Jessie Close’s guest blog yesterday hit a nerve and sparked an email from Dr. Dinah Miller, a Baltimore psychiatrist and founder of SHRINK RAP, one of the most helpful mental health blogs on the Internet.
I want to share Dr. Miller’s email with you. I would encourage you to read the editorial from the Baltimore Sun that follows her note. In it, Dr. Miller points out that most of the legislation being suggested is a knee jerk reaction to the Sandy Hook shootings. There is no evidence that many of the bills being rushed through will accomplish much except further stigmatizing individuals with mental disorders.
Dear Pete,
Please thank Jessie Close for writing about guns and medical records — an issue that all of us need to monitor. The Newtown massacre ignited legislators to propose many bills which will attempt to keep guns out of the hands of the mentally ill. In Maryland alone, I believe we have about 40 bills before our General Assembly. I have been writing about the intrusion that mandated reporting may have on doctor-patient confidentiality, and how that may stigmatize patients and discourage them from getting care.
In terms of Jessie’s concerns, reporting (if it even passes) will consist of adding names to a database. While the local gun dealer will know that someone can’t buy a gun, he won’t know why– though the imagination certainly doesn’t lead to nice places since the disqualifiers include criminal convictions, involuntary psychiatric hospitalizations, being a drug addict, or a “habitual drunkard.” But the gun dealer will not have access to medical records.
I have not seen or heard of any legislation that will mandate reporting of outpatients who aren’t dangerous. This simply wouldn’t make sense given the numbers of people who seek treatment. Even a patient who talks about suicidal thoughts is not likely to be put into a database. Many people think about suicide, many people have passing fantasies about harming someone who has done them wrong, and psychiatrists are used to hearing such things. Doctors don’t like reporting their patients, so I don’t think there is going to be a big rush to report outpatients unless the doctor is truly worried that the patient is going to really kill someone. Of course, there are those patients who really are quite dangerous and would be better off without access to guns. I don’t think the argument that more mentally ill people use guns to kill themselves than others is going to encourage anyone to leave the mentally ill with access to guns.
As you know, I feel strongly that it’s not the psychiatrist’s role to serve the state and populate a database, but rather to do what is in the best interest of the patient.
— Dinah
Here is Dr. Miller’s editorial and a link to an article that she wrote about medical records for the Clinical Psychiatric News.
Bills to keep guns out of the hands of psychiatric patients pose risks
Requiring psychiatrists to report on their patients could discourage some to get help
In December, a young man in Newtown, Conn., killed 20 small children and seven adults, including his mother, and then committed suicide. This tragic massacre has prompted legislators to reexamine firearms laws and quickly propose legislation that might prevent future mass murders. Much of it focuses on people who have sought mental health care.
The Maryland General Assembly is considering legislation that requires mental health clinicians to report patients who are potentially dangerous for the purpose of restricting their access to guns. Gov. Martin O’Malley’s proposed 2013 Firearms Safety Act (SB 281) includes a number of items that are specific to patients with mental illnesses. The act would require that all voluntary psychiatric patients who are hospitalized for 30 days or more be reported to an FBI database.
Most patients with mood and psychotic disorders are released much sooner than 30 days, and this mandate may well capture populations who are at low risk of becoming spree killers. Involuntary patients would be reported much sooner if they are determined to be potentially dangerous, presumably at the time of their commitment hearings. If any of these individuals later wants their right to own firearms returned, one step of the process includes having a psychiatrist or psychologist file a certificate that states the person is safe to own a gun. I don’t know any mental health professional who would be willing to risk the liability of making such predictions about safety; we are psychiatrists, not clairvoyants.
House Bill 810, sponsored by Del. Luiz Simmons, requires that mental health professionals report patients they believe are likely to be dangerous to, in its words, the “Director of Mental Hygiene,” who would then decide whether to report those patients to the State Police.
Although the Newtown massacre spawned this legislation, so far there has been nothing in the media to suggest the Newtown shooter would have been brought to the attention of authorities if such laws had been in place. We’ve heard he had an autism-spectrum illness; that he was anxious, intelligent and a loner — but no reports that he’d been violent, hospitalized, or ever told a mental health professional that he was planning a school shooting.
