Category: Systems

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Policy Systems

Guns, Mental Illness, and Background Checks.

To my knowledge, I’ve only had one “long-term” patient attempt suicide with a gun. [1. I have worked with other people who have tried to kill themselves with guns. They usually report that these attempts had occurred years ago. Other people told me that they owned guns, but had no desire to kill themselves in the time we worked together. Still others owned guns and were struggling with ideas of suicide. Thankfully, we were able to work through this together and these people chose life. Then there are people who own guns and want to kill themselves, but share neither detail with me. I don’t know who they are because I either (1) never meet them in the first place or (2) I never see them again.]

This Person Who Attempted Suicide with a Gun did not show up for an appointment one day. For reasons I could not explain, I had great concerns that This Person had attempted suicide. After leaving several phone messages, I got a phone call from This Person, who was in the hospital.

“I swallowed a bullet,” This Person said.

“What?”

“I don’t know how it happened, but I swallowed a bullet.”

When I later spoke to This Person’s hospital physician, I learned that This Person had not swallowed a bullet. A bullet had gone through This Person’s chest wall, through a lung, and out the back.

I told This Person what I had learned.

“It was my friend’s gun,” This Person said. “I went over when no one was at home.”

The New York Times has a short article about “Why People With Mental Illness Are Able to Obtain Guns“. [2. While the title of this article, “Why People With Mental Illness Are Able to Obtain Guns”, is simply an accurate description of the piece, I still feel annoyed with it. I think my reaction is due to the pairing of “mental illness” and “guns”. There is no reference that most deaths from guns are due to suicide. Where are the articles that pair guns with other conditions? “Why People With Substance Use Disorders Are Able to Obtain Guns”? “Why People With Incurable, Painful Diseases Are Able to Obtain Guns”? “Why People in Financial Ruin Are Able to Obtain Guns”?] One reason offered is “Their Mental Health Records Are Not Accessible”. The author, unfortunately, does not provide much elaboration on this, which alarmed me. Just what records would the FBI National Instant Criminal Background Check System have access to? If it is accurate that about one in five Americans will experience any mental illness in a year, how much private health information will the FBI have access to?

The government released a document, “Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule and the National Instant Criminal Background Check System (NICS)“, that clarifies some of this. The summary from the document notes:

Among the persons subject to the Federal mental health prohibitor established under the Gun Control Act of 1968 and implementing regulations issued by the Department of Justice (DOJ) are individuals who have been involuntarily committed to a mental institution; found incompetent to stand trial or not guilty by reason of insanity; or otherwise have been determined by a court, board, commission, or other lawful authority to be a danger to themselves or others or to lack the mental capacity to contract or manage their own affairs, as a result of marked subnormal intelligence or mental illness, incompetency, condition, or disease. (emphasis mine)

Thus, three populations of people will have their “mental health records” accessible to the FBI National Instant Criminal Background Check System:

  1. people who have been hospitalized against their wills for psychiatric reasons
  2. people who are deemed by a court to be incompetent to stand trial, or the court ruled that they are not guilty by reason of insanity
  3. people who are deemed by a lawful authority to be a danger to themselves or others, or are “gravely disabled” (unable to care for themselves)

The summary adds:

The disclosure is restricted to limited demographic and certain other information needed for NICS purposes. The rule specifically prohibits the disclosure of diagnostic or clinical information, from medical records or other sources, and any mental health information beyond the indication that the individual is subject to the Federal mental health prohibitor.

This offers partial relief, though I still have concerns:

  • What is the “limited demographic” information? Name? Age? Sex? Race?
  • What is the “certain other information”? Country of birth? Political party registration? Contacts with law enforcement in the past year? Religious affiliation?

This Person who “swallowed a bullet” was ultimately “involuntarily committed to a mental institution”. Under Washington State law, This Person lost the right to own a firearm because of the involuntary detention.

As such, I generally agree with the three populations described above in the “mental health prohibitor”. There is data that argues that people who own guns are more likely to complete suicide. There is also data that argues that people are more likely to complete suicide in the first few weeks after discharge from a psychiatric hospital. I would not want This Person to purchase a gun and attempt suicide again.

