Shrink Rap News

After 3 years of work, Anne Hanson and I are delighted that our book, “Committed: The Battle over Involuntary Psychiatric Care” was officially released Nov. 1! Our publisher, Johns Hopkins University Press, asked me to write a post for its blog to start the launch and with permission, Clinical Psychiatry News has let me begin the story of our research here as well.

So how did I find myself sitting in courtrooms and riding alongside a police officer? Let me tell you a little about the process of writing this book, because it was a quite the adventure for me. The title implies that this is another book by psychiatrists for psychiatrists, but for me, the days I spent working on this manuscript were days off from psychiatry. Those mornings I woke up a psychiatrist and felt like I walked into a phone booth (maybe it was just my shower) and emerged as a journalist.

Those days I spent doing research in a whole new way: I cajoled people into talking with me; made call after call that sometimes led to dead ends; trolled message boards; shadowed a variety of psychiatrists, judges, and a crisis intervention police officer; attended legislative hearings; and sat in on government work groups. I arranged video meetings with patients, doctors, lawyers, advocates, and adversaries by phone and Skype, including one with a psychiatrist in New Zealand – quite the challenge with the 18-hour time difference.

To read more, please visit the Johns Hopkins University blog here.
 

After 3 years of work, Anne Hanson and I are delighted that our book, “Committed: The Battle over Involuntary Psychiatric Care” was officially released Nov. 1! Our publisher, Johns Hopkins University Press, asked me to write a post for its blog to start the launch and with permission, Clinical Psychiatry News has let me begin the story of our research here as well.

So how did I find myself sitting in courtrooms and riding alongside a police officer? Let me tell you a little about the process of writing this book, because it was a quite the adventure for me. The title implies that this is another book by psychiatrists for psychiatrists, but for me, the days I spent working on this manuscript were days off from psychiatry. Those mornings I woke up a psychiatrist and felt like I walked into a phone booth (maybe it was just my shower) and emerged as a journalist.

Those days I spent doing research in a whole new way: I cajoled people into talking with me; made call after call that sometimes led to dead ends; trolled message boards; shadowed a variety of psychiatrists, judges, and a crisis intervention police officer; attended legislative hearings; and sat in on government work groups. I arranged video meetings with patients, doctors, lawyers, advocates, and adversaries by phone and Skype, including one with a psychiatrist in New Zealand – quite the challenge with the 18-hour time difference.

To read more, please visit the Johns Hopkins University blog here.
 

After 3 years of work, Anne Hanson and I are delighted that our book, “Committed: The Battle over Involuntary Psychiatric Care” was officially released Nov. 1! Our publisher, Johns Hopkins University Press, asked me to write a post for its blog to start the launch and with permission, Clinical Psychiatry News has let me begin the story of our research here as well.

So how did I find myself sitting in courtrooms and riding alongside a police officer? Let me tell you a little about the process of writing this book, because it was a quite the adventure for me. The title implies that this is another book by psychiatrists for psychiatrists, but for me, the days I spent working on this manuscript were days off from psychiatry. Those mornings I woke up a psychiatrist and felt like I walked into a phone booth (maybe it was just my shower) and emerged as a journalist.

Those days I spent doing research in a whole new way: I cajoled people into talking with me; made call after call that sometimes led to dead ends; trolled message boards; shadowed a variety of psychiatrists, judges, and a crisis intervention police officer; attended legislative hearings; and sat in on government work groups. I arranged video meetings with patients, doctors, lawyers, advocates, and adversaries by phone and Skype, including one with a psychiatrist in New Zealand – quite the challenge with the 18-hour time difference.

To read more, please visit the Johns Hopkins University blog here.
 

 

Where – and how – do we even begin to talk about suicide? In psychiatry, we understand it as a product of mental illness: an act borne of the hopelessness of depression or as a way to escape psychic torment. In that sense, it is understandable and preventable: All we need to do is educate people about the symptoms and destigmatize the disorders so that those who have them will seek treatment. Suicide is an epidemic, and tens of thousands of people die this way every year. The figures quoted are that 90% of those who die from suicide suffer from a psychiatric illness, most often a mood disorder.

It’s a simple equation, and often the assumption is made that the suicidal person did not recognize his illness, did not know how to get help, did not believe treatment would work, was fearful of the stigma or consequences of seeking help, could not access care (because that is no simple task), or did not get the right care. It’s perplexing that suicide rates have continued to rise when the rates of antidepressant use also have risen. And while we don’t want to stigmatize mental illness, we do want to stigmatize suicide; it shouldn’t be anyone’s answer to life’s inevitable rough patches.

When actor Robin Williams died of suicide in August 2014, the National Suicide Prevention Lifeline saw a surge in callers. The loss of a brilliant, energetic, public figure left everyone reeling, myself included. Williams was known to have difficulties with alcohol and depression, but despite his problems, he was everyone’s definition of success, and he certainly had access to the best of care. Stigma? I’m going to guess that in the California entertainment industry there’s no shame to seeing a psychiatrist.

Soon after his death, it was made public that Robin Williams suffered from Parkinson’s disease, then later that was revised – he had Lewy body dementia.

On Sept. 27, his widow, Susan Schneider Williams, published an article called “The terrorist inside my husband’s brain” in the journal Neurology (2016. 87[13]:1308-11).

Mrs. Williams writes about the joy of their relationship, and she notes that many months before he died, her husband was under the care of doctors for a multitude of symptoms, including gastrointestinal problems, insomnia, and a tremor. His symptoms worsened, and he became plagued by anxiety and panic, memory difficulties, and delusions with paranoia. She describes a change in his personality and a preoccupation with his anxiety, physical failings, and memory problems that interfered with his ability to memorize movie lines. Robin Williams was changing and declining. He was treated with both psychotherapy and psychotropic medications. He went to Stanford for hypnosis to treat his anxiety. He exercised with a physical trainer. In May, he received the Parkinson’s disease diagnosis, and while he was told that it was early and mild, his wife wrote,

Robin was growing weary. The parkinsonian mask was ever present and his voice was weakened. His left hand tremor was continuous now and he had a slow, shuffling gait. He hated that he could not find the words he wanted in conversations. He would thrash at night and still had terrible insomnia. At times, he would find himself stuck in a frozen stance, unable to move, and frustrated when he came out of it. He was beginning to have trouble with visual and spatial abilities in the way of judging distance and depth. His loss of basic reasoning just added to his growing confusion.

Just months later, Robin Williams took his own life.

The story doesn’t fit the simple equation: Mr. Williams knew something was wrong, he sought help, he received psychiatric care, and he ended his life, anyway. Could more have been done? Of course, there are always more treatments that can be tried to address depression, but more may not have helped. The article notes that he was scheduled to have an inpatient neuropsychiatric assessment. But the truth is that even if a treatment were found that would have lifted his spirits, Robin Williams was suffering from a severe form of an incurable dementing illness, and his wife describes that he was in a great deal of distress with both his symptoms and his decline. This illness is a tragedy, but perhaps his suicide was a rational decision and not a preventable death. As a psychiatrist, it feels like taboo to suggest that suicide might ever be anything but the ultimate failure on both the part of the doctor and the patient, or that there isn’t always hope to be had. Robin Williams most certainly missed out on some good moments in the time he had remaining; his wife describes the pleasures of their last day together. But if he decided that he wanted to escape his suffering and avoid the undeniable decline and debility that he saw in his future, can we – or should we – blame him and call this a preventable tragedy? Is this the suicide that should be stigmatized and used for our “get help” slogans?

Obviously, I can’t know if Robin Williams was competent to make such a decision, or if his family would have suffered less if he’d lived out his natural life, but the truth is that competent or not, he made a choice and without anyone’s input, he took the action he chose.

The issue has become a heated one as some states have legalized physician-assisted suicide. In Belgium, intractable psychiatric illness is considered a valid reason for euthanasia, even in a young person. Make no mistake about my sentiments on this: Doctoring is about healing, and we have no business killing people or aiding in their deaths. Psychiatry, in particular, is about hope. Each person’s life has value, but each person’s life also ends. And while there is tremendous societal value in stigmatizing suicide, not all suicides are the same.

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” which is due out this fall from Johns Hopkins University Press.

 

Where – and how – do we even begin to talk about suicide? In psychiatry, we understand it as a product of mental illness: an act borne of the hopelessness of depression or as a way to escape psychic torment. In that sense, it is understandable and preventable: All we need to do is educate people about the symptoms and destigmatize the disorders so that those who have them will seek treatment. Suicide is an epidemic, and tens of thousands of people die this way every year. The figures quoted are that 90% of those who die from suicide suffer from a psychiatric illness, most often a mood disorder.

It’s a simple equation, and often the assumption is made that the suicidal person did not recognize his illness, did not know how to get help, did not believe treatment would work, was fearful of the stigma or consequences of seeking help, could not access care (because that is no simple task), or did not get the right care. It’s perplexing that suicide rates have continued to rise when the rates of antidepressant use also have risen. And while we don’t want to stigmatize mental illness, we do want to stigmatize suicide; it shouldn’t be anyone’s answer to life’s inevitable rough patches.

When actor Robin Williams died of suicide in August 2014, the National Suicide Prevention Lifeline saw a surge in callers. The loss of a brilliant, energetic, public figure left everyone reeling, myself included. Williams was known to have difficulties with alcohol and depression, but despite his problems, he was everyone’s definition of success, and he certainly had access to the best of care. Stigma? I’m going to guess that in the California entertainment industry there’s no shame to seeing a psychiatrist.

Soon after his death, it was made public that Robin Williams suffered from Parkinson’s disease, then later that was revised – he had Lewy body dementia.

On Sept. 27, his widow, Susan Schneider Williams, published an article called “The terrorist inside my husband’s brain” in the journal Neurology (2016. 87[13]:1308-11).

Mrs. Williams writes about the joy of their relationship, and she notes that many months before he died, her husband was under the care of doctors for a multitude of symptoms, including gastrointestinal problems, insomnia, and a tremor. His symptoms worsened, and he became plagued by anxiety and panic, memory difficulties, and delusions with paranoia. She describes a change in his personality and a preoccupation with his anxiety, physical failings, and memory problems that interfered with his ability to memorize movie lines. Robin Williams was changing and declining. He was treated with both psychotherapy and psychotropic medications. He went to Stanford for hypnosis to treat his anxiety. He exercised with a physical trainer. In May, he received the Parkinson’s disease diagnosis, and while he was told that it was early and mild, his wife wrote,

Robin was growing weary. The parkinsonian mask was ever present and his voice was weakened. His left hand tremor was continuous now and he had a slow, shuffling gait. He hated that he could not find the words he wanted in conversations. He would thrash at night and still had terrible insomnia. At times, he would find himself stuck in a frozen stance, unable to move, and frustrated when he came out of it. He was beginning to have trouble with visual and spatial abilities in the way of judging distance and depth. His loss of basic reasoning just added to his growing confusion.

Just months later, Robin Williams took his own life.

The story doesn’t fit the simple equation: Mr. Williams knew something was wrong, he sought help, he received psychiatric care, and he ended his life, anyway. Could more have been done? Of course, there are always more treatments that can be tried to address depression, but more may not have helped. The article notes that he was scheduled to have an inpatient neuropsychiatric assessment. But the truth is that even if a treatment were found that would have lifted his spirits, Robin Williams was suffering from a severe form of an incurable dementing illness, and his wife describes that he was in a great deal of distress with both his symptoms and his decline. This illness is a tragedy, but perhaps his suicide was a rational decision and not a preventable death. As a psychiatrist, it feels like taboo to suggest that suicide might ever be anything but the ultimate failure on both the part of the doctor and the patient, or that there isn’t always hope to be had. Robin Williams most certainly missed out on some good moments in the time he had remaining; his wife describes the pleasures of their last day together. But if he decided that he wanted to escape his suffering and avoid the undeniable decline and debility that he saw in his future, can we – or should we – blame him and call this a preventable tragedy? Is this the suicide that should be stigmatized and used for our “get help” slogans?

Obviously, I can’t know if Robin Williams was competent to make such a decision, or if his family would have suffered less if he’d lived out his natural life, but the truth is that competent or not, he made a choice and without anyone’s input, he took the action he chose.

The issue has become a heated one as some states have legalized physician-assisted suicide. In Belgium, intractable psychiatric illness is considered a valid reason for euthanasia, even in a young person. Make no mistake about my sentiments on this: Doctoring is about healing, and we have no business killing people or aiding in their deaths. Psychiatry, in particular, is about hope. Each person’s life has value, but each person’s life also ends. And while there is tremendous societal value in stigmatizing suicide, not all suicides are the same.

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” which is due out this fall from Johns Hopkins University Press.

 

Where – and how – do we even begin to talk about suicide? In psychiatry, we understand it as a product of mental illness: an act borne of the hopelessness of depression or as a way to escape psychic torment. In that sense, it is understandable and preventable: All we need to do is educate people about the symptoms and destigmatize the disorders so that those who have them will seek treatment. Suicide is an epidemic, and tens of thousands of people die this way every year. The figures quoted are that 90% of those who die from suicide suffer from a psychiatric illness, most often a mood disorder.

It’s a simple equation, and often the assumption is made that the suicidal person did not recognize his illness, did not know how to get help, did not believe treatment would work, was fearful of the stigma or consequences of seeking help, could not access care (because that is no simple task), or did not get the right care. It’s perplexing that suicide rates have continued to rise when the rates of antidepressant use also have risen. And while we don’t want to stigmatize mental illness, we do want to stigmatize suicide; it shouldn’t be anyone’s answer to life’s inevitable rough patches.

When actor Robin Williams died of suicide in August 2014, the National Suicide Prevention Lifeline saw a surge in callers. The loss of a brilliant, energetic, public figure left everyone reeling, myself included. Williams was known to have difficulties with alcohol and depression, but despite his problems, he was everyone’s definition of success, and he certainly had access to the best of care. Stigma? I’m going to guess that in the California entertainment industry there’s no shame to seeing a psychiatrist.

Soon after his death, it was made public that Robin Williams suffered from Parkinson’s disease, then later that was revised – he had Lewy body dementia.

On Sept. 27, his widow, Susan Schneider Williams, published an article called “The terrorist inside my husband’s brain” in the journal Neurology (2016. 87[13]:1308-11).

Mrs. Williams writes about the joy of their relationship, and she notes that many months before he died, her husband was under the care of doctors for a multitude of symptoms, including gastrointestinal problems, insomnia, and a tremor. His symptoms worsened, and he became plagued by anxiety and panic, memory difficulties, and delusions with paranoia. She describes a change in his personality and a preoccupation with his anxiety, physical failings, and memory problems that interfered with his ability to memorize movie lines. Robin Williams was changing and declining. He was treated with both psychotherapy and psychotropic medications. He went to Stanford for hypnosis to treat his anxiety. He exercised with a physical trainer. In May, he received the Parkinson’s disease diagnosis, and while he was told that it was early and mild, his wife wrote,

Robin was growing weary. The parkinsonian mask was ever present and his voice was weakened. His left hand tremor was continuous now and he had a slow, shuffling gait. He hated that he could not find the words he wanted in conversations. He would thrash at night and still had terrible insomnia. At times, he would find himself stuck in a frozen stance, unable to move, and frustrated when he came out of it. He was beginning to have trouble with visual and spatial abilities in the way of judging distance and depth. His loss of basic reasoning just added to his growing confusion.

Just months later, Robin Williams took his own life.

The story doesn’t fit the simple equation: Mr. Williams knew something was wrong, he sought help, he received psychiatric care, and he ended his life, anyway. Could more have been done? Of course, there are always more treatments that can be tried to address depression, but more may not have helped. The article notes that he was scheduled to have an inpatient neuropsychiatric assessment. But the truth is that even if a treatment were found that would have lifted his spirits, Robin Williams was suffering from a severe form of an incurable dementing illness, and his wife describes that he was in a great deal of distress with both his symptoms and his decline. This illness is a tragedy, but perhaps his suicide was a rational decision and not a preventable death. As a psychiatrist, it feels like taboo to suggest that suicide might ever be anything but the ultimate failure on both the part of the doctor and the patient, or that there isn’t always hope to be had. Robin Williams most certainly missed out on some good moments in the time he had remaining; his wife describes the pleasures of their last day together. But if he decided that he wanted to escape his suffering and avoid the undeniable decline and debility that he saw in his future, can we – or should we – blame him and call this a preventable tragedy? Is this the suicide that should be stigmatized and used for our “get help” slogans?

Obviously, I can’t know if Robin Williams was competent to make such a decision, or if his family would have suffered less if he’d lived out his natural life, but the truth is that competent or not, he made a choice and without anyone’s input, he took the action he chose.

The issue has become a heated one as some states have legalized physician-assisted suicide. In Belgium, intractable psychiatric illness is considered a valid reason for euthanasia, even in a young person. Make no mistake about my sentiments on this: Doctoring is about healing, and we have no business killing people or aiding in their deaths. Psychiatry, in particular, is about hope. Each person’s life has value, but each person’s life also ends. And while there is tremendous societal value in stigmatizing suicide, not all suicides are the same.

 

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” which is due out this fall from Johns Hopkins University Press.

When it comes to political candidates and psychiatric disorders, the idea of diagnosing from afar is not new. In 1964, Fact magazine published an article called “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.” For the article, more than 2,400 psychiatrists responded to a survey, and many described the presidential candidate using a host of diagnostic and symptomatic terms. Mr. Goldwater lost the election in a landslide and successfully sued the magazine for $75,000.

In 1973, nearly a decade later, the American Psychiatric Association specifically noted in its code of ethics that psychiatrists should not offer diagnostic opinions on anyone who has not been personally examined and has not signed the proper authorization for this information to be released. The edict has been informally called The Goldwater Rule.

In the current election cycle, it has been a challenge for some psychiatrists to refrain from making public statements about our presidential candidates. Some have said the Goldwater Rule amounts to a gag order, and that the specifics of this election are different from other elections, and might warrant allowing psychiatrists to issue their professional opinions. The APA has reminded psychiatrists that to do so is unethical, and on Aug. 15, The New York Times ran an article by Benedict Carey titled: “The Psychiatric Question: Is it Fair to Analyze Donald Trump from Afar?”

I want to look at the question from a different stance. In assessing our political candidates, I’d like you to consider this: What difference does it make? Psychiatric diagnostic criteria are determined by consensus opinions of APA workgroup members. They aren’t perfect; they aren’t always accurate even when a patient is evaluated in person and seen over time; they are influenced by culture; and they aren’t always prognostic. One person’s experience of bipolar disorder is not another person’s experience of bipolar disorder, and personality disorders – such as narcissism or antisocial personality disorder – don’t have uniform presentations or outcomes. Some people with these difficulties head corporations and nations, while others wilt in prisons.

Half of the population will suffer from an episode of psychiatric illness at some point in their lives, and one in five people is affected in any given year. While we might all agree that many psychiatric symptoms are not compatible with being president, should the fact that a candidate has had a distant episode of mental illness, either fully resolved or controlled with treatment, disqualify him or her from holding office?

