Racism and gun violence both exist in an overtly gun extremist society: They cannot be explained away by mental illness.

I suppose I should have not been very shocked that a Wall Street Journal editorial this morning (1) chose to double down on both gun rights and the myth that racism is not a problem and had nothing to do with the recent mass shooting – while scapegoating both mental illness and the rationed system of mental health care that we have in this country.  For good measure he added another conservative agenda item - that there was also blame for the public health officials like Dr. Fauci for mismanaging the pandemic.  This post is to straighten all of that out.

Let me preface these remarks by saying that I have no information about the most recent mass shooting other than what is reported in the media.  The author of the editorial does not seem to either. What I do have is 22 years of experience in acute care psychiatry and involuntary care. That’s right – for 22 years I was one of the guys you would have to see if you were admitted to my hospital on a legal hold for behavior that involved threatening or harming other people or yourself.  That included all kinds of violence - homicide, suicide attempts and severe self injury, and violent confrontations/shoot outs with the police.  I had to evaluate the situation with the considerable assistance from my colleagues and decide if that person could be released or needed to be held for further assessment and treatment. People (including psychiatrists) like to summarize that situation by saying: “Nobody can predict future dangerousness” and that is certainly true. But we do pretty well in the short term (hours to days).  We also do well coming up with a plan to prevent future violence.

The details about the most recent mass shooting are still being reported at this time, but so far include interviews with the families of the victims, police reports, videos, and excerpts from a manifesto written by the perpetrator.  According to reports that manifesto discussed Replacement Theory as a potential motive for the mass shooting.  Replacement Theory is a white nationalist, far right ideology that claims non-whites are a threat to the white majority in several countries including the US. A corollary is that the Democrats are trying to get aligned with more non-white voters to develop more political power. This is the rationale currently given in the media for the actions of the mass shooter who scouted neighborhoods and said very explicitly in documents that his intent was to murder as many black people as possible. He had no difficulty obtaining firearms legally – even though he was detained and sent for an emergency evaluation a little less than a year earlier for stating “murder-suicide” in response to an online question about what he planned to do upon retirement.  Those details and his response talking about how he got out of it and continued to plan to kill people are at this link.  

As a psychiatrist and member of the American Psychiatric Association, I can’t speculate on the diagnosis of anyone who I have not personally assessed and if I did do an assessment – I would need a release from the person to discuss any details.  The editorialist is under no constraints speculating that “signals were missed” and that “psychotic young males whose outlet is killing” is not the object of his column.  Instead, he makes the claim that he is really concerned about the post pandemic mental illness and addiction trends in this country. He is apparently not consulting the correct sources about what has happened in this country in terms of mental health care before the pandemic.

I will start with his anchor point in the 1970s.  At about that time Len Stein, MD and coworkers invented Assertive Community Treatment and a number of additional innovative approaches that were focused on keeping people with severe mental illnesses in their own homes.  Dr. Stein was one of my mentors and in seminars he would show what Wisconsin state hospital wards used to look like. About a hundred patients in one large room with their cots edge-to-edge and all wearing hospital pajamas. By the time I was working with him in the 1980s, those folks were living independently supported by case management teams and psychiatrists. Dr. Stein and his colleagues also ran a community mental health center that included crisis intervention services and outreach. That model of community mental health and crisis intervention is still practiced and has been covered in the New England Journal of Medicine.  Psychiatric residents are still trained in community mental health settings and many prefer to practice there.  Counties are not as enthusiastic and have shut down many if not most community mental health centers.

Community psychiatry is an obvious 50-year-old solution but it has to be funded. The same is true of affordable housing.  In some cases that housing needs to be supervised and also a sober environment. Both community psychiatry and affordable housing are casualties of business rationing that can only occur with the full cooperation of both state and federal governments. The current system costs about a trillion dollars in overhead that is directed to Wall Street profits and unnecessary meddling by middle managers. The only people who “sweep mental health under the rug” are large healthcare organizations and state bureaucrats who disproportionately ration it.  The "science of mental health" is not difficult at all.  Being forced to do it for free is difficult.

The 1980s were a critical time in establishing the managed care industry and taking all healthcare out of the purview of physicians.  While rationing psychiatric resources was being ramped up, services to treat alcoholism and addiction were essentially demolished. Suddenly you could not longer get detoxification services at most hospitals.  People were sent to social detox units run by counties where there was no medical coverage.  The thinking was that if a person developed medical complications like seizures or delirium tremens they could always be sent back to the hospital. The biggest risk was continued substance use and immediate relapse. Residential and outpatient treatment facilities never materialized.  Inadequate funding was a significant problem.  The managed care industry played a role in that case as well with absurd expectations and limits on treatment.  It is no accident that treatment for substance use disorders basically became non-existent.  None of the disproportionate rationing of mental health or substance abuse treatment is new.  It has been like this for 30 years because it is the government endorsed model of care.  