The hope might be that more funds will be funneled into following up on all those who are identified as dangerous, reclaiming their weapons, and overseeing the storage of firearms by residents of their households. Proposed legislation, however, seems to be more about populating government databases. Increased treatment of those identified as dangerous is certainly desirable, but it remains to be seen if such funding will follow these measures — especially in times when psychiatric hospitals are closing, medical reimbursements are decreasing, paperwork burdens are shifting doctor time away from patient care, and psychiatric services are difficult to access.
Let’s be thoughtful. These bills are not about public safety; they are about “doing something” — and in the process, scapegoating the mentally ill in a way that distracts from enacting substantive legislation. And shouldn’t we acknowledge that all this talk of identifying and reporting those with psychiatric problems is at direct odds with the intention to increase access to care and decrease stigma as a means of preventing tragedies?
These proposed laws set in motion a barrier to getting help for those who most need it. Who would willingly seek treatment and tell a psychiatrist their dark thoughts, knowing such thoughts will be reported to law enforcement authorities and entered into an FBI database? Certainly no gun owner, and certainly no troubled law enforcement officer.
True, other laws have sometimes overridden doctor-patient confidentiality, but those laws address problems that have already happened. While I am an avid proponent of stricter gun control regulation, as a psychiatrist, I find the requirement to report patients to the police to be quite troublesome. It makes us agents of the state, whereas to be a physician one must be an agent of the patient; the ethical conflict here is profound. These laws annihilate psychiatrist-patient confidentiality in the most egregious of ways: by inserting the government into situations where violent acts have not even occurred. They mandate government intrusions into our ruminations, and they set a precedent to end the relationship that is necessary for psychiatric treatment to occur.
Keep in mind that violent thoughts are very common, and in the absence of specific indicators, mental health professionals are not particularly good at predicting who will act on them. If we allow this, in the name of public safety and health, what else might we extend reporting requirements to include? The sexual activities of patients with HIV? Patients who drive while intoxicated? The financial behaviors of those running Ponzi schemes?
Ironically, all of these measures target mental health settings, while preserving doctor-patient confidentiality elsewhere. As a result, a person having violent thoughts who wants to retain his gun rights or to stay out of a government database may be more comfortable confiding in his internist and refusing care by a mental health specialist. Is this really what we want?
Dinah Miller, M.D., is a psychiatrist in Baltimore. Her email is dinahmiller@yahoo.com
About the author:
Dr. Miller, you sound like a very nice person. No, doctors are not clairovoyant, and did not sign to study medicine for a dozen years to alieinate their patients w/ mandatory reporting. “First, do no harm”, must be activated as legal, ethical, moral righteousness to every jerk, including the Gabby Giffords, and other high-powered politicals who have the audacity, and ignorance, to propose a database of folks seeking mental health treatment. There are many, including gun shop owners who feel that gun ownership should be liscenced, individually, like a drivers, but much more stringent. Its the obvious, most sensible answer. The fear-mongering in this country is out of control. 9-11 gave us Moslem -phobia, AIDS gave us homosexual phobia, and now Newtown-like mass murders are creating
mentally ill phobia. Where does it stop? The U.S. has more legal and illegal guns circulating and more citizens in prisons than any other country in the world, per capita! We are a failure to ourselves, and obviously lack the mindfullness to correct any of our social ills!
Liscence gun ownership.Mandate each individual to prove sanity, etc.
Re-route money from obscene unregulated drug company profits into
better mental health care.
Let the Sunday schools and Moms and Dads teach about bullying,like
they have for years.
Use that money instead for educating schoolchildren and the public
about mental illness.
Give the psychiatrists back the jobs they sacrificed years for –
to help mentally ill get back on their feet, before they get lost and
go to prison, and otherwise become burdens to themselves and others.
Re-open psych hospitals where they’re useful for the sick to get well.
Strengthen the out-patient clinics with real doctors, not GED trained staff.
Get rid of HIPPA. Re-write it giving responsible loved ones access to
useful info a loved one would need to facilitate healing.
Create a federal task force in every county to find and confiscate illegal weapons
and traffiking. Or use the military, as illegal gun use is homegrown terrorism.
Everyone wants theri freedoms and rights,and privacy, but no one wants to
understand the give and take of it all. There is an old adage that states, there are
three things only, that all people aspire to – Health, Wealth, and Happiness – without the first, the other two are useless.
America’s priorities are ass-backwards. God help us, I hope some sanity will touch our elected leaders.