In an article published in the January 2006 issue of the Journal of Nervous and Mental Disease, Jonathan R. Davidson, MD; Kathryn M. Connor, MD; and Marvin Swartz, MD, looked at the biographical data on U.S. presidents from 1776 to 1974 and concluded that 49% met criteria for an Axis I psychiatric disorder. During those cycles, 27% had psychiatric difficulties while in office. Our presidents have suffered from depression and bipolar disorder, anxiety and alcoholism (J Nerv Ment Dis. 2006 Jan;194[1]47-51). No one has publicly attempted to tally personality disorders or use of other addictive substances. It may be safe to say that if the existence of psychiatric pathology had always been a disqualifier for public office, we’d live in a very different country.

Hopefully, when we approach our patients, we do so with warmth, kindness, and a genuine desire to help them heal. Psychiatry, at its best, is about intimacy and trust, and it is in that venue that people share their inner worlds and allow themselves to be vulnerable. Compassion is part of the deal; no one wants to have a mental illness. To refer to an unknown celebrity as “schizophrenic,” “psychotic,” or “having a godlike self-image” – or calling him “a dangerous lunatic,” as Sen. Goldwater was called – is not about careful diagnosis and compassion; it’s simply about name calling. To say that a politician or celebrity’s undesirable behavior is the result of a psychiatric illness based on cavalier observation is an insult to our patients, and it perpetuates stigma.

Psychiatric diagnoses are made by observing a constellation of symptoms that occur together. Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1988. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him assure the nation during a primary debate that his genitals are big enough. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.

 

And please, let me be the first to admit that my perspective is biased: I’ve pointed out some of Mr. Trump’s more troubling behaviors and said nothing of the many wonderful things he may have done as both an entrepreneur and as a human being. Those don’t make the headlines or Twitter, and so I’m left with my own observations and those of a liberal press (Of course, there’s a right-wing press, too, but that’s a topic for another time). For voters who align their beliefs with the National Rifle Association, and feel that illegal immigrants are a drain on our country and that people of certain faiths represent a terror threat to Americans, Mr. Trump apparently remains a reasonable candidate.

Is there a role here for living room consults from psychiatrists? Is there something for us as professionals to add to the prediction of Mr. Trump’s behavior if he becomes president? I don’t think so. Every American has ample data, and for those who are curious about Mr. Trump’s psychiatric status, they are free to Google the criteria for psychiatric disorders and see if they believe he meets them. The input of psychiatrists would neither change the election outcome nor accurately predict his behavior if elected. But it might make us look a bit grandiose.

Finally, I’ve focused here on Mr. Trump, while saying nothing about Secretary Hillary Clinton and her psychiatric status. She, too, has lived a public life, and while many of her activities have attracted media attention and scrutiny, I’ve seen nothing that has suggested she suffers from a psychiatric condition. There was, however, an op-ed piece in The New York Times on Aug. 23, 2016, by Frank Bruni, suggesting that Mrs. Clinton may have an 11th toe.

If nothing else, it’s time for this election to be over.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

When it comes to political candidates and psychiatric disorders, the idea of diagnosing from afar is not new. In 1964, Fact magazine published an article called “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.” For the article, more than 2,400 psychiatrists responded to a survey, and many described the presidential candidate using a host of diagnostic and symptomatic terms. Mr. Goldwater lost the election in a landslide and successfully sued the magazine for $75,000.

In 1973, nearly a decade later, the American Psychiatric Association specifically noted in its code of ethics that psychiatrists should not offer diagnostic opinions on anyone who has not been personally examined and has not signed the proper authorization for this information to be released. The edict has been informally called The Goldwater Rule.

In the current election cycle, it has been a challenge for some psychiatrists to refrain from making public statements about our presidential candidates. Some have said the Goldwater Rule amounts to a gag order, and that the specifics of this election are different from other elections, and might warrant allowing psychiatrists to issue their professional opinions. The APA has reminded psychiatrists that to do so is unethical, and on Aug. 15, The New York Times ran an article by Benedict Carey titled: “The Psychiatric Question: Is it Fair to Analyze Donald Trump from Afar?”

I want to look at the question from a different stance. In assessing our political candidates, I’d like you to consider this: What difference does it make? Psychiatric diagnostic criteria are determined by consensus opinions of APA workgroup members. They aren’t perfect; they aren’t always accurate even when a patient is evaluated in person and seen over time; they are influenced by culture; and they aren’t always prognostic. One person’s experience of bipolar disorder is not another person’s experience of bipolar disorder, and personality disorders – such as narcissism or antisocial personality disorder – don’t have uniform presentations or outcomes. Some people with these difficulties head corporations and nations, while others wilt in prisons.

Half of the population will suffer from an episode of psychiatric illness at some point in their lives, and one in five people is affected in any given year. While we might all agree that many psychiatric symptoms are not compatible with being president, should the fact that a candidate has had a distant episode of mental illness, either fully resolved or controlled with treatment, disqualify him or her from holding office?

In an article published in the January 2006 issue of the Journal of Nervous and Mental Disease, Jonathan R. Davidson, MD; Kathryn M. Connor, MD; and Marvin Swartz, MD, looked at the biographical data on U.S. presidents from 1776 to 1974 and concluded that 49% met criteria for an Axis I psychiatric disorder. During those cycles, 27% had psychiatric difficulties while in office. Our presidents have suffered from depression and bipolar disorder, anxiety and alcoholism (J Nerv Ment Dis. 2006 Jan;194[1]47-51). No one has publicly attempted to tally personality disorders or use of other addictive substances. It may be safe to say that if the existence of psychiatric pathology had always been a disqualifier for public office, we’d live in a very different country.

Hopefully, when we approach our patients, we do so with warmth, kindness, and a genuine desire to help them heal. Psychiatry, at its best, is about intimacy and trust, and it is in that venue that people share their inner worlds and allow themselves to be vulnerable. Compassion is part of the deal; no one wants to have a mental illness. To refer to an unknown celebrity as “schizophrenic,” “psychotic,” or “having a godlike self-image” – or calling him “a dangerous lunatic,” as Sen. Goldwater was called – is not about careful diagnosis and compassion; it’s simply about name calling. To say that a politician or celebrity’s undesirable behavior is the result of a psychiatric illness based on cavalier observation is an insult to our patients, and it perpetuates stigma.

Psychiatric diagnoses are made by observing a constellation of symptoms that occur together. Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1988. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him assure the nation during a primary debate that his genitals are big enough. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.

 

And please, let me be the first to admit that my perspective is biased: I’ve pointed out some of Mr. Trump’s more troubling behaviors and said nothing of the many wonderful things he may have done as both an entrepreneur and as a human being. Those don’t make the headlines or Twitter, and so I’m left with my own observations and those of a liberal press (Of course, there’s a right-wing press, too, but that’s a topic for another time). For voters who align their beliefs with the National Rifle Association, and feel that illegal immigrants are a drain on our country and that people of certain faiths represent a terror threat to Americans, Mr. Trump apparently remains a reasonable candidate.

Is there a role here for living room consults from psychiatrists? Is there something for us as professionals to add to the prediction of Mr. Trump’s behavior if he becomes president? I don’t think so. Every American has ample data, and for those who are curious about Mr. Trump’s psychiatric status, they are free to Google the criteria for psychiatric disorders and see if they believe he meets them. The input of psychiatrists would neither change the election outcome nor accurately predict his behavior if elected. But it might make us look a bit grandiose.

Finally, I’ve focused here on Mr. Trump, while saying nothing about Secretary Hillary Clinton and her psychiatric status. She, too, has lived a public life, and while many of her activities have attracted media attention and scrutiny, I’ve seen nothing that has suggested she suffers from a psychiatric condition. There was, however, an op-ed piece in The New York Times on Aug. 23, 2016, by Frank Bruni, suggesting that Mrs. Clinton may have an 11th toe.

If nothing else, it’s time for this election to be over.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

When it comes to political candidates and psychiatric disorders, the idea of diagnosing from afar is not new. In 1964, Fact magazine published an article called “The Unconscious of a Conservative: A Special Issue on the Mind of Barry Goldwater.” For the article, more than 2,400 psychiatrists responded to a survey, and many described the presidential candidate using a host of diagnostic and symptomatic terms. Mr. Goldwater lost the election in a landslide and successfully sued the magazine for $75,000.

In 1973, nearly a decade later, the American Psychiatric Association specifically noted in its code of ethics that psychiatrists should not offer diagnostic opinions on anyone who has not been personally examined and has not signed the proper authorization for this information to be released. The edict has been informally called The Goldwater Rule.

In the current election cycle, it has been a challenge for some psychiatrists to refrain from making public statements about our presidential candidates. Some have said the Goldwater Rule amounts to a gag order, and that the specifics of this election are different from other elections, and might warrant allowing psychiatrists to issue their professional opinions. The APA has reminded psychiatrists that to do so is unethical, and on Aug. 15, The New York Times ran an article by Benedict Carey titled: “The Psychiatric Question: Is it Fair to Analyze Donald Trump from Afar?”

I want to look at the question from a different stance. In assessing our political candidates, I’d like you to consider this: What difference does it make? Psychiatric diagnostic criteria are determined by consensus opinions of APA workgroup members. They aren’t perfect; they aren’t always accurate even when a patient is evaluated in person and seen over time; they are influenced by culture; and they aren’t always prognostic. One person’s experience of bipolar disorder is not another person’s experience of bipolar disorder, and personality disorders – such as narcissism or antisocial personality disorder – don’t have uniform presentations or outcomes. Some people with these difficulties head corporations and nations, while others wilt in prisons.

Half of the population will suffer from an episode of psychiatric illness at some point in their lives, and one in five people is affected in any given year. While we might all agree that many psychiatric symptoms are not compatible with being president, should the fact that a candidate has had a distant episode of mental illness, either fully resolved or controlled with treatment, disqualify him or her from holding office?

In an article published in the January 2006 issue of the Journal of Nervous and Mental Disease, Jonathan R. Davidson, MD; Kathryn M. Connor, MD; and Marvin Swartz, MD, looked at the biographical data on U.S. presidents from 1776 to 1974 and concluded that 49% met criteria for an Axis I psychiatric disorder. During those cycles, 27% had psychiatric difficulties while in office. Our presidents have suffered from depression and bipolar disorder, anxiety and alcoholism (J Nerv Ment Dis. 2006 Jan;194[1]47-51). No one has publicly attempted to tally personality disorders or use of other addictive substances. It may be safe to say that if the existence of psychiatric pathology had always been a disqualifier for public office, we’d live in a very different country.

Hopefully, when we approach our patients, we do so with warmth, kindness, and a genuine desire to help them heal. Psychiatry, at its best, is about intimacy and trust, and it is in that venue that people share their inner worlds and allow themselves to be vulnerable. Compassion is part of the deal; no one wants to have a mental illness. To refer to an unknown celebrity as “schizophrenic,” “psychotic,” or “having a godlike self-image” – or calling him “a dangerous lunatic,” as Sen. Goldwater was called – is not about careful diagnosis and compassion; it’s simply about name calling. To say that a politician or celebrity’s undesirable behavior is the result of a psychiatric illness based on cavalier observation is an insult to our patients, and it perpetuates stigma.

Psychiatric diagnoses are made by observing a constellation of symptoms that occur together. Mr. Trump has given the whole world years of data – he’s lived his life in a very public way. As a real estate developer, he has had countless employees who all know how they’ve been treated. We’ve seen him through three marriages and watched how he interacts with his children. We’ve seen him take out full-page ads calling for the death penalty for a group of young men who were wrongly convicted in the rape and assault of the Central Park jogger in 1988. If that’s not enough, he has hosted his own reality television show, and we’ve now seen him countless times in debates and rallies. We know how he treats his running mates, journalist Megyn Kelly, a news reporter with a disability, and the parents of a fallen soldier. We’ve watched him assure the nation during a primary debate that his genitals are big enough. Every individual is free to decide if Mr. Trump’s widely viewed patterns of behavior represent much-needed spunk and change with political beliefs that align with their own, or if his words and behaviors represent cruelty, impulsivity, poor judgment, and a pattern of actions that some might not feel is dignified enough for our country’s leader. No degree is required to observe and draw conclusions.

 

And please, let me be the first to admit that my perspective is biased: I’ve pointed out some of Mr. Trump’s more troubling behaviors and said nothing of the many wonderful things he may have done as both an entrepreneur and as a human being. Those don’t make the headlines or Twitter, and so I’m left with my own observations and those of a liberal press (Of course, there’s a right-wing press, too, but that’s a topic for another time). For voters who align their beliefs with the National Rifle Association, and feel that illegal immigrants are a drain on our country and that people of certain faiths represent a terror threat to Americans, Mr. Trump apparently remains a reasonable candidate.

Is there a role here for living room consults from psychiatrists? Is there something for us as professionals to add to the prediction of Mr. Trump’s behavior if he becomes president? I don’t think so. Every American has ample data, and for those who are curious about Mr. Trump’s psychiatric status, they are free to Google the criteria for psychiatric disorders and see if they believe he meets them. The input of psychiatrists would neither change the election outcome nor accurately predict his behavior if elected. But it might make us look a bit grandiose.

Finally, I’ve focused here on Mr. Trump, while saying nothing about Secretary Hillary Clinton and her psychiatric status. She, too, has lived a public life, and while many of her activities have attracted media attention and scrutiny, I’ve seen nothing that has suggested she suffers from a psychiatric condition. There was, however, an op-ed piece in The New York Times on Aug. 23, 2016, by Frank Bruni, suggesting that Mrs. Clinton may have an 11th toe.

If nothing else, it’s time for this election to be over.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

Gina Henderson, my editor at Clinical Psychiatry News, recently asked me an interesting question. She wanted to know what I believe the five most important issues are for psychiatry today. My first thought was that I am the wrong person to ask – aside from what comes through on my Twitter feed and the Maryland Psychiatric Society’s listserv, I have my own areas of interest and don’t know that I’m the best measure for the pulse of today’s psychiatric issues.

I imagine that different psychiatrists would respond with different answers. If I were to guess – and I haven’t verified this – I think my co-columnist, Anne Hanson, might suggest that the single most important issue for psychiatry is new legislation related to physician-assisted suicide and how that will be applied to psychiatric patients with reportedly intractable illnesses. Steve Daviss, who also writes for our Shrink Rap News column, has had an interest in parity legislation, adequacy of insurance networks, and the application of information technology to psychiatry, and he might say those are our pressing issues. My own interest has been in involuntary treatment, its impact on patients, and if there are ways we might avoid this or do it better.

I wonder if I am missing some new breakthrough now that patients are getting genetic testing to guide their treatment with results that befuddle me.

Using the social media forums of Twitter and Facebook, I put the question out there as to what is the single most important issue for psychiatry today. Mostly, the answer I got was my own: access to care. Peter Kramer, a psychiatrist at Brown University, Providence, R.I., and author of “Ordinarily Well” tweeted that “finding disease mechanisms and finding related treatments” was important, along with access to currently available treatments. My most interesting response was from forensic psychiatrist Erik Roskes, who bluntly said on Facebook, “For someone like me, working in the trenches of our “system,” the biggest problem I see is advocates who think there is a simple solution to our problem. No offense, but asking this question is the problem, not the solution. Feel free to advocate, to be sure, but don’t be surprised when your suggested panacea does not work or is not tried, because it is too expensive and cannot compete with many other priorities that are important to advocates for other important causes.” Finally, a high school friend who works as a teaching assistant and has struggled with her own children’s issues has said the biggest problem is a lack of resources for parents of children with mental disorders.

So with a little reassurance that my ideas are not so far out of date, I’ll start my David Letterman list of what the biggest issues are for psychiatry today.

1. Access to care. No matter how wonderful our treatments are, the fact remains that they are inaccessible to many people, and those who are able to negotiate treatment often struggle to do so. This struggle to find care often comes at a time when people are depressed, psychotic, or vulnerable and often not their own best advocates. It involves bargaining with insurers, being led to believe that coverage is better than it is, and few options for the uninsured and underinsured, who often must rely on public health clinics – which often are not accepting patients or have long waits. Even those with insurance are sent a formidable list of participating providers, many of whom are dead, have relocated, are not accepting new patients, or have never been heard of by their agencies. And for the working individual who needs after-hours care, the struggle is even harder. Let’s not even talk about the number of voice mail prompts and time on hold that each call entails.

In half of all counties in this country, there are no mental health professionals at all, not just a lack of psychiatrists. So folded into the access-to-care problem, I’d like to include the fact that there are just not enough psychiatrists to see everyone who needs to be seen. As a shortage field, more than half of psychiatrists do not participate in health insurance plans, and despite long battles for parity legislation, this does little to help insured patients, who must go out of network, where they face high deductibles and low rates of reimbursement under designated “usual and customary rates,” leaving well-insured patients with very high copays, often amounting to no coverage at all, and often much to their surprise. Simply put, we need to make it easier for patients to find psychiatrists, and we need insurance to pay for psychiatric care.

 

2. We need to stop dichotomizing people as being mentally ill or not. The “us” versus “them” mentality and the idea that there are specific chronically mentally ill folks who are somehow different from the rest of humanity is not helpful. Yes, there are people who cycle in and out of institutions and whose symptoms are resistant to treatments, but some very sick people end up becoming very well and very successful. Sometimes they get better because of the treatment they receive, and once in a while, their improvement is tied to a spontaneous remission. Part of being human is going through rough spots where many people don’t adapt perfectly and don’t behave well during crises. The problem with reallocating resources to the sickest of the sick – those who don’t know they are ill – with a “treatment before tragedy” approach, is that it advocates forcing people who will never hurt anyone into care and pulls resources away from those whose illnesses are somehow dismissed as “the worried well,” who misuse services they don’t really need. People with less obviously severe, debilitating, and retractable illnesses can prove to be very disturbed and very tormented: a teenager who is heartbroken by a breakup and unexpectedly dies of suicide is no less deserving of care than a psychotic individual on his fourth admission. And a graduate student with no history of hospitalization or violence may well be the one to unexpectedly massacre a theater full of moviegoers. We need to offer help to those who ask for it and not suggest rationing our care to the sickest mentally ill, as though there were an obvious line in the sand. This dichotomy does not bear out clinically.

3. We need new and better treatments with fewer side effects and greater efficacy that target the truly disabling symptoms of low motivation, executive dysfunction, and deterioration of social interactions. Only with tolerable and effective treatments will we truly eradicate stigma. As long as we see that the effects of untreated or inadequately treated psychiatric symptoms lead people to frankly embarrassing behaviors, stigma will exist in a way that colorful billboards cannot counter.

