Pediatric Deaths From Firearms

 

If American society every becomes rational for any sustained period in the future – everyone living in the current epoch will be mocked.  We will be mocked for the absurd and obvious inconsistencies in society almost entirely driven by politics.  Guns, abortion, the discrimination and scapegoating of small segments of society, persistent racism, misogyny, a lack of concern for the disabled and disadvantaged, and a total lack of concern for the planet.  Sometime in the very near past – we stepped into a fantasy world where politicians could say anything – no matter how absurd, be believed, and get elected.

The lesson today is firearms and gun laws.  Over the course of writing this blog I have written about this many times. How the gun issue has been co-opted by one party and their judges.  That party has extremist views about gun laws and the Second Amendment.  Those extremist views endanger all of us and make the likelihood of ending school and other mass shootings impossible.

About a week ago, a paper came out in JAMA Pediatrics (1) that looked at the issue of permissive gun laws and pediatric mortality.  Guns in the United States are the number one cause of pediatric deaths in the country.  There are no other countries in the world where that is the case.  It speaks to these unique aspects of gun extremism in American culture and the degree to which people will rationalize gun access and laws that enable rapid deployment of guns with very little rationale.  Children and young men are dying in that crossfire and they have been for some time.

The research design of this paper was very interesting. It looks at the change in pediatric gun mortality over time stratifying states by their degree of gun permissiveness before and after the 2010 Supreme Court decision McDonald v. City of Chicago. In that case, a retiree and two additional plaintiffs brought action against the city of Chicago because they wanted to purchase handguns – but were not able to due to a citywide ban on issuing permits that began in 1982.  Details of the decision are included at the above link and my assessment is that the decision against the Chicago law was based on technical interpretations about whether gun ownership is a fundamental right. 

The overall effect of this decision was that many states changed their gun laws to make them much more permissive. Permissive gun laws are what I have been calling gun extremism.  Examples include mandatory issuance of gun permits and carry permits,  permitless carry laws, open carry laws (with or without permits including all types of firearms), stand your ground  or castle laws that say if you are armed you have no duty to retreat in certain environments, no bans on assault weapons, high-capacity magazine, or bump stocks, no red flag laws that remove weapons from individuals considered to be high risk, and no local laws that override state laws.  There is action in some cases to remove the ban on returning firearms to people convicted of domestic violence or drug charges.

You do not have to be a public health researcher to figure out what is wrong with these laws.  They basically return us to the days of the Wild West, where it took the local sheriff to come up with laws that guns needed to be checked at the city limits.  People roaming the streets carrying high-capacity automatic weapons is a recipe for disaster.  The current televised real crime genre – is an endless source of stories about gun homicides that occurred because somebody was angry, had access to a firearm, and impulsively shot somebody.  In the case of children and adolescents there is the additional risk of accidental shootings, suicide, and in some well publicized cases holding parents responsible for giving their child access to a gun that is subsequently used in the commission of a crime by that same child. When guns are everywhere – gun tragedies follow.

In this paper the researchers group states into 3 categories based on how permissive their gun laws have become since the MacDonald decision.   The categories were strict, permissive, and most permissive based on a classification protocol available in this supplement.    States rated as strict (total of 9) include:  California, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island.  States rated as permissive (total of 11) include:  Colorado, Delaware, Michigan. Minnesota, Nevada, New Mexico, Oregon, Pennsylvania, Vermont, Virginia, and Washington.  The remaining states were rated most permissive (total of 30) and include:  Alabama, Alaska, Arizona, Arkansas, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin, and Wyoming.

What might a head-to-head comparison of states from each category look like.  Here are three states from the upper Midwest – one from each category (taken from supplementary data from reference 1).

