tag:blogger.com,1999:blog-7772182113499451603.post7271563367040771222..comments2024-03-27T10:50:53.692-05:00Comments on Real Psychiatry: Will Changing The Commitment Standard Decrease The Rates Of Mass Shootings?George Dawson, MD, DFAPAhttp://www.blogger.com/profile/03474899831557543486noreply@blogger.comBlogger9125tag:blogger.com,1999:blog-7772182113499451603.post-10386690163766017332014-06-01T15:02:22.493-05:002014-06-01T15:02:22.493-05:00Clark,
I don't see it as a big mystery.
Ther...Clark,<br /><br />I don't see it as a big mystery.<br /><br />There is a clear cultural movement in the US to bring increasing numbers of people under the control of inefficient managers. The financial system is an obvious case in point for everyone except the managers. But it is also the reason I keep bringing up the way medicine is managed. Medicine has become one of the largest taxes that any person or family pays in their lifetime and like many investments that we are locked into - it is a bad one.<br /><br />The interest today is in making sure unnecessary managers and the people at the top make money. That comes at the high price of rationing or just not providing service and a much less enthusiastic and inquisitive physician workforce.<br /><br />I think I was one of those physicians you are writing about. I always paid close attention to existing medical conditions and making sure they were treated adequately. I was told many times that my approach was "too expensive" and I was targeted by administrators and insurance companies. I can recall treating a complicated delirium only to be told by the insurance company that "delirium is not a psychiatric condition". <br /><br />It probably is when other specialists are sending you the cases.<br /><br />I agree with you that in today's "cost effective" environment - there is a lot less time and effort allocated to complicated problems. It will only get worse as business consolidates its power with the help of politicians.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-15442997663035649522014-06-01T14:34:17.454-05:002014-06-01T14:34:17.454-05:00Sorry, I apparently posted the same abstract twice...Sorry, I apparently posted the same abstract twice.<br /><br />Personally, I think it goes back at least 100 years; the original charity medical system of Psychiatry (staffed by physicians from all existing fields) was lost to history, and nothing ever replaced it.<br /><br />I wish there was more public discussion about the treatment of physical illness causative to, and co-occurring with, mental illness. We need specialists to be able have access to, and treat, the mentally ill for their medical illnesses. <br /><br />I'm not sure what society's problem is; there was so much public and government support 200 years ago when medicine was too primitive to accomplish anything. Yet today, when we can actually do so much more, there's just no interest... It's utterly bizarre.<br /><br />thanks for the reply.Clarknoreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-18805441693158520582014-06-01T10:44:14.532-05:002014-06-01T10:44:14.532-05:00Dr. Allen,
In 1987, I saw a violent young manic ...Dr. Allen, <br /><br />In 1987, I saw a violent young manic who had been stopped by the police and committed under a 5150. He rapidly responded to lithium and Haldol as he had done in the past, but he was chronically noncompliant.<br /><br />The 72 hours were up and I want to Court 95 in the San Fernando Valley to continue treatment involuntarily as I felt he was gravely disabled. He flatly denied any suicidal or homicidal ideation but I pushed the latter point since he had only recently got into it pretty heavily with the police. <br /><br />The judge accepted the cardboard box on the street corner plan as sufficient shelter and he was released since in her mind that was enough to prove he wasn't gravely disabled. <br /><br />Two days later he was shot dead by cops in a violent confrontation, which might have been suicide by cop.<br /><br />The next time I saw the judge she could not even look at me without looking away in disgrace. <br /><br />That was right about at the end of my time working in a hospital setting. I realized the LPS law was a joke in the way it was being interpreted. This is one of a handful of unpleasant experiences I had with Court 95 in the 1980s. It saddened and depressed me, and the only consolation I had was that I had covered my ass and the families knew I did everything I could.<br /><br />I am a civil libertarian by temperament, but only a fool fails to see how this logic does not apply to the severely mentally ill.James O'Brien, M.D.https://www.blogger.com/profile/14994350319492582321noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-35541436662013377022014-05-31T18:30:28.159-05:002014-05-31T18:30:28.159-05:00Your comment stopped me dead in my tracks. I didn&...Your comment stopped me dead in my tracks. I didn't know it was this bad. <br />And, I am one for choosing my own care, but this is possibly the worst I have ever seen related.RBnoreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-18105866282190890432014-05-31T13:23:48.970-05:002014-05-31T13:23:48.970-05:00The current legal approaches make the issue of med...The current legal approaches make the issue of medical illnesses in the context of mental illnesses even scarier. People end up with no care for mental illness based on an inflated commitment standard and they end up with no medical care based on an inflated guardianship standard.<br /><br />To illustrate, in the last county I practiced no emergency guardianships were available for medical treatment. Each county had their own standard, but in the county where I worked - a private legal firm had to be paid $1,000 in order to do the case and the paperwork to get the case considered. Even then it would take 2 - 3 months. In that environment, I found myself caring for people with acute medical problems that needed urgent treatment that they were refusing. The specialists involved refused to do anything without the guardianship in place out of the fear they would be "assaulting" the patient without adequate substituted consent. They were of course correct.