However, This Person used someone else’s gun in the suicide attempt. Neither Washington State law nor this new Federal rule has relevance.

I don’t know what the answer is.

Increasing the amount of data in background checks may help reduce suicides and homicides. The current implementation, however, may only increase stigma for people with mental health conditions. We want to increase the awareness and acceptance of mental health conditions. We don’t want to increase fear.

It does not appear that banning guns outright is possible. I am also not totally convinced that an outright firearm ban would result in less gun homicides due to some of the reasons listed here. Would a ban on guns decrease suicides? Maybe, as states with firearm registration and licensing regulations seem to have less suicides.

As I have noted elsewhere, a psychiatric diagnosis alone does not explain why people kill other people, whether with guns or other means. Yes, there are sociopaths who kill people, but they are extremely uncommon. Does the mental health of a society affect and shape the mental health of an individual? Does context matter?

If so, how can we as a society help change the context?

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Consult-Liaison Education Funding Medicine Policy Systems

The Value of Psychiatrists.

While slogging through a crappy first draft of a document about the value of psychiatrists in mental health and substance use disorder services, I did a literature search for supporting evidence.

I found nothing.[1. Physicians, as a population, don’t advocate for ourselves as much as we should because we’re “too busy taking care of patients”. This is true. However, our busy-ness creates a vacuum where non-physicians step in and make decisions for us. We then express resentment that we have to follow the edicts of people who have never done the work. If we did a better job of regulating and advocating for ourselves, we might not be in this position.]

“So how exactly are we helpful?” I mused out loud. Maybe we aren’t: There are groups out there who do not believe that psychiatrists can or do help anyone.

I am an N of 1. Therefore, this post is an anecdote, not evidence. Nonetheless:

Psychiatrists provide psychiatric services. These are increasingly limited to only medication management, which is unfortunate. Psychiatrists need psychotherapy skills—or, abilities to connect with people to build trusting and respectful relationships—to do effective medication management. I can write dozens of prescriptions and change doses as much as I want, but if the person I am working with doesn’t trust me, none of my tinkering matters.

When people think about medication management, they often think only of adding medications or exchanging one for another. Medication management also includes helping people come off of medications. This “deprescribing” also requires the use of psychotherapy skills: Some people feel great discomfort when coming off of medications. Sometimes the reasons are physiological; sometimes they’re psychological. Psychotherapeutic interventions and education are necessary in helping people cope with and overcome these discomforts.[2. For any psychiatrists out there: You could build an entire practice around “deprescribing”. This is one of the most common clinical requests I receive through my blog. I don’t have a private practice, so I turn all these people away. To be clear, deprescribing isn’t limited to private practices; I deprescribe in my clinical work in the jail.]

Psychiatrists often have the most clinical expertise. Most have had exposure to the spectrum of psychiatric services (in residency training) and thus have perspective about how systems work (or fail). Thus, psychiatrists can provide clinical consultation about specific patients and program design, implementation, and improvement. One example is the use of medication assisted treatment for substance use disorders. Certain programs or agencies may believe in abstinence only and will view medications as another misused substance. That perspective is not invalid, though giving people more options may help someone reach the goal of abstinence.

Psychiatrists can provide education to other staff to improve their clinical skills, which can elevate the quality of care clients receive across the agency. Psychiatrists can also provide leadership and influence the direction and ethos of a clinical service. For example, you can imagine how a psychiatrist might influence a service if he believes that the only way to help patients is to convince them to take psychotropic medications forever. A different psychiatrist who believes that employment or housing may be more effective than medication for some patients would provide a different influence.

Psychiatrists can triage patients who are in crisis. A roving psychiatrist on the streets or visiting people in their homes often can’t do things like draw blood, but they can assess people and circumstances to determine whether a visit to the emergency department can be avoided. Psychiatrists can also provide strong advocacy: Psychiatrists can work with law enforcement so that people who would be better served in a hospital actually go to the hospital, and not to jail. Similarly, if someone who has a significant psychiatric condition requires medical attention, psychiatrists can talk with hospital staff to advocate for this. Too many of us have stories about our patients who needed medical interventions, but others thought their symptoms were entirely due to psychiatric conditions.

