Gun Extremism Not Mental Illness

With the most recent school shooting in Uvalde, Texas the familiar repetition persists. There is public outcry to do something.  Many commentators make the comparison to the Sandy Hook Elementary School shooting a decade ago that produced public outcry but no effective response.  In fact, since Sandy Hook there have been 266 additional incidents of school shootings. Member of the pro-gun party have already spoken out and it is clear that their position of supporting gun ownership at all costs is essentially unchanged. That includes access to military grade weapons and high capacity weapons, with minimum and in many cases no regulations.  We keep hearing about all of the polls of “responsible gun owners” who support more reasonable regulation of firearms and more reasonable firearms – but they are generally drowned out by the aggressive tactics of the gun extremism faction.

Before going any further, I will provide my assessment of gun extremism. It is based on my personal observation about how guns have essentially been radicalized over the past 50 years.  When I was in middle school in the early 1960s living in a small town in northern Wisconsin, gun ownership by adults was common.  That gun ownership was focused on hunting seasons – primarily water fowl and deer hunting.  Middle schoolers took the NRA Hunter safety course in order to be able to handle firearms and hunt. Gun safety was taught primarily with the use of lectures and pamphlets. I can still recall some of the passages in the pamphlet with captions like “alcohol and gunpowder don’t mix” and a page with suggestions about what a safe target was. There was no explanation about why a crow is a safe target. The practical side of the training was with BB guns and then a .22 caliber rifle. Even though the common deer hunting rifles at the time were larger calibers like 30.06 there was no training with those guns. There was a competition series based on accuracy and most people in the class were eventually awarded Distinguished Marksman if they practiced and submitted enough targets. Memberships in the NRA was required and for $18.00/year – you got the National Rifleman magazine sent to your home every month.  The centerfold of that magazine was an array of inexpensive rifles, often “sporterized” surplus rifles from WWII.  They typically held 5 cartridges and could be used for hunting.

But like most kids taking the course. I never went hunting or acquired any additional firearms. My family was not a family of hunters and we did not have a typical cabin in the woods where everybody gathered during hunting season. The course was taught by an instructor who had been doing it for years. His overriding message was that guns had to be taken very seriously. In fact, one of the prerequisites for taking the course was that students had to vow never to “play” at guns again. That involved never pointing a gun at a person, even accidentally on the gun range. He described a number of incidents where people were accidentally shot by relatives to emphasize that point.  We all took it very seriously and there were no close calls in the class. There was no emphasis on “gun rights”, the need for self-protection, or the Second Amendment.  Handguns were not discussed because they were not used for hunting and you had to be 21 years of age to own one.  Gun rights was not an issue in any political campaign.

I don’t want to create the impression that the firearm situation was idyllic during my childhood.  Two classmates died by firearm suicide and one was killed in a hunting accident. I knew all three of them.

That is the backdrop against which gun extremism has evolved and it contains several elements.  First of all, politics. There are obvious contradictions when politicians say it is not a time for politics in the wake of the next mass shooting after they have passed laws that allow people to avoid background checks, carry military grade weapons with high capacity magazines, allow large purchased of ammunition, carry guns without permits, carry guns openly, and not have to “stand down” in confrontations – even when their opponent is not armed. That is all politics and if you are trying to deal with the aftermath pf a shooting – you are dealing with the aftermath of that politics especially if your politics facilitated that.

At a broader political level what has to be considered is how most polls show that Americans favor “common sense” gun laws – but the gun extremists continue to have their way.  In the decade following the Sandy Hook Elementary School Shooting, nothing has been done at the federal level.  Even the most basic fix of eliminating loopholes in the background checks laws has been avoided. Even when a law has been passed in the House (HR8) that makes a few changes – to the background check law there is practically no chance that it will pass in the Senate, even though the Republicans in the Senate represent 44 million fewer people. This situation has been referred to as the tyranny of the minority or a highly motivated smaller group of people dictating in this case the laws of the nation. That tyranny is even more complicated by Republican appointed Supreme Court making decisions on both gun laws and probably abortion consistent with what the minority party wants. Demographically that comes down to white, rural, less college educated voters making the laws that in the case of guns carry out an extremist agenda.

What do I mean about gun extremism?  Basically, all of the interventions over the past two generations that have allowed lax background checks and registration, lowered minimum age to purchase handguns and high-capacity military grade weapons, the increased carrying of weapons (both concealed and open) in many cases without permits, and stand your ground laws that say there is no obligation to retreat in a confrontation – even in the case where one of the parties is unarmed. There is an associated lack of gun safety and that has clearly been a factor in accidental death of adolescents and teenagers, suicides, carrying firearms into schools, and even arming mass shooters. That lack of basic gun safety is a likely contributing factor to firearm deaths being the leading cause of death in children and adolescents (1). And finally, there is a constant stream of pro-gun rhetoric that routinely distorts those facts about gun availability and usefulness.   There is good evidence that this gun extremism began in the 1970 and 1980s and has been unabated since then. 

Since the school shooting in Uvalde, gun extremists jumped to the defense of permissive to non-existent gun laws.  They offered alternate explanations for the school shooting. Governor Abbot of Texas suggested the shooter had a “mental health challenge” since anyone who shoots someone does.  That is clearly not true.  Recent evidence from high profile media cases where a homicide occurred during a fight over a firearm are cases in point. The vast majority of homicides by firearms does not involve mental illness of any kind.  In carefully selected samples – probably biased because they are selected based on forensic criteria – only 10-25% of the sample is described as having a mental illness diagnosis (2,3).

If mental illness is not an explanation for a mass shooter or mass school shooter behavior what is more likely? Given the fact that this behavior has been going on for at least 2-3 generations at this point it likely represents a subcultural phenomenon.  Subcultures are cultural groups within a larger culture that hold beliefs at variance with the larger culture.  American culture in general is steeped in violence and crime largely through entertainment and news media outlets. There are well known violent subcultures in the United States including organized crime, gangs, domestic terrorists, and various hate groups that perpetrate violence against specific people.  These other crimes are frequently seen in the news. It is easy to ascribe some of the behaviors of these groups to individual psychopathology. You can see these efforts in many true crime television shows. Crime dramas are likely to emphasize profiling as a way that the crimes are solved. Practically all of these cases lack features that are typically seen with individual psychopathology. Instead, we hear about a profile of social factors and circumstances that are cited as motivations for the violence and aggression. Those factors are also not uniform explanations for all of the violence and aggression seen across all categories and typically are collected long after the commission of the crime and by people who seemingly have unlimited time to do that task.  A good example was a forensic psychiatrist giving a profile of the Uvalde, Texas shooter describing him as a marginalized loner who had been bullied in the past and pointing out that many shooters have this profile but only a small number of people with the profile ever engage in firearm violence.

