Negotiated Rates: What No One Talks About in Health Care Legislation

Last week, the House of Representatives passed legislation for the American Health Care Act, the first step in repealing the Affordable Care Act, or as some would call it, Trumpcare versus Obamacare.  The American Psychiatric Association and the American Medical Association (and many other medical societies) oppose the new legislation.  An enormous concern is that the new legislation won't require insurance companies to cover preexisting conditions, or require coverage for mental health treatment or prenatal/maternity care.  Over the coming years, the new legislation is predicted to leave 24 million more Americans without health insurance coverage.

There are many criticisms of the ACA, one being that it forces people to pay for care for illnesses that they don't have and many will never get.  I'm not sure why no one talks about policies where people can opt out of having coverage for cancer. Cancer is a very expensive disease, and not everyone gets it.  If you believe you're at low risk, why should you have to foot the bill for someone's lung cancer any more than you should have to foot the bill for your neighbor's episode of depression?  

Sarcasm aside, I wanted to talk about something that I don't see discussed anywhere.  One huge and accurate criticism of the ACA is that premiums are high and deductibles are high.  I'm not a fan, and it leaves people angry that they pay so much for health insurance and get so little out of it.  But there is something missing in this discussion: if a person has health insurance and they see a doctor, have a procedure, have a lab test done, or get a scan, then the cost to the patient is the cost that has been negotiated by the the health insurance company, and it's remarkably lower than the cost to that a person with no health insurance. The craziness of our current health care system is that the people who can most afford to pay for their care are the ones who pay the least.  So the high deductible may mean that a person pays for his own care, and only sees the benefit of being insured if there is a catastrophic illness, but it also means that while paying for that high-deductible care, out-of-pocket care non-catastrophic costs much less than the uninsured person pays.  It's a crazy system where the poor subsidize the rich -- if a hospital will much lower fees from an insured person, why not accept those same lower fees from someone who doesn't have insurance?   Does requiring people to purchase health insurance even out in the end?  Not for those who are healthy: it leaves the "well" subsidizing the "sick," which in my opinion is better than the "poor" subsidizing the "rich." 

No answers here.  I don't believe that health insurance should be allowed to exclude those with pre-existing conditions: it dissuades people from getting care for fear of acquiring this label, and it provides a service that only the healthy or financially comfortable can afford.  It's not even clear to me what defines a pre-existing condition: 23% of women in their 40's take an SSRI, do they all have a preexisting condition?  If you told your doctor you were struggling with stress during a difficult time and she jotted "anxiety" on as a diagnosis once, does that mean you have a condition?

 For catastrophic conditions, the taxpayer ends up with the bill anyway: before the ACA, if your car crashed or you were diagnosed with cancer or you ended up in the ER in a psychotic state, you were treated. Then you went bankrupt and got Medicaid; this didn't help anyone.  If we can pick and choose, like playing Russian roulette with our health, well, I might not want to pay for your prostate cancer treatments any more than you wanted to pay for my maternity benefits, and I've never smoked, so I may be willing to role the dice on not getting lung cancer. Insurance is about diversifying risk. Mental health, addiction, and maternity services need to be part of the deal and you shouldn't get to pick and choose what health conditions you think you might get.  

We need a mechanism beyond employer-based health insurance to care for those who are self-employed or who work at part-time or contractual jobs; we shouldn't have a situation again where someone in a family must work for an institution large enough to provide health benefits.  Our young people today are not all poised to go straight from college to a job with health insurance; continuing family coverage until age 26 for this mostly health group of young people makes sense.  For those in higher income brackets, it may make sense to charge more for family coverage for each adult child over age 21, but I've not seen that option mentioned anywhere.  Finally,  and perhaps most importantly, Trumpcare decreases funding to Medicaid: it denies the poorest among us health insurance, and as Mr. Trump might tweet: BAD! I can't see a way that leaving those who can least afford care uncovered would be cost-effective.

In all fairness, the administrative hassles of the ACA have not been good: they've diverted doctor time away from patient care and we have physician shortages. But perhaps the answer is to fix the troubled legislation that we have, not to start over. Personally, I think we should look to other countries and see if we can figure out what we're doing wrong: the US has the highest health care costs, and our results don't support this, we have the 46th longest life-span.  Not so good for the greatest country on earth.

Roy on the Pros and Cons of Medical Marijuana

Medical marijuana was legalized in Maryland two years ago, and this summer we will be getting our first dispensaries.  Psychiatrists are starting to ask what this means in terms of treating patients.  Roy did a great job summing up some of the research for our colleagues:

Unfortunately, because of the many historical restrictions on research, there is increasing amounts of data available, yet few "facts" to go by ("fact" as in "a thing that is indisputably the case"). These data are often viewed from differing perspectives. Such as absolute vs relative risks. Harm reduction vs harm avoidance. Public health vs criminalization perspectives. Use vs abuse (eg, plenty people use alcohol without abuse it, getting drunk, rotting their liver... same with cannabis).