Overall, this editorial is a smokescreen over the proximate issues of guns and racism.  The author trivializes this as political rhetoric when in fact the rhetoric has all been pro-guns and pro-white supremacy.  It is the only rational explanation for turning the United States into an armed camp that has progressively increased the likelihood of gun violence. We are not talking about a pandemic precipitated phenomenon.  The gun violence has been multi-year and the pro-gun party has “doubled down” on it to make it more likely.  As far as politics go – now that we know how a partisan Supreme Court works – the Heller decision and the resulting liberalization of gun ownership should not come as a surprise.  On the issue of hate crimes, I can’t really think of anything more relevant in a case based on the public disclosures.  This was a specific crime directed at black Americans intentionally perpetrated in a neighborhood that was scouted ahead of time for that ethnicity. Brushing that aside to claim that this is a response to an embarrassing record on mental illness, when there is no evidence that is a factor is disingenuous.

American history including other recent mass shootings tells us that racism can be a causative factor.  What is never addressed is the omnipresent gun culture in the USA.  People with an apparent need for military weapons and handguns and politicians willing to give them unlimited access to carrying them in public, carrying them without permits, and stand your ground laws - encouraging violent confrontations with firearms.  All fueled by one party and their affiliated special interests.

Disingenuous discourse and misinformation is what we typically see these days. If you want the facts about what needs to be there in terms of a functional mental health system (and I know there are absolutely no business people and very few politicians that do) – ask a psychiatrist. If you want to know about what gun control needs to be in effect rather than claiming that psychiatrists are not preventing gun violence from people with no mental illness – you can also ask me.

I could put all of those details on a 4” x 6” card and it would work. 

But there is certainly nobody on the right or at the WSJ who wants to know that either.

 

George Dawson, MD, DFAPA

 

References:

1:  Daniel Henninger. The Next Pandemic: Mental Illness.  Wall Street Journal. May 18, 2022.

Graphics Credit:  Eduardo Colon, MD

My Opinion on Community Mental Health From 1989....

A friend of mine who also worked with me as an RN on an acute care psychiatric unit sent me this newspaper clip from 1989.  It is from the St. Paul Pioneer Press.  At that time I had just started working on an acute care inpatient unit at St. Paul-Ramsey Medical Center (SPRMC) after working in a community mental health center (CMHC) for three years.  The CMHC was in northern Wisconsin and SPRMC is in St. Paul, Minnesota.  In this brief letter to the editor, I was listing the style points between both systems.  Wisconsin was known to be an innovator in community mental health essentially inventing active outreach, providing meaningful crisis intervention services, and active case management with a goal of keeping people with severe mental illnesses in their own apartments in the community and out of hospitals.  Anyone with any experience at all realizes that this is the best approach to the problem.  We did not worry about it at the time, but it also kept people out of jail.  We had working relationships with law enforcement and would often see people in jail and facilitate their treatment there and transition back to the community.

As the medical director of a CMHC in Wisconsin in those days, I had a team meeting with case managers and nursing staff every morning.  We discussed crises and treatment plans for the 100 to 110 individuals under our care.  After that meeting everyone (except me) was driving off to meet our patients in the community.  We had an exemplary record of helping these folks stay out of the hospital and our case managers would go to the hospital and help get them discharged if they were at baseline.  We knew the resources, landlords, relatives, doctors, and local crisis housing.  We worked within a system that had a single-minded focus of supporting people in the community and at the administrative level we had state support mandated that the "money follows the client".  That did involve an incredible amount of paper work on the part of our case managers and needing to deal with a county bureaucrat but there were clear significant advantages over other systems.

Flashing forward 30 years has there been much progress?  I can say with certainly there has been absolutely no progress on the Minnesota side.  They have funded some assertive community treatment (ACT) teams but there is still a rationing mentality.  I heard the rationing mentality recently restated by the current head of the state hospital system.  Minnesota currently has a large steady state population of chronically mentally ill patients circulating through emergency departments, available beds, jails, and homelessness.  There is limited bed availability to the point that outpatient psychiatrists have to send their patients to the emergency department (ED) rather than referring them directly to affiliated hospital because they know there are no beds. That is also true for patients who need electroconvulsive therapy.  The constant stream of people to the ED creates a backlog there and getting patients out occurs only if they are held long enough for an inpatient bed to open, discharged untreated, or transferred to another hospital often several counties away.  In the meantime, the state hospital system has been reduced.