I think it is highly likely that the mass shooter and mass school shooter have become a meme that is passed in this subculture of primarily men or boys who feel that they have been victimized and they begin to see this as acceptable payback for their perceived victimization.  It is subculturally acceptable even though it produces outrage and is completely unacceptable in the larger culture and that is why the questions about “motivation” always go unanswered. Firearms and secrecy are obviously a big part of this meme and the way it is typically enacted. Gun extremism makes it much easier to enact.  In analyzing these situations, the usual starting point is where the individual perpetrator has gone wrong.  From the perspective of an alienated subculture these people and those who identify with them consider what they are doing to be correct for various reasons and more importantly widely accepted in that subculture (7). There are many reports that these subcultures are reinforced and more accessible through social media sites where manifestos, threats, time lines, and in some cases photos and recordings of the violence are posted.

In addition to the subcultural effects, important developmental effects are seldom considered.  In the past 20 years development and brain maturation has been the object of increasing neuroscience scrutiny and in addition to structural brain changes – correlations with culture, socioeconomic class, and social network/peer environment have also been investigated. In an excellent review of this topic Foulkes and Blakemore (3) point out that averaging of large samples has been used so far to get to statistical significance – but they discuss the benefits of looking beyond the averages at the total variation of normal brain development. They illustrate significant variation in the brain volume of subcortical grey matter structures over the course of ages 7 to 23.3.  I think it is generally accepted that brain maturation by these indices is not complete until mid-20s for most people, but the graphs also suggest that there may be quite a lot of variation even at that point. Beyond that they discuss several aspects of cognition and social cognition that develop in the transition from adolescence to adulthood including reasoning, risk perception, risk taking, the varied effects of social exclusion, and the use of others’ perceptions in decision making. They demonstrate what appear to be specific cultural, socioeconomic and peer effects and discuss the neuroscience correlates where they are known.  An analysis of mass shooters at this level of detail may provide better answers in terms of prevention.

What can be done to interrupt this cycle of school and mass shooter violence? Plenty can be done.  A basic time-tested public health intervention is to remove the means for perpetrating the violence and injury. This has worked in the case of suicide prevention by specific methods as well as preventing gun violence.  In a previous post, I pointed out that Tombstone had an ordinance in 1881 forbidding the carrying of deadly weapons within the city. This was a time commonly referred to as the Wild West (1865-1895).  This period is typically idealized by movies like Gunfight at the OK Corral. That was a 30 second gunfight between three Earp brothers and Doc Holiday and 5 cowboys that occurred in 1881.  One of the precipitants of that gunfight was violation of the city ordinance about carrying deadly weapons. Contrary to most accounts – both Wyatt Earp and Doc Holliday were arrested and charged with murder.  They were released after a three-day probable cause hearing. Even during America’s Wild West days, people knew that removing deadly weapons would lead to less violence.

In many ways American streets are less protected from gun violence than they were in Tombstone in 1881.  All 50 states allow people to carry handguns.  Twenty-four states require no permit to carry a firearm.  Federal law requires a handgun holder to be 18 years of age and 21 years of age to purchase a handgun. There are currently 21 million concealed carry permit holders in the US.   There is no minimum age for possessing a rifle or a shotgun.  There was a ten-year ban on assault rifles at the federal level from 1994-2004.  The ban grandfathered in all assault weapons before 1994 and there were also many other qualifications that decreased the overall impact of the bill.  Despite these limitations the ban may have decreased the frequency of mass shootings when it was in effect. (6).  Considering that there are 258.3 million Americans over the age of 18, the manufacture and importation of firearms is brisk to say the least as well as the concentration of handguns. (Click to expand the graphic)

Concluding this post, the most clearcut path to reducing gun violence of all kinds is to improve gun regulation.  The evidence is clearly there in terms of reductions in suicides, homicides and accidental deaths. The idea that gun regulation has no effect on gun deaths or that the Second Amendment is a sacred clause that mandates gun extremism is pure misinformation.  Even as I typed this post today, the Prime Minister of Canada announced stricter handgun regulations in the interest of safety.  There is absolutely no reason that high-capacity military grade weapons are necessary in society and there are many groups of responsible gun owners who openly acknowledge that fact.

Gun extremists’ additional rhetoric about how mental illness is the real problem rather than gun access is also incorrect.  Mental illness is not defined by homicide, but by constellations of findings and associated disability. There are general developmental, socioeconomic, cultural and subcultural trends associated with violence and aggression – but none are precise enough to allow for predictions of who will likely perpetrate mass homicide.  It will take continued large longitudinal studies to examine all of these factors close enough to produce an effective population wide intervention. One of my suggestions since I started writing this blog is explicit homicide prevention.  You won’t be able to find that is a book or research paper – it is based on my experience in acute care psychiatry. In that context, I encountered many people with acute homicidal thinking who ended up on my inpatient unit.  Irrespective of any psychiatric diagnosis, we were able to help them resolve that crisis.  Before the rationed mental health system takes on another significant task, it has to be adequately funded.  And beyond the mental health system – social services are required to address many of the factors associated with violence and aggression.

George Dawson, MD, DFAPA

 

 

References:

 

1:  Goldstick JE, Cunningham RM, Carter PM. Current Causes of Death in Children and Adolescents in the United States. N Engl J Med. 2022 May 19;386(20):1955-1956. doi: 10.1056/NEJMc2201761. Epub 2022 Apr 20. PMID: 35443104.

2:  Stone MH. Mass murder, mental illness, and men. Violence and Gender. 2015 Mar 1;2(1): 51-86.

3:  Hall RCW, Friedman SH, Sorrentino R, Lapchenko M, Marcus A, Ellis R. The myth of school shooters and psychotropic medications. Behav Sci Law. 2019 Sep;37(5):540-558. doi: 10.1002/bsl.2429. Epub 2019 Sep 12. PMID: 31513302.

4:  Firearms Commerce Report in the United States: Accessed 05.29.2022:  https://www.atf.gov/firearms/docs/report/2021-firearms-commerce-report/download

5:  Foulkes L, Blakemore SJ. Studying individual differences in human adolescent brain development. Nature Neuroscience. 2018 Mar;21(3):315-23.

6:   DiMaggio C, Avraham J, Berry C, Bukur M, Feldman J, Klein M, Shah N, Tandon M, Frangos S. Changes in US mass shooting deaths associated with the 1994-2004 federal assault weapons ban: Analysis of open-source data. J Trauma Acute Care Surg. 2019 Jan;86(1):11-19. doi: 10.1097/TA.0000000000002060. PMID: 30188421.

7: Simon Cottee (2021) Incel (E)motives: Resentment, Shame and Revenge, Studies in Conflict & Terrorism, 44:2, 93-114, DOI: 10.1080/1057610X.2020.1822589

8: Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018 Jul;108(7):865-867. doi: 10.2105/AJPH.2018.304450. PMID: 29874513; PMCID: PMC5993413

9:  Loftin C, McDowall D, Wiersema B, Cottey TJ. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med. 1991 Dec 5;325(23):1615-20. doi: 10.1056/NEJM199112053252305. PMID: 1669841.

Graphics Credit:

Photo by Ed Colon, MD

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Unsane - It Sure Is

I watch TV while working out - usually Amazon, Netflix, or HBO.  It is all on the Amazon Fire interface.  Today I saw Unsane advertised and despite my aversion to the ongoing One Flew Over The Cuckoo's Nest portrayals of psychiatry - I decided to watch it on the strength of Claire Foy as the leading actor.  Could the actor save the predictable portrayal?  I was skeptical but forged ahead anyway.  The film was a Steven Soderbergh film and I later learned that he shot it on an iPhone 7 Plus.