That being said, the National Academy of Science and Medicine just put out in January a comprehensive (500 pages) report on the health risks of cannabis. I have attached the 3MB pdf file for our MPS readers' enjoyment. They found about 10,000 relevant abstracts to review (leaving out another 10,000 that did not meet their quality review). I was surprised there was that much out there. 

I'll boil it down to the Executive Summary level. Their major conclusion appears to be that, essentially, we need more research. Beyond that, they divided up additional findings based on the strength and quality of the research:

Strongest evidence:

There is conclusive or substantial evidence that cannabis or cannabinoids are effective:

• For the treatment of chronic pain in adults (cannabis) (4-1)
• As antiemetics in the treatment of chemotherapy-induced nausea and vomiting (oral cannabinoids) (4-3)
• For improving patient-reported multiple sclerosis spasticity symptoms (oral cannabinoids) (4-7a)

Moderate evidence for:

• Improving short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, fibromyalgia, chronic pain, and multiple sclerosis (cannabinoids, primarily nabiximols) (4-19)

Limited evidence for: 

• Increasing appetite and decreasing weight loss associated with HIV/AIDS (cannabis and oral cannabinoids) (4-4a)   
• Improving clinician-measured multiple sclerosis spasticity symptoms (oral cannabinoids) (4-7a)
• Improving symptoms of Tourette syndrome (THC capsules) (4-8) 
• Improving anxiety symptoms, as assessed by a public speaking test, in individuals with social anxiety disorders (cannabidiol) (4-17) 
• Improving symptoms of posttraumatic stress disorder (nabilone; a single, small fair-quality trial) (4-20)

Limited evidence of a statistical association between cannabinoids and: 

• Better outcomes (i.e., mortality, disability) after a traumatic brain injury or intracranial hemorrhage (4-15)

The above is from the first page of about 10 pages of summary findings, including findings of both benefit and risk that are in the Exec Summary of the document. If still interested, turn to pages 13 to 22 to read the rest. And dive deeper if you are really interested. 

As for patient education, I think one could turn these 10 pages into maybe 2 pages of "here is what we know and here is what we don't know". Of course, where one draws the dividing line is arbitrary, but start with those things that have the strongest evidence, with benefits on the left and risks on the right.

Then people make up their own mind, like anything else... a risk/benefit discussion. Would you risk liver failure for headache relief? Here's two Tylenol (or four or six).

Sorry if you were looking for a simple answer.

Guest Poster Dr. Maher on Dealing with Changes in Psychiatry Through the Years (But Especially Now)

Obviously, psychiatry has changed over time. We've gone from a field where treatment was mostly psychotherapy-- I'll purposely omit insulin shock, leeches, and lobotomy-- to one of symptoms, prescriptions, and side effects, as though these things occur outside of the context of a person's life.  Ah, you've heard me rant before.  And like all of medicine, it's no longer just about treating patients, it's about checking the right boxes, coding what happened in the session by the minute, those damn CPT codes, and now about the technology and the hits your fees take if you won't e-prescribe, file PQRS (?huh) data, and practice the way the insurers want, if you choose to accept insurance or work for an agency that does.  With all that in mind, I saw this lovely and angsty post on Facebook, and asked the author to join Shrink Rap as a guest poster.  I was so pleased when Dr. Maher said yes.  Her guest post is below.
------

 I'll be 65 next month, I will have been in private practice for nearly 40 years, and I'm trying to decide where to go from here. If you have time, would you help me think through this difficult decision?
I trained in a time and a place when psychiatric treatment, other than for the severe mental illnesses, was about psychoanalysis. Even if you didn't go on for analytic training (which I did, right after residency, at one of the most classical institutes in NYC), your primary goal was to search for and speak to the complex humanity of the other. My 4th year psychopharm course was optional.

Yes, the classical model was flawed in significant ways, but over time I took what I needed from it, I owned it and I loved it.
Then prozac arrived on the scene and I woke up in a different profession. No longer was it about meaning and humanity and insight into who you are, how you got to be that way, and the unconscious forces that led you to get in your own way. No longer was transference the mechanism of action. My field became about symptom constellations, drugs and/or skills to fix what was wrong with you.

This perspective always felt wrong to me, but over time I came to integrate the parts that felt right with the work I was trained to do, and it worked pretty well. I have a very good practice, partially private pay and partially insurance based. Aside from Medicare (helpful when some of your patients have been with you for 30 years), the other insurance I accept is the one that the NYC Dept of Education uses. Many of my patients are teachers, so their psychopathology falls within a range that I'm comfortable treating.