Illinois (strict)	Minnesota (permissive)	Wisconsin (most permissive)
2013: Concealed Carry Act - Allowed concealed carry of firearms. 2013: Firearm Concealed Carry Act - strict requirements for obtaining a concealed carry license. 2014: Private Sale Background Check Law - Required private sellers to verify buyer's FOID card with state police. 2018: 72-Hour Waiting Period Law - Enacted a 72-hour waiting period for all firearm purchases. 2019: Firearm Dealer License Certification Act - Required gun dealers to obtain a state license in addition to federal license. 2019: Red Flag Law - Allowed family or law enforcement to petition for temporary firearm removal from at-risk individuals. 2021: Universal Background Check Expansion - Extended background check requirements to all private firearm transfers. 2022: Ghost Gun Ban - Prohibited the sale and manufacture of unserialized and untraceable firearms. 2023: Protect Illinois Communities Act - Banned sale, manufacture, and possession of assault weapons and high-capacity magazines. 2024: FOID Fingerprint Requirement - Mandated fingerprint submission for FOID card applicants   FOID = Firearm Owner Identification Card	2003: Minnesota Citizens' Personal Protection Act - Established a "shall-issue" system for concealed carry permits. 2005: Stand Your Ground Law - Expanded self-defense rights, removing the duty to retreat in certain situations. 2014: Domestic Violence Gun Ban - Prohibited individuals convicted of domestic violence or subject to protective orders from possessing firearms. 2015: Suppressor Legalization - Legalized the ownership and use of firearm suppressors. 2019: Gun Violence Protective Order Law - Allowed family members and law enforcement to petition courts for temporary removal of firearms from individuals deemed a risk. 2021: Capitol Carry Notification Law - Required the Department of Public Safety to notify permit holders about their right to carry in the State Capitol complex. 2023: Universal Background Check Law - Required background checks for private firearm transfers, with some exceptions. 2023: Red Flag Law - Implemented an Extreme Risk Protection Order system, allowing courts to temporarily remove firearms from individuals deemed a significant danger. 2023: Safe Storage Law - Required firearms to be securely stored to prevent unauthorized access, especially by minors. 2024: Ghost Gun Regulation - Restricted the sale and possession of unserialized firearms and unfinished frames or receivers.	2011: Concealed Carry - Legalized concealed carry of firearms with a permit. 2011: Castle Doctrine - Expanded self-defense rights in one's home, vehicle, and place of business. 2015: Waiting Period Repeal - Eliminated the 48-hour waiting period for handgun purchases. 2015: Switchblade Legalization - Legalized the possession and carry of switchblade knives. 2017: Constitutional Carry for Knives - Removed restrictions on carrying knives, including in a vehicle. 2018: Extreme Risk Protection Orders - Implemented "red flag" law allowing temporary removal of firearms from individuals deemed a risk (Note: This may have faced legal challenges or implementation delays). 2021: Second Amendment Sanctuary - Some counties declared themselves Second Amendment sanctuaries, though not at the state level. 2022 (L): Campus Carry Proposal - Significant discussions about allowing concealed carry on college campuses, though it may not have been enacted. 2023: Universal Background Checks - Implemented background checks for private gun sales (Note: If not enacted, this was a significant proposal during this period).

 

Note that there is significant overlap in terms of gun permissiveness.  For example, all states now have concealed carry laws.  Illinois was the last state to legalize this but all 50 states legalized concealed carry within a period of 10 years.  The creates the obvious question of how we all survived without concealed carry for a period of 222 years after the Second Amendment was ratified?  Minnesota and Wisconsin both have stand your ground laws.  Stand your ground and castle laws are euphemisms for shoot first and ask questions later.  All 3 states have red flag laws that allow for gun removal from high risk individuals but only one state mentions domestic violence as a condition.  Illinois has a FOID (Firearm Owner Identification Card) requirement.  Minnesota used to have one in order to purchase firearms but currently the concealed carry permit serves that purpose. Minnesota also allows businesses to post whether firearms can be carried on their campuses – but there is no enforcement.  Any way you look at these comparisons – the last 20 years has resulted in an unprecedented growth in firearm access.

The study period was 1999-2023 and during that time there were 41,012 pediatric firearm deaths accounting for about 4% of the total mortality.  Expected mortality calculations were done comparing the pre-decision period (199-2010) to the post decision period (2011-2023) and excess mortality was determined.  Incident rates as deaths per million were calculated based on the populations in each study period.  The firearm mortality crude rate increased in 33 states (see Table. Incident Rates Pre– and Post–McDonald v Chicago With Incident Rate Ratios).  Suicide and homicide by firearms both increased.  The most permissive states had the greatest number of deaths due to firearm suicide and homicide..

