Shrink Rap News

A few weeks ago, I highlighted the blog post of National Institute on Mental Health Director Dr. Thomas Insel, in which he discussed how some patients with schizophrenia do better on lower doses of antipsychotic medications (or even off medications), over the long-run.

Soon afterward, the American Psychiatric Association announced that psychiatrists should use care when prescribing antipsychotics, and specific recommendations were made, along with information that was posted to the Choosing Wisely website. Choosing Wisely is an initiative of the ABIM Foundation aimed at promoting discussions between physicians and patients about the overuse of medical tests and procedures. The APA "identified five targeted evidence-based recommendations" that can be used to prompt conversations with patients:

• Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

• Don’t routinely prescribe two or more antipsychotic medications concurrently.

• Don’t prescribe antipsychotics as a first-line intervention to treat behavioral and psychological symptoms of dementia.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

"As clinicians, we know we can improve the care we deliver by engaging our patients in conversations about their care. The recommendations from APA released today provide valuable information to help patients and physicians start important conversations about treatment options and make informed choices about their health care," Dr. Jeffrey Lieberman, APA president, said in the announcement. "This is not to preclude the use of antipsychotic medications for these indications and populations, but to suggest that other treatment options should be considered first, and patients should be engaged in discussion of the rationale for use and the potential benefits and risks."

We can add to this call for caution the growing information we have that psychiatric medications are a mixed blessing for some patients. In a June 1, American Journal of Psychiatry article, "Relapse Duration, Treatment Intensity, and Brain Tissue Loss in Schizophrenia: A Prospective Longitudinal MRI Study," Dr. Nancy C. Andreasen and her colleagues reported data that left us with the perplexing conundrum that decreasing brain volume is associated both with longer duration of psychosis (but not with increased number of episodes) and with increased exposure to antipsychotic medications.

The authors noted, "Relapse prevention is important, but it should be sustained using the lowest possible medication dosages that will control symptoms." However, the only way to ascertain the lowest possible dose is to decrease the dosage until the patient becomes symptomatic, thereby risking another episode of psychosis (Am. J. Psychiatry 2013;170:609-15).

Whenever news circulates about the downside of commonly used psychotropic medications, the media is quick to circulate the news. As if on cue, USA Today printed an article 3 days after the APA released its list, headlined "Doctors: Antipsychotic meds overused for dementia, kids."

The study by Dr. Andreasen recirculated on Twitter recently but has been quoted by antipsychiatry sources on and off over the past 5 years. To most psychiatrists, it is not quite news that these medications might be overprescribed or that they can have adverse effects.

We’re in a really tough place. The longer antipsychotic medications are available, the more we become aware of the health problems associated with them, hence the justified call for caution. On the other hand, the morbidity and mortality from the conditions these medications address are considerable, and we often don’t have safe, effective alternatives with side effect profiles that are acceptable to patients.

And to state the obvious, the general public seeking psychiatric care has come to agree that symptoms are caused by "chemical imbalances," and both patients and their caretakers now request medications to fix their problems. This isn’t all bad; there’s more awareness of psychiatric symptoms and more willingness to seek treatment, and for many patients, their suffering (or the suffering of their caretakers) is eased. For the psychiatrist, however, the options are often limited, and it seems possible that we’re damned if we do prescribe and damned if we don’t.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I highlighted the blog post of National Institute on Mental Health Director Dr. Thomas Insel, in which he discussed how some patients with schizophrenia do better on lower doses of antipsychotic medications (or even off medications), over the long-run.

Soon afterward, the American Psychiatric Association announced that psychiatrists should use care when prescribing antipsychotics, and specific recommendations were made, along with information that was posted to the Choosing Wisely website. Choosing Wisely is an initiative of the ABIM Foundation aimed at promoting discussions between physicians and patients about the overuse of medical tests and procedures. The APA "identified five targeted evidence-based recommendations" that can be used to prompt conversations with patients:

• Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

• Don’t routinely prescribe two or more antipsychotic medications concurrently.

• Don’t prescribe antipsychotics as a first-line intervention to treat behavioral and psychological symptoms of dementia.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

"As clinicians, we know we can improve the care we deliver by engaging our patients in conversations about their care. The recommendations from APA released today provide valuable information to help patients and physicians start important conversations about treatment options and make informed choices about their health care," Dr. Jeffrey Lieberman, APA president, said in the announcement. "This is not to preclude the use of antipsychotic medications for these indications and populations, but to suggest that other treatment options should be considered first, and patients should be engaged in discussion of the rationale for use and the potential benefits and risks."

We can add to this call for caution the growing information we have that psychiatric medications are a mixed blessing for some patients. In a June 1, American Journal of Psychiatry article, "Relapse Duration, Treatment Intensity, and Brain Tissue Loss in Schizophrenia: A Prospective Longitudinal MRI Study," Dr. Nancy C. Andreasen and her colleagues reported data that left us with the perplexing conundrum that decreasing brain volume is associated both with longer duration of psychosis (but not with increased number of episodes) and with increased exposure to antipsychotic medications.

The authors noted, "Relapse prevention is important, but it should be sustained using the lowest possible medication dosages that will control symptoms." However, the only way to ascertain the lowest possible dose is to decrease the dosage until the patient becomes symptomatic, thereby risking another episode of psychosis (Am. J. Psychiatry 2013;170:609-15).

Whenever news circulates about the downside of commonly used psychotropic medications, the media is quick to circulate the news. As if on cue, USA Today printed an article 3 days after the APA released its list, headlined "Doctors: Antipsychotic meds overused for dementia, kids."

The study by Dr. Andreasen recirculated on Twitter recently but has been quoted by antipsychiatry sources on and off over the past 5 years. To most psychiatrists, it is not quite news that these medications might be overprescribed or that they can have adverse effects.

We’re in a really tough place. The longer antipsychotic medications are available, the more we become aware of the health problems associated with them, hence the justified call for caution. On the other hand, the morbidity and mortality from the conditions these medications address are considerable, and we often don’t have safe, effective alternatives with side effect profiles that are acceptable to patients.

And to state the obvious, the general public seeking psychiatric care has come to agree that symptoms are caused by "chemical imbalances," and both patients and their caretakers now request medications to fix their problems. This isn’t all bad; there’s more awareness of psychiatric symptoms and more willingness to seek treatment, and for many patients, their suffering (or the suffering of their caretakers) is eased. For the psychiatrist, however, the options are often limited, and it seems possible that we’re damned if we do prescribe and damned if we don’t.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I highlighted the blog post of National Institute on Mental Health Director Dr. Thomas Insel, in which he discussed how some patients with schizophrenia do better on lower doses of antipsychotic medications (or even off medications), over the long-run.

Soon afterward, the American Psychiatric Association announced that psychiatrists should use care when prescribing antipsychotics, and specific recommendations were made, along with information that was posted to the Choosing Wisely website. Choosing Wisely is an initiative of the ABIM Foundation aimed at promoting discussions between physicians and patients about the overuse of medical tests and procedures. The APA "identified five targeted evidence-based recommendations" that can be used to prompt conversations with patients:

• Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

• Don’t routinely prescribe two or more antipsychotic medications concurrently.

• Don’t prescribe antipsychotics as a first-line intervention to treat behavioral and psychological symptoms of dementia.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

"As clinicians, we know we can improve the care we deliver by engaging our patients in conversations about their care. The recommendations from APA released today provide valuable information to help patients and physicians start important conversations about treatment options and make informed choices about their health care," Dr. Jeffrey Lieberman, APA president, said in the announcement. "This is not to preclude the use of antipsychotic medications for these indications and populations, but to suggest that other treatment options should be considered first, and patients should be engaged in discussion of the rationale for use and the potential benefits and risks."

We can add to this call for caution the growing information we have that psychiatric medications are a mixed blessing for some patients. In a June 1, American Journal of Psychiatry article, "Relapse Duration, Treatment Intensity, and Brain Tissue Loss in Schizophrenia: A Prospective Longitudinal MRI Study," Dr. Nancy C. Andreasen and her colleagues reported data that left us with the perplexing conundrum that decreasing brain volume is associated both with longer duration of psychosis (but not with increased number of episodes) and with increased exposure to antipsychotic medications.

The authors noted, "Relapse prevention is important, but it should be sustained using the lowest possible medication dosages that will control symptoms." However, the only way to ascertain the lowest possible dose is to decrease the dosage until the patient becomes symptomatic, thereby risking another episode of psychosis (Am. J. Psychiatry 2013;170:609-15).

Whenever news circulates about the downside of commonly used psychotropic medications, the media is quick to circulate the news. As if on cue, USA Today printed an article 3 days after the APA released its list, headlined "Doctors: Antipsychotic meds overused for dementia, kids."

The study by Dr. Andreasen recirculated on Twitter recently but has been quoted by antipsychiatry sources on and off over the past 5 years. To most psychiatrists, it is not quite news that these medications might be overprescribed or that they can have adverse effects.

We’re in a really tough place. The longer antipsychotic medications are available, the more we become aware of the health problems associated with them, hence the justified call for caution. On the other hand, the morbidity and mortality from the conditions these medications address are considerable, and we often don’t have safe, effective alternatives with side effect profiles that are acceptable to patients.

And to state the obvious, the general public seeking psychiatric care has come to agree that symptoms are caused by "chemical imbalances," and both patients and their caretakers now request medications to fix their problems. This isn’t all bad; there’s more awareness of psychiatric symptoms and more willingness to seek treatment, and for many patients, their suffering (or the suffering of their caretakers) is eased. For the psychiatrist, however, the options are often limited, and it seems possible that we’re damned if we do prescribe and damned if we don’t.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

One of the most influential experiences I had as a medical student was the opportunity to work with a psychiatric patient with multiple personality disorder during my inpatient rotation at a tertiary care center. Already inclined toward psychiatry, I had read every popular book I could find about the brain, human behavior, and mental disturbances in additional to my regular textbooks. Multiple personality disorder was a popular topic in the mainstream paperback press then, but I never thought that I would meet someone with the disorder.

My resident at the time felt he had scored a coup, because he was the only one of the patient’s many psychiatrists to consider and diagnose her rare condition. At the time of intake, she had been diagnosed with three alternate personalities. By the end of my rotation, about a year later, she was reported to have nearly 20. As a medical student, it never occurred to me to ask why her condition had gotten worse over time rather than better.

The 1980s brought other disturbing and dramatic events to the forefront of mental health care. Therapists in disparate parts of the country began to report cases of patients who suddenly recalled horrific memories of degrading and violent sexual abuse committed by organized cults. These reports of satanic ritual abuse led to intense investigations by local law enforcement as well as the FBI. Families were torn apart, as falsely accused members were alienated from one another or even criminally prosecuted.

Eventually, the drama died down. Falsely accused family members had their convictions overturned based upon expert evidence regarding false memory syndrome caused by hypnotically induced memories or improper questioning of child witnesses. A series of malpractice suits were filed against trauma recovery therapists based upon negligent use of hypnosis, failure to recognize the effects of suggestion, and improper diagnosis. Juries awarded some of the highest damages ever recorded for psychiatric malpractice. To this day, the FBI has found no evidence of any organized satanic child abuse rings.

All this was uncomfortable to watch even from a distance, but I’m glad I had this experience in my formative years as a psychiatrist. And this all seemed like a remote memory until recently, when my state started requiring all public mental health clinicians to receive education in trauma-informed care.

Trauma-informed care requires a clinician to be mindful that many psychiatric patients have had significant exposure to sexual and physical abuse, domestic violence, and other life events that make a person sensitive to being retraumatized. Trauma-informed care means being cautious and conservative with regard to the use of physical interventions or other measures that could inadvertently reenact a previous traumatic event. Trauma history is associated with many adult psychiatric conditions that we see in our patients: mood disorders, substance abuse, and maladaptive behaviors. According to this training, trauma-informed care would require the clinician to assume that a patient who presents with these problems has had a history of abuse or other traumatic experiences.

The first time I went through this training, my response was inexplicably visceral. I had a sickening sense that I was watching history slowly repeat itself. I wondered if the trauma informed care people knew that their training could cause a traumatic reaction like mine.

While I don’t question the fact that childhood trauma is real or can cause significant adult psychological problems, I’d be more comfortable with mandatory trauma-informed care training if the trainers would recognize and acknowledge certain risks inherent in their approach.

They should acknowledge that patients with a trauma history are likely to fear abandonment or punishment. In order to avoid this, a trauma patient may consciously or unconsciously confabulate symptoms in order to keep the therapist interested and engaged. Failure to differentiate between historical truth and narrative truth was a key issue in the development of the satanic ritual abuse debacle. Trauma recovery trainers should recognize that screening for trauma may not be appropriate under certain circumstances. For example, screening for past trauma would not be appropriate in a jail intake setting, where the incarceration process itself may be inherently traumatic. Finally, while trauma is associated with many psychological problems, the answer to all problems is not trauma recovery therapy. Substance abuse treatment, medication, and standard rehabilitation services can be beneficial even when separate from or without trauma-specific therapy.

This leads me to my final point: There is nothing specific to trauma-informed care that is specific to a history of trauma. The need to be sensitive and humane, and the need to be cautious and judicious about physical interventions, is just good psychiatric care. And we don’t need a law to require training in humane care.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One of the most influential experiences I had as a medical student was the opportunity to work with a psychiatric patient with multiple personality disorder during my inpatient rotation at a tertiary care center. Already inclined toward psychiatry, I had read every popular book I could find about the brain, human behavior, and mental disturbances in additional to my regular textbooks. Multiple personality disorder was a popular topic in the mainstream paperback press then, but I never thought that I would meet someone with the disorder.

My resident at the time felt he had scored a coup, because he was the only one of the patient’s many psychiatrists to consider and diagnose her rare condition. At the time of intake, she had been diagnosed with three alternate personalities. By the end of my rotation, about a year later, she was reported to have nearly 20. As a medical student, it never occurred to me to ask why her condition had gotten worse over time rather than better.