Once long ago, that insurance company called and asked me to take a patient off their hands. She was a paranoid, depressed, obsessional, suicidal, entitled, angry and litigious woman who fired every psychiatrist she saw, called the plan daily and threatened to sue everyone she spoke to. I told them I would only take her if I could see her 4 days/week indefinitely, no questions asked. They said yes, and she never bothered them again.

They left me alone after that. I've seen some people weekly for years without being bothered.

But times are changing, yet again. No one would remember me from that time. No one would bend the rules to allow a shrink with dynamic understanding to engage a patient like that. The billing, coding and documentation requirements, and the medical complexities, are becoming more than I feel comfortable with. I'm finding it increasingly hard to integrate the complex, struggling human being that I see with the symptom and treatment picture that I'm required to see.

I've moved into other arenas, including a not-for-profit organization, documentary filmmaking, and the development of an emotional literacy curriculum for young people. But there's no money involved in any of them. They cost money.

I love my work and I love my patients and I think they benefit from working with me. I know what I know and I know when to refer to to ask for help. When I do psychodynamic "talk therapy" (I hate when they call it that!!), I'm doing something very complex, something I'm very well trained for. But there's no code for that and very little respect for it, and I live in fear of being audited.
If you've read this far, thanks so much. I'd be grateful to hear your reactions.

Committed has a Website

http://www.committedbook.com/

You are cordially invited to visit CommittedBook.com to read about our book on involuntary psychiatric care.  There are links to reviews, radio shows, and some stuff about us and where we'll be speaking.

I hope you like the new website.

And while I have your attention, I'd like to send you to a personal essay in the New England Journal of Medicine by Dr. Adam Hill.  He talks about fighting stigma and his own struggles with depression and alcoholism.  My kudos to Dr. Hill. Medicine is not a gentle world and I admire his bravery in making his struggles so public.

Really? Can't we be nicer? Objecting to sending those in mental health crisis directly to jail.

Hi, it's been a while.  I have been ranting in other venues, and caught up a bit in the All-Trump-All-The-Time phenomena.  

So my latest thing to rant about is hospitals that send patients to jail when they don't have beds.  I don't mean people who've committed crimes, I mean people who are in crisis, who are presumed to be a danger to themselves or others.  Here are some of my thoughts:

On Psychology Today's website, I wrote "A simple solution to the bed shortage? Unfortunately, Jail"  The link to that is Here.
Over on Clinical Psychiatry News, I did a little more research on the topic and spoke with the reporter, one of the doctors, and the Rapid City Sheriff. See "Mentally Ill? Go Directly to Jail"
The link to that is HERE.

But I've learned that it's not just in Rapid City, South Dakota where it's an issue -- oh, and the sheriff there is apparently refusing to take these patients -- but other states have these issues as well.  My friend, Pete Earley the mental health advocate has been kind enough to share my outrage HERE. 

On Facebook, I've noted:

When we submitted our book proposal for Committed, our editor told us we had to take a stance and the message had to be something more than be kind to patients. Lately, I'm thinking that "Be kind to patients" is not such an obvious thing in our crazy world. Last week, I wrote an article about a hospital in Rapid City SD that announced their overflow psychiatry patients would be held in jail (--I researched the article after I first saw it on this FB page, so thank you to the poster). Today I read that in 6 states people in mental health crises can be (and are) held in jail when there are no hospital beds available. These are not people who have committed a crime. Why, as a society, don't we think this is unconscionable? Could you imagine going to the hospital for pneumonia, being told there were no beds so you were going to jail? Why is jail ever an alternative to health care? What is wrong with us?

Colorado would outlaw using jails for mental health holds, increase services under $9.5 million proposal denverpost.com

 Mostly I've been surprised at how little outrage there is, though I hear the APA is now writing an action paper to oppose jailing psych patients. Will that help? Does anyone read APA action papers?  Commenters say, well, most mental health care is given in jail (and, sigh, we seem to accept that as okay), but this is different: these are not people who've committed a crime, these are patients going to an ER for help!  They haven't broken a law, they aren't under arrest.  Advocates want to increase laws to make it easier to force care, how about making it easier to access care in a humane and kind way?

Still More on Guns and Mental Illness

The issue with mental illness and guns is so hard to explain to people. While there have been mass shooters with mental illness, in very few cases does the "mental illness" serve to explain what happened, and statistically, you should be much more worried about being killed by your spouse, the car next to you on the highway, that extra pain pill you take (especially if you take it with a sleeping pill or a drink), than you ever should be about a mentally ill mass shooter in a public place. Where the numbers of gun deaths rise is when you mix guns with substance abuse, especially in people prone to violence, anger, and impulsive actions; suicide (where people sometimes take action within minutes of making a now-irreversible decision); or accidental deaths where people are careless (which may be higher in people with cognitive problems or who are abusing substances). 

