Shrink Rap News

I am what you’d call an unwilling sports fan – and then just barely – in that I reside in a family where everyone else is riveted by sports, and by football in particular. The National Football League is the backdrop to my home life on Sundays, Mondays, and Thursdays, with Saturday reserved for college football, all the more so since both of my children have attended Big 10 universities. With that as a background, I was delighted when the Sept. 19 episode of the NFL’s “A Football Life,” focused on Brandon Marshall, the Chicago Bears wide receiver who has talked publicly about his personal struggles with borderline personality disorder.

While many psychiatric disorders are stigmatized by people who are unfamiliar with them, borderline personality disorder is likely the illness that gets most stigmatized within our profession. “Borderline” or “Cluster B” are sometimes uttered as code, to mean that a patient is difficult to work with, unlikeable, or perhaps even manipulative. We often blame patients for their behaviors in ways that we don’t when a patient is ill with an Axis I disorder, and few psychiatrists relish the opportunity to work with patients who have borderline personality disorder.

The television episode focused on Marshall’s football career, his legal struggles, and his interpersonal relationships both on and off the playing field. There were spotlights on many of the people who were affected by his troubling behavior. Marshall described his relationship with his best friend and quarterback, Jay Cutler, as, “We’re the couple that really love each other but shouldn’t be together.”

Cutler was interviewed. He described Marshall as an emotional man who loved media attention and who would lose his temper and hang on to grudges. They first played together for the Denver Broncos, and now both men play for the Chicago Bears.

Marshall’s agent was interviewed and made the point that Marshall had “…