In the introductory section we learn that the main character Sawyer Valentini (Claire Foy) has moved from Boston to Pennsylvania.  She is a financial analyst in a bank and does financial analysis and reports.  We see her in a contentious phone call with a client in the opening scene.  He coworker expresses some concern and another coworker looks and rolls his eyes.  She meets with her boss and the conversation has overtones of sexual harassment.  Later there is a computer dating scenario where she ends up at her apartment with the date and starts to react like he is assaulting her.  She ends up taking some medication out of a medicine cabinet.  Later we see her Google "Support groups for stalking victims".  She drives out to a psychiatric facility for an initial appointment and that is where the drama begins.  I am going to list the problems point-by-point.

1.  She meets with the intake staff person and describes her concerns about being stalked as well as the residual "neurosis" (her term) of being in an new city and having a tendency to see her stalker everywhere. At one point she alludes to feeling depressed at times and thinking about whether there is any point in going on.  The staff person asks her if she has ever had suicidal ideation and she goes into a detailed discussion of Therapeutic Index and how she would be experimenting with that if she was going to attempt suicide (translation - overdosing).  The therapist leaves and has her complete routine paperwork.

2.  She completes the "routine paperwork" that is also described as "boilerplate" and learns that in doing so she has voluntarily committed herself for 24 hours.  In other words she was tricked into being hospitalized and that trick was apparently irreversible.

3.  While voicing strong objections she is asked by a nurse to disrobe, be searched, and change into hospital clothing.  The nurse's tone is threatening and she complies.

4.  She is taken to a psychiatric ward of about 10 people.  It is a combination of men and women and they are all locked into a room with no supervision all night long.  She is threatened by the other patients, gets into a physical confrontation with two of them and is eventually sedated in the same 10 bed ward in full view of the other patients with no safety monitoring.  She is subsequently restrained in the same manner in full view of all of the male and female patients and not protected.

5.  She finally sees the psychiatrist the next day.  He does the world's most cursory evaluation - largely reading chart notes in between phone calls.  It lasts about 5 minutes. She makes a compelling argument to be released. He informs her that she needs to stay another 7 days based on her assaults on another patient and staff. At no point in the interview does he ask her any direct questions about depression, suicidal thinking, or the details of the incidents of aggression.

6.  She befriends another patient who has smuggled in a cell phone and convinces him to let her use it.  We learn that the patient with the cell phone is really an undercover reporter investigating the hospital.  She calls her mother who comes to the facility and demands that they release Sawyer. The psychiatrist refers her to an administrator. The administrator gives her an irrelevant sales pitch on all of the good work that is done there and passive-aggressively acknowledges that it is her mother's prerogative to contact an attorney in order to get her daughter freed. 

From a creative and artistic standpoint - it was apparent to me from the outset that Sawyer's reality testing was not impaired.  Hypervigilance is not psychosis. So when she recognized her stalker on the nursing staff passing out medications it was not a surprise.

Spoiler alert right here - if you really wanted to be surprised see another film.  If you don't want to know the ending to this predictable one stop reading right here.

A series of implausible scenes unfold that depend both on the stalker as nursing staff and Sawyer's transformation to homicidality bent on killing the stalker/staff person. The stalker gives Sawyer a "megadose" of methylphenidate a stimulant a - controlled substance. Special effects at that moment seem to indicate she has some kind of psychedelic experience from the drug.  The stalker is warned by the nurse that he has to be more cautious of "we could lose our jobs." The stalker ends up killing two patients and torturing one of them with cardioversion paddles - right out of the old action series 24.  Some reviews of the film think this was an electroconvulsive therapy device - more proof that old Hollywood stereotypes about psychiatry don't ever go away.

The stalker traps Sawyer in an isolated seclusion room and in an excruciatingly long exchange, she tricks him and ends up stabbing him in the neck.  Like most films of this genre, he survives and recaptures her outside of the hospital and kidnaps her.  During the kidnap sequence we learn that he killed her mother and the hospital staff person who he has been impersonating.  Sawyer gets another chance to kill him and apparently does in the most gruesome manner  possible.

We flash forward 6 months and see Sawyer eating at a restaurant with a friend.  She looks out into the room and see the profile of a man who appears to be the stalker. She hears him saying things the stalker would say.  She grabs a steak knife and approaches him from behind.............. 

All of the points above are what a psychiatrist would consider to be highly problematic.  By that I mean they would all merit investigation by the appropriate authorities,  legal penalties, and disciplinary action against licensed health professionals. If I was prone to discuss malpractice - the incidents could also lead to that type of civil litigation.  Anyone experiencing a fraction of what Sawyer experienced in this psychiatric hospital should contact the responsible officials or an attorney about what could be done.  In my experience health officials are quite eager to do exhaustive investigations of these complaints both in the case of licensed health care professionals and institutions.  In the film it took a dead body on the premises to get any action from the police.  In real life, a call from Sawyer's mother would be enough to get action in any state that I have practiced in.

The commitment law in Pennsylvania did not seem to be adequately portrayed.  The statute says that any interested party can initiate commitment based on an imminent dangerousness standard.  That was certainly not present in the film.  At no point was Sawyer suicidal and the brief scraps that she was in would not have required physical restraint or forced medication in any setting that I ever worked in.  The maximum period of confinement in the state of Pennsylvania without a court order is 5 days and in this case Sawyer was detained 1 day initially and then another week.  That is a violation of the law.  In the state where I work, the longest period of time that a person can be help without a court order signed by a judge is 72 hours. In cases where it appeared a high risk person would be released, attorneys have always advised me that the person needs to be released according to the law - no matter what the possible adverse outcome.   

There are some continuity problems with the film.  How is it that her stalker would happen to know that she would be inappropriately admitted to a psychiatric hospital and be able to identify and kill a prospective employee in order to work there?  Wouldn't it be much easier to get close to her in real life rather than inside an institution?  And what about Sawyer?  She has insight into the fact that she is hypervigilant and needs to avoid the stalker. Is there a better film just exploring that theme and what happens to people in these situations plus or minus the real stalker?

In the past, my standard for films has been recognizing that they are entertainment and not really about psychiatry.  This film fails at both levels.  I suppose at some point all actors might be interested in doing a horror movie - but the psychiatric hospital as horror genre is as tiresome as it gets.  How many times can you show a gun toting Dr. Sam Loomis battling evil incarnate as a former asylum patient?   How many times can you show hospital staff that are sadistic, abusive, or grossly incompetent? Apparently there is no limit. The idea that a film like this should just be brushed off as fiction minimizes the fact that One Flew Over the Cuckoo's Nest seems to have stigmatized the most effective treatment in psychiatry for two generations.

