Hard Talk

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Over the past months, society has reflected on the role of law enforcement. The shocking murder of George Floyd has forced Americans to reconsider the place of police officers in maintaining order.

The death of Mr. Floyd is certainly not a lone incident; in 2019, 1,098 people were killed by those tasked with protecting us.¹ The United States holds 25% of the world’s incarcerated, though it makes up only 5% of the world’s population.² Society is demanding a newer and better system.

The phrase “defund the police” can easily be dismissed because, to many, it implies an appeal to lawlessness. While we certainly cannot speak for any one protester, we think that many of the necessary changes are painfully obvious.³ Society wants law enforcement where force is not the default position but the last option. Society wants law enforcement where verbal conflict resolution is the primary focus of training and intervention. Society wants a correctional system that is more rehabilitative than it is punitive.⁴

Major U.S. cities spend up to 40% of their funds on police budgeting, much more than what is dedicated to community resources and infrastructure. This trend continues to increase between 1986 and 2013, state spending for correctional facilities increased by 141%.⁵ Yet, as psychiatrists, we are well aware that social determinants are a strong factor in future criminality.⁶ Increasing police budgets without addressing structural root causes and risk factors for future asocial behavior is not a wise approach to reducing unlawful behavior. Investing more into programs and policies that reduce these risks is essential.

Using the adverse childhood experiences (ACE) questionnaires, researchers have supported the idea that social programs are a key player in an improved criminal system. The ACE study identified 10 forms of childhood trauma in 17,000 patients, including abuse, neglect, abandonment, household dysfunction, and exposure to violence, that were strongly associated with negative psychological outcomes, engagement in high-risk behaviors, significant medical consequences, and even early death.⁷ More recent research has shown that those ACEs were four times more prevalent in a criminal offender group than in the general population.⁸ Psychiatry is in a unique position to address and provide education about ACEs as a tool to identify and help at-risk youths.

Many protesters have asked for mental health providers to have a primary role in this societal reflection and in providing a solution.⁹ This makes particular sense when considering that almost 20% of calls to law enforcement are for persons with impaired judgment from mental illness or intoxication, and one in four patients with mental illness has been arrested.^10,11 We are humbled by this public trust and request. We believe psychiatry can provide many answers to this societal angst. After all, psychiatry is a specialty dedicated to addressing behavioral problems in an evidence-based way.

Yet, we should not forget psychiatry’s imperfect past and our own role in the creation of this system. While this article does not attempt to catalog psychiatry’s faults, one can start by recognizing that mass incarceration is partly a response to how poorly human beings were treated in asylums. Psychiatry was at one time a main enforcer of societal disenfranchisement. After most asylums were closed in 1963 with the Community Mental Health Act, correctional facilities became the largest purveyors of mental health care, often with damaging results.¹² If psychiatry were to advocate for the reestablishment of asylums as a solution, we fear that psychiatry would have missed the point. We wonder whether the psychiatrists who have railed against deinstitutionalization since the 1970s do not realize that violence, unethical experimentation, and even racism were at times attributes of asylums.¹³

Psychiatry can and should be much more than what it once was. Instead of indirectly and inaccurately suggesting that our patients commit mass murders, we should improve research in the field of violence risk assessment and management. As many have already pointed out, violence risk assessment is permeated with overestimation of its potential and, more concerningly, tainted by evidence of implicit racism.¹⁴ Implicit racism extends to rights-limiting treatments as well. As previously studied, involuntary outpatient programs often referred to as assisted outpatient treatment are disproportionately levied on Black Americans.¹⁵ Instead of routinely seeking to expand abilities to involuntary treat and limit the rights of our patients, we should strive to be a violence-free alternative to law enforcement, not the medical version of police.

Psychiatrists should start actively training, practicing, and researching how to address nonviolent emergency calls. Training should include more robust deescalation training, techniques on the evaluation of patients outside of health care facilities (for example, the street), and a broadening of interventions to include proficiency in the treatment of subclinical populations seeking emergency care without the need to be formally labeled with a psychiatric disorder. Ride-alongs with police officers, volunteering at crisis hotlines, and home calls should not be volunteer or elective experiences for psychiatrists but a required part of training.

Thankfully, some local jurisdictions already have started promising practices that merit replication or at least academic review. Austin, Tex., recently implemented the capability of requesting mental health emergency calls when contacting 911.¹⁷ Eugene, Ore., has had the CAHOOTS (Crisis Assistance Helping Out On The Streets) program since 1989, where a medical provider and a mental health provider respond to calls without any law enforcement officers.¹⁸ Our own San Diego County has an innovative PERT (Psychiatric Emergency Response Team) program, which partners a mental health provider to a police patrol, allowing an ability to quickly provide different types of services.¹⁹ Programs like these show us what is possible. At this time, there is little research to evaluate many programs’ effectiveness.²⁰ Psychiatry should seize this moment to be at the forefront of studying, then educating the public on what works and how to reproduce it.

Police officers have a difficult profession. They are tasked with preventing and predicting crime, often to the point of risking their own lives. Historically, police have been the first call to handle issues for which they are not equipped, ranging from fixing homelessness to arresting violent people using nonviolent means. The idea that police should be able to protect us in all situations has been mistakenly ingrained in our minds. Officers themselves do not feel adequately trained to handle mental health crises.²¹ “Defund the police” also means a recognition by governments, the public, and police themselves that officers should not be on the front lines for every emergency situation. We must diversify our first responders. Psychiatry should hear this call and be ready.

Since the death of Mr. Floyd, mental health professionals have attempted to voice empathy and warmth to those feeling left out and disenfranchised. Mental health professionals have voiced a desire to educate themselves on systemic biases and antiracism. However, we argue that psychiatry is not and has never been a bystander to the societal debate on the management of different and criminal behavior. While it may be enough for many fields to express sympathy from the sidelines, psychiatry has been and continues to be an active player in the disenfranchisement of minority populations in the criminal justice system. Society appears to be offering us a chance at repairing our past and helping the future. Let’s take it with honor and humility.
 

References

1. Collins S. Police killings can be captured in data. The terror police create cannot. Vox.com. 2020 Jun 19.

2. Lee MYH. Yes, U.S. locks people up at a higher rate than any other country. The Washington Post. 2015 Jul 7.

3. McDowell MG, Fernandez LA. Critical Criminology. 2018;26(3):373-91.

4. Thielo AJ et al. Criminology & Public Policy. 2016;15(1):137-70.

5. The Center for Popular Democracy. Freedom to Thrive.

6. Hipp JR. Criminology. 2007;45(3):665-97.

7. Felitti VJ et al. Am J Prev Med. 1998;14(4):245-58.

8. Reavis JA. Perm J. 2013 Spring;17(2):44-8.

9. McHarris PV, McHarris T. No more money for the police. The New York Times. 2020 May 20.

10. Kaminski RJ et al. Police Quarterly. 2004;7(3):311-38.

11. Livington JD. Psychiatr Serv. 2016 Aug 1;67(8):850-7.

12. Galanek JD. Cult Med Psychiatry. 2013 Mar;37(1):195-225.

13. Raz M. Nature. Book Review. 2020 Apr 21.

14. Dressel J, Farid H. Sci Adv. 2018 J 17;4(1):eaao5580.

15. Swartz MS et al. New York State assisted outpatient treatment program evaluation. 2009 Jun 30.

16. Barnes SS and Badre N. Psychiatr Serv. 2016 Jul 1;67(7):784-6.

17. Fox A. Austin budget adds millions for mental health response in 911 services. efficientgov.com. 2019 Sep 13.

18. Elinson Z. When mental health experts, not police, are the first responders. The Wall Street Journal. 2018 Nov 14.

19. Improved responses in psychiatric crises: The Psychiatric Emergency Response Team.

20. Kane E et al. Crim Behav Ment Health. 2018 Apr;28(2):108-19.

21. Wells W, Schafer JA. Officer perceptions of police responses to persons with a mental illness, in “Policing: An International Journal of Police Strategies & Management,” 2006 Oct;29(4):578-61.

Dr. Malik is a first-year psychiatry resident at the University of California, San Diego. She has a background in policy and grassroots organizing through her time working at the National Coalition for the Homeless and the Women’s Law Project. Dr. Malik has no disclosures.

Dr. Amendolara is a first-year psychiatry resident at University of California, San Diego. He spent years advocating for survivors of rape and domestic violence at the Crime Victims Treatment Center in New York and conducted public health research at Lourdes Center for Public Health in Camden, N.J. Dr. Amendolara has no disclosures.

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019). He has no disclosures.

Prior to the current crisis of COVID-19, I had a critical view of the direction of our psychiatric field. We have given up on complicated psychotherapies in favor of dispensing medications. We have given up on complicated diagnostic assessments in favor of simple self-rated symptoms questionnaires. Many of us even chose to give up on seeing patients face to face in favor of practicing telepsychiatry in the comfort of our homes. Some even promoted a future of psychiatry in which psychiatrists treated patients through large spreadsheets of evidence-based rating tools following evidence-based algorithms without even ever meeting the patients.

I do not view this problem as unique to psychiatry but rather as part of a larger trend in society. For the past couple of years, Vivek Murthy, MD, the former U.S. surgeon general, has popularized the idea that we are in a loneliness epidemic, saying, “We live in the most technologically connected age in the history of civilization, yet rates of loneliness have doubled since the 1980s.” Despite having enumerable means to reach other human beings, so many of us feel distant and out of touch with others. This loneliness has a measurable impact on our well-being with one study that states, “Actual and perceived social isolation are both associated with increased risk for early mortality.”

Then, seemingly out of nowhere, we were confronted with the largest challenge to our sense of connectedness in my lifetime. Throughout the past months, we have been asked to meet each other less frequently, do so through sterile means, and certainly not shake hands, hug, or embrace. The COVID-19 crisis has quickly made us all experts in telepsychiatry, remote work, and doing more with less. The COVID-19 crisis has asked many of us to put aside some of our human rituals like eating together, enjoying artistic experiences as a group, and touching, for the sake of saving lives.

For many, socially distancing has been a considerable added stressor – a stressor that continues to test humanity’s ability to be resilient. I am saddened by prior patients reaching out to seek comfort in these difficult times. I am touched by their desire to reconnect with someone they know, someone who feels familiar. I am surprised by the power of connection through phone and video calls. For some patients, despite the added burden, the current crisis has been an opportunity for their mental health and a reminder of the things that are important, including calling old friends and staying in touch with those who matter the most.

Yet, as the social restrictions continue, the stressors mount and the resilience becomes harder to find. Checking in on others can become a chore. The social norm to partake in fashion, and self-care, become harder to find. In some cases, even hygiene and our health take a side role. The weekly phone visits with a therapist can feel just as mundane and repetitive as life. Sleep becomes harder to find, and food loses its taste. At this point, we realize the humanity that we lost in all this.

In the past couple of months, we have all become much more aware of the fragility of connectedness. However, we should recognize that the impact was well on its way before the COVID-19 crisis. It is my opinion that psychiatry should champion the issue of human relations. I do not think that we need to wait for a new DSM diagnosis, an evidence-based paradigm, or a Food and Drug Administration–approved medication to do so. The COVID-19 crisis has rendered us all cognizant of the importance of relationships.

While it may be that psychiatry continues to foray in electronic means of communication, use of impersonal scales and diagnosis, as well as anonymized algorithmic treatment plans, we should also promote as much humanity as society and public health safety will permit. Getting dressed to see your psychiatrist, face to face, to have an open-ended conversation about the nature of one’s life has clearly become something precious and powerful that should be cherished and protected. My hope is the rules and mandates we are required to use during the pandemic today do not become a continued habit that result in further loneliness and disconnect. If we chose to, the lessons we learn today can, in fact, strengthen our appreciation and pursuit of human connection.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019). He has no disclosures.

Prior to the current crisis of COVID-19, I had a critical view of the direction of our psychiatric field. We have given up on complicated psychotherapies in favor of dispensing medications. We have given up on complicated diagnostic assessments in favor of simple self-rated symptoms questionnaires. Many of us even chose to give up on seeing patients face to face in favor of practicing telepsychiatry in the comfort of our homes. Some even promoted a future of psychiatry in which psychiatrists treated patients through large spreadsheets of evidence-based rating tools following evidence-based algorithms without even ever meeting the patients.

I do not view this problem as unique to psychiatry but rather as part of a larger trend in society. For the past couple of years, Vivek Murthy, MD, the former U.S. surgeon general, has popularized the idea that we are in a loneliness epidemic, saying, “We live in the most technologically connected age in the history of civilization, yet rates of loneliness have doubled since the 1980s.” Despite having enumerable means to reach other human beings, so many of us feel distant and out of touch with others. This loneliness has a measurable impact on our well-being with one study that states, “Actual and perceived social isolation are both associated with increased risk for early mortality.”

Then, seemingly out of nowhere, we were confronted with the largest challenge to our sense of connectedness in my lifetime. Throughout the past months, we have been asked to meet each other less frequently, do so through sterile means, and certainly not shake hands, hug, or embrace. The COVID-19 crisis has quickly made us all experts in telepsychiatry, remote work, and doing more with less. The COVID-19 crisis has asked many of us to put aside some of our human rituals like eating together, enjoying artistic experiences as a group, and touching, for the sake of saving lives.

For many, socially distancing has been a considerable added stressor – a stressor that continues to test humanity’s ability to be resilient. I am saddened by prior patients reaching out to seek comfort in these difficult times. I am touched by their desire to reconnect with someone they know, someone who feels familiar. I am surprised by the power of connection through phone and video calls. For some patients, despite the added burden, the current crisis has been an opportunity for their mental health and a reminder of the things that are important, including calling old friends and staying in touch with those who matter the most.

Yet, as the social restrictions continue, the stressors mount and the resilience becomes harder to find. Checking in on others can become a chore. The social norm to partake in fashion, and self-care, become harder to find. In some cases, even hygiene and our health take a side role. The weekly phone visits with a therapist can feel just as mundane and repetitive as life. Sleep becomes harder to find, and food loses its taste. At this point, we realize the humanity that we lost in all this.

In the past couple of months, we have all become much more aware of the fragility of connectedness. However, we should recognize that the impact was well on its way before the COVID-19 crisis. It is my opinion that psychiatry should champion the issue of human relations. I do not think that we need to wait for a new DSM diagnosis, an evidence-based paradigm, or a Food and Drug Administration–approved medication to do so. The COVID-19 crisis has rendered us all cognizant of the importance of relationships.

While it may be that psychiatry continues to foray in electronic means of communication, use of impersonal scales and diagnosis, as well as anonymized algorithmic treatment plans, we should also promote as much humanity as society and public health safety will permit. Getting dressed to see your psychiatrist, face to face, to have an open-ended conversation about the nature of one’s life has clearly become something precious and powerful that should be cherished and protected. My hope is the rules and mandates we are required to use during the pandemic today do not become a continued habit that result in further loneliness and disconnect. If we chose to, the lessons we learn today can, in fact, strengthen our appreciation and pursuit of human connection.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019). He has no disclosures.

Prior to the current crisis of COVID-19, I had a critical view of the direction of our psychiatric field. We have given up on complicated psychotherapies in favor of dispensing medications. We have given up on complicated diagnostic assessments in favor of simple self-rated symptoms questionnaires. Many of us even chose to give up on seeing patients face to face in favor of practicing telepsychiatry in the comfort of our homes. Some even promoted a future of psychiatry in which psychiatrists treated patients through large spreadsheets of evidence-based rating tools following evidence-based algorithms without even ever meeting the patients.

I do not view this problem as unique to psychiatry but rather as part of a larger trend in society. For the past couple of years, Vivek Murthy, MD, the former U.S. surgeon general, has popularized the idea that we are in a loneliness epidemic, saying, “We live in the most technologically connected age in the history of civilization, yet rates of loneliness have doubled since the 1980s.” Despite having enumerable means to reach other human beings, so many of us feel distant and out of touch with others. This loneliness has a measurable impact on our well-being with one study that states, “Actual and perceived social isolation are both associated with increased risk for early mortality.”

Then, seemingly out of nowhere, we were confronted with the largest challenge to our sense of connectedness in my lifetime. Throughout the past months, we have been asked to meet each other less frequently, do so through sterile means, and certainly not shake hands, hug, or embrace. The COVID-19 crisis has quickly made us all experts in telepsychiatry, remote work, and doing more with less. The COVID-19 crisis has asked many of us to put aside some of our human rituals like eating together, enjoying artistic experiences as a group, and touching, for the sake of saving lives.

For many, socially distancing has been a considerable added stressor – a stressor that continues to test humanity’s ability to be resilient. I am saddened by prior patients reaching out to seek comfort in these difficult times. I am touched by their desire to reconnect with someone they know, someone who feels familiar. I am surprised by the power of connection through phone and video calls. For some patients, despite the added burden, the current crisis has been an opportunity for their mental health and a reminder of the things that are important, including calling old friends and staying in touch with those who matter the most.

Yet, as the social restrictions continue, the stressors mount and the resilience becomes harder to find. Checking in on others can become a chore. The social norm to partake in fashion, and self-care, become harder to find. In some cases, even hygiene and our health take a side role. The weekly phone visits with a therapist can feel just as mundane and repetitive as life. Sleep becomes harder to find, and food loses its taste. At this point, we realize the humanity that we lost in all this.

In the past couple of months, we have all become much more aware of the fragility of connectedness. However, we should recognize that the impact was well on its way before the COVID-19 crisis. It is my opinion that psychiatry should champion the issue of human relations. I do not think that we need to wait for a new DSM diagnosis, an evidence-based paradigm, or a Food and Drug Administration–approved medication to do so. The COVID-19 crisis has rendered us all cognizant of the importance of relationships.

While it may be that psychiatry continues to foray in electronic means of communication, use of impersonal scales and diagnosis, as well as anonymized algorithmic treatment plans, we should also promote as much humanity as society and public health safety will permit. Getting dressed to see your psychiatrist, face to face, to have an open-ended conversation about the nature of one’s life has clearly become something precious and powerful that should be cherished and protected. My hope is the rules and mandates we are required to use during the pandemic today do not become a continued habit that result in further loneliness and disconnect. If we chose to, the lessons we learn today can, in fact, strengthen our appreciation and pursuit of human connection.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019). He has no disclosures.

Recently, Nicolas Badre, MD, challenged psychiatrists who care for patients involved in the legal system. He encouraged “a resurgence of personal accountability and responsibility.”