The 1980s brought other disturbing and dramatic events to the forefront of mental health care. Therapists in disparate parts of the country began to report cases of patients who suddenly recalled horrific memories of degrading and violent sexual abuse committed by organized cults. These reports of satanic ritual abuse led to intense investigations by local law enforcement as well as the FBI. Families were torn apart, as falsely accused members were alienated from one another or even criminally prosecuted.

Eventually, the drama died down. Falsely accused family members had their convictions overturned based upon expert evidence regarding false memory syndrome caused by hypnotically induced memories or improper questioning of child witnesses. A series of malpractice suits were filed against trauma recovery therapists based upon negligent use of hypnosis, failure to recognize the effects of suggestion, and improper diagnosis. Juries awarded some of the highest damages ever recorded for psychiatric malpractice. To this day, the FBI has found no evidence of any organized satanic child abuse rings.

All this was uncomfortable to watch even from a distance, but I’m glad I had this experience in my formative years as a psychiatrist. And this all seemed like a remote memory until recently, when my state started requiring all public mental health clinicians to receive education in trauma-informed care.

Trauma-informed care requires a clinician to be mindful that many psychiatric patients have had significant exposure to sexual and physical abuse, domestic violence, and other life events that make a person sensitive to being retraumatized. Trauma-informed care means being cautious and conservative with regard to the use of physical interventions or other measures that could inadvertently reenact a previous traumatic event. Trauma history is associated with many adult psychiatric conditions that we see in our patients: mood disorders, substance abuse, and maladaptive behaviors. According to this training, trauma-informed care would require the clinician to assume that a patient who presents with these problems has had a history of abuse or other traumatic experiences.

The first time I went through this training, my response was inexplicably visceral. I had a sickening sense that I was watching history slowly repeat itself. I wondered if the trauma informed care people knew that their training could cause a traumatic reaction like mine.

While I don’t question the fact that childhood trauma is real or can cause significant adult psychological problems, I’d be more comfortable with mandatory trauma-informed care training if the trainers would recognize and acknowledge certain risks inherent in their approach.

They should acknowledge that patients with a trauma history are likely to fear abandonment or punishment. In order to avoid this, a trauma patient may consciously or unconsciously confabulate symptoms in order to keep the therapist interested and engaged. Failure to differentiate between historical truth and narrative truth was a key issue in the development of the satanic ritual abuse debacle. Trauma recovery trainers should recognize that screening for trauma may not be appropriate under certain circumstances. For example, screening for past trauma would not be appropriate in a jail intake setting, where the incarceration process itself may be inherently traumatic. Finally, while trauma is associated with many psychological problems, the answer to all problems is not trauma recovery therapy. Substance abuse treatment, medication, and standard rehabilitation services can be beneficial even when separate from or without trauma-specific therapy.

This leads me to my final point: There is nothing specific to trauma-informed care that is specific to a history of trauma. The need to be sensitive and humane, and the need to be cautious and judicious about physical interventions, is just good psychiatric care. And we don’t need a law to require training in humane care.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One of the most influential experiences I had as a medical student was the opportunity to work with a psychiatric patient with multiple personality disorder during my inpatient rotation at a tertiary care center. Already inclined toward psychiatry, I had read every popular book I could find about the brain, human behavior, and mental disturbances in additional to my regular textbooks. Multiple personality disorder was a popular topic in the mainstream paperback press then, but I never thought that I would meet someone with the disorder.

My resident at the time felt he had scored a coup, because he was the only one of the patient’s many psychiatrists to consider and diagnose her rare condition. At the time of intake, she had been diagnosed with three alternate personalities. By the end of my rotation, about a year later, she was reported to have nearly 20. As a medical student, it never occurred to me to ask why her condition had gotten worse over time rather than better.

The 1980s brought other disturbing and dramatic events to the forefront of mental health care. Therapists in disparate parts of the country began to report cases of patients who suddenly recalled horrific memories of degrading and violent sexual abuse committed by organized cults. These reports of satanic ritual abuse led to intense investigations by local law enforcement as well as the FBI. Families were torn apart, as falsely accused members were alienated from one another or even criminally prosecuted.

Eventually, the drama died down. Falsely accused family members had their convictions overturned based upon expert evidence regarding false memory syndrome caused by hypnotically induced memories or improper questioning of child witnesses. A series of malpractice suits were filed against trauma recovery therapists based upon negligent use of hypnosis, failure to recognize the effects of suggestion, and improper diagnosis. Juries awarded some of the highest damages ever recorded for psychiatric malpractice. To this day, the FBI has found no evidence of any organized satanic child abuse rings.

All this was uncomfortable to watch even from a distance, but I’m glad I had this experience in my formative years as a psychiatrist. And this all seemed like a remote memory until recently, when my state started requiring all public mental health clinicians to receive education in trauma-informed care.

Trauma-informed care requires a clinician to be mindful that many psychiatric patients have had significant exposure to sexual and physical abuse, domestic violence, and other life events that make a person sensitive to being retraumatized. Trauma-informed care means being cautious and conservative with regard to the use of physical interventions or other measures that could inadvertently reenact a previous traumatic event. Trauma history is associated with many adult psychiatric conditions that we see in our patients: mood disorders, substance abuse, and maladaptive behaviors. According to this training, trauma-informed care would require the clinician to assume that a patient who presents with these problems has had a history of abuse or other traumatic experiences.

The first time I went through this training, my response was inexplicably visceral. I had a sickening sense that I was watching history slowly repeat itself. I wondered if the trauma informed care people knew that their training could cause a traumatic reaction like mine.

While I don’t question the fact that childhood trauma is real or can cause significant adult psychological problems, I’d be more comfortable with mandatory trauma-informed care training if the trainers would recognize and acknowledge certain risks inherent in their approach.

They should acknowledge that patients with a trauma history are likely to fear abandonment or punishment. In order to avoid this, a trauma patient may consciously or unconsciously confabulate symptoms in order to keep the therapist interested and engaged. Failure to differentiate between historical truth and narrative truth was a key issue in the development of the satanic ritual abuse debacle. Trauma recovery trainers should recognize that screening for trauma may not be appropriate under certain circumstances. For example, screening for past trauma would not be appropriate in a jail intake setting, where the incarceration process itself may be inherently traumatic. Finally, while trauma is associated with many psychological problems, the answer to all problems is not trauma recovery therapy. Substance abuse treatment, medication, and standard rehabilitation services can be beneficial even when separate from or without trauma-specific therapy.

This leads me to my final point: There is nothing specific to trauma-informed care that is specific to a history of trauma. The need to be sensitive and humane, and the need to be cautious and judicious about physical interventions, is just good psychiatric care. And we don’t need a law to require training in humane care.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

A few weeks ago, I was talking to a psychiatrist about one of his former patients whom I was interviewing for a book. The patient was hospitalized years ago for a single episode of mania. She spent a few weeks on an inpatient unit where she raised all hell and was in and out of seclusion, only to be heavily medicated, and still have it in her to raise Cain. She then spent a few weeks in a day hospital. She ended her single psychiatric episode by being discharged on three antipsychotic medications, one benzodiazepine, and Cogentin, all in sizeable doses.

The inpatient psychiatrist did not remember this patient; why would he? Aside from her unusual age (54) at the time of her presentation, the chart documented just another manic patient who was certified, committed for being gravely disabled, and authorized for medication administration against her will, and she recovered. The patient left the hospital settings and began to slowly taper her medications because the side effects were intolerable (perhaps because she was on enough medicine to drop a Clydesdale). She found a psychiatrist she could work with, one with a reputation for using medication only as a last resort, and she has been off medication, without a relapse, for 7 years now. I mentioned this to the psychiatrist who had seen her in the hospital and his response – without remembering the patient and without reviewing her chart – was swift: "She’ll get sick again." And she may; bipolar disorder is a recurrent illness, but since she presented following unusual circumstances, at an atypical age, and has done quite well in the intervening years, I am hoping his dismal prognosis will prove to be wrong. Perhaps a single episode of mania was just a single episode of mania – a few bad weeks in someone’s life precipitated by extreme stress. The patient believes her course was worsened by the medication she was given and the unkind treatment she received.

We were taught that if patients are diagnosed with certain psychiatric disorders, the recommendation is for them to remain on medication for life.

In clinical practice, we’ve also learned that as much as we may recommend that patients take their medicine, most patients try the experiment of going off, with or without our agreement, concession, or even our encouragement. And we certainly know that some of those people try this experiment over and over, only to land in the same bad place (often the psychiatric unit or jail) again and again. What we see less is that some of those people do just fine without the medications one might have predicted they’d need for the rest of their life. In private practice, a few will stop their medications – or refuse to take them in the first place – and do quite well. They may continue to come for supportive or insight-oriented psychotherapy. But the truth is that most patients who stop their medications and do fine just drift off, lost to the attrition of being well. They may never return or may come later when they have a recurrence, but we are left to wonder if the risks of prophylactic medication are worth the benefit given the following: These recurrences can be years or even decades apart, not all recurrences are catastrophic or difficult to treat, and the medications are often not benign. For patients who have repeatedly become psychotic, suicidal, and unable to function within weeks of stopping their medication, there is little choice; they need chronic treatment.

For the patient who gets delusional every 10 years, it may not be worth the tradeoff of chronic antipsychotics if that patient is one of the many who develop a metabolic syndrome. These are things we’ve known in clinical practice for a long time; not every teenager labeled "bipolar" needs lifelong lithium.

But what’s new, and what should shake us up, is the blog National Institute of Mental Health Director Thomas Insel posted on Aug. 28. Dr. Insel discussed the research that has shown that a subset of psychotic patients do significantly better if they lower or even completely stop their antipsychotic medication following the acute phase of treatment of schizophrenia. If you haven’t read Dr. Insel’s post, "Antipsychotics: Taking the Long View," it’s well worth the read.

He wrote: "Wunderink and colleagues from the Netherlands report on a 7-year follow-up of 103 people with schizophrenia and related disorders who had experienced a first episode of psychosis between 2001 and 2002. After 6 months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by 7 years, the discontinuation group had achieved twice the functional recovery rate: 40.4% vs. only 17.6% among the medication maintenance group. To be clear, this study started with patients in remission, and only 17 of the 103 patients – 21% of the discontinuation group and 11% of the maintenance group – were off medication entirely during the last 2 years of follow-up. An equal number were taking very low doses of medication – meaning that roughly one-third of all study patients were eventually taking little or no medication."

Our antipsychiatry foes will read this as saying that people do better without antipsychotics, and that’s not what this says at all. But what it does say is that a subset of people, whom we can’t identify beforehand, will do better over the long term with lower doses, or no, medication. Although we can’t identify who will do better beforehand, this does totally change the risk-benefit discussion we have with our patients, especially the more compliant of those patients, and it completely disrupts the idea that prophylaxis for all patients with schizophrenia is the right and only thing to do.

Psychiatry seems to have its own leagues of critics. Certainly, assumptions are made in all areas of medicine, but there isn’t an outspoken group of antioncology patients who take to the streets with signs and megaphones. And being a cancer survivor is a good thing, while being a "psychiatry survivor" is not.

But psychiatry is not alone in being faced with challenges to assumptions we’ve taken as gospel. The food pyramid is one example of a frequently changing ideal about what we should be consuming. Is coronary artery stenting good, bad, or just oversold? The Institute of Medicine released a 169-page report this year discussing how the evidence that a sodium-restricted diet, which does lower blood pressure, is short on proof that it also lowers the risk of stroke and cardiac events. Knee jerk hormone replacement therapy for postmenopausal women proved to be a big mistake. But we have been prescribing long-term antipsychotics without question for more than 50 years, and I applaud Dr. Insel for asking us to at least reconsider the status quo, whether it’s how we establish our diagnostic criteria or the assumptions we make about what treatments best help all patients.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I was talking to a psychiatrist about one of his former patients whom I was interviewing for a book. The patient was hospitalized years ago for a single episode of mania. She spent a few weeks on an inpatient unit where she raised all hell and was in and out of seclusion, only to be heavily medicated, and still have it in her to raise Cain. She then spent a few weeks in a day hospital. She ended her single psychiatric episode by being discharged on three antipsychotic medications, one benzodiazepine, and Cogentin, all in sizeable doses.

The inpatient psychiatrist did not remember this patient; why would he? Aside from her unusual age (54) at the time of her presentation, the chart documented just another manic patient who was certified, committed for being gravely disabled, and authorized for medication administration against her will, and she recovered. The patient left the hospital settings and began to slowly taper her medications because the side effects were intolerable (perhaps because she was on enough medicine to drop a Clydesdale). She found a psychiatrist she could work with, one with a reputation for using medication only as a last resort, and she has been off medication, without a relapse, for 7 years now. I mentioned this to the psychiatrist who had seen her in the hospital and his response – without remembering the patient and without reviewing her chart – was swift: "She’ll get sick again." And she may; bipolar disorder is a recurrent illness, but since she presented following unusual circumstances, at an atypical age, and has done quite well in the intervening years, I am hoping his dismal prognosis will prove to be wrong. Perhaps a single episode of mania was just a single episode of mania – a few bad weeks in someone’s life precipitated by extreme stress. The patient believes her course was worsened by the medication she was given and the unkind treatment she received.

We were taught that if patients are diagnosed with certain psychiatric disorders, the recommendation is for them to remain on medication for life.

In clinical practice, we’ve also learned that as much as we may recommend that patients take their medicine, most patients try the experiment of going off, with or without our agreement, concession, or even our encouragement. And we certainly know that some of those people try this experiment over and over, only to land in the same bad place (often the psychiatric unit or jail) again and again. What we see less is that some of those people do just fine without the medications one might have predicted they’d need for the rest of their life. In private practice, a few will stop their medications – or refuse to take them in the first place – and do quite well. They may continue to come for supportive or insight-oriented psychotherapy. But the truth is that most patients who stop their medications and do fine just drift off, lost to the attrition of being well. They may never return or may come later when they have a recurrence, but we are left to wonder if the risks of prophylactic medication are worth the benefit given the following: These recurrences can be years or even decades apart, not all recurrences are catastrophic or difficult to treat, and the medications are often not benign. For patients who have repeatedly become psychotic, suicidal, and unable to function within weeks of stopping their medication, there is little choice; they need chronic treatment.