I had an editorial on a proposed repeal of a gun law this week, and the Chicago Tribune wrote on the same issue. Note their emphasis on mass shootings (none of which pertained to this ruling as none of the shooters received Social Security Disability Payments) and it didn't explain why someone would be on disability and might need a payee. Mine was not about violence but about common sense. Obviously I like mine better, but compare and see what you think, same issue, different arguments:
 

Guns and mental illness: Don't scrap this rule

If someone has a mental illness severe enough that he cannot work or manage his own money, should he be allowed to own a gun?

chicagotribune.com|By Editorial Board

Assorted Frustrations, Plus a Book and TV Series Review

I've been finding the world to be a frustrating place, and when I'm frustrated, I write.  It could be worse.  I've written a lot this week.  

First I'll send you to a commentary piece I wrote for the Wall Street Journal asking the Senate not to repeal a ruling that prohibits those who are both disabled by chronic, severe, mental illnesses and are unable to manage their finances (often because they are cognitively impaired or have poor judgement.  I would not have concocted nor supported this original ruling under the Obama administration because I don't think mental illness and gun legislation mix, but given that it exists, it's a pretty low bar.  But mostly, I hate that the NRA has the power that it does in our country and that tens of thousands of people die from firearms each year. See: Don't Repeal Obama's Modest Gun Limit.  
If you need to get around the paywall, try going through our Facebook page to the Link: https://www.facebook.com/shrinkrapbook/

For a bit of a break, I reviewed Patrick Kennedy's wonderful memoir A Common Struggle, in the same article with the dark comedy Showtime TV series, Nurse Jackie -- an odd combination, but they are both about addiction.  See Nurse Jackie and Patrick Kennedy.

And finally, I want to rant about using jails INSTEAD of medical facilities for psychiatric patients.  I'm containing my outrage (or perhaps I'm not), but when we hear about correctional facilities being the biggest providers of psychiatric care in this country, we do assume that the people that are being housed there have either committed a crime or are suspected of committing one with pending charges.  Read my short article on Psychology Today about own hospital in South Dakota now sends their overflow psychiatric patients to the local jail.  These are not people who have committed any crime.  In what alternate universe is this okay?   So much for controlling my outrage.
See: https://www.psychologytoday.com/blog/committed/201702/simple-solution-the-bed-shortage-unfortunately-jail

 And while I'm ranting about this, please see Pete Earley's blog about a man who stole $5 worth of candy then spent 101 days in jail waiting for a bed at a state hospital.  His jail term ended when he starved to death his jail cell.  We can do so much better.  

Thanks for listening. 

Breaking Heroin's Grip: a documentary by Maryland's Department of Health and Mental Hygiene

Breaking Heroin’s Grip: 

Road to Recovery

Airing Saturday, February 11 at 7pm

Breaking Heroin's Grip: 
Road to Recovery is a
poignant and personal
 documentary shedding
 light on our region’s
pressing heroin problem.

 Told through the lens of adults that have
 experienced heroin’s grip first-hand, viewers
will get an authentic look inside the complexities
 of this harrowing epidemic.

The program includes a 40-minute documentary
followed by a 20-minute live phone bank offering
viewers expert information about treatment. The
documentary is produced by Maryland Public
 Television in partnership with the
Maryland Department of Health and Mental Hygiene.
The program will be simulcast by numerous broadcasters
 (both TV and radio) in Maryland, as well as surrounding states.

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WBAL-TV / Baltimore, MD Channel 11

WBAL-AM / Baltimore, MD Channel 1090

WJZ-TV / Baltimore, MD Channel 13

WYPR-FM / Baltimore, MD Channel 88.1

WMAR-TV / Baltimore, MD Channel 2

WJZ-FM / Baltimore, MD Channel 105.7

WNUV-TV / Baltimore, MD Channel 54

WLIF-FM / Baltimore, MD Channel 101.9

WRDE-TV / Lewes, DE Channel Comcast 9, 209, 809,
       Direct TV and Dish Network 31, Over The Air 31.1

WOLB-AM / Baltimore, MD Channel 1010

WHAG-TV / Hagerstown, MD Channel 25

WWMX-FM / Baltimore, MD Channel 106.5

WMDT-TV / Salisbury, MD Channel 47

WHFC-FM / Bel Air, MD Channel 91.1

WHUT-TV / Washington, DC Channel 32

WJEJ-AM / Hagerstown, MD Channel 1240

WUSA-TV / Washington, DC Channel 9

WPTX-AM / Lexington Park, MD Channel 1690

WITF-TV / Harrisburg, PA Channel Digital: 36 (UHF)
       Virtual: 33 (PSIP)

WITF-FM / Harrisburg, PA Channel 89.5

WTHU-AM / Thurmont, MD Channel 1450

WMPH-FM / Wilmington, DE Channel 91.7

WKHS-FM / Worton, MD Channel 90.5

WRNR-FM / Annapolis, MD Channel 103.1

WOL-AM / Washington, DC Channel 1450

WNAV-AM /Annapolis, MD Channel 1430

WPRS-FM / Washington, DC Channel 104.1

What's In Committed? So Glad You Asked....

