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