The psychiatric hospital that Soderberg is reaching for is the spooky old asylum of the late 19th and early 20th century.  What made that asylum spooky was that people were freaked out about severe mental illness.  They did not know what it was and they did not have a name for the symptoms or disorders. They knew that some of their relatives went to these places and never came back. They lived the rest of their lives there.  They were warehoused and never got better.  That was the real scary part.  Most if not all of those places are shut down and have been for a long time.

The real horror story these days is trying to get into a mental hospital when it is needed.  Contrary to Sawyer's experience in the film, nobody is trying to recruit people into hospitals.  They are rationing the beds and turning people away.  All of the beds are typically full.  The emergency department psychiatric staff will do whatever they can to discharge.  A lot of people end up waiting a day or two and just give up and go home.  In some cases if people with mental problems are brought in by the police, the choice is admission to the hospital or jail.  Jail is the most likely outcome.

Jail is the real scary place these days and it has been for at least 20 years.  That is where a diverted patient needs to worry about incompetent or nonexistent treatment, physical assaults, and encounters with the evil people that Hollywood typically, uses to populate psychiatric hospitals.

The real evil out there today - is the system of non care that exists.  That is what people feared - developing a mental illness for which there was no treatment and being sent away for a lifetime. 

That is what Hollywood needs to understand.

That and a ton about modern psychiatric treatment.


George Dawson,  MD, DFAPA





Graphic Credit:  Inked Pixels.  A ghostly figure casts a long shadow down the middle of a dimly lit passage of a dilapidated mental asylum.  Downloaded from Shutterstock per their standard licensing agreement on 11/12/2018.

The NYTimes Editorial On Why Mental Health Can't Stop Mass Shooters -What's Wrong With It?

There was a New York Times editorial titled "The Mental Health System Can't Stop Mass Shooters" dated February 20, 2018.  It was written by Amy Barnhorst, MD, a psychiatrist and vice chairwoman of community psychiatry for University of California, Davis.  Since it popped up it is being posted to Twitter by more and more psychiatrists.  It does contain a lot of accuracy and realism about the issue of assessing people acutely and whether or not they can be legally held on the basis of their dangerous behavior.  Dr. Barnhorst gives examples of people who allegedly make threats and then deny them.  She discusses the legal standard for commitment and its subjective interpretation.  For example, even though a statute seems to have a clear standard they are many scenarios in the grey zone, where a decision could be made to err on the safe side.  That involves hospitalizing the patient against his or her will because the risk is there and their behavior cannot be predicted.  If hospitalized, she anticipates the outcome when the patient appears in front of a hearing officer and gets released.  That last scenario is very real and I would guess that the majority of decisions on the front end in these cases take into account what might happen in court.

If the hypothetical patient did get committed he would not be able to acquire a gun with a functional background check system. That system does not currently exist. If guns were involved in his case before hospitalization, the police may have confiscated them.  Unless his legal status changes they may give him the guns back.  In some cases the patient is told to ask their psychiatrist to write a letter to get their guns back.  I am not aware of any psychiatrist who has done that.  The FBI NICS system lists all of the conditions that would prohibit a point of purchase gun sale (assuming a check is done).  That list includes: "A person adjudicated mental defective or involuntarily committed to a mental institution or incompetent to handle own affairs, including dispositions to criminal charges of found not guilty by reason of insanity or found incompetent to stand trial."   Various crimes including domestic abuse can also trigger a failure of the NICS check and when that happens the gun sale is cancelled.  Unfortunately not all states participate in this check system and there are numerous exceptions if they do.

I have diagrammed the various levels of arguments that apply to a psychiatrist doing a crisis evaluation on a person brought to the emergency department for making threats with firearms.  At the political level there is no nuance.  At this level the degree of distortion is the greatest.  The usual arguments about guns not killing people is a good example, but it extends even this morning to President Trump suggesting that more mental health resources will solve the mass shooting problem, when it clearly will not.  The legal arguments are slightly more informed, but still fairly crude.  Like most legal arguments they threaten or reassure.  For example, most psychiatric crisis statutes hold harmless anyone who reports a suicidal or aggressive person to the authorities.  On the other hand, if a psychiatrist places a person on a legal hold because they are potentially dangerous - it is typically illegal for that same psychiatrist to extend the hold if the court system has not done anything by the time it expires.  The civil commitment system has a way of starting to make decisions based on available resources and in many cases the statutes seem reinterpreted that way.

At the medical level, psychiatrists are left living with the legal and political arguments no matter how biased they may be and trying to come up with a plan to contain and treat the aggression.  It is not an easy task given the resource allocation to psychiatry - but after doing ti for 20 years - it is fairly obvious that acute care psychiatrists know what they are doing.  They are successful at stopping violence acutely and on a long term basis.  Given the legal biases they cannot do it alone.  There needs to be cooperation from the courts and the legal system and some patients should be treated in the legal rather than the mental health system. 

Getting back to Dr. Barnhorst's article one sentence that I disagreed completely with was:

"The reason the mental health system fails to prevent mass shootings is that mental illness is rarely the cause of such violence." 

She cites "angry young men who harbor violent fantasies" as basically being incurable.  The problem with mental illness and gun violence is that it is dealt with at a political level rather than a medical and diagnostic one.  The facts are seldom considered.  There are political factions that see violence as stigmatizing the mentally ill and political factions who want to scapegoat the mentally ill and take the heat off the gun advocates.  The reality is that people with severe mental illness are overrepresented in acts of violence compared with the nonmentally ill population. It is a small but significant number. In studies of mass homicides the number increases but it depends on the methodology.  There are for example school shooter databases that record events as anytime a firearm is discharged in a school.  That results in a very large number of weapon discharges but most where nobody is injured.  There are databases that just list events but there is no analysis of whether mental illness was a factor or not.  In mass shootings in half the cases the shooter is killed or suicides.  Even when the shooter survives the data is affected by the subsequent hearings - so there is rarely a pure diagnostic interview available.  The data analysis depends on making sure that both the events and the mental health diagnoses are as accurate as possible.

The most parsimonious assessment of this data was published by Michael Stone, MD in 2015 (1).  The paper is fairly exhaustive and I am not going to discuss the obvious pluses and minuses.  I do see it as a break from the usual sensational headlines and the analysis of the trends in mass homicide over time, especially associated with semiautomatic firearms - leaves no doubt that this is a large problem.

He identifies 235 mass murderers, and estimates that 46 (22%) of them were mentally ill.  His definition of mentally ill as essentially being psychotic.  He goes on to say that in the remaining fraction and additional 48 had paranoid personality disorder, 11 were depressed, and 2 had autism spectrum disorders. In other words another 26% of the sample had significant mental disorders that were not considered in the analysis because he did not consider them to be psychotic.  Another 45 (19%) has either antisocial personality disorder or psychopathic personality disorder - both mental conditions associated with criminal activity and thought to have no known methods of treatment.  Using this conservative methodology - it is apparent that mental illness in this population is not rare at all.  What should not be lost is that although mass shootings are very noticeable events - they are rare and therefore any overrepresentation of mental illness in this group, is diluted by what happens across the entire population where the majority of violent activity is associated with people having no mental illness and the overall trends in violent crimes are at a 20 year low.