4. Since our resources are precious and overextended, we need to eliminate red tape for psychiatrists (and all physicians) that does not lead to improved patient care. Maintenance of certification exams that are not relevant to what the physician sees, time spent catering to clicks on required screens of electronic health records, time spent justifying obviously needed treatment, preauthorization requests for inexpensive medications, meaningful use, clinical notes catering to insurer requirements that do not encourage better treatment, PQRS and MACRA (whatever they may be!) are diversions of physician time. They lead to burnout, job dissatisfaction, and early retirement, and they worsen the shortage of psychiatrists – all while decreasing the number of patients any individual doctor can see. At this point, we are asking our physicians to both treat their patients and to serve as government data collectors, and this is simply too much.

5. Any conversation of noncompliance by people with mental disorders moves quickly to the realm of forced care. Patients who have no insight into their illness are presumed to be unwilling to take medications, and psychiatry has become a series of 15-minute medication checks, where time can’t be devoted to understanding the patient and his hesitations to taking medications. Often, if the patient feels understood and has a sense of trust in the clinician, this noncompliance can be overcome. We need to understand our patients and work with them – and sometimes admit that our treatments just don’t work for everyone – with the hopes of making them more comfortable. Obviously, in emergency situations or when someone is violent, there may be no choice but to use force, but that needs to be a true last resort. It is a disgrace that our current system goes so quickly to talk of involuntary treatment when there are so many people in this country eager to accept voluntary care, and it is so difficult to access.

There you have it, my five bullet points of the most important issues in psychiatry. To those who contributed, both named and unnamed, thank you.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

Gina Henderson, my editor at Clinical Psychiatry News, recently asked me an interesting question. She wanted to know what I believe the five most important issues are for psychiatry today. My first thought was that I am the wrong person to ask – aside from what comes through on my Twitter feed and the Maryland Psychiatric Society’s listserv, I have my own areas of interest and don’t know that I’m the best measure for the pulse of today’s psychiatric issues.

I imagine that different psychiatrists would respond with different answers. If I were to guess – and I haven’t verified this – I think my co-columnist, Anne Hanson, might suggest that the single most important issue for psychiatry is new legislation related to physician-assisted suicide and how that will be applied to psychiatric patients with reportedly intractable illnesses. Steve Daviss, who also writes for our Shrink Rap News column, has had an interest in parity legislation, adequacy of insurance networks, and the application of information technology to psychiatry, and he might say those are our pressing issues. My own interest has been in involuntary treatment, its impact on patients, and if there are ways we might avoid this or do it better.

I wonder if I am missing some new breakthrough now that patients are getting genetic testing to guide their treatment with results that befuddle me.

Using the social media forums of Twitter and Facebook, I put the question out there as to what is the single most important issue for psychiatry today. Mostly, the answer I got was my own: access to care. Peter Kramer, a psychiatrist at Brown University, Providence, R.I., and author of “Ordinarily Well” tweeted that “finding disease mechanisms and finding related treatments” was important, along with access to currently available treatments. My most interesting response was from forensic psychiatrist Erik Roskes, who bluntly said on Facebook, “For someone like me, working in the trenches of our “system,” the biggest problem I see is advocates who think there is a simple solution to our problem. No offense, but asking this question is the problem, not the solution. Feel free to advocate, to be sure, but don’t be surprised when your suggested panacea does not work or is not tried, because it is too expensive and cannot compete with many other priorities that are important to advocates for other important causes.” Finally, a high school friend who works as a teaching assistant and has struggled with her own children’s issues has said the biggest problem is a lack of resources for parents of children with mental disorders.

So with a little reassurance that my ideas are not so far out of date, I’ll start my David Letterman list of what the biggest issues are for psychiatry today.

1. Access to care. No matter how wonderful our treatments are, the fact remains that they are inaccessible to many people, and those who are able to negotiate treatment often struggle to do so. This struggle to find care often comes at a time when people are depressed, psychotic, or vulnerable and often not their own best advocates. It involves bargaining with insurers, being led to believe that coverage is better than it is, and few options for the uninsured and underinsured, who often must rely on public health clinics – which often are not accepting patients or have long waits. Even those with insurance are sent a formidable list of participating providers, many of whom are dead, have relocated, are not accepting new patients, or have never been heard of by their agencies. And for the working individual who needs after-hours care, the struggle is even harder. Let’s not even talk about the number of voice mail prompts and time on hold that each call entails.

In half of all counties in this country, there are no mental health professionals at all, not just a lack of psychiatrists. So folded into the access-to-care problem, I’d like to include the fact that there are just not enough psychiatrists to see everyone who needs to be seen. As a shortage field, more than half of psychiatrists do not participate in health insurance plans, and despite long battles for parity legislation, this does little to help insured patients, who must go out of network, where they face high deductibles and low rates of reimbursement under designated “usual and customary rates,” leaving well-insured patients with very high copays, often amounting to no coverage at all, and often much to their surprise. Simply put, we need to make it easier for patients to find psychiatrists, and we need insurance to pay for psychiatric care.

 

2. We need to stop dichotomizing people as being mentally ill or not. The “us” versus “them” mentality and the idea that there are specific chronically mentally ill folks who are somehow different from the rest of humanity is not helpful. Yes, there are people who cycle in and out of institutions and whose symptoms are resistant to treatments, but some very sick people end up becoming very well and very successful. Sometimes they get better because of the treatment they receive, and once in a while, their improvement is tied to a spontaneous remission. Part of being human is going through rough spots where many people don’t adapt perfectly and don’t behave well during crises. The problem with reallocating resources to the sickest of the sick – those who don’t know they are ill – with a “treatment before tragedy” approach, is that it advocates forcing people who will never hurt anyone into care and pulls resources away from those whose illnesses are somehow dismissed as “the worried well,” who misuse services they don’t really need. People with less obviously severe, debilitating, and retractable illnesses can prove to be very disturbed and very tormented: a teenager who is heartbroken by a breakup and unexpectedly dies of suicide is no less deserving of care than a psychotic individual on his fourth admission. And a graduate student with no history of hospitalization or violence may well be the one to unexpectedly massacre a theater full of moviegoers. We need to offer help to those who ask for it and not suggest rationing our care to the sickest mentally ill, as though there were an obvious line in the sand. This dichotomy does not bear out clinically.

3. We need new and better treatments with fewer side effects and greater efficacy that target the truly disabling symptoms of low motivation, executive dysfunction, and deterioration of social interactions. Only with tolerable and effective treatments will we truly eradicate stigma. As long as we see that the effects of untreated or inadequately treated psychiatric symptoms lead people to frankly embarrassing behaviors, stigma will exist in a way that colorful billboards cannot counter.

4. Since our resources are precious and overextended, we need to eliminate red tape for psychiatrists (and all physicians) that does not lead to improved patient care. Maintenance of certification exams that are not relevant to what the physician sees, time spent catering to clicks on required screens of electronic health records, time spent justifying obviously needed treatment, preauthorization requests for inexpensive medications, meaningful use, clinical notes catering to insurer requirements that do not encourage better treatment, PQRS and MACRA (whatever they may be!) are diversions of physician time. They lead to burnout, job dissatisfaction, and early retirement, and they worsen the shortage of psychiatrists – all while decreasing the number of patients any individual doctor can see. At this point, we are asking our physicians to both treat their patients and to serve as government data collectors, and this is simply too much.

5. Any conversation of noncompliance by people with mental disorders moves quickly to the realm of forced care. Patients who have no insight into their illness are presumed to be unwilling to take medications, and psychiatry has become a series of 15-minute medication checks, where time can’t be devoted to understanding the patient and his hesitations to taking medications. Often, if the patient feels understood and has a sense of trust in the clinician, this noncompliance can be overcome. We need to understand our patients and work with them – and sometimes admit that our treatments just don’t work for everyone – with the hopes of making them more comfortable. Obviously, in emergency situations or when someone is violent, there may be no choice but to use force, but that needs to be a true last resort. It is a disgrace that our current system goes so quickly to talk of involuntary treatment when there are so many people in this country eager to accept voluntary care, and it is so difficult to access.

There you have it, my five bullet points of the most important issues in psychiatry. To those who contributed, both named and unnamed, thank you.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

Gina Henderson, my editor at Clinical Psychiatry News, recently asked me an interesting question. She wanted to know what I believe the five most important issues are for psychiatry today. My first thought was that I am the wrong person to ask – aside from what comes through on my Twitter feed and the Maryland Psychiatric Society’s listserv, I have my own areas of interest and don’t know that I’m the best measure for the pulse of today’s psychiatric issues.

I imagine that different psychiatrists would respond with different answers. If I were to guess – and I haven’t verified this – I think my co-columnist, Anne Hanson, might suggest that the single most important issue for psychiatry is new legislation related to physician-assisted suicide and how that will be applied to psychiatric patients with reportedly intractable illnesses. Steve Daviss, who also writes for our Shrink Rap News column, has had an interest in parity legislation, adequacy of insurance networks, and the application of information technology to psychiatry, and he might say those are our pressing issues. My own interest has been in involuntary treatment, its impact on patients, and if there are ways we might avoid this or do it better.

I wonder if I am missing some new breakthrough now that patients are getting genetic testing to guide their treatment with results that befuddle me.

Using the social media forums of Twitter and Facebook, I put the question out there as to what is the single most important issue for psychiatry today. Mostly, the answer I got was my own: access to care. Peter Kramer, a psychiatrist at Brown University, Providence, R.I., and author of “Ordinarily Well” tweeted that “finding disease mechanisms and finding related treatments” was important, along with access to currently available treatments. My most interesting response was from forensic psychiatrist Erik Roskes, who bluntly said on Facebook, “For someone like me, working in the trenches of our “system,” the biggest problem I see is advocates who think there is a simple solution to our problem. No offense, but asking this question is the problem, not the solution. Feel free to advocate, to be sure, but don’t be surprised when your suggested panacea does not work or is not tried, because it is too expensive and cannot compete with many other priorities that are important to advocates for other important causes.” Finally, a high school friend who works as a teaching assistant and has struggled with her own children’s issues has said the biggest problem is a lack of resources for parents of children with mental disorders.

So with a little reassurance that my ideas are not so far out of date, I’ll start my David Letterman list of what the biggest issues are for psychiatry today.

1. Access to care. No matter how wonderful our treatments are, the fact remains that they are inaccessible to many people, and those who are able to negotiate treatment often struggle to do so. This struggle to find care often comes at a time when people are depressed, psychotic, or vulnerable and often not their own best advocates. It involves bargaining with insurers, being led to believe that coverage is better than it is, and few options for the uninsured and underinsured, who often must rely on public health clinics – which often are not accepting patients or have long waits. Even those with insurance are sent a formidable list of participating providers, many of whom are dead, have relocated, are not accepting new patients, or have never been heard of by their agencies. And for the working individual who needs after-hours care, the struggle is even harder. Let’s not even talk about the number of voice mail prompts and time on hold that each call entails.

In half of all counties in this country, there are no mental health professionals at all, not just a lack of psychiatrists. So folded into the access-to-care problem, I’d like to include the fact that there are just not enough psychiatrists to see everyone who needs to be seen. As a shortage field, more than half of psychiatrists do not participate in health insurance plans, and despite long battles for parity legislation, this does little to help insured patients, who must go out of network, where they face high deductibles and low rates of reimbursement under designated “usual and customary rates,” leaving well-insured patients with very high copays, often amounting to no coverage at all, and often much to their surprise. Simply put, we need to make it easier for patients to find psychiatrists, and we need insurance to pay for psychiatric care.

 

2. We need to stop dichotomizing people as being mentally ill or not. The “us” versus “them” mentality and the idea that there are specific chronically mentally ill folks who are somehow different from the rest of humanity is not helpful. Yes, there are people who cycle in and out of institutions and whose symptoms are resistant to treatments, but some very sick people end up becoming very well and very successful. Sometimes they get better because of the treatment they receive, and once in a while, their improvement is tied to a spontaneous remission. Part of being human is going through rough spots where many people don’t adapt perfectly and don’t behave well during crises. The problem with reallocating resources to the sickest of the sick – those who don’t know they are ill – with a “treatment before tragedy” approach, is that it advocates forcing people who will never hurt anyone into care and pulls resources away from those whose illnesses are somehow dismissed as “the worried well,” who misuse services they don’t really need. People with less obviously severe, debilitating, and retractable illnesses can prove to be very disturbed and very tormented: a teenager who is heartbroken by a breakup and unexpectedly dies of suicide is no less deserving of care than a psychotic individual on his fourth admission. And a graduate student with no history of hospitalization or violence may well be the one to unexpectedly massacre a theater full of moviegoers. We need to offer help to those who ask for it and not suggest rationing our care to the sickest mentally ill, as though there were an obvious line in the sand. This dichotomy does not bear out clinically.

3. We need new and better treatments with fewer side effects and greater efficacy that target the truly disabling symptoms of low motivation, executive dysfunction, and deterioration of social interactions. Only with tolerable and effective treatments will we truly eradicate stigma. As long as we see that the effects of untreated or inadequately treated psychiatric symptoms lead people to frankly embarrassing behaviors, stigma will exist in a way that colorful billboards cannot counter.

4. Since our resources are precious and overextended, we need to eliminate red tape for psychiatrists (and all physicians) that does not lead to improved patient care. Maintenance of certification exams that are not relevant to what the physician sees, time spent catering to clicks on required screens of electronic health records, time spent justifying obviously needed treatment, preauthorization requests for inexpensive medications, meaningful use, clinical notes catering to insurer requirements that do not encourage better treatment, PQRS and MACRA (whatever they may be!) are diversions of physician time. They lead to burnout, job dissatisfaction, and early retirement, and they worsen the shortage of psychiatrists – all while decreasing the number of patients any individual doctor can see. At this point, we are asking our physicians to both treat their patients and to serve as government data collectors, and this is simply too much.

5. Any conversation of noncompliance by people with mental disorders moves quickly to the realm of forced care. Patients who have no insight into their illness are presumed to be unwilling to take medications, and psychiatry has become a series of 15-minute medication checks, where time can’t be devoted to understanding the patient and his hesitations to taking medications. Often, if the patient feels understood and has a sense of trust in the clinician, this noncompliance can be overcome. We need to understand our patients and work with them – and sometimes admit that our treatments just don’t work for everyone – with the hopes of making them more comfortable. Obviously, in emergency situations or when someone is violent, there may be no choice but to use force, but that needs to be a true last resort. It is a disgrace that our current system goes so quickly to talk of involuntary treatment when there are so many people in this country eager to accept voluntary care, and it is so difficult to access.

There you have it, my five bullet points of the most important issues in psychiatry. To those who contributed, both named and unnamed, thank you.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

On June 30, New Mexico became the latest state to throw out a challenge to a law banning physician-assisted suicide. In Morris v. Brandenburg, proponents of the right-to-die movement contended that medical aid in dying was a fundamental right, meaning that any law that restricted the right should be presumed to be invalid unless the state had a compelling reason for the restriction.

In a unanimous decision, the New Mexico Supreme Court held that there was no such right under that state’s constitution, and that even if the right had existed, the state had several compelling reasons to restrict it: to protect “the integrity and ethics of the medical profession”; to protect “vulnerable groups – including the poor, the elderly, and disabled persons – from the risk of subtle coercion and undue influence in end-of-life situations, including pressures associated with the substantial financial burden of end-of-life health care costs”; and to protect “against voluntary or involuntary euthanasia because if physician aid in dying is a constitutional right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication.”¹

Let me repeat that last point:

If aid in dying is a constitutional right, then medical euthanasia is inevitable. In other words, if a patient is too disabled to commit suicide on his or her own, a physician would be obligated to kill the patient.

Proponents will dismiss this last statement as alarmist and unfounded. They will point to a 20-year history of legalized aid in dying in Oregon, and insist there has never been a problem and no attempt to expand the practice to include euthanasia.

What they don’t mention is that such an attempt would be politically disastrous for the right-to-die movement. In 2015, 25 states and the District of Columbia considered legalization bills.² After careful consideration and debate, these bills failed in every state except California, and in that state it passed only because of an extraordinary and unusual legislative maneuver. The bill initially failed in regular session, but passed in special session when the California Medical Association (CMA) shifted to a neutral stance. That shift would never have happened had CMA members been aware of the legal inevitability of euthanasia. At this stage of the political process, the goal of the right-to-die movement is to get laws on the books in as many states as possible before pushing for more.

The New Mexico opinion echoes a similar decision issued this past May by a New York appellate court. The plaintiffs in that case were three terminally ill New Yorkers and five doctors, as well as two euthanasia advocacy groups. The arguments were virtually identical to those made in New Mexico, asserting a fundamental right to medical aid in dying based upon personal autonomy. They additionally sought an exception to New York criminal law, which defined assisted suicide as second-degree manslaughter. In Myers v. Schneiderman, the court observed that no appellate court had ever found medical aid in dying to be a fundamental right and that no new developments justified a change in this interpretation.³ While the court acknowledged some change in public opinion as reflected in telephone surveys, it correctly gave little weight to this argument: “Plaintiffs fail to allege whether those public polls reflect the opinion of people who are fully informed of the arguments espoused by those who caution against permitting aid-in-dying, such as those articulated in the New York State Task Force on Life and the Law.”

This task force issued the following recommendation in its 1994 report,⁴ “When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context”: “The Task Force members unanimously recommend that existing law should not be changed to permit assisted suicide or euthanasia. Legalizing assisted suicide and euthanasia would pose profound risks to many individuals who are ill and vulnerable. The Task Force members concluded that the potential dangers of this dramatic change in public policy would outweigh any benefit that might be achieved” (Chapter 6, p. 120).

The New York aid-in-dying bill did not progress out of committee by the time the session ended in June.

Lastly, both of these cases concluded that medical aid in dying was suicide. In Myers, Judge Angela M. Mazzarelli stated: “The word ‘suicide’ has a straightforward meaning, and a dictionary is hardly necessary … It is traditionally defined as ‘the act or instance of taking one’s own life voluntarily and intentionally.’ ... Whatever label one puts on the act that plaintiffs are asking us to permit, it unquestionably fits that literal description.”

 

Regardless of the label used – aid in dying, assisted suicide, or self-deliverance – it is not a civil right.

Resources

1. http://www.nmcompcomm.us/nmcases/nmsc/slips/SC35,478.pdf

2. https://www.deathwithdignity.org/assisted-dying-chronology/

3. http://www.nycourts.gov/reporter/3dseries/2016/2016_03457.htm

4. https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/

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.

On June 30, New Mexico became the latest state to throw out a challenge to a law banning physician-assisted suicide. In Morris v. Brandenburg, proponents of the right-to-die movement contended that medical aid in dying was a fundamental right, meaning that any law that restricted the right should be presumed to be invalid unless the state had a compelling reason for the restriction.