Using the chronically disenfranchised patients who are repetitiously shuttled between jails and mental hospitals as examples, he pointed out that we psychiatrists must “step up to the plate” and approach clinical problems with the attitude that “the buck stops with me.” As Dr. Badre pointed out, this is especially true when dealing with large, complex systems in which fragmented care exists without clear leadership. This, in turn, allows for a dissolution of accountability.

Accountability is a natural continuation of our training as physicians. We all remember the transition from medical student to intern, the steep learning curve as well as growth and maturation during this changeover. A dramatic transformation occurs over the course of 1 year, from medical students who tag along learning from patients to interns expected to be on their own for endless hours.

Over the course of those hours, we came to the understanding that people’s lives were in our hands. This causes a shift in our identity. This process continues throughout residency and onward in our careers. At some point, it becomes part of our innate identity as physicians or our professional sense of self – which is hard to describe to nonphysicians.

A profound example of a sense of accountability within the medical profession can be found in “How We Live,” a book by National Book Award winner Sherwin B. Nuland, MD. In the book, the late Dr. Nuland recounted how, as a 49-year-old seasoned surgeon working at Yale University, New Haven, Conn., and casually rounding on patients, he heard a frantic message: “Any general surgeon! Any general surgeon! Go immediately to the operating room – immediately – any general surgeon!”

The case involved a 42-year-old wife and mother who had been rushed to the ED after having been found in the community in a profound state of shock. In the ED, it was suspected that the patient was bleeding heavily from a ruptured tubal pregnancy. She was sped rapidly to the operating room with an undetectable blood pressure and a barely palpable pulse. The on-call ob.gyn. had been summoned from home, and he rushed to the operating room along with his department chairman.

Because the woman had lost much of her blood supply, there was no time for crossmatching. The anesthesiologist had placed large-bore intravenous lines and transfused her with O-negative blood (the universal donor blood type) to try maintain some level of blood pressure. Before she could be even fully anesthetized, the ob.gyn had made an incision in her lower abdomen. The bleeding he encountered was profound.

After a quick evaluation, the ob.gyn. realized that the blood was coming from above, not below, leading to the emergency page that Dr. Nuland heard. Dr. Nuland described bounding up the stairs three at a time. He recalled: “[A] very real apprehension had entered my mind. I might encounter a situation that was beyond me, something that I might make even worse, something that would cause me to regret for the rest of my life that I had answered the page’s insistent call instead of simply turning my back on its urgency and slinking off to my car before anyone noticed I was there.”

However, he could not see himself doing such a thing and he rushed up to the operating room because, “walking away from that kind of cry for help would have violated every precept taught me by my life and my training, and every bit of moral sense I had. … . I bear an obsessive preoccupation with accepting responsibility, amounting really to a compulsively neurotic sense of duty.”

And yet in the next few seconds, as he was running to the operating room, he wondered: “Am I about to botch something up? Will I, in one quick stroke of ineptness and fate, bring my career crashing down around my feet and with it my sense of what I am? Am I on my way to destroy an unknown patient and myself at the same time?”

In Dr. Nuland’s thoughts lie the conundrum of responsibility for physicians. Thankfully for Dr. Nuland, he was able to save the day and diagnose a rare case of rupture of an aneurysm of the splenic artery and keep the patient alive. This dramatic story involved a surgical colleague who had to make split-second decisions while a patient’s life hanged in the balance, but the same principles apply to us as psychiatrists.

Sadly, like a ruptured splenic artery, depression and other mental illnesses can end lives in vulnerable patients facing overwhelming life crises. I would note that, in the above example of the surgical patient, the “system” for saving the woman’s life was well organized and resourced to allow for a comprehensive and time-limited intervention into a life-threatening situation. There was an operating room staffed by various professionals who all had a defined role. It required the leader, Dr. Nuland, to step in, make the right diagnosis, and then issue commands to the identified professionals who all recognized his leadership and were skilled in carrying out their assigned duties. Dr. Nuland clearly was the leader once he took charge.

An outpatient psychiatrist facing a suicidal patient must deal with a different set of challenges, often involving various complex systems as well as multiple barriers. Clinical barriers include available interdisciplinary resources/personnel to assist not only with the critical encounter, but also with extended evaluation and treatment in a secure, well-resourced environment. Administrative barriers can include justifying the optimal treatment plan to payors. Our lethal patients often require both outpatient and inpatient services with sometimes-conflicting agendas. In a recent article, I pointed out some of the vexing problems that arise when communication and collaboration are poor between inpatient and outpatient psychiatrists. In such complex environments, it is less clear what is involved in the outpatient psychiatrist stepping up to the plate and asserting leadership.

An emotionally wrenching article about an emergency physician, Matthew E. Seaman, MD, who died by suicide, reminds us of the potential for suicide in a complicated patient (in this case, a medical colleague) involving complex systems. Plagued by a review of his care by the medical board (they had forced him to surrender his medical license and allowed the allegations to go public in lieu of further disciplinary proceedings), a subsequent lawsuit and an ultimate attempt by the plaintiff to obtain Dr. Seaman’s personal assets led to his worsening mental health. According to his wife, also a physician, he was getting “more depressed by the insults and assaults on his integrity and professionalism.”

Just before the investigation, he had received a 30-year pin from the American Board of Emergency Medicine for his “dedication to the specialty.” He fell into a deep depression from which he could not recover despite several psychiatric admissions and several medication trials. Along with his depression, he suffered from severe anxiety, a known risk factor for suicide. Dr. Seaman was feeling overwhelmed by the lengthy legal process targeting him as being negligent. He begged his attorney to settle the case, but his insurance carrier would not allow it. According to his wife: “All sense of human worth had been beaten out of him.”

Dr. Seaman had been known as resilient. He could handle complex ED situations, including simultaneously dealing with multiple traumas. He previously had been named in three malpractice lawsuits and had prevailed in each one. But his resilience had greatly diminished, and he became overwhelmed. He previously had, as a physician, been able to step up to the plate of accountability. But now, because of a confluence of depression and anxiety as well as the “insults and assaults on his integrity and professionalism,” he found life to be unbearable with the resulting tragic end.

So how would we as psychiatrists step up to the plate and be accountable when faced with a struggling fellow physician at risk for suicide such as Dr. Seaman?

Be aware of relevant risk factors

In addition to being aware of the usual risk factors for suicide, it would behoove us to also understand how physician suicides differ from suicides among nonphysicians.¹ For example, physicians who have died by suicide were far more likely to have experienced job-related problems than nonphysicians, but less likely to have experienced the recent death of a loved one. Also noteworthy is that physicians who end their lives were more often married. In addition, Michael F. Myers, MD, a psychiatrist who has studied physician suicides, noted in the article about Dr. Seaman that struggling physicians are likely to suffer from shame and embarrassment.
 

Consider shame, burdensomeness, and secrecy

When suicide risk factors are taught to students and professionals, rarely is shame mentioned. Perhaps it is not a common risk factor in the general population, but shame and its cousin, disgrace, are known risk factors that likely apply more to people – such as physicians – who have built a reputation over their careers. One whole chapter is given to disgrace suicides in a book about suicide notes.² A reputation often is one of the most important factors for professionals, which creates their sense of identity and, by extension, a sense of purpose in life.

When a doctor perceives that his or her reputation is being destroyed, it can produce a profound sense of shame, one of the most powerful of negative emotions.³ Another feature among completed suicides that applies more generally is perceived burdensomeness, according to Thomas E. Joiner Jr., PhD, one of the deep and innovative researchers in the field of suicidology.⁴ Once a doctor starts feeling that he has been a failure in his professional life and starts ruminating about it, the feelings of failure may generalize to other areas of his life, so that he starts feeling that he is a burden to his spouse. This, then, only increases his shame.

The issue of secrecy also is noteworthy. I was struck reading a book by Dr. Myers on physician suicide by the many spouses and family members who were caught completely unaware of problems when their spouse, a doctor, ended their lives by suicide.⁵ The doctors hid their problems well, perhaps not wanting to burden their family members. Also, if feelings of shame are an issue, then concealment tends to occur. This concealment of suicidality runs counter to the current narrative among some in the professional community that suicides are preventable (this despite the continuing increase in rates of suicide at the same time that there are increases in mental health services and suicide prevention programs).⁶

As pointed out in some of the letters quoted in Dr. Myers’s book, those who completed suicide are smart and know how to hide their symptoms well. Although Dr. Seaman’s wife, Linda Seaman, MD, was aware of her husband’s suicidality, when he eventually determined that he was going to end his life, he apparently did not reveal his more serious intention to her. Aside from spouses and family, determined suicide completers often hide their intentions from their clinicians.⁷
 

Attempt to obtain collateral information

By being aware of the usual and less-usual risk factors for suicide that our physician colleagues may present with as explained above, we can use strategies for mitigating risk. If secrecy because of shame and embarrassment prevents our physician patient from being fully candid, include the spouse or another significant family member in sessions. While the physician might hide his suicidal intent from both the clinician and spouse, it remains prudent to include the spouse in the treatment plan. Give the spouse a telephone number with which they can contact you if they notice any worrisome change in functioning or behavior. Collateral information often is helpful. (Example: Is the patient not eating, not sleeping, or giving away valued possessions?)
 

Assess for competency

In Dr. Seaman’s case, it was noted that, with a trial approaching, Dr. Seaman had written in a journal entry that he could not mentally endure a trial. “For me, the stress is overwhelming.” Such a patient, suffering from severe depression, often is unable to properly assist his attorney in his defense. The outpatient psychiatrist can notify the court or one of the attorneys that the competency of the physician patient is questionable (or express a definite opinion of incompetency), and offer the opinion that it would be best to postpone further legal action until the patient is in a more healthy state of mind.
 

Know when hospitalization is needed

Obviously, the process will go smoother if the admission is voluntary. If the patient physician resists and the psychiatrist believes that the risk for self-harm is too high for the physician patient to remain as an outpatient, try to get a spouse or family member to persuade him to be admitted. An involuntary admission opens up a whole new can of worms and may fracture the therapeutic alliance.

In the end, it might be better to take that risk rather than having a dead patient on your hands. If a hospitalization is necessary, contact the admitting psychiatrist and verbally express your concerns and the reasons why a hospitalization is needed. Ask the inpatient psychiatrist to contact you when a discharge is approaching so that you have an opportunity to ask relevant questions.

For example, during his second psychiatric admission, as the time for discharge was approaching, Dr. Seaman wrote: “I am not well enough for discharge. I am still mentally ill.” Ask the inpatient doctor whether the patient has gotten sufficiently better and he feels confident he can function as an outpatient. If there is a conflicting opinion about the readiness of the patient for discharge, notify the medical director of the service or an administrator about your concerns.
 

Ask for consultation

At any stage of the process consider getting consultation for a trusted colleague or senior clinician if you are failing to make progress. Sometimes it helps to get the perspective from a fresh pair of eyes or ears.

Get a reality check

Having recounted the inspiring story of Dr. Nuland’s magnificent efforts and joyous success in preserving a life that was on the verge of being lost in the battle against death at the last possible second, I would note the following: Surgeons will tell you that, despite their most heroic efforts and teamwork, there are times when luck runs out and the patient dies on the operating table. Also, small lapses, which all mortals are prone to despite their best efforts at conscientiousness, sometimes can lead to a bad outcome.

Similarly, in psychiatry, no matter how much effort we put into saving a life, sometimes it is all to no avail. Despite all we have learned about suicide and its risk factors, and no matter how much care we take to contain risk, our patients who are determined will find a way of ending their own lives. The vexing problem of suicide seems intractable. A suicide among our patients humbles us, but also hopefully inspires us to keep trying harder to step up to the plate of accountability.

In conclusion, for us physicians, accountability is not a facet, a trait, or even a pursuit, accountability is at the core of who are and how we define ourselves. Accountability is the reason we leap stairs three at time when we are urgently paged. Accountability is the reason malpractice lawsuits cut at the core of our self-image. Accountability allows us to always have hope for a positive outcome, despite overwhelming barriers, and gives our lives a sense of purpose.

For me, in preparing this article, accountability was reviewing and studying physician suicide and then applying best practices in risk assessment after reading the tragic story of Dr. Seaman. I hope I inspire you to do the same in the pursuit of helping our vulnerable patients.

Learning how to care for our complex patients is a never-ending journey.
 

References

1. Gold KJ. Gen Hosp Psychiatry. 2013 Jan;35(1):45-9.

2. Etkind M. ...Or Not to Be: A Collection of Suicide Notes. New York: Riverhead Books, 1997.

3. Lamia LC. Shame: A concealed, contagious, and dangerous emotion. Psychology Today. 2011 Apr 4.

4. Joiner TE. Why People Die by Suicide. Cambridge: Harvard University Press, 2005.

5. Myers MF. Why Physicians Die by Suicide. 2017.

6. National Institutes of Health. Suicide Prevention. https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml.

7. Levy AG et al. JAMA Netw Open. 2019 Aug 14. doi: 10.1001/jamanetworkopen.2019.9277.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University, Cleveland, as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

Recently, Nicolas Badre, MD, challenged psychiatrists who care for patients involved in the legal system. He encouraged “a resurgence of personal accountability and responsibility.”

Using the chronically disenfranchised patients who are repetitiously shuttled between jails and mental hospitals as examples, he pointed out that we psychiatrists must “step up to the plate” and approach clinical problems with the attitude that “the buck stops with me.” As Dr. Badre pointed out, this is especially true when dealing with large, complex systems in which fragmented care exists without clear leadership. This, in turn, allows for a dissolution of accountability.

Accountability is a natural continuation of our training as physicians. We all remember the transition from medical student to intern, the steep learning curve as well as growth and maturation during this changeover. A dramatic transformation occurs over the course of 1 year, from medical students who tag along learning from patients to interns expected to be on their own for endless hours.

Over the course of those hours, we came to the understanding that people’s lives were in our hands. This causes a shift in our identity. This process continues throughout residency and onward in our careers. At some point, it becomes part of our innate identity as physicians or our professional sense of self – which is hard to describe to nonphysicians.

A profound example of a sense of accountability within the medical profession can be found in “How We Live,” a book by National Book Award winner Sherwin B. Nuland, MD. In the book, the late Dr. Nuland recounted how, as a 49-year-old seasoned surgeon working at Yale University, New Haven, Conn., and casually rounding on patients, he heard a frantic message: “Any general surgeon! Any general surgeon! Go immediately to the operating room – immediately – any general surgeon!”

The case involved a 42-year-old wife and mother who had been rushed to the ED after having been found in the community in a profound state of shock. In the ED, it was suspected that the patient was bleeding heavily from a ruptured tubal pregnancy. She was sped rapidly to the operating room with an undetectable blood pressure and a barely palpable pulse. The on-call ob.gyn. had been summoned from home, and he rushed to the operating room along with his department chairman.

Because the woman had lost much of her blood supply, there was no time for crossmatching. The anesthesiologist had placed large-bore intravenous lines and transfused her with O-negative blood (the universal donor blood type) to try maintain some level of blood pressure. Before she could be even fully anesthetized, the ob.gyn had made an incision in her lower abdomen. The bleeding he encountered was profound.

After a quick evaluation, the ob.gyn. realized that the blood was coming from above, not below, leading to the emergency page that Dr. Nuland heard. Dr. Nuland described bounding up the stairs three at a time. He recalled: “[A] very real apprehension had entered my mind. I might encounter a situation that was beyond me, something that I might make even worse, something that would cause me to regret for the rest of my life that I had answered the page’s insistent call instead of simply turning my back on its urgency and slinking off to my car before anyone noticed I was there.”

However, he could not see himself doing such a thing and he rushed up to the operating room because, “walking away from that kind of cry for help would have violated every precept taught me by my life and my training, and every bit of moral sense I had. … . I bear an obsessive preoccupation with accepting responsibility, amounting really to a compulsively neurotic sense of duty.”

And yet in the next few seconds, as he was running to the operating room, he wondered: “Am I about to botch something up? Will I, in one quick stroke of ineptness and fate, bring my career crashing down around my feet and with it my sense of what I am? Am I on my way to destroy an unknown patient and myself at the same time?”

In Dr. Nuland’s thoughts lie the conundrum of responsibility for physicians. Thankfully for Dr. Nuland, he was able to save the day and diagnose a rare case of rupture of an aneurysm of the splenic artery and keep the patient alive. This dramatic story involved a surgical colleague who had to make split-second decisions while a patient’s life hanged in the balance, but the same principles apply to us as psychiatrists.

Sadly, like a ruptured splenic artery, depression and other mental illnesses can end lives in vulnerable patients facing overwhelming life crises. I would note that, in the above example of the surgical patient, the “system” for saving the woman’s life was well organized and resourced to allow for a comprehensive and time-limited intervention into a life-threatening situation. There was an operating room staffed by various professionals who all had a defined role. It required the leader, Dr. Nuland, to step in, make the right diagnosis, and then issue commands to the identified professionals who all recognized his leadership and were skilled in carrying out their assigned duties. Dr. Nuland clearly was the leader once he took charge.

An outpatient psychiatrist facing a suicidal patient must deal with a different set of challenges, often involving various complex systems as well as multiple barriers. Clinical barriers include available interdisciplinary resources/personnel to assist not only with the critical encounter, but also with extended evaluation and treatment in a secure, well-resourced environment. Administrative barriers can include justifying the optimal treatment plan to payors. Our lethal patients often require both outpatient and inpatient services with sometimes-conflicting agendas. In a recent article, I pointed out some of the vexing problems that arise when communication and collaboration are poor between inpatient and outpatient psychiatrists. In such complex environments, it is less clear what is involved in the outpatient psychiatrist stepping up to the plate and asserting leadership.

An emotionally wrenching article about an emergency physician, Matthew E. Seaman, MD, who died by suicide, reminds us of the potential for suicide in a complicated patient (in this case, a medical colleague) involving complex systems. Plagued by a review of his care by the medical board (they had forced him to surrender his medical license and allowed the allegations to go public in lieu of further disciplinary proceedings), a subsequent lawsuit and an ultimate attempt by the plaintiff to obtain Dr. Seaman’s personal assets led to his worsening mental health. According to his wife, also a physician, he was getting “more depressed by the insults and assaults on his integrity and professionalism.”