Psychiatrists go through medical training and often have ongoing contact with other medical specialties. They are thus familiar with the practical realities of communication about and coordination of care for patients across systems. While overcoming the financial and policy hurdles to integrate care are important, the reason why integration matters (or, at least why I hope it matters) is to improve the experience for the patient. Administrators should consider the interaction and experience between the physician and the patient as paramount. The system should not sacrifice that relationship to make administration easier.

This is the message that all physicians, psychiatrists or otherwise, need to communicate to administrators. We don’t do ourselves any favors by assuming that people know what value we bring to patients or to the system. Sometimes it also helps to remind ourselves, too, so we can improve our work for the people we serve.

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Lessons Medicine Reflection Systems

Reflections on Psychiatry.

A medical student named Anthony sent me an e-mail and asked:

Are [the items listed below] things that have nagged at you during your training or as a psychiatrist now? How do you deal with the ambiguity of psychiatry, or do you find that as your clinical experience grows, you find yourself more reassured in what you do from seeing your patients improve? Where do you see psychiatry going in the next couple of decades? I understand these are big questions, but I feel it would be incredibly helpful to hear from someone who’s been practicing for a while.

Indeed, these are big questions, but the big questions make us reflect on what we do: What is the point? Why do we bother? Are we doing the “right” thing?

Are these things that have nagged at you during your training or as a psychiatrist now?

The things Anthony listed as frustrations—the primacy of the biological model, the lack of novel and consistently effective medications, the role of medications and pharmaceutical companies, the medicalization of “normal” human experience—resonate with me, too. These things bothered me while I was in medical school, irritated me when I was a resident, and continue to vex me as an attending.

What bothers me the most is how psychiatry can become an agent of social control. Psychiatry can lend its vocabulary and constructs to authorities to oppress or exclude certain populations.

Consider the spate of school shootings. If we label the shooters as “mentally ill”, that distracts from the culture of fear and violence. Homosexuality was a legitimate psychiatric diagnosis until 1973. African Americans are more likely to receive diagnoses of schizophrenia.

Words are powerful. The ramifications of diagnosis are serious. We must not forget how our words can affect how people perceive themselves and how others treat them.

This overlaps with the medicalization of human experience. Is it okay that people receive Xanax from physicians when they are grieving the death of a loved one? Is it okay that students receive Adderall from physicians when they are striving for academic excellence? Is it okay that people from other cultures receive antipsychotic medication from physicians when they report hearing the voices of their ancestors?

My discomfort with this has affected my practice: I purposely choose to work with people who exhibit symptoms that rarely overlap with the general spectrum of human experience. Most people do not believe that someone has stolen their internal organs. Most people do not drink a fifth of alcohol each day to cope with guilt and shame. Most people do not fear that aliens will execute them if they move into housing from the streets.

A natural consequence of working with this population is that advocacy becomes a large part of the work: People with severe conditions can and do get better. Most people enter medicine to help people, to see people get better. The gains in this population may take longer and sometimes may not be as great as in other populations, but they do occur.

How do you deal with the ambiguity of psychiatry, or do you find that as your clinical experience grows, you find yourself more reassured in what you do from seeing your patients improve?

I learned early on that, if I don’t know the answer, the best thing to do is to say, “I don’t know.” It can be hard to say that out loud because we don’t want to admit our ignorance to ourselves or to others. Perhaps the difficulty isn’t the ambiguity of psychiatry. Maybe the challenge is managing our own vulnerability.

This is how I deal with the ambiguity:

  • I remind myself that it is impossible for me—or for anyone—to know everything. That doesn’t mean I give up and walk away: I do the work to learn as much as I can. The learning never stops, even when I want it to.
  • I remind myself that I will mess up. I hope that I will make fewer mistakes as I advance in my career, but I trust that I will screw up. I also hope that I will have the wisdom and humility to learn from my errors and avoid them in the future.
  • I remind myself to “First, do no harm.” I may feel pressure[1. Know that the system will often put pressure on you to “do something”. That doesn’t mean the system is right. Unless someone is dying in that moment, there is always time to stop and think.] to “do” something—prescribe a medication! send someone to the hospital! intervene right now! There is always time to pause and consider: “Will this cause (more) harm?” To be clear, I don’t advocate living life through avoidance. Sometimes the way to navigate ambiguity is to avoid actions that will make things worse.