In a unanimous decision, the New Mexico Supreme Court held that there was no such right under that state’s constitution, and that even if the right had existed, the state had several compelling reasons to restrict it: to protect “the integrity and ethics of the medical profession”; to protect “vulnerable groups – including the poor, the elderly, and disabled persons – from the risk of subtle coercion and undue influence in end-of-life situations, including pressures associated with the substantial financial burden of end-of-life health care costs”; and to protect “against voluntary or involuntary euthanasia because if physician aid in dying is a constitutional right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication.”¹

Let me repeat that last point:

If aid in dying is a constitutional right, then medical euthanasia is inevitable. In other words, if a patient is too disabled to commit suicide on his or her own, a physician would be obligated to kill the patient.

Proponents will dismiss this last statement as alarmist and unfounded. They will point to a 20-year history of legalized aid in dying in Oregon, and insist there has never been a problem and no attempt to expand the practice to include euthanasia.

What they don’t mention is that such an attempt would be politically disastrous for the right-to-die movement. In 2015, 25 states and the District of Columbia considered legalization bills.² After careful consideration and debate, these bills failed in every state except California, and in that state it passed only because of an extraordinary and unusual legislative maneuver. The bill initially failed in regular session, but passed in special session when the California Medical Association (CMA) shifted to a neutral stance. That shift would never have happened had CMA members been aware of the legal inevitability of euthanasia. At this stage of the political process, the goal of the right-to-die movement is to get laws on the books in as many states as possible before pushing for more.

The New Mexico opinion echoes a similar decision issued this past May by a New York appellate court. The plaintiffs in that case were three terminally ill New Yorkers and five doctors, as well as two euthanasia advocacy groups. The arguments were virtually identical to those made in New Mexico, asserting a fundamental right to medical aid in dying based upon personal autonomy. They additionally sought an exception to New York criminal law, which defined assisted suicide as second-degree manslaughter. In Myers v. Schneiderman, the court observed that no appellate court had ever found medical aid in dying to be a fundamental right and that no new developments justified a change in this interpretation.³ While the court acknowledged some change in public opinion as reflected in telephone surveys, it correctly gave little weight to this argument: “Plaintiffs fail to allege whether those public polls reflect the opinion of people who are fully informed of the arguments espoused by those who caution against permitting aid-in-dying, such as those articulated in the New York State Task Force on Life and the Law.”

This task force issued the following recommendation in its 1994 report,⁴ “When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context”: “The Task Force members unanimously recommend that existing law should not be changed to permit assisted suicide or euthanasia. Legalizing assisted suicide and euthanasia would pose profound risks to many individuals who are ill and vulnerable. The Task Force members concluded that the potential dangers of this dramatic change in public policy would outweigh any benefit that might be achieved” (Chapter 6, p. 120).

The New York aid-in-dying bill did not progress out of committee by the time the session ended in June.

Lastly, both of these cases concluded that medical aid in dying was suicide. In Myers, Judge Angela M. Mazzarelli stated: “The word ‘suicide’ has a straightforward meaning, and a dictionary is hardly necessary … It is traditionally defined as ‘the act or instance of taking one’s own life voluntarily and intentionally.’ ... Whatever label one puts on the act that plaintiffs are asking us to permit, it unquestionably fits that literal description.”

 

Regardless of the label used – aid in dying, assisted suicide, or self-deliverance – it is not a civil right.

Resources

1. http://www.nmcompcomm.us/nmcases/nmsc/slips/SC35,478.pdf

2. https://www.deathwithdignity.org/assisted-dying-chronology/

3. http://www.nycourts.gov/reporter/3dseries/2016/2016_03457.htm

4. https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/

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.

On June 30, New Mexico became the latest state to throw out a challenge to a law banning physician-assisted suicide. In Morris v. Brandenburg, proponents of the right-to-die movement contended that medical aid in dying was a fundamental right, meaning that any law that restricted the right should be presumed to be invalid unless the state had a compelling reason for the restriction.

In a unanimous decision, the New Mexico Supreme Court held that there was no such right under that state’s constitution, and that even if the right had existed, the state had several compelling reasons to restrict it: to protect “the integrity and ethics of the medical profession”; to protect “vulnerable groups – including the poor, the elderly, and disabled persons – from the risk of subtle coercion and undue influence in end-of-life situations, including pressures associated with the substantial financial burden of end-of-life health care costs”; and to protect “against voluntary or involuntary euthanasia because if physician aid in dying is a constitutional right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication.”¹

Let me repeat that last point:

If aid in dying is a constitutional right, then medical euthanasia is inevitable. In other words, if a patient is too disabled to commit suicide on his or her own, a physician would be obligated to kill the patient.

Proponents will dismiss this last statement as alarmist and unfounded. They will point to a 20-year history of legalized aid in dying in Oregon, and insist there has never been a problem and no attempt to expand the practice to include euthanasia.

What they don’t mention is that such an attempt would be politically disastrous for the right-to-die movement. In 2015, 25 states and the District of Columbia considered legalization bills.² After careful consideration and debate, these bills failed in every state except California, and in that state it passed only because of an extraordinary and unusual legislative maneuver. The bill initially failed in regular session, but passed in special session when the California Medical Association (CMA) shifted to a neutral stance. That shift would never have happened had CMA members been aware of the legal inevitability of euthanasia. At this stage of the political process, the goal of the right-to-die movement is to get laws on the books in as many states as possible before pushing for more.

The New Mexico opinion echoes a similar decision issued this past May by a New York appellate court. The plaintiffs in that case were three terminally ill New Yorkers and five doctors, as well as two euthanasia advocacy groups. The arguments were virtually identical to those made in New Mexico, asserting a fundamental right to medical aid in dying based upon personal autonomy. They additionally sought an exception to New York criminal law, which defined assisted suicide as second-degree manslaughter. In Myers v. Schneiderman, the court observed that no appellate court had ever found medical aid in dying to be a fundamental right and that no new developments justified a change in this interpretation.³ While the court acknowledged some change in public opinion as reflected in telephone surveys, it correctly gave little weight to this argument: “Plaintiffs fail to allege whether those public polls reflect the opinion of people who are fully informed of the arguments espoused by those who caution against permitting aid-in-dying, such as those articulated in the New York State Task Force on Life and the Law.”

This task force issued the following recommendation in its 1994 report,⁴ “When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context”: “The Task Force members unanimously recommend that existing law should not be changed to permit assisted suicide or euthanasia. Legalizing assisted suicide and euthanasia would pose profound risks to many individuals who are ill and vulnerable. The Task Force members concluded that the potential dangers of this dramatic change in public policy would outweigh any benefit that might be achieved” (Chapter 6, p. 120).

The New York aid-in-dying bill did not progress out of committee by the time the session ended in June.

Lastly, both of these cases concluded that medical aid in dying was suicide. In Myers, Judge Angela M. Mazzarelli stated: “The word ‘suicide’ has a straightforward meaning, and a dictionary is hardly necessary … It is traditionally defined as ‘the act or instance of taking one’s own life voluntarily and intentionally.’ ... Whatever label one puts on the act that plaintiffs are asking us to permit, it unquestionably fits that literal description.”

 

Regardless of the label used – aid in dying, assisted suicide, or self-deliverance – it is not a civil right.

Resources

1. http://www.nmcompcomm.us/nmcases/nmsc/slips/SC35,478.pdf

2. https://www.deathwithdignity.org/assisted-dying-chronology/

3. http://www.nycourts.gov/reporter/3dseries/2016/2016_03457.htm

4. https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/

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.

Truly, the right to bear firearms is not something that should be in the domain of the psychiatrist, but in our current landscape, it’s fallen into our realm. Personally, (as opposed to professionally), it seems to me that there is no reason that someone needs to own an assault weapon, and Americans somehow survived without them for 10 years from 1994 to 2004 during a national ban on assault weapons, inspired in part by the massacre of children in a 1989 mass shooting at a Stockton, Calif., school, followed in 1993 by a street shooting where eight people were killed in San Francisco.

A CNN poll conducted in 1993 revealed that 73% of those polled opposed the manufacture, sale, or possession of assault weapons, and back then, the politics of gun control were less partisan: Former Republican President Ronald Reagan supported legislation to make them illegal. The ban on assault weapons expired in 2004, and mass shooters have been able to obtain these weapons legally and have used them for many of the highly publicized massacres we read about, now several times a year.

What shocks me is that we manufacture these weapons to allow for rapid and efficient discharge, we make these firearms easily accessible to anyone who wants them in more than 40 states, and then we are surprised when people use them to do exactly what they were designed to do: kill lots of people quickly. Those who oppose bans on these weapons insist that terrorists will find other ways: They will use illegal weapons, bombs made from pressure cookers, biologic agents, or explosives. They may be right; that doesn’t mean our government needs to make it easy for gunmen to massacre innocent people.

Until recently, the discussion about mass murder somehow pitted mental illness against gun control, so like it or not, psychiatry was pulled into the discussion of mass murder. Does this make sense? Very little of gun violence takes the form of these highly publicized mass murders – perhaps 1%. But if you’ve turned on CNN lately, they get a lot of air time, while the deaths of countless others – dozens a day in our gun-drenched cities – are now just part of the routine risks of life. If you hold your definition of mass murders to the deaths of four victims in a public place, then most mass murders are what we see in the news: Aurora, Newtown, Fort Hood, Isla Vista, and the list goes on. Of those shooters, roughly half had some history of some kind of mental illness. If you enlarge the definition, as some do, to include any shooting where four or more victims die, then the association with mental illness drops. Many of these killings are domestic and gang violence, or deaths that occur during the commission of another crime.

Overall, it is estimated that less than 10% of gun murders are caused by mental illness, and the politically correct mantra of the time is to point out that people with mental illness are more likely to be the victims of violence than to perpetrate it. Finally, most gun deaths are suicides and not homicides – a distinction not made by CNN.

Despite the staggering rise in gun deaths in our country, and the clear link between gun availability and gun deaths, our federal legislators are stuck; no new gun legislation has passed. Our Congress has made the quiet statement after Newtown that the National Rifle Association (NRA) is remarkably powerful, and perhaps the story was over when we decided that killing children is acceptable. If that’s not enough, Congress was not propelled to action when one of their own was shot in the head during a massacre.

If I feel frustrated and let off steam by tweeting, how awful former U.S. Rep. Gabby Giffords must feel that her former colleagues have not embraced her advocacy actions with Americans for Responsible Solutions.

Over the last week, we’ve seen Sen. Chris Murphy (D-Conn.) stage a 15-hour filibuster on two gun safety amendments. One would close the terror gap; the other sought to expand background checks for firearms purchases. Both measures failed, as did two other gun control measures in the Senate. We’ve also seen House Democrats conduct a sit-in in an effort to force gun control votes. We can’t even agree that those under FBI surveillance for terrorist activities and those on a no-fly list should not be allowed to purchase firearms of any type, including assault rifles. The response is that the right to own guns is protected by the Constitution and can’t be denied without a judicial process.

 

In the case of those with mental illnesses, individual states do not allow for such protections. In New York, the NYSAFE Act allows that patients can be reported to the state, then placed on the National Instant Criminal Background Check System, to prevent gun purchases if a therapist believes a patient is at risk of violence. There needs to be no dangerous act and no history of hospitalization to set this in motion, just a therapist’s belief. And all patients who are involuntarily hospitalized in New York are placed in the database.

California is different with its efforts to keep guns from those with mental disorders: Anyone brought in for a psychiatric evaluation by law enforcement or involuntarily hospitalized from an ER on what is commonly known as a “5150 hold,” loses the right to own a gun for 5 years. There is no hearing at that point, and those who are later released at the commitment hearing do not get their gun rights back.

In Maryland, where I live, the restrictions are a mixed bag: Anyone who remains in a psychiatric hospital for more than 30 days, voluntarily or otherwise and without regard to dangerousness, loses his right to own a gun. In addition, more recent legislation has added that at commitment hearings, the administrative law judge determines whether the patient may retain gun rights based on an assessment of his dangerousness toward others.

Each state is different, but for psychiatric patients who are lawful gun owners, seeking help can be a mixed bag, and they certainly do not get the national civil rights protections that we afford terror suspects. Does the fear of losing the right to bear arms play into a hunter’s decision to seek mental health care? It’s hard to imagine that it would not. While we advocate for decreasing stigma and getting care for those who need help, we also erect barriers and increase stigma in this odd mixed-message public health endeavor.

Given the vocal nature of gun control advocates, it’s hard not to wonder whether the unwillingness of Congress to pass laws that might make us safer is about the will of the people or the dollar amount that legislatures receive from the NRA. I am sure there are readers who disagree with me and feel that more guns in the hands of “good guys” make us all safer, but I continue to find it interesting that mental illness does not cause mass murder – at least not with the numbers we see in the United States – in countries with stricter gun control.

Those who advocate for gun rights remain unconcerned about the high incidence of guns and suicide. Many believe that people should have the right to take their own lives, and if a gun were not available, another means would be found. In some cases, there is no doubt that this is true. In others, we worry that an easily accessible gun in the hands of a suicidal person has a very high rate of mortality, and there is no room for second thoughts or chances after an impulsive decision.

Psychiatry has been lassoed here – guns are our domain whether we want them to be or not – and we already are starting to see patients who want us to advocate for their right to retain their firearms. While I can’t imagine taking on the responsibility or liability of saying my patient (or anyone else) is safe with a firearm, there may be moments where it seems there is little choice, especially when a firearm is required for the patient’s employment. In the meantime, I keep hoping our legislators will wake up and come to their senses.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

Truly, the right to bear firearms is not something that should be in the domain of the psychiatrist, but in our current landscape, it’s fallen into our realm. Personally, (as opposed to professionally), it seems to me that there is no reason that someone needs to own an assault weapon, and Americans somehow survived without them for 10 years from 1994 to 2004 during a national ban on assault weapons, inspired in part by the massacre of children in a 1989 mass shooting at a Stockton, Calif., school, followed in 1993 by a street shooting where eight people were killed in San Francisco.

A CNN poll conducted in 1993 revealed that 73% of those polled opposed the manufacture, sale, or possession of assault weapons, and back then, the politics of gun control were less partisan: Former Republican President Ronald Reagan supported legislation to make them illegal. The ban on assault weapons expired in 2004, and mass shooters have been able to obtain these weapons legally and have used them for many of the highly publicized massacres we read about, now several times a year.

What shocks me is that we manufacture these weapons to allow for rapid and efficient discharge, we make these firearms easily accessible to anyone who wants them in more than 40 states, and then we are surprised when people use them to do exactly what they were designed to do: kill lots of people quickly. Those who oppose bans on these weapons insist that terrorists will find other ways: They will use illegal weapons, bombs made from pressure cookers, biologic agents, or explosives. They may be right; that doesn’t mean our government needs to make it easy for gunmen to massacre innocent people.

Until recently, the discussion about mass murder somehow pitted mental illness against gun control, so like it or not, psychiatry was pulled into the discussion of mass murder. Does this make sense? Very little of gun violence takes the form of these highly publicized mass murders – perhaps 1%. But if you’ve turned on CNN lately, they get a lot of air time, while the deaths of countless others – dozens a day in our gun-drenched cities – are now just part of the routine risks of life. If you hold your definition of mass murders to the deaths of four victims in a public place, then most mass murders are what we see in the news: Aurora, Newtown, Fort Hood, Isla Vista, and the list goes on. Of those shooters, roughly half had some history of some kind of mental illness. If you enlarge the definition, as some do, to include any shooting where four or more victims die, then the association with mental illness drops. Many of these killings are domestic and gang violence, or deaths that occur during the commission of another crime.

Overall, it is estimated that less than 10% of gun murders are caused by mental illness, and the politically correct mantra of the time is to point out that people with mental illness are more likely to be the victims of violence than to perpetrate it. Finally, most gun deaths are suicides and not homicides – a distinction not made by CNN.

Despite the staggering rise in gun deaths in our country, and the clear link between gun availability and gun deaths, our federal legislators are stuck; no new gun legislation has passed. Our Congress has made the quiet statement after Newtown that the National Rifle Association (NRA) is remarkably powerful, and perhaps the story was over when we decided that killing children is acceptable. If that’s not enough, Congress was not propelled to action when one of their own was shot in the head during a massacre.

If I feel frustrated and let off steam by tweeting, how awful former U.S. Rep. Gabby Giffords must feel that her former colleagues have not embraced her advocacy actions with Americans for Responsible Solutions.

Over the last week, we’ve seen Sen. Chris Murphy (D-Conn.) stage a 15-hour filibuster on two gun safety amendments. One would close the terror gap; the other sought to expand background checks for firearms purchases. Both measures failed, as did two other gun control measures in the Senate. We’ve also seen House Democrats conduct a sit-in in an effort to force gun control votes. We can’t even agree that those under FBI surveillance for terrorist activities and those on a no-fly list should not be allowed to purchase firearms of any type, including assault rifles. The response is that the right to own guns is protected by the Constitution and can’t be denied without a judicial process.

 

In the case of those with mental illnesses, individual states do not allow for such protections. In New York, the NYSAFE Act allows that patients can be reported to the state, then placed on the National Instant Criminal Background Check System, to prevent gun purchases if a therapist believes a patient is at risk of violence. There needs to be no dangerous act and no history of hospitalization to set this in motion, just a therapist’s belief. And all patients who are involuntarily hospitalized in New York are placed in the database.

California is different with its efforts to keep guns from those with mental disorders: Anyone brought in for a psychiatric evaluation by law enforcement or involuntarily hospitalized from an ER on what is commonly known as a “5150 hold,” loses the right to own a gun for 5 years. There is no hearing at that point, and those who are later released at the commitment hearing do not get their gun rights back.

In Maryland, where I live, the restrictions are a mixed bag: Anyone who remains in a psychiatric hospital for more than 30 days, voluntarily or otherwise and without regard to dangerousness, loses his right to own a gun. In addition, more recent legislation has added that at commitment hearings, the administrative law judge determines whether the patient may retain gun rights based on an assessment of his dangerousness toward others.

Each state is different, but for psychiatric patients who are lawful gun owners, seeking help can be a mixed bag, and they certainly do not get the national civil rights protections that we afford terror suspects. Does the fear of losing the right to bear arms play into a hunter’s decision to seek mental health care? It’s hard to imagine that it would not. While we advocate for decreasing stigma and getting care for those who need help, we also erect barriers and increase stigma in this odd mixed-message public health endeavor.

Given the vocal nature of gun control advocates, it’s hard not to wonder whether the unwillingness of Congress to pass laws that might make us safer is about the will of the people or the dollar amount that legislatures receive from the NRA. I am sure there are readers who disagree with me and feel that more guns in the hands of “good guys” make us all safer, but I continue to find it interesting that mental illness does not cause mass murder – at least not with the numbers we see in the United States – in countries with stricter gun control.

Those who advocate for gun rights remain unconcerned about the high incidence of guns and suicide. Many believe that people should have the right to take their own lives, and if a gun were not available, another means would be found. In some cases, there is no doubt that this is true. In others, we worry that an easily accessible gun in the hands of a suicidal person has a very high rate of mortality, and there is no room for second thoughts or chances after an impulsive decision.