In a November meeting of the Minnesota Psychiatric Society (MPS), Kylee Ann Stevens, MD the Executive Director Direct Care and Treatment of the state hospital system provided some numbers for mental illness treatment but not addiction resources.  Those numbers are summarized in the graphic below.      

It is apparent by inspection that there has been a massive reduction is state hospital beds.  Just over the course of my career they have dropped by over 1,000%.  The bed situation is compounded by a "48 hour rule" enacted in 2014 that states that all patients with a question of mental competency in jails or correctional institutes must be admitted to a state facility within 48 hours.  That gives county Sheriffs preferred access to state hospital beds over treating psychiatrists.  Rather than look at recommended hospital beds per population the state does not plan to try to increase the beds.  A quote from the  National Association of State Mental Health Program Directors (NASMHPD) that "Building more inpatient bed capacity to meet demand is unsustainable" provided the rationale.  The conflict of interest there is obvious.  State Directors are basically accountable to politicians and bureaucrats who want to ration state supported health care especially to those with the least vocal advocacy. At one point in Minnesota over 11,000 beds were sustainable. The only thing different today is politics.

There is also a chronic unanswered question that has been hanging in the air for the last 20 years.  Did Minnesota intend to just shut down the state hospital system entirely? Certainly the trajectory of bed closures was on track to do that.  In the MPS meeting we never learned what the absolute minimum number of beds was.  In talking with doctors and nurses who worked in that system they certainly thought that was the goal.  The current minimalist system may be in place by default rather than design - the end product of a failed attempt to close down all of the state hospital beds.

So Minnesota continues to flounder.  What about Wisconsin?  I don't think that their inpatient bed capacity is much better but I don't have the exact number.  The community mental health movement is still alive and well but I am aware of no significant innovation.  The Wisconsin Mental Health Statutes appear to have expanded significantly and law enforcement seems to have assumed more of a gatekeeper role in emergency treatment.  I can't comment on whether the Wisconsin system is more cost effective and patient centered than Minnesota but I invite clinicians to comment on that.

Relative to the initial news clip - progress in general in the treatment of psychiatric disorders is not a word that can be used.  Politicians run these systems and not physicians.  As long as that is true we can depend on no progress.

George Dawson, MD, DFAPA  

See also:

Minnesota's Abandonment Of Severely Mentally Ill - Nearly Complete

News Flash From the StarTribune - Psychiatric Patients Have "Nowhere To Go"

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 years of Rationing

Running the numbers Minnesota has 3.2 state hospital beds for 100,000 people.

New England Journal of Medicine Discovers Assertive Community Treatment

I have been a reader and subscriber to the New England Journal of Medicine (NEJM) every year since medical school.  One of the first courses they taught us in those days was Biochemistry and being an undergrad chem major I had a natural affiliation with many of the biochem professors.  The format in those days was lectures focused on the major topics and seminars to take a more detailed look at the experimental and theoretical aspects of the field.  They were fairly intensive discussions and critiques of research papers selected by the professors.  The department head was the mastermind behind this technique and one days he discussed his rationale for it.  He hoped that every medical student coming through that course would continue to read current research.  He strongly recommended subscribing to and reading the NEJM not just in Medical School but for years to come.  In my case it worked.

One of the sections that you don't hear too much about is the clinicopathological exercise that comes out each week.  It is basically a publication of formal case records of Massachusetts General Hospital and the associated findings and discussions.  These case reports are interesting for a couple of reasons - they show patterns of illness that clinicians can familiarize themselves with and they show at least some of the diagnostic thinking of experts.  During the time I have been reading them, they also discuss psychiatric comorbidity of physical illness and medical etiologies of psychiatric symptoms.  At one point I was a member of an informatics group and was very interested in studying this section of the NEJM from a psychiatric perspective.  At that time it seemed that I was the only psychiatrist with that interest.  With modern technology a study like this is more possible than ever.  For example, searching the case records feature of the NEJM from December 1989 to December 2015 yields a total of 31 cases of psychosis.  The etiologies of these cases range from purely medical etiologies, to delirium associated with the medical condition to pure psychiatric disorders with no specific medical etiology.  I have never seen this referred to as a teaching source for psychiatric residents admitting patients to acute care hospitals or consultation liaison services, but I could see it serving that function.  Instead of the usual lectures on medical psychiatry that typically contain PowerPoint slides of the "240 medical etiologies of psychosis" - a discussion of common mechanisms noted in these cases might be more instructive and be a better source for acquiring pattern matching capacity to broaden diagnostic capabilities.  It also put the DSM approach to psychiatry in proper perspective.  Knowing the lists and definitions of psychosis is nowhere enough to be a psychiatrist in a medical setting.  A seminar including this material can make these points and teach valuable skills.