I’m sure this isn’t the first time you have heard an attending say this: The farther along I go the more I realize how little I know. There is so much more for me to learn.

Where do you see psychiatry going in the next couple of decades?

Experts are much better at describing base rates than they are at predicting the future.[2. This idea about base rates and predictions comes from the book Decisive, which I recommend with enthusiasm.] This is an important question that deserves more reflection. Different ideas spin in my head: Psychiatry will have to reconcile with people who have experienced mistreatment from our field. Psychiatry must examine social determinants of health and scrutinize how they affect diagnosis and treatment. Psychiatry must collaborate with other fields and cannot expect that isolation will actually help patients, our colleagues, or the specialty.

For you (and me) I would add that we cannot expect to influence or change a system if we do not take part in it.[3. Full disclosure: I am not a member of the American Psychiatric Association. My values do not seem to align with theirs. However, who am I to complain about the values of the APA if I’m not willing to help shift them? And how can I contribute to any shift if I do not join them?]

Good questions, Anthony. I encourage you to ask other psychiatrists these same questions. Regardless of which field you choose to enter, I hope you continue to exercise curiosity and healthy skepticism of the work you do. This will not only help you grow as a person and physician, but will also help your patients and field of expertise.

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Education Funding Policy Systems

Jail Costs versus Hospital Costs.

We received the State of Washington Voters’ Pamphlet in the mail today. One of the initiatives, I-1401, concerns “trafficking of animal species threatened with extinction”.

Have no fear: This post is unrelated to trafficking of animal species threatened with extinction.

The “Fiscal Impact Statement” includes a statement about jail costs (highlighted for emphasis):

jailcost

“No wonder why people with psychiatric conditions end up in jail!” I exclaimed. “It’s so much cheaper for them to be there!”

Information about hospital costs are public. This page shares inpatient hospital rates for people who have Medicaid insurance in August 2015. All the hospitals in Washington State are listed in the leftmost column. One of the columns has the title “Psych_ Per Diem”. That column tells you how much money each hospital is paid if a patient with Medicaid is admitted there for psychiatric reasons. First, you will note that hospitals are paid[1. Forgive the passive voice when I write “hospitals are paid”. In Washington, hospitals send bills for Medicaid patients to the state. The state pays the hospital bill. The state then turns around and sends a bill to the region that the patient “belongs” to. The region then pays that state bill. The region gets money to pay that bill from a mix of federal and state Medicaid dollars, which ultimately come from taxpayers. Confusing, right?] different amounts. That alone is fascinating—what accounts for that? who decides how much money each hospital will receive?

More to the point, it costs anywhere between $711.55 and $1788.93 per day for an adult with Medicaid to stay in a hospital. The average cost of incarceration in Washington is $88 per day. Thus, it is at least eight times cheaper for someone to stay in jail than in a psychiatric hospital.[2. This page shares inpatient hospital rates for people who don’t have any insurance. Note that the rates are lower compared to the Medicaid rates. They are nonetheless still much higher than the daily jail rate.]

On the one hand, the differences in cost aren’t surprising: Hospitals often have more staff, equipment, and services. On the other hand, we also know that jails are often the largest psychiatric hospitals in any given region. For example, in Seattle, the jail has about 120 psychiatric beds. The largest psychiatric hospital in Seattle has about 61 beds.

I really want to believe that no one intentionally designed the system this way. Surely no person or system could be so heinous and miserly to funnel people into jail instead of a psychiatric hospital. Right?

Right?

But, then the disgust kicks in: What if the costs were reversed? What if it cost $88 a day for someone to stay in a psychiatric hospital and $712 a day for someone to stay in a jail? Would we see as many people with psychiatric conditions in jail? Of course not.[3. To be clear, we should also help people stay out of psychiatric hospitals, too. Inpatient services should be available if people need them, but let’s focus on prevention and help people stay in their communities. Being in a hospital generally sucks.]