Just before the investigation, he had received a 30-year pin from the American Board of Emergency Medicine for his “dedication to the specialty.” He fell into a deep depression from which he could not recover despite several psychiatric admissions and several medication trials. Along with his depression, he suffered from severe anxiety, a known risk factor for suicide. Dr. Seaman was feeling overwhelmed by the lengthy legal process targeting him as being negligent. He begged his attorney to settle the case, but his insurance carrier would not allow it. According to his wife: “All sense of human worth had been beaten out of him.”

Dr. Seaman had been known as resilient. He could handle complex ED situations, including simultaneously dealing with multiple traumas. He previously had been named in three malpractice lawsuits and had prevailed in each one. But his resilience had greatly diminished, and he became overwhelmed. He previously had, as a physician, been able to step up to the plate of accountability. But now, because of a confluence of depression and anxiety as well as the “insults and assaults on his integrity and professionalism,” he found life to be unbearable with the resulting tragic end.

So how would we as psychiatrists step up to the plate and be accountable when faced with a struggling fellow physician at risk for suicide such as Dr. Seaman?

Be aware of relevant risk factors

In addition to being aware of the usual risk factors for suicide, it would behoove us to also understand how physician suicides differ from suicides among nonphysicians.¹ For example, physicians who have died by suicide were far more likely to have experienced job-related problems than nonphysicians, but less likely to have experienced the recent death of a loved one. Also noteworthy is that physicians who end their lives were more often married. In addition, Michael F. Myers, MD, a psychiatrist who has studied physician suicides, noted in the article about Dr. Seaman that struggling physicians are likely to suffer from shame and embarrassment.
 

Consider shame, burdensomeness, and secrecy

When suicide risk factors are taught to students and professionals, rarely is shame mentioned. Perhaps it is not a common risk factor in the general population, but shame and its cousin, disgrace, are known risk factors that likely apply more to people – such as physicians – who have built a reputation over their careers. One whole chapter is given to disgrace suicides in a book about suicide notes.² A reputation often is one of the most important factors for professionals, which creates their sense of identity and, by extension, a sense of purpose in life.

When a doctor perceives that his or her reputation is being destroyed, it can produce a profound sense of shame, one of the most powerful of negative emotions.³ Another feature among completed suicides that applies more generally is perceived burdensomeness, according to Thomas E. Joiner Jr., PhD, one of the deep and innovative researchers in the field of suicidology.⁴ Once a doctor starts feeling that he has been a failure in his professional life and starts ruminating about it, the feelings of failure may generalize to other areas of his life, so that he starts feeling that he is a burden to his spouse. This, then, only increases his shame.

The issue of secrecy also is noteworthy. I was struck reading a book by Dr. Myers on physician suicide by the many spouses and family members who were caught completely unaware of problems when their spouse, a doctor, ended their lives by suicide.⁵ The doctors hid their problems well, perhaps not wanting to burden their family members. Also, if feelings of shame are an issue, then concealment tends to occur. This concealment of suicidality runs counter to the current narrative among some in the professional community that suicides are preventable (this despite the continuing increase in rates of suicide at the same time that there are increases in mental health services and suicide prevention programs).⁶

As pointed out in some of the letters quoted in Dr. Myers’s book, those who completed suicide are smart and know how to hide their symptoms well. Although Dr. Seaman’s wife, Linda Seaman, MD, was aware of her husband’s suicidality, when he eventually determined that he was going to end his life, he apparently did not reveal his more serious intention to her. Aside from spouses and family, determined suicide completers often hide their intentions from their clinicians.⁷
 

Attempt to obtain collateral information

By being aware of the usual and less-usual risk factors for suicide that our physician colleagues may present with as explained above, we can use strategies for mitigating risk. If secrecy because of shame and embarrassment prevents our physician patient from being fully candid, include the spouse or another significant family member in sessions. While the physician might hide his suicidal intent from both the clinician and spouse, it remains prudent to include the spouse in the treatment plan. Give the spouse a telephone number with which they can contact you if they notice any worrisome change in functioning or behavior. Collateral information often is helpful. (Example: Is the patient not eating, not sleeping, or giving away valued possessions?)
 

Assess for competency

In Dr. Seaman’s case, it was noted that, with a trial approaching, Dr. Seaman had written in a journal entry that he could not mentally endure a trial. “For me, the stress is overwhelming.” Such a patient, suffering from severe depression, often is unable to properly assist his attorney in his defense. The outpatient psychiatrist can notify the court or one of the attorneys that the competency of the physician patient is questionable (or express a definite opinion of incompetency), and offer the opinion that it would be best to postpone further legal action until the patient is in a more healthy state of mind.
 

Know when hospitalization is needed

Obviously, the process will go smoother if the admission is voluntary. If the patient physician resists and the psychiatrist believes that the risk for self-harm is too high for the physician patient to remain as an outpatient, try to get a spouse or family member to persuade him to be admitted. An involuntary admission opens up a whole new can of worms and may fracture the therapeutic alliance.

In the end, it might be better to take that risk rather than having a dead patient on your hands. If a hospitalization is necessary, contact the admitting psychiatrist and verbally express your concerns and the reasons why a hospitalization is needed. Ask the inpatient psychiatrist to contact you when a discharge is approaching so that you have an opportunity to ask relevant questions.

For example, during his second psychiatric admission, as the time for discharge was approaching, Dr. Seaman wrote: “I am not well enough for discharge. I am still mentally ill.” Ask the inpatient doctor whether the patient has gotten sufficiently better and he feels confident he can function as an outpatient. If there is a conflicting opinion about the readiness of the patient for discharge, notify the medical director of the service or an administrator about your concerns.
 

Ask for consultation

At any stage of the process consider getting consultation for a trusted colleague or senior clinician if you are failing to make progress. Sometimes it helps to get the perspective from a fresh pair of eyes or ears.

Get a reality check

Having recounted the inspiring story of Dr. Nuland’s magnificent efforts and joyous success in preserving a life that was on the verge of being lost in the battle against death at the last possible second, I would note the following: Surgeons will tell you that, despite their most heroic efforts and teamwork, there are times when luck runs out and the patient dies on the operating table. Also, small lapses, which all mortals are prone to despite their best efforts at conscientiousness, sometimes can lead to a bad outcome.

Similarly, in psychiatry, no matter how much effort we put into saving a life, sometimes it is all to no avail. Despite all we have learned about suicide and its risk factors, and no matter how much care we take to contain risk, our patients who are determined will find a way of ending their own lives. The vexing problem of suicide seems intractable. A suicide among our patients humbles us, but also hopefully inspires us to keep trying harder to step up to the plate of accountability.

In conclusion, for us physicians, accountability is not a facet, a trait, or even a pursuit, accountability is at the core of who are and how we define ourselves. Accountability is the reason we leap stairs three at time when we are urgently paged. Accountability is the reason malpractice lawsuits cut at the core of our self-image. Accountability allows us to always have hope for a positive outcome, despite overwhelming barriers, and gives our lives a sense of purpose.

For me, in preparing this article, accountability was reviewing and studying physician suicide and then applying best practices in risk assessment after reading the tragic story of Dr. Seaman. I hope I inspire you to do the same in the pursuit of helping our vulnerable patients.

Learning how to care for our complex patients is a never-ending journey.
 

References

1. Gold KJ. Gen Hosp Psychiatry. 2013 Jan;35(1):45-9.

2. Etkind M. ...Or Not to Be: A Collection of Suicide Notes. New York: Riverhead Books, 1997.

3. Lamia LC. Shame: A concealed, contagious, and dangerous emotion. Psychology Today. 2011 Apr 4.

4. Joiner TE. Why People Die by Suicide. Cambridge: Harvard University Press, 2005.

5. Myers MF. Why Physicians Die by Suicide. 2017.

6. National Institutes of Health. Suicide Prevention. https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml.

7. Levy AG et al. JAMA Netw Open. 2019 Aug 14. doi: 10.1001/jamanetworkopen.2019.9277.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University, Cleveland, as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

Recently, Nicolas Badre, MD, challenged psychiatrists who care for patients involved in the legal system. He encouraged “a resurgence of personal accountability and responsibility.”

Using the chronically disenfranchised patients who are repetitiously shuttled between jails and mental hospitals as examples, he pointed out that we psychiatrists must “step up to the plate” and approach clinical problems with the attitude that “the buck stops with me.” As Dr. Badre pointed out, this is especially true when dealing with large, complex systems in which fragmented care exists without clear leadership. This, in turn, allows for a dissolution of accountability.

Accountability is a natural continuation of our training as physicians. We all remember the transition from medical student to intern, the steep learning curve as well as growth and maturation during this changeover. A dramatic transformation occurs over the course of 1 year, from medical students who tag along learning from patients to interns expected to be on their own for endless hours.

Over the course of those hours, we came to the understanding that people’s lives were in our hands. This causes a shift in our identity. This process continues throughout residency and onward in our careers. At some point, it becomes part of our innate identity as physicians or our professional sense of self – which is hard to describe to nonphysicians.

A profound example of a sense of accountability within the medical profession can be found in “How We Live,” a book by National Book Award winner Sherwin B. Nuland, MD. In the book, the late Dr. Nuland recounted how, as a 49-year-old seasoned surgeon working at Yale University, New Haven, Conn., and casually rounding on patients, he heard a frantic message: “Any general surgeon! Any general surgeon! Go immediately to the operating room – immediately – any general surgeon!”

The case involved a 42-year-old wife and mother who had been rushed to the ED after having been found in the community in a profound state of shock. In the ED, it was suspected that the patient was bleeding heavily from a ruptured tubal pregnancy. She was sped rapidly to the operating room with an undetectable blood pressure and a barely palpable pulse. The on-call ob.gyn. had been summoned from home, and he rushed to the operating room along with his department chairman.

Because the woman had lost much of her blood supply, there was no time for crossmatching. The anesthesiologist had placed large-bore intravenous lines and transfused her with O-negative blood (the universal donor blood type) to try maintain some level of blood pressure. Before she could be even fully anesthetized, the ob.gyn had made an incision in her lower abdomen. The bleeding he encountered was profound.

After a quick evaluation, the ob.gyn. realized that the blood was coming from above, not below, leading to the emergency page that Dr. Nuland heard. Dr. Nuland described bounding up the stairs three at a time. He recalled: “[A] very real apprehension had entered my mind. I might encounter a situation that was beyond me, something that I might make even worse, something that would cause me to regret for the rest of my life that I had answered the page’s insistent call instead of simply turning my back on its urgency and slinking off to my car before anyone noticed I was there.”

However, he could not see himself doing such a thing and he rushed up to the operating room because, “walking away from that kind of cry for help would have violated every precept taught me by my life and my training, and every bit of moral sense I had. … . I bear an obsessive preoccupation with accepting responsibility, amounting really to a compulsively neurotic sense of duty.”

And yet in the next few seconds, as he was running to the operating room, he wondered: “Am I about to botch something up? Will I, in one quick stroke of ineptness and fate, bring my career crashing down around my feet and with it my sense of what I am? Am I on my way to destroy an unknown patient and myself at the same time?”

In Dr. Nuland’s thoughts lie the conundrum of responsibility for physicians. Thankfully for Dr. Nuland, he was able to save the day and diagnose a rare case of rupture of an aneurysm of the splenic artery and keep the patient alive. This dramatic story involved a surgical colleague who had to make split-second decisions while a patient’s life hanged in the balance, but the same principles apply to us as psychiatrists.

Sadly, like a ruptured splenic artery, depression and other mental illnesses can end lives in vulnerable patients facing overwhelming life crises. I would note that, in the above example of the surgical patient, the “system” for saving the woman’s life was well organized and resourced to allow for a comprehensive and time-limited intervention into a life-threatening situation. There was an operating room staffed by various professionals who all had a defined role. It required the leader, Dr. Nuland, to step in, make the right diagnosis, and then issue commands to the identified professionals who all recognized his leadership and were skilled in carrying out their assigned duties. Dr. Nuland clearly was the leader once he took charge.

An outpatient psychiatrist facing a suicidal patient must deal with a different set of challenges, often involving various complex systems as well as multiple barriers. Clinical barriers include available interdisciplinary resources/personnel to assist not only with the critical encounter, but also with extended evaluation and treatment in a secure, well-resourced environment. Administrative barriers can include justifying the optimal treatment plan to payors. Our lethal patients often require both outpatient and inpatient services with sometimes-conflicting agendas. In a recent article, I pointed out some of the vexing problems that arise when communication and collaboration are poor between inpatient and outpatient psychiatrists. In such complex environments, it is less clear what is involved in the outpatient psychiatrist stepping up to the plate and asserting leadership.

An emotionally wrenching article about an emergency physician, Matthew E. Seaman, MD, who died by suicide, reminds us of the potential for suicide in a complicated patient (in this case, a medical colleague) involving complex systems. Plagued by a review of his care by the medical board (they had forced him to surrender his medical license and allowed the allegations to go public in lieu of further disciplinary proceedings), a subsequent lawsuit and an ultimate attempt by the plaintiff to obtain Dr. Seaman’s personal assets led to his worsening mental health. According to his wife, also a physician, he was getting “more depressed by the insults and assaults on his integrity and professionalism.”

Just before the investigation, he had received a 30-year pin from the American Board of Emergency Medicine for his “dedication to the specialty.” He fell into a deep depression from which he could not recover despite several psychiatric admissions and several medication trials. Along with his depression, he suffered from severe anxiety, a known risk factor for suicide. Dr. Seaman was feeling overwhelmed by the lengthy legal process targeting him as being negligent. He begged his attorney to settle the case, but his insurance carrier would not allow it. According to his wife: “All sense of human worth had been beaten out of him.”

Dr. Seaman had been known as resilient. He could handle complex ED situations, including simultaneously dealing with multiple traumas. He previously had been named in three malpractice lawsuits and had prevailed in each one. But his resilience had greatly diminished, and he became overwhelmed. He previously had, as a physician, been able to step up to the plate of accountability. But now, because of a confluence of depression and anxiety as well as the “insults and assaults on his integrity and professionalism,” he found life to be unbearable with the resulting tragic end.

So how would we as psychiatrists step up to the plate and be accountable when faced with a struggling fellow physician at risk for suicide such as Dr. Seaman?

Be aware of relevant risk factors

In addition to being aware of the usual risk factors for suicide, it would behoove us to also understand how physician suicides differ from suicides among nonphysicians.¹ For example, physicians who have died by suicide were far more likely to have experienced job-related problems than nonphysicians, but less likely to have experienced the recent death of a loved one. Also noteworthy is that physicians who end their lives were more often married. In addition, Michael F. Myers, MD, a psychiatrist who has studied physician suicides, noted in the article about Dr. Seaman that struggling physicians are likely to suffer from shame and embarrassment.
 

Consider shame, burdensomeness, and secrecy

When suicide risk factors are taught to students and professionals, rarely is shame mentioned. Perhaps it is not a common risk factor in the general population, but shame and its cousin, disgrace, are known risk factors that likely apply more to people – such as physicians – who have built a reputation over their careers. One whole chapter is given to disgrace suicides in a book about suicide notes.² A reputation often is one of the most important factors for professionals, which creates their sense of identity and, by extension, a sense of purpose in life.

When a doctor perceives that his or her reputation is being destroyed, it can produce a profound sense of shame, one of the most powerful of negative emotions.³ Another feature among completed suicides that applies more generally is perceived burdensomeness, according to Thomas E. Joiner Jr., PhD, one of the deep and innovative researchers in the field of suicidology.⁴ Once a doctor starts feeling that he has been a failure in his professional life and starts ruminating about it, the feelings of failure may generalize to other areas of his life, so that he starts feeling that he is a burden to his spouse. This, then, only increases his shame.

The issue of secrecy also is noteworthy. I was struck reading a book by Dr. Myers on physician suicide by the many spouses and family members who were caught completely unaware of problems when their spouse, a doctor, ended their lives by suicide.⁵ The doctors hid their problems well, perhaps not wanting to burden their family members. Also, if feelings of shame are an issue, then concealment tends to occur. This concealment of suicidality runs counter to the current narrative among some in the professional community that suicides are preventable (this despite the continuing increase in rates of suicide at the same time that there are increases in mental health services and suicide prevention programs).⁶

As pointed out in some of the letters quoted in Dr. Myers’s book, those who completed suicide are smart and know how to hide their symptoms well. Although Dr. Seaman’s wife, Linda Seaman, MD, was aware of her husband’s suicidality, when he eventually determined that he was going to end his life, he apparently did not reveal his more serious intention to her. Aside from spouses and family, determined suicide completers often hide their intentions from their clinicians.⁷
 

Attempt to obtain collateral information

By being aware of the usual and less-usual risk factors for suicide that our physician colleagues may present with as explained above, we can use strategies for mitigating risk. If secrecy because of shame and embarrassment prevents our physician patient from being fully candid, include the spouse or another significant family member in sessions. While the physician might hide his suicidal intent from both the clinician and spouse, it remains prudent to include the spouse in the treatment plan. Give the spouse a telephone number with which they can contact you if they notice any worrisome change in functioning or behavior. Collateral information often is helpful. (Example: Is the patient not eating, not sleeping, or giving away valued possessions?)
 

Assess for competency

In Dr. Seaman’s case, it was noted that, with a trial approaching, Dr. Seaman had written in a journal entry that he could not mentally endure a trial. “For me, the stress is overwhelming.” Such a patient, suffering from severe depression, often is unable to properly assist his attorney in his defense. The outpatient psychiatrist can notify the court or one of the attorneys that the competency of the physician patient is questionable (or express a definite opinion of incompetency), and offer the opinion that it would be best to postpone further legal action until the patient is in a more healthy state of mind.
 

Know when hospitalization is needed

Obviously, the process will go smoother if the admission is voluntary. If the patient physician resists and the psychiatrist believes that the risk for self-harm is too high for the physician patient to remain as an outpatient, try to get a spouse or family member to persuade him to be admitted. An involuntary admission opens up a whole new can of worms and may fracture the therapeutic alliance.

In the end, it might be better to take that risk rather than having a dead patient on your hands. If a hospitalization is necessary, contact the admitting psychiatrist and verbally express your concerns and the reasons why a hospitalization is needed. Ask the inpatient psychiatrist to contact you when a discharge is approaching so that you have an opportunity to ask relevant questions.