As I prepared to play Taps for a military funeral yesterday a sailor honor guard member approached me to express his concern that any veteran diagnosed with PTSD would be prohibited from owning a firearm because it is a “mental illness.” He correctly predicted that this would discourage many of the people who need psychiatric treatment from seeking it.
Psychiatric professionals should not only oppose these laws but refuse to participate in any policy that involves holding one person responsible for the deliberate acts of another, even if that other person may qualify for a psychiatric diagnosis. As a forensic psychiatrist I am on strike: I will no longer perform violence risk assessments.
I think what you wrote happening with PTSD will happen with legislation like this. I have already heard several patients say they will stop psychiatric treatment if legislation like this passes in their state, and I will be among them. It makes me sick to my stomach that people want to lump all people with serious mental illness in with mass murderers. I believe that legislation like this will cause many people with mental illness to avoid treatment. It has nothing to do with guns for me. I hate guns, and I have no desire to own one. But, I am not interested in having my medical information handed over to the government or giving up more of my civil liberties because someone else planned and carried out the murders of people. I will not be punished for what that guy did. I didn’t do it.
No one even acknowledges the difference between severe mental illness that is abated only by proper medical treatment and “mental health issues” which can run the gamut from to divorce counseling to inpatient treatment for psychosis. Too, I would like to say as a gun opponent (no matter the circumstances, I will never own one) that I am not sure I want gun enthusiasts to have my name or other information on any kind of list, for any reason. I’m not sure what the answer to gun violence is: but the fact that there is a 90,000 bed deficit for the severely mentally ill and scant services in this country should be addressed separately, because it’s been this way for years; lack of beds and services, and in some areas, psychiatrists to actually treat medical brain disease, has caused rampant homelessness and damaging, cruel prison sentences for sick people; those depressing facts should not have to come forward as a reaction to gun control measures. I appreciate the psychiatrist’s concerns and this blog, making critical points around a national shame: our treatment of the mentally ill.
Maybe the legislation should go one step farther. Pass out some sort of symbol we could wear on our front lapels in order to warn the public of what we are. People always laugh when I say that, but what is the difference? Politicians, pharmaceutical companies, and psychiatry have been sacrificing the mentally ill for their on agendas since before Hitler’s Third Reich, they just chose a group to target that society has labeled disposable. They don’t even think about the ease in which they say, crazies, but would never consider saying a racial slur with the same unabashed hatred. As far as legislation being criticized by psychologists and doctors, I find it hilarious that they can even keep a straight face. You’ve been repeating the same nonsense (in my personal experience) for at least twenty five years. Yet, since the first mention of my disorder in 2nd century AD, what great contributions have you made? Nothing. You just repeat Phizer slogans and create new disorders that happily seem to come to light just in time for your new pharmaceutical break through. At least politicians are openly lying to us. You say that I’m too dangerous to own a gun.. to mentally unsound… to crazy… but you see nothing wrong with medications that take years off life expectancy, medications that you don’t know have any benefits other than making patients more compliant and you can’t even tell me how they work, faked test results and studies, monetary kickbacks, ad campaigns as diagnostics (chemical imbalance… then, tell me what chemical… Mood stabilizers… this is just jargon for drugs that have less negative effects than others… I’m the one considered dangerous, but one word that in effect is really just profit driven opinion, and you can rob me of my entire life. I suppose the plus is, with new studies showing an average loss of 34 years off life expectancy, I probably won’t live to sue you for any dangerous side effects. Legislators may have found the perfect scapegoat for their agendas, but you doctors, you’ve been effectively killing us for years. A silent holocaust with a massive net profit. As much as psychiatry has taken from me, I think I’d rather be crazy because my insanity, for all it’s stigma, still means I could never do what you do. Personally, I think the best thing for mental illness would be to disallow psychiatrists to continue to speak for us at all. They’ve been repeating the same nihilistic chant for over thirty years, and I’m sick of hearing my motivations, my intentions, and my mentality translated by someone who can’t even decide on a definition for my disorder for more than a handful of years. You may feel free to interpret my motivations and intent when you can tell me what’s wrong with me, and how even one of the eleven medications I currently take actually helps me, and what good your medicine has given me in the last 25 years. (Figure it out: you will never understand or adequately treat mental illness as long as you insist in generalizing us into a label, and dehumanizing us into US and THEM. Try listening, and throw out that ridiculous book.)