Psychiatry has been lassoed here – guns are our domain whether we want them to be or not – and we already are starting to see patients who want us to advocate for their right to retain their firearms. While I can’t imagine taking on the responsibility or liability of saying my patient (or anyone else) is safe with a firearm, there may be moments where it seems there is little choice, especially when a firearm is required for the patient’s employment. In the meantime, I keep hoping our legislators will wake up and come to their senses.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

Truly, the right to bear firearms is not something that should be in the domain of the psychiatrist, but in our current landscape, it’s fallen into our realm. Personally, (as opposed to professionally), it seems to me that there is no reason that someone needs to own an assault weapon, and Americans somehow survived without them for 10 years from 1994 to 2004 during a national ban on assault weapons, inspired in part by the massacre of children in a 1989 mass shooting at a Stockton, Calif., school, followed in 1993 by a street shooting where eight people were killed in San Francisco.

A CNN poll conducted in 1993 revealed that 73% of those polled opposed the manufacture, sale, or possession of assault weapons, and back then, the politics of gun control were less partisan: Former Republican President Ronald Reagan supported legislation to make them illegal. The ban on assault weapons expired in 2004, and mass shooters have been able to obtain these weapons legally and have used them for many of the highly publicized massacres we read about, now several times a year.

What shocks me is that we manufacture these weapons to allow for rapid and efficient discharge, we make these firearms easily accessible to anyone who wants them in more than 40 states, and then we are surprised when people use them to do exactly what they were designed to do: kill lots of people quickly. Those who oppose bans on these weapons insist that terrorists will find other ways: They will use illegal weapons, bombs made from pressure cookers, biologic agents, or explosives. They may be right; that doesn’t mean our government needs to make it easy for gunmen to massacre innocent people.

Until recently, the discussion about mass murder somehow pitted mental illness against gun control, so like it or not, psychiatry was pulled into the discussion of mass murder. Does this make sense? Very little of gun violence takes the form of these highly publicized mass murders – perhaps 1%. But if you’ve turned on CNN lately, they get a lot of air time, while the deaths of countless others – dozens a day in our gun-drenched cities – are now just part of the routine risks of life. If you hold your definition of mass murders to the deaths of four victims in a public place, then most mass murders are what we see in the news: Aurora, Newtown, Fort Hood, Isla Vista, and the list goes on. Of those shooters, roughly half had some history of some kind of mental illness. If you enlarge the definition, as some do, to include any shooting where four or more victims die, then the association with mental illness drops. Many of these killings are domestic and gang violence, or deaths that occur during the commission of another crime.

Overall, it is estimated that less than 10% of gun murders are caused by mental illness, and the politically correct mantra of the time is to point out that people with mental illness are more likely to be the victims of violence than to perpetrate it. Finally, most gun deaths are suicides and not homicides – a distinction not made by CNN.

Despite the staggering rise in gun deaths in our country, and the clear link between gun availability and gun deaths, our federal legislators are stuck; no new gun legislation has passed. Our Congress has made the quiet statement after Newtown that the National Rifle Association (NRA) is remarkably powerful, and perhaps the story was over when we decided that killing children is acceptable. If that’s not enough, Congress was not propelled to action when one of their own was shot in the head during a massacre.

If I feel frustrated and let off steam by tweeting, how awful former U.S. Rep. Gabby Giffords must feel that her former colleagues have not embraced her advocacy actions with Americans for Responsible Solutions.

Over the last week, we’ve seen Sen. Chris Murphy (D-Conn.) stage a 15-hour filibuster on two gun safety amendments. One would close the terror gap; the other sought to expand background checks for firearms purchases. Both measures failed, as did two other gun control measures in the Senate. We’ve also seen House Democrats conduct a sit-in in an effort to force gun control votes. We can’t even agree that those under FBI surveillance for terrorist activities and those on a no-fly list should not be allowed to purchase firearms of any type, including assault rifles. The response is that the right to own guns is protected by the Constitution and can’t be denied without a judicial process.

 

In the case of those with mental illnesses, individual states do not allow for such protections. In New York, the NYSAFE Act allows that patients can be reported to the state, then placed on the National Instant Criminal Background Check System, to prevent gun purchases if a therapist believes a patient is at risk of violence. There needs to be no dangerous act and no history of hospitalization to set this in motion, just a therapist’s belief. And all patients who are involuntarily hospitalized in New York are placed in the database.

California is different with its efforts to keep guns from those with mental disorders: Anyone brought in for a psychiatric evaluation by law enforcement or involuntarily hospitalized from an ER on what is commonly known as a “5150 hold,” loses the right to own a gun for 5 years. There is no hearing at that point, and those who are later released at the commitment hearing do not get their gun rights back.

In Maryland, where I live, the restrictions are a mixed bag: Anyone who remains in a psychiatric hospital for more than 30 days, voluntarily or otherwise and without regard to dangerousness, loses his right to own a gun. In addition, more recent legislation has added that at commitment hearings, the administrative law judge determines whether the patient may retain gun rights based on an assessment of his dangerousness toward others.

Each state is different, but for psychiatric patients who are lawful gun owners, seeking help can be a mixed bag, and they certainly do not get the national civil rights protections that we afford terror suspects. Does the fear of losing the right to bear arms play into a hunter’s decision to seek mental health care? It’s hard to imagine that it would not. While we advocate for decreasing stigma and getting care for those who need help, we also erect barriers and increase stigma in this odd mixed-message public health endeavor.

Given the vocal nature of gun control advocates, it’s hard not to wonder whether the unwillingness of Congress to pass laws that might make us safer is about the will of the people or the dollar amount that legislatures receive from the NRA. I am sure there are readers who disagree with me and feel that more guns in the hands of “good guys” make us all safer, but I continue to find it interesting that mental illness does not cause mass murder – at least not with the numbers we see in the United States – in countries with stricter gun control.

Those who advocate for gun rights remain unconcerned about the high incidence of guns and suicide. Many believe that people should have the right to take their own lives, and if a gun were not available, another means would be found. In some cases, there is no doubt that this is true. In others, we worry that an easily accessible gun in the hands of a suicidal person has a very high rate of mortality, and there is no room for second thoughts or chances after an impulsive decision.

Psychiatry has been lassoed here – guns are our domain whether we want them to be or not – and we already are starting to see patients who want us to advocate for their right to retain their firearms. While I can’t imagine taking on the responsibility or liability of saying my patient (or anyone else) is safe with a firearm, there may be moments where it seems there is little choice, especially when a firearm is required for the patient’s employment. In the meantime, I keep hoping our legislators will wake up and come to their senses.

Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Psychiatric Care,” forthcoming from Johns Hopkins University Press in fall 2016.

With his 1993 landmark book, “Listening to Prozac,” psychiatrist Peter D. Kramer became one of the most famous psychiatrists in America – second perhaps only to the fictional Frasier Crane of primetime TV. Since then, Dr. Kramer has continued to write – including a novel, books on other psychiatric topics, a blog, and articles for mainstream media, including the New York Times. In his latest book, “Ordinarily Well: The Case for Antidepressants,” Dr. Kramer will return to the role he left behind 23 years ago: defending the use of antidepressants.

Dr. Kramer notes that he doesn’t do this easily. In the preface, with a bit of dismay, he talks about how reviewers have called him “Dr. Prozac.” He’s felt stuck on a wave that didn’t reflect his diverse interests, and he didn’t want to be covered by the spreading stain of Big Pharma.

“Against all indications, I remained hopeful that I might walk free by day, alter my obituary,” Dr. Kramer tells the reader.

With “Ordinarily Well,” Peter Kramer is back as Dr. Prozac. The book is written as a response to the “research”– now seen so often in headlines – that antidepressants are as effective as sugar pills for mild to moderate depression, and they should be prescribed only for severe major depression. He gets even more specific: The book is written partly in response to an article by Dr. Marcia Angell, former editor in chief of the New England Journal of Medicine, published in June 2011 in the New York Review of Books, and Dr. Angell’s assertion that psychiatric medications are no more effective than placebo. Since psychotropics come with more side effects than placebos, the next logical conclusion is that they are not only ineffective – they are harmful.

As a clinical psychiatrist, I’ve found this evidence-based stance to be perplexing. People get better on antidepressants, even if you aren’t measuring Hamilton rating scores and even if you aren’t limiting treatment to those with severe major depression. I would estimate that at least some of the people, some of the time, get better, and when you progress to strategies of switching and augmenting, most of the the people, most of the time, get significant relief from their major depression.

Obviously, this is my clinical impression and not research, and Dr. Kramer takes a more ardent stance: Most patients with depression, be it mild, moderate, severe, or long-standing dysthymia, have a good response to antidepressants. It’s the minority who don’t respond.

Dr. Kramer goes through the “science” that would suggest that antidepressants are not effective for milder forms of depression, dysthymia, and neuroticism. He does a systematic and comprehensive review of how pharmaceutical studies are conducted, and what factors might skew results, and there is plenty here to fill the pages. He explains complex issues – such as meta-analyses and numbers needed to treat – such that the lay reader can follow.

As just one example, Dr. Kramer talks about screening research subjects for participation in antidepressant studies: “If raters have a sense of the minimum Hamilton score for admission to a study, and if they are under pressure to fill an enrollment quota, they will be inclined to tack on questionable Hamilton points. The boost will not be uniform. There’s no need to raise rating in the very ill. Scores for least afflicted participants will be most inflated.

“When off-site raters, with no stake in the pace of enrollment, analyze tapes of admission interviews,” he continues, “they find patients to be much healthier than the on-site Hamilton scores suggest. According to off-site assessments, many patients admitted to drug studies simply are not depressed.”

Dr. Kramer methodically marches through problems with finding patients for the studies, shortcomings of the Hamilton rating scale, which gives suicidal ideation the same point as a somatic symptom; the bias some studies have of excluding people with severe depression; substance abuse, or comorbid disorders; and “the floor effect,” which underestimates efficacy in patients with fewer symptoms.

He follows subjects at an unnamed for-profit research center and praises the skills of everyone who comes in contact with the research subjects, including the friendly van driver who fetches patients from their homes.

In a chapter titled “How We’re Doing,” Dr. Kramer goes into detail about specific studies, including the STAR*D trials, where patients were recruited from primary care and psychiatric clinics with the guarantee that they would be provided active medication, and those with comorbid conditions were not excluded.

 

“Only the sickest came. For nearly 80% of the participants (more than 2,800 were tested), the disorder was chronic. The average length of the current depressive episode was more than 2 years, generally despite attempts at treatment. The average enrollee had lived with depression on and off for more than15 years and was now in a seventh episode. Most patients were alcoholics or had other forms of mental illness.

“In the first phase, patients were put on Celexa [citalopram], managed by their own doctors. About 30% of patients achieved remission within weeks – with virtually no symptoms. Responses (including remissions) ran at just under 50%.

“Commentators considered this outcome disappointing, but is it?”

So this is Dr. Kramer’s strength: He writes an engaging book about a complex topic, arguing throughout that antidepressants work well and have been given a bum rap by flawed research and careless journalism that enjoy the sensationalism of villainizing psychotropics. There are no headlines, he points out, singing the praises of antidepressants for milder forms of depression, even when the evidence is there. Despite the complexity of the topic and the breadth of his research reviews, Dr. Kramer tells the story of antidepressant research in a way that a lay reader can follow. There are no mice or moleculars, no genetic loci, and no explanations of cytochrome P450 metabolism, neurotransmission, or synaptic blockade. The complexities are explained without medical lingo and, in the end, he concludes what psychiatrists see every day: Antidepressants work. They work for the sickest of the sick, and they work for those who are suffering from less-severe forms of depression.

Dr. Kramer ends the book with a discussion of his own clinical experiences, which are not always in tune with what the “science” declares to be true. He cites studies that show that psychotherapy adds nothing to the treatment of depression, yet still, he treats his own patients with psychotherapy. He notes studies that show maximal efficacy when medications are used at high doses and continue for the long haul at these high doses, yet in his own practice, he sometimes uses lower doses and weans patients off medications. He does a wonderful job of pointing out the disconnect of the promise of evidence-based medicine and how its usefulness has limits in clinical practice.

In our communications, Dr. Kramer wrote to me: “There were many reasons not to write this book, and I was reluctant. I took up the topic only after declining a series of opportunities to weigh in. This book is the only one of mine that I wrote primarily out of a sense of duty. The debunking of antidepressants had gone too far and been too widely accepted, and I believed that the underlying research was shaky.”

He worried that I saw his view of antidepressants as more favorable than he intended it to be, and in fact, his perception is correct: While I prescribe antidepressants and see their benefits (as well as their side effects) with many of my patients, I believe Peter Kramer is more enthusiastic than I am about the efficacy of antidepressants for milder forms of depression, dysthymia, and neuroticism.

“My view is the one expressed in the title,” Dr. Kramer countered, “Our medications work ordinarily well, and they bring patients to a state of ordinary wellness.”

“Ordinarily Well” will be available on June 7; it is available for preorder on Amazon now.

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

With his 1993 landmark book, “Listening to Prozac,” psychiatrist Peter D. Kramer became one of the most famous psychiatrists in America – second perhaps only to the fictional Frasier Crane of primetime TV. Since then, Dr. Kramer has continued to write – including a novel, books on other psychiatric topics, a blog, and articles for mainstream media, including the New York Times. In his latest book, “Ordinarily Well: The Case for Antidepressants,” Dr. Kramer will return to the role he left behind 23 years ago: defending the use of antidepressants.

Dr. Kramer notes that he doesn’t do this easily. In the preface, with a bit of dismay, he talks about how reviewers have called him “Dr. Prozac.” He’s felt stuck on a wave that didn’t reflect his diverse interests, and he didn’t want to be covered by the spreading stain of Big Pharma.

“Against all indications, I remained hopeful that I might walk free by day, alter my obituary,” Dr. Kramer tells the reader.

With “Ordinarily Well,” Peter Kramer is back as Dr. Prozac. The book is written as a response to the “research”– now seen so often in headlines – that antidepressants are as effective as sugar pills for mild to moderate depression, and they should be prescribed only for severe major depression. He gets even more specific: The book is written partly in response to an article by Dr. Marcia Angell, former editor in chief of the New England Journal of Medicine, published in June 2011 in the New York Review of Books, and Dr. Angell’s assertion that psychiatric medications are no more effective than placebo. Since psychotropics come with more side effects than placebos, the next logical conclusion is that they are not only ineffective – they are harmful.

As a clinical psychiatrist, I’ve found this evidence-based stance to be perplexing. People get better on antidepressants, even if you aren’t measuring Hamilton rating scores and even if you aren’t limiting treatment to those with severe major depression. I would estimate that at least some of the people, some of the time, get better, and when you progress to strategies of switching and augmenting, most of the the people, most of the time, get significant relief from their major depression.

Obviously, this is my clinical impression and not research, and Dr. Kramer takes a more ardent stance: Most patients with depression, be it mild, moderate, severe, or long-standing dysthymia, have a good response to antidepressants. It’s the minority who don’t respond.

Dr. Kramer goes through the “science” that would suggest that antidepressants are not effective for milder forms of depression, dysthymia, and neuroticism. He does a systematic and comprehensive review of how pharmaceutical studies are conducted, and what factors might skew results, and there is plenty here to fill the pages. He explains complex issues – such as meta-analyses and numbers needed to treat – such that the lay reader can follow.

As just one example, Dr. Kramer talks about screening research subjects for participation in antidepressant studies: “If raters have a sense of the minimum Hamilton score for admission to a study, and if they are under pressure to fill an enrollment quota, they will be inclined to tack on questionable Hamilton points. The boost will not be uniform. There’s no need to raise rating in the very ill. Scores for least afflicted participants will be most inflated.

“When off-site raters, with no stake in the pace of enrollment, analyze tapes of admission interviews,” he continues, “they find patients to be much healthier than the on-site Hamilton scores suggest. According to off-site assessments, many patients admitted to drug studies simply are not depressed.”

Dr. Kramer methodically marches through problems with finding patients for the studies, shortcomings of the Hamilton rating scale, which gives suicidal ideation the same point as a somatic symptom; the bias some studies have of excluding people with severe depression; substance abuse, or comorbid disorders; and “the floor effect,” which underestimates efficacy in patients with fewer symptoms.

He follows subjects at an unnamed for-profit research center and praises the skills of everyone who comes in contact with the research subjects, including the friendly van driver who fetches patients from their homes.

In a chapter titled “How We’re Doing,” Dr. Kramer goes into detail about specific studies, including the STAR*D trials, where patients were recruited from primary care and psychiatric clinics with the guarantee that they would be provided active medication, and those with comorbid conditions were not excluded.

 

“Only the sickest came. For nearly 80% of the participants (more than 2,800 were tested), the disorder was chronic. The average length of the current depressive episode was more than 2 years, generally despite attempts at treatment. The average enrollee had lived with depression on and off for more than15 years and was now in a seventh episode. Most patients were alcoholics or had other forms of mental illness.

“In the first phase, patients were put on Celexa [citalopram], managed by their own doctors. About 30% of patients achieved remission within weeks – with virtually no symptoms. Responses (including remissions) ran at just under 50%.

“Commentators considered this outcome disappointing, but is it?”

So this is Dr. Kramer’s strength: He writes an engaging book about a complex topic, arguing throughout that antidepressants work well and have been given a bum rap by flawed research and careless journalism that enjoy the sensationalism of villainizing psychotropics. There are no headlines, he points out, singing the praises of antidepressants for milder forms of depression, even when the evidence is there. Despite the complexity of the topic and the breadth of his research reviews, Dr. Kramer tells the story of antidepressant research in a way that a lay reader can follow. There are no mice or moleculars, no genetic loci, and no explanations of cytochrome P450 metabolism, neurotransmission, or synaptic blockade. The complexities are explained without medical lingo and, in the end, he concludes what psychiatrists see every day: Antidepressants work. They work for the sickest of the sick, and they work for those who are suffering from less-severe forms of depression.

Dr. Kramer ends the book with a discussion of his own clinical experiences, which are not always in tune with what the “science” declares to be true. He cites studies that show that psychotherapy adds nothing to the treatment of depression, yet still, he treats his own patients with psychotherapy. He notes studies that show maximal efficacy when medications are used at high doses and continue for the long haul at these high doses, yet in his own practice, he sometimes uses lower doses and weans patients off medications. He does a wonderful job of pointing out the disconnect of the promise of evidence-based medicine and how its usefulness has limits in clinical practice.

In our communications, Dr. Kramer wrote to me: “There were many reasons not to write this book, and I was reluctant. I took up the topic only after declining a series of opportunities to weigh in. This book is the only one of mine that I wrote primarily out of a sense of duty. The debunking of antidepressants had gone too far and been too widely accepted, and I believed that the underlying research was shaky.”