For example, during his second psychiatric admission, as the time for discharge was approaching, Dr. Seaman wrote: “I am not well enough for discharge. I am still mentally ill.” Ask the inpatient doctor whether the patient has gotten sufficiently better and he feels confident he can function as an outpatient. If there is a conflicting opinion about the readiness of the patient for discharge, notify the medical director of the service or an administrator about your concerns.
 

Ask for consultation

At any stage of the process consider getting consultation for a trusted colleague or senior clinician if you are failing to make progress. Sometimes it helps to get the perspective from a fresh pair of eyes or ears.

Get a reality check

Having recounted the inspiring story of Dr. Nuland’s magnificent efforts and joyous success in preserving a life that was on the verge of being lost in the battle against death at the last possible second, I would note the following: Surgeons will tell you that, despite their most heroic efforts and teamwork, there are times when luck runs out and the patient dies on the operating table. Also, small lapses, which all mortals are prone to despite their best efforts at conscientiousness, sometimes can lead to a bad outcome.

Similarly, in psychiatry, no matter how much effort we put into saving a life, sometimes it is all to no avail. Despite all we have learned about suicide and its risk factors, and no matter how much care we take to contain risk, our patients who are determined will find a way of ending their own lives. The vexing problem of suicide seems intractable. A suicide among our patients humbles us, but also hopefully inspires us to keep trying harder to step up to the plate of accountability.

In conclusion, for us physicians, accountability is not a facet, a trait, or even a pursuit, accountability is at the core of who are and how we define ourselves. Accountability is the reason we leap stairs three at time when we are urgently paged. Accountability is the reason malpractice lawsuits cut at the core of our self-image. Accountability allows us to always have hope for a positive outcome, despite overwhelming barriers, and gives our lives a sense of purpose.

For me, in preparing this article, accountability was reviewing and studying physician suicide and then applying best practices in risk assessment after reading the tragic story of Dr. Seaman. I hope I inspire you to do the same in the pursuit of helping our vulnerable patients.

Learning how to care for our complex patients is a never-ending journey.
 

References

1. Gold KJ. Gen Hosp Psychiatry. 2013 Jan;35(1):45-9.

2. Etkind M. ...Or Not to Be: A Collection of Suicide Notes. New York: Riverhead Books, 1997.

3. Lamia LC. Shame: A concealed, contagious, and dangerous emotion. Psychology Today. 2011 Apr 4.

4. Joiner TE. Why People Die by Suicide. Cambridge: Harvard University Press, 2005.

5. Myers MF. Why Physicians Die by Suicide. 2017.

6. National Institutes of Health. Suicide Prevention. https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml.

7. Levy AG et al. JAMA Netw Open. 2019 Aug 14. doi: 10.1001/jamanetworkopen.2019.9277.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University, Cleveland, as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.

Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?

According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.

Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.

The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.

I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.

Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. Burnout can give physicians the impression that their problems are social and occupational, thus not requiring a medical solution or intervention. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?

I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.

Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.

Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?

According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.

Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.

The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.

I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.

Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. Burnout can give physicians the impression that their problems are social and occupational, thus not requiring a medical solution or intervention. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?

I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.

Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

Over the past years, I have had the opportunity to attend countless lectures on burnout provided by colleagues spanning across many fields in mental health and health care in general. The talks generally follow a common narration: 1. Your work is important and meaningful to many. 2. Your work requires significant training, dedication, and passion. 3. While you get personal gratification from your work, it does come with a cost. 4. This cost can be great and can affect you physically and mentally. 5. This cost is called burnout.

Burnout is described as irritability (poor mood), low energy, poor concentration, difficulty appreciating enjoyable things (anhedonia), and poor sleep, among other symptoms, as a result of work stress. At this point in the lectures, I usually ask whomever is sitting next to me: “I came in late, is this a lecture on depression?” to which the answer is typically “No! Of course not, this is about ‘burnout’ not mental illness.” And here lies a concern about burnout: Is burnout a concept describing depression that we have repackaged to protect professionals from the stigmatization of mental illness? Does our tendency not to characterize patients’ struggles as burnout stigmatize them – and imply that their employment is not challenging to cause burnout?

According to the literature, a range of factors affects burnout in professionals: lack of control, unclear job expectations, dysfunctional workplace dynamics, extremes of activity, lack of social support, work-life imbalance. Contrary to depression, burnout is not caused by neurobiological problems. Patients with burnout don’t have chemical imbalances, hyperactive default mode networks, or overactive amygdalas. Burnout is caused by social factors and affects dedicated, caring, and exceptional individuals who have been pushed outside their window of tolerance.

Literature suggests a variety of remedies to treat burnout: Reevaluate your employment, discuss occupational concerns with your supervisor, discuss with colleagues, receive help from your social support system, and seek human resources services. In addition, experts recommend engaging in relaxing activities, improving your sleep hygiene, exercising regularly, and participating in mindfulness to reduce symptoms. Contrary to depression, burnout does not require individuals to fix their maladaptive thoughts or discover inadequate unconscious beliefs that may be affecting their work. Contrary to depression, burnout does not require the rebalancing of neurochemistry using psychotropic medication.

The concept of burnout engenders concerns. I fear that it divides physicians and patients into two different classes and thus further stigmatizes those with mental illness. It implies that we physicians are somehow immune from mental illness and its consequences. We do not suffer from brain abnormalities, we do not require mind-altering medications, we are not “mentally ill.” Contrarily, at times it might be implied that patients’ jobs are not important enough to cause burnout; if they feel sad, anhedonic, have poor energy and poor sleep, it is because they have mental illness. Their brains are inadequate and flawed. But for physicians, our brains are intact, just pushed beyond human capabilities.

I should point out that I do not think that burnout experts believe or desire to promote such concepts. I am not aware of burnout experts championing physician exceptionalism or promoting the stigmatization of patients. I believe that this problem is an unintended consequence, a side effect, of the idea of burnout itself.

Another concern I have is that the concept of burnout may actually hinder physicians from seeking necessary and appropriate professional services to address symptoms. Interestingly, most lectures I have attended on burnout have not discussed the concerning number of physicians who end their lives by suicide. Burnout can give physicians the impression that their problems are social and occupational, thus not requiring a medical solution or intervention. There was a time when I argued against the removal of the grief exclusion in the DSM; I worried that we were pathologizing natural emotional reactions to trauma. However, I have come to realize that, if someone is debilitated by depression, seeking professional help should not be predicated on the trigger. As such, I would recommend the vast number of physicians who state burnout in surveys to seriously consider the possibility that they may, in fact, be suffering from mental illness. We encourage our patients to seek help and speak out against stigmatization; isn’t it time that we as professionals should not be afraid to do the same?

I have concerns about the concept of burnout, but I certainly do not think that we should get rid of the idea. On the contrary, I applaud this attempt at de-pathologizing, and de-medicalizing human suffering. As many have argued with more or less success and controversy of the years, many emotional problems are not best suited to be treated by psychotropic medication or even psychiatry. I think that psychiatry should embrace paradigms that include social and occupational constructs of emotional pain, not rooted in diseases and/or chemical imbalances. Such paradigms should, furthermore, not be limited to certain professions or life circumstances. We are all affected by human suffering. Access and willingness to appropriate care or support should not be granted only to those with a mental illness diagnosis.

Burnout is a promising idea that challenges our conceptualization of mental disorders. Burnout brings a humanity to emotional pain frequently lost in the medicalized diagnoses of the DSM. Psychiatry should seriously consider opening its door to nonmedicalized understanding of psychological suffering. By opening those doors, we begin to create a less medicalized construct for human suffering. We begin to create one based on shared human experience.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

Numerous articles, books, and newspaper editorials have been written about the “crisis” in mental health care in our country from various perspectives, and the phrase is often used that the mental health system is “broken.” It seems that lately, this topic is often brought up after the most recent mass shooting.¹

Philip T. Yanos, PhD, correctly asked recently whether we should be talking about a “broken” system, because implicit in the phrase is the assumption that the mental health system was once “whole,” and he has pointed out² chronic deficiencies, such as the absence of affordable housing, and the availability of services to those with chronic mental illness.

In addition, many authors have asserted that, with deinstitutionalization – which occurred starting with the Community Mental Health Act of 1963 – homelessness also became a big problem for people in our prisons and jails, which became the default treatment providers for many of those with serious mental illness.Once authors make this point, they often offer up ways to start addressing various parts of the system, and it usually comes down to asking for more funding for more outpatient treatment and services as well as more inpatient beds. Some authors make the point³ that people with mental illness often lack insight into their illness and the need for treatment. Thus, we have the quandary of people with severe mental illness not believing that they need help, and thus not even trying to access services, which can lead to homelessness and jail time.

But what of those individuals with serious mental health problems who aren’t facing those obstacles and complications? What about individuals who aren’t facing homelessness, who haven’t gotten embroiled in the legal system, who do have insurance coverage, who live in areas with sufficient numbers of outpatient mental health centers to choose from, and who have no problems finding an inpatient bed when needed? Let’s suppose that we have an individual who does have insight into his mental illness and need for treatment, and is motivated to seek treatment. How responsive is the system to such individuals? That will be the focus on my article.

In a recent report,⁴ the author quotes American Psychiatric Association President Bruce J. Schwartz, MD, appealing to members of the U.S. Congress to step in. According to the author, Dr. Schwartz’s position is that the crisis in American mental health begins specifically with a drastic, and growing, shortage of psychiatric beds, especially in publicly funded state and county hospital beds. From there, the crisis spreads to the nation’s city streets, and its jails and prisons, where the largest number of people with serious mental illness now reside. He also talks about a shortage of psychiatrists and child psychiatrists, and says the shortage is likely to worsen. The proposed solution to this problem, of course, is more funding from Congress to open more psychiatric beds, as well as providing more funding for mental health in general and funding to residency programs to increase the numbers of psychiatrists.

I respect the opinions of Dr. Schwartz and that of the other authors who want to talk about lack of adequate beds, outpatient clinics and services, insufficient numbers of psychiatrists, and a lack of funding by Congress. However, I would like to provide further information, from a personal perspective, which causes me to believe that the problem is even more complex than that, and that the failures of the system are compounded by a dysfunctional culture within the ranks of professional caregivers. In other words, once the pieces are in place and assembled, the mental health system still seems to be “broken” but from within. I worry about apathy and an absence of motivation to provide good or even adequate services by the very people who are or should be aware of the problems and what it takes to help our vulnerable patients lead better lives.

I have practiced psychiatry for many years in various settings. I have spent many years working as an inpatient psychiatrist in a large state hospital. I have worked in community mental health outpatient settings. I have also worked in a private practice doing both inpatient and outpatient patient care as well as significant forensic work. At the hospitals, I have witnessed and prepared internal reports about patients who are “revolving doors.” Such patients often had more than 50 psychiatric hospitalizations and no apparent solution to keep them stable enough in the community.

But mental illness is not just a career for me. In addition to being psychiatrist, I am the father of a son with severe and persistent mental illness. I have watched him struggle to find stability. He, too, has been in and out of hospitals. My wife is also in the mental health field. She and I have endlessly tried to work with our son’s local community mental health center to provide them with feedback and to get them to respond to his needs – often with great frustration. It has been our impression that clinicians have difficulty listening to us and understanding the difficulties our son is having, from my son’s case manager to the treating psychiatrist, to the director of the agency. We have tried shifting him to other programs in a neighboring county, including one known to be a “model” program, but had the same issues.

Psychiatry is more of an art than science. Our other medical colleagues can try to resolve a clinical problem, no matter their rank, by ordering the right blood test or getting certain imaging. Psychiatry has no such biomarkers, or validated tests, to rely on to resolve disputes. We have only our training and experience and, unfortunately, our biases. If we don’t agree with a colleague, we often resort to rank and argument.

It is hard to hear, but psychiatrists sometimes resort to name-calling, often behind their colleagues’ backs, and to acting superior. There seems to be a certain attitude. Psychiatrists (just as can colleagues in other specialties) can be insufferably arrogant.

My personal experience has been that the hospital and the community often don’t communicate well. This seems to be a systems problem, as is the case for many complex unsolvable problems. I have been to discharge meetings involving hospital staff and the receiving community system. The attitude of the inpatient psychiatrist is often: “If you guys only did your job better, this patient wouldn’t keep having to be admitted. It’s your job to keep him out of the hospital.”

Alternatively, the community rejects this attitude and points to the absence of resources that prevents them from seeing patients in a timely manner and from adequately monitoring them. They say they are shackled by their resource constraints and that the endless admissions are inevitable. Further, the outpatient psychiatrists complain bitterly that all the inpatient doctors do is make a bunch of useless medication changes and then don’t keep patients in long enough to make sure the patient stays well. And on and on the arguments go with no resolution.

Sadly, and confirmed by my personal experience, when well-meaning and knowledgeable family members try to communicate with the community mental health system about their son’s mental disintegration, the community agency often doesn’t welcome the feedback. They resort to “confidentiality” concerns, often ill advised. Their opinion seems to be that the patient, (i.e. the patient who is falling apart and is becoming psychotic), should be the one calling the agency, waiting on hold forever, and not getting a call back. When my son has been in this situation, he has hung up his telephone out of frustration, then headed off to the emergency room, where he knew he would be seen.

The other area of frustration is that of the ideal of recovery. Mental health programs love to tout that their mission is “recovery,” and they list it as one of their primary areas of vision and goals. Yet, when we tried to communicate with community clinicians, they usually ignored our request to assist our son with supported employment and to help him achieve independence and a social life. When we tried to convey our recovery concerns to the psychiatrist, the usual response was also to ignore it and focus on “meds, meds, meds,” which most psychiatrists seem to view as their mission and area of expertise. Many psychiatrists have embraced the “bio-bio-bio” model of evaluation and treatment⁵ with only lip service paid to the “biopsychosocial” theory they like to say they advocate. When we reached out to our son’s psychiatrists and could get through, we found that they mostly failed to display much interest in paying attention to broader areas of functioning, instead focusing on symptoms, which they could observe in person.

So, I add to the chorus complaining that our mental health system is broken. Broken not only in terms of adequate funding, but also broken from within. It would require much wisdom and self-examination to even begin to address the problem. Without a better plan, throwing money at this broken system won’t improve the lives of our seriously ill and vulnerable psychiatric patients.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University in Cleveland as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

References

1. Doroshow D. “We need to stop focusing on the mental health of mass shooters.” Washington Post. 2019 May 20.

2. Yanos P. “Is the mental health system ‘broken’?” Psychology Today. 2018 Oct 11.

3. Orenstein N. “How to fix a broken mental health system.” The Atlantic. 2016 Jun 8.

4. Moran M. APA rings alarm in nation’s capitol about crisis in mental health care. Psychiatr News. 2020 Jan 1.

5. Paris J. “Psychotherapy in an Age of Neuroscience.” New York: Oxford University Press, 2017.

Numerous articles, books, and newspaper editorials have been written about the “crisis” in mental health care in our country from various perspectives, and the phrase is often used that the mental health system is “broken.” It seems that lately, this topic is often brought up after the most recent mass shooting.¹

Philip T. Yanos, PhD, correctly asked recently whether we should be talking about a “broken” system, because implicit in the phrase is the assumption that the mental health system was once “whole,” and he has pointed out² chronic deficiencies, such as the absence of affordable housing, and the availability of services to those with chronic mental illness.

In addition, many authors have asserted that, with deinstitutionalization – which occurred starting with the Community Mental Health Act of 1963 – homelessness also became a big problem for people in our prisons and jails, which became the default treatment providers for many of those with serious mental illness.Once authors make this point, they often offer up ways to start addressing various parts of the system, and it usually comes down to asking for more funding for more outpatient treatment and services as well as more inpatient beds. Some authors make the point³ that people with mental illness often lack insight into their illness and the need for treatment. Thus, we have the quandary of people with severe mental illness not believing that they need help, and thus not even trying to access services, which can lead to homelessness and jail time.

But what of those individuals with serious mental health problems who aren’t facing those obstacles and complications? What about individuals who aren’t facing homelessness, who haven’t gotten embroiled in the legal system, who do have insurance coverage, who live in areas with sufficient numbers of outpatient mental health centers to choose from, and who have no problems finding an inpatient bed when needed? Let’s suppose that we have an individual who does have insight into his mental illness and need for treatment, and is motivated to seek treatment. How responsive is the system to such individuals? That will be the focus on my article.

In a recent report,⁴ the author quotes American Psychiatric Association President Bruce J. Schwartz, MD, appealing to members of the U.S. Congress to step in. According to the author, Dr. Schwartz’s position is that the crisis in American mental health begins specifically with a drastic, and growing, shortage of psychiatric beds, especially in publicly funded state and county hospital beds. From there, the crisis spreads to the nation’s city streets, and its jails and prisons, where the largest number of people with serious mental illness now reside. He also talks about a shortage of psychiatrists and child psychiatrists, and says the shortage is likely to worsen. The proposed solution to this problem, of course, is more funding from Congress to open more psychiatric beds, as well as providing more funding for mental health in general and funding to residency programs to increase the numbers of psychiatrists.

I respect the opinions of Dr. Schwartz and that of the other authors who want to talk about lack of adequate beds, outpatient clinics and services, insufficient numbers of psychiatrists, and a lack of funding by Congress. However, I would like to provide further information, from a personal perspective, which causes me to believe that the problem is even more complex than that, and that the failures of the system are compounded by a dysfunctional culture within the ranks of professional caregivers. In other words, once the pieces are in place and assembled, the mental health system still seems to be “broken” but from within. I worry about apathy and an absence of motivation to provide good or even adequate services by the very people who are or should be aware of the problems and what it takes to help our vulnerable patients lead better lives.

I have practiced psychiatry for many years in various settings. I have spent many years working as an inpatient psychiatrist in a large state hospital. I have worked in community mental health outpatient settings. I have also worked in a private practice doing both inpatient and outpatient patient care as well as significant forensic work. At the hospitals, I have witnessed and prepared internal reports about patients who are “revolving doors.” Such patients often had more than 50 psychiatric hospitalizations and no apparent solution to keep them stable enough in the community.

But mental illness is not just a career for me. In addition to being psychiatrist, I am the father of a son with severe and persistent mental illness. I have watched him struggle to find stability. He, too, has been in and out of hospitals. My wife is also in the mental health field. She and I have endlessly tried to work with our son’s local community mental health center to provide them with feedback and to get them to respond to his needs – often with great frustration. It has been our impression that clinicians have difficulty listening to us and understanding the difficulties our son is having, from my son’s case manager to the treating psychiatrist, to the director of the agency. We have tried shifting him to other programs in a neighboring county, including one known to be a “model” program, but had the same issues.