That authors list three minor limitations to their study, but seem to omit a major one and that is a control or no-gun category.  That may seem like a truism – how can you have gun related suicides and homicides if you have no guns?  One estimate is to compare firearm mortality to peer countries like the graphic from the Kaiser Family foundation at the top of this post.  The US child and teen firearm mortality rate is 10 to 200 times that in peer countries. The same is true for adult gun homicides and suicides.  All of those thousands of excess child deaths are due to easy gun availability in the US that is getting even easier.

We have a grim reality of a country that is chock full of guns to the point that we are trying to establish a dose-response curve. We are doing that exercise in a landscape that is still driven by gun extremists wanting even more permissive gun laws. Common sense has clearly been suspended in favor of political convenience in the US when it comes to guns.  Until it returns America’s children will pay the price in the form of completely unnecessary deaths and the ruined lives and families of the both the victims and perpetrators.

 

George Dawson, MD, DFAPA

 

References:

1:  Faust JS, Chen J, Bhat S, Otugo O, Yaver M, Renton B, Chen AJ, Lin Z, Krumholz HM. Firearm Laws and Pediatric Mortality in the US. JAMA Pediatr. 2025 Jun 9:e251363. doi: 10.1001/jamapediatrics.2025.1363. Epub ahead of print. PMID: 40489107; PMCID: PMC12150223.  

Graphics Credit:

Excellent analysis of child firearm death rates compared to peer countries is from the Kaiser Family Foundation at this link:  https://www.kff.org/mental-health/issue-brief/child-and-teen-firearm-mortality-in-the-u-s-and-peer-countries/

Use here is per the CC BY-NC-ND 4.0 license:  https://creativecommons.org/licenses/by-nc-nd/4.0/

No changes were made to this graphic downloaded on June 16, 2025.

My Diet - A Work In Progress

 

The easy way to eat all your fruits and vegetables….

 

Diet is endlessly debated in the US.  The health and wellness industry is three times larger than the pharmaceutical business. Much of their focus is influencers telling you about what you should eat and what supplements to take. They don’t let science or conflict of interest get in their way. 

For most of my life – I did not eat correctly.  I ate mostly carbohydrates; some fish but usually dairy based proteins and too much sugar sweetened foods.  I always rationalized it as a cultural or genetic distaste for vegetables and fruits were just too problematic to store.  I read all the papers on diet and the advantages of a well-balanced diet.  That led to some gradual improvements. 

About 40 years ago I stopped eating processed meat products like hot dogs, sausage, and pepperoni.  30 years ago, I stopped eating beef.  20 years ago, I started to cut sugar sweetened foods way back to reduce gout attacks and minimize body weight fluctuations between cycling and skating seasons. 15 years ago, I started to eat a salad every day that consisted of lettuce, olives, and matchstick carrots.  Then about 3 years ago, I was at a restaurant and had a blueberry burrata salad made with spring greens and decided that blueberries needed to be in all my salads.  For the past two years my typical salad consists of tri-color slaw, blueberries, a light raspberry vinaigrette, and croutons.  I ate about 120 lbs of blueberries last year. 

My main protein source consists of Greek yogurt, skim milk, and eggs.  I do eat chicken and fish when available.  The yogurt ranges from 15-25 g of protein per serving and I eat 3 servings per day.  For breakfast I eat yogurt mixed with a combination of blueberries, blackberries, and raspberries.  I am considering expanding the berry selection to black currants and strawberries.

I don’t need a lot of variation in my diet. I was in the Peace Corps and ate homemade French Fries every day and a grilled cheese sandwich. Powdered milk was an additional protein source. I still eat desserts now and then and sprinkle chocolate chips on my yogurt and call that dessert.  I eat large restaurant salads made with spring mix generally because of the storage problem with spring mix.  I also tend to eat beet salads that are popular in Minnesota restaurants. Cubed beets drenched in ice cold vinaigrette with spring mix is a fantastic salad.  The tri-color slaw lasts longer and I can generally expect to eat it all (5 servings) before it goes bad. I have had too much lettuce go bad in about 3 days and by the official expiration date it looks like a bag full of motor oil.  I regularly eat large bean (black, chili) burritos, nachos with beans, and just plain beans.  I drink 2 cups of coffee per day – not because I like it but for the antioxidants. It must be hazelnut flavored.