He worried that I saw his view of antidepressants as more favorable than he intended it to be, and in fact, his perception is correct: While I prescribe antidepressants and see their benefits (as well as their side effects) with many of my patients, I believe Peter Kramer is more enthusiastic than I am about the efficacy of antidepressants for milder forms of depression, dysthymia, and neuroticism.

“My view is the one expressed in the title,” Dr. Kramer countered, “Our medications work ordinarily well, and they bring patients to a state of ordinary wellness.”

“Ordinarily Well” will be available on June 7; it is available for preorder on Amazon now.

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

With his 1993 landmark book, “Listening to Prozac,” psychiatrist Peter D. Kramer became one of the most famous psychiatrists in America – second perhaps only to the fictional Frasier Crane of primetime TV. Since then, Dr. Kramer has continued to write – including a novel, books on other psychiatric topics, a blog, and articles for mainstream media, including the New York Times. In his latest book, “Ordinarily Well: The Case for Antidepressants,” Dr. Kramer will return to the role he left behind 23 years ago: defending the use of antidepressants.

Dr. Kramer notes that he doesn’t do this easily. In the preface, with a bit of dismay, he talks about how reviewers have called him “Dr. Prozac.” He’s felt stuck on a wave that didn’t reflect his diverse interests, and he didn’t want to be covered by the spreading stain of Big Pharma.

“Against all indications, I remained hopeful that I might walk free by day, alter my obituary,” Dr. Kramer tells the reader.

With “Ordinarily Well,” Peter Kramer is back as Dr. Prozac. The book is written as a response to the “research”– now seen so often in headlines – that antidepressants are as effective as sugar pills for mild to moderate depression, and they should be prescribed only for severe major depression. He gets even more specific: The book is written partly in response to an article by Dr. Marcia Angell, former editor in chief of the New England Journal of Medicine, published in June 2011 in the New York Review of Books, and Dr. Angell’s assertion that psychiatric medications are no more effective than placebo. Since psychotropics come with more side effects than placebos, the next logical conclusion is that they are not only ineffective – they are harmful.

As a clinical psychiatrist, I’ve found this evidence-based stance to be perplexing. People get better on antidepressants, even if you aren’t measuring Hamilton rating scores and even if you aren’t limiting treatment to those with severe major depression. I would estimate that at least some of the people, some of the time, get better, and when you progress to strategies of switching and augmenting, most of the the people, most of the time, get significant relief from their major depression.

Obviously, this is my clinical impression and not research, and Dr. Kramer takes a more ardent stance: Most patients with depression, be it mild, moderate, severe, or long-standing dysthymia, have a good response to antidepressants. It’s the minority who don’t respond.

Dr. Kramer goes through the “science” that would suggest that antidepressants are not effective for milder forms of depression, dysthymia, and neuroticism. He does a systematic and comprehensive review of how pharmaceutical studies are conducted, and what factors might skew results, and there is plenty here to fill the pages. He explains complex issues – such as meta-analyses and numbers needed to treat – such that the lay reader can follow.

As just one example, Dr. Kramer talks about screening research subjects for participation in antidepressant studies: “If raters have a sense of the minimum Hamilton score for admission to a study, and if they are under pressure to fill an enrollment quota, they will be inclined to tack on questionable Hamilton points. The boost will not be uniform. There’s no need to raise rating in the very ill. Scores for least afflicted participants will be most inflated.

“When off-site raters, with no stake in the pace of enrollment, analyze tapes of admission interviews,” he continues, “they find patients to be much healthier than the on-site Hamilton scores suggest. According to off-site assessments, many patients admitted to drug studies simply are not depressed.”

Dr. Kramer methodically marches through problems with finding patients for the studies, shortcomings of the Hamilton rating scale, which gives suicidal ideation the same point as a somatic symptom; the bias some studies have of excluding people with severe depression; substance abuse, or comorbid disorders; and “the floor effect,” which underestimates efficacy in patients with fewer symptoms.

He follows subjects at an unnamed for-profit research center and praises the skills of everyone who comes in contact with the research subjects, including the friendly van driver who fetches patients from their homes.

In a chapter titled “How We’re Doing,” Dr. Kramer goes into detail about specific studies, including the STAR*D trials, where patients were recruited from primary care and psychiatric clinics with the guarantee that they would be provided active medication, and those with comorbid conditions were not excluded.

 

“Only the sickest came. For nearly 80% of the participants (more than 2,800 were tested), the disorder was chronic. The average length of the current depressive episode was more than 2 years, generally despite attempts at treatment. The average enrollee had lived with depression on and off for more than15 years and was now in a seventh episode. Most patients were alcoholics or had other forms of mental illness.

“In the first phase, patients were put on Celexa [citalopram], managed by their own doctors. About 30% of patients achieved remission within weeks – with virtually no symptoms. Responses (including remissions) ran at just under 50%.

“Commentators considered this outcome disappointing, but is it?”

So this is Dr. Kramer’s strength: He writes an engaging book about a complex topic, arguing throughout that antidepressants work well and have been given a bum rap by flawed research and careless journalism that enjoy the sensationalism of villainizing psychotropics. There are no headlines, he points out, singing the praises of antidepressants for milder forms of depression, even when the evidence is there. Despite the complexity of the topic and the breadth of his research reviews, Dr. Kramer tells the story of antidepressant research in a way that a lay reader can follow. There are no mice or moleculars, no genetic loci, and no explanations of cytochrome P450 metabolism, neurotransmission, or synaptic blockade. The complexities are explained without medical lingo and, in the end, he concludes what psychiatrists see every day: Antidepressants work. They work for the sickest of the sick, and they work for those who are suffering from less-severe forms of depression.

Dr. Kramer ends the book with a discussion of his own clinical experiences, which are not always in tune with what the “science” declares to be true. He cites studies that show that psychotherapy adds nothing to the treatment of depression, yet still, he treats his own patients with psychotherapy. He notes studies that show maximal efficacy when medications are used at high doses and continue for the long haul at these high doses, yet in his own practice, he sometimes uses lower doses and weans patients off medications. He does a wonderful job of pointing out the disconnect of the promise of evidence-based medicine and how its usefulness has limits in clinical practice.

In our communications, Dr. Kramer wrote to me: “There were many reasons not to write this book, and I was reluctant. I took up the topic only after declining a series of opportunities to weigh in. This book is the only one of mine that I wrote primarily out of a sense of duty. The debunking of antidepressants had gone too far and been too widely accepted, and I believed that the underlying research was shaky.”

He worried that I saw his view of antidepressants as more favorable than he intended it to be, and in fact, his perception is correct: While I prescribe antidepressants and see their benefits (as well as their side effects) with many of my patients, I believe Peter Kramer is more enthusiastic than I am about the efficacy of antidepressants for milder forms of depression, dysthymia, and neuroticism.

“My view is the one expressed in the title,” Dr. Kramer countered, “Our medications work ordinarily well, and they bring patients to a state of ordinary wellness.”

“Ordinarily Well” will be available on June 7; it is available for preorder on Amazon now.

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

March 24, 2016, marks 1 year since a Germanwings copilot locked the pilot out of the cockpit, then purposely crashed his plane into the French Alps, killing all those aboard the commercial airliner. You can think of it as a suicide or as a mass murder; it was both.

Initially, it was reported that the pilot had taken 10 months off from training in 2008-2009 because of depression. A full report released earlier this month by France’s Civil Aviation Safety Investigation Authority reveals that the copilot recently had resumed treatment with a psychiatrist, as well as several other physicians, without informing his employer.

According to the report, the initial episode of depression included a hospitalization. The copilot was judged to be “entirely healthy,” and communications occurred between the aviation authorities, and his psychiatrist and psychotherapist. The copilot was issued a class I, unrestricted medical certificate that allowed him to fly as long as he did not have a recurrence of depression. It would be revoked if he had either symptoms or a need for medication. The medical certificate was renewed yearly, most recently in July 2014.

In November 2014, the copilot consulted with “private physician A” and was placed on sick leave for a week. Beginning in December, the copilot saw “several private physicians” for visual difficulties and sleep disturbance. He was seen by several eye specialists who found no visual problems. On Feb. 17, 2015, the copilot saw “private physician B,” who placed him on sick leave for 8 days; he did not forward this information to Germanwings. On the same day, he saw “private physician C,” who referred him to a psychiatrist and a psychotherapist, and prescribed zopiclone, a sleep medication similar to Lunesta (eszopiclone), the report says.

On Feb. 22, 2015, the copilot returned to see “private physician C” and was placed on sick leave for 3 days. Two days later, he met with a psychiatrist and was given a prescription for mirtazapine. On March 9, “private physician D” issued a note for sick leave, which the copilot did not report to the airline. The following day, he returned to “private physician C,” who recommended hospitalization for possible psychosis. He returned to “private physician C” on March 12, 2 days later, and was given a note for sick leave – which he did not relay to Germanwings. On March 16, the treating psychiatrist prescribed escitalopram, Dominal f (a phenothiazine similar to compazine), and zolpidem. On March 18, he received a note for sick leave by “private physician E.” An email to his treating psychiatrist sometime in March also revealed that he was taking an additional dose of mirtazapine and lorazepam. In reading the list of medical contacts, one has the sense that the copilot was frantic. His remains tested positive for citalopram, mirtazapine, and zopiclone.

If I am reading the report correctly, the copilot took medical leave twice during the months preceding the crash, and copiloted flights both the day before the crash and earlier that same morning.

The aviation authority’s report noted: “The limited medical and personal data available to the safety investigation did not make it possible for an unambiguous psychiatric diagnosis to be made. In particular an interview with the copilot’s relatives and his private physicians was impossible, as they exercised their right to refuse to be interviewed.” The investigators concluded that it was likely that the copilot suffered from a psychotic depressive episode dating back to December 2014 and lasting until the tragedy.

It’s important to note that German laws are more stringent than American laws about patient privacy: Violations include criminal sanctions. What is striking from the report is that there is so little communication between the physicians, even between physician C, who referred the patient to a psychiatrist, and the treating psychiatrist. In fact, physician C recommended hospitalization, and there is no report that the psychiatrist recommended either time off or hospitalization. We don’t know if the physicians were aware of who else was treating this patient, or if the doctors even knew he was a pilot. It’s even more striking that the physicians of a dead mass murderer can simply refuse to be interviewed by aviation authorities.

When the report came out, forensic psychiatrist Paul Appelbaum tweeted, “Germanwings crash shows results of fetishing privacy when lives are at stake; I’d like to think US drs. would have reported psychotic pilot.” Please note that Dr. Appelbaum’s grammar is restricted by the 140-character limit imposed by Twitter. A tweeted discussion ensued, including Dr. Annette Hanson, over whether it would be better to hospitalize or report a pilot, and if it might be difficult to figure out whom a private psychiatrist would even report to. Dr. Hanson, who favored hospitalization, tweeted, “Creating a duty to report ‘unfitness’ apart from dangerousness could expand to other professions-liability growth.”

 

It does seem that in the United States, physicians treating pilots with possible psychosis and depression – serious enough to require sedating medications, time off from work, and a recommendation for hospitalization – would likely feel obligated to prevent this patient from flying an aircraft.

The issue seems complicated; if there is no way to obtain confidential treatment, those with psychiatric disorders may well go untreated, especially if those who get care risk losing their livelihoods. We do know this is the case: A survey of pilots who have inquired about the consequences of getting psychiatric care showed that the majority would forgo treatment to maintain their right to fly.

According to the French aviation report: “As an example, the Aviation Medicine Advisory Service (AMAS), a U.S.-based company providing aeromedical advice for pilots, reviewed its database of telephone inquiries from pilots between 1992 and 1997. It had received 1,200 telephone inquiries from pilots who had been diagnosed as having clinical depressions and who had been advised by their physicians to take antidepressant medications. These pilots had called AMAS to discuss the aeromedical implications of their situations. O[f] the 1,200 pilots, approximately 60% told the AMAS that they would refuse medication and continue to fly. About 15% indicated an intention to take the medications and continue their flying duties without informing the Federal Aviation Administration. And the remaining 25% said they would take sick leave, undergo the recommended treatment, and return to work when aeromedically cleared to do so. As the data were representative only of pilots who telephoned for information, the [Aerospace Medical Association] underlined the fact that the presence of depressed and untreated pilots (or treated without aeromedical supervision) was undoubtedly underreported.”

We might like to believe that psychiatric treatment would offer protection from tragedy, and that regulations that dissuade people from getting help might ultimately create more problems than they solve. In this case, the pilot was seeing a psychiatrist, and, none of his many efforts to get care prevented this suicide/mass murder. I found it interesting that there is no indication that the airline might request more information after the pilot presented two notes from outside doctors requesting sick leave, especially given his history of disabling depression. Still, without input from the physicians and the family, we will never know whether anyone had any indication that the pilot was so imminently dangerous.

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

March 24, 2016, marks 1 year since a Germanwings copilot locked the pilot out of the cockpit, then purposely crashed his plane into the French Alps, killing all those aboard the commercial airliner. You can think of it as a suicide or as a mass murder; it was both.

Initially, it was reported that the pilot had taken 10 months off from training in 2008-2009 because of depression. A full report released earlier this month by France’s Civil Aviation Safety Investigation Authority reveals that the copilot recently had resumed treatment with a psychiatrist, as well as several other physicians, without informing his employer.

According to the report, the initial episode of depression included a hospitalization. The copilot was judged to be “entirely healthy,” and communications occurred between the aviation authorities, and his psychiatrist and psychotherapist. The copilot was issued a class I, unrestricted medical certificate that allowed him to fly as long as he did not have a recurrence of depression. It would be revoked if he had either symptoms or a need for medication. The medical certificate was renewed yearly, most recently in July 2014.

In November 2014, the copilot consulted with “private physician A” and was placed on sick leave for a week. Beginning in December, the copilot saw “several private physicians” for visual difficulties and sleep disturbance. He was seen by several eye specialists who found no visual problems. On Feb. 17, 2015, the copilot saw “private physician B,” who placed him on sick leave for 8 days; he did not forward this information to Germanwings. On the same day, he saw “private physician C,” who referred him to a psychiatrist and a psychotherapist, and prescribed zopiclone, a sleep medication similar to Lunesta (eszopiclone), the report says.

On Feb. 22, 2015, the copilot returned to see “private physician C” and was placed on sick leave for 3 days. Two days later, he met with a psychiatrist and was given a prescription for mirtazapine. On March 9, “private physician D” issued a note for sick leave, which the copilot did not report to the airline. The following day, he returned to “private physician C,” who recommended hospitalization for possible psychosis. He returned to “private physician C” on March 12, 2 days later, and was given a note for sick leave – which he did not relay to Germanwings. On March 16, the treating psychiatrist prescribed escitalopram, Dominal f (a phenothiazine similar to compazine), and zolpidem. On March 18, he received a note for sick leave by “private physician E.” An email to his treating psychiatrist sometime in March also revealed that he was taking an additional dose of mirtazapine and lorazepam. In reading the list of medical contacts, one has the sense that the copilot was frantic. His remains tested positive for citalopram, mirtazapine, and zopiclone.

If I am reading the report correctly, the copilot took medical leave twice during the months preceding the crash, and copiloted flights both the day before the crash and earlier that same morning.

The aviation authority’s report noted: “The limited medical and personal data available to the safety investigation did not make it possible for an unambiguous psychiatric diagnosis to be made. In particular an interview with the copilot’s relatives and his private physicians was impossible, as they exercised their right to refuse to be interviewed.” The investigators concluded that it was likely that the copilot suffered from a psychotic depressive episode dating back to December 2014 and lasting until the tragedy.

It’s important to note that German laws are more stringent than American laws about patient privacy: Violations include criminal sanctions. What is striking from the report is that there is so little communication between the physicians, even between physician C, who referred the patient to a psychiatrist, and the treating psychiatrist. In fact, physician C recommended hospitalization, and there is no report that the psychiatrist recommended either time off or hospitalization. We don’t know if the physicians were aware of who else was treating this patient, or if the doctors even knew he was a pilot. It’s even more striking that the physicians of a dead mass murderer can simply refuse to be interviewed by aviation authorities.

When the report came out, forensic psychiatrist Paul Appelbaum tweeted, “Germanwings crash shows results of fetishing privacy when lives are at stake; I’d like to think US drs. would have reported psychotic pilot.” Please note that Dr. Appelbaum’s grammar is restricted by the 140-character limit imposed by Twitter. A tweeted discussion ensued, including Dr. Annette Hanson, over whether it would be better to hospitalize or report a pilot, and if it might be difficult to figure out whom a private psychiatrist would even report to. Dr. Hanson, who favored hospitalization, tweeted, “Creating a duty to report ‘unfitness’ apart from dangerousness could expand to other professions-liability growth.”

 

It does seem that in the United States, physicians treating pilots with possible psychosis and depression – serious enough to require sedating medications, time off from work, and a recommendation for hospitalization – would likely feel obligated to prevent this patient from flying an aircraft.

The issue seems complicated; if there is no way to obtain confidential treatment, those with psychiatric disorders may well go untreated, especially if those who get care risk losing their livelihoods. We do know this is the case: A survey of pilots who have inquired about the consequences of getting psychiatric care showed that the majority would forgo treatment to maintain their right to fly.

According to the French aviation report: “As an example, the Aviation Medicine Advisory Service (AMAS), a U.S.-based company providing aeromedical advice for pilots, reviewed its database of telephone inquiries from pilots between 1992 and 1997. It had received 1,200 telephone inquiries from pilots who had been diagnosed as having clinical depressions and who had been advised by their physicians to take antidepressant medications. These pilots had called AMAS to discuss the aeromedical implications of their situations. O[f] the 1,200 pilots, approximately 60% told the AMAS that they would refuse medication and continue to fly. About 15% indicated an intention to take the medications and continue their flying duties without informing the Federal Aviation Administration. And the remaining 25% said they would take sick leave, undergo the recommended treatment, and return to work when aeromedically cleared to do so. As the data were representative only of pilots who telephoned for information, the [Aerospace Medical Association] underlined the fact that the presence of depressed and untreated pilots (or treated without aeromedical supervision) was undoubtedly underreported.”

We might like to believe that psychiatric treatment would offer protection from tragedy, and that regulations that dissuade people from getting help might ultimately create more problems than they solve. In this case, the pilot was seeing a psychiatrist, and, none of his many efforts to get care prevented this suicide/mass murder. I found it interesting that there is no indication that the airline might request more information after the pilot presented two notes from outside doctors requesting sick leave, especially given his history of disabling depression. Still, without input from the physicians and the family, we will never know whether anyone had any indication that the pilot was so imminently dangerous.

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

March 24, 2016, marks 1 year since a Germanwings copilot locked the pilot out of the cockpit, then purposely crashed his plane into the French Alps, killing all those aboard the commercial airliner. You can think of it as a suicide or as a mass murder; it was both.

Initially, it was reported that the pilot had taken 10 months off from training in 2008-2009 because of depression. A full report released earlier this month by France’s Civil Aviation Safety Investigation Authority reveals that the copilot recently had resumed treatment with a psychiatrist, as well as several other physicians, without informing his employer.