That brings me to the case this week A Homeless Woman with Headache, Hypertension, and Psychosis.  Two of the authors are psychiatrists and the third is an internist.  The authors describe a 40 year old homeless woman with a diagnosis of schizophrenia and severe hypertension and how they established care over a number of years using the Assertive Community Treatment (ACT) model of care.  The patient's history was remarkable for a 12 year history of psychosis characterized primarily by paranoid and grandiose delusions.  She was homeless sleeping in public buildings for about 4 years and that seemed to be due to the thought that she needed to stay outside to watch over people.  She had a brief episode of treatment with olanzapine during a hospitalization about 5 years prior to the initiation of care by the authors, but did not follow up with the medication or outpatient treatment.  She was also briefly treated with hydrochlorothiazide 4 years earlier with no follow up care or medication.   She was admitted for treatment of a severe headache and a blood pressure of 212 systolic.  At the time of the admission physical BP were noted to be 208/118 and 240/130 with a pulse of 95 bpm.  She had bilateral pitting edema to the knees and bilateral stasis dermatitis.  She had auditory hallucinations consisting of voice of God and Satan and grandiose delusions.  Lab data showed a microcytic anemia.  She had standard labs to rule out myocardial infarction and vitamin deficiency states.  Blood pressure was acutely stabilized and she was discharged on lisinopril, thiamine, multivitamin, omeprazole, and ferrous sulfate.  The final diagnoses include schizophrenia, cognitive impairment associated with schizophrenia, hypertension, and homelessness.

The authors provide a good discussion of diagnosis of primary and secondary psychotic disorders and provide some guidance on timely medical testing for metabolic, intoxicant, and neurological abnormalities.  Delirium is identified as more of a medical emergency and necessitating more scrutiny.  The idea that delirium can be mistaken for psychosis is a valuable point that is often missed during emergency assessment especially if the patient has a pre-existing psychiatric diagnosis on their medical record.  The authors sum up screening tests that are necessary for all patient with psychosis and the tests that  are reserved for specific clinical concerns like encephalitis, seizures, structural brain disease, and inflammatory conditions.  They also suggest screening for treatable conditions and inflammatory conditions.

There is a good section on the follow up care that this patient received.  She was seen in a clinic for the homeless, where problems were gradually noted and worked on with her full cooperation.  This is not the typical approach in medicine where it is assumed that the patient will tolerate a complete history and physical exam and then cooperate with any suggested medical testing and treatment.  In this case, the practical problems of foot care were addressed.  She was eventually seen in 60 visits over two years.  By visit 19 she described concerns about cognitive symptoms and by visit 33 she was accepting treatment for psychosis with olanzapine.  She eventually allowed a more complete treatment of here associated physical symptoms including an MRI scan of the brain and treatment for migraine headaches.  The authors point out that tolerating medical and psychiatric uncertainty is a critical skill in treating people who need to habituate to medical systems of care.  A more direct approach is alienating.  It does tend to create anxiety in physicians about what is being missed and not addressed in a timely manner.  There is always a trade off in engaging people for long term care in more stable social settings and pushing to maximize diagnosis and treatment in a way that they might not be able to tolerate.  The ACT model stresses the former.           

There are some very relevant ACT concepts illustrated in this article.  First and foremost the rate at which medical interventions are prescribed depends almost entirely on the patient's ability to accept them.  This is at odds with the timeliness of medical interventions that most physicians are taught.  I say "almost entirely" in this case because the authors were very fortunate that the patient cooperated with treatment of extreme hypertension.  One of the common hospital consultations for psychiatric is a person with a mental illness and life-threatening illness who is not able to recognize it.  Even on the subacute side of care there are many tragedies due to patient with mental illness not being able to make decisions that could have saved their life.

I think that there are also some very practical applications for psychiatry on an outpatient basis.  Most patients with severe mental illnesses are never going to see a primary care provider 60 times before starting treatment.  It only happens in a subsidized setting with physicians who are highly motivated to see a certain approach work.  The care model described in the paper is certainly not the collaborative care model that some authors, the American Psychiatric Association (APA), and the managed care industry keeps talking about.  There is also the obvious point that people don't go into primary care because they like talking with people who have severe mental illnesses.  Psychiatrists need to see these people either in ACT teams or community mental health centers.  It won't work in a standard managed care clinic seeing a patient who is this ill - 2- 4 times a year for 10 - 15 minutes. ACT psychiatrists need to know about primary care providers who work better with the chronically mentally ill or people with addictions and make the appropriate referrals.  All psychiatrists should be focused on blood pressure measurements and work on getting reliable data.  Funding for psychiatric treatment often precludes ancillary staff present in all other medical settings to make these determinations.  Existing collaborative care models in primary care clinics can get blood pressure measurements on the chart but restrict patient access to psychiatrists.  