My proposed solutions to the problem of semiautomatic weapon access and mass shooters/murders is approached this way:

1.  Increase the purchase age to 21 years.  Eliminate access to military style weapons.

2.  All purchases must be cleared through the NICS system.  All states must participate. Currently only 12 states participate in full point of contact background checks on every gun sale.

3.  The NICS system should include terroristic threats, stalking, and any gun confiscation by the police because of mental health grounds as exclusion criteria.  In other words, you are eliminated from gun purchases if you have been reported for these problems.  That may sound a bit stringent but I think there is precedent.  You cannot make threats about air travel at an airport.  If you have been charged with domestic abuse (Misdemeanor Crimes of Domestic Violence (MCDV)
 the are special instructions on what it takes to keep firearms from you.  I consider the safety of children in schools to be on par with these two cases (air travel and domestic violence threats).

4.  At the level of law enforcement, any firearms confiscated during a threat investigation should not be returned and that person should be investigated and reported to NICS Database.

5.  Uniform protocols need to be in place for terroristic threat assessment.  It is no longer acceptable to wait for a person to commit an act of aggression before there is a law enforcement intervention.  The person making the threat should be removed from that environment and contained pending further investigation.

6.  On the mental health side - rebuilding the infrastructure to adequately deal with this problem is a start.  Hospitals with large enough mental health capacity should have a unit to deal with aggression and violence.  There should be specialty units that collect outcome data on the diagnoses represented and work on improving those outcomes.

7.  On the law enforcement/corrections side there needs to be recognition that not all mental health problems can be treated like mental health problems.  Violent people with antisocial personality disorder and psychopathy are best treated in law enforcement setting and not in psychiatric settings.  In psychiatric setting they have a tendency to exploit and intimidate the other patients in those settings as well as the staff.  They should be treated by psychiatrist with expertise in these conditions and been seen in correctional settings.  Probation and parole contingencies may be the best approach but I am open to any references that suggest otherwise.

8.  In the early years of this blog - I was an advocate for violence prevention and I still am.  Violence and aggression have the most stigmatizing effects of any mental health symptoms.  I think it is safe to day that most psychiatrists actively avoid practicing in setting where they may have contact with aggressive patients.  It needs to be seen as a public health problem and education and prevention are a first step.

Those are my ideas this morning.  I may add more to this page later.  If you have a real interest in this topic Dr. Stone's paper is a compelling read.  If I find others of similar quality I will post them here.  Don't hesitate to send me a reference if you have one.

The bottom line is that no psychiatrist can operate in the current vacuum of realistic options and hope to contain a potential mass shooter.  And yet there is a clear overepresentation of mental illness in this population.  Some level of cooperation as suggested above will result in a much tighter system for addressing this issue.  We do it in airports and in domestic violence situations.  We can also apply more uniform and stringent expectations to schools.


George Dawson, MD, DFAPA


References:

1:  Amy Barnhorst.  The Mental Health System Can't Stop Mass Shooters.  New York Times February 20, 2018.  Full Text Link

2:  Stone MH.  Mass Murder, Mental Illness, and Men.   Violence and Gender. Mar 2015: 51-86. Free Full Text Link



Graphics Credit:

Photo of the M4 Assault Rifle is per Shutterstock and licensed through their agreement.

Layered arguments graphic was done by me in Visio.

 

Stigma and Addiction

The basic position that I take on this blog is that stigma is an overblown concept.  Certainly no professional should ever be in the position of treating a person with a mental illness or addiction in any way that conforms to stereotypes.  I have been in many situations where that occurred during my training.  In those days a lot of alcoholics were admitted to medicine services because they needed detoxification by people who knew what they were doing .  They also needed close monitoring by nursing staff.  That did not mean that they were treated like all of the other medical patients.  There was usually a sense of hopelessness on the part of the house staff who could see several of these men admitted repeatedly during a 3 month rotation.  Men with hepatic encephalopathy, recurrent pancreatitis, alcoholic hepatitis, and upper GI bleeding from varices.  During one of the rotations, I encountered the term "incorrigible alcoholic" right there in the PGY3 note countersigning my intern note.  I had never seen a term in a medical chart like that before.  I had to look it up to make sure I knew what it meant and sure enough the first definition was bad beyond reform.

These reactions extended far beyond alcohol use problems.  Young addicts using various street and prescriptions drugs would present confused and aggressive.  At times paranoia and aggressive behavior were also prominent problems.  Nursing staff and house staff were frequently injured and in these emotionally charged encounters, the word "dirtball" was frequently uttered.  It was clear that at least some professionals viewed the confusion or aggressive behavior as volitional on the part of the patient and classified them as people who were intentionally trying to injure the staff.  The only way that you can make it in psychiatry is if you realize that aggressive behavior is a component of the illness.  It needs to be contained, but it does not need to be seen as a conscious "choice" of the patient involved.  Neither does their hygiene, cognitive problems, general lack of self care, inability to follow through with discharge instructions or stay away from drugs or alcohol.  That is not "excusing" them because you don't think they have a legitimate illness or can't prove that their behavior  is biologically based.  It is treating them like a human being and recognizing that you might be bringing too much emotion into the equation yourself.  There is nobody who needs a doctor with a cool head more than an addict or an alcoholic.

Those experiences led me to pay close attention to an opinion piece in JAMA about stigma and addiction.  One of the authors was from the White House Office of National Dug Control Policy.  The other was from Harvard T.H. Chan School of Public Health.  I looked even closer when it became apparent that their arguments were focused on the stigma arguments that were used for mental illness.  The authors use mental illness and the early days of the HIV epidemic as examples of how the language used to describe these patients implied moral deficiencies and led to discrimination.  They go on to cite studies of how differences in words can affect how treatment decision made by professionals can be similarly biased depending  on how loaded the stigmatizing term is.  They describe how the fear of stigma keeps people out of treatment.  Finally they outline the government's approach to changing the language about addiction and how that will help.  The White House Office of National Drug Control Policy is releasing Changing the Language of Addiction for guidance on these issues.  Common examples include changing "substance abuser" or person with a drug "habit" to a "person with a substance use disorder."  Near the end of the essay they acknowledge language changes are not enough.

Their initiative will not have any impact for the same the same reason that the anti-stigma campaigns for mental illness don't have any impact and here is why:


1.  The real bias occurs at the level of the insurance industry -  Coverage for addictive disorders varies widely and the only unifying theme seems to be rationing of treatment resources.  That rationing has been going on for 30 years and has led to inadequate treatment capacity.  The best time to provide treatment is right at the point that the affected person needs help.  Setting them up for an appointment 2 - 4 weeks later does not make any sense and can be dangerous if they are using dangerous levels of addictive compounds.  It makes absolutely no sense at all to deny care to a person who is using dangerous levels of addictive drugs simply because they have not yet tried outpatient treatment.