<br /><br />In the most absurd cases, people were bleeding on the floor and I was told: "Call us when they pass out and we will make a decision about emergency treatment."<br /><br />That is a good example of the extreme state of neglect that occurs as a result of legal and business systems preventing indicated care of the mentally ill.<br /><br />That contrasts with my ability to get appropriate medical care when I started out 30 years ago. At that point I had a patient with cancer who did not believe he had cancer due to a delusional system. I was able to get a court hearing at no cost to the patient or her family and within a week she was being seen and treated by a cancer specialist. I don't know why nobody else seem to talk about it, but treatable cancer is a significant cause of mortality in people with severe mental illness. And over the past three decades our society has decided that it is an acceptable standard to allow people to die, based on the fact that severe mental illness has affected their decision making. George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-12038805094374517282014-05-31T12:03:49.591-05:002014-05-31T12:03:49.591-05:00I think that the so called commitment standards ha...I think that the so called commitment standards have basically become a way to rubber stamp inadequate psychiatric care. When you think of it as a service industry - there is no other such industry out there that will keep you somewhere for a day or two doing absolutely nothing positive for you and then tell you that we don't have to provide you with any service because you don't meet our "imminent dangerousness" standard for service. In the meantime any discharge before the DRG designated date is money in the bank.<br /><br />It is an absurd world where medical care is dictated by businesses and governments. All of the incentives are aligned to provide the maximum profit for hospitals and healthcare systems and less work for the counties involved. It is a perfect world for everyone except the patient. That is after all how Greyhound Therapy got started:<br /><br />http://real-psychiatry.blogspot.com/2013/05/greyhound-therapy-suddenly-wrong.htmlGeorge Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-6700058357040306542014-05-31T11:19:44.800-05:002014-05-31T11:19:44.800-05:00I work in California and it is next to impossible ...I work in California and it is next to impossible to keep someone in the hospital involuntarily for more than a 72 hour hold. And I have zero confidence that there is any followup to weapons removal if and when it ever happens. Even if the police hadn't botched the check up, I don't know if it matters in the eventual outcome.James O'Brien, M.D.https://www.blogger.com/profile/14994350319492582321noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-30264250789516667782014-05-29T11:38:28.038-05:002014-05-29T11:38:28.038-05:00David,
My experience echoes yours and I have lost...David,<br /><br />My experience echoes yours and I have lost count of how may times I have reminded county and court officials of the "gravely disabled" standard. They of course look at me like I am a dinosaur and continue to talk of "imminent dangerousness" even though it is not in any statute.<br /><br />For a while we had some counter rhetoric to the cardboard box as a residence scenario and people would refer to it as "dying with your rights on". But as you point out this is another significant area of conflict of interest - can you get somebody "off" in a commitment, conservatorship, or guardian proceeding or can you get them the help they need. Attorneys experienced in these matters seem to opt for help rather than dismissal.<br /><br />My guess is that is because of the bad outcomes they witnessed and the number of clients who followed them out to the parking lot looking for help afterwards.<br /><br />With the reset of the lowest possible standard that we have now, everybody is less guilty. We just can't do anything if a person is not "imminently dangerous" or "holdable."<br /><br />What a travesty.George Dawson, MD, DFAPAhttps://www.blogger.com/profile/03474899831557543486noreply@blogger.comtag:blogger.com,1999:blog-7772182113499451603.post-48948966869191706472014-05-29T09:42:25.321-05:002014-05-29T09:42:25.321-05:00A little history I personally observed: The inabil...A little history I personally observed: The inability to provide for food, clothing and shelter due to mental illness, called "gravely disabled," was one of three major criteria for involuntary commitment in California's groundbreaking Lanterman-Petris-Short Act of 1969 (along with danger to self or others). The LPS act was also the original source of the "72 hour hold" (or 5150 for any Van Halen fans). The LPS act became the standard for many states across the country. <br /><br />As you point out, the grave disability criteria gradually became itself gravely disabled, as a cardboard box on skid row gradually came to be seen as evidence of an ability to provide shelter. This was spurheaded not by managed care, as it is now, but by so-called patients rights advocates who took concerns about earlier abusive commitment practices in the field to a ridiculous opposite extreme. <br /><br />Sometimes when I was in LA during this process I was sorely tempted to hand out the patient's rights advocates' personal addresses to homeless schizophrenics, and then take bets on how soon the advocates would call the police if said person pee'ed on THEIR doorstep.David M. Allen M.D.https://www.blogger.com/profile/06280912088483192599noreply@blogger.com