Is President Obama Reading This Blog?

Not really, but you can find the mass shooting links on this blog at this link.  They extend back three years and they overlap with a number of posts on homicide prevention.  They also overlap in many areas with the President's speech.  This was President Obama's 15th address to the nation following a mass shooting incident.  A couple of other landmarks - this was the 40th time this year that a gunman opened fire in a school and the 294th mass shooting incident this year.  Both of these markers illustrate how tragic but absurd this problem is in America.  How can responsible people allow this to happen?

The President is coming to the only logical conclusion that a person can come to about mass shootings and the relationship to firearms.  That point in this speech was when he said that our thoughts and prayers for the families and survivors are not enough.  We cannot keep making these pat statements in response to continuous mass shootings as though nothing can be done to prevent them.  We cannot treat mass shootings like they are routine:

"Earlier this year, I answered a question in an interview by saying, “The United States of America is the one advanced nation on Earth in which we do not have sufficient common-sense gun-safety laws -- even in the face of repeated mass killings.”  And later that day, there was a mass shooting at a movie theater in Lafayette, Louisiana.  That day!  Somehow this has become routine.  The reporting is routine.  My response here at this podium ends up being routine.  The conversation in the aftermath of it.  We've become numb to this."

 The familiar refrain about condolences to everyone and now it is time to move on needs to stop.  With governments that regulate what a lot of us do at work every day - right down to how we cross the Ts and dot the Is - it is difficult to believe that more functional gun control laws cannot be passed.  In his speech he points out that this is possible and there are laws that have been shown to work in other countries and in specific counties and municipalities in the United States.

At one point he speaks to the mind of the perpetrator:

"We don't yet know why this individual did what he did. And it's fair to say that anybody who does this has a sickness in their minds, regardless of what they think their motivations may be. But we are not the only country on Earth that has people with mental illnesses or want to do harm to other people. We are the only advanced country on Earth that sees these kinds of mass shootings every few months."

People tend to get hung up on whether specific perpetrators have a diagnosable mental illness and whether it is treatable.  They tend to get hung up on whether the behavior of violent individuals can be predicted over time.  They tend to be very pessimistic about the nature of the problem and whether insightless people will ever be able to get the kind of help that they need to prevent mass shootings.  It might be easier if there was some education about the types of situations that lead to these problems and the fact that in most of those cases, help is available.  That specific help will prevent homicides and prevent the unnecessary loss of lives of both the perpetrators and the victims.  

The President ended with a comment on the political process and an appeal to gun owners on the issue of whether they are being supported on this issue by an unnamed organization or not.  It was a compelling speech and the arguments are powerful.  As a politician, he is focused on political action and on common sense gun safety laws.  I have stated that it might be best to proceed from a public health standpoint and a focus on violence prevention and forget about legal approaches largely because there has been no political will on this issue.  President Obama has given one of the most compelling speeches on this issue that I have ever witnessed and it will be interesting to see the result.

From the medical and psychiatric side, our advocacy still needs to be on the public health side of the equation.  For me that comes down to seeing the problem to a significant extent as violence and homicide prevention.  We need more public education on the predisposing mental states and how to get assistance when these states are recognized.




George Dawson, MD, DFAPA


References:

Statement by the President on the Shootings at Umpqua Community College, Roseburg, Oregon.  October 1, 2015.  Transcript

Straight Talk About the Government Dismantling Care for Serious Mental Illness

The ShrinkRap blog posted a link to an E. Fuller Torrey and D.J. Jaffe editorial in the National Review about how the government has dismantled mental health care for serious mental illnesses and some of the repercussions.   Since I have been saying the exact same thing for the past 20 years, they will get no argument from me.  Only in the theatre of the absurd that passes for press coverage of mental illness and psychiatry in this country can this subject be ignored and silenced for so long.  It was obviously much more important to see an endless stream of articles trying to make the DSM-5 seem relevant for every man.  The stunning part about the Newtown article is the commentary about what government officials responsible for policy have actually been saying about it.

The authors waste very little time examining the sequence of events in the Obama administration following the Newtown, Connecticut mass shooting.  President Obama initially stated he would "make access to mental health care as easy as access to guns." and set up a Task Force under Vice President Biden to make recommendations.  The authors argue that the agency that was consulted, the Substance Abuse and Mental Health Services Administration (SAMHSA) promotes a model of treating mental illness that has no proven efficacy, does not discuss serious mental illnesses in its planning document, ignores effective treatments for serious mental illnesses and actually goes so far as to fund programs that block the implementation of effective treatment programs.  In an example of the obstruction of effective programming by SAMHSA funded programs following the Newtown mass shooting:

"But, alas, the situation is even worse. SAMHSA does not merely ignore effective treatments for individuals with severe mental illness. It also funds programs that attempt to undermine the implementation of such treatments at the state and county level. One such program is the Protection and Advocacy program, a $34 million SAMHSA program that was originally implemented to protect patients in mental hospitals from abuse. It was kidnapped by civil-liberties zealots and has been used to block the implementation of assisted outpatient treatment, funding efforts to undermine it in at least 13 states. For example in Connecticut, following the Newtown massacre of schoolchildren, the federally funded Connecticut Office of Protection and Advocacy for Persons with Disabilities testified before a state-legislature working group in opposition to the proposed implementation of a proposed law permitting court-ordered outpatient treatment for individuals with severe mental illness who have been proven dangerous. The law did not pass."  (page 3, par 2.)