It shouldn’t be all about money, but when the cost differences are that big, money has undue weight. If we actually want to help people with psychiatric conditions, we must pay for services. Otherwise, we will only see more and more of them in jail.

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Education Medicine Observations Systems

Everything Changes, Nothing Changes.

The Mutter Museum Instagram account recently posted this photo:

Thorazine

“Thorazine” is the trade name for chlorpromazine. It is considered the medication that ushered in the “psychopharmacological revolution”, thus allowing some patients to leave psychiatric institutions. (You can read the interesting history of chlorpromazine here. Spoiler alert: It was designed for use in surgery, not psychiatry.)

Chlorpromazine is often touted as the first medication that could reduce symptoms of schizophrenia. Other FDA-approved “psychiatric” uses of chlorpromazine[1. Other FDA-approved uses of chlorpromazine that are unrelated to psychiatry include acute intermittent porphyria; intractable hiccoughs; nausea and vomiting; and tetanus, “adjunct”.] include:

  • Apprehension, presurgical
  • Bipolar disorder, manic episode
  • Problem behavior, severe

I don’t know the context of the ad (who was the intended audience: physicians? patients? husbands?). One wonders why the ad features a woman and puts greater emphasis on “emotional stress”. A hefty dose of chlorpromazine will result in “prompt” sedation that will give someone—perhaps not the patient—”sustained relief” for several hours.

Did physicians in that era tell patients that the original use of this medication was for schizophrenia? Or did physicians focus primarily on the tranquilizing effects of chlorpromazine for those individuals who had more neurotic, not psychotic, symptoms?

Everything changes, nothing changes. Quetiapine (tradename: Seroquel) was also developed for the treatment of schizophrenia. Now, its uses include:

(1) add-on treatment to an antidepressant for patients with major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; (2) acute depressive episodes in bipolar disorder; (3) acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; (4) long-term treatment of bipolar disorder with lithium or divalproex; and (5) schizophrenia.

The header for the page (what shows up on the browser tab) doesn’t even list the drug’s name. It says only “bipolar disorder medication”.

If you search for “Abilify” (generic name: aripiprazole) on Google, the brief summary that shows up under the first link says:

Official pharmaceutical site for this antipsychotic medication indicated for the treatment of schizophrenia.

However, when you actually go to the official website, the listed uses include:

Use as an add-on treatment for adults with depression when an antidepressant alone is not enough
Treatment of manic or mixed episodes associated with bipolar I disorder in adults and in pediatric patients 10 to 17 years of age
Treatment of schizophrenia in adults and in adolescents 13 to 17 years of age
Treatment of irritability associated with autistic disorder in pediatric patients 6 to 17 years of age

Asenapine (trade name: Saphris) also has approval to treat both schizophrenia and bipolar disorder. Should we be surprised if paliperidone (trade name: Invega[2. Does it mean anything that, of the five photos on the landing page for paliperidone, only one of them features white males?]) and iloperidone (trade name: Fanapt) soon also receive FDA approval to treat conditions other than schizophrenia?

This is why skepticism is indicated—nay, essential—whenever people exclaim with confidence that “we” understand the biology of psychiatric conditions. We live in an era where cancer drugs can be designed to interact with specific receptors because scientists have located and studied those specific receptors. That specificity does not exist in psychiatry. If it did, one drug class would treat one condition, not four.

While I am probably more reluctant than the “average” psychiatrist to prescribe medications, I believe that, for some people with significant psychiatric conditions, medications can offer great benefit. First, however, do no harm.

It is frustrating when many in the field of psychiatry insist that the serotonin hypothesis is true when, in fact, it is just a hypothesis that is probably false. Also frustrating are the multiple forces that insist that medications are the primary and sole forms of treatment for psychiatric conditions. What about exercise? Therapy? Diet? Social support?

If medications alone could successfully treat these conditions, wouldn’t the pharmaceutical companies have saved us all by now?