2.  Clinicians don't resist evidence based treatment  - there is nobody around to deliver it -  It is well known that psychiatric and addiction services are understaffed and have been for decades and the situation will probably get worse.  The number of addiction psychiatrists and addictionologists is even lower on population based metrics.  Policy makers seem to have the idea that primary care physicians will start actively treating addiction because treatment is currently described as being contained in a medication.  A recent study showed the underutilization of buprenorphine by these physicians.  They expressed in that same survey that they wished that they had someone who they could refer their patient to.  It is very difficult to go from prescribing opioids for a pain diagnosis to diagnosing and treating addiction in the  same setting.  It is also very difficult to provide treatment without adequate cross coverage.  There need to be adequate numbers of clinicians in any primary care clinic who are interested and competent to treat addictions.  In the case of buprenorphine maintenance. they need to be licensed to prescribe it.  Even then they need referrals sources to physicians who specialize in treating addictions and have some access to more resources.

3.  Community factors are prominent -  Insurance companies still discriminate against anyone with a substance use disorder.  I had a recent conversation with a person who needed some form of treatment. but was concerned about what would happen once the medical records got out to a long term insurance carrier.  Previous experience suggests that company takes 5 years to reconsider any application from a person with an alcohol or drug use disorder.  He  declined any form of treatment that would become part of the medical record that could be accessed by the insurance carrier.

4.  The Mental Health Parity and Addiction Equity Act of 2008 is a bust - time to stop pretending that it means much -    This is the highly acclaimed parity act started by Senators Paul Wellstone and Pete Domenici.  Discrimination and unfair treatment are widespread and contrary to what was expected there has been no boom in treatment for addictions.  Addiction and mental illnesses are still subjected to the same rationing policies and lack of infrastructure as they were before this act.

5.  It all starts and ends with the government -  This essay has that familiar ring to it:  "We are from the government and we are here to help you."  Let's not forget who started the system of discrimination against people with mental illness and addiction in the first place - the government at all levels.  The government invented the managed care industry as its surrogate in the first place.  If they were really interested in solving the problem - they could use the same top down approach that they used to create it in the first place.  They could provide medical detoxification in hospitals and coordinate the development of those guidelines.  They could provide access to Addiction Psychiatrists and  Addiction medicine practitioners.  They could open up bed capacity for residential and sober house care.  They could fund clinics where medication assisted treatments for opioid use and alcohol use are conducted.  They could fund addiction centers of excellence.  They could fund research on treatment for court ordered offenders and whether it is effective.  This is all evidence-based care, but the article suggests that primary care physicians who are currently overworked by government mismanagement are going to suddenly see hundreds or thousands of new patients with addictions.  Suggesting that this is a language based problem put the blames directly on clinicians.  It is clear to me that there are no psychiatrists blaming people for mental illness or addiction.  Who are these people and how extensive is the problem?  The idea that everyone needs to be reformed or reeducated is a familiar tactic used by politicians and policy makers.  It was the rationale for managed care rationing in the first place.

6.  Prevention is a priority - The prevention of drug use is the surest way to prevent increasing number of people from experiencing morbidity and mortality due to drug and alcohol use.  Prevention of drug use at this point in time is historically difficult as the country swings into another era of permissive attitudes toward drug use.  Individuals not abusing their first opioids will have a much greater impact on the prevalence of addiction than all of treatments after an addiction has started.

All of these factors are what clinicians like me see as everyday interference with helping patients who have a substance use disorder.  Semantics may help some.  Training and recruiting physicians who know that it is only luck that separates them from people with addictions and mental illnesses will help more.  Ending insurance company dominance over clinicians will help the most.

In the end - words don't keep people with addictions from lifesaving treatment.

The government and health insurance companies do.             

  



George Dawson, MD, DFAPA


Reference:   

1: Botticelli MP, Koh HK. Changing the Language of Addiction. JAMA. 2016 Oct 4;316(13):1361-1362. doi: 10.1001/jama.2016.11874. PubMed PMID: 27701667. (free full text).

Welcome To 1974

A colleague forwarded me a link to a newspaper article today about the latest Twin Cities managed care innovations for treating people with severe mental illnesses.  It had nothing to do with managed care companies trying to save money or avoid penalties.  Like most of these stories in the press there is a heavy human interest focus.  The treatment details are given of a man with schizophrenia and depression who is benefitting "from a fundamental shift in the way hospitals and health plans treat people with severe mental illnesses."  The author goes on to explain how social services including housing, transportation, and job training are being implemented prior to discharge and coordinated by social workers.   The article suggests that the reasons for this are two fold - to prevent the "revolving door" of readmissions to the hospital and a new Medicare penalty for readmissions during the first  30 days of discharge from a hospital.  The programs at a number of Twin cities hospitals are described.  The Minnesota law requiring admission to a psychiatric hospital from a jail within 48 hours of commitment is also cited as a complicating factor in the large group of patients that have no stable housing, no medical or psychiatric care, substance use problems and who continue to rotate in and out of psychiatric hospitals.  One of the managed care administrators describes it as a "sea change".

It turns out the "sea change" occurred in 1974.  It occurred in Wisconsin and not Minnesota.  That was the year that Len Stein, MD and a group of dedicated clinicians came up with the idea that patient with severe mental illnesses could be maintained outside of hospitals as long as they were provided with appropriate housing, support, and in some cases vocational services.  I know because I trained under Dr. Stein.  He was a personal supervisor and I did a training rotation at the Dane County Mental Health Center.  I can still remember the slide from his community psychiatry presentation that showed the overcrowded conditions at the state hospital - one of the reasons behind the community psychiatry movement.  My training occurred about a decade later and at that time there were three  different models of care that all involved community support.  The most well-known of those models is Assertive Community Treatment or ACT.   I was well versed in these models and providing the necessary care and for the first three years out of training I was the medical director at a community mental health center and spent have of my time working with the community support team.  That team provided crisis services and support on a 24/7 basis to patients with severe mental illnesses.  That was 30 years ago.

After the community mental health center,  I moved to the Twin Cities where I spent the next 23 years working in a metropolitan hospital primarily running an inpatient unit.  My focus for the first 10 years was trying to get people interested in community support services for patient we were discharging to the community.  At first, there was a patchwork of public health nursing and large housing units  with nursing supervision for our discharged patients.  But eventually there was nothing.  I was told point blank by various administrators that they really were not interested in hearing how things worked in Wisconsin.  They did things differently in Minnesota.  When I could no longer ask public health nurses to check on discharged patients - there was no help for them at all, except for an appointment to see a psychiatrist if they did not forget it.

That changed slightly when the state decided to shut down state hospital bed capacity and one of the psychiatrists there was able to get funding for ACT teams.  The rationale by the state was that some of the money to maintain state hospital beds would be diverted to the ACT teams.  Eventually that initiative increased but there was still not enough capacity.  There was still a large patient population without adequate housing or assistance.  The economic plight of many of these people was worsened by "spend down" provisions implemented by the state.  That meant that even though their income was 100% disability payments, they could be expected to pay up to 60% of it for medications.  That typically meant that the person went from poverty status to worse in order to continue recommended medications for their psychiatric disability.