I decided to post this today because of two reasons.  I just got back from my annual checkups at the Mayo Clinic and had to answer their nutritional questionnaire twice.  One of the questions focused on combined vegetable and fruit consumption.  They defined serving size as a tennis ball sized volume of the fruit or vegetable and that is somewhat controversial.  Some have the opinion that the volume of a tennis ball is ½ cup and others think it is closer to 1 cup.  When I look at a measuring cup my portions are easily closer to the 1 cup size, although in the case of tri-color slaw (carrots, red cabbage, green cabbage) it gets complicated.  

On the Mayo survey – you can land on the 2-4 or 4-6 portions per day.  I tallied it up as red cabbage, green cabbage, carrots, blueberries, blackberries, and raspberries or a total of 6 portions per day.  On their extended survey I got credit for low fat dairy consumption and eating nuts (cashews, pistachios, pecans, Brazil nuts, almonds, pine nuts, walnuts) – but lost credit for eating cookies (Animal Crackers, ginger snaps) nearly every day.  In the end I was rated as having a moderately good diet.

The second reason is to illustrate that you can overcome a bad diet gradually over time by finding something that you like. I always preferred carbohydrates as a calorie source but at some point – I came to the realization that even if potatoes were a healthy food – eating them deep fried or drenched in butter or in the case of sweet potatoes coated in brown sugar and butter probably did not add much nutritional value.  I have never been much of a meat eater.  The nuts and berries really broadened my horizons and markedly improved the taste of cabbage and leafy green vegetables. I have the advantage of being able to eat the exact same thing every day without the need for variation. I heard David Lynch describe this once.  He ate a chocolate malt and a grilled cheese sandwich every day for years. 

There are a couple of related current issues that are relevant.  Lately there is a lot in the media about processed foods. They are simply defined by having a lot of additives to enhance flavor or shelf life.  It is hard to avoid them, but the bulk of my diet has none. All the berries are frozen and the only ingredients are the frozen berries.  The Greek yogurt contains stevia – a natural sweetener but no artificial sweeteners. The slaw mix is only cabbage and carrots. The salad dressing contains the usual components.  I drink the occasional zero alcohol beer for additional antioxidants.  Although I do not have a specific antioxidant strategy – I am genetically loaded for a lethal neurodegenerative disease that I really hope to avoid (see Supplementary 2 below).  Like all these diseases oxidative stress is considered a potential mechanism so the antioxidants from this diet can’t hurt.

That is the diet I have come up with after decades of trial and error.  I am not recommending it to anyone else or suggesting that it will work for anyone but me.  It is not for anyone who needs a lot of variation in their diet.  You will also have a hard time keeping your teeth white.  The berries in this diet are one of the few things I have found that can stain Corelle dishware.  

In the end I have a moderately good diet according to Mayo and would never have guessed that I would land there. It took about 50 years to piece it together.

 

George Dawson, MD, DFAPA

 

References:

1:  The Mayo Clinic Diet Score (test your diet):  https://diet.mayoclinic.org/us/get-my-free-diet-score/

2:  Carlsen MH, Halvorsen BL, Holte K, Bøhn SK, Dragland S, Sampson L, Willey C, Senoo H, Umezono Y, Sanada C, Barikmo I, Berhe N, Willett WC, Phillips KM, Jacobs DR Jr, Blomhoff R. The total antioxidant content of more than 3100 foods, beverages, spices, herbs and supplements used worldwide. Nutr J. 2010 Jan 22;9:3. doi: 10.1186/1475-2891-9-3. PMID: 20096093; PMCID: PMC2841576.

3:  The Antioxidant Food Table, Carlsen et al. 2010. the main results of the present study; the table includes all the 3139 products with product descriptions, details and antioxidant analysis results, categorized into 24 categories and arranged alphabetically within each category

https://pmc.ncbi.nlm.nih.gov/articles/instance/2841576/bin/1475-2891-9-3-S1.PDF

4:  Ejaz A, Waliat S, Afzaal M, Saeed F, Ahmad A, Din A, Ateeq H, Asghar A, Shah YA, Rafi A, Khan MR. Biological activities, therapeutic potential, and pharmacological aspects of blackcurrants (Ribes nigrum L): A comprehensive review. Food Sci Nutr. 2023 Aug 15;11(10):5799-5817. doi: 10.1002/fsn3.3592. PMID: 37823094; PMCID: PMC10563683.