For the patient who gets delusional every 10 years, it may not be worth the tradeoff of chronic antipsychotics if that patient is one of the many who develop a metabolic syndrome. These are things we’ve known in clinical practice for a long time; not every teenager labeled "bipolar" needs lifelong lithium.

But what’s new, and what should shake us up, is the blog National Institute of Mental Health Director Thomas Insel posted on Aug. 28. Dr. Insel discussed the research that has shown that a subset of psychotic patients do significantly better if they lower or even completely stop their antipsychotic medication following the acute phase of treatment of schizophrenia. If you haven’t read Dr. Insel’s post, "Antipsychotics: Taking the Long View," it’s well worth the read.

He wrote: "Wunderink and colleagues from the Netherlands report on a 7-year follow-up of 103 people with schizophrenia and related disorders who had experienced a first episode of psychosis between 2001 and 2002. After 6 months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by 7 years, the discontinuation group had achieved twice the functional recovery rate: 40.4% vs. only 17.6% among the medication maintenance group. To be clear, this study started with patients in remission, and only 17 of the 103 patients – 21% of the discontinuation group and 11% of the maintenance group – were off medication entirely during the last 2 years of follow-up. An equal number were taking very low doses of medication – meaning that roughly one-third of all study patients were eventually taking little or no medication."

Our antipsychiatry foes will read this as saying that people do better without antipsychotics, and that’s not what this says at all. But what it does say is that a subset of people, whom we can’t identify beforehand, will do better over the long term with lower doses, or no, medication. Although we can’t identify who will do better beforehand, this does totally change the risk-benefit discussion we have with our patients, especially the more compliant of those patients, and it completely disrupts the idea that prophylaxis for all patients with schizophrenia is the right and only thing to do.

Psychiatry seems to have its own leagues of critics. Certainly, assumptions are made in all areas of medicine, but there isn’t an outspoken group of antioncology patients who take to the streets with signs and megaphones. And being a cancer survivor is a good thing, while being a "psychiatry survivor" is not.

But psychiatry is not alone in being faced with challenges to assumptions we’ve taken as gospel. The food pyramid is one example of a frequently changing ideal about what we should be consuming. Is coronary artery stenting good, bad, or just oversold? The Institute of Medicine released a 169-page report this year discussing how the evidence that a sodium-restricted diet, which does lower blood pressure, is short on proof that it also lowers the risk of stroke and cardiac events. Knee jerk hormone replacement therapy for postmenopausal women proved to be a big mistake. But we have been prescribing long-term antipsychotics without question for more than 50 years, and I applaud Dr. Insel for asking us to at least reconsider the status quo, whether it’s how we establish our diagnostic criteria or the assumptions we make about what treatments best help all patients.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I was talking to a psychiatrist about one of his former patients whom I was interviewing for a book. The patient was hospitalized years ago for a single episode of mania. She spent a few weeks on an inpatient unit where she raised all hell and was in and out of seclusion, only to be heavily medicated, and still have it in her to raise Cain. She then spent a few weeks in a day hospital. She ended her single psychiatric episode by being discharged on three antipsychotic medications, one benzodiazepine, and Cogentin, all in sizeable doses.

The inpatient psychiatrist did not remember this patient; why would he? Aside from her unusual age (54) at the time of her presentation, the chart documented just another manic patient who was certified, committed for being gravely disabled, and authorized for medication administration against her will, and she recovered. The patient left the hospital settings and began to slowly taper her medications because the side effects were intolerable (perhaps because she was on enough medicine to drop a Clydesdale). She found a psychiatrist she could work with, one with a reputation for using medication only as a last resort, and she has been off medication, without a relapse, for 7 years now. I mentioned this to the psychiatrist who had seen her in the hospital and his response – without remembering the patient and without reviewing her chart – was swift: "She’ll get sick again." And she may; bipolar disorder is a recurrent illness, but since she presented following unusual circumstances, at an atypical age, and has done quite well in the intervening years, I am hoping his dismal prognosis will prove to be wrong. Perhaps a single episode of mania was just a single episode of mania – a few bad weeks in someone’s life precipitated by extreme stress. The patient believes her course was worsened by the medication she was given and the unkind treatment she received.

We were taught that if patients are diagnosed with certain psychiatric disorders, the recommendation is for them to remain on medication for life.

In clinical practice, we’ve also learned that as much as we may recommend that patients take their medicine, most patients try the experiment of going off, with or without our agreement, concession, or even our encouragement. And we certainly know that some of those people try this experiment over and over, only to land in the same bad place (often the psychiatric unit or jail) again and again. What we see less is that some of those people do just fine without the medications one might have predicted they’d need for the rest of their life. In private practice, a few will stop their medications – or refuse to take them in the first place – and do quite well. They may continue to come for supportive or insight-oriented psychotherapy. But the truth is that most patients who stop their medications and do fine just drift off, lost to the attrition of being well. They may never return or may come later when they have a recurrence, but we are left to wonder if the risks of prophylactic medication are worth the benefit given the following: These recurrences can be years or even decades apart, not all recurrences are catastrophic or difficult to treat, and the medications are often not benign. For patients who have repeatedly become psychotic, suicidal, and unable to function within weeks of stopping their medication, there is little choice; they need chronic treatment.

For the patient who gets delusional every 10 years, it may not be worth the tradeoff of chronic antipsychotics if that patient is one of the many who develop a metabolic syndrome. These are things we’ve known in clinical practice for a long time; not every teenager labeled "bipolar" needs lifelong lithium.

But what’s new, and what should shake us up, is the blog National Institute of Mental Health Director Thomas Insel posted on Aug. 28. Dr. Insel discussed the research that has shown that a subset of psychotic patients do significantly better if they lower or even completely stop their antipsychotic medication following the acute phase of treatment of schizophrenia. If you haven’t read Dr. Insel’s post, "Antipsychotics: Taking the Long View," it’s well worth the read.

He wrote: "Wunderink and colleagues from the Netherlands report on a 7-year follow-up of 103 people with schizophrenia and related disorders who had experienced a first episode of psychosis between 2001 and 2002. After 6 months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by 7 years, the discontinuation group had achieved twice the functional recovery rate: 40.4% vs. only 17.6% among the medication maintenance group. To be clear, this study started with patients in remission, and only 17 of the 103 patients – 21% of the discontinuation group and 11% of the maintenance group – were off medication entirely during the last 2 years of follow-up. An equal number were taking very low doses of medication – meaning that roughly one-third of all study patients were eventually taking little or no medication."

Our antipsychiatry foes will read this as saying that people do better without antipsychotics, and that’s not what this says at all. But what it does say is that a subset of people, whom we can’t identify beforehand, will do better over the long term with lower doses, or no, medication. Although we can’t identify who will do better beforehand, this does totally change the risk-benefit discussion we have with our patients, especially the more compliant of those patients, and it completely disrupts the idea that prophylaxis for all patients with schizophrenia is the right and only thing to do.

Psychiatry seems to have its own leagues of critics. Certainly, assumptions are made in all areas of medicine, but there isn’t an outspoken group of antioncology patients who take to the streets with signs and megaphones. And being a cancer survivor is a good thing, while being a "psychiatry survivor" is not.

But psychiatry is not alone in being faced with challenges to assumptions we’ve taken as gospel. The food pyramid is one example of a frequently changing ideal about what we should be consuming. Is coronary artery stenting good, bad, or just oversold? The Institute of Medicine released a 169-page report this year discussing how the evidence that a sodium-restricted diet, which does lower blood pressure, is short on proof that it also lowers the risk of stroke and cardiac events. Knee jerk hormone replacement therapy for postmenopausal women proved to be a big mistake. But we have been prescribing long-term antipsychotics without question for more than 50 years, and I applaud Dr. Insel for asking us to at least reconsider the status quo, whether it’s how we establish our diagnostic criteria or the assumptions we make about what treatments best help all patients.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Recently, the simultaneous publication of two stories, one in The New York Times and one in The Economist, gave me a unique opportunity to write about a problem I’ve seen in our mental health system.

The first story, "The Woman Who Ate Cutlery," by Dr. Christine Montross, was published in the Times on Aug. 3.

That same day, The Economist published a story headlined, "Locked in."

Both articles started out with a patient vignette. The Economist presented the story of Tracey Aldridge, a jail inmate with 27 incarcerations for misdemeanor offenses (which the article characterized as "typical of the mentally ill"). While incarcerated, Ms. Aldridge required special arm coverings to keep her from ripping her veins out with her teeth. Later, she ate her protective gauntlets.

The Times article similarly began with an anonymized patient vignette about Patient M. Patient M was not psychotic, but did have repeatedly self-injurious behaviors, such as swallowing knives and forks, and inserting sharp objects into her vagina. Swallowed cutlery was the usual reason for her 72 admissions.

Thomas Dart, the sheriff of the jail where Ms. Aldridge was held, expressed anger about her incarcerations, or more specifically, about the cost of her care. He blamed the lack of psychiatric beds and short lengths of stay for the number of inmates with mental illness in his facility. His main responsibility, according to the article, was "to keep people safe while they await trial" rather than act as director of a pseudo-psychiatric hospital. To his credit, he created a novel program to house, supervise, and support misdemeanor mentally ill offenders outside of the jail.

Dr. Montross similarly bemoaned M’s presence on her inpatient unit for her 73rd admission and suggested that M would be better served in the community. In her opinion, failure to provide outpatient services created an unnecessary and costly burden on hospital emergency rooms and inpatient units.

I don’t want to sound like a curmudgeon, so let me be clear that both writers have valid points about the need for well-funded inpatient and outpatient services and about the problems inherent in the incarceration of people with mental illnesses. I agree with their conclusions. Psychiatric patients in jail run the risk of inappropriate segregation, abuse, discrimination, and denial of institutional jobs or rehabilitation programs.

Both writers also vividly portray the challenges inherent in institution-based care for certain patients with severely disruptive, aggressive, or self-injurious behavior. The care of these patients can be both time and staff intensive, thus costly. The physical management required by these patients – the use of seclusion or physical restraint, for example – might draw the scrutiny of external agencies such as the hospital accreditation agency, the Joint Commission, or patients’ rights and inmate advocacy organizations. Physical intervention and seclusion also can draw the attention of the news media, as in the series of articles published in The Atlantic over the use of long-term segregation in a federal control unit prison.

In a worst-case scenario, an adverse treatment outcome could lead to individual or class action litigation.

While I agree with the writers’ conclusions, I also have concern about the implicit messages conveyed in these stories.

The first implicit message is that there is a single, monolithic entity known as "the mentally ill" with clearly demarcated edges separating "us" and "them." This is untrue because of limitations inherent in our diagnostic system but also because of the nature of mental illness. Most psychiatric patients don’t commit crimes, much less misdemeanor offenses "typical of the mentally ill." They also don’t tear out their veins with their teeth or insert sharp objects into their genitalia. Mental illness can strike anyone, and from a statistical standpoint, there is almost certainly a person with a mental illness employed, rather than housed, in Sheriff Dart’s jail – possibly even caring for inmate Aldridge. There are also likely people with mental illness among the policy makers, legislators, and administrators who make funding decisions for correctional and psychiatric facilities.

The patients these stories are really talking about are a small subset of psychiatric patients, people with psychiatric disorders who also happen to have substance abuse problems, legal issues, and poor social supports in addition to their severely maladaptive behaviors. In other words, they are my forensic patients. I know these patients well, because I have worked with them for many years, as a treating clinician in a prison and as a forensic evaluator. I also know how my nonforensic mental health colleagues feel about working with my patients, after release or discharge. They are uncomfortable with them and concerned, reasonably or not, about liability issues and the potential for violence.

This leads to my concern about the second implicit message in these news stories. That message is: "I shouldn’t have to be responsible for these people." While the discussion is framed in benevolent terms – who could argue against the need for better access to community care? – the underlying message from both sides is that neither agency wants them in their facilities. Wardens don’t want them in their jails and they are also not welcome in hospitals. Is it any wonder that Patient M had to swallow cutlery to get help? If I could pick up the vibe from a news story, I’m sure Patient M could pick it up in person. I can only hope that both Ms. Aldridge and Patient M would be more welcome in the outpatient setting that Sheriff Dart and author Montross would send them to.

Our mental health services will not improve as long as agencies continue to shift responsibility between one another and compartmentalize care. Treatment should begin at the point of contact, regardless of location, and transition smoothly between agencies as the patient’s level of care changes. I’m aware that when it comes to mentally ill offenders and insanity acquittees, a humanitarian argument will fall on deaf ears, which explains the reliance on an economic rationale. But let’s not lose sight of the fact that the practice of medicine reflects the essence of humanitarian values. Care of the most challenging patients is the best demonstration of those values.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, the simultaneous publication of two stories, one in The New York Times and one in The Economist, gave me a unique opportunity to write about a problem I’ve seen in our mental health system.

The first story, "The Woman Who Ate Cutlery," by Dr. Christine Montross, was published in the Times on Aug. 3.

That same day, The Economist published a story headlined, "Locked in."

Both articles started out with a patient vignette. The Economist presented the story of Tracey Aldridge, a jail inmate with 27 incarcerations for misdemeanor offenses (which the article characterized as "typical of the mentally ill"). While incarcerated, Ms. Aldridge required special arm coverings to keep her from ripping her veins out with her teeth. Later, she ate her protective gauntlets.

The Times article similarly began with an anonymized patient vignette about Patient M. Patient M was not psychotic, but did have repeatedly self-injurious behaviors, such as swallowing knives and forks, and inserting sharp objects into her vagina. Swallowed cutlery was the usual reason for her 72 admissions.

Thomas Dart, the sheriff of the jail where Ms. Aldridge was held, expressed anger about her incarcerations, or more specifically, about the cost of her care. He blamed the lack of psychiatric beds and short lengths of stay for the number of inmates with mental illness in his facility. His main responsibility, according to the article, was "to keep people safe while they await trial" rather than act as director of a pseudo-psychiatric hospital. To his credit, he created a novel program to house, supervise, and support misdemeanor mentally ill offenders outside of the jail.