Another problem was the bed situation and approaches that were being used to manage those beds.   That last half of my inpatient career, there was a continuous large pool of patients flooding Twin Cities emergency departments.  That resulted in initiatives to admit and discharge as soon as possible.  The entire focus of admissions and discharges was on "imminent dangerousness" even though there is no such legal standard.  It was a business standard of care.  Many people seeking admission because they were miserable realized this and said they were suicidal in order to get admitted.  Conversely, many people who still had significant problems and no good way to resolve them were discharge because they no longer met the "imminent dangerousness" criteria.  There were no quality approaches to care only a focus on rapid discharges of very ill people.

So I have to shake my head when I read about the "new" approach to treating mental illness and helping people to maintain themselves in the community.  There is really nothing here that was not done in Wisconsin nearly 40 years ago.  In the meantime there is a severely deteriorated infrastructure with fewer beds in both designated hospitals but also supportive housing.  I have significant doubts about the funding of these services since we know that managed care companies don't do community support services.  Who is paying for these social workers and psychologists?  Will they have to submit billing documents that are not practical to complete?  Even if they are being paid for by the state, that doesn't necessarily guarantee future funding.   At one point all of the public health nurses I was working with in the 1980s were told they could no longer see patients with psychiatric problems.  And what about the continued rationing by managed care companies now being made to look like it is innovation?

Welcome to 1974.

George Dawson, MD, DFAPA

Chris Serres.  Strategies shift for treating mental illnesses.  Star Tribune January 19, 2016.

DOJ Sanctions America's Largest Psychiatric Hospital

The Department of Justice came out with a report this week on the way that psychiatric problems are being managed in the LA County Jail.  The conclusion was that prisoners were prevented in getting their constitutionally-required care for  mental illness and they cited deplorable environmental conditions, deficient care for inmates with obvious needs, inadequate supervision, and failure to provide adequate suicide prevention services.  There were 15 deaths by suicide in 30 months and the conclusion was that several of those deaths were preventable.  By previous agreement, the county had demonstrated compliance with suggested measures including the development of a robust electronic health record.  The resulting Memorandum of Agreement Between the United States and Los Angeles County, California Regarding Mental Health Services at the Los Angeles County Jail (MOA) is an interesting read and could be viewed as a blueprint for transferring psychiatric services from managed care hospitals to correctional facilities.  Unfortunately there is no obviously available detailed report on the findings at this time, but I have requested it through their web site.

The issue of psychiatric services being provided in county jails is a national scandal that hardly anyone seems to care about.  In terms of awareness it is probably well below the issue of mass shootings by people with mental illnesses.  Why is that important?  There are several issues that never seem to be mentioned in the press.  The first and foremost is how psychiatric services have been excised from clinics and hospitals by managed care companies - especially complex psychiatric issues.  Anyone who cannot be seen in a 15-20 minutes brief discussion about medications usually gets the message that they need to get services elsewhere.  Many people who end up in jail these days have chronic mental illnesses have been involved in minor violations (trespassing, disorderly conduct, drug possession/paraphernalia charges, etc) that are a product of mental illness.  Their stays are often complicated by a lack of available legal and financial resources that increase their stay times in jail.  The following table is based on data in Forbes magazine and corroborated by other sources describing the total populations in these facilities.


         County Jail by Size                                                Population

1.  LA County Jail	19,836
2.  Riker’s Island (New York City)	13,849
3.  Harris County Jail (Texas)	10,000
4.  Cook County Jail (Chicago)	9,900
5.  Maricopa County Jail (Arizona)	9,265
6.  Philadelphia, PA	8,811
7.  Miami Dade County Jail	7,050
8.  Dallas County (Texas)	6,385
9.  Orange County (California)	6,000
10.  Shelby County (Tennessee)	5,765

The epidemiology of mental illness in incarcerated populations varies by site, authors, and agencies involved but there is no dispute about it being significant.  In a 2005 survey by the Bureau of Justice Statistics, 64% of inmates reported a mental health problem.  Recent study of incarcerated women showed that 43% met lifetime criteria for severe mental illness and 33% met 12 month criteria.  Forty five percent of the women meeting 12 month criteria had severe impairment of functional capacity.  The authors of that study emphasized the need for assessment of mental health needs at the point of entry into the justice system in order to meet the complex needs of the patients.  The inherent problem is that the US justice system and American culture are set up to pay lip service to recognizing mental illness and diminished capacity and that has recently been complicated by essentially shutting down psychiatric services and offering jails as an alternative.

What are the basic problems here?  The first is a clash of paradigms - treatment versus punishment.  If a judge actually puts you in jail for trespassing when you are so confused you can't find your way off someone's property due to mental illness, substance use, or some combination that amounts to punishment for having a mental illness.  Some systems are more enlightened than others in dealing with that problem.  In some communities, the lack of psychiatric resources results in jail as an alternative to hospitalization or non-existent community services.  The hand off between corrections and medical systems of care is complex and it depends on a medical staff who know how to approach and treat patients from correctional systems.  It also depends on judges and prosecuting attorneys with resources to decide who can be adjudicated as unable to proceed and be diverted to treatment rather than trial.  Those resources need to include examiners who can see people in jail and make the necessary assessments about court versus jail.

The second problem is rationed services.  This is best illustrated not only by the collapse of the number of beds in community hospitals and the lengths of stay much shorter than comparable facilities in the European Union but by the underlying cause of all of these problems.  That cause was simply managed care.  Managed care has done an expert job of cost shifting by developing business friendly treatment criteria, abandoning the social and community mission of treating difficult problems associated with mental illness and addiction, and removing the element of humanism from psychiatric treatment.  When I first started to practice, discharging people from a hospital when a psychiatrist had serious concerns about whether or not they could make it or whether they would be safe was very uncommon.  Today those discharges are the rule rather than the exception largely due to the imaginary dangerousness criteria.  It frequently comes down to whether or not a person is "dangerous".  If they are not, they will find themselves whisked out the front door at their first request.  I have seen that happen when the patient could not find the front door.  The same dangerousness criteria allow for blocked admission from jails or law enforcement.

The third problem is the violent offender or criminal with mental illness.  The distinction is much less clear than most people think.  Psychiatrists Dorothy Ontnow Lewis and Harold Pincus published papers on the high prevalence of neurological abnormalities and histories of brain injury in death row inmates.  Many criminals start to use various substances early in their development and can develop psychiatric comorbidity s a result of this drug use.   In my experience treating criminals or more technically persons with antisocial personality disorder who develop mental illnesses as a result of their criminal lifestyle is a much different problem than a mentally ill person who runs afoul of the law due to their psychiatric symptoms.  The patient who is antisocial or a criminal first needs to be separated from patients without those characteristics to prevent exploitation of vulnerable patients.  Any psychiatric facility in a metropolitan area needs to have this type of capacity or it will diminish the ability of the inpatient service from caring for individuals who are violent and aggressive due to treatable psychiatric disorders.  These individuals are at high risk if they are cared for in correctional settings.

I hope that this post highlights the problem and the potential solutions.  I just read a piece in Nature this morning that highlighted the need to study suicidal behavior.  The Dutch psychiatrists who wrote it emphasize that research on suicide is underrepresented in the psychiatric literature relative to articles on schizophrenia.  In America today we currently have ten times as many mentally ill patients in jails than state hospitals.  We have mass shooting homicides and many of those aggressive individuals either had no resources for treatment or there was no identified path of care for those individuals.  We need an array of psychiatric services focused on violence prevention and treating people who have impaired functional capacity to the point that they run into problems with the law.  We need better systems of care for criminals with primary and acquired forms of mental illness.