Psychiatry is more of an art than science. Our other medical colleagues can try to resolve a clinical problem, no matter their rank, by ordering the right blood test or getting certain imaging. Psychiatry has no such biomarkers, or validated tests, to rely on to resolve disputes. We have only our training and experience and, unfortunately, our biases. If we don’t agree with a colleague, we often resort to rank and argument.

It is hard to hear, but psychiatrists sometimes resort to name-calling, often behind their colleagues’ backs, and to acting superior. There seems to be a certain attitude. Psychiatrists (just as can colleagues in other specialties) can be insufferably arrogant.

My personal experience has been that the hospital and the community often don’t communicate well. This seems to be a systems problem, as is the case for many complex unsolvable problems. I have been to discharge meetings involving hospital staff and the receiving community system. The attitude of the inpatient psychiatrist is often: “If you guys only did your job better, this patient wouldn’t keep having to be admitted. It’s your job to keep him out of the hospital.”

Alternatively, the community rejects this attitude and points to the absence of resources that prevents them from seeing patients in a timely manner and from adequately monitoring them. They say they are shackled by their resource constraints and that the endless admissions are inevitable. Further, the outpatient psychiatrists complain bitterly that all the inpatient doctors do is make a bunch of useless medication changes and then don’t keep patients in long enough to make sure the patient stays well. And on and on the arguments go with no resolution.

Sadly, and confirmed by my personal experience, when well-meaning and knowledgeable family members try to communicate with the community mental health system about their son’s mental disintegration, the community agency often doesn’t welcome the feedback. They resort to “confidentiality” concerns, often ill advised. Their opinion seems to be that the patient, (i.e. the patient who is falling apart and is becoming psychotic), should be the one calling the agency, waiting on hold forever, and not getting a call back. When my son has been in this situation, he has hung up his telephone out of frustration, then headed off to the emergency room, where he knew he would be seen.

The other area of frustration is that of the ideal of recovery. Mental health programs love to tout that their mission is “recovery,” and they list it as one of their primary areas of vision and goals. Yet, when we tried to communicate with community clinicians, they usually ignored our request to assist our son with supported employment and to help him achieve independence and a social life. When we tried to convey our recovery concerns to the psychiatrist, the usual response was also to ignore it and focus on “meds, meds, meds,” which most psychiatrists seem to view as their mission and area of expertise. Many psychiatrists have embraced the “bio-bio-bio” model of evaluation and treatment⁵ with only lip service paid to the “biopsychosocial” theory they like to say they advocate. When we reached out to our son’s psychiatrists and could get through, we found that they mostly failed to display much interest in paying attention to broader areas of functioning, instead focusing on symptoms, which they could observe in person.

So, I add to the chorus complaining that our mental health system is broken. Broken not only in terms of adequate funding, but also broken from within. It would require much wisdom and self-examination to even begin to address the problem. Without a better plan, throwing money at this broken system won’t improve the lives of our seriously ill and vulnerable psychiatric patients.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University in Cleveland as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

References

1. Doroshow D. “We need to stop focusing on the mental health of mass shooters.” Washington Post. 2019 May 20.

2. Yanos P. “Is the mental health system ‘broken’?” Psychology Today. 2018 Oct 11.

3. Orenstein N. “How to fix a broken mental health system.” The Atlantic. 2016 Jun 8.

4. Moran M. APA rings alarm in nation’s capitol about crisis in mental health care. Psychiatr News. 2020 Jan 1.

5. Paris J. “Psychotherapy in an Age of Neuroscience.” New York: Oxford University Press, 2017.

Numerous articles, books, and newspaper editorials have been written about the “crisis” in mental health care in our country from various perspectives, and the phrase is often used that the mental health system is “broken.” It seems that lately, this topic is often brought up after the most recent mass shooting.¹

Philip T. Yanos, PhD, correctly asked recently whether we should be talking about a “broken” system, because implicit in the phrase is the assumption that the mental health system was once “whole,” and he has pointed out² chronic deficiencies, such as the absence of affordable housing, and the availability of services to those with chronic mental illness.

In addition, many authors have asserted that, with deinstitutionalization – which occurred starting with the Community Mental Health Act of 1963 – homelessness also became a big problem for people in our prisons and jails, which became the default treatment providers for many of those with serious mental illness.Once authors make this point, they often offer up ways to start addressing various parts of the system, and it usually comes down to asking for more funding for more outpatient treatment and services as well as more inpatient beds. Some authors make the point³ that people with mental illness often lack insight into their illness and the need for treatment. Thus, we have the quandary of people with severe mental illness not believing that they need help, and thus not even trying to access services, which can lead to homelessness and jail time.

But what of those individuals with serious mental health problems who aren’t facing those obstacles and complications? What about individuals who aren’t facing homelessness, who haven’t gotten embroiled in the legal system, who do have insurance coverage, who live in areas with sufficient numbers of outpatient mental health centers to choose from, and who have no problems finding an inpatient bed when needed? Let’s suppose that we have an individual who does have insight into his mental illness and need for treatment, and is motivated to seek treatment. How responsive is the system to such individuals? That will be the focus on my article.

In a recent report,⁴ the author quotes American Psychiatric Association President Bruce J. Schwartz, MD, appealing to members of the U.S. Congress to step in. According to the author, Dr. Schwartz’s position is that the crisis in American mental health begins specifically with a drastic, and growing, shortage of psychiatric beds, especially in publicly funded state and county hospital beds. From there, the crisis spreads to the nation’s city streets, and its jails and prisons, where the largest number of people with serious mental illness now reside. He also talks about a shortage of psychiatrists and child psychiatrists, and says the shortage is likely to worsen. The proposed solution to this problem, of course, is more funding from Congress to open more psychiatric beds, as well as providing more funding for mental health in general and funding to residency programs to increase the numbers of psychiatrists.

I respect the opinions of Dr. Schwartz and that of the other authors who want to talk about lack of adequate beds, outpatient clinics and services, insufficient numbers of psychiatrists, and a lack of funding by Congress. However, I would like to provide further information, from a personal perspective, which causes me to believe that the problem is even more complex than that, and that the failures of the system are compounded by a dysfunctional culture within the ranks of professional caregivers. In other words, once the pieces are in place and assembled, the mental health system still seems to be “broken” but from within. I worry about apathy and an absence of motivation to provide good or even adequate services by the very people who are or should be aware of the problems and what it takes to help our vulnerable patients lead better lives.

I have practiced psychiatry for many years in various settings. I have spent many years working as an inpatient psychiatrist in a large state hospital. I have worked in community mental health outpatient settings. I have also worked in a private practice doing both inpatient and outpatient patient care as well as significant forensic work. At the hospitals, I have witnessed and prepared internal reports about patients who are “revolving doors.” Such patients often had more than 50 psychiatric hospitalizations and no apparent solution to keep them stable enough in the community.

But mental illness is not just a career for me. In addition to being psychiatrist, I am the father of a son with severe and persistent mental illness. I have watched him struggle to find stability. He, too, has been in and out of hospitals. My wife is also in the mental health field. She and I have endlessly tried to work with our son’s local community mental health center to provide them with feedback and to get them to respond to his needs – often with great frustration. It has been our impression that clinicians have difficulty listening to us and understanding the difficulties our son is having, from my son’s case manager to the treating psychiatrist, to the director of the agency. We have tried shifting him to other programs in a neighboring county, including one known to be a “model” program, but had the same issues.

Psychiatry is more of an art than science. Our other medical colleagues can try to resolve a clinical problem, no matter their rank, by ordering the right blood test or getting certain imaging. Psychiatry has no such biomarkers, or validated tests, to rely on to resolve disputes. We have only our training and experience and, unfortunately, our biases. If we don’t agree with a colleague, we often resort to rank and argument.

It is hard to hear, but psychiatrists sometimes resort to name-calling, often behind their colleagues’ backs, and to acting superior. There seems to be a certain attitude. Psychiatrists (just as can colleagues in other specialties) can be insufferably arrogant.

My personal experience has been that the hospital and the community often don’t communicate well. This seems to be a systems problem, as is the case for many complex unsolvable problems. I have been to discharge meetings involving hospital staff and the receiving community system. The attitude of the inpatient psychiatrist is often: “If you guys only did your job better, this patient wouldn’t keep having to be admitted. It’s your job to keep him out of the hospital.”

Alternatively, the community rejects this attitude and points to the absence of resources that prevents them from seeing patients in a timely manner and from adequately monitoring them. They say they are shackled by their resource constraints and that the endless admissions are inevitable. Further, the outpatient psychiatrists complain bitterly that all the inpatient doctors do is make a bunch of useless medication changes and then don’t keep patients in long enough to make sure the patient stays well. And on and on the arguments go with no resolution.

Sadly, and confirmed by my personal experience, when well-meaning and knowledgeable family members try to communicate with the community mental health system about their son’s mental disintegration, the community agency often doesn’t welcome the feedback. They resort to “confidentiality” concerns, often ill advised. Their opinion seems to be that the patient, (i.e. the patient who is falling apart and is becoming psychotic), should be the one calling the agency, waiting on hold forever, and not getting a call back. When my son has been in this situation, he has hung up his telephone out of frustration, then headed off to the emergency room, where he knew he would be seen.

The other area of frustration is that of the ideal of recovery. Mental health programs love to tout that their mission is “recovery,” and they list it as one of their primary areas of vision and goals. Yet, when we tried to communicate with community clinicians, they usually ignored our request to assist our son with supported employment and to help him achieve independence and a social life. When we tried to convey our recovery concerns to the psychiatrist, the usual response was also to ignore it and focus on “meds, meds, meds,” which most psychiatrists seem to view as their mission and area of expertise. Many psychiatrists have embraced the “bio-bio-bio” model of evaluation and treatment⁵ with only lip service paid to the “biopsychosocial” theory they like to say they advocate. When we reached out to our son’s psychiatrists and could get through, we found that they mostly failed to display much interest in paying attention to broader areas of functioning, instead focusing on symptoms, which they could observe in person.

So, I add to the chorus complaining that our mental health system is broken. Broken not only in terms of adequate funding, but also broken from within. It would require much wisdom and self-examination to even begin to address the problem. Without a better plan, throwing money at this broken system won’t improve the lives of our seriously ill and vulnerable psychiatric patients.
 

Dr. Kausch is a clinical and forensic psychiatrist who is on the faculty at Case Western Reserve University in Cleveland as an assistant clinical professor. He spends most of his time seeing patients through the Akron General/Cleveland Clinic health system. He has published in the area of forensic psychiatry, addictions, pathological gambling, and suicide. He has recently taken an interest in conducting marital therapy and is now publishing in that area as well.

References

1. Doroshow D. “We need to stop focusing on the mental health of mass shooters.” Washington Post. 2019 May 20.

2. Yanos P. “Is the mental health system ‘broken’?” Psychology Today. 2018 Oct 11.

3. Orenstein N. “How to fix a broken mental health system.” The Atlantic. 2016 Jun 8.

4. Moran M. APA rings alarm in nation’s capitol about crisis in mental health care. Psychiatr News. 2020 Jan 1.

5. Paris J. “Psychotherapy in an Age of Neuroscience.” New York: Oxford University Press, 2017.

In legal settings, the “sequential intercept model” for targeting people involved in the criminal justice system with mental illness has been proposed as an improvement for the status quo.

The model intends to divert individuals with mental illnesses at any one of five described stages in their journey through the legal system. In the first stage, a patient may be provided enough care in the community to never enter the criminal system. If that works, the patient may be diverted by first responders out of the legal system and back into treatment. Sequentially, throughout the remaining stages, the patient can be diverted by an attorney, the court, a presentencing correctional facility, the sentencing judge, a postsentencing correctional facility, or probation. The model rightfully encourages anyone in the continuum of care to take ownership of a situation and intervene.

I applaud the model for encouraging all participants to intervene in changing the course of our most challenging patients. However, I am reminded of the complexity of large systems trying to change. In practice, what I have seen is a series of half-hearted recommendations: Emergency responders who consider their role finished after giving a patient the number of the suicide hotline, attorneys who are satisfied by giving their clients an outdated list of community mental health clinics, judges who interpret their recommendations for treatment as a fait accompli, and correctional facilities that release patients with an absurdly short supply of medications and the address of an emergency room. I worry that by creating a model encouraging all to participate, we have just absolved ones who make any effort, even if inadequate.

In some ways, the sequential intercept model has similarities with modern mental health treatment teams. In many settings, a treatment team includes a series of providers who are sequentially involved in the life of a patient. A team can include a psychiatrist for psychopharmacology; a neuropsychologist for psychological testing; a social worker for psychotherapeutic strategies; another social worker to assist in obtaining social assistance; an addiction counselor for substance use disorder; another psychiatrist who monitors the administration of a single medication, like ketamine; and a pharmacist who approves the medication regimen. That’s several providers for the treatment of one patient.

As a forensic psychiatrist, I am often asked to review treatment plans of other providers. I am asked to comment on the appropriate nature of a given treatment. Often, insurance companies want to review the continued need for treatment or whether any treatment is warranted at all. Sometimes, employers want to review a treatment plan to ensure the safety of their employees. At times, courts will ask for a review and expectations from treatment of a defendant to assist in sentencing determinations. However, I have not yet been asked by anyone if the amount of care a patient is obtaining is too fragmented and without any clear leadership.

In our endless pursuit of medicalization and standardization of mental health, we have, especially in large systems, created specialization silos for the care of our patients. Many, if not most psychiatrists, do not participate in any psychotherapy; social workers and psychologists do not prescribe (for the most part); many substance abuse counselors only address sobriety and not other primary mental illness factors; and pharmacists cannot diagnose nor are they trained in psychosocial approaches. In many ways, we have defined participants not by what they do, but what they don’t do.

One also can be saddened by the enormous logistical complexity imposed on patients required to make numerous appointments, which can deprive them of time for recovery. However, my bigger concern is that the multiplicity of providers also permits the dissolution of accountability. In my experience, those large teams have an ability to deflect responsibility in ways that are unmatched by any single provider who cannot rely on putting the fault on someone else.

Sadly and ironically, those two parallel paradigms of mental illness and criminal care impose those problems on each other by averting any attempt at interception, a “no-intercept model.” Mental health programs will deny clients involved in the criminal justice system for requiring too much treatment, too little treatment, for lack of availability of one of the necessary providers, for requiring substance use treatment, or simply for being part of the criminal justice system. Accordingly, the legal system will fail to accept recommendations by mental health providers that mental health treatment is not paramount at this time and that the defendant would be better served by addressing his criminogenic risk factors. In response, the multitude of participants in the legal system will point to the mental health system for all answers.

Contrary to many if not most problems, I do not think that the solution lies somewhere in the middle, as this would require the five stages of the legal system to compromise with the nine hypothetical participants of the mental health system. I think that the solution lies in a resurgence of personal accountability and responsibility. For our part, as psychiatrists, we must accept that we are ultimately responsible for all levels of care. As a field, we are also responsible for educating the public and the legal system of our role and limitations in providing care as well as being available for providing such care. Correspondingly, the legal system is responsible for putting an adequate effort into diverting patients and having or obtaining adequate understanding of available and appropriate care for their defendants.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

In legal settings, the “sequential intercept model” for targeting people involved in the criminal justice system with mental illness has been proposed as an improvement for the status quo.

The model intends to divert individuals with mental illnesses at any one of five described stages in their journey through the legal system. In the first stage, a patient may be provided enough care in the community to never enter the criminal system. If that works, the patient may be diverted by first responders out of the legal system and back into treatment. Sequentially, throughout the remaining stages, the patient can be diverted by an attorney, the court, a presentencing correctional facility, the sentencing judge, a postsentencing correctional facility, or probation. The model rightfully encourages anyone in the continuum of care to take ownership of a situation and intervene.

I applaud the model for encouraging all participants to intervene in changing the course of our most challenging patients. However, I am reminded of the complexity of large systems trying to change. In practice, what I have seen is a series of half-hearted recommendations: Emergency responders who consider their role finished after giving a patient the number of the suicide hotline, attorneys who are satisfied by giving their clients an outdated list of community mental health clinics, judges who interpret their recommendations for treatment as a fait accompli, and correctional facilities that release patients with an absurdly short supply of medications and the address of an emergency room. I worry that by creating a model encouraging all to participate, we have just absolved ones who make any effort, even if inadequate.

In some ways, the sequential intercept model has similarities with modern mental health treatment teams. In many settings, a treatment team includes a series of providers who are sequentially involved in the life of a patient. A team can include a psychiatrist for psychopharmacology; a neuropsychologist for psychological testing; a social worker for psychotherapeutic strategies; another social worker to assist in obtaining social assistance; an addiction counselor for substance use disorder; another psychiatrist who monitors the administration of a single medication, like ketamine; and a pharmacist who approves the medication regimen. That’s several providers for the treatment of one patient.

As a forensic psychiatrist, I am often asked to review treatment plans of other providers. I am asked to comment on the appropriate nature of a given treatment. Often, insurance companies want to review the continued need for treatment or whether any treatment is warranted at all. Sometimes, employers want to review a treatment plan to ensure the safety of their employees. At times, courts will ask for a review and expectations from treatment of a defendant to assist in sentencing determinations. However, I have not yet been asked by anyone if the amount of care a patient is obtaining is too fragmented and without any clear leadership.

In our endless pursuit of medicalization and standardization of mental health, we have, especially in large systems, created specialization silos for the care of our patients. Many, if not most psychiatrists, do not participate in any psychotherapy; social workers and psychologists do not prescribe (for the most part); many substance abuse counselors only address sobriety and not other primary mental illness factors; and pharmacists cannot diagnose nor are they trained in psychosocial approaches. In many ways, we have defined participants not by what they do, but what they don’t do.

One also can be saddened by the enormous logistical complexity imposed on patients required to make numerous appointments, which can deprive them of time for recovery. However, my bigger concern is that the multiplicity of providers also permits the dissolution of accountability. In my experience, those large teams have an ability to deflect responsibility in ways that are unmatched by any single provider who cannot rely on putting the fault on someone else.