Dr. Montross similarly bemoaned M’s presence on her inpatient unit for her 73rd admission and suggested that M would be better served in the community. In her opinion, failure to provide outpatient services created an unnecessary and costly burden on hospital emergency rooms and inpatient units.

I don’t want to sound like a curmudgeon, so let me be clear that both writers have valid points about the need for well-funded inpatient and outpatient services and about the problems inherent in the incarceration of people with mental illnesses. I agree with their conclusions. Psychiatric patients in jail run the risk of inappropriate segregation, abuse, discrimination, and denial of institutional jobs or rehabilitation programs.

Both writers also vividly portray the challenges inherent in institution-based care for certain patients with severely disruptive, aggressive, or self-injurious behavior. The care of these patients can be both time and staff intensive, thus costly. The physical management required by these patients – the use of seclusion or physical restraint, for example – might draw the scrutiny of external agencies such as the hospital accreditation agency, the Joint Commission, or patients’ rights and inmate advocacy organizations. Physical intervention and seclusion also can draw the attention of the news media, as in the series of articles published in The Atlantic over the use of long-term segregation in a federal control unit prison.

In a worst-case scenario, an adverse treatment outcome could lead to individual or class action litigation.

While I agree with the writers’ conclusions, I also have concern about the implicit messages conveyed in these stories.

The first implicit message is that there is a single, monolithic entity known as "the mentally ill" with clearly demarcated edges separating "us" and "them." This is untrue because of limitations inherent in our diagnostic system but also because of the nature of mental illness. Most psychiatric patients don’t commit crimes, much less misdemeanor offenses "typical of the mentally ill." They also don’t tear out their veins with their teeth or insert sharp objects into their genitalia. Mental illness can strike anyone, and from a statistical standpoint, there is almost certainly a person with a mental illness employed, rather than housed, in Sheriff Dart’s jail – possibly even caring for inmate Aldridge. There are also likely people with mental illness among the policy makers, legislators, and administrators who make funding decisions for correctional and psychiatric facilities.

The patients these stories are really talking about are a small subset of psychiatric patients, people with psychiatric disorders who also happen to have substance abuse problems, legal issues, and poor social supports in addition to their severely maladaptive behaviors. In other words, they are my forensic patients. I know these patients well, because I have worked with them for many years, as a treating clinician in a prison and as a forensic evaluator. I also know how my nonforensic mental health colleagues feel about working with my patients, after release or discharge. They are uncomfortable with them and concerned, reasonably or not, about liability issues and the potential for violence.

This leads to my concern about the second implicit message in these news stories. That message is: "I shouldn’t have to be responsible for these people." While the discussion is framed in benevolent terms – who could argue against the need for better access to community care? – the underlying message from both sides is that neither agency wants them in their facilities. Wardens don’t want them in their jails and they are also not welcome in hospitals. Is it any wonder that Patient M had to swallow cutlery to get help? If I could pick up the vibe from a news story, I’m sure Patient M could pick it up in person. I can only hope that both Ms. Aldridge and Patient M would be more welcome in the outpatient setting that Sheriff Dart and author Montross would send them to.

Our mental health services will not improve as long as agencies continue to shift responsibility between one another and compartmentalize care. Treatment should begin at the point of contact, regardless of location, and transition smoothly between agencies as the patient’s level of care changes. I’m aware that when it comes to mentally ill offenders and insanity acquittees, a humanitarian argument will fall on deaf ears, which explains the reliance on an economic rationale. But let’s not lose sight of the fact that the practice of medicine reflects the essence of humanitarian values. Care of the most challenging patients is the best demonstration of those values.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, the simultaneous publication of two stories, one in The New York Times and one in The Economist, gave me a unique opportunity to write about a problem I’ve seen in our mental health system.

The first story, "The Woman Who Ate Cutlery," by Dr. Christine Montross, was published in the Times on Aug. 3.

That same day, The Economist published a story headlined, "Locked in."

Both articles started out with a patient vignette. The Economist presented the story of Tracey Aldridge, a jail inmate with 27 incarcerations for misdemeanor offenses (which the article characterized as "typical of the mentally ill"). While incarcerated, Ms. Aldridge required special arm coverings to keep her from ripping her veins out with her teeth. Later, she ate her protective gauntlets.

The Times article similarly began with an anonymized patient vignette about Patient M. Patient M was not psychotic, but did have repeatedly self-injurious behaviors, such as swallowing knives and forks, and inserting sharp objects into her vagina. Swallowed cutlery was the usual reason for her 72 admissions.

Thomas Dart, the sheriff of the jail where Ms. Aldridge was held, expressed anger about her incarcerations, or more specifically, about the cost of her care. He blamed the lack of psychiatric beds and short lengths of stay for the number of inmates with mental illness in his facility. His main responsibility, according to the article, was "to keep people safe while they await trial" rather than act as director of a pseudo-psychiatric hospital. To his credit, he created a novel program to house, supervise, and support misdemeanor mentally ill offenders outside of the jail.

Dr. Montross similarly bemoaned M’s presence on her inpatient unit for her 73rd admission and suggested that M would be better served in the community. In her opinion, failure to provide outpatient services created an unnecessary and costly burden on hospital emergency rooms and inpatient units.

I don’t want to sound like a curmudgeon, so let me be clear that both writers have valid points about the need for well-funded inpatient and outpatient services and about the problems inherent in the incarceration of people with mental illnesses. I agree with their conclusions. Psychiatric patients in jail run the risk of inappropriate segregation, abuse, discrimination, and denial of institutional jobs or rehabilitation programs.

Both writers also vividly portray the challenges inherent in institution-based care for certain patients with severely disruptive, aggressive, or self-injurious behavior. The care of these patients can be both time and staff intensive, thus costly. The physical management required by these patients – the use of seclusion or physical restraint, for example – might draw the scrutiny of external agencies such as the hospital accreditation agency, the Joint Commission, or patients’ rights and inmate advocacy organizations. Physical intervention and seclusion also can draw the attention of the news media, as in the series of articles published in The Atlantic over the use of long-term segregation in a federal control unit prison.

In a worst-case scenario, an adverse treatment outcome could lead to individual or class action litigation.

While I agree with the writers’ conclusions, I also have concern about the implicit messages conveyed in these stories.

The first implicit message is that there is a single, monolithic entity known as "the mentally ill" with clearly demarcated edges separating "us" and "them." This is untrue because of limitations inherent in our diagnostic system but also because of the nature of mental illness. Most psychiatric patients don’t commit crimes, much less misdemeanor offenses "typical of the mentally ill." They also don’t tear out their veins with their teeth or insert sharp objects into their genitalia. Mental illness can strike anyone, and from a statistical standpoint, there is almost certainly a person with a mental illness employed, rather than housed, in Sheriff Dart’s jail – possibly even caring for inmate Aldridge. There are also likely people with mental illness among the policy makers, legislators, and administrators who make funding decisions for correctional and psychiatric facilities.

The patients these stories are really talking about are a small subset of psychiatric patients, people with psychiatric disorders who also happen to have substance abuse problems, legal issues, and poor social supports in addition to their severely maladaptive behaviors. In other words, they are my forensic patients. I know these patients well, because I have worked with them for many years, as a treating clinician in a prison and as a forensic evaluator. I also know how my nonforensic mental health colleagues feel about working with my patients, after release or discharge. They are uncomfortable with them and concerned, reasonably or not, about liability issues and the potential for violence.

This leads to my concern about the second implicit message in these news stories. That message is: "I shouldn’t have to be responsible for these people." While the discussion is framed in benevolent terms – who could argue against the need for better access to community care? – the underlying message from both sides is that neither agency wants them in their facilities. Wardens don’t want them in their jails and they are also not welcome in hospitals. Is it any wonder that Patient M had to swallow cutlery to get help? If I could pick up the vibe from a news story, I’m sure Patient M could pick it up in person. I can only hope that both Ms. Aldridge and Patient M would be more welcome in the outpatient setting that Sheriff Dart and author Montross would send them to.

Our mental health services will not improve as long as agencies continue to shift responsibility between one another and compartmentalize care. Treatment should begin at the point of contact, regardless of location, and transition smoothly between agencies as the patient’s level of care changes. I’m aware that when it comes to mentally ill offenders and insanity acquittees, a humanitarian argument will fall on deaf ears, which explains the reliance on an economic rationale. But let’s not lose sight of the fact that the practice of medicine reflects the essence of humanitarian values. Care of the most challenging patients is the best demonstration of those values.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

It wouldn’t be the American Psychiatric Association’s annual meeting without them: the protestors. Every year for as long as I can remember, they line up with their signs and chant. In more recent years, there have been megaphones, speaker systems, and a Jumbotron.

It takes dedication.

It’s easy to ignore those who have beefs with psychiatry. We’re in demand, and I believe that because our practices remain busy with long waits to access psychiatrists in the public mental health system, it’s been to easy to ignore a small, but growing, group of individuals we may have once written off as being zealots or “kooks.” With time, their numbers and voice have gotten stronger, and their constituents more mainstream.

In the last few weeks, the New York Times published an article about the financial benefits of mandated (also called “assisted” or “forced”) outpatient programs. A letter in response was written by three professors of social work and social welfare who have authored a book called “Mad Science” (Livingston, N.J.: Transaction Publishers, 2013). It joins a number of books by Robert Whitaker that denounce our profession. This year, the National Alliance on Mental Illness invited Mr. Whitaker to speak at its annual convention – a controversial choice by any standard.

How should we, as a profession, deal with those who denounce the benefits of psychiatric care? It’s a difficult question, because they are often intent on using sensational examples, and their tone is offensive and not open to conflicting ideas. “Mad Science” uses for its first clinical example of psychiatric mistreatment a vignette about a young man with symptoms of depression who is brought to the hospital by his parents. There, with no evaluation, he is strapped to a gurney and taken immediately for brain surgery, and he is left with permanent brain damage. We have to read for several pages before the authors mention that this happened in China, even though their book is about American psychiatry. 

For starters, I believe we need to acknowledge that some of the points the protesters make are valid. Our diagnostic criteria are arrived at by consensus and not by biological markers. This is a major point that those against pharmacologic treatments want to make. They seem unaware that the values for defining diabetes and hypertension were also arrived at by consensus, and in June, the American Medical Association decided that obesity was a disease. We have loosened the criteria for diagnosis of bipolar disorder and attention-deficit disorder to the point that we should use caution before recommending lifetime treatment, and should probably not do so at the initial interview with outpatients, especially if the patients are teenagers. Few psychiatrists do this anymore, but those examples circulate. 

The hopes we’ve had for finding the biological basis to psychiatric disorders have, so far, been disappointing. The pharmaceutical companies have skewed the publication of data to show only the positive results, and there are individual research psychiatrists who have been corrupt in manipulating data for their own financial gain (for this, our own profession should join the opposition in being angry). And our treatments don’t help everyone, which is not news to any psychiatrist.

Other antipsychiatry voices go on to talk about how treatments are not only not helpful, but also harmful. They present cases such that perfectly well individuals were given medications that caused them to become psychiatrically ill, physically ill, occupationally disabled, suicidal, and even homicidal. We might point out that perfectly well people don’t generally seek psychiatric care, and be more open about the fact that people have a variety of responses to our medications, such that the bad sometimes outweighs the good. We need to respond to studies showing fault with psychiatry that have been overly touted by the media and are simply wrong. For example, a widely publicized and often quoted study showed that an initial trial of antidepressants is comparable in efficacy to placebo. But this is not reflective of psychiatric practice, where we often need trials of several medications, sometimes with augmenting agents, to yield much higher improvement rates. That fact is left out, and the message the public sees is that antidepressants don’t work. Only with my patients, they do work. 

I often wonder why there isn’t a loud and growing anti-oncology movement. Oncologists offer toxic treatments with horrible side effects to dying patients. Our protesters would point out that treatments for cancer are never forced, and perhaps we should look more carefully at the impact of civil commitment and forced medications on patient satisfaction and outcomes.

As a profession, I don’t know what we should say to the antipsychiatry advocates, and I don’t know that they want to hear from us, anyway. I do think we should listen to them long enough to process their points, respond when appropriate, and question our own clinical practices. 

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011).

It wouldn’t be the American Psychiatric Association’s annual meeting without them: the protestors. Every year for as long as I can remember, they line up with their signs and chant. In more recent years, there have been megaphones, speaker systems, and a Jumbotron.

It takes dedication.

It’s easy to ignore those who have beefs with psychiatry. We’re in demand, and I believe that because our practices remain busy with long waits to access psychiatrists in the public mental health system, it’s been to easy to ignore a small, but growing, group of individuals we may have once written off as being zealots or “kooks.” With time, their numbers and voice have gotten stronger, and their constituents more mainstream.

In the last few weeks, the New York Times published an article about the financial benefits of mandated (also called “assisted” or “forced”) outpatient programs. A letter in response was written by three professors of social work and social welfare who have authored a book called “Mad Science” (Livingston, N.J.: Transaction Publishers, 2013). It joins a number of books by Robert Whitaker that denounce our profession. This year, the National Alliance on Mental Illness invited Mr. Whitaker to speak at its annual convention – a controversial choice by any standard.

How should we, as a profession, deal with those who denounce the benefits of psychiatric care? It’s a difficult question, because they are often intent on using sensational examples, and their tone is offensive and not open to conflicting ideas. “Mad Science” uses for its first clinical example of psychiatric mistreatment a vignette about a young man with symptoms of depression who is brought to the hospital by his parents. There, with no evaluation, he is strapped to a gurney and taken immediately for brain surgery, and he is left with permanent brain damage. We have to read for several pages before the authors mention that this happened in China, even though their book is about American psychiatry. 

For starters, I believe we need to acknowledge that some of the points the protesters make are valid. Our diagnostic criteria are arrived at by consensus and not by biological markers. This is a major point that those against pharmacologic treatments want to make. They seem unaware that the values for defining diabetes and hypertension were also arrived at by consensus, and in June, the American Medical Association decided that obesity was a disease. We have loosened the criteria for diagnosis of bipolar disorder and attention-deficit disorder to the point that we should use caution before recommending lifetime treatment, and should probably not do so at the initial interview with outpatients, especially if the patients are teenagers. Few psychiatrists do this anymore, but those examples circulate. 