5:  Singh M, Arseneault M, Sanderson T, Murthy V, Ramassamy C. Challenges for research on polyphenols from foods in Alzheimer's disease: bioavailability, metabolism, and cellular and molecular mechanisms. J Agric Food Chem. 2008 Jul 9;56(13):4855-73. doi: 10.1021/jf0735073. Epub 2008 Jun 17. PMID: 18557624.

6:  Spreng S, Dawid C, Dunkel A, Hofmann T. Quantitation of Key Antioxidants and Their Contribution to the Oxidative Stability of Beer. J Agric Food Chem. 2024 Jul 24;72(29):16423-16437. doi: 10.1021/acs.jafc.4c01000. Epub 2024 Jul 15. PMID: 39010731; PMCID: PMC11273605.

Graphic Credit:

Click on photo to see photographer and CC license for use.  It is used as is with no modifications.

Supplementary 1:  I have attached a brief but selective table on the antioxidants in my diet. The antioxidant literature is interesting to an old chemist like me because the reported values depend on what food was analyzed, the extraction methods, what chemical group is analyzed, and the reporting methods.  As an example, on reporting the Antioxidant Content column below reports mmol/100g (from reference 3).  Many papers will report mg/100 g instead. 

The analysis in reference 2 was spectrophotometric based on the reduction of Fe³⁺TPTZ (2,4,6-tri-pyridyl-s-triazine) complex to Fe^2+--TPTZ complex that results in a blue solution that can be measured at 600 nM and the content estimated in mmol. The 100g is the amount of each sample extracted for this determination. That main limitation of this assay method is that it will not measure glutathione or other sulfhydryl groups due to the redox potentials, but some of these compounds can interact and lead to overestimates of the antioxidant content.   

The specific groups of antioxidants in column 2 are generally polyphenols with the capacity to transfer electrons and buffer what are known as Reactive Oxygen Species (ROS) that cause oxidative stress.  Any one of the foods in the table can be searched and you probably will be able to find a specific paper about the antioxidant content ranging from basic (like the 20 foods with the highest antioxidant content) to highly technical papers on the redox (oxidation-reduction) equations and potentials of these compounds.

Food	Antioxidant Content mmol/100g (3/5)	Antioxidant Mix:  Anthocyanins, Flavonols, Flavone, Flavanones, Isoflavones, Catechins, Proanthocyanidins,  PP polyphenols
Red cabbage	0.8/ 2.153	F, Cat
Yellow cabbage	0.15	Kaempferol, quercetin, apigenin
Carrots	0.02	Kaempferol, quercetin, and apigenin, cyanidin
Beets	1.50	A
Peas	0.61	PP
Corn	0.20	PP, vitamin C
Blueberries	7.13/ 2.159	A, F, Pro
Blackberries	5.98/ 3.99	A, F, Pro
Raspberries	3.46/ 2.334	A, F, Pro
Strawberries	5.44/ 2.159	A, F, Pro
Black Currants		A, F, Pro
Walnuts	1.27/ 13.126
Cashews	0.66	cardanols, cardols, phytosterol, triacontanes, anacardic acid
Pecans	9.67	Tocopherols, PP
Pistachios	1.43	A, PP
Pine Nuts	0.77	Polyphenols, xanthenes, carotenoids, tocopherols
Brazil nuts	0.47	Se, vitamin E, PP
Almonds	0.26	caffeic acid, sinapic acid, ferulic acid, p-coumaric acid
Red Beans	0.33	Delphinidin, cyanidin, procyanidin, phenolic acids
Chili Beans	0.26	gallic acid, rutin
Coffee filtered	2.60	chlorogenic acids, caffeine, nicotinic acid, trigonelline, tocopherols, cafestol, kahweol
Chocolate chips 70%	10.74/ 4.188	Pro
Bakers Chocolate	10.47/ 4.188	Pro
Diet Pepsi	0.04	caffeine
Yogurt Greek Zero Fat	0.06	Bioactive peptides
Stevia	0.04	Stevia glycosides
Chicken	0.02	Selenium, niacin (vitamin B3), 2-oxo-imidazole-containing dipeptides (2-oxo-IDPs), vitamin E, carotenoids
Fish – Walleye	0.04	vitamin E, peptides, glutathione peroxidase, superoxide dismutase, ubiquinones, and catalase
Eggs – Whole	0.06	ovalbumin, ovotransferrin, phosvitin, phospholipids, vitamin E, vitamin A, selenium, and carotenoids
Pizza/marinara sauce	0.88	Lycopene, PP
Potato	0.33	A, carotenoids. PP
Baked Sweet Potato	0.79	A, PP
Beer (zero alcohol)	0.10	hordatines A–C, saponarin, and quercetin-3-O-β-d-(6″-malonyl) glucoside