According to the report, the initial episode of depression included a hospitalization. The copilot was judged to be “entirely healthy,” and communications occurred between the aviation authorities, and his psychiatrist and psychotherapist. The copilot was issued a class I, unrestricted medical certificate that allowed him to fly as long as he did not have a recurrence of depression. It would be revoked if he had either symptoms or a need for medication. The medical certificate was renewed yearly, most recently in July 2014.

In November 2014, the copilot consulted with “private physician A” and was placed on sick leave for a week. Beginning in December, the copilot saw “several private physicians” for visual difficulties and sleep disturbance. He was seen by several eye specialists who found no visual problems. On Feb. 17, 2015, the copilot saw “private physician B,” who placed him on sick leave for 8 days; he did not forward this information to Germanwings. On the same day, he saw “private physician C,” who referred him to a psychiatrist and a psychotherapist, and prescribed zopiclone, a sleep medication similar to Lunesta (eszopiclone), the report says.

On Feb. 22, 2015, the copilot returned to see “private physician C” and was placed on sick leave for 3 days. Two days later, he met with a psychiatrist and was given a prescription for mirtazapine. On March 9, “private physician D” issued a note for sick leave, which the copilot did not report to the airline. The following day, he returned to “private physician C,” who recommended hospitalization for possible psychosis. He returned to “private physician C” on March 12, 2 days later, and was given a note for sick leave – which he did not relay to Germanwings. On March 16, the treating psychiatrist prescribed escitalopram, Dominal f (a phenothiazine similar to compazine), and zolpidem. On March 18, he received a note for sick leave by “private physician E.” An email to his treating psychiatrist sometime in March also revealed that he was taking an additional dose of mirtazapine and lorazepam. In reading the list of medical contacts, one has the sense that the copilot was frantic. His remains tested positive for citalopram, mirtazapine, and zopiclone.

If I am reading the report correctly, the copilot took medical leave twice during the months preceding the crash, and copiloted flights both the day before the crash and earlier that same morning.

The aviation authority’s report noted: “The limited medical and personal data available to the safety investigation did not make it possible for an unambiguous psychiatric diagnosis to be made. In particular an interview with the copilot’s relatives and his private physicians was impossible, as they exercised their right to refuse to be interviewed.” The investigators concluded that it was likely that the copilot suffered from a psychotic depressive episode dating back to December 2014 and lasting until the tragedy.

It’s important to note that German laws are more stringent than American laws about patient privacy: Violations include criminal sanctions. What is striking from the report is that there is so little communication between the physicians, even between physician C, who referred the patient to a psychiatrist, and the treating psychiatrist. In fact, physician C recommended hospitalization, and there is no report that the psychiatrist recommended either time off or hospitalization. We don’t know if the physicians were aware of who else was treating this patient, or if the doctors even knew he was a pilot. It’s even more striking that the physicians of a dead mass murderer can simply refuse to be interviewed by aviation authorities.

When the report came out, forensic psychiatrist Paul Appelbaum tweeted, “Germanwings crash shows results of fetishing privacy when lives are at stake; I’d like to think US drs. would have reported psychotic pilot.” Please note that Dr. Appelbaum’s grammar is restricted by the 140-character limit imposed by Twitter. A tweeted discussion ensued, including Dr. Annette Hanson, over whether it would be better to hospitalize or report a pilot, and if it might be difficult to figure out whom a private psychiatrist would even report to. Dr. Hanson, who favored hospitalization, tweeted, “Creating a duty to report ‘unfitness’ apart from dangerousness could expand to other professions-liability growth.”

 

It does seem that in the United States, physicians treating pilots with possible psychosis and depression – serious enough to require sedating medications, time off from work, and a recommendation for hospitalization – would likely feel obligated to prevent this patient from flying an aircraft.

The issue seems complicated; if there is no way to obtain confidential treatment, those with psychiatric disorders may well go untreated, especially if those who get care risk losing their livelihoods. We do know this is the case: A survey of pilots who have inquired about the consequences of getting psychiatric care showed that the majority would forgo treatment to maintain their right to fly.

According to the French aviation report: “As an example, the Aviation Medicine Advisory Service (AMAS), a U.S.-based company providing aeromedical advice for pilots, reviewed its database of telephone inquiries from pilots between 1992 and 1997. It had received 1,200 telephone inquiries from pilots who had been diagnosed as having clinical depressions and who had been advised by their physicians to take antidepressant medications. These pilots had called AMAS to discuss the aeromedical implications of their situations. O[f] the 1,200 pilots, approximately 60% told the AMAS that they would refuse medication and continue to fly. About 15% indicated an intention to take the medications and continue their flying duties without informing the Federal Aviation Administration. And the remaining 25% said they would take sick leave, undergo the recommended treatment, and return to work when aeromedically cleared to do so. As the data were representative only of pilots who telephoned for information, the [Aerospace Medical Association] underlined the fact that the presence of depressed and untreated pilots (or treated without aeromedical supervision) was undoubtedly underreported.”

We might like to believe that psychiatric treatment would offer protection from tragedy, and that regulations that dissuade people from getting help might ultimately create more problems than they solve. In this case, the pilot was seeing a psychiatrist, and, none of his many efforts to get care prevented this suicide/mass murder. I found it interesting that there is no indication that the airline might request more information after the pilot presented two notes from outside doctors requesting sick leave, especially given his history of disabling depression. Still, without input from the physicians and the family, we will never know whether anyone had any indication that the pilot was so imminently dangerous.

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

In early December, I was fortunate to be invited to a film screening of “Touched With Fire,” starring Katie Holmes and Luke Kirby. The movie is about two young poets with bipolar disorder who meet and fall in love while on a psychiatric unit. It opens in theaters on Feb.12.

The screening was introduced by Johns Hopkins Hospital’s psychiatrist in chief Ray DePaulo and following the movie, director Paul Dalio and psychologist Kay Redfield Jamison, Ph.D., both gave short talks and answered questions. The movie was inspired by Dalio’s personal experience with bipolar disorder. Jamison, author of Touched With Fire: Manic-Depressive Illness and the Artistic Temperament (New York: Free Press, 1996) had offered hope to Dalio during a difficult moment with his illness. Numbed by the medications that made his moods tolerable, she had assured him that his creativity would reemerge, as indeed it did. Jamison’s book lent its name to the movie title, and she had a cameo role in the film. In the movie, Jamison, playing herself, tells the couple that it took a while for her moods to calibrate, but that medicines were a godsend and they helped her to become both happier and more productive.

“You’re concerned about losing your art and losing your passion,” Jamison says to Marco, the character played by Kirby. “Medication’s not going to take your personality away; it’s not going to take away your own gift. It’s a fire when it’s out of control, and what medication can do is tamp that down a bit without losing that gift.”

While this insight was helpful to the real-life Dalio, the character Marco struggles deeply as tries to hang on enough to love, work, and strive toward a future he longs for, all while mourning what he sees as the loss of himself. “I want the mania!” he tells Carla, played by Holmes, in one of the more poignant scenes.

Enough plot spoilers. The love story is emotional, and the portrayal of bipolar disorder is the best I have ever seen in the popular media. The characters are three-dimensional and about so much more than their illnesses, and many of the scenes ring so true. This is bipolar disorder with all its raw passion and pain laid out for an audience. No one has odd mannerisms and no one walks around dressed in plastic bags; instead, these are beautiful people ravaged by psychosis and the extremes of their moods, and when it’s not horrible, it’s absolutely wonderful.

In the question-and-answer session after the movie, a member of the audience asked Paul Dalio how to get treatment for someone who is manic. Dalio’s answer was swift: “You have to force them. There is no other way.” As someone who has been interested in patient responses to involuntary psychiatric care, I was a bit surprised to hear that answer from someone who has suffered with the condition and whom I presumed had been treated against his will. When I was asked a few weeks later if I’d like to interview Mr. Dalio, my answer was also swift: Yes, I would.

Dalio talked openly with me about his own psychiatric history, and he was quick to say that he shared Marco’s struggles. The love story that unfolded with Carla was fictional, but when I asked about several of the scenes, Dalio said, “Yes, that happened to me!”

Dalio has been admitted to the hospital four times, twice as an involuntary patient. “I know that in a manic state, no one is going to convince you to go into a hospital,” he said. “My experience was not good at all – it was horrific and frustrating – but it was the lesser of two evils. As difficult as it was, it doesn’t hold a candle to the pain. There is no way I can communicate the pain of bipolar depression.”

Like his character, Marco, Paul Dalio spent years ravaged by his illness. He worked in a warehouse, and he says that during those years he was not very likable. He credits his family with keeping him alive; his father would spend hours on the phone talking him out of committing suicide. The family researched treatment options, and eventually, Dalio began to travel from New York City to see a bipolar disorder expert in Baltimore. His treatment at Hopkins enabled his meeting with Kay Jamison.

“You can’t lie about this disorder,” Dalio said, “and you can’t sugarcoat it.”

Dalio’s life has done a turnaround from his days of being psychotic, suicidal, and unable to function. He holds a degree in screenwriting from New York University and has attended the NYU graduate program in filmmaking. He is married and has two small children.

 

I asked what helped.

“I resolved to stay on meds,” he said, “even if I felt numb. I don’t drink, not even a toast to the movie. I go to bed at 10 every night, drink green juices all day, use a light box, and take walks. Transcendental meditation helps. And patience – it took 3-5 years before I was really able to feel emotion again. I’ve been stable since 2007, but thriving since 2010, with rich emotions. I have a severe form of the condition.”

Dalio experiences symptoms if he misses even a couple of doses of medication, and with two toddlers, it can be difficult for his wife that he can’t help with the children in the middle of the night. It’s not all hard, though. “My wife is Eastern European, and she has a connection to the darkness. She was always attracted to crazy people and artists, and she finds a lot of pleasure in our lives.” Like Dalio, she is screenwriter, and they collaborate on their work.

Dalio is clear about his agenda for this movie. He sees his bipolar disorder as a gift that fuels creative pursuits, and he wants others to understand how people with this disorder struggle. He used the word “beautiful” to describe the intensity of emotions that Carla and Marco experience in the film, but tragedy and torment are also screaming on the big screen. His second agenda is a plug for mainstream psychiatry and a billboard for hope: take the medications, tolerate the downside, be patient; things will work out.

Well worth seeing.

Dr. Miller is a psychiatrist who practices in Baltimore.

In early December, I was fortunate to be invited to a film screening of “Touched With Fire,” starring Katie Holmes and Luke Kirby. The movie is about two young poets with bipolar disorder who meet and fall in love while on a psychiatric unit. It opens in theaters on Feb.12.

The screening was introduced by Johns Hopkins Hospital’s psychiatrist in chief Ray DePaulo and following the movie, director Paul Dalio and psychologist Kay Redfield Jamison, Ph.D., both gave short talks and answered questions. The movie was inspired by Dalio’s personal experience with bipolar disorder. Jamison, author of Touched With Fire: Manic-Depressive Illness and the Artistic Temperament (New York: Free Press, 1996) had offered hope to Dalio during a difficult moment with his illness. Numbed by the medications that made his moods tolerable, she had assured him that his creativity would reemerge, as indeed it did. Jamison’s book lent its name to the movie title, and she had a cameo role in the film. In the movie, Jamison, playing herself, tells the couple that it took a while for her moods to calibrate, but that medicines were a godsend and they helped her to become both happier and more productive.

“You’re concerned about losing your art and losing your passion,” Jamison says to Marco, the character played by Kirby. “Medication’s not going to take your personality away; it’s not going to take away your own gift. It’s a fire when it’s out of control, and what medication can do is tamp that down a bit without losing that gift.”

While this insight was helpful to the real-life Dalio, the character Marco struggles deeply as tries to hang on enough to love, work, and strive toward a future he longs for, all while mourning what he sees as the loss of himself. “I want the mania!” he tells Carla, played by Holmes, in one of the more poignant scenes.

Enough plot spoilers. The love story is emotional, and the portrayal of bipolar disorder is the best I have ever seen in the popular media. The characters are three-dimensional and about so much more than their illnesses, and many of the scenes ring so true. This is bipolar disorder with all its raw passion and pain laid out for an audience. No one has odd mannerisms and no one walks around dressed in plastic bags; instead, these are beautiful people ravaged by psychosis and the extremes of their moods, and when it’s not horrible, it’s absolutely wonderful.

In the question-and-answer session after the movie, a member of the audience asked Paul Dalio how to get treatment for someone who is manic. Dalio’s answer was swift: “You have to force them. There is no other way.” As someone who has been interested in patient responses to involuntary psychiatric care, I was a bit surprised to hear that answer from someone who has suffered with the condition and whom I presumed had been treated against his will. When I was asked a few weeks later if I’d like to interview Mr. Dalio, my answer was also swift: Yes, I would.

Dalio talked openly with me about his own psychiatric history, and he was quick to say that he shared Marco’s struggles. The love story that unfolded with Carla was fictional, but when I asked about several of the scenes, Dalio said, “Yes, that happened to me!”

Dalio has been admitted to the hospital four times, twice as an involuntary patient. “I know that in a manic state, no one is going to convince you to go into a hospital,” he said. “My experience was not good at all – it was horrific and frustrating – but it was the lesser of two evils. As difficult as it was, it doesn’t hold a candle to the pain. There is no way I can communicate the pain of bipolar depression.”

Like his character, Marco, Paul Dalio spent years ravaged by his illness. He worked in a warehouse, and he says that during those years he was not very likable. He credits his family with keeping him alive; his father would spend hours on the phone talking him out of committing suicide. The family researched treatment options, and eventually, Dalio began to travel from New York City to see a bipolar disorder expert in Baltimore. His treatment at Hopkins enabled his meeting with Kay Jamison.

“You can’t lie about this disorder,” Dalio said, “and you can’t sugarcoat it.”

Dalio’s life has done a turnaround from his days of being psychotic, suicidal, and unable to function. He holds a degree in screenwriting from New York University and has attended the NYU graduate program in filmmaking. He is married and has two small children.

 

I asked what helped.

“I resolved to stay on meds,” he said, “even if I felt numb. I don’t drink, not even a toast to the movie. I go to bed at 10 every night, drink green juices all day, use a light box, and take walks. Transcendental meditation helps. And patience – it took 3-5 years before I was really able to feel emotion again. I’ve been stable since 2007, but thriving since 2010, with rich emotions. I have a severe form of the condition.”

Dalio experiences symptoms if he misses even a couple of doses of medication, and with two toddlers, it can be difficult for his wife that he can’t help with the children in the middle of the night. It’s not all hard, though. “My wife is Eastern European, and she has a connection to the darkness. She was always attracted to crazy people and artists, and she finds a lot of pleasure in our lives.” Like Dalio, she is screenwriter, and they collaborate on their work.

Dalio is clear about his agenda for this movie. He sees his bipolar disorder as a gift that fuels creative pursuits, and he wants others to understand how people with this disorder struggle. He used the word “beautiful” to describe the intensity of emotions that Carla and Marco experience in the film, but tragedy and torment are also screaming on the big screen. His second agenda is a plug for mainstream psychiatry and a billboard for hope: take the medications, tolerate the downside, be patient; things will work out.

Well worth seeing.

Dr. Miller is a psychiatrist who practices in Baltimore.

In early December, I was fortunate to be invited to a film screening of “Touched With Fire,” starring Katie Holmes and Luke Kirby. The movie is about two young poets with bipolar disorder who meet and fall in love while on a psychiatric unit. It opens in theaters on Feb.12.

The screening was introduced by Johns Hopkins Hospital’s psychiatrist in chief Ray DePaulo and following the movie, director Paul Dalio and psychologist Kay Redfield Jamison, Ph.D., both gave short talks and answered questions. The movie was inspired by Dalio’s personal experience with bipolar disorder. Jamison, author of Touched With Fire: Manic-Depressive Illness and the Artistic Temperament (New York: Free Press, 1996) had offered hope to Dalio during a difficult moment with his illness. Numbed by the medications that made his moods tolerable, she had assured him that his creativity would reemerge, as indeed it did. Jamison’s book lent its name to the movie title, and she had a cameo role in the film. In the movie, Jamison, playing herself, tells the couple that it took a while for her moods to calibrate, but that medicines were a godsend and they helped her to become both happier and more productive.

“You’re concerned about losing your art and losing your passion,” Jamison says to Marco, the character played by Kirby. “Medication’s not going to take your personality away; it’s not going to take away your own gift. It’s a fire when it’s out of control, and what medication can do is tamp that down a bit without losing that gift.”

While this insight was helpful to the real-life Dalio, the character Marco struggles deeply as tries to hang on enough to love, work, and strive toward a future he longs for, all while mourning what he sees as the loss of himself. “I want the mania!” he tells Carla, played by Holmes, in one of the more poignant scenes.

Enough plot spoilers. The love story is emotional, and the portrayal of bipolar disorder is the best I have ever seen in the popular media. The characters are three-dimensional and about so much more than their illnesses, and many of the scenes ring so true. This is bipolar disorder with all its raw passion and pain laid out for an audience. No one has odd mannerisms and no one walks around dressed in plastic bags; instead, these are beautiful people ravaged by psychosis and the extremes of their moods, and when it’s not horrible, it’s absolutely wonderful.

In the question-and-answer session after the movie, a member of the audience asked Paul Dalio how to get treatment for someone who is manic. Dalio’s answer was swift: “You have to force them. There is no other way.” As someone who has been interested in patient responses to involuntary psychiatric care, I was a bit surprised to hear that answer from someone who has suffered with the condition and whom I presumed had been treated against his will. When I was asked a few weeks later if I’d like to interview Mr. Dalio, my answer was also swift: Yes, I would.

Dalio talked openly with me about his own psychiatric history, and he was quick to say that he shared Marco’s struggles. The love story that unfolded with Carla was fictional, but when I asked about several of the scenes, Dalio said, “Yes, that happened to me!”

Dalio has been admitted to the hospital four times, twice as an involuntary patient. “I know that in a manic state, no one is going to convince you to go into a hospital,” he said. “My experience was not good at all – it was horrific and frustrating – but it was the lesser of two evils. As difficult as it was, it doesn’t hold a candle to the pain. There is no way I can communicate the pain of bipolar depression.”

Like his character, Marco, Paul Dalio spent years ravaged by his illness. He worked in a warehouse, and he says that during those years he was not very likable. He credits his family with keeping him alive; his father would spend hours on the phone talking him out of committing suicide. The family researched treatment options, and eventually, Dalio began to travel from New York City to see a bipolar disorder expert in Baltimore. His treatment at Hopkins enabled his meeting with Kay Jamison.

“You can’t lie about this disorder,” Dalio said, “and you can’t sugarcoat it.”

Dalio’s life has done a turnaround from his days of being psychotic, suicidal, and unable to function. He holds a degree in screenwriting from New York University and has attended the NYU graduate program in filmmaking. He is married and has two small children.