The hopes we’ve had for finding the biological basis to psychiatric disorders have, so far, been disappointing. The pharmaceutical companies have skewed the publication of data to show only the positive results, and there are individual research psychiatrists who have been corrupt in manipulating data for their own financial gain (for this, our own profession should join the opposition in being angry). And our treatments don’t help everyone, which is not news to any psychiatrist.

Other antipsychiatry voices go on to talk about how treatments are not only not helpful, but also harmful. They present cases such that perfectly well individuals were given medications that caused them to become psychiatrically ill, physically ill, occupationally disabled, suicidal, and even homicidal. We might point out that perfectly well people don’t generally seek psychiatric care, and be more open about the fact that people have a variety of responses to our medications, such that the bad sometimes outweighs the good. We need to respond to studies showing fault with psychiatry that have been overly touted by the media and are simply wrong. For example, a widely publicized and often quoted study showed that an initial trial of antidepressants is comparable in efficacy to placebo. But this is not reflective of psychiatric practice, where we often need trials of several medications, sometimes with augmenting agents, to yield much higher improvement rates. That fact is left out, and the message the public sees is that antidepressants don’t work. Only with my patients, they do work. 

I often wonder why there isn’t a loud and growing anti-oncology movement. Oncologists offer toxic treatments with horrible side effects to dying patients. Our protesters would point out that treatments for cancer are never forced, and perhaps we should look more carefully at the impact of civil commitment and forced medications on patient satisfaction and outcomes.

As a profession, I don’t know what we should say to the antipsychiatry advocates, and I don’t know that they want to hear from us, anyway. I do think we should listen to them long enough to process their points, respond when appropriate, and question our own clinical practices. 

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011).

It wouldn’t be the American Psychiatric Association’s annual meeting without them: the protestors. Every year for as long as I can remember, they line up with their signs and chant. In more recent years, there have been megaphones, speaker systems, and a Jumbotron.

It takes dedication.

It’s easy to ignore those who have beefs with psychiatry. We’re in demand, and I believe that because our practices remain busy with long waits to access psychiatrists in the public mental health system, it’s been to easy to ignore a small, but growing, group of individuals we may have once written off as being zealots or “kooks.” With time, their numbers and voice have gotten stronger, and their constituents more mainstream.

In the last few weeks, the New York Times published an article about the financial benefits of mandated (also called “assisted” or “forced”) outpatient programs. A letter in response was written by three professors of social work and social welfare who have authored a book called “Mad Science” (Livingston, N.J.: Transaction Publishers, 2013). It joins a number of books by Robert Whitaker that denounce our profession. This year, the National Alliance on Mental Illness invited Mr. Whitaker to speak at its annual convention – a controversial choice by any standard.

How should we, as a profession, deal with those who denounce the benefits of psychiatric care? It’s a difficult question, because they are often intent on using sensational examples, and their tone is offensive and not open to conflicting ideas. “Mad Science” uses for its first clinical example of psychiatric mistreatment a vignette about a young man with symptoms of depression who is brought to the hospital by his parents. There, with no evaluation, he is strapped to a gurney and taken immediately for brain surgery, and he is left with permanent brain damage. We have to read for several pages before the authors mention that this happened in China, even though their book is about American psychiatry. 

For starters, I believe we need to acknowledge that some of the points the protesters make are valid. Our diagnostic criteria are arrived at by consensus and not by biological markers. This is a major point that those against pharmacologic treatments want to make. They seem unaware that the values for defining diabetes and hypertension were also arrived at by consensus, and in June, the American Medical Association decided that obesity was a disease. We have loosened the criteria for diagnosis of bipolar disorder and attention-deficit disorder to the point that we should use caution before recommending lifetime treatment, and should probably not do so at the initial interview with outpatients, especially if the patients are teenagers. Few psychiatrists do this anymore, but those examples circulate. 

The hopes we’ve had for finding the biological basis to psychiatric disorders have, so far, been disappointing. The pharmaceutical companies have skewed the publication of data to show only the positive results, and there are individual research psychiatrists who have been corrupt in manipulating data for their own financial gain (for this, our own profession should join the opposition in being angry). And our treatments don’t help everyone, which is not news to any psychiatrist.

Other antipsychiatry voices go on to talk about how treatments are not only not helpful, but also harmful. They present cases such that perfectly well individuals were given medications that caused them to become psychiatrically ill, physically ill, occupationally disabled, suicidal, and even homicidal. We might point out that perfectly well people don’t generally seek psychiatric care, and be more open about the fact that people have a variety of responses to our medications, such that the bad sometimes outweighs the good. We need to respond to studies showing fault with psychiatry that have been overly touted by the media and are simply wrong. For example, a widely publicized and often quoted study showed that an initial trial of antidepressants is comparable in efficacy to placebo. But this is not reflective of psychiatric practice, where we often need trials of several medications, sometimes with augmenting agents, to yield much higher improvement rates. That fact is left out, and the message the public sees is that antidepressants don’t work. Only with my patients, they do work. 

I often wonder why there isn’t a loud and growing anti-oncology movement. Oncologists offer toxic treatments with horrible side effects to dying patients. Our protesters would point out that treatments for cancer are never forced, and perhaps we should look more carefully at the impact of civil commitment and forced medications on patient satisfaction and outcomes.

As a profession, I don’t know what we should say to the antipsychiatry advocates, and I don’t know that they want to hear from us, anyway. I do think we should listen to them long enough to process their points, respond when appropriate, and question our own clinical practices. 

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011).

One year ago this month, after the theater shooting in Aurora, Colo., I wrote a column for this newspaper headlined, “The Aurora Shootings: Why the Mental Health Community Must Show Restraint.” In this column, I talked about the risks inherent in offering public comments about a defendant’s mental state and about Section 7.3 of the American Psychiatric Association’s Principles of Medical Ethics, which state:

“On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself or herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general.

However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

This section, also known as the Goldwater Rule, was created prior to the invention of the Internet and social media. Modern digital communication now has the power to transmit off-the-cuff, casual comments globally. Mental health professionals must practice additional care about making unwarranted or unsupported statements about individuals in the public eye whom they’ve never met or examined. This is particularly true for those facing trial, where freedom or even life itself may be at stake.

Three months after my column, the APA Assembly voted unanimously to accept an action paper urging the organization to update and amend Section 7.3 to include a discussion and cautionary statement regarding the impact of public commentary on the criminal prosecution, sentencing, and suicide risk of individuals charged with high-profile crimes.

This amendment is not made lightly or without careful consideration. Those making public statements about a criminal defendant have often not had the opportunity to review information available to an expert witness. When making a decision about sanity or the presence of mental illness, a forensic psychiatrist typically reviews a lengthy list of information sources: medical records, investigation and other police reports, witness statements, crime scene photos, surveillance videos, medical examiner’s reports, audio tapes of 911 calls, interrogation transcripts or videotapes, school records, jail or prison treatment records, criminal history reports, Internet search histories, social media content, cell phone records, and text messages.

In addition, a pretrial evaluation would include an interview with the defendant, his friends and family or co-workers, witnesses, investigating officers and the victim, if living.

Considering this, I was dismayed to see this tweet by APA President Jeff Lieberman come across my APA twitter feed:

“Fort Hood shooter is an ideological zealot, not mentally ill as originally claimed.”https://twitter.com/drjlieberman/status/363290629696409600

The tweet included a link to a Reuters story http://www.reuters.com/article/2013/07/27/us-usa-crime-forthood-idUSBRE96Q0B120130727 that relied upon a Fox News report. Fox released quotes from a six-page statement sent to the service by alleged Fort Hood shooter Major Nidal Hasan. Hasan reportedly did not discuss the offense directly in this letter. Nevertheless, Dr. Lieberman relied upon this 274-word press release from a secondary source to globally express a professional opinion about a defendant whose trial begins this week. If convicted, Hasan could face the death penalty.

I would urge mental health professionals to be mindful of the limitations of publicly available information, which is likely to be incomplete or may even be inaccurate.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One year ago this month, after the theater shooting in Aurora, Colo., I wrote a column for this newspaper headlined, “The Aurora Shootings: Why the Mental Health Community Must Show Restraint.” In this column, I talked about the risks inherent in offering public comments about a defendant’s mental state and about Section 7.3 of the American Psychiatric Association’s Principles of Medical Ethics, which state:

“On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself or herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general.

However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

This section, also known as the Goldwater Rule, was created prior to the invention of the Internet and social media. Modern digital communication now has the power to transmit off-the-cuff, casual comments globally. Mental health professionals must practice additional care about making unwarranted or unsupported statements about individuals in the public eye whom they’ve never met or examined. This is particularly true for those facing trial, where freedom or even life itself may be at stake.

Three months after my column, the APA Assembly voted unanimously to accept an action paper urging the organization to update and amend Section 7.3 to include a discussion and cautionary statement regarding the impact of public commentary on the criminal prosecution, sentencing, and suicide risk of individuals charged with high-profile crimes.

This amendment is not made lightly or without careful consideration. Those making public statements about a criminal defendant have often not had the opportunity to review information available to an expert witness. When making a decision about sanity or the presence of mental illness, a forensic psychiatrist typically reviews a lengthy list of information sources: medical records, investigation and other police reports, witness statements, crime scene photos, surveillance videos, medical examiner’s reports, audio tapes of 911 calls, interrogation transcripts or videotapes, school records, jail or prison treatment records, criminal history reports, Internet search histories, social media content, cell phone records, and text messages.

In addition, a pretrial evaluation would include an interview with the defendant, his friends and family or co-workers, witnesses, investigating officers and the victim, if living.

Considering this, I was dismayed to see this tweet by APA President Jeff Lieberman come across my APA twitter feed:

“Fort Hood shooter is an ideological zealot, not mentally ill as originally claimed.”https://twitter.com/drjlieberman/status/363290629696409600

The tweet included a link to a Reuters story http://www.reuters.com/article/2013/07/27/us-usa-crime-forthood-idUSBRE96Q0B120130727 that relied upon a Fox News report. Fox released quotes from a six-page statement sent to the service by alleged Fort Hood shooter Major Nidal Hasan. Hasan reportedly did not discuss the offense directly in this letter. Nevertheless, Dr. Lieberman relied upon this 274-word press release from a secondary source to globally express a professional opinion about a defendant whose trial begins this week. If convicted, Hasan could face the death penalty.

I would urge mental health professionals to be mindful of the limitations of publicly available information, which is likely to be incomplete or may even be inaccurate.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

One year ago this month, after the theater shooting in Aurora, Colo., I wrote a column for this newspaper headlined, “The Aurora Shootings: Why the Mental Health Community Must Show Restraint.” In this column, I talked about the risks inherent in offering public comments about a defendant’s mental state and about Section 7.3 of the American Psychiatric Association’s Principles of Medical Ethics, which state:

“On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself or herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general.

However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.”

This section, also known as the Goldwater Rule, was created prior to the invention of the Internet and social media. Modern digital communication now has the power to transmit off-the-cuff, casual comments globally. Mental health professionals must practice additional care about making unwarranted or unsupported statements about individuals in the public eye whom they’ve never met or examined. This is particularly true for those facing trial, where freedom or even life itself may be at stake.

Three months after my column, the APA Assembly voted unanimously to accept an action paper urging the organization to update and amend Section 7.3 to include a discussion and cautionary statement regarding the impact of public commentary on the criminal prosecution, sentencing, and suicide risk of individuals charged with high-profile crimes.

This amendment is not made lightly or without careful consideration. Those making public statements about a criminal defendant have often not had the opportunity to review information available to an expert witness. When making a decision about sanity or the presence of mental illness, a forensic psychiatrist typically reviews a lengthy list of information sources: medical records, investigation and other police reports, witness statements, crime scene photos, surveillance videos, medical examiner’s reports, audio tapes of 911 calls, interrogation transcripts or videotapes, school records, jail or prison treatment records, criminal history reports, Internet search histories, social media content, cell phone records, and text messages.

In addition, a pretrial evaluation would include an interview with the defendant, his friends and family or co-workers, witnesses, investigating officers and the victim, if living.

Considering this, I was dismayed to see this tweet by APA President Jeff Lieberman come across my APA twitter feed:

“Fort Hood shooter is an ideological zealot, not mentally ill as originally claimed.”https://twitter.com/drjlieberman/status/363290629696409600

The tweet included a link to a Reuters story http://www.reuters.com/article/2013/07/27/us-usa-crime-forthood-idUSBRE96Q0B120130727 that relied upon a Fox News report. Fox released quotes from a six-page statement sent to the service by alleged Fort Hood shooter Major Nidal Hasan. Hasan reportedly did not discuss the offense directly in this letter. Nevertheless, Dr. Lieberman relied upon this 274-word press release from a secondary source to globally express a professional opinion about a defendant whose trial begins this week. If convicted, Hasan could face the death penalty.

I would urge mental health professionals to be mindful of the limitations of publicly available information, which is likely to be incomplete or may even be inaccurate.

<[QM]>—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Oh, I’m so glad I’m not a correctional psychiatrist in California right now. Late last week, nearly a quarter of the inmates in the entire state prison system began a unified, declared hunger strike. I’ve evaluated and worked with individual prisoners on a hunger strike before, but nothing on this scale.

Fortunately, standards and policies are in place that a jail or prison can rely upon when managing the individual hunger striker. Common elements of this policy would include a formal notice to custody and to the medical department about an inmate’s declared hunger strike.

Even without formal notice, a policy might require both the medical and psychology departments to be notified when an inmate refuses a set number of meals. At that point, a mental health referral is made to rule out psychiatric illness such as psychosis or depression and to assess the inmate’s competency to refuse food, hydration, or medical procedures. The medical department would assess the inmate to determine his nutritional status on a regular basis through daily weights and laboratory values. As the strike progresses, the inmate may require inpatient medical monitoring of hydration status. In extreme cases, a correctional facility may seek a court order to feed an inmate involuntarily.

Throughout this process, the facility uses a multidisciplinary approach to continuously educate the inmate about the medical consequences of starvation, to assess ongoing mental capacity, and to monitor the patient’s willingness to consent to medical care. The correctional clinician also may be asked to talk to the inmate about what he would want done if he lost the capacity to make medical decisions.

