Although the media can certainly pump up the volume on trivia like the DSM-5 their coverage of the critical day-to-day issues involving mental illness continue to be lacking in both depth and breadth. It is weak. From a depth perspective I will point to an article about a man convicted of shooting at people on the I-96 freeway in southeastern Michigan. His reason for the shootings? He thought he was getting coded messages from the Detroit Tigers to shoot people. He also believed that military helicopters were hovering above his home and that his home contained "advanced technologies" that caused his daughter to develop a skin disease and his wife have a miscarriage. The article contains a layman's description of a not guilty by reason of mental disorder defense and that defense was never advanced based on a judges ruling. As a psychiatrist familiar with these criteria there is an overwhelming bias to convict people who are mentally ill and mentally compromised. That is why the defense is generally a failure. In this case the defendant did not have the opportunity to present that defense because as the article explains:
"Diminished capacity is a claim that says a defendant was unable to form specific intent required to commit a crime under the law by reason of mental illness, and as a result, the defendant’s responsibility in the alleged crime is diminished. The judge earlier ruled that the defense could not make this argument because it failed to give proper notice of a defense of insanity."
In other portions of the article we learn that he has been treated for an unnamed mental illness since 2009. The symptoms are described as delusions that respond to medication and the delusions associated with the shooting incidents are currently in remission. When the defendant is asked about whether he knew that firing a gun into an automobile might hurt someone. His response was "In hindsight - yes". I have not seen the final sentencing after a no contest plea but he faces up to 12 years in prison on firearms and assault charges after they decided to drop a terrorism charge.
From a breadth of coverage perspective, I will suggest a second article that points out the critical shortage in acute care inpatient beds with the capacity to address severe mental illness and aggressive behavior. In those case Virginia State Senator Creigh Deeds discusses an incident where his son stabbed him and subsequently shot himself. After the incident Senator Deeds states that the read his son's diary and it said that if he killed his father he would go directly to heaven. In his taped discussion he talks about all of the relevant points that I try to cover here involving stigma, a lack of respect for providers, and diversion of resources to more areas of care that are viewed as more prestigious - like Cardiology. Amazingly, Virginia apparently has a rule where you must be released from the emergency department if they can't find a psychiatric bed within 6 hours. Based on his proposed reforms it doesn't seem like there has to be much of an effort to look elsewhere. The sequence of events has been managed care companies shutting down psychiatric bed capacity by defunding it. That is followed by states deciding to act like managed care companies and either shutting down their capacity or getting completely out of the field. The end result is a pool of people who cycle in and out of short stays on inpatient units to overcrowded emergency departments to the street and back again. Many permanently drop out of that cycle when they become homeless or go to America's newest mental hospitals - the county jail. This is a problem everywhere in the United States. I used to qualify that by saying it was a problem in areas of high managed care penetration. Today that is everywhere.
Apart from the isolated pieces that are written with the obvious intent to get somebody a Pulitzer Prize, these stories are typical of what you see in the press. The first article lacks basic information on what mental illness is and how decision making in a delusional state bears no resemblance to answering questions "in hindsight" after the delusions are gone. It lacks psychiatric perspective. Any newspaper reporter probably has access to acute care psychiatrists to tell them about those problems. In that situation reporters always want a "diagnosis" of the person in the news and psychiatrists cannot speculate on that without having examined the patient and getting their release for that information. But they can provide a rich perspective based on their clinical experience treating thousands of similar problems and the effect of delusions on a person's conscious state. They can also provide an opinion on the mental illness defense in this country as well as the state of psychiatric services to treat the problem. I know that I would be happy to provide those details. At the minimum somebody in charge of journalism school curricula needs to examine how reporters can come out and ignore all of those facts. I might even suggest objective criteria for coverage as at least 5 times the words used to cover the least relevant mental illness story that year. I would give the least relevant story this year as anything having to do with the DSM-5. On that basis a lot of additional writing needs to be done on these two stories.
In the case of Senator Deeds, his analysis of the problem in this brief soundbite is spot on. He needs a broader platform to advocate for his plan and support against the people who are opposing him and the 6 hour rule in state of Virginia. He should work the the American Psychiatric Association, receive their support, and have access to their social media venues. The APA should come out with their own solution to this problem. I cannot think of anything more absurd and more consistent with a managed business approach to treating severe health problems than this 6 hour rule. At some point the patient and their severe problem is totally meaningless relative to business concerns. And Senator Deeds is right. That doesn't happen with any other medical problem in the emergency department.
It only happens with mental illness.
George Dawson, MD, DFAPA
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