In other words, a SAMHSA funded program was opposed to a law in Connecticut that could potentially reduce violence from persons with severe mental illness.

SAMHSA administrators are quoted at times in the article. Any quote can be taken out of context but the characterizations of severe mental illness as "severe emotional distress", "a spiritual experience" and "a coping mechanism and not a disease" reflect a serious lack of knowledge about these disorders.  The idea that "the  covert mission of the mental health system ...is social control" is standard antipsychiatry philosophy from the 1960s.  How is it that after the Decade of the Brain and the new Obama Brain Initiative  we can have a lead federal agency that apparently knows nothing about the treatment of serious mental illnesses?  How is it that apart from  some fairly obscure testimony, no professional organizations have pointed this out?  How is it in an era where governments at all levels seem to demand evidence based care, that a lead agency on mental health promotes treatment that has no evidence basis and ignores the treatment that is evidence based?

Having been a long time advocate for the prevention of violence by the treatment of severe mental illnesses my comments parallel those of the authors.  Inpatient bed capacity in psychiatry has been decimated.  They point out that there are only 5% of the public psychiatry beds available that there were 50 years ago.  It is well known that people with mental illnesses are being incarcerated in record numbers and some of the nation's county jails have become the largest psychiatric institutions.  Where are all of the civil liberties advocates trying to get the mentally ill out of jail?

Only a small portion of the beds available can be used for potentially violent or aggressive patients and that number gets much smaller if a violent act has actually been committed. Most of the bed capacity in this country is under the purview of some type of managed care organization and that reduces the likelihood of adequate assessment or treatment.  The discharge plan in some cases is to just put the patient on a bus to another state.

Community psychiatry is a valuable unmentioned resource in this area.  In most of the individual cases mentioned in this article, the lack of insight into mental illness or anosognosia is prominent.  It is not reasonable to expect that a person with anosognosia will follow up with outpatient appointments or even continue to take a medication that treats their symptoms into remission.  Active treatment in the community by a psychiatrists and a team who knows the patient and their family is the best way to proceed.  All of this active treatment has been cost shifted out of insurance coverage and is subject to budget cuts at the county and state level.

Civil commitment laws and proceedings are probably the weakest link in treatment.  Further cost shifting occurs and violent patients often end up aggregating in the counties with the most resources.  Even while they are there, many courts hear (from a budgetary perspective) that they are committing too many people and the interpretation of the commitment law becomes more liberal until there is an incident that leads to the interpretation tightening up again.  Bureaucrats involved often become libertarians and suggest that commitment can occur only if an actual violent incident has happened rather than the threat of violence.

Although Torrey and Jaffe are using the extreme situation of violence in the seriously mentally ill to make their point, the majority of the seriously mentally ill are not violent.  They need the same resources.  It has been thirty years of systematic discrimination against these people, their families and the doctors trying to treat them that has led to these problems.  I pointed out earlier on this blog the problem I have with SAMHSA and the use of the term "behavioral health".  The problems with SAMHSA and current federal policy are covered in this article and I encourage anyone with an interest to read it.  If history is any indication, I don't expect anything serious to come of the criticism.  I anticipate a lot of rhetorical blow back at Dr. Torrey.  But as a psychiatrist who has worked in these environments for most of my career, his analysis of the problem is right on the mark.

George Dawson, MD, DFAPA

E. Fuller Torrey & D.J. Jaffe.  After Newtown.  National Review Online.

White House.  Now Is The Time.  The President's plan to protect our children and our communities by reducing gun violence.  January 16, 2013.

No applause from me

The APA came out with a press release today in response to President Obama's initiative to reduce gun violence and prevent future mass shootings.  Although the release "applauds" these proposals they seem to be short on the mental health side. From the APA release:

“ We are heartened that the Administration plans to finalize rules governing mental health parity under the 2008 Mental Health Parity and Addiction Equity Act, the Affordable Care Act, and Medicaid. We strongly urge the Administration to close loopholes involving so-called ‘non-quantitative treatment limits’ and to ensure that health plans deliver a full scope of mental health services in order to comply with the law. Such action will best ensure that Americans get the full range of mental health services we believe they are intended to receive under federal law.”

So I guess the APA is applauding the initiative but encouraging the closing of loopholes. Call me a skeptic but 20 years of rationing mental health services and cutting them to the bone through managed care intermediaries and aggregating those managed care intermediaries into accountable care organizations does not bode well for the "full range of mental health services". The APA seems to have the naïve position that you can support managed care tactics and provide increased access to quality mental health services.

