Sunday, September 29, 2013

A Familiar Story - Another Shooting

The story is familiar and the media writes about it the same way.  A mass shooting and the shooter has anger control problems, social problems, and finally probable symptoms of psychosis.  The "ELF" considerations here were interesting.  ELF is extremely low frequency as specified in this Wiki primer that covers most of the relevant facts.  I grew up about 30 miles away from the original ELF site in Clam Lake, Wisconsin and there were plenty of conspiracy theories and environmental concerns right in the area at the time that surrounded this project including the effect of ELF on the residents.

The usual interviews with politicians about gun access and psychiatrists about whether or not violence can be predicted.  It is a very familiar sequence of events.  The White House is less vocal this time because I think everyone realizes that the government has no interest in solving the problem.  You can click on mass homicide and mass shooting and see my previous posts on the matter for a more complete elaboration.  There seems to be nothing new in the response to this mass shooting other than the question of security at American military installations.

My response is also the same and it is basically the following:

1.  Mass homicide is a public health problem that can be addressed with public health interventions.

2.  Violence and homicide prevention can occur even in the absence of firearm legislation.

3.  Violence and homicide prevention does not require prediction of future events but the capacity to recognize markers of violence and psychiatric disorders and respond to them appropriately.

4.  There need to be accessible speciality programs for the safe assessment and treatment of people with severe mental illnesses and aggressive behavior.  That includes the assessment of threats since they are the precursors to the actual violence.

5.  A standardized legal approach to the problem of the potentially dangerous person and whether or not mental illness is a factor is necessary.

6.  A comprehensive policy that addresses the issues of progressively inadequate mental health funding is necessary to reverse these trends will provide the funding.

All of the above elements require a standardized approach to the care of the aggressive person and there are several clear reasons why that does not happen.  The so-called mental health systems is fragmented and it has been for decades.  It is basically designed to ration rather than provide care.  That is a massive conflict of interest.  Until that is acknowledged by the politicians and advocates nothing will be accomplished.  It is very hard for politicians to acknowledge when they are backing a national agency that essentially endorses rationing and managed care.  You can also compare my writing and suggested solutions to this problem to a recent "call to action" by American Psychiatric Association President Jeffrey A. Lieberman, MD.

How many "calls to action" does the APA need?

George Dawson, MD, DFAPA


  1. Lieberman is such an Obama fanboy after his White House tour that he can't see ACA has nothing to do with this problem. I also think he wants it both ways on the issue of mental health stigma. If you take away their gun rights because of their delusions, you are basically stigmatizing them, but so what? Sometimes you need to stigmatize. This is something most psychiatrists fail to really be honest about. I hear all these platitudes and I ask them a simple question. Would you want to live next to a pedophile? That puts it in perspective.

    The suspect was a "hot" lead. So was the Colorado shooter. So was Hasan. The first should have never gotten a security clearance and the second should have been hospitalized. The third should have been reported by his supervisors after that Jihad grand rounds. Broad based mental health screening for needles in haystacks won't do a think unless the system can handle obviously dangerous individuals.

    1. I think there is a lot of confusion about the term "stigma" or "stigmatizing" and it flows from a basic lack of understanding of violence and aggression. Psychiatrists who treat a lot of violence and aggression generally don't have a problem recognizing that this can be a feature of severe mental illness. Advocacy organizations have the same problem and hence the initial disclaimer that is everywhere about how only a minority of people with mental illness are aggressive.

  2. Did you catch the article in the WSJ last week about integrative mental health care under ACA? The most depressing article I have ever read about psychiatry. Taking care of 500 patients you never met. Under the same malpractice rules. As if this kind of system will identify the dangerous mentally when there is even less individual attention.

    No wonder they got rid of the oral boards. Under today's low standards, there is no reason to examine the patient anymore.

    I really don't know how any ethical psychiatrist over 50 can get behind this kind of thing or be comfortable with this treatment model. I think Lieberman is blinded by politics and magical thinking.

  3. I saw the article and was in the process of developing a post about the fallacy of certainty with a psychiatric checklist. How is it that you can apply it to one of the least reliable diagnostic categories and suddenly you are certain that you have diagnosed depression? As far as getting behind the model. the APA already has (see previous post here ). It will all be part of the "cost savings" in the ACA by further restrictions to psychiatric care. I can't think of a better way to ration than not having you see a psychiatrist at all. This all flies in the face of suddenly needing to treat all of the seriously mentally ill who are threatening or aggressive. There is no consistency. I have always believed that you either do things the right way or not at all.

    There are a couple of other themes here. The ratings scales are being institutionalized as "measurement based care". They are actually showing up in psychiatric CME as a legitimate topic. I have heard that there has been court testimony in some cases that rating scales are the standard of care probably in order to win a legal argument. I guess nobody payed attention in 2000 when the Joint Commission said that a 1->10 pain scale was a quantitative measure of pain.

    The other issue that have posted here is the exposure of people to antidepressants who do not have depression. If we are to believe the FDA and the warnings on citalopram, you would think that there would be an initiative to reduce exposure to antidepressants or at least consider non-medical alternative like computer based psychotherapies that are easily as cost effective, I guess that would not be as advertising friendly to the companies who are advertising these "population based" treatments as a major advantage to mankind.

    Finally the cost effective argument is worn thin. It has really not applied to psychiatry for over a decade. We should consider it irrelevant until we have the kind of infrastructure that Cardiology and Oncology have built up in he last 20 years. I would put that at several trillion dollars.

    1. We're not only down to the bones, the cost cutting in mental health is now deep into the marrow. I remember going to insight oriented talk therapy twice a week as a resident and having a small monthly deductible. When I got into practice in the mid-80s there was overhospitalization of people with character disorders and dysthymia. There really isn't anymore to cut in psychiatry except maybe compounded medication scams. In addition to cardio and oncology (although the cardiologists have been pretty much driven out of private practice already) I would like at back surgery for nonradicular pain or stenosis as a good place to start if you are serious.