Sadly and ironically, those two parallel paradigms of mental illness and criminal care impose those problems on each other by averting any attempt at interception, a “no-intercept model.” Mental health programs will deny clients involved in the criminal justice system for requiring too much treatment, too little treatment, for lack of availability of one of the necessary providers, for requiring substance use treatment, or simply for being part of the criminal justice system. Accordingly, the legal system will fail to accept recommendations by mental health providers that mental health treatment is not paramount at this time and that the defendant would be better served by addressing his criminogenic risk factors. In response, the multitude of participants in the legal system will point to the mental health system for all answers.

Contrary to many if not most problems, I do not think that the solution lies somewhere in the middle, as this would require the five stages of the legal system to compromise with the nine hypothetical participants of the mental health system. I think that the solution lies in a resurgence of personal accountability and responsibility. For our part, as psychiatrists, we must accept that we are ultimately responsible for all levels of care. As a field, we are also responsible for educating the public and the legal system of our role and limitations in providing care as well as being available for providing such care. Correspondingly, the legal system is responsible for putting an adequate effort into diverting patients and having or obtaining adequate understanding of available and appropriate care for their defendants.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

In legal settings, the “sequential intercept model” for targeting people involved in the criminal justice system with mental illness has been proposed as an improvement for the status quo.

The model intends to divert individuals with mental illnesses at any one of five described stages in their journey through the legal system. In the first stage, a patient may be provided enough care in the community to never enter the criminal system. If that works, the patient may be diverted by first responders out of the legal system and back into treatment. Sequentially, throughout the remaining stages, the patient can be diverted by an attorney, the court, a presentencing correctional facility, the sentencing judge, a postsentencing correctional facility, or probation. The model rightfully encourages anyone in the continuum of care to take ownership of a situation and intervene.

I applaud the model for encouraging all participants to intervene in changing the course of our most challenging patients. However, I am reminded of the complexity of large systems trying to change. In practice, what I have seen is a series of half-hearted recommendations: Emergency responders who consider their role finished after giving a patient the number of the suicide hotline, attorneys who are satisfied by giving their clients an outdated list of community mental health clinics, judges who interpret their recommendations for treatment as a fait accompli, and correctional facilities that release patients with an absurdly short supply of medications and the address of an emergency room. I worry that by creating a model encouraging all to participate, we have just absolved ones who make any effort, even if inadequate.

In some ways, the sequential intercept model has similarities with modern mental health treatment teams. In many settings, a treatment team includes a series of providers who are sequentially involved in the life of a patient. A team can include a psychiatrist for psychopharmacology; a neuropsychologist for psychological testing; a social worker for psychotherapeutic strategies; another social worker to assist in obtaining social assistance; an addiction counselor for substance use disorder; another psychiatrist who monitors the administration of a single medication, like ketamine; and a pharmacist who approves the medication regimen. That’s several providers for the treatment of one patient.

As a forensic psychiatrist, I am often asked to review treatment plans of other providers. I am asked to comment on the appropriate nature of a given treatment. Often, insurance companies want to review the continued need for treatment or whether any treatment is warranted at all. Sometimes, employers want to review a treatment plan to ensure the safety of their employees. At times, courts will ask for a review and expectations from treatment of a defendant to assist in sentencing determinations. However, I have not yet been asked by anyone if the amount of care a patient is obtaining is too fragmented and without any clear leadership.

In our endless pursuit of medicalization and standardization of mental health, we have, especially in large systems, created specialization silos for the care of our patients. Many, if not most psychiatrists, do not participate in any psychotherapy; social workers and psychologists do not prescribe (for the most part); many substance abuse counselors only address sobriety and not other primary mental illness factors; and pharmacists cannot diagnose nor are they trained in psychosocial approaches. In many ways, we have defined participants not by what they do, but what they don’t do.

One also can be saddened by the enormous logistical complexity imposed on patients required to make numerous appointments, which can deprive them of time for recovery. However, my bigger concern is that the multiplicity of providers also permits the dissolution of accountability. In my experience, those large teams have an ability to deflect responsibility in ways that are unmatched by any single provider who cannot rely on putting the fault on someone else.

Sadly and ironically, those two parallel paradigms of mental illness and criminal care impose those problems on each other by averting any attempt at interception, a “no-intercept model.” Mental health programs will deny clients involved in the criminal justice system for requiring too much treatment, too little treatment, for lack of availability of one of the necessary providers, for requiring substance use treatment, or simply for being part of the criminal justice system. Accordingly, the legal system will fail to accept recommendations by mental health providers that mental health treatment is not paramount at this time and that the defendant would be better served by addressing his criminogenic risk factors. In response, the multitude of participants in the legal system will point to the mental health system for all answers.

Contrary to many if not most problems, I do not think that the solution lies somewhere in the middle, as this would require the five stages of the legal system to compromise with the nine hypothetical participants of the mental health system. I think that the solution lies in a resurgence of personal accountability and responsibility. For our part, as psychiatrists, we must accept that we are ultimately responsible for all levels of care. As a field, we are also responsible for educating the public and the legal system of our role and limitations in providing care as well as being available for providing such care. Correspondingly, the legal system is responsible for putting an adequate effort into diverting patients and having or obtaining adequate understanding of available and appropriate care for their defendants.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Among his writings is chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Springer, 2019).

A series of case discussions recently engendered discord among colleagues of ours. The conflicts raised questions about systemic biases within our field and their possible ramifications.

The cases discussed, like many in psychiatry, involved patients with severely maladaptive coping skills who lived with punishing friends, had little rewarding purpose, and had dismissive or abusive families. The conflicts involved whether the treating psychiatrists should promote seemingly obvious life choices or whether those perspectives were based in socionormative stereotypes seeped in mistaken traditional values that do not account for the rich array of experiences our patients come from.

One such case involved a seemingly masochistic patient who repeatedly found herself in abusive relationships and whether the psychiatrist should consider criticizing her partner choices. Another case involved a severely suffering veteran who felt paralyzed at home and whether the psychiatrist should encourage employment to diminish isolation. Yet another case involved a suicidal transgender patient who was in despair when feeling little relief after receiving gender-conforming surgery and – whether the psychiatrist should or could discuss perspectives on gender.

Those cases have led to accusations of misunderstanding science on both sides – and questions about the political justifications and consequences of psychiatric recommendations.

The field of psychiatry is appropriately embarrassed by its former association to misogynistic, homophobic, and even racist schools of thought. However, we wonder whether our current attempts at penance are at times discouraging important discussions. In some cases, our lowest-functioning patients living on the fringe of society benefit the most from the stabilizing influences of family, employment, social institutions, or religious worship. This is especially true considering how much social isolation has become an increasing reality of modern life. As such, we worry when colleagues argue that the promotion of common values is inherently suspect.

This problem may be exemplified by the public attacks on Allan Josephson, MD. Dr. Josephson, a child psychiatrist at the University of Louisville (Ky.), contends that he was ostracized and later fired from his position for communicating at a Heritage Foundation forum on his concerns about current recommended treatments and approaches for gender dysphoria. It appears that, despite being a renowned and previously deeply respected expert in the field, his opinions on the subject now go beyond the acceptable discourse of psychiatry. It is not just that the establishment disagrees with him, he allegedly has gone beyond the acceptable bounds of professionalism.

This reaction is surprising from numerous perspectives. First, his opinions would have seemed mainstream to many only a few years ago. Second, there is no large body of scientific evidence that has been generated to confirm that he is promoting an unscientific perspective that should rightly get ostracized by the medical community – such as anti-vaccination. Actually, some evidence suggests that some medical approaches to gender dysphoria have not always ameliorated the distress found in some patients.

After reviewing the evidence on gender reassignment surgery a few years ago, the Centers for Medicare & Medicaid Services concluded: “Based on an extensive assessment of the clinical evidence as described above, there is not enough high-quality evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria and whether patients most likely to benefit from these types of surgical intervention can be identified prospectively.”

Whether such a diagnosis should exist at all in the DSM is a worthy topic of discussion with inclusive arguments on both sides. Pathologizing gender dysphoria is stigmatizing. At the same time, a diagnosis may permit one to receive assistance for a recognized condition. One may rightfully want to discuss the scientific merit of a diagnosis without the interference of arguments based on political or social ramifications of said diagnosis, despite their obvious existence and import.

One should be able to voice scientific opinions in a fair-minded, nonpolitically biased manner that is not designed to intimidate and harass dissenters. One should note that a debate about the appropriateness of having said diagnosis will bring up many philosophical and deeply uncomfortable questions. Those questions point out the apparent nosologic problems inherent in DSM methodology that are extraordinarily difficult to solve. If psychiatry chooses to produce or dismiss psychiatric diagnoses based on the inherent political inconvenience of said diagnoses, rather than their scientific and medical basis, the entire field will rightly be called into question.

One may deplore the static and at times oppressive nature of cultural biases. However, it should be noted that the ability to safely step outside the supportive structure of family, employment, and social and religious institution is itself a privilege, one in which some our patients do not have the luxury of engaging in. We are concerned that psychiatrists promoting individualism and dismissing conservative principles may, instead, push our most vulnerable patients to more disenfranchised corners of society.

It is not clear to us how we got to this juncture. Part of psychiatric and medical training does involve learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition may be exaggerated into a desire to solve the human condition without challenging patients’ fundamental need for a well-rounded biologic, psychological, and social recovery. It is also possible that our desire to promote utopian hopes for society has blinded us from accepting the idea that, for many of our lowest-functioning patients, fitting in and participating in society can be their best path to recovery.

Psychiatry attempts to define and alleviate the suffering that accompanies some behaviors. As such, psychiatry has always and will always address and confront behaviors that society may condemn. At times, psychiatrists will be in sync or clash with societal trends. Sometimes science will contradict societal wishes. And ultimately, psychiatrists will hopefully make decisions informed in biopsychosocial constructs that best suit the patient in front of them no matter what society may want. In a polarized environment, psychiatry should remind itself that we cannot always or ever fix society, and that maintaining reasonable cultural norms and societal stability – while avoiding the traps of superficial culture wars and utopian visions – is often the wisest path.

Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

A series of case discussions recently engendered discord among colleagues of ours. The conflicts raised questions about systemic biases within our field and their possible ramifications.

The cases discussed, like many in psychiatry, involved patients with severely maladaptive coping skills who lived with punishing friends, had little rewarding purpose, and had dismissive or abusive families. The conflicts involved whether the treating psychiatrists should promote seemingly obvious life choices or whether those perspectives were based in socionormative stereotypes seeped in mistaken traditional values that do not account for the rich array of experiences our patients come from.

One such case involved a seemingly masochistic patient who repeatedly found herself in abusive relationships and whether the psychiatrist should consider criticizing her partner choices. Another case involved a severely suffering veteran who felt paralyzed at home and whether the psychiatrist should encourage employment to diminish isolation. Yet another case involved a suicidal transgender patient who was in despair when feeling little relief after receiving gender-conforming surgery and – whether the psychiatrist should or could discuss perspectives on gender.

Those cases have led to accusations of misunderstanding science on both sides – and questions about the political justifications and consequences of psychiatric recommendations.

The field of psychiatry is appropriately embarrassed by its former association to misogynistic, homophobic, and even racist schools of thought. However, we wonder whether our current attempts at penance are at times discouraging important discussions. In some cases, our lowest-functioning patients living on the fringe of society benefit the most from the stabilizing influences of family, employment, social institutions, or religious worship. This is especially true considering how much social isolation has become an increasing reality of modern life. As such, we worry when colleagues argue that the promotion of common values is inherently suspect.

This problem may be exemplified by the public attacks on Allan Josephson, MD. Dr. Josephson, a child psychiatrist at the University of Louisville (Ky.), contends that he was ostracized and later fired from his position for communicating at a Heritage Foundation forum on his concerns about current recommended treatments and approaches for gender dysphoria. It appears that, despite being a renowned and previously deeply respected expert in the field, his opinions on the subject now go beyond the acceptable discourse of psychiatry. It is not just that the establishment disagrees with him, he allegedly has gone beyond the acceptable bounds of professionalism.

This reaction is surprising from numerous perspectives. First, his opinions would have seemed mainstream to many only a few years ago. Second, there is no large body of scientific evidence that has been generated to confirm that he is promoting an unscientific perspective that should rightly get ostracized by the medical community – such as anti-vaccination. Actually, some evidence suggests that some medical approaches to gender dysphoria have not always ameliorated the distress found in some patients.

After reviewing the evidence on gender reassignment surgery a few years ago, the Centers for Medicare & Medicaid Services concluded: “Based on an extensive assessment of the clinical evidence as described above, there is not enough high-quality evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria and whether patients most likely to benefit from these types of surgical intervention can be identified prospectively.”

Whether such a diagnosis should exist at all in the DSM is a worthy topic of discussion with inclusive arguments on both sides. Pathologizing gender dysphoria is stigmatizing. At the same time, a diagnosis may permit one to receive assistance for a recognized condition. One may rightfully want to discuss the scientific merit of a diagnosis without the interference of arguments based on political or social ramifications of said diagnosis, despite their obvious existence and import.

One should be able to voice scientific opinions in a fair-minded, nonpolitically biased manner that is not designed to intimidate and harass dissenters. One should note that a debate about the appropriateness of having said diagnosis will bring up many philosophical and deeply uncomfortable questions. Those questions point out the apparent nosologic problems inherent in DSM methodology that are extraordinarily difficult to solve. If psychiatry chooses to produce or dismiss psychiatric diagnoses based on the inherent political inconvenience of said diagnoses, rather than their scientific and medical basis, the entire field will rightly be called into question.

One may deplore the static and at times oppressive nature of cultural biases. However, it should be noted that the ability to safely step outside the supportive structure of family, employment, and social and religious institution is itself a privilege, one in which some our patients do not have the luxury of engaging in. We are concerned that psychiatrists promoting individualism and dismissing conservative principles may, instead, push our most vulnerable patients to more disenfranchised corners of society.

It is not clear to us how we got to this juncture. Part of psychiatric and medical training does involve learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition may be exaggerated into a desire to solve the human condition without challenging patients’ fundamental need for a well-rounded biologic, psychological, and social recovery. It is also possible that our desire to promote utopian hopes for society has blinded us from accepting the idea that, for many of our lowest-functioning patients, fitting in and participating in society can be their best path to recovery.

Psychiatry attempts to define and alleviate the suffering that accompanies some behaviors. As such, psychiatry has always and will always address and confront behaviors that society may condemn. At times, psychiatrists will be in sync or clash with societal trends. Sometimes science will contradict societal wishes. And ultimately, psychiatrists will hopefully make decisions informed in biopsychosocial constructs that best suit the patient in front of them no matter what society may want. In a polarized environment, psychiatry should remind itself that we cannot always or ever fix society, and that maintaining reasonable cultural norms and societal stability – while avoiding the traps of superficial culture wars and utopian visions – is often the wisest path.

Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

A series of case discussions recently engendered discord among colleagues of ours. The conflicts raised questions about systemic biases within our field and their possible ramifications.

The cases discussed, like many in psychiatry, involved patients with severely maladaptive coping skills who lived with punishing friends, had little rewarding purpose, and had dismissive or abusive families. The conflicts involved whether the treating psychiatrists should promote seemingly obvious life choices or whether those perspectives were based in socionormative stereotypes seeped in mistaken traditional values that do not account for the rich array of experiences our patients come from.

One such case involved a seemingly masochistic patient who repeatedly found herself in abusive relationships and whether the psychiatrist should consider criticizing her partner choices. Another case involved a severely suffering veteran who felt paralyzed at home and whether the psychiatrist should encourage employment to diminish isolation. Yet another case involved a suicidal transgender patient who was in despair when feeling little relief after receiving gender-conforming surgery and – whether the psychiatrist should or could discuss perspectives on gender.

Those cases have led to accusations of misunderstanding science on both sides – and questions about the political justifications and consequences of psychiatric recommendations.

The field of psychiatry is appropriately embarrassed by its former association to misogynistic, homophobic, and even racist schools of thought. However, we wonder whether our current attempts at penance are at times discouraging important discussions. In some cases, our lowest-functioning patients living on the fringe of society benefit the most from the stabilizing influences of family, employment, social institutions, or religious worship. This is especially true considering how much social isolation has become an increasing reality of modern life. As such, we worry when colleagues argue that the promotion of common values is inherently suspect.

This problem may be exemplified by the public attacks on Allan Josephson, MD. Dr. Josephson, a child psychiatrist at the University of Louisville (Ky.), contends that he was ostracized and later fired from his position for communicating at a Heritage Foundation forum on his concerns about current recommended treatments and approaches for gender dysphoria. It appears that, despite being a renowned and previously deeply respected expert in the field, his opinions on the subject now go beyond the acceptable discourse of psychiatry. It is not just that the establishment disagrees with him, he allegedly has gone beyond the acceptable bounds of professionalism.

This reaction is surprising from numerous perspectives. First, his opinions would have seemed mainstream to many only a few years ago. Second, there is no large body of scientific evidence that has been generated to confirm that he is promoting an unscientific perspective that should rightly get ostracized by the medical community – such as anti-vaccination. Actually, some evidence suggests that some medical approaches to gender dysphoria have not always ameliorated the distress found in some patients.

After reviewing the evidence on gender reassignment surgery a few years ago, the Centers for Medicare & Medicaid Services concluded: “Based on an extensive assessment of the clinical evidence as described above, there is not enough high-quality evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria and whether patients most likely to benefit from these types of surgical intervention can be identified prospectively.”

Whether such a diagnosis should exist at all in the DSM is a worthy topic of discussion with inclusive arguments on both sides. Pathologizing gender dysphoria is stigmatizing. At the same time, a diagnosis may permit one to receive assistance for a recognized condition. One may rightfully want to discuss the scientific merit of a diagnosis without the interference of arguments based on political or social ramifications of said diagnosis, despite their obvious existence and import.

One should be able to voice scientific opinions in a fair-minded, nonpolitically biased manner that is not designed to intimidate and harass dissenters. One should note that a debate about the appropriateness of having said diagnosis will bring up many philosophical and deeply uncomfortable questions. Those questions point out the apparent nosologic problems inherent in DSM methodology that are extraordinarily difficult to solve. If psychiatry chooses to produce or dismiss psychiatric diagnoses based on the inherent political inconvenience of said diagnoses, rather than their scientific and medical basis, the entire field will rightly be called into question.

One may deplore the static and at times oppressive nature of cultural biases. However, it should be noted that the ability to safely step outside the supportive structure of family, employment, and social and religious institution is itself a privilege, one in which some our patients do not have the luxury of engaging in. We are concerned that psychiatrists promoting individualism and dismissing conservative principles may, instead, push our most vulnerable patients to more disenfranchised corners of society.