Force-feeding of prisoners carries obvious ethical and practical consequences for the correctional clinician. On the one hand, we are obligated to respect individual autonomy and freedom, but we are appositely required to protect individual health and safety. Because of the potential for behavioral contagion, hunger strikes also can lead to unrest in the facility and further consumption of health care resources. Institutional safety is a dual concern for the correctional clinician.

The 2006 World Medical Association’s Declaration of Malta on Hunger Strikers contains international guidelines for the management of hunger strikes. A key component is an assessment to determine whether a mental impairment undermines the inmate’s ability to make health care decisions. In that case, the inmate is a patient rather than a hunger striker, and the clinician must provide treatment rather than allow deterioration or death. Conversely, if the decision to fast is made free of disability or coercion, the Declaration of Malta bars forced feeding as unethical.

The Malta guidelines also state that "physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities, or others, such as family members."

There’s the dilemma. In the case of mass hunger strikes such as the current one in California, the strike is a political movement designed to force the state prison system to modify its use of long-term segregation. The strike was planned in advance through social media and is fueled by the support of individual celebrities and advocacy organizations. Considerable public attention and scrutiny have been given to the strike by online and traditional media. A single prisoner’s decision to strike may be attributable to his individual beliefs and values but now could also be tied to overwhelming peer intimidation and public pressure. It would be unethical for a clinician to allow a vulnerable prisoner to place his health at risk as a result of coercion.

To my knowledge, no procedures or guidelines exist to help the clinician assess the voluntariness of a hunger strike, so I’m going to propose an assessment. In my opinion, a coercion assessment would include consideration of the inmate’s history as well as current functioning within the facility. I would look for factors that might make him more vulnerable to harassment or intimidation, such as small physical stature, serious mental illness, intellectual disability, history of peer-on-peer victimization, or placement on protective custody. I would review his history of previous institutional protests, if any, such as a documented history of formal protest through the administrative grievance system, pro se lawsuits or individual hunger strikes.

I would also ask the following questions: When did you decide to strike? What led to this decision? Has anyone on the tier talked to you about your decision? What about your family? What would have happened if you hadn’t joined the strike? Have others on your tier refused to fast? What happened to them? What do you hope will happen as a result of this strike? Has anyone offered you any privileges or made any threats related to your decision to strike?

Depending upon the results of this evaluation, the inmate could be offered protective custody, transfer to another facility, or movement to a tier – where inmates are not participating in the strike.

In light of the public attention given to mass hunger strikes lately, anyone working in a jail or prison now should be prepared to handle a coercion assessment.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Oh, I’m so glad I’m not a correctional psychiatrist in California right now. Late last week, nearly a quarter of the inmates in the entire state prison system began a unified, declared hunger strike. I’ve evaluated and worked with individual prisoners on a hunger strike before, but nothing on this scale.

Fortunately, standards and policies are in place that a jail or prison can rely upon when managing the individual hunger striker. Common elements of this policy would include a formal notice to custody and to the medical department about an inmate’s declared hunger strike.

Even without formal notice, a policy might require both the medical and psychology departments to be notified when an inmate refuses a set number of meals. At that point, a mental health referral is made to rule out psychiatric illness such as psychosis or depression and to assess the inmate’s competency to refuse food, hydration, or medical procedures. The medical department would assess the inmate to determine his nutritional status on a regular basis through daily weights and laboratory values. As the strike progresses, the inmate may require inpatient medical monitoring of hydration status. In extreme cases, a correctional facility may seek a court order to feed an inmate involuntarily.

Throughout this process, the facility uses a multidisciplinary approach to continuously educate the inmate about the medical consequences of starvation, to assess ongoing mental capacity, and to monitor the patient’s willingness to consent to medical care. The correctional clinician also may be asked to talk to the inmate about what he would want done if he lost the capacity to make medical decisions.

Force-feeding of prisoners carries obvious ethical and practical consequences for the correctional clinician. On the one hand, we are obligated to respect individual autonomy and freedom, but we are appositely required to protect individual health and safety. Because of the potential for behavioral contagion, hunger strikes also can lead to unrest in the facility and further consumption of health care resources. Institutional safety is a dual concern for the correctional clinician.

The 2006 World Medical Association’s Declaration of Malta on Hunger Strikers contains international guidelines for the management of hunger strikes. A key component is an assessment to determine whether a mental impairment undermines the inmate’s ability to make health care decisions. In that case, the inmate is a patient rather than a hunger striker, and the clinician must provide treatment rather than allow deterioration or death. Conversely, if the decision to fast is made free of disability or coercion, the Declaration of Malta bars forced feeding as unethical.

The Malta guidelines also state that "physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities, or others, such as family members."

There’s the dilemma. In the case of mass hunger strikes such as the current one in California, the strike is a political movement designed to force the state prison system to modify its use of long-term segregation. The strike was planned in advance through social media and is fueled by the support of individual celebrities and advocacy organizations. Considerable public attention and scrutiny have been given to the strike by online and traditional media. A single prisoner’s decision to strike may be attributable to his individual beliefs and values but now could also be tied to overwhelming peer intimidation and public pressure. It would be unethical for a clinician to allow a vulnerable prisoner to place his health at risk as a result of coercion.

To my knowledge, no procedures or guidelines exist to help the clinician assess the voluntariness of a hunger strike, so I’m going to propose an assessment. In my opinion, a coercion assessment would include consideration of the inmate’s history as well as current functioning within the facility. I would look for factors that might make him more vulnerable to harassment or intimidation, such as small physical stature, serious mental illness, intellectual disability, history of peer-on-peer victimization, or placement on protective custody. I would review his history of previous institutional protests, if any, such as a documented history of formal protest through the administrative grievance system, pro se lawsuits or individual hunger strikes.

I would also ask the following questions: When did you decide to strike? What led to this decision? Has anyone on the tier talked to you about your decision? What about your family? What would have happened if you hadn’t joined the strike? Have others on your tier refused to fast? What happened to them? What do you hope will happen as a result of this strike? Has anyone offered you any privileges or made any threats related to your decision to strike?

Depending upon the results of this evaluation, the inmate could be offered protective custody, transfer to another facility, or movement to a tier – where inmates are not participating in the strike.

In light of the public attention given to mass hunger strikes lately, anyone working in a jail or prison now should be prepared to handle a coercion assessment.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Oh, I’m so glad I’m not a correctional psychiatrist in California right now. Late last week, nearly a quarter of the inmates in the entire state prison system began a unified, declared hunger strike. I’ve evaluated and worked with individual prisoners on a hunger strike before, but nothing on this scale.

Fortunately, standards and policies are in place that a jail or prison can rely upon when managing the individual hunger striker. Common elements of this policy would include a formal notice to custody and to the medical department about an inmate’s declared hunger strike.

Even without formal notice, a policy might require both the medical and psychology departments to be notified when an inmate refuses a set number of meals. At that point, a mental health referral is made to rule out psychiatric illness such as psychosis or depression and to assess the inmate’s competency to refuse food, hydration, or medical procedures. The medical department would assess the inmate to determine his nutritional status on a regular basis through daily weights and laboratory values. As the strike progresses, the inmate may require inpatient medical monitoring of hydration status. In extreme cases, a correctional facility may seek a court order to feed an inmate involuntarily.

Throughout this process, the facility uses a multidisciplinary approach to continuously educate the inmate about the medical consequences of starvation, to assess ongoing mental capacity, and to monitor the patient’s willingness to consent to medical care. The correctional clinician also may be asked to talk to the inmate about what he would want done if he lost the capacity to make medical decisions.

Force-feeding of prisoners carries obvious ethical and practical consequences for the correctional clinician. On the one hand, we are obligated to respect individual autonomy and freedom, but we are appositely required to protect individual health and safety. Because of the potential for behavioral contagion, hunger strikes also can lead to unrest in the facility and further consumption of health care resources. Institutional safety is a dual concern for the correctional clinician.

The 2006 World Medical Association’s Declaration of Malta on Hunger Strikers contains international guidelines for the management of hunger strikes. A key component is an assessment to determine whether a mental impairment undermines the inmate’s ability to make health care decisions. In that case, the inmate is a patient rather than a hunger striker, and the clinician must provide treatment rather than allow deterioration or death. Conversely, if the decision to fast is made free of disability or coercion, the Declaration of Malta bars forced feeding as unethical.

The Malta guidelines also state that "physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the peer group, the authorities, or others, such as family members."

There’s the dilemma. In the case of mass hunger strikes such as the current one in California, the strike is a political movement designed to force the state prison system to modify its use of long-term segregation. The strike was planned in advance through social media and is fueled by the support of individual celebrities and advocacy organizations. Considerable public attention and scrutiny have been given to the strike by online and traditional media. A single prisoner’s decision to strike may be attributable to his individual beliefs and values but now could also be tied to overwhelming peer intimidation and public pressure. It would be unethical for a clinician to allow a vulnerable prisoner to place his health at risk as a result of coercion.

To my knowledge, no procedures or guidelines exist to help the clinician assess the voluntariness of a hunger strike, so I’m going to propose an assessment. In my opinion, a coercion assessment would include consideration of the inmate’s history as well as current functioning within the facility. I would look for factors that might make him more vulnerable to harassment or intimidation, such as small physical stature, serious mental illness, intellectual disability, history of peer-on-peer victimization, or placement on protective custody. I would review his history of previous institutional protests, if any, such as a documented history of formal protest through the administrative grievance system, pro se lawsuits or individual hunger strikes.

I would also ask the following questions: When did you decide to strike? What led to this decision? Has anyone on the tier talked to you about your decision? What about your family? What would have happened if you hadn’t joined the strike? Have others on your tier refused to fast? What happened to them? What do you hope will happen as a result of this strike? Has anyone offered you any privileges or made any threats related to your decision to strike?

Depending upon the results of this evaluation, the inmate could be offered protective custody, transfer to another facility, or movement to a tier – where inmates are not participating in the strike.

In light of the public attention given to mass hunger strikes lately, anyone working in a jail or prison now should be prepared to handle a coercion assessment.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

When a doctor treats a patient – any patient, and perhaps psychotherapy patients in particular – there is one tenet that holds true for all visits: The visit is about the patient. Psychiatrists vary a great deal with respect to how much they reveal to patients about their personal lives. As the years have gone by, and we’ve talked more about controlled clinical trials and evidence-based medicine, we’ve talked less about boundaries and how much to disclose, or not, to patients about our personal lives.

I’m not a psychoanalyst. For them, boundaries about such things are clear, and self-disclosure about the therapist’s life is often taboo. Still, I do think it’s important to limit talking about oneself in psychotherapy for several reasons. For one thing, it takes up time that the patient could be using to do work and risks turning the session into a meeting that is about the therapist, and not the patient. And finally, having some distance keeps it clear that the relationship is a professional and therapeutic one, and not a friendship or romantic encounter, and that message hopefully is conveyed in a number of other ways as well.

I often tell people stories from my own life if I think it will convey a message or resonate for them: I may briefly talk about a movie I saw that pertains to the patient’s concerns or commiserate with them about life’s aggravations. My favorite story to tell patients who worry excessively that they might do something that will embarrass them, is that I once went to work at the clinic with my dress on inside out. Yes, it was immediately noticeable, but after my initial mortification and dash to the restroom, I was happy that I gave some kind social workers a good laugh. And life does go on, even after one embarrasses oneself. I share short stories that I hope will resonate, or give some perspective to an individual’s troubles, or simply let the patient know that we are all part of the same muck of humanity and things are not always easy.

What I don’t offer are stories that are very personal. I don’t talk about my children or husband, I don’t offer information about my health unless it’s absolutely necessary, the only relevant example being two pregnancies when I first started practicing.

But lives don’t always go smoothly. There was an unexpected death in my family a few weeks ago – the impetus for my thinking and writing about this topic now – and I felt I needed to offer an explanation to the patients I canceled on very little notice. It left those patients knowing that I’ve been struggling, though I am mostly able to put it aside while I work. Still, I feel badly that the patients have worried about me when they have their own difficulties.

The other day, the door of my suite bore a sign: One of my colleagues had a family emergency and requested that patients call to reschedule. I did learn that she had to run a sick child to the doctor, but I don’t know what she told those patients.

Although disclosing personal information can be distracting, or even disturbing, it seems reasonable to let patients know about emergencies that directly affect them. I long ago gave up on absolute answers to such questions; some patients press me for personal information and if it doesn’t feel overly intrusive, I simply respond and I don’t always ask why they want to know. When I do delve, sometimes the reasons reveal interesting information, but not always. Other patients never ask a thing. So while I have no answers but to say what has mostly worked for me, it somehow feels comfortable to revisit an old topic that doesn’t get much attention anymore.

Dr. Miller is coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). 

When a doctor treats a patient – any patient, and perhaps psychotherapy patients in particular – there is one tenet that holds true for all visits: The visit is about the patient. Psychiatrists vary a great deal with respect to how much they reveal to patients about their personal lives. As the years have gone by, and we’ve talked more about controlled clinical trials and evidence-based medicine, we’ve talked less about boundaries and how much to disclose, or not, to patients about our personal lives.

I’m not a psychoanalyst. For them, boundaries about such things are clear, and self-disclosure about the therapist’s life is often taboo. Still, I do think it’s important to limit talking about oneself in psychotherapy for several reasons. For one thing, it takes up time that the patient could be using to do work and risks turning the session into a meeting that is about the therapist, and not the patient. And finally, having some distance keeps it clear that the relationship is a professional and therapeutic one, and not a friendship or romantic encounter, and that message hopefully is conveyed in a number of other ways as well.

I often tell people stories from my own life if I think it will convey a message or resonate for them: I may briefly talk about a movie I saw that pertains to the patient’s concerns or commiserate with them about life’s aggravations. My favorite story to tell patients who worry excessively that they might do something that will embarrass them, is that I once went to work at the clinic with my dress on inside out. Yes, it was immediately noticeable, but after my initial mortification and dash to the restroom, I was happy that I gave some kind social workers a good laugh. And life does go on, even after one embarrasses oneself. I share short stories that I hope will resonate, or give some perspective to an individual’s troubles, or simply let the patient know that we are all part of the same muck of humanity and things are not always easy.