It's Sunday night, so I'm hopeful that our new president is watching TV and not signing any new executive orders that re-shape our democracy.  Seems like a good time to tell readers a little more about Committed, and what better way then by posting the Table of Contents?  Each chapter focuses on a story, and the tales of the two patients weave their way throughout the discussion of a variety of issues.  Okay, so the topics might be boring to everyone but the most interested of readers, but we hoped that by focusing on people, that it would make this important and controversial topic more approachable.  Psychiatry? Yes, but perhaps more so ethics and patient rights.  

In a review in Psychiatric Times last week, Dr. Mark Komrad wrote:

Drs. Dinah Miller and Annette Hanson, both seasoned clinicians who have worked in a diverse range of settings, have produced one of the most important and readable contributions to this discussion that I have encountered. This is actually a book on psychiatric ethics, but it is presented in a disarming, journalistic style. The ethical tensions with which this issue is loaded are unpacked in a clear, accessible way, articulating not just the questions, but also offering sensible and realistic conclusions.

Ah, but I promised the Table of Contents, so if you'll forgive the funky colors,  pasted below:

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© 2016 The Johns Hopkins University Press

Foreword by Pete Earley

Before We Get Started 

 Part 1 THE PATIENTS 

1 Eleanor and the Case against Involuntary Hospitalization 

2 Lily and the Case for Civil Commitment 

Part 2 THE BATTLEGROUND 

3 In Favor of Involuntary Treatments 

E. Fuller Torrey and the Treatment Advocacy Center ; Ronald Honberg and the National Alliance on Mental Illness; Paul Summergrad and the American Psychiatric Association ;

4 Against Involuntary Treatments 

Citizens Commission on Human Rights; Celia Brown, Janet Foner, and MindFreedom International ; Daniel Fisher and the National Empowerment Center ; Ira Burnim and the Bazelon Center for Mental Health Law 

Part 3  CIVIL RIGHTS 

5 Eleanor, Lily, and the Process of Civil Commitment 

6 Christina Schumacher and the History of Civil Commitment Laws 

Part 4  THE HOSPITAL 

7 Scott Davis on Law Enforcement and Crisis Intervention Teams

8 Leonard Skivorski and the Emergency Department

9 Eleanor’s Hospital Experience

10 Ray DePaulo and Inpatient Psychiatry at a University Hospital 

11 Steven Sharfstein, Bruce Hershfield, and Free-Standing Psychiatric Hospitals 

12 Annette Hanson and the Use of Seclusion and Restraint 

13 Anthony Kelly and Involuntary Medications

14 Jim and Involuntary Electroconvulsive Therapy

Part 5 INVOLUNTARY OUTPATIENT COMMITMENT 

15 Marsha and Outpatient Civil Commitment

16 Outpatient Commitment on the Books 

17 Jack Lesser and Mental Health Courts

Part 6   A DANGER TO SELF OR OTHERS 

18 Dan, Guns, and Mental Illness

19 Bryan Stanley, Violence, and Psychiatric Illness 

20 Amy and Involuntary Treatment for Suicide Prevention 

21 Will Forcing Treatment on People with Psychiatric Disorders Prevent Mass Murders?

Part 7. FUTURE DIRECTIONS 

22 Transforming the Battleground

 

The Answer to the Problem of Violence & What I learned at #WomensMarchinWashington

Yesterday, I was among the 1% or more the US population to show up at one of the Women's Marches. These weren't just in the US, but worldwide .  



If you ask me what I was marching for, I'd have to say it was an act of personal catharsis, a statement in favor of human rights, and an opposition to many of the things that our new president has said he intends to support.  I've long ago come to peace with the idea that many people have different political ideas than I do, and that is not what defines who I associate with (or even marry).  But what I haven't been able to come to peace with is our new president's lack of kindness.  My sign, made with every bit of knowledge I gathered from my public school art classes (thank you, Mr. Trogler), and a couple of YouTube videos on 'how to make a sign' videos, but no natural artistic talent,  simply said, "Make America Kind Again."  Please, this has no deep philosophical meaning, take it at face value. And if kindness is too much to ask, then simply the wish that we would not expend energy to be actively unkind-- the Jewish version of "Do not do unto others that which you would not have done to you."  

There are just  too many stories where our new president puts his

efforts into being unkind, towards women, towards the disabled, towards immigrants, towards minorities, and towards those with less fortunate beginnings than his own.  I'll leave it to others to talk politics, I'm putting in my vote for kindness.