 

Supplementary 2: 

In the above post I described being at high risk for a neurodegenerative disease.  The following graphic is a polygenic risk analysis of my DNA that shows I am in the 100th percentile risk for amyotrophic lateral sclerosis or ALS - a fatal neurodegenerative disease.  There is no known treatment or cure and dietary factors play an uncertain role.  Environmental factors including diet are thought to be an important factor in all neurodegenerative diseases despite the clear biological components.  

Less Time To Do More…. Psychotherapy On Acute Care Units

 

Less Time To Do More….

As part of my brief series on the role of psychotherapy in psychiatry I thought I would pull this book off my bookshelves and discuss it.  It was published in 1993 and that was about the time I bought it.  At that time, I had just finished working as the Medical Director of a CMHC and consulting at a local hospital and was about 4 years into my role as an acute care psychiatrist on an inpatient unit.  I was trained in psychotherapy in residency and provided it across all of these settings as well as individual and group supervision to masters level psychotherapists.  That supervision included accepting cases referred from them for psychotherapy if they felt uncomfortable treating that person.

Managed care hit hard from my first day on the acute care unit.  Companies decided that they could easily deny care to psychiatric inpatients by using what was eventually became their dangerousness standard.  In other words, if a reviewer made an arbitrary decision that the patient was no longer dangerous, they would stop payment and the patient would be discharged.  As someone who did this work for 22 years that is a bizarre standard designed primarily save the insurance company money and they were very good at that. They were also successful in setting up a sham appeal process that could not be challenged.  The result is suboptimal care and inpatient units that are essentially revolving doors that discharge patients before they are stable.

If you think of a competency-based standard for psychotherapy – that is the ability to manage your own life and medical care, make decisions in your best interest, and problem solve and make good decisions in novel situations that was all a second priority to symptom stabilization.  If a patient was admitted because of mania and grandiose delusions – those symptoms were targeted with pharmacotherapy and once they were mostly gone – the patient needed to be discharged.  At some point in the late 1990s – public payors like Medicaid and Medicare stopped using contractors to do these utilization reviews and the process was internalized by health care organizations.  Instead of being harassed by an outside reviewer – the harassment became internal for patients covered by public insurance.

The additional context at the time was a rift in psychiatry between psychiatrists who identified as either biologically based, therapy based or eclectic meaning a combination of both (2).  This paper was written at the time I trained but even that description was an oversimplification. There were medical psychiatrists, consultation-liaison psychiatrists, neuropsychiatrists, and community psychiatrists.  They all had their models of care and their own ideas about how psychotherapy should or should not be integrated into that care.  I was fortunate to have access to a wide variety of psychotherapists and very active didactics.  But nobody really talked much about how psychotherapy fits into typical psychiatric practices. In a previous post, I listed supportive psychotherapy resources and that was an obvious skill needed across all settings.  It was occasionally demonstrated by attending physicians but most of what they seemed to do were diagnostic interviews. 

Less Time to Do More seemed to take on that problem specifically in the inpatient setting. The introductory chapter on therapeutic communities discussed a common model used to run inpatient units.  The regulatory function of the community was discussed to help patients with severe mental illnesses reintegrate following an episode of decompensation. Kohut’s self-psychology was presented as a possible model of the self-object matrix critical for early childhood development with groups and group processes taking on that role.  Groups leaders need to monitor the level of cohesion in both patient and staff groups to main their roles in assisting in self-regulation and reinforcing adaptive behavior.