What I don’t offer are stories that are very personal. I don’t talk about my children or husband, I don’t offer information about my health unless it’s absolutely necessary, the only relevant example being two pregnancies when I first started practicing.

But lives don’t always go smoothly. There was an unexpected death in my family a few weeks ago – the impetus for my thinking and writing about this topic now – and I felt I needed to offer an explanation to the patients I canceled on very little notice. It left those patients knowing that I’ve been struggling, though I am mostly able to put it aside while I work. Still, I feel badly that the patients have worried about me when they have their own difficulties.

The other day, the door of my suite bore a sign: One of my colleagues had a family emergency and requested that patients call to reschedule. I did learn that she had to run a sick child to the doctor, but I don’t know what she told those patients.

Although disclosing personal information can be distracting, or even disturbing, it seems reasonable to let patients know about emergencies that directly affect them. I long ago gave up on absolute answers to such questions; some patients press me for personal information and if it doesn’t feel overly intrusive, I simply respond and I don’t always ask why they want to know. When I do delve, sometimes the reasons reveal interesting information, but not always. Other patients never ask a thing. So while I have no answers but to say what has mostly worked for me, it somehow feels comfortable to revisit an old topic that doesn’t get much attention anymore.

Dr. Miller is coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). 

When a doctor treats a patient – any patient, and perhaps psychotherapy patients in particular – there is one tenet that holds true for all visits: The visit is about the patient. Psychiatrists vary a great deal with respect to how much they reveal to patients about their personal lives. As the years have gone by, and we’ve talked more about controlled clinical trials and evidence-based medicine, we’ve talked less about boundaries and how much to disclose, or not, to patients about our personal lives.

I’m not a psychoanalyst. For them, boundaries about such things are clear, and self-disclosure about the therapist’s life is often taboo. Still, I do think it’s important to limit talking about oneself in psychotherapy for several reasons. For one thing, it takes up time that the patient could be using to do work and risks turning the session into a meeting that is about the therapist, and not the patient. And finally, having some distance keeps it clear that the relationship is a professional and therapeutic one, and not a friendship or romantic encounter, and that message hopefully is conveyed in a number of other ways as well.

I often tell people stories from my own life if I think it will convey a message or resonate for them: I may briefly talk about a movie I saw that pertains to the patient’s concerns or commiserate with them about life’s aggravations. My favorite story to tell patients who worry excessively that they might do something that will embarrass them, is that I once went to work at the clinic with my dress on inside out. Yes, it was immediately noticeable, but after my initial mortification and dash to the restroom, I was happy that I gave some kind social workers a good laugh. And life does go on, even after one embarrasses oneself. I share short stories that I hope will resonate, or give some perspective to an individual’s troubles, or simply let the patient know that we are all part of the same muck of humanity and things are not always easy.

What I don’t offer are stories that are very personal. I don’t talk about my children or husband, I don’t offer information about my health unless it’s absolutely necessary, the only relevant example being two pregnancies when I first started practicing.

But lives don’t always go smoothly. There was an unexpected death in my family a few weeks ago – the impetus for my thinking and writing about this topic now – and I felt I needed to offer an explanation to the patients I canceled on very little notice. It left those patients knowing that I’ve been struggling, though I am mostly able to put it aside while I work. Still, I feel badly that the patients have worried about me when they have their own difficulties.

The other day, the door of my suite bore a sign: One of my colleagues had a family emergency and requested that patients call to reschedule. I did learn that she had to run a sick child to the doctor, but I don’t know what she told those patients.

Although disclosing personal information can be distracting, or even disturbing, it seems reasonable to let patients know about emergencies that directly affect them. I long ago gave up on absolute answers to such questions; some patients press me for personal information and if it doesn’t feel overly intrusive, I simply respond and I don’t always ask why they want to know. When I do delve, sometimes the reasons reveal interesting information, but not always. Other patients never ask a thing. So while I have no answers but to say what has mostly worked for me, it somehow feels comfortable to revisit an old topic that doesn’t get much attention anymore.

Dr. Miller is coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). 

I’ll warn you in advance that this column contains a bit of speculative fiction. Nevertheless, today’s science fiction sometimes will become tomorrow’s fact. For example, in William Gibson’s classic 1984 novel "Neuromancer," he coined the term "cyberspace" and speculated about a world where people lived simultaneously in a virtual reality and a physical reality. With the invention of social media, real-time news, and Google databases, our cyberworlds and physical worlds have started to converge.

One way this has shown up is in the realm of targeted, predictive advertising. Last year, Target made news when it sent coupons and advertisements for baby diapers to a 16-year-old girl. Her father called the store to complain angrily about this, only to later discover that his daughter actually was pregnant. It turned out that Target had collected and analyzed extensive shopping data from its customers and was able to use this information to pick out which female shoppers were likely to be pregnant and even how close they were to delivery.

Unsurprisingly, the general public reacted strongly to this invasion of privacy and Target had to change advertising tactics. Instead of sending the targeted customer only maternity-related coupons, it buried the coupons among ads for other unrelated products to make the coupons appear random. This worked. The pseudo-coincidental coupons were used by targeted pregnant customers.

I had a flashback to this story recently when I came across a recently published 300-page document entitled "Using Behavioral Indicators to Help Detect Potential Violent Acts." It is an overview of existing research compiled by the national security research division of Rand, a federally funded agency that does research and planning for the U.S. Secretary of Defense, the U.S. military, and the intelligence community. The purpose of the report was to present a review of the currently available methods for using real-time or stored digital data to predict insurgent and terrorist activity by individuals.

The report talks about characteristics of individuals at risk and methods for gathering and analyzing data about those individuals. Data would be drawn from several sources. Smartphone data would provide travel patterns and physical movement, while existing commercial databases such as those available through Google or Amazon would contain information about purchases, opinions, interests, and political affiliations. Social-media accounts would enable examination and surveillance of an individual’s communications or planning activity with known foreign operatives.

All of this information would be considered "pattern of life" data that could be collected in real time and analyzed through a proposed "fusion center." The fusion center would do data analysis using machine algorithms or natural language processing and layer this data with information drawn from law enforcement or national intelligence sources. Some studies have already been done that have shown that smartphone data can be used to predict personality traits and travel patterns. Facial-recognition software can be applied to surveillance videos to interpret emotions such as anxiety or anger preceding an impending attack.

In theory, all of this information could be collated to generate a checklist security screen or risk score. Specifically, the report suggested building an individual profile drawn from "whole-life data (e.g., from school, criminal, civil, legal, interrogation, medical [emphasis mine], travel, financial, consumer, and social/public communication)."

The report goes on to discuss what would happen after the individual is identified:

"First, an indicator that would by no means justify an arrest or enforced medical treatment (emphasis mine) might, in connection with other information, have value at a checkpoint or an intelligence center pondering a tip about terrorist action. The result might be to increase caution, double check a discrepancy, look for more information, put the person in question under surveillance, or conduct an interrogation."

Of course, no one anticipates that this kind of activity might affect them, but consider what the report identifies as some of the psychological underpinnings of a terrorist: someone with a history of childhood trauma or cruelty to animals; someone with rapid shifts in mood; or someone showing evidence of stress, fear, or anger. In other words, characteristics sometimes associated with our patients.

For what it’s worth, the Rand report recognizes that individuals with mental illness are unlikely to become involved in organized terrorist activities. The report also acknowledges that there are likely to be a high number of false-positive identifications and that "such data could be [a] start down a very slippery slope" and would be "quite controversial, both scientifically and with respect to privacy and civil liberties."

Unfortunately, like Target, rather than cautioning against such activity, the report discussed ways to mitigate civilian concerns and potential damage.

To my knowledge, no medical information is being drawn from health information systems for this purpose yet. But given the recent concern about potentially dangerous patients during the debate about gun legislation, it’s not too much of a stretch to speculate that eventually some agency might wish to bypass the clinician entirely and draw certain risk-associated data directly from a health information system. The Rand report concluded that such information fusion is "likely essential for success" in the prevention of terrorism.

As hospitals, clinics, and the public mental health system move to integrate their information systems, privacy protections might need to include more than protection from unauthorized access by employees.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I’ll warn you in advance that this column contains a bit of speculative fiction. Nevertheless, today’s science fiction sometimes will become tomorrow’s fact. For example, in William Gibson’s classic 1984 novel "Neuromancer," he coined the term "cyberspace" and speculated about a world where people lived simultaneously in a virtual reality and a physical reality. With the invention of social media, real-time news, and Google databases, our cyberworlds and physical worlds have started to converge.

One way this has shown up is in the realm of targeted, predictive advertising. Last year, Target made news when it sent coupons and advertisements for baby diapers to a 16-year-old girl. Her father called the store to complain angrily about this, only to later discover that his daughter actually was pregnant. It turned out that Target had collected and analyzed extensive shopping data from its customers and was able to use this information to pick out which female shoppers were likely to be pregnant and even how close they were to delivery.

Unsurprisingly, the general public reacted strongly to this invasion of privacy and Target had to change advertising tactics. Instead of sending the targeted customer only maternity-related coupons, it buried the coupons among ads for other unrelated products to make the coupons appear random. This worked. The pseudo-coincidental coupons were used by targeted pregnant customers.

I had a flashback to this story recently when I came across a recently published 300-page document entitled "Using Behavioral Indicators to Help Detect Potential Violent Acts." It is an overview of existing research compiled by the national security research division of Rand, a federally funded agency that does research and planning for the U.S. Secretary of Defense, the U.S. military, and the intelligence community. The purpose of the report was to present a review of the currently available methods for using real-time or stored digital data to predict insurgent and terrorist activity by individuals.

The report talks about characteristics of individuals at risk and methods for gathering and analyzing data about those individuals. Data would be drawn from several sources. Smartphone data would provide travel patterns and physical movement, while existing commercial databases such as those available through Google or Amazon would contain information about purchases, opinions, interests, and political affiliations. Social-media accounts would enable examination and surveillance of an individual’s communications or planning activity with known foreign operatives.

All of this information would be considered "pattern of life" data that could be collected in real time and analyzed through a proposed "fusion center." The fusion center would do data analysis using machine algorithms or natural language processing and layer this data with information drawn from law enforcement or national intelligence sources. Some studies have already been done that have shown that smartphone data can be used to predict personality traits and travel patterns. Facial-recognition software can be applied to surveillance videos to interpret emotions such as anxiety or anger preceding an impending attack.

In theory, all of this information could be collated to generate a checklist security screen or risk score. Specifically, the report suggested building an individual profile drawn from "whole-life data (e.g., from school, criminal, civil, legal, interrogation, medical [emphasis mine], travel, financial, consumer, and social/public communication)."

The report goes on to discuss what would happen after the individual is identified:

"First, an indicator that would by no means justify an arrest or enforced medical treatment (emphasis mine) might, in connection with other information, have value at a checkpoint or an intelligence center pondering a tip about terrorist action. The result might be to increase caution, double check a discrepancy, look for more information, put the person in question under surveillance, or conduct an interrogation."

Of course, no one anticipates that this kind of activity might affect them, but consider what the report identifies as some of the psychological underpinnings of a terrorist: someone with a history of childhood trauma or cruelty to animals; someone with rapid shifts in mood; or someone showing evidence of stress, fear, or anger. In other words, characteristics sometimes associated with our patients.

For what it’s worth, the Rand report recognizes that individuals with mental illness are unlikely to become involved in organized terrorist activities. The report also acknowledges that there are likely to be a high number of false-positive identifications and that "such data could be [a] start down a very slippery slope" and would be "quite controversial, both scientifically and with respect to privacy and civil liberties."

Unfortunately, like Target, rather than cautioning against such activity, the report discussed ways to mitigate civilian concerns and potential damage.

To my knowledge, no medical information is being drawn from health information systems for this purpose yet. But given the recent concern about potentially dangerous patients during the debate about gun legislation, it’s not too much of a stretch to speculate that eventually some agency might wish to bypass the clinician entirely and draw certain risk-associated data directly from a health information system. The Rand report concluded that such information fusion is "likely essential for success" in the prevention of terrorism.

As hospitals, clinics, and the public mental health system move to integrate their information systems, privacy protections might need to include more than protection from unauthorized access by employees.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I’ll warn you in advance that this column contains a bit of speculative fiction. Nevertheless, today’s science fiction sometimes will become tomorrow’s fact. For example, in William Gibson’s classic 1984 novel "Neuromancer," he coined the term "cyberspace" and speculated about a world where people lived simultaneously in a virtual reality and a physical reality. With the invention of social media, real-time news, and Google databases, our cyberworlds and physical worlds have started to converge.

One way this has shown up is in the realm of targeted, predictive advertising. Last year, Target made news when it sent coupons and advertisements for baby diapers to a 16-year-old girl. Her father called the store to complain angrily about this, only to later discover that his daughter actually was pregnant. It turned out that Target had collected and analyzed extensive shopping data from its customers and was able to use this information to pick out which female shoppers were likely to be pregnant and even how close they were to delivery.

Unsurprisingly, the general public reacted strongly to this invasion of privacy and Target had to change advertising tactics. Instead of sending the targeted customer only maternity-related coupons, it buried the coupons among ads for other unrelated products to make the coupons appear random. This worked. The pseudo-coincidental coupons were used by targeted pregnant customers.

I had a flashback to this story recently when I came across a recently published 300-page document entitled "Using Behavioral Indicators to Help Detect Potential Violent Acts." It is an overview of existing research compiled by the national security research division of Rand, a federally funded agency that does research and planning for the U.S. Secretary of Defense, the U.S. military, and the intelligence community. The purpose of the report was to present a review of the currently available methods for using real-time or stored digital data to predict insurgent and terrorist activity by individuals.

The report talks about characteristics of individuals at risk and methods for gathering and analyzing data about those individuals. Data would be drawn from several sources. Smartphone data would provide travel patterns and physical movement, while existing commercial databases such as those available through Google or Amazon would contain information about purchases, opinions, interests, and political affiliations. Social-media accounts would enable examination and surveillance of an individual’s communications or planning activity with known foreign operatives.