This Case Report is a good example of what can happen with a real collaborative care model that focuses on the needs of a person with severe chronic mental illness.  It is a model of care that I learned 30 years ago from one of the originators and it is more relevant today than ever.  It is also a model of care that is currently rationed and provided in the states where it is available to a small minority of patients.  It is not the method of collaborative care that you hear about from the APA, the managed care industry, or government officials.  It should be widely available to all psychiatric patients with complex problems.


George Dawson, MD, DFAPA


References:

1: Shtasel DL, Freudenreich O, Baggett TP. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 40-2015. A 40-Year-Old Homeless Woman with Headache, Hypertension, and Psychosis. N Engl J Med. 2015 Dec 24;373(26):2563-70. doi: 10.1056/NEJMcpc1405204. PubMed PMID: 26699172.

2:  New England Journal of Medicine Case Records of MGH x psychosis (on Medline).  Shows 101 references as opposed to 31 on NEJM search engine and 10 on basic Medline search.

3:  Marx AJ, Test MA, Stein LI. Extrohospital management of severe mental illness.Feasibility and effects of social functioning. Arch Gen Psychiatry. 1973 Oct;29(4):505-11. PubMed PMID: 4748311.

4:  Stein LI, Test MA, Marx AJ. Alternative to the hospital: a controlled study.Am J Psychiatry. 1975 May;132(5):517-22. PubMed PMID: 164129.

5:  Test MA, Stein LI. Alternative to mental hospital treatment. III. Social cost.  Arch Gen Psychiatry. 1980 Apr;37(4):409-12. PubMed PMID: 7362426.

6:  Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptualmodel, treatment program, and clinical evaluation. Arch Gen Psychiatry. 1980 Apr;37(4):392-7. PubMed PMID: 7362425.

7:  Weisbrod BA, Test MA, Stein LI. Alternative to mental hospital treatment. II.   Economic benefit-cost analysis. Arch Gen Psychiatry. 1980 Apr;37(4):400-5. PubMed PMID: 6767462.


Attribution: 

Photo at the top of this post is by Jonathan McIntosh (Own work) [CC BY 2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons.  Original photo at https://commons.wikimedia.org/wiki/File%3ARNC_04_protest_77.jpg

Rampage Killing - The Public Health Approach Is Still Ignored

I was watching the news this morning on the latest rampage killing.  This news coverage features numerous replays of a YouTube video posted by the killer about twenty minutes before he started shooting.  I listened to an expert, (at least as much of an expert as you can be) talk about his approach to the problem.  He talked about the limitations of the post event "psychoanalysis" of the  killer and how a more functional approach would be to harden targets and warn the victims.  He talked about the false positive rate of how most people who threaten or post videos like this do not carry out the threatened violence making it impossible to detain all the people making the threats.  He said that it may be useful to talk to people with these problems but the psychology of this individual not only made that impossible, but even talking with mental health professionals was not likely to help him.

I had just finished reading the latest Psychiatric Annals.  This month's topic was Psychotic Rampage Killers.  Three of the four articles were written by C. Ray Lake, MD,  and the fourth by James l. Knoll, MD and J. Reid Meloy, PhD.  Dr. Lake also had an opinion piece on why mass murder diagnoses were justification for breaking the Goldwater Rule specifically the part ".... it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement."  He points out that this rule is currently routinely broken with speculative diagnoses about psychotic mass killers.  He also suggests that the correct diagnosis is still an open question.  He also points out that the inadequate care of individuals with psychosis is an issue and that has been one of the themes of this blog.