Chapter 2 (3) starts to get to the heart of the matter. It discusses relevant psychodynamics at the individual patient and staff level. Inpatient treatment is ideally multidisciplinary. The team I worked with consisted of nurses, nursing assistants, social workers, and occupational therapists. Each team member plays an invaluable role in how the inpatient environment works and how it is therapeutic for patients. The psychodynamic model is the best way to make sense of it. Even then it is not an easy job. Most hospitals use siloed management with every discipline under different administrators. There is no assurance that any of the administrators know as much about how to care for patients as the inpatient staff does. There is internal politics as well as the question about what happens when there is an inevitable staff-wide crisis. Examples of those crises include threats or violence against staff members, serious allegations against staff by patients or their families, and incidents resulting in patient injury. Many of these complications can be prevented by staff awareness of the involved psychodynamics that includes transference and countertransference reactions and defenses that are typically used by people with severe psychiatric disorders and their families.

I have seen psychiatrists operate at two extremes in the acute care inpatient environment.  At one end I would call it the old hospital visit model.  The assumption is that inpatient care is basically a side hustle and most of the serious work occurs in this physician’s outpatient practice or clinic.  They appear briefly early in the morning on the inpatient unit, talk to the patients under their care briefly, do not participate in any team meetings, and may or may not talk with nursing staff.  They may depend on nurses to call them at points during the day with progress reports and decide whether to make medication changes or discharge the patient.  Before a hospitalist model in medicine – this is how many primary care physicians worked as attendings at hospitals.  

At the other end is the full time attending.  The inpatient unit is his or her primary job.  They have daily team meeting with all team members in attendance and discuss progress as well as problems. Those problems can be at the level of the individual patient, their family, the staff, the administration, the probate court, outside consultants, law enforcement, and the physical environment. Team meetings are necessarily complex and in a less time environment rapid decision making is the rule rather than the exception. The schedule of when patients are seen depends on what happens in that team meeting.  Any acute medical or psychiatric problems take priority, followed by systems problems like conflicts between staff and administrators, followed by discharges.  That all happens before noon and individual patients are seen (along with new admissions) over the rest of the day. That is the most straightforward description of this model where most days are far from routine.

A psychiatrist operating in that second environment needs certain technical skills. Above all else – they need to be aware of their personal reactions to what is going on in the inpatient environment.  How much of that reaction is reality based and how much is based in countertransference?  I heard a quote recently from Kernberg where he said the most significant work of a therapist is to contain their countertransference aggression and there is no better place to practice that than an inpatient unit. The psychiatrist operating in that environment is often a flash point for scapegoating when anything goes wrong or even not as well as expected. During my tenure it was common to see psychiatrists blamed for being assaulted by patients, for not discharging patients fast enough, for ignoring nursing staff requests, and for being too authoritarian.  In todays overmanaged health care environment any one of those complaints can trigger a major investigation by hospital committees and result in reports credentialling agencies or medical boards whether they are factual or not. Controlling countertransference aggression in such an environment can be an impossible task.

Ideally the psychiatrist is in a role with reasonable team members and can interact with them in such a way they recognize their value.  That occurs by genuine active dialogue with them discussing patient care and any problems that the staff member might be having. This may seem obvious but it was not until my first few years as an inpatient psychiatrist that I realized the only reason my patients were in the hospital was that they needed nursing care.  I could do my 30–60-minute visits anywhere. The nursing staff was with them 24/7 and for clear reasons.  Other disciplines also need support form psychiatry.   Inpatient social work is a clear example.  The social workers I had the privilege of working with were all excellent and found themselves doing the impossible job of discharge planning.  They were calling 20-30 places a day for a single patients trying to get them out of the hospital (we rarely discharged anyone to the street).  That is a high stress situation especially when you have a supervisor asking you why you have not seen enough of the other patients.

All of these scenarios require a psychiatrist who can intervene supportively (education, encouragement, problem solving) and existentially (empathic listening and reflection) with fellow staff members.  That does not mean they are doing supportive psychotherapy with their colleagues.  It does mean that the genuine and human interactions they have with their valued coworkers may translate well into the therapy they are able to do to assist patients.  It may also lead to valuable insights like the one I had about the nursing staff. 