It is not clear to us how we got to this juncture. Part of psychiatric and medical training does involve learning nonjudgmental approaches to human suffering and an identification with individual needs over societal demands. Our suspicion is that a nonjudgmental approach to the understanding of the human condition may be exaggerated into a desire to solve the human condition without challenging patients’ fundamental need for a well-rounded biologic, psychological, and social recovery. It is also possible that our desire to promote utopian hopes for society has blinded us from accepting the idea that, for many of our lowest-functioning patients, fitting in and participating in society can be their best path to recovery.

Psychiatry attempts to define and alleviate the suffering that accompanies some behaviors. As such, psychiatry has always and will always address and confront behaviors that society may condemn. At times, psychiatrists will be in sync or clash with societal trends. Sometimes science will contradict societal wishes. And ultimately, psychiatrists will hopefully make decisions informed in biopsychosocial constructs that best suit the patient in front of them no matter what society may want. In a polarized environment, psychiatry should remind itself that we cannot always or ever fix society, and that maintaining reasonable cultural norms and societal stability – while avoiding the traps of superficial culture wars and utopian visions – is often the wisest path.

Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at UCSD and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com.

Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.¹

In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.

Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.²

To prevent furthering the process by which our correctional facilities have become the new asylums,³ law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?

Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”

However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”

We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.

If mental illness (for the most part) does not cause violence, then when patients with or without mental illness commit a violent act, the response (for the most part) should not be a psychiatric one. Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.⁴ The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.

Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.

However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.

With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.

When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.

References

1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.

2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.

3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.

4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.

Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.¹

In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.

Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.²

To prevent furthering the process by which our correctional facilities have become the new asylums,³ law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?

Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”

However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”

We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.

If mental illness (for the most part) does not cause violence, then when patients with or without mental illness commit a violent act, the response (for the most part) should not be a psychiatric one. Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.⁴ The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.

Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.

However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.

With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.

When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.

References

1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.

2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.

3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.

4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.

Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.¹

In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.

Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.²

To prevent furthering the process by which our correctional facilities have become the new asylums,³ law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?

Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”

However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”

We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.

If mental illness (for the most part) does not cause violence, then when patients with or without mental illness commit a violent act, the response (for the most part) should not be a psychiatric one. Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.⁴ The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.

Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.

However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.

With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.

When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.

References

1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.

2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.

3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.

4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.

Every guideline and lecture on suicide risk assessment includes the message: “Do not use suicide contracts.” Yet, as forensic psychiatrists, we continue to see medical records that rely solely on the patient verbalizing, agreeing, or signing that they will be safe, in order to justify medical decision-making. A recent case we reviewed involving a grossly psychotic male spotlighted the meaninglessness of suicide contracts. In an attempt to understand the impulse by clinicians to use suicide contracts, we decided to review the topic.

Suicide risk assessment is a confusing and poorly explained skill in our field. Suicide risk assessment tools are well-intended. They are meant to identify and stratify risk, and help guide medical decision-making. Popular tools are startlingly different. How can two scales represent adequate psychiatric knowledge yet be completely different? SADPERSONS¹ is widely used and still considered standard of care yet has nothing in common with the Columbia–Suicide Severity Rating Scale (CSSRS).²

For those of us working in forensic settings, we are aghast that neither assessment is modified for use in correctional settings or accounts for essential risk factors of suicide in jails and prisons (placement in solitary, significant charges, homeless, etc.) Yet, they are widely used in jails and prisons across the country. This can be extrapolated to all of us who work with specific populations yet are asked to follow generic scales by administrators.

In reviewing the literature, we are surprised to see the lack of acknowledgment that many tools used in suicide risk assessment have little to no evidence. Despite their numerous appearances in medical records that we review, we are not aware of existing evidence for asking patients whether patients are suicidal on an hourly basis, for psychotropic treatment other than lithium and clozapine (Clozaril), and for safety plans that involve telling the patient to call 911. Of even greater concern, suicide risk assessments themselves may have limited value because of a lack of evidence as suggested by large study findings. It may surprise some to learn that the National Institute for Health and Care Excellence (NICE) in the United Kingdom includes the following statement in its guidelines: “Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.”³

In 2017, Carter et al.⁴ reviewed 70 studies using suicide risk scales to stratify patients in higher-risk groups for self-harm or suicide, during a follow-up period. The study reviewed biological tests such as the dexamethasone suppression test and 5-hydroxyindoleacetic acid; as well as psychological scales, including Buglass & Horton, SADPERSONS, the Beck Hopelessness Scale, the Beck’s Depression Inventory, Manchester Self Harm Rule, and the Edinburgh Risk Rating Scale. Their conclusion was clear: “No individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”

Despite the bad reputation, one must admit that suicide contracts intuitively feel right. Just as we ask patients whether they believe they will stay sober in the future, or ask patients if they will be compliant with their psychotropics, asking them if they feel that they can maintain safety seems relevant. Reading through the literature, one can even find articles promoting this approach. In 2011, researchers simply asked 147 patients in psychiatric hospitals considered to be high risk for suicide whether they would engage in self-harm in the following weeks. They followed those patients for 15 weeks after their discharge for acts of self-harm. They concluded that “self-perceptions of risk seem to perform as well as the best [standardized assessment tools] the field has to offer” for the prediction of self-harm^.5 We are unconvinced that juries would find suicide contracts irrelevant despite the lack of evidence. American society values individual autonomy and self-decision making. Patients telling their clinicians, “I will be OK” is relevant to suicide risk assessment. One can argue that the problem is not with the suicide contract itself, but with its blind use as a marker of safety.

The standard of care dictates that we try to assess suicide risk using evidence-based techniques. To the providers who see merit in asking patients whether they will be able to maintain their safety, we empathize with this impulse despite the lack of evidence. We do not ask those providers to stop but to supplement suicide contracts with more evidence-based tools that could lessen their liability. This will contribute in our shared effort to minimize suicide.

We acknowledge that the evidence of any assessment is limited and might miss a greater point in this entire discussion: Why are new iterations of suicide risk assessments not an improvement on the prior ones but a competing theory? New assessments emphasizing different facets of suicidal thinking do not include key demographic factors, while older tools do not include more recent understanding, such as the importance of hopelessness. From a provider’s perspective, the debate appears to be a battle of trends, theories, and acronyms rather than comprehensive analysis of the latest evidence. We, therefore, are concerned by “suicide experts” who advocate for any one assessment as the only gold standard and give false hopes about its efficacy.

As suicide rates continue to climb across the country, one wonders what we, as psychiatrists, are trying to achieve. Promises of zero suicides by hospitals,⁶ academic institutions,⁷ and even governments⁸ are well-meaning but possibly misleading to families and patients. Psychiatry should advocate within the standard of care for reasonable attempts at suicide risk assessment, including demographic factors (see SADPERSONS), as well as examination of the actual suicidality (see the CSSRS). Our professional organizations should clarify expectations for clinicians while also clarifying the limitations of our current knowledge base.
 

References

1. Patterson WM et al. Evaluation of suicidal patients: the SADPERSONS scale. Psychosomatics. 1983 Apr;24[4]:343-5, 348-9.

2. Posner K et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77.

3. Kendall T et al. Longer term management of self harm: summary of NICE guidance. BMJ. 2011;343. doi: 10.1136/bmj.d7073.

4. Carter G et al. Predicting suicidal behaviors using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017 Jun;210(6):387-95.

5. Peterson J et al. If you want to know, consider asking: How likely is it that patients will hurt themselves in the future? Psychol Assess. 2011 Sep;23(3):626-34.

5. Byrne JM et al. Implementation and impact of the central district of California’s suicide prevention program for crime defendants. Federal Probation. 2012 Jun;76(1):3-13.

6. “R.I.’s Butler Hospital sets ‘zero suicide’ goal for patients”/audio. Providence Journal. May 15, 2018.

7. “NIMH funds 3 ‘zero suicide’ grants.” National Institute of Mental Health. Sep 16, 2016.

8. Rothschild N. “Is it possible to eliminate suicide?” Atlantic. Jun 5, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.

Every guideline and lecture on suicide risk assessment includes the message: “Do not use suicide contracts.” Yet, as forensic psychiatrists, we continue to see medical records that rely solely on the patient verbalizing, agreeing, or signing that they will be safe, in order to justify medical decision-making. A recent case we reviewed involving a grossly psychotic male spotlighted the meaninglessness of suicide contracts. In an attempt to understand the impulse by clinicians to use suicide contracts, we decided to review the topic.

Suicide risk assessment is a confusing and poorly explained skill in our field. Suicide risk assessment tools are well-intended. They are meant to identify and stratify risk, and help guide medical decision-making. Popular tools are startlingly different. How can two scales represent adequate psychiatric knowledge yet be completely different? SADPERSONS¹ is widely used and still considered standard of care yet has nothing in common with the Columbia–Suicide Severity Rating Scale (CSSRS).²

For those of us working in forensic settings, we are aghast that neither assessment is modified for use in correctional settings or accounts for essential risk factors of suicide in jails and prisons (placement in solitary, significant charges, homeless, etc.) Yet, they are widely used in jails and prisons across the country. This can be extrapolated to all of us who work with specific populations yet are asked to follow generic scales by administrators.

In reviewing the literature, we are surprised to see the lack of acknowledgment that many tools used in suicide risk assessment have little to no evidence. Despite their numerous appearances in medical records that we review, we are not aware of existing evidence for asking patients whether patients are suicidal on an hourly basis, for psychotropic treatment other than lithium and clozapine (Clozaril), and for safety plans that involve telling the patient to call 911. Of even greater concern, suicide risk assessments themselves may have limited value because of a lack of evidence as suggested by large study findings. It may surprise some to learn that the National Institute for Health and Care Excellence (NICE) in the United Kingdom includes the following statement in its guidelines: “Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.”³

In 2017, Carter et al.⁴ reviewed 70 studies using suicide risk scales to stratify patients in higher-risk groups for self-harm or suicide, during a follow-up period. The study reviewed biological tests such as the dexamethasone suppression test and 5-hydroxyindoleacetic acid; as well as psychological scales, including Buglass & Horton, SADPERSONS, the Beck Hopelessness Scale, the Beck’s Depression Inventory, Manchester Self Harm Rule, and the Edinburgh Risk Rating Scale. Their conclusion was clear: “No individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”

Despite the bad reputation, one must admit that suicide contracts intuitively feel right. Just as we ask patients whether they believe they will stay sober in the future, or ask patients if they will be compliant with their psychotropics, asking them if they feel that they can maintain safety seems relevant. Reading through the literature, one can even find articles promoting this approach. In 2011, researchers simply asked 147 patients in psychiatric hospitals considered to be high risk for suicide whether they would engage in self-harm in the following weeks. They followed those patients for 15 weeks after their discharge for acts of self-harm. They concluded that “self-perceptions of risk seem to perform as well as the best [standardized assessment tools] the field has to offer” for the prediction of self-harm^.5 We are unconvinced that juries would find suicide contracts irrelevant despite the lack of evidence. American society values individual autonomy and self-decision making. Patients telling their clinicians, “I will be OK” is relevant to suicide risk assessment. One can argue that the problem is not with the suicide contract itself, but with its blind use as a marker of safety.

The standard of care dictates that we try to assess suicide risk using evidence-based techniques. To the providers who see merit in asking patients whether they will be able to maintain their safety, we empathize with this impulse despite the lack of evidence. We do not ask those providers to stop but to supplement suicide contracts with more evidence-based tools that could lessen their liability. This will contribute in our shared effort to minimize suicide.

We acknowledge that the evidence of any assessment is limited and might miss a greater point in this entire discussion: Why are new iterations of suicide risk assessments not an improvement on the prior ones but a competing theory? New assessments emphasizing different facets of suicidal thinking do not include key demographic factors, while older tools do not include more recent understanding, such as the importance of hopelessness. From a provider’s perspective, the debate appears to be a battle of trends, theories, and acronyms rather than comprehensive analysis of the latest evidence. We, therefore, are concerned by “suicide experts” who advocate for any one assessment as the only gold standard and give false hopes about its efficacy.

As suicide rates continue to climb across the country, one wonders what we, as psychiatrists, are trying to achieve. Promises of zero suicides by hospitals,⁶ academic institutions,⁷ and even governments⁸ are well-meaning but possibly misleading to families and patients. Psychiatry should advocate within the standard of care for reasonable attempts at suicide risk assessment, including demographic factors (see SADPERSONS), as well as examination of the actual suicidality (see the CSSRS). Our professional organizations should clarify expectations for clinicians while also clarifying the limitations of our current knowledge base.
 

References

1. Patterson WM et al. Evaluation of suicidal patients: the SADPERSONS scale. Psychosomatics. 1983 Apr;24[4]:343-5, 348-9.

2. Posner K et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77.

3. Kendall T et al. Longer term management of self harm: summary of NICE guidance. BMJ. 2011;343. doi: 10.1136/bmj.d7073.

4. Carter G et al. Predicting suicidal behaviors using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017 Jun;210(6):387-95.

5. Peterson J et al. If you want to know, consider asking: How likely is it that patients will hurt themselves in the future? Psychol Assess. 2011 Sep;23(3):626-34.

5. Byrne JM et al. Implementation and impact of the central district of California’s suicide prevention program for crime defendants. Federal Probation. 2012 Jun;76(1):3-13.

6. “R.I.’s Butler Hospital sets ‘zero suicide’ goal for patients”/audio. Providence Journal. May 15, 2018.

7. “NIMH funds 3 ‘zero suicide’ grants.” National Institute of Mental Health. Sep 16, 2016.

8. Rothschild N. “Is it possible to eliminate suicide?” Atlantic. Jun 5, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.

Every guideline and lecture on suicide risk assessment includes the message: “Do not use suicide contracts.” Yet, as forensic psychiatrists, we continue to see medical records that rely solely on the patient verbalizing, agreeing, or signing that they will be safe, in order to justify medical decision-making. A recent case we reviewed involving a grossly psychotic male spotlighted the meaninglessness of suicide contracts. In an attempt to understand the impulse by clinicians to use suicide contracts, we decided to review the topic.

Suicide risk assessment is a confusing and poorly explained skill in our field. Suicide risk assessment tools are well-intended. They are meant to identify and stratify risk, and help guide medical decision-making. Popular tools are startlingly different. How can two scales represent adequate psychiatric knowledge yet be completely different? SADPERSONS¹ is widely used and still considered standard of care yet has nothing in common with the Columbia–Suicide Severity Rating Scale (CSSRS).²

For those of us working in forensic settings, we are aghast that neither assessment is modified for use in correctional settings or accounts for essential risk factors of suicide in jails and prisons (placement in solitary, significant charges, homeless, etc.) Yet, they are widely used in jails and prisons across the country. This can be extrapolated to all of us who work with specific populations yet are asked to follow generic scales by administrators.

In reviewing the literature, we are surprised to see the lack of acknowledgment that many tools used in suicide risk assessment have little to no evidence. Despite their numerous appearances in medical records that we review, we are not aware of existing evidence for asking patients whether patients are suicidal on an hourly basis, for psychotropic treatment other than lithium and clozapine (Clozaril), and for safety plans that involve telling the patient to call 911. Of even greater concern, suicide risk assessments themselves may have limited value because of a lack of evidence as suggested by large study findings. It may surprise some to learn that the National Institute for Health and Care Excellence (NICE) in the United Kingdom includes the following statement in its guidelines: “Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.”³

In 2017, Carter et al.⁴ reviewed 70 studies using suicide risk scales to stratify patients in higher-risk groups for self-harm or suicide, during a follow-up period. The study reviewed biological tests such as the dexamethasone suppression test and 5-hydroxyindoleacetic acid; as well as psychological scales, including Buglass & Horton, SADPERSONS, the Beck Hopelessness Scale, the Beck’s Depression Inventory, Manchester Self Harm Rule, and the Edinburgh Risk Rating Scale. Their conclusion was clear: “No individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”

Despite the bad reputation, one must admit that suicide contracts intuitively feel right. Just as we ask patients whether they believe they will stay sober in the future, or ask patients if they will be compliant with their psychotropics, asking them if they feel that they can maintain safety seems relevant. Reading through the literature, one can even find articles promoting this approach. In 2011, researchers simply asked 147 patients in psychiatric hospitals considered to be high risk for suicide whether they would engage in self-harm in the following weeks. They followed those patients for 15 weeks after their discharge for acts of self-harm. They concluded that “self-perceptions of risk seem to perform as well as the best [standardized assessment tools] the field has to offer” for the prediction of self-harm^.5 We are unconvinced that juries would find suicide contracts irrelevant despite the lack of evidence. American society values individual autonomy and self-decision making. Patients telling their clinicians, “I will be OK” is relevant to suicide risk assessment. One can argue that the problem is not with the suicide contract itself, but with its blind use as a marker of safety.

The standard of care dictates that we try to assess suicide risk using evidence-based techniques. To the providers who see merit in asking patients whether they will be able to maintain their safety, we empathize with this impulse despite the lack of evidence. We do not ask those providers to stop but to supplement suicide contracts with more evidence-based tools that could lessen their liability. This will contribute in our shared effort to minimize suicide.

We acknowledge that the evidence of any assessment is limited and might miss a greater point in this entire discussion: Why are new iterations of suicide risk assessments not an improvement on the prior ones but a competing theory? New assessments emphasizing different facets of suicidal thinking do not include key demographic factors, while older tools do not include more recent understanding, such as the importance of hopelessness. From a provider’s perspective, the debate appears to be a battle of trends, theories, and acronyms rather than comprehensive analysis of the latest evidence. We, therefore, are concerned by “suicide experts” who advocate for any one assessment as the only gold standard and give false hopes about its efficacy.

As suicide rates continue to climb across the country, one wonders what we, as psychiatrists, are trying to achieve. Promises of zero suicides by hospitals,⁶ academic institutions,⁷ and even governments⁸ are well-meaning but possibly misleading to families and patients. Psychiatry should advocate within the standard of care for reasonable attempts at suicide risk assessment, including demographic factors (see SADPERSONS), as well as examination of the actual suicidality (see the CSSRS). Our professional organizations should clarify expectations for clinicians while also clarifying the limitations of our current knowledge base.
 

References

1. Patterson WM et al. Evaluation of suicidal patients: the SADPERSONS scale. Psychosomatics. 1983 Apr;24[4]:343-5, 348-9.