Lake's main contention is that Psychotic Rampage Killers are really bipolar and manic and do not have schizophrenia.  He briefly reviews some of the facts including that even though a small percentage of killers (<10%) are psychotic, there are a distinct number of correlates that cause them to differ from non-psychotic killers most notably a motivation that is delusional in nature, the fact that they are always caught (as opposed to 33% of non-psychotic killers never being caught), warnings  and plans prior to the act are common, and half attempt or commit suicide.  The psychotic killer basically focuses on the event as a final stage and does not plan to escape or benefit from the event.  He makes the point that all of the psychotic killers realize that what they are doing is illegal and that can exclude an insanity defense if they survive.  I think this is also a common misconception on the part of the public.  People who are psychotic can carry out detailed plans that are consistent with the logic of their psychosis.  It certainly does not mean that they are rational.  He briefly reviews the issue of violence and psychosis and takes on the political issue that "violence perpetrated by mentally ill is no greater than violence carried out by the non-mentally ill population."  This has always been a statistical fallacy balancing the violence by a subgroup of the mentally ill against the violence of high risk members in the general population.  By now there should be no doubt that some people with severe mental illness have a much higher rate of violence than the general population.   Further there are known diagnostic features within that subgroup that are associated with the increased risk of violence including alcohol and drug addiction, paranoia, command hallucinations, and a lack of treatment.

Lake's initial discussion of prevention points out that gun legislation is not likely to be a solution because of existing biases by legislators in this area to do nothing despite the fact that most rampage killer use firearms and 75% of them were legally acquired.  Civil commitment laws were described as "limited by our sensitivity to personal freedoms."  In my experience, it comes down to the courts involved and the administrative element through the involved counties.  I have been personally involved in thousands of civil commitments and decisions by the courts often depend on the most recent "mistake" defined as an adverse outcome that occurred when a potentially violent person was released.  Certainly any case involving firearms and hundreds of rounds of ammunition or an actual shoot out with the police needs very close scrutiny.  Any "welfare check" by the police of a potentially dangerous person should involve a search for weapons and actual threats especially if they were posted on social media.  Mental health professional contact was described as being potentially useful but also limited by the nature of the follow up of patients with psychosis.  In fact, violence needs to be incorporated into the treatment  plan for patients with psychosis and violence and addressed in a comprehensive manner.  An appointment for a ten minute discussion of medications is not acceptable and it really is not an acceptable level of care for anyone with psychosis whether they are potentially violent or not.  Lake points out that there is also a call to avoid using the names and other materials posted by rampage killers.  I think that is a good idea and therefore do not refer to any of these materials here.

The discussion of what is the proper diagnosis of these murderers is the next article. Lake reviews the evidence (largely from media reports) and concludes that psychotic mania is the most likely diagnosis.  He has an interesting diagram in the article that shows both psychotic depression and psychotic mania converging on the diagnosis of "paranoid psychosis from mood disorders".  He also has interesting graphic using Venn diagram approaches that range from Kraepelin's initial clear distinction between bipolar disorder and schizophrenia to the more spectrum based approach beginning with Timothy Crow's continuum with schizophrenia and bipolar disorder being at opposite ends of the spectrum.  He expressed some surprise that schizoaffective disorder was still in the DSM-5, but it also considers Schizophrenia Spectrum and Other Psychotic Disorders separate from Bipolar and Related Disorders.  In reviewing the details from the media of five Rampage Killers, he concludes that in all cases psychotic mania was a diagnostic consideration based on hyperactivity, insomnia, and delusional thinking.  In one case there was a family history of bipolar disorder.

Lake goes on to point out that without an accurate diagnosis of bipolar disorder, patients do not receive standard of care which he defines as mood-stabilizing drugs.  He digresses to talk about the legal profession changing the diagnostic habits of professional and uses false memory syndrome as a case in point.  He goes on to suggest that "Successful legal action in the form of a class action lawsuit filed on behalf of unrecognized bipolar disorder misdiagnosed with and mistreated for schizophrenia could quickly change psychiatric diagnostic practices.  Another potential class action lawsuit is possible from some of the mass murder victims families in cases where before the rampage, the psychotic murderer had been treated for schizophrenia and not bipolar disorder."  Dr. Lake considers the problem basically to be one of "obsolete diagnostic concepts that promote substandard medical care for psychotic patients."

In 30 years of practice, I have not made the same observations that Dr. Lake has made.  In the example of false memory syndrome, that diagnosis and the associated multiple personality disorder phenomena was really practiced by a small minority of psychiatrists.  It was actively criticized at the time by prominent psychiatrists in prominent journals.  I  doubt that lawsuits against anyone had any impact on the diagnostic concepts of the vast majority of psychiatrists.  On the issue of diagnosing bipolar disorder based on a spectrum concept and the features of hyperactivity and insomnia. I would suggest that is fraught with problems.  Having seen patients over time patients with schizophrenia can also have these features. The same problems occur when considering standard of care arguments for mood stabilizers.  All of them (lithium, divalproex, lamotrigine) have significant problems with both efficacy and side effects profiles.  Antipsychotic medication is probably necessary in at least 50% of bipolar patients (in addition to the mood stabilizer), and many antipsychotics are FDA approved for acute bipolar disorder and bipolar depression.  But the larger problem is that there needs to be a standard of care than encompasses much more than medication.  That is good for all patients with psychosis and potentially very good for those at risk for violence.

