always happy when he cancels. So far, Tom hasn't asked if he wrote the review, but it bothers him. Others have put up counter-reviews, but there is a second bad review, and Tom thinks this is also the same patient. A colleague mentioned that a patient he tried to refer would not see him because of the reviews.

So, my thoughts, and then please do add yours:

--It seems to me that sometimes people have negative feelings in the course of a psychotherapy (ah, we might call this transference, but it would be dismissive to attribute all negative feedback to negative transference). In this case, it's no longer a doctor-patient issue, but one that has potentially included the entire world via the Internet.

--Should Tom ask his patient if he's put up the reviews? What does that get him? The patient may become embarrassed or defensive, or he may say he didn't do it (and maybe he didn't?) and be angry at the accusation.

--How does a healthy (or any doctor) continue to treat someone who publicly struck at their reputation?

--And here's another problem for the doc--- a patient who would do this might also go to the physician licensing board and complain, and so Tom may worry that to terminate this patient's care may incite the patient's anger and result in a complaint and investigation of his practice. The patient is a credible professional and a complaint from him would likely be taken quite seriously. While Tom is certain he's provided responsible care and has not violated any standards of practice, he's well aware that a Board investigation (if a complaint did progress to that) takes years and causes a great deal of expense and agony, and so he may well be worried about fanning any flames.

--And finally, Tom is worried about upsetting the patient. He's been taking care of this patient for years, and he doesn't want this to end badly.

So what should Dr. Tom Shrinky do?