So what can I tell you about the Women's March in Washington yesterday.  
--It was crowded.  It was really crowded, as was the metro.  
--There were lots of people in pink hats.
--There were lots of people with lots of issues.  While many had issues pertaining to women, and I particularly liked "Let's talk about the elephant in the womb" with a little Republican symbol elephant inside a drawing of a uterus, there were many other issues represented, including climate change, health care, education, gun control, immigration, equality for all, and the list marches on.  --There were many angry posters (sorry, I don't think F*ck Trump accomplishes much) and many posters about love.  I was a bit amused that people with angry signs or wrapped in tape that bore obscenities asked to photography my Make America Kind Again sign.  And some of my friends were wearing Nasty Women shirts; not much for consistency, but they aren't actually nasty women (in fact, they are all quite nice).
--It was civil. 
--In fact, it was kind.  On the jammed metro on the way back, I asked a friend if she had a piece of gum; when she didn't, a stranger gave me a piece.  We argued over who would take the empty seat.   ("you take it...") when one became available.  The packed people all moved for cars, for people in distress, for those with young children. 
--People jeered outside the Trump Hotel.  I didn't witness anyone throwing anything, charging the gates, or behaving badly.  Judge the jeering as you will.
--There were lots of men.
--In Baltimore, 5,000 people gathered.  I'm not aware that there was any violence.  This is a city where there are shootings at birthday parties for toddlers, and where peaceful protests have turned into full-scale riots that make national headlines.  Yet thousands of distressed people gathered to protest without event!  I wish I could tell you that no one died a violent death in Baltimore yesterday, but I can't; just not at the women's march.
--A colorful sign is a very useful way to keep a group from getting dispersed at a huge rally.

There were over 600 marches worldwide.  I don't know that there was no violence, but it seems that riots didn't make the news.  These were people who were angry about many issues and our new administration.  But they were also women, or people supporting women, and the fewer men, the less the likelihood of violence.  Obviously, the vast majority of men are not violent, and I don't want you to walk away thinking that I believe that men are violent, but for whatever reason (cultural conditioning, less testosterone?), women, as a demographic, are much less so. 

I would have said this before-- and there is no way anyone wants to hear it-- but if you want to end gun deaths and mass murder, there is a simple solution.  Stop talking about mental illness and keep guns out of the hands of men. 

I was glad I was there.  I hope our president gets a message that his plans are not as popular as he'd like them to be. And I hope he strives for kindness. 

Another Mass Murder Spurs Many Responses

Almost two weeks ago, it happened again: a man with a history of psychiatric symptoms opened fire and killed people in the Fort Lauderdale airport.  In our book, Committed, we have researched and written about mental illness and violence, guns, and specifically addressed the question of Can Forced Psychiatric Care Prevent Mass Murders?

Pete Earley, on his blog, offers the idea that it would help to change the standard for involuntary care from "dangerous" to "a need for treatment."  You can read Pete's blog, Another Mass Murder With Plenty of Warning Signs: We Need to Address the Dangerous Criteria.

But ClinkShrink doesn't agree with Pete that the issue is one of who we force into care. She says we'd be safer if we took guns from people who exhibit dangerous behaviors, not specific diagnoses. Pete's always up for a good debate, so he asked her to write about her ideas and posted them on Dr. Hanson Offers A Different View About Mass Murder and The Dangerous Criteria.  

I have my own thoughts on all of this.
In Clinical Psychiatry News, I wrote an article directed to mental health professionals in Analyses of Fort Lauderdale Shooting Need a Reset and in the  The Baltimore Sun, an Op Ed article Tragedy Again Spotlights Mental Illness.

There have been so many articles by other people attributing mass murders to everything from terrorism to mental illness to guns to  psychiatric medications. 

 One that stirred me was an article in the Sun-Sentinel by Congressman Timothy Murphy, who drafted the Helping Families in Mental Health Crisis Act (now passed as the Mental Health Reform Act of 2016) as a response to the Newtown tragedy of 2012.  In his Op Ed piece, System Failure: Not Treating The Mentally Ill Has Consequences,  Murphy makes  assumptions about the sequence of events in the Fort Lauderdale shooting that we just don't know.  I responded to his article on Psychology Today in  Laws To Force Treatment Are Not the Answer to Mass Murders.

So if you haven't had enough of us (!) we were on a local NPR

radio affiliate this morning-- Sheilah Kast's On The Record--  talking about our book and you can listen on WYPR's website HERE.

Last night we taped a segment for Forward Motion, a Montgomery County, Maryland television talk show with host Karen Allyn that will start airing at the very end of January and we'll post a link when that is up. 