The recommendations I have discussed before on this blog that I think will have the most impact would be:

1.  Establish centers of excellence for treating psychotic disorders.  We know the outcome of rationing mental health services.  We end up with inadequate inpatient and outpatient care for patients with psychosis and bipolar disorder.  The focus of all for profit systems is to transfer the cost of care for these individuals to public systems including correctional facilities.  If they end up being cared for in a for profit system, the care is concentrated on their ability to see a physician or more appropriately a "prescriber" for about 10-20 minutes and accurately describe their problems.  It is well known that psychotic rampage killers do not consider their homicidal ideation to be a problem and may actively try to hide those thoughts from any interviewer.

2.  A standardized approach to law enforcement intervention.  Law enforcement has a number of possible interventions available to them that are not available to mental health professionals.  The duty to warn legislation has blurred these distinctions and essentially removed a lot of responsibility from law enforcement.  There is really no reason why a person posting obvious threats on the Internet should not be treated with the same degree of caution as perpetrators of domestic violence.  That would include proscriptions against owning and acquiring firearms, police surveillance and where necessary orders for protection.  Threats to kill should trigger a response that involves a search for firearms and materials showing a plan to perpetrate violence.

3.  A public health approach focused on the issue of homicidal ideation as a potential symptom of mental illness.  The public and the patients themselves need to be able to conceptualize this problem as an illness and a symptom that does not need to be acted upon.  The article reference here refer to outdated diagnostic concepts and I would include the idea that patients with psychosis especially delusions cannot modify their thinking by means other than medication.  It certainly happens in response to events but also as a result of psychotherapy.

4.  Comprehensive outpatient care.  Brief checks focused on medications are doomed to fail.  These patients and all patients with psychoses need comprehensive outpatient care that includes home visits when necessary, psychotherapy, comprehensive cognitive assessments, and vocational rehabilitation.  When I first started working these were all available in my clinic.  Today it is unheard of.

Psychosis and psychotic people who kill are the psychiatric equivalent of a heart attack.  Any middle aged person in the country with chest pain gets admitted and goes through about 24 hours of comprehensive testing and imaging.  I don't know the actual statistics but I would guess that most of these people are not having heart attacks and their hospital and Cardiology bill is about $30,000 - $50,000.  Our system of care expects a person with psychosis who is totally unaware of the fact that they have a significant disturbance in their thinking to want to actively manage that illness on resources that are trivial in comparison.  In the case of an identified heart attack, that person will receive hundreds of thousands of dollars of additional care.  By comparison a person receiving the most comprehensive level of community care - Assertive Community Treatment or ACT receives those services for about $10,000 per year.  That service is typically limited to a few hundred people in each state and not covered by medical insurance.

The best approach to rampage killers is to offer a much better standard of care to all people with psychosis.  If it the right thing to do from the perspective of psychiatry, public health, and humanism.

George Dawson, MD, DFAPA

Lake CR.  Rampage murders, Part I: Psychotic versus non-psychotic and a role for psychiatry in prevention.  Psychiatric Annals 2104 (44) 5: 216-225.

Lake CR.  Psychotic rampage murders, Part II: Psychotic mania, not schizophrenia.  Psychiatric Annals 2104 (44) 5: 216-225.

Supplementary 1:

"Charges for chest pain, for instance, rose 10 percent to an average of $18,505 in 2012, from $16,815 in 2011. Average hospital charges for digestive disorders climbed 8.5 percent to nearly $22,000, from $20,278 in 2011."

J Creswell, S Fink, S Cohen.  Hospital Charges Surge for Common Ailments, Data Shows.  New York Times; June 2, 2014.

American Psychosis - The Final Take

I finished reading E. Fuller Torrey's recently released book American Psychosis - How the Federal Government Destroyed the Mental Illness Treatment System .  I recommended it on the basis of a a quick initial read of a brief section on managed care but can provide additional details at this time.  I will start with the conclusion.  Criticizing an expensive, fragmented, and poorly conceived system of care for severe mental illness is a fairly easy task for any psychiatrist who tries to provide care for the target population of people with schizophrenia, bipolar disorder and severe mood disorders. This book concentrates many of the references about deinstitutionalization, incarceration of the mentally ill, victimization of the mentally ill, and aggression and violence by the mentally ill in one place.  In the conclusion Dr. Torrey also recommends some 10 potential solutions to the problems and more importantly suggests the some of these need to be implemented on a small scale rather system wide.  