All of this information would be considered "pattern of life" data that could be collected in real time and analyzed through a proposed "fusion center." The fusion center would do data analysis using machine algorithms or natural language processing and layer this data with information drawn from law enforcement or national intelligence sources. Some studies have already been done that have shown that smartphone data can be used to predict personality traits and travel patterns. Facial-recognition software can be applied to surveillance videos to interpret emotions such as anxiety or anger preceding an impending attack.

In theory, all of this information could be collated to generate a checklist security screen or risk score. Specifically, the report suggested building an individual profile drawn from "whole-life data (e.g., from school, criminal, civil, legal, interrogation, medical [emphasis mine], travel, financial, consumer, and social/public communication)."

The report goes on to discuss what would happen after the individual is identified:

"First, an indicator that would by no means justify an arrest or enforced medical treatment (emphasis mine) might, in connection with other information, have value at a checkpoint or an intelligence center pondering a tip about terrorist action. The result might be to increase caution, double check a discrepancy, look for more information, put the person in question under surveillance, or conduct an interrogation."

Of course, no one anticipates that this kind of activity might affect them, but consider what the report identifies as some of the psychological underpinnings of a terrorist: someone with a history of childhood trauma or cruelty to animals; someone with rapid shifts in mood; or someone showing evidence of stress, fear, or anger. In other words, characteristics sometimes associated with our patients.

For what it’s worth, the Rand report recognizes that individuals with mental illness are unlikely to become involved in organized terrorist activities. The report also acknowledges that there are likely to be a high number of false-positive identifications and that "such data could be [a] start down a very slippery slope" and would be "quite controversial, both scientifically and with respect to privacy and civil liberties."

Unfortunately, like Target, rather than cautioning against such activity, the report discussed ways to mitigate civilian concerns and potential damage.

To my knowledge, no medical information is being drawn from health information systems for this purpose yet. But given the recent concern about potentially dangerous patients during the debate about gun legislation, it’s not too much of a stretch to speculate that eventually some agency might wish to bypass the clinician entirely and draw certain risk-associated data directly from a health information system. The Rand report concluded that such information fusion is "likely essential for success" in the prevention of terrorism.

As hospitals, clinics, and the public mental health system move to integrate their information systems, privacy protections might need to include more than protection from unauthorized access by employees.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work." The opinions expressed are those of the author only and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The Federal Prison Rape Elimination Act of 2003 requires an annual survey of prisoners to collect data regarding episodes of sexual abuse and victimization between and against inmates. The 2013 report from the Department of Justice was released in May and covered data from the preceding year. I spent some time wading through the 108-page report and wanted to present some of my “take-away” points for correctional clinicians.

First, some background regarding how the survey was conducted. Both public and privately run facilities were selected based upon a randomized, stratified list of all jails, prisons, military, and immigration facilities as well as correctional facilities in Native American jurisdictions. In all, 225 prisons and 358 jails reported data.

Within each facility, a random sampling of prisoners were selected to participate, and the survey was designed to capture a representative sample based on gender and age. Inmates as young as 16 years of age were surveyed, making this the first report of sexual victimization of juveniles held in adult facilities. More than 92,000 inmates were surveyed. Each inmate was asked questions regarding any incident of sexual contact, activity or abuse within the past 12 months as well as the frequency of the abuse.

The survey was administered anonymously and confidentially, so no data were available to confirm accuracy of the inmate report or the outcome of a given incident if it was reported.

Respondents were asked about incidents of inmate-upon-inmate sexual contact as well as staff-upon-inmate events. The activity was classified as either consensual or abusive when committed by an inmate; when committed by staff the activity was classified as either “willing” or “unwilling.”

In addition to information about the sexual activity, respondents were asked to provide information about previous psychiatric contacts. They were asked whether they had ever been told they had a mental disorder, had been kept overnight in a psychiatric unit or facility, had been treated with medication or participated in counseling. All respondents also were asked to complete an epidemiologic screening instrument known as the K6, which is a brief measure of psychological symptoms. They were then classified as being “seriously psychologically distressed” (SPD) based upon the K6 cutoff score.

Overall, 4% of jail and prison inmates reported one or more incidents of sexual victimization by another inmate or by staff. Among prison inmates, 2% reported the incident involved another inmate, while 2.4% involved staff. Both inmates and staff perpetrated assaults on 0.4% of prisoners. Rates were similar but slightly lower for jail detainees.

Victim characteristics differed based upon the perpetrator of the abuse. Victims of inmate abuse tended to be female, white, never-married, and college educated. Victims of staff abuse tended to be male, black, and in the 20- to 24-year age group.

Age generally was not a factor in inmate victimization in that juveniles held in adult facilities had no different rate of victimization than adults. However, risk of abuse generally appeared to decrease after the age of 55.

Physical stature, as measured by the calculated body mass index (BMI), was related to sexual victimization in jail, where underweight and morbidly obese inmates both had nearly double the rate of inmate-on-inmate victimization. Conversely, among prisoners, overweight or obese inmates were less likely to be victimized by their peers.

Inmates held for violent sex offenses had higher rates of inmate-on-inmate victimization than inmates held for other offenses.

Sexual orientation was significantly correlated with victimization for both adults and juveniles. Non-heterosexual inmates were among those with the highest rates of victimization. In prison, 12.2% were victimized by peers and 5.4% by staff. Non-heterosexual juveniles were similarly at risk, particularly those charged with violent sex offenses. Most juveniles were victimized more than once and fewer than one in six reported the incident to staff, family or another outsider.

Peer victimization rates were two to four times higher among inmates with a history of medication use or counseling. Inmates classified as having “serious psychological distress” (SPD) had significantly higher rates of both inmate and staff inflicted victimization, however they also were more likely to report the abuse. A non-heterosexual orientation also was associated with high rates of victimization for SPD prisoners.

Given this information, correctional clinicians can be cognizant of risk factors for sexual victimization among jail and prison inmates. Gay or bisexual prisoners, prisoners charged with violent sex offenses, and those exhibiting high levels of psychological distress might warrant additional questions regarding victimization during previous incarceration or current problems in the facility. Protective custody might be considered, but should not be mandated by policy given that this might reduce access to rehabilitation programs or services. Inmates at risk also can be educated about reporting mechanisms and available counseling services should the need arise.

 —Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The Federal Prison Rape Elimination Act of 2003 requires an annual survey of prisoners to collect data regarding episodes of sexual abuse and victimization between and against inmates. The 2013 report from the Department of Justice was released in May and covered data from the preceding year. I spent some time wading through the 108-page report and wanted to present some of my “take-away” points for correctional clinicians.

First, some background regarding how the survey was conducted. Both public and privately run facilities were selected based upon a randomized, stratified list of all jails, prisons, military, and immigration facilities as well as correctional facilities in Native American jurisdictions. In all, 225 prisons and 358 jails reported data.

Within each facility, a random sampling of prisoners were selected to participate, and the survey was designed to capture a representative sample based on gender and age. Inmates as young as 16 years of age were surveyed, making this the first report of sexual victimization of juveniles held in adult facilities. More than 92,000 inmates were surveyed. Each inmate was asked questions regarding any incident of sexual contact, activity or abuse within the past 12 months as well as the frequency of the abuse.

The survey was administered anonymously and confidentially, so no data were available to confirm accuracy of the inmate report or the outcome of a given incident if it was reported.

Respondents were asked about incidents of inmate-upon-inmate sexual contact as well as staff-upon-inmate events. The activity was classified as either consensual or abusive when committed by an inmate; when committed by staff the activity was classified as either “willing” or “unwilling.”

In addition to information about the sexual activity, respondents were asked to provide information about previous psychiatric contacts. They were asked whether they had ever been told they had a mental disorder, had been kept overnight in a psychiatric unit or facility, had been treated with medication or participated in counseling. All respondents also were asked to complete an epidemiologic screening instrument known as the K6, which is a brief measure of psychological symptoms. They were then classified as being “seriously psychologically distressed” (SPD) based upon the K6 cutoff score.

Overall, 4% of jail and prison inmates reported one or more incidents of sexual victimization by another inmate or by staff. Among prison inmates, 2% reported the incident involved another inmate, while 2.4% involved staff. Both inmates and staff perpetrated assaults on 0.4% of prisoners. Rates were similar but slightly lower for jail detainees.

Victim characteristics differed based upon the perpetrator of the abuse. Victims of inmate abuse tended to be female, white, never-married, and college educated. Victims of staff abuse tended to be male, black, and in the 20- to 24-year age group.

Age generally was not a factor in inmate victimization in that juveniles held in adult facilities had no different rate of victimization than adults. However, risk of abuse generally appeared to decrease after the age of 55.

Physical stature, as measured by the calculated body mass index (BMI), was related to sexual victimization in jail, where underweight and morbidly obese inmates both had nearly double the rate of inmate-on-inmate victimization. Conversely, among prisoners, overweight or obese inmates were less likely to be victimized by their peers.

Inmates held for violent sex offenses had higher rates of inmate-on-inmate victimization than inmates held for other offenses.

Sexual orientation was significantly correlated with victimization for both adults and juveniles. Non-heterosexual inmates were among those with the highest rates of victimization. In prison, 12.2% were victimized by peers and 5.4% by staff. Non-heterosexual juveniles were similarly at risk, particularly those charged with violent sex offenses. Most juveniles were victimized more than once and fewer than one in six reported the incident to staff, family or another outsider.

Peer victimization rates were two to four times higher among inmates with a history of medication use or counseling. Inmates classified as having “serious psychological distress” (SPD) had significantly higher rates of both inmate and staff inflicted victimization, however they also were more likely to report the abuse. A non-heterosexual orientation also was associated with high rates of victimization for SPD prisoners.

Given this information, correctional clinicians can be cognizant of risk factors for sexual victimization among jail and prison inmates. Gay or bisexual prisoners, prisoners charged with violent sex offenses, and those exhibiting high levels of psychological distress might warrant additional questions regarding victimization during previous incarceration or current problems in the facility. Protective custody might be considered, but should not be mandated by policy given that this might reduce access to rehabilitation programs or services. Inmates at risk also can be educated about reporting mechanisms and available counseling services should the need arise.

 —Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

The Federal Prison Rape Elimination Act of 2003 requires an annual survey of prisoners to collect data regarding episodes of sexual abuse and victimization between and against inmates. The 2013 report from the Department of Justice was released in May and covered data from the preceding year. I spent some time wading through the 108-page report and wanted to present some of my “take-away” points for correctional clinicians.

First, some background regarding how the survey was conducted. Both public and privately run facilities were selected based upon a randomized, stratified list of all jails, prisons, military, and immigration facilities as well as correctional facilities in Native American jurisdictions. In all, 225 prisons and 358 jails reported data.

Within each facility, a random sampling of prisoners were selected to participate, and the survey was designed to capture a representative sample based on gender and age. Inmates as young as 16 years of age were surveyed, making this the first report of sexual victimization of juveniles held in adult facilities. More than 92,000 inmates were surveyed. Each inmate was asked questions regarding any incident of sexual contact, activity or abuse within the past 12 months as well as the frequency of the abuse.

The survey was administered anonymously and confidentially, so no data were available to confirm accuracy of the inmate report or the outcome of a given incident if it was reported.

Respondents were asked about incidents of inmate-upon-inmate sexual contact as well as staff-upon-inmate events. The activity was classified as either consensual or abusive when committed by an inmate; when committed by staff the activity was classified as either “willing” or “unwilling.”

In addition to information about the sexual activity, respondents were asked to provide information about previous psychiatric contacts. They were asked whether they had ever been told they had a mental disorder, had been kept overnight in a psychiatric unit or facility, had been treated with medication or participated in counseling. All respondents also were asked to complete an epidemiologic screening instrument known as the K6, which is a brief measure of psychological symptoms. They were then classified as being “seriously psychologically distressed” (SPD) based upon the K6 cutoff score.

Overall, 4% of jail and prison inmates reported one or more incidents of sexual victimization by another inmate or by staff. Among prison inmates, 2% reported the incident involved another inmate, while 2.4% involved staff. Both inmates and staff perpetrated assaults on 0.4% of prisoners. Rates were similar but slightly lower for jail detainees.

Victim characteristics differed based upon the perpetrator of the abuse. Victims of inmate abuse tended to be female, white, never-married, and college educated. Victims of staff abuse tended to be male, black, and in the 20- to 24-year age group.

Age generally was not a factor in inmate victimization in that juveniles held in adult facilities had no different rate of victimization than adults. However, risk of abuse generally appeared to decrease after the age of 55.

Physical stature, as measured by the calculated body mass index (BMI), was related to sexual victimization in jail, where underweight and morbidly obese inmates both had nearly double the rate of inmate-on-inmate victimization. Conversely, among prisoners, overweight or obese inmates were less likely to be victimized by their peers.

Inmates held for violent sex offenses had higher rates of inmate-on-inmate victimization than inmates held for other offenses.

Sexual orientation was significantly correlated with victimization for both adults and juveniles. Non-heterosexual inmates were among those with the highest rates of victimization. In prison, 12.2% were victimized by peers and 5.4% by staff. Non-heterosexual juveniles were similarly at risk, particularly those charged with violent sex offenses. Most juveniles were victimized more than once and fewer than one in six reported the incident to staff, family or another outsider.

Peer victimization rates were two to four times higher among inmates with a history of medication use or counseling. Inmates classified as having “serious psychological distress” (SPD) had significantly higher rates of both inmate and staff inflicted victimization, however they also were more likely to report the abuse. A non-heterosexual orientation also was associated with high rates of victimization for SPD prisoners.

Given this information, correctional clinicians can be cognizant of risk factors for sexual victimization among jail and prison inmates. Gay or bisexual prisoners, prisoners charged with violent sex offenses, and those exhibiting high levels of psychological distress might warrant additional questions regarding victimization during previous incarceration or current problems in the facility. Protective custody might be considered, but should not be mandated by policy given that this might reduce access to rehabilitation programs or services. Inmates at risk also can be educated about reporting mechanisms and available counseling services should the need arise.

 —Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.