Additional chapters in this book provide good information on interacting with outpatient therapists and the importance of recognizing potentially disruptive defense mechanisms like projection, projective identification and splitting and how they can be contained on inpatient units. Containing countertransference aggression was emphasized especially because it can be magnified more in an inpatient setting where there are more possible recipients.     

The authors were generally confident about providing inpatient psychotherapy to a patients with a diverse number of conditions.  Some of the time frames discussed approximated 2 weeks and these days that is about a week longer than many these days. Some variables affecting length of stay (LOS) were not discussed.  The most important one of these is involvement in civil commitment and how that is handled. I looked at the issue on my unit and it added another 21 days and even longer after the State of Minnesota passed a law allowing county sheriffs to send mentally ill inmates directly to state hospitals on a priority basis. Like all inpatient factors it was a mixed blessing – more time for all therapies and recovery but the wrath of administrators blaming staff for not using enough medication fast enough, doing too many civil commitments, or not discharging unstable patients.

My approach in the inpatient setting was to have daily team meetings, engage my team in productive patient focused discussions, and see all my patients for at least 30 minutes a day.  I would also see family members at their request when they came in to visit or scheduled family meetings with or without my social work staff and at times nursing staff of they had available time.  I was very focused on the phenomenological-empathic approach to interviewing people with severe problems. I generally felt that patients realized that I was very interested in talking to them about more than symptoms.  Just that aspect had significant effects on people who were angry, non-disclosing, paranoid and accusatory, and used projection and splitting defenses. I was able to establish long term relationships with many people who were considered refractory to treatment and they were able to make progress.

Part of those discussions involved a detailed discussion of delusional thought content and how it was affecting their life. I commonly asked for their initial experience and the very first time they had those thoughts.  We would reconstruct that incident and discuss what happened as a place to begin.  From there we would discuss how these thoughts affected their relationships and ability to manage their lives.  I found that asking them about their theory of what happened or was happening to them was a useful question. Once their theory was discussed we could discuss whether they were aware of other possible theories to explain what happened.  This is a much better approach than getting into an argument of who believes what.  “Well, I understand you believe that!” is a judgmental rather than an empathic statement that simply states that you are not interested in what the patient has to say. 

Inpatient psychotherapy is also a place where competency can not only be emphasized but it may be critical for survival.  Exploring why a patient believes that they do not have diabetes or a fatal illness and trying to help them with a working solution is one example.  Working with them on how to avoid confrontations with the police is another. I have worked with many manic patients who found themselves in life threatening situations when they overestimated their physical abilities due to mania. And there are the more frequent discussions of how to avoid hospitalizations, how to manage severe psychiatric illnesses including suicidal thoughts and inability to function at times.

The thousands of discussions I have had with these folks over the years led me to the conclusion that supportive psychotherapy is the language of psychiatry.  On the inpatient unit it operates at multiple levels in a very high stress environment.  In the next few posts, I will look at more specific interventions.

The main theme I am hoping to stress in these posts is that no matter what you are going as a psychiatrist – a psychotherapeutic intervention should be part of it. It reminds me of a thought experiment one of my brightest teachers presented to ma as we were talking after clinic one day:

“OK George - suppose you are out there as a psychiatrist for a few years and you are at a party.  A woman comes over to you at that party that you don’t know and starts to make small talk. Are you thinking like a psychiatrist or not?”

The tenor of these posts should suggest the answer…..

 

George Dawson, MD, DFAPA

 

 

References:

1:  Leibenluft E, Tasman A, Green SA (eds).  Less Time To Do More: Psychotherapy on the Short-Term Inpatient Unit.  Washington, DC. 1993.

This is a 1993 publication so I am not recommending it at this point. It is a good outline of necessary psychotherapeutic concepts but is not long on specifics apart from some vignettes.

2:  McHugh PR. William Osler and the new psychiatry. Ann Intern Med. 1987 Dec;107(6):914-8. doi: 10.7326/0003-4819-107-6-914. PMID: 3318611.

3:  Silver PA, Goldberg RL.  Integrating Somatic and Psychological Treatment in Inpatient Settigs. in:  Leibenluft E, Tasman A, Green SA (eds).  Less Time To Do More: Psychotherapy on the Short-Term Inpatient Unit.  Washington, DC. pp: 23-38.