 

I asked what helped.

“I resolved to stay on meds,” he said, “even if I felt numb. I don’t drink, not even a toast to the movie. I go to bed at 10 every night, drink green juices all day, use a light box, and take walks. Transcendental meditation helps. And patience – it took 3-5 years before I was really able to feel emotion again. I’ve been stable since 2007, but thriving since 2010, with rich emotions. I have a severe form of the condition.”

Dalio experiences symptoms if he misses even a couple of doses of medication, and with two toddlers, it can be difficult for his wife that he can’t help with the children in the middle of the night. It’s not all hard, though. “My wife is Eastern European, and she has a connection to the darkness. She was always attracted to crazy people and artists, and she finds a lot of pleasure in our lives.” Like Dalio, she is screenwriter, and they collaborate on their work.

Dalio is clear about his agenda for this movie. He sees his bipolar disorder as a gift that fuels creative pursuits, and he wants others to understand how people with this disorder struggle. He used the word “beautiful” to describe the intensity of emotions that Carla and Marco experience in the film, but tragedy and torment are also screaming on the big screen. His second agenda is a plug for mainstream psychiatry and a billboard for hope: take the medications, tolerate the downside, be patient; things will work out.

Well worth seeing.

Dr. Miller is a psychiatrist who practices in Baltimore.

Last week, the Washington Post reported that Virginia state Sen. Creigh Deeds has filed a $6 million wrongful death lawsuit against the state of Virginia and the mental health agency that employed an evaluator who saw his son during a psychiatric crisis. In November 2013, Sen. Deeds’ son, Gus, had been brought to an emergency department for evaluation. He was judged to be both psychotic and dangerous, but a bed could not be located for him within the state-mandated 6-hour time frame, and Gus Deeds was released. Soon after, he repeatedly stabbed his father, then took his own life with a firearm.

My knowledge of the case is limited to what has been reported in the media, but as a psychiatrist practicing in Maryland where there are no time limits on locating beds, the story is unthinkable. Why would a very ill and very violent – and perhaps very treatable – young man be released from an emergency department because the gong went off in someone’s ill-conceived game of human “beat the clock?” While I have no inside knowledge of the Deeds’ family tragedy, I do want to talk about the Virginia laws that may have enabled a predictable calamity.

Most psychiatrists are familiar with the practice of psychiatric boarding, or holding a patient in the emergency department for a prolonged period of time because a bed cannot be located on a psychiatry inpatient unit. It’s not unusual for EDs to take many hours, or even several days, to transfer psychiatry patients to treatment units. In some places, it can take even longer. In Vermont, where the state hospital was demolished by a tropical storm, there were instances when patients remained in the ED for up to 6 weeks. On Native American reservations without hospital facilities, very ill psychiatric patients may be housed in jails, again for weeks, while an appropriate hospital bed is located off the reservation. Boarding is, by any measure, inhumane, and in 2014, the Washington state Supreme Court ruled it unlawful, though it did not say exactly where the patients were to be held pending bed availability.

With the civil rights of patients in mind, there is something to be said for mandating that beds be located for patients in a timely manner, and for the patient who is distressed, 6 hours may seem to be quite a long enough time. A drop-dead time, however, leaves no room for unforeseen issues, or even for the possibility that medication could be administered in the ED that might avert the need for an involuntary admission. A time limit of this type forces an immediate decision before a thoughtful assessment can be done and other interventions can be explored. In 2014, as one response to the Deeds’ family tragedy, the law was changed to lengthen the period to 8 hours.

In Virginia, the logistics of admitting a patient are more complex than in most states. Any citizen who is concerned about another person’s mental state and safety can apply to a magistrate for an emergency custody order. The patient is then transported by the sheriff, and the clock starts ticking on the 8-hour time frame. In the ED, the patient is seen by the emergency physician, but regardless of how obviously ill and dangerous the patient is, the physician has no authority to involuntarily admit a psychiatric patient. An outside agency – a local community service board (CSB) – is contacted, and an emergency services staff person is summoned to evaluate the patient, perform preadmission screening, and locate a bed.

Virginia is divided into 41 catchment areas, each served by a community service board. Each CSB is required to have crisis staff who assess patients for civil commitment. Virginia is a state with both urban and rural areas consisting of nearly 43,000 square miles. While the CSB prescreener drives in, performs the evaluation, and searches for an available bed, the clock continues to tick.

The qualifications to be a screener are not precise. The website in the county where Gus Deeds lived advertises: “QUALIFICATIONS: Master’s Degree in human services related field, mental health and/or substance abuse experience; or equivalent combination of education and experience including BSN RN’s with Psychiatric Nursing experience in outpatient or inpatient settings. Extensive knowledge of the DSM, mental health and substance abuse assessments, treatment, crisis assessment and intervention strategies for clients of all ages; must be certified or eligible to be certified as a prescreener by the CSB and Virginia DBHDS” (Department of Behavioral Health & Developmental Services). The prescreener has the authority to override the ED physician and release a patient the physician believes should be admitted.

 

It’s not uncommon to hear people compare the treatment of an acute myocardial infarction to the treatment of an agitated psychosis, especially when the topic of parity is raised. Could one imagine a scenario where an ED physician could not admit a patient with chest pain without first waiting hours for an outside consultant to come – a consultant who was not even a physician? Presumably, this is not an issue meant to defy parity but to prevent financial conflicts of interest in situations where patient civil rights are a sensitive concern.

Given all the obstacles, what’s surprising is that the vast majority of the time, if it’s determined that a patient needs involuntary admission, a temporary detention order (TDO) is issued and a bed is located. A study done in 2013 looked at the outcome of TDOs issued in a 3-month period. Of an estimated 5,000 TDOs, beds were located for 98.5% of the patients. Still, 72 patients who had been found to be in need of admission were released because beds could not be found before the emergency custody order expired. The practice of releasing patients in crisis has been assigned its own jargon: “streeting.” It’s not quite that simple, however: Not everyone was released as the gong struck. In 273 instances, patients were admitted after the TDO expired, with an average time to admission of just over 16 hours.

A major issue is that Virginia, like nearly all states, has a shortage of psychiatric beds. In Virginia, the problems may be unnecessarily complex with the added requirement to pull in an outside agency and not leave admission decisions to ED clinicians, coupled with a short time limit for transport, treatment, and admission of a complex, sometimes dangerous patient population. According to the Post article, the Deeds suit is particularly troublesome, because beds were available: The CSB prescreener did not call every available hospital, and he attempted to contact one nearby hospital by fax. The fax number he had was wrong, so the request for the bed was never received by the facility. But the facility did, in fact, have a bed. What hasn’t been legislated is how fast a screener needs to drive to the hospital, or how fast he or she is expected to dial for beds, or what happens if he gets a flat tire or if the responses don’t come fast enough.

Tragedy often leads to change, and laws in Virginia changed after the Virginia Tech shootings, and again after the Deeds’ family tragedy. Legislative gaps remain, however, and bed shortages, time limits, and the requirement for an outside agency assessment continue to leave room for the possibility of more tragedy. Clearly, there is more to be done.

With thanks to Dr. Anita Everett for her consultation.

Dr. Miller is coauthor of the forthcoming book, “Committed: The Battle Over Involuntary Psychiatric Care.”

Last week, the Washington Post reported that Virginia state Sen. Creigh Deeds has filed a $6 million wrongful death lawsuit against the state of Virginia and the mental health agency that employed an evaluator who saw his son during a psychiatric crisis. In November 2013, Sen. Deeds’ son, Gus, had been brought to an emergency department for evaluation. He was judged to be both psychotic and dangerous, but a bed could not be located for him within the state-mandated 6-hour time frame, and Gus Deeds was released. Soon after, he repeatedly stabbed his father, then took his own life with a firearm.

My knowledge of the case is limited to what has been reported in the media, but as a psychiatrist practicing in Maryland where there are no time limits on locating beds, the story is unthinkable. Why would a very ill and very violent – and perhaps very treatable – young man be released from an emergency department because the gong went off in someone’s ill-conceived game of human “beat the clock?” While I have no inside knowledge of the Deeds’ family tragedy, I do want to talk about the Virginia laws that may have enabled a predictable calamity.

Most psychiatrists are familiar with the practice of psychiatric boarding, or holding a patient in the emergency department for a prolonged period of time because a bed cannot be located on a psychiatry inpatient unit. It’s not unusual for EDs to take many hours, or even several days, to transfer psychiatry patients to treatment units. In some places, it can take even longer. In Vermont, where the state hospital was demolished by a tropical storm, there were instances when patients remained in the ED for up to 6 weeks. On Native American reservations without hospital facilities, very ill psychiatric patients may be housed in jails, again for weeks, while an appropriate hospital bed is located off the reservation. Boarding is, by any measure, inhumane, and in 2014, the Washington state Supreme Court ruled it unlawful, though it did not say exactly where the patients were to be held pending bed availability.

With the civil rights of patients in mind, there is something to be said for mandating that beds be located for patients in a timely manner, and for the patient who is distressed, 6 hours may seem to be quite a long enough time. A drop-dead time, however, leaves no room for unforeseen issues, or even for the possibility that medication could be administered in the ED that might avert the need for an involuntary admission. A time limit of this type forces an immediate decision before a thoughtful assessment can be done and other interventions can be explored. In 2014, as one response to the Deeds’ family tragedy, the law was changed to lengthen the period to 8 hours.

In Virginia, the logistics of admitting a patient are more complex than in most states. Any citizen who is concerned about another person’s mental state and safety can apply to a magistrate for an emergency custody order. The patient is then transported by the sheriff, and the clock starts ticking on the 8-hour time frame. In the ED, the patient is seen by the emergency physician, but regardless of how obviously ill and dangerous the patient is, the physician has no authority to involuntarily admit a psychiatric patient. An outside agency – a local community service board (CSB) – is contacted, and an emergency services staff person is summoned to evaluate the patient, perform preadmission screening, and locate a bed.

Virginia is divided into 41 catchment areas, each served by a community service board. Each CSB is required to have crisis staff who assess patients for civil commitment. Virginia is a state with both urban and rural areas consisting of nearly 43,000 square miles. While the CSB prescreener drives in, performs the evaluation, and searches for an available bed, the clock continues to tick.

The qualifications to be a screener are not precise. The website in the county where Gus Deeds lived advertises: “QUALIFICATIONS: Master’s Degree in human services related field, mental health and/or substance abuse experience; or equivalent combination of education and experience including BSN RN’s with Psychiatric Nursing experience in outpatient or inpatient settings. Extensive knowledge of the DSM, mental health and substance abuse assessments, treatment, crisis assessment and intervention strategies for clients of all ages; must be certified or eligible to be certified as a prescreener by the CSB and Virginia DBHDS” (Department of Behavioral Health & Developmental Services). The prescreener has the authority to override the ED physician and release a patient the physician believes should be admitted.

 

It’s not uncommon to hear people compare the treatment of an acute myocardial infarction to the treatment of an agitated psychosis, especially when the topic of parity is raised. Could one imagine a scenario where an ED physician could not admit a patient with chest pain without first waiting hours for an outside consultant to come – a consultant who was not even a physician? Presumably, this is not an issue meant to defy parity but to prevent financial conflicts of interest in situations where patient civil rights are a sensitive concern.

Given all the obstacles, what’s surprising is that the vast majority of the time, if it’s determined that a patient needs involuntary admission, a temporary detention order (TDO) is issued and a bed is located. A study done in 2013 looked at the outcome of TDOs issued in a 3-month period. Of an estimated 5,000 TDOs, beds were located for 98.5% of the patients. Still, 72 patients who had been found to be in need of admission were released because beds could not be found before the emergency custody order expired. The practice of releasing patients in crisis has been assigned its own jargon: “streeting.” It’s not quite that simple, however: Not everyone was released as the gong struck. In 273 instances, patients were admitted after the TDO expired, with an average time to admission of just over 16 hours.

A major issue is that Virginia, like nearly all states, has a shortage of psychiatric beds. In Virginia, the problems may be unnecessarily complex with the added requirement to pull in an outside agency and not leave admission decisions to ED clinicians, coupled with a short time limit for transport, treatment, and admission of a complex, sometimes dangerous patient population. According to the Post article, the Deeds suit is particularly troublesome, because beds were available: The CSB prescreener did not call every available hospital, and he attempted to contact one nearby hospital by fax. The fax number he had was wrong, so the request for the bed was never received by the facility. But the facility did, in fact, have a bed. What hasn’t been legislated is how fast a screener needs to drive to the hospital, or how fast he or she is expected to dial for beds, or what happens if he gets a flat tire or if the responses don’t come fast enough.

Tragedy often leads to change, and laws in Virginia changed after the Virginia Tech shootings, and again after the Deeds’ family tragedy. Legislative gaps remain, however, and bed shortages, time limits, and the requirement for an outside agency assessment continue to leave room for the possibility of more tragedy. Clearly, there is more to be done.

With thanks to Dr. Anita Everett for her consultation.

Dr. Miller is coauthor of the forthcoming book, “Committed: The Battle Over Involuntary Psychiatric Care.”

Last week, the Washington Post reported that Virginia state Sen. Creigh Deeds has filed a $6 million wrongful death lawsuit against the state of Virginia and the mental health agency that employed an evaluator who saw his son during a psychiatric crisis. In November 2013, Sen. Deeds’ son, Gus, had been brought to an emergency department for evaluation. He was judged to be both psychotic and dangerous, but a bed could not be located for him within the state-mandated 6-hour time frame, and Gus Deeds was released. Soon after, he repeatedly stabbed his father, then took his own life with a firearm.

My knowledge of the case is limited to what has been reported in the media, but as a psychiatrist practicing in Maryland where there are no time limits on locating beds, the story is unthinkable. Why would a very ill and very violent – and perhaps very treatable – young man be released from an emergency department because the gong went off in someone’s ill-conceived game of human “beat the clock?” While I have no inside knowledge of the Deeds’ family tragedy, I do want to talk about the Virginia laws that may have enabled a predictable calamity.

Most psychiatrists are familiar with the practice of psychiatric boarding, or holding a patient in the emergency department for a prolonged period of time because a bed cannot be located on a psychiatry inpatient unit. It’s not unusual for EDs to take many hours, or even several days, to transfer psychiatry patients to treatment units. In some places, it can take even longer. In Vermont, where the state hospital was demolished by a tropical storm, there were instances when patients remained in the ED for up to 6 weeks. On Native American reservations without hospital facilities, very ill psychiatric patients may be housed in jails, again for weeks, while an appropriate hospital bed is located off the reservation. Boarding is, by any measure, inhumane, and in 2014, the Washington state Supreme Court ruled it unlawful, though it did not say exactly where the patients were to be held pending bed availability.

With the civil rights of patients in mind, there is something to be said for mandating that beds be located for patients in a timely manner, and for the patient who is distressed, 6 hours may seem to be quite a long enough time. A drop-dead time, however, leaves no room for unforeseen issues, or even for the possibility that medication could be administered in the ED that might avert the need for an involuntary admission. A time limit of this type forces an immediate decision before a thoughtful assessment can be done and other interventions can be explored. In 2014, as one response to the Deeds’ family tragedy, the law was changed to lengthen the period to 8 hours.

In Virginia, the logistics of admitting a patient are more complex than in most states. Any citizen who is concerned about another person’s mental state and safety can apply to a magistrate for an emergency custody order. The patient is then transported by the sheriff, and the clock starts ticking on the 8-hour time frame. In the ED, the patient is seen by the emergency physician, but regardless of how obviously ill and dangerous the patient is, the physician has no authority to involuntarily admit a psychiatric patient. An outside agency – a local community service board (CSB) – is contacted, and an emergency services staff person is summoned to evaluate the patient, perform preadmission screening, and locate a bed.

Virginia is divided into 41 catchment areas, each served by a community service board. Each CSB is required to have crisis staff who assess patients for civil commitment. Virginia is a state with both urban and rural areas consisting of nearly 43,000 square miles. While the CSB prescreener drives in, performs the evaluation, and searches for an available bed, the clock continues to tick.

The qualifications to be a screener are not precise. The website in the county where Gus Deeds lived advertises: “QUALIFICATIONS: Master’s Degree in human services related field, mental health and/or substance abuse experience; or equivalent combination of education and experience including BSN RN’s with Psychiatric Nursing experience in outpatient or inpatient settings. Extensive knowledge of the DSM, mental health and substance abuse assessments, treatment, crisis assessment and intervention strategies for clients of all ages; must be certified or eligible to be certified as a prescreener by the CSB and Virginia DBHDS” (Department of Behavioral Health & Developmental Services). The prescreener has the authority to override the ED physician and release a patient the physician believes should be admitted.

 

It’s not uncommon to hear people compare the treatment of an acute myocardial infarction to the treatment of an agitated psychosis, especially when the topic of parity is raised. Could one imagine a scenario where an ED physician could not admit a patient with chest pain without first waiting hours for an outside consultant to come – a consultant who was not even a physician? Presumably, this is not an issue meant to defy parity but to prevent financial conflicts of interest in situations where patient civil rights are a sensitive concern.

Given all the obstacles, what’s surprising is that the vast majority of the time, if it’s determined that a patient needs involuntary admission, a temporary detention order (TDO) is issued and a bed is located. A study done in 2013 looked at the outcome of TDOs issued in a 3-month period. Of an estimated 5,000 TDOs, beds were located for 98.5% of the patients. Still, 72 patients who had been found to be in need of admission were released because beds could not be found before the emergency custody order expired. The practice of releasing patients in crisis has been assigned its own jargon: “streeting.” It’s not quite that simple, however: Not everyone was released as the gong struck. In 273 instances, patients were admitted after the TDO expired, with an average time to admission of just over 16 hours.

A major issue is that Virginia, like nearly all states, has a shortage of psychiatric beds. In Virginia, the problems may be unnecessarily complex with the added requirement to pull in an outside agency and not leave admission decisions to ED clinicians, coupled with a short time limit for transport, treatment, and admission of a complex, sometimes dangerous patient population. According to the Post article, the Deeds suit is particularly troublesome, because beds were available: The CSB prescreener did not call every available hospital, and he attempted to contact one nearby hospital by fax. The fax number he had was wrong, so the request for the bed was never received by the facility. But the facility did, in fact, have a bed. What hasn’t been legislated is how fast a screener needs to drive to the hospital, or how fast he or she is expected to dial for beds, or what happens if he gets a flat tire or if the responses don’t come fast enough.

Tragedy often leads to change, and laws in Virginia changed after the Virginia Tech shootings, and again after the Deeds’ family tragedy. Legislative gaps remain, however, and bed shortages, time limits, and the requirement for an outside agency assessment continue to leave room for the possibility of more tragedy. Clearly, there is more to be done.

With thanks to Dr. Anita Everett for her consultation.

Dr. Miller is coauthor of the forthcoming book, “Committed: The Battle Over Involuntary Psychiatric Care.”