 And we are enjoying our 15 minutes of fame, even if it's on disturbing, but very important, topic.  As somber as this all is, one thing I don't think we get across is that Committed is about people and their stories, it's not just research and facts, and the book is meant to be accessible and compelling to anyone interested in the topic, not just psychiatrists.

Looking Ahead to APA in San Diego

This May, the American Psychiatric Association's Annual Meeting will be in San Diego.  I'm thinking ahead here, but people often make their travel plans in January, so I'd like to tell you about the talks we'll be involved in and invite you to come listen and participate. 
--------------------
To search for sessions by topic or presenter, go to this link:
http://s4.goeshow.com/apa/annual/2017/itinerary_planner.cfm
 
Session ID: 3019 Symposium
 Outpatient Commitment: A Tour of the Practices Across States
Date: Tuesday, May 23
Time: 8:00 AM–11:00 AM

Speakers:
Chair: Dinah Miller (Maryland)
Presenter: Ryan C. Bell, M.D., J.D. (New York State)
Presenter: Kimberly W. Butler, L.C.S.W., M.S. (New York State)
Presenter: Adam Nelson, M.D. (California)
Presenter: Erin Klekot, M.D. (Ohio)
Presenter: Mustafa Mufti, M.D. (Delaware)
Discussant: Marvin S. Swartz, M.D. (North Carolina)

                           ______________________________

Session ID: 2284  Workshop

Are You a Sitting Duck Online? What You Can (and Can’t or Shouldn’t) Do About—and Avoid in the First Place—Negative Reviews by Patients

Date: Tuesday, May 23

Time: 1:30 PM–3:00 PM

 

Speakers:

Chair: Robert Hsiung, M.D.

Presenter: Paul S. Appelbaum, M.D.

Presenter: Dinah Miller, M.D.

                 _____________________

Session ID: 3010 Symposium

 The Battle Over Involuntary Psychiatric Care

Date: Wednesday, May 24

Time: 2:00 PM–5:00 PM

 

Speakers:

Chair: Dinah Miller, M.D.

Presenter: Roger Peele, M.D. (in favor)

Presenter: Paul S. Appelbaum, M.D. (APA's views)

Presenter: Elyn R. Saks, J.D. (Saks Institute for policy, law, and ethics)

Presenter: Al Galves, Ph.D. (MindFreedom International)

Discussant: Annette Hanson, M.D.

--------------------------
Measurement-Based Care: Using Multidimensional Assessments to Drive Improvements in Outcomes in Integrated Care Settings 
Rapid Fire Talks Focused on Behavioral Care
 May 22, 2017  Room 27
1:30 PM - 1:50 PM

Presenter: Steven R. Daviss, M.D.

Honoring Carrie Fisher

10. On not being defined by your mental illness:

Rene Macura / ASSOCIATED PRESS / Via bphope.com

 

This was my favorite of the 13 things.  If you'd like to read them all on Buzzfeed, go Here.

Helping Doctors Get Help

Every year, roughly 400 doctors and medical students die from suicide.  To put this in perspective, there are roughly 100 medical students in a medical school class, and schooling takes four years: each year in the United States, we lose an entire school worth of doctors to suicide.  For more perspective: there are 141 medical schools and 31 osteopathic schools in the country; educating students takes time, money, and a tremendous amount of resources, and we have a doctor shortage.  Losing a school worth of physicians each year is an awful thing.  Furthermore, surveys have shown that about 30% of medical students have significant symptoms of depression, a percentage notably higher than the general population.

This seems a bit odd: medicine is still a profession that is held in esteem.  People work for years to get into medical school and it's a very competitive process.  Those who have made it are, for the most part, lucky.  Academically, they are the cream of the crop: motivated, hardworking, organized, driven, and among the few who get the privilege of working in a field where you help people and earn good money.  And as someone who treats patients, I will tell you that it truly is an honor to be a doctor and a psychiatrist; I am grateful for the career I've been able to have and for the flexibility and diversity it has afforded me as both a healer and writer. 

So why the high rates of suicide and depression?  The blame has been put on the rigors of training, the demoralization of doctoring, the disappointments and the tremendous stress.  And doctors are people, they  get psychiatric illnesses for the same reasons others do: genetic predispositions, personal losses, stress and a fear of failure, sleep deprivation, or devastation over a bad personal or professional event.  We still don't know why some people are resilient in the face of difficulties and others are not.

And doctors hesitate to get help: after all, mental illness is stigmatized and doctors may be asked about their mental health issues for licensing and for jobs.  I knew one medical student who took Prozac-- it helped with anxiety and irritability, though she never had a full blown episode of disabling depression-- and said so on health forms when she started residency. She had to explain and get documentation that she was capable of working.  Obviously, we don't want someone in the throes of a disabling psychiatric episode treating patients, but we also don't want people to avoid getting care because they might be called out on it, or even lose their license when they have treatable conditions.  It seems it might be better to encourage people with psychiatric and substance abuse disorders to get help rather than to have them treating patients when they aren't at their best or to have them die from suicide. It's a mixed bag, because many psychiatric and substance abuse problems can be hidden, especially by someone who is able to show up at work and function reasonably everyday, and treatment is generally available to this group of professionals in that they have insurance and resources.