2. Posner K et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011 Dec;168(12):1266-77.

3. Kendall T et al. Longer term management of self harm: summary of NICE guidance. BMJ. 2011;343. doi: 10.1136/bmj.d7073.

4. Carter G et al. Predicting suicidal behaviors using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017 Jun;210(6):387-95.

5. Peterson J et al. If you want to know, consider asking: How likely is it that patients will hurt themselves in the future? Psychol Assess. 2011 Sep;23(3):626-34.

5. Byrne JM et al. Implementation and impact of the central district of California’s suicide prevention program for crime defendants. Federal Probation. 2012 Jun;76(1):3-13.

6. “R.I.’s Butler Hospital sets ‘zero suicide’ goal for patients”/audio. Providence Journal. May 15, 2018.

7. “NIMH funds 3 ‘zero suicide’ grants.” National Institute of Mental Health. Sep 16, 2016.

8. Rothschild N. “Is it possible to eliminate suicide?” Atlantic. Jun 5, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Rao is a San Diego–based board-certified psychiatrist with expertise in forensic psychiatry, correctional psychiatry, telepsychiatry, and inpatient psychiatry.

Since the biological revolution in psychiatry, with the introduction of chlorpromazine in the 1950s,1 psychiatrists have been introduced to the economic questions inherent in the tension between funding psychotropic medications for the treatment of mental illness versus funding psychosocial interventions. Of course, our natural inclination is to advocate for all available treatments for our patients, but the economic realities of medical care – especially government-subsidized or regulated medical care – force us to weigh the relative advantages of these treatments and to promote our patients’ interests with a wise allocation of limited resources.

It has become common practice for the American Psychiatric Association to advocate for additional funds for both research into mental illness as well as treatment. The promotion of mental health parity and the demonization of prior authorizations are examples of our natural priorities in the debates over funding for medical care. A bias has played out in the national conversation about medical care in general regarding the right to said care, but economists understand that medical care is a limited resource and, as such, treating it as a “right,” per se, does not make sense: One has to make hard decisions about its allocation or simply leave it to the free market to make said decisions.

Recently, the government has proposed to eliminate certain psychotropic medications from their protected status within Medicare Part D. Those medications include all drugs labeled as antidepressants, antipsychotics, and anticonvulsants. As expected, the APA’s medical director has written a formal statement opposing the proposal. His statement includes warnings about suicides and overwhelmed emergency departments. He compared the mental health situation in the United States to a crisis. He described the availability of expensive and new psychotropics to be “lifesaving.”²

The goals of the APA and its leaders are honorable. We are inspired by the dedication that some psychiatrists have to advocate for us all as well as for our patients. However, we are concerned that unfounded claims are being made. We are even more troubled when those claims promote the interests of a fallible pharmaceutical industry, an industry that has opened up our field to extensive critical scrutiny over the past few years. We wonder whether a brief examination of the scientific evidence warrants the statements made by the APA.

After reviewing clinical textbooks and search engines, we were not able to find reliable and convincing evidence that newer psychotropics reduce emergency department stays or that lengths of stay in the hospital correlate with the use of newer agents. We have actually not even heard of that claim made before in any serious forum. Reviews of predictors of length of stay in psychiatric hospitals have typically included demographic factors, diagnostic factors, logistical factors such as time of day, and social factors, such as insurance status and homelessness.^3,4 We found no review mentioning the use of patented drugs as a predictor of shorter stays.

At a larger level, we are unsure that the newer psychotropics are particularly better than older ones. The Food and Drug Administration approves psychiatric medications based on superiority to placebo and not superiority to existing – and usually much cheaper – medications. Our subscription to Epocrates informs us that a 1-month supply of once-a-day brand-name Abilify, Invega, or Latuda is more than $1,000.⁵ Alternatively, a 1-month supply of generic olanzapine, risperidone, or quetiapine is available for $4 at Walmart.⁶ As famously described in the CATIE trial⁷ of patients with schizophrenia, newer antipsychotics are not particularly better than older ones. In addition, a more recent meta-analysis⁸ did not find significant differences among antipsychotics’ efficacy.

A similar analysis can be made of antidepressants without addressing debates surrounding the effectiveness of antidepressants as a class and the value of psychological interventions over chemical ones. Reviews of the literature do not suggest that newer antidepressants are more effective than older ones. A recent meta-analysis of antidepressant efficacy did not find significant differences among antidepressants and, when looking at trends, amitriptyline, a much older antidepressant, was most effective.9

The most surprising part of the APA medical director’s statement was the claim of reduced suicidality. While lithium and clozapine have some evidence for reducing the risk of suicide, the evidence that antidepressants reduce suicide is equivocal. Quite the contrary, some evidence exists that antidepressants may increase the risk of suicide,¹⁰ and we are not aware of evidence suggesting that any newer agents can reduce suicide at any higher rate. One psychiatrist has even made a career out of testifying that antidepressants increase impulsivity and suicide.¹¹

We are not politicians, and we trust the APA to have good intentions with a desire to help patients suffering from mental illness. We understand the need to advocate for any measure that provides additional resources for the treatment of mental illness. We have no doubt that a publicly funded and appropriately regulated mental health system is a wise goal from both an ethical as well as a societal perspective. The APA has an imperative to advocate for our patients with the goal to improve our society.

However, we are concerned when our field makes unfounded claims. Advocating that insurance companies and the government provide most psychotropics without prior authorization and without discrimination does not appear to be based on scientific evidence and has serious economic implications that are not being weighed in a transparent manner. Whatever funding levels the APA recommends for the treatment of mental illness, said treatments will remain a limited resource, and then it becomes a question not just of ethics but of economics. What combination of resources produce the most benefit for the most people in question? Would the increased cost of a newer psychotropic be better spent on a system with more elaborate psychosocial interventions? In making this argument, does one risk repeating the historical blunder made when, in the 1960s, long-term psychiatric hospitals were closed with the intention of replacing their costs with outpatient treatments that then never materialized?

A review of the literature does not support the claim that newer psychotropic agents are more effective from either a clinical or an economic perspective. Cost-saving measures are ethical and possibly beneficial if they permit a more justifiable allocation of resources.



Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He is also the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019).
 

References

1. Ann Med Psychol (Paris). 1952 Jun;110(2 1):112-7.

2. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2019.3b26.

3. Am J Emerg Med. 2016 Feb;34(2):133-9.

4. Eur Psychiatry. 2018 Feb;48:6-12.

5. https://online.epocrates.com/drugs. Retrieved March 3, 2019.

6. https://www.walmart.com/cp/$4-prescriptions/1078664. Retrieved March 27, 2019.

7. N Engl J Med. 2005 Sep 22;353(12):1209-23.

8. Am J Psychiatry. 2017. 174(10):927-42.

9. Lancet. 2018 Apr 7. 391(10128):P1357-66.

10. BMJ. 2009.339;b2880.

11. https://breggin.com/.

Since the biological revolution in psychiatry, with the introduction of chlorpromazine in the 1950s,1 psychiatrists have been introduced to the economic questions inherent in the tension between funding psychotropic medications for the treatment of mental illness versus funding psychosocial interventions. Of course, our natural inclination is to advocate for all available treatments for our patients, but the economic realities of medical care – especially government-subsidized or regulated medical care – force us to weigh the relative advantages of these treatments and to promote our patients’ interests with a wise allocation of limited resources.

It has become common practice for the American Psychiatric Association to advocate for additional funds for both research into mental illness as well as treatment. The promotion of mental health parity and the demonization of prior authorizations are examples of our natural priorities in the debates over funding for medical care. A bias has played out in the national conversation about medical care in general regarding the right to said care, but economists understand that medical care is a limited resource and, as such, treating it as a “right,” per se, does not make sense: One has to make hard decisions about its allocation or simply leave it to the free market to make said decisions.

Recently, the government has proposed to eliminate certain psychotropic medications from their protected status within Medicare Part D. Those medications include all drugs labeled as antidepressants, antipsychotics, and anticonvulsants. As expected, the APA’s medical director has written a formal statement opposing the proposal. His statement includes warnings about suicides and overwhelmed emergency departments. He compared the mental health situation in the United States to a crisis. He described the availability of expensive and new psychotropics to be “lifesaving.”²

The goals of the APA and its leaders are honorable. We are inspired by the dedication that some psychiatrists have to advocate for us all as well as for our patients. However, we are concerned that unfounded claims are being made. We are even more troubled when those claims promote the interests of a fallible pharmaceutical industry, an industry that has opened up our field to extensive critical scrutiny over the past few years. We wonder whether a brief examination of the scientific evidence warrants the statements made by the APA.

After reviewing clinical textbooks and search engines, we were not able to find reliable and convincing evidence that newer psychotropics reduce emergency department stays or that lengths of stay in the hospital correlate with the use of newer agents. We have actually not even heard of that claim made before in any serious forum. Reviews of predictors of length of stay in psychiatric hospitals have typically included demographic factors, diagnostic factors, logistical factors such as time of day, and social factors, such as insurance status and homelessness.^3,4 We found no review mentioning the use of patented drugs as a predictor of shorter stays.

At a larger level, we are unsure that the newer psychotropics are particularly better than older ones. The Food and Drug Administration approves psychiatric medications based on superiority to placebo and not superiority to existing – and usually much cheaper – medications. Our subscription to Epocrates informs us that a 1-month supply of once-a-day brand-name Abilify, Invega, or Latuda is more than $1,000.⁵ Alternatively, a 1-month supply of generic olanzapine, risperidone, or quetiapine is available for $4 at Walmart.⁶ As famously described in the CATIE trial⁷ of patients with schizophrenia, newer antipsychotics are not particularly better than older ones. In addition, a more recent meta-analysis⁸ did not find significant differences among antipsychotics’ efficacy.

A similar analysis can be made of antidepressants without addressing debates surrounding the effectiveness of antidepressants as a class and the value of psychological interventions over chemical ones. Reviews of the literature do not suggest that newer antidepressants are more effective than older ones. A recent meta-analysis of antidepressant efficacy did not find significant differences among antidepressants and, when looking at trends, amitriptyline, a much older antidepressant, was most effective.9

The most surprising part of the APA medical director’s statement was the claim of reduced suicidality. While lithium and clozapine have some evidence for reducing the risk of suicide, the evidence that antidepressants reduce suicide is equivocal. Quite the contrary, some evidence exists that antidepressants may increase the risk of suicide,¹⁰ and we are not aware of evidence suggesting that any newer agents can reduce suicide at any higher rate. One psychiatrist has even made a career out of testifying that antidepressants increase impulsivity and suicide.¹¹

We are not politicians, and we trust the APA to have good intentions with a desire to help patients suffering from mental illness. We understand the need to advocate for any measure that provides additional resources for the treatment of mental illness. We have no doubt that a publicly funded and appropriately regulated mental health system is a wise goal from both an ethical as well as a societal perspective. The APA has an imperative to advocate for our patients with the goal to improve our society.

However, we are concerned when our field makes unfounded claims. Advocating that insurance companies and the government provide most psychotropics without prior authorization and without discrimination does not appear to be based on scientific evidence and has serious economic implications that are not being weighed in a transparent manner. Whatever funding levels the APA recommends for the treatment of mental illness, said treatments will remain a limited resource, and then it becomes a question not just of ethics but of economics. What combination of resources produce the most benefit for the most people in question? Would the increased cost of a newer psychotropic be better spent on a system with more elaborate psychosocial interventions? In making this argument, does one risk repeating the historical blunder made when, in the 1960s, long-term psychiatric hospitals were closed with the intention of replacing their costs with outpatient treatments that then never materialized?

A review of the literature does not support the claim that newer psychotropic agents are more effective from either a clinical or an economic perspective. Cost-saving measures are ethical and possibly beneficial if they permit a more justifiable allocation of resources.



Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He is also the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019).
 

References

1. Ann Med Psychol (Paris). 1952 Jun;110(2 1):112-7.

2. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2019.3b26.

3. Am J Emerg Med. 2016 Feb;34(2):133-9.

4. Eur Psychiatry. 2018 Feb;48:6-12.

5. https://online.epocrates.com/drugs. Retrieved March 3, 2019.

6. https://www.walmart.com/cp/$4-prescriptions/1078664. Retrieved March 27, 2019.

7. N Engl J Med. 2005 Sep 22;353(12):1209-23.

8. Am J Psychiatry. 2017. 174(10):927-42.

9. Lancet. 2018 Apr 7. 391(10128):P1357-66.

10. BMJ. 2009.339;b2880.

11. https://breggin.com/.

Since the biological revolution in psychiatry, with the introduction of chlorpromazine in the 1950s,1 psychiatrists have been introduced to the economic questions inherent in the tension between funding psychotropic medications for the treatment of mental illness versus funding psychosocial interventions. Of course, our natural inclination is to advocate for all available treatments for our patients, but the economic realities of medical care – especially government-subsidized or regulated medical care – force us to weigh the relative advantages of these treatments and to promote our patients’ interests with a wise allocation of limited resources.

It has become common practice for the American Psychiatric Association to advocate for additional funds for both research into mental illness as well as treatment. The promotion of mental health parity and the demonization of prior authorizations are examples of our natural priorities in the debates over funding for medical care. A bias has played out in the national conversation about medical care in general regarding the right to said care, but economists understand that medical care is a limited resource and, as such, treating it as a “right,” per se, does not make sense: One has to make hard decisions about its allocation or simply leave it to the free market to make said decisions.

Recently, the government has proposed to eliminate certain psychotropic medications from their protected status within Medicare Part D. Those medications include all drugs labeled as antidepressants, antipsychotics, and anticonvulsants. As expected, the APA’s medical director has written a formal statement opposing the proposal. His statement includes warnings about suicides and overwhelmed emergency departments. He compared the mental health situation in the United States to a crisis. He described the availability of expensive and new psychotropics to be “lifesaving.”²

The goals of the APA and its leaders are honorable. We are inspired by the dedication that some psychiatrists have to advocate for us all as well as for our patients. However, we are concerned that unfounded claims are being made. We are even more troubled when those claims promote the interests of a fallible pharmaceutical industry, an industry that has opened up our field to extensive critical scrutiny over the past few years. We wonder whether a brief examination of the scientific evidence warrants the statements made by the APA.

After reviewing clinical textbooks and search engines, we were not able to find reliable and convincing evidence that newer psychotropics reduce emergency department stays or that lengths of stay in the hospital correlate with the use of newer agents. We have actually not even heard of that claim made before in any serious forum. Reviews of predictors of length of stay in psychiatric hospitals have typically included demographic factors, diagnostic factors, logistical factors such as time of day, and social factors, such as insurance status and homelessness.^3,4 We found no review mentioning the use of patented drugs as a predictor of shorter stays.

At a larger level, we are unsure that the newer psychotropics are particularly better than older ones. The Food and Drug Administration approves psychiatric medications based on superiority to placebo and not superiority to existing – and usually much cheaper – medications. Our subscription to Epocrates informs us that a 1-month supply of once-a-day brand-name Abilify, Invega, or Latuda is more than $1,000.⁵ Alternatively, a 1-month supply of generic olanzapine, risperidone, or quetiapine is available for $4 at Walmart.⁶ As famously described in the CATIE trial⁷ of patients with schizophrenia, newer antipsychotics are not particularly better than older ones. In addition, a more recent meta-analysis⁸ did not find significant differences among antipsychotics’ efficacy.

A similar analysis can be made of antidepressants without addressing debates surrounding the effectiveness of antidepressants as a class and the value of psychological interventions over chemical ones. Reviews of the literature do not suggest that newer antidepressants are more effective than older ones. A recent meta-analysis of antidepressant efficacy did not find significant differences among antidepressants and, when looking at trends, amitriptyline, a much older antidepressant, was most effective.9

The most surprising part of the APA medical director’s statement was the claim of reduced suicidality. While lithium and clozapine have some evidence for reducing the risk of suicide, the evidence that antidepressants reduce suicide is equivocal. Quite the contrary, some evidence exists that antidepressants may increase the risk of suicide,¹⁰ and we are not aware of evidence suggesting that any newer agents can reduce suicide at any higher rate. One psychiatrist has even made a career out of testifying that antidepressants increase impulsivity and suicide.¹¹

We are not politicians, and we trust the APA to have good intentions with a desire to help patients suffering from mental illness. We understand the need to advocate for any measure that provides additional resources for the treatment of mental illness. We have no doubt that a publicly funded and appropriately regulated mental health system is a wise goal from both an ethical as well as a societal perspective. The APA has an imperative to advocate for our patients with the goal to improve our society.

However, we are concerned when our field makes unfounded claims. Advocating that insurance companies and the government provide most psychotropics without prior authorization and without discrimination does not appear to be based on scientific evidence and has serious economic implications that are not being weighed in a transparent manner. Whatever funding levels the APA recommends for the treatment of mental illness, said treatments will remain a limited resource, and then it becomes a question not just of ethics but of economics. What combination of resources produce the most benefit for the most people in question? Would the increased cost of a newer psychotropic be better spent on a system with more elaborate psychosocial interventions? In making this argument, does one risk repeating the historical blunder made when, in the 1960s, long-term psychiatric hospitals were closed with the intention of replacing their costs with outpatient treatments that then never materialized?

A review of the literature does not support the claim that newer psychotropic agents are more effective from either a clinical or an economic perspective. Cost-saving measures are ethical and possibly beneficial if they permit a more justifiable allocation of resources.



Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He is also the course director for the UCSD third-year medical student psychiatry clerkship. Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Among his writings is Chapter 7 in the new book “Critical Psychiatry: Controversies and Clinical Implications” (Cham, Switzerland: Springer, 2019).
 

References

1. Ann Med Psychol (Paris). 1952 Jun;110(2 1):112-7.

2. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2019.3b26.

3. Am J Emerg Med. 2016 Feb;34(2):133-9.

4. Eur Psychiatry. 2018 Feb;48:6-12.

5. https://online.epocrates.com/drugs. Retrieved March 3, 2019.

6. https://www.walmart.com/cp/$4-prescriptions/1078664. Retrieved March 27, 2019.

7. N Engl J Med. 2005 Sep 22;353(12):1209-23.

8. Am J Psychiatry. 2017. 174(10):927-42.

9. Lancet. 2018 Apr 7. 391(10128):P1357-66.

10. BMJ. 2009.339;b2880.

11. https://breggin.com/.