The next point in the APA release supports school screening and enhanced mental health services in schools for both violence prevention and to identify children at risk or in need of current mental health services. Those are certainly laudable goals but there is minimal evidence that screening is effective. There is also the problem of a lack of infrastructure.  Twenty years of rationing and restricting access to psychiatric services has resulted in long waiting lists or completely unavailable services. If you talk with a child psychiatrist, they will tell you that the current system is set up to offer medications in place of a more comprehensive approach to psychiatric treatment. At the social services level, residential treatment for children with severe problems is practically nonexistent. As a recent example, I was informed last week of a school social worker who could not get a child assessed for admission to an adolescent psychiatric unit and when that was not possible could not get an appointment to see a psychiatrist in a major metropolitan area. Screening for problems does not make any sense unless there is an infrastructure available to address those problems when they are found.

The final point in the APA release addresses the issue of physicians being able to discuss firearms at home with their patients. This has been a standard intervention for physicians ever since I have been practicing and it is always part of an assessment for suicide and homicide risk. There was a state initiative last year making it illegal for physicians to discuss firearms in the home with their patients. Part of the rationale for that law was that it could result in firearm owners being identified and placed them at theoretical risk for their firearms to be confiscated by the state.  I can say from experience that my discussions with patients about firearm safety and the discussions of other physicians that I have been aware of have been highly productive and have probably saved countless lives. The best example I can think of is talking with a primary care physician who asked me to take a look at a closet full of firearms that he convinced patients to turn into him over the years before he turned them into the police. Those patients were all depressed and suicidal and at high risk for impulsive acts. He would not have been able to make that intervention with a gag law in place preventing those discussions.

What about the President's original release?  It had 84 instances of the word "mental" usually as "mental illness" or "mental health".  As noted above it has received some accolades from the APA and other members of the mental health community. It elicited a strong and poorly thought out response from the NRA  who produced a YouTube video accusing the President of being elitist and a “hypocrite” because his daughters had armed security but he expected that everyone else’s kids would be protected by gun free zones.  The White House responded quickly:

“Most Americans agree that a president’s children should not be used as pawns in a political fight,” said Jay Carney, the White House press secretary. “But to go so far as to make the safety of the president’s children the subject of an attack ad is repugnant and cowardly.”

The full text of the White House 22 page document is located at this link.  It is ambitious and covers a lot of ground in terms of the specific regulation of firearms, school safety, and increasing mental health services. The firearm regulation is most specific in that it closes background check loopholes, bans assault weapons, outlaws armor piercing bullets, and sets the maximum magazine size at 10 cartridges.  Part of this document is a "call to Congress" so it is not clear to me how much can be accomplished by the President's executive orders as opposed to Congressional action.  I am reminded of the NRA President last weekend stating that Congress would never pass a ban on assault weapons.  The Executive Order section of that part of the document lists the following activities:

1.  Addressing unnecessary legal barriers in health laws that prevent some states from making information available about those prohibited from having guns.

2.  Improving incentives for states to share information with the system.

3.  Ensuring federal agencies share relevant information with the system.

4.  Directing the Attorney General to work with other agencies to review our

laws to make sure they are effective at identifying the dangerous or untrustworthy individuals that should not have access to guns.

The school safety initiative seems more nebulous. There is funding for 1000 "school resource officers and school based mental health professionals" and the recommendation to train 5000 additional “social workers, counselors, and psychologists.”   Considering the fact that there are probably close to 100,000 schools, this seems like a drop in the bucket.   Ensuring that each school has an emergency plan for contingencies like mass shootings does not seem to be a novel idea.  Creating safer school climates and reducing bullying has already been initiated in many school districts. There seems to be a clear lack of public health measures in the school that would reduce the likelihood of violent events.

The mental health initiative is equally lacking. In addition to the deficiencies I pointed out initially in this document, there is discussion of providing mental health training to teachers and school staff. There is probably evidence that teachers and school staff may over identify mental illness rather than under identify it.  Is this really a problem and will this level of screening be effective?   The document describes the initiative here as "increasing access" to mental health services. Screening larger numbers of students and identifying them as having potential problems actually creates a bottleneck in the system rather than increasing access.  The suggested mental health interventions in this document fall short in terms of both primary and secondary prevention of mental illness and associated aggressive behavior. Depending on a managed care model that has an established track record of dismantling the mental health infrastructure and providing limited access to poor quality care will do nothing to accommodate increasing referrals other than assure that referred students will be rapidly medicated.

My final analysis of the President’s initiative today is that it may be a starting point.  He is certainly taking the issue seriously and deserves plenty of credit for that.  His support for reopening firearm safety research that was closed by the gun lobby is important. What will become of the firearm regulation is anyone's guess at this point. The school and mental health initiatives are largely symbolic and I would not expect them to have any impact. What is sorely needed is the American Psychiatric Association coming out with standards, quality guidelines, and medical education initiatives to improve the care of people with severe mental illnesses who also happen to be aggressive.  An important piece of those guidelines should include the public health measures that were previously mentioned on this blog and those measures should also play a much larger role in any Executive initiative.

George Dawson, MD, DFAPA