The 'stigma' of quiet mental illness is still a bit odd to me.  As a medical student in New York City in the 1980's, psychiatry wasn't just about being mentally ill, it was, to some extent, about self-examination.  Psychiatrists who did psychotherapy were expected to have psychotherapy, and psychoanalysts were required to undergo an analysis.  

As students, we were told that the school had a mental health service which provided an evaluation and 10 visits with a private practice psychiatrist (and then the student could pay for more if they wanted), or treatment with a psychiatry resident for very low fees.  Many of my classmates were very open about being in treatment, and people went because they were stressed, disturbed about relationships, or having more serious psychiatric issues.  During my psychiatry rotation, the chief resident wrote his analytic hours on the board in the nursing station so he would not be disrupted, and I sat in a class where one resident said to another, "Hey Bob's not here because he's starting therapy today."  One of my classmates had a serious suicide attempt and was treated in the ICU.  It wasn't someone I knew very well and I know none of the details.  What I do know is that this classmate graduated and went on to a prestigious residency program.  Google let me learn that my classmate is now, over 25 years later, a physician at a top academic institution.  Today, I'm not sure if that outcome could happen.  

This month, I saw an article in one of the psychiatric newspapers calling on licensing boards not to require doctors to report past episodes of psychiatric illness, only present episodes, in an effort to encourage doctors to get treatment.  Really? Why single out psychiatric disorders?  Shouldn't reporting requirements encompass all disabling disorders?  Do you want your surgeon seizing while he's operating on you?  Or having his blood sugar drop?  Do we really care about the fact of an illness?  Shouldn't we care more about whether it impairs a physician?

So I was pleased to read this month's newsletter from the Maryland Board of Physicians: there was a specific discussion on mental health/substance abuse treatment that noted that Maryland's licensing board asks only about current conditions (including physical conditions) that impair a physician's ability to practice.  It lists some resources for getting care, and notes that this is not the same as mandated treatment in the case where it's come to the attention of the Board that someone has a health issue which obviously impairs them-- one that has been reported by a third party to the Board as being a risk to patient safety.  

So Maryland docs, if you are quietly depressed, anxious, suicidal, or wonder if those happy blips in your mood mean you have bipolar tendencies -- go for it and get help.  Tell who you want, and don't tell who you don't want.  Will decreasing stigma or reporting requirements lower suicide rates?  I hope so.  And finally, if you're in Maryland and need a private practice psychiatrist to see you quickly, don't forget our resource at MarylandPsychiatrists.net where psychiatrists with availability within two weeks may list their practice.  It's a free service for both shrinks and patients.

Home Inspection and Double Billing: Two Kindle Novels for Free, and Happy Holidays to Our Shrink Rap Readers

Happy Holidays!

At this time of year, I like to set up free downloads to two of my novels. You can get these books for free on your Kindle from Sunday to Thursday.

Double Billing is the story of a woman whose life changes when she discovers she has an identical twin. It's a quick read with a little  psychiatry sprinkled in.  One reviewer said:

 The book was a page-turner because of elegant structure and pacing.  I really cared about the author’s take on things –because she is a psychiatrist? because I’ve followed  her blog for a while?– which meant that I was interested in the protagonist’s thoughts, feelings and actions.  At times I ached for the mess her life was in, at others I wanted to shake her into action, and then she’d find her backbone again, just in the nick.  

Home Inspection is a story told through psychotherapy sessions in a format that is similar to the HBO series In Treatment. Dr. Julius Strand is a psychiatrist who plods along in his already-lived life until two of his patients inspire him through their own struggles to find meaning.  One reviewer wrote:

 I like to read all sorts of books, but books where there's something in it that reflects a part of me, a part of my life, a part of my experiences, are something I go out of my way to find. I have not found any fiction book that does nearly as much to show what psychotherapy is like.

There is is a single link to my Amazon page with all my books here. 

If you don't own a Kindle reader, you can install a free Kindle app on your computer, tablet, or cell phone by going here and then you can read any Kindle book. You don't need to buy a Kindle to read on your computer, tablet, or smartphone.

 Both novels are also available as as paperbacks from Amazon, but not for free.  And our two non-fiction books can also be found on that page, but again, not for free.

I'm more than happy to have people download my novels at no cost -- I'll be keeping the doctor day gig -- so please tell/tweet/blog/share the free promotions to anyone you think might be interested.

Finally, If you do read any of the books, please consider putting a review on Amazon.