I am sure that Dr. Torrey and the publisher of this book would not be very happy if I put all 10 of his proposed solutions on this blog, so I am going to focus on one that is consistent with my initial post and one of the major themes of this blog:

"For profit funding of of public mental illness services has been tried and it does not work." 

This is the real experience of anyone who has worked in psychiatric acute care and by that I mean the hospital in your community where people are brought in by the police on emergency holds.  Even in that setting there are levels of acuity.  In a metropolitan area there may be 8 or 10 psychiatric inpatient units but only one or two of them will accept patients with high levels of aggression or suicidal behavior.  In an ideal world these would be units where there are staff with high levels of expertise in treating these severe conditions, but the reality is that economic considerations are at the top of the list.  There needs to be adequate staffing for close supervision and the staff have to be able to deal with high levels of aggression toward self or others.  There also needs to be expertise in recognizing and treating alcohol and drug intoxication and withdrawal states.  There is usually minimal attention paid to the therapeutic aspects of the environment.

When I first started working in that environment it was the late 1980s.  I had just completed a three year stint as the medical director of a very good community mental health clinic that offered case management and Assertive Community Treatment.  I was well trained in community psychiatry at the University of Wisconsin Psychiatry Department and it was good to actually practice it with a team of highly motivated people.  
                                                                   
The first months on the inpatient unit resulted in several "denials" by insurance company intermediaries functioning to ration care.  Keep in mind that all of these patients were in the highest acuity unit in the hospital, had problems with suicidal and aggressive behavior, and many needed detoxification. The rationale of the "peer reviewers" was the the patient did not require acute care or the care could be provided at a less intensive facility.  Apart from county detox facilities that had policies against admitting suicidal or aggressive patients - no less intensive facilities existed.

When you are in that environment trying to provide care, it is pretty obvious that this peer review process is basically an insurance company game to make money.  In the small print in the denial letters there was an option to appeal all denials to an administrative law judge within the state.  I asked my colleagues and nobody had tried that route.  I collected 12 denials and requested a hearing in front of the administrative law judge.  I took a day of vacation to go to court.  A week before the hearing I was informed that my hearing was cancelled and the administrative law judge decided in favor of the insurance company.  I appealed to the Attorney General on the basis of conflict of interest stating that the peer reviewers worked for a competing organization and therefore this was anticompetitive activity.  The AG informed me that they were independent contractors.  How can you be an independent contractor if you collect a paycheck from the organization that is denying care by your competitor?  It was clear to me that the state government was very friendly to the managed care industry.

The whole managed care strategy for rationing care or in  extreme cases shutting down entire psychiatric units was outlined in my previous post on overutilization.  It is the basic money making strategy of managed care organizations.  It essentially doubles down on rationing.  That occurs because hospitals are paid a set amount for taking care of people regardless of how long they are there and that amount is denied in as many as 10% of cases.  If there is one deficiency of this book it is a lack of granularity on this issue.  Dr. Torrey approaches the problem as a top down problem of policy deficiency, driven by an ideology that bed capacity could be shut down and not missed either because of the toxicity of state hospital settings or too much faith in the federal initiated community mental health movement. 

Assuming that a patient can actually get the level of acute care that they need without being thrown out of the hospital by an insurance company, the fragmentation of care does not stop there.  Even though insurance companies say they are emphasizing outpatient care, getting an appointment may be impossible.  The prescribed medications may be denied.  Housing options or community case management for people with severe mental illness are not usually available unless the insurance changes to a public option.

American Psychosis covers the funding and policy issues on a global level before it gets to the suggested solutions.  Excellent examples are given to illustrate these points.  For example, North Carolina is given as the example of what happens when a state mental health system is privatized (p 158).  The parameters of the dramatic deterioration in services that resulted from this maneuver is a well documented example of what happens when a for-profit entity begins to manage care and shift the responsibility for care of serious mental illnesses to the correctional system.

American Psychosis is a well organized analysis of the problems that occurred as the result of an initiative in the Kennedy administration.  It contains a lot of information and references about what has happened as the result of these decisions.  There is also a subtext and that is it is written from the perspective of a psychiatrist who has been a thought leader on the issue of treating people with severe mental illness.  Only a minority of people in the United States understand that perspective and I think that there will be predictable backlash from the constituencies that believe a severe mental illness is a preferred state and that everyone should have the right to enjoy it.  

That is not the experience of any acute care psychiatrist and Dr. Torrey presents that perspective very well. 

George Dawson, MD, DFAPA