Locking all of those people up in jail and restricting their access to medical care is good for business, but it is no way to treat human beings.



George Dawson, MD, DFAPA

Supplementary 1:  "In 2006 there were 228 state hospitals operating some 49,000 beds."

Fisher WH, Geller JL, Pandiani JA. The changing role of the state psychiatric hospital. Health Aff (Millwood). 2009 May-Jun;28(3):676-84. doi: 10.1377/hlthaff.28.3.676. PubMed PMID: 19414875.

Psychiatric care versus gun control - an expected outcome

Just in case you are keeping score the Senate voted down some modest gun control proposals last week.  The issue of coming together over mental health care to address one of the dimensions of mass shootings also did not happen.  In the political calculus, it makes sense that if legislators did not fear the gun control lobby they had a lot less to fear from a mental health lobby ambivalent about dovetailing improved mental health care with gun control.

The pro gun advocates especially the NRA have always underscored the idea that they support law abiding citizens having access to firearms.  Their mantra for years has been that if there are more obstacles to law abiding citizens getting guns then only criminals would have them.  Never mind the significant number of accidental deaths every year and the fact that firearm suicide is consistently greater that firearm homicide in this country.  That detail is not lost on psychiatrists interviewing patients who have told us that they were impulsively looking for a gun to kill themselves and the only thing that prevented it was a background check and a waiting period.  The main provision of the attempted legislation was an extension of background checks.  If the pro gun lobby believes that it is protecting the right of law abiding citizens to purchase firearms, there should be no problem at all with universal background checks.  That should cut across all venues where firearms are bought and traded.  I have not heard a single rational explanation for voting down extended or universal background checks.

Reaction to the failure of this legislation was as swift as the Sunday morning talk shows.  Bob Scheiffer interviewed family members of the victims of the Sandy Hook incident on Face the Nation.  They were clearly upset about the vote in the Senate as captured in this quote from Neil Heslin father of 6 year old Jesse Heslin one of the victims of this incident:

"....As simple as a background check, putting aside the assault weapon ban or limitation or control, it's just a stepping stone of the background check with the mental health and the school security. I think the most discouraging part of this week was to, after the vote, to see who voted and who didn't vote, support it, and realize it's a political game. It was nothing bipartisan about it, at all. And we aren't going to go away. I know I'm not. We're not going to stop until there are changes that are made."

In the vacuum of no discussion of the vote against the bill or partisan rhetoric, very little was said in the press about the money behind the vote.  OpenSecrets.org did an excellent job of showing that like most things in American politics it looks like a significant factor.  Their research clearly shows that the pro-gun lobby can outspend the gun control lobby by as much as 15:1 with most of the money going to Republicans.  There are a couple of things working against the pro-gun lobby and all of that money - public support for common sense gun measures like background checks is at an all time high.   The second factor is difficult to say out loud but in American culture you can depend on it.  There will be more incidents and the pro-gun solutions (armed guards in schools, keeping the guns out of the hands of criminals and the mentally ill) are not really solutions.  The pro-gun lobby has demonstrated that they do not take that task seriously.

George Dawson, MD, DFAPA

Senate Blocks Drive for Gun Control.  NYTimes April 17, 2013.

S. 649 Roll Call Vote

Dr. Dawson's Neighborhood

 “Politicized science is an inevitable part of the human condition, but society must strive to control it. Although history shows that politicized science does much more damage in totalitarian societies than in democracies, even democracies are sometimes stampeded into doing very foolish and damaging things." – William Happer, Harmful Politicization of Science in Politicizing Science: The Alchemy of Policymaking

When I was a kid, I walked five blocks a day back and forth to primary school and kindergarten for the first seven years of my schooling. I got to know the people along that route very well. In those days in a small town people looked out for you when you were a kid. They offered you things to eat and you knew it was safe to eat.  You got to know their problems.  They told me about being gassed in World War I and never getting over it or drinking a pint of gin a day for thirty years and then stopping.  Some were engaged in behaviors that were difficult to explain such as laughing uncontrollably or making statements that seemed to be directed to you but that did not make any sense. Other people told me about their neighbors having alcoholism or having undergone shock treatments. There were adults with developmental disabilities. I visited several families with my parents and I can remember witnessing shocking behavior in those private residences - shocking for a kid but not so much for a psychiatrist.  Plenty of shocking events happened right at my own home.  That was my neighborhood as a kid and I lived there a long time.

Over the next four decades, I have thought a lot about my old neighborhood from time to time. The most frequent thought I get is how common psychiatric disorders are and how they are easily recognized by most people in your neighborhood.  The second most frequent thought I get is how there was nearly a complete lack of professional help for people with those problems. There was an extremely high threshold for assistance and when that threshold was met people were often sent hundreds of miles away to institutions until they recovered or remained in those institutions on an indefinite basis.  Some of these institutions doubled as sanatoriums for the mentally ill and patients with tuberculosis.  My aunt was a nurse in one of those places and was assaulted.  I can remember thinking: “Why would somebody with TB attack her?”

My mother had severe bipolar disorder, and was treated for years with tricyclic antidepressants by her family physicians. She eventually was able to see a psychiatrist and got more appropriate mood stabilization, but only after decades of mood instability.  My father seemed very depressed and lethargic. He probably had obstructive sleep apnea, a condition that psychiatrists routinely screen for these days but back then it was unknown. I found him dead one morning when he was 42 years old.  Medical treatment in general was pretty bad in those days.  Treatment for mental illness and access to psychiatry was practically nonexistent.  

There was no DSM when I was walking back and forth from school.  And yet the people with mental illnesses who were impaired were obvious to most people. That consensus was necessary, because their neighbors knew that they had to be more patient and kind based on those problems.  They knew they had to keep children from teasing or ridiculing these folks and teach them how to treat the disabled.  Some of our neighbors who interacted with my mother were incredibly tolerant at all hours of the day or night.   I don't know where I would have ended up without that level of assistance and recognition that there was a huge problem.  I think that level of common sense prevails today and is the basis of studies that look at whether or not psychiatric disorders are considered to be "diseases" by most people.  Those survey studies generally show that most people view severe mental illnesses and addictions as diseases. The idea that there is no such thing as a psychiatric disorder, forms the basis of anti-psychiatry rhetoric, but it is not rooted in reality or common sense.  The average person on the street does not need a DSM to detect mental illness.

The reality of psychiatric disorders and their treatment is really the focus of this blog.  It is something I have been focused on since before I became a psychiatrist.  Psychiatry is the most politicized and maligned medical specialty. It is rarely covered in an objective manner by the media. It has been manipulated by businesses and the government for their mutual advantage. It is the only specialty where there are significant profits made from continuously criticizing every aspect of the discipline.  It has few rational and fewer effective advocates.     

I continue this blog with those thoughts and the memories of my old neighborhood in mind and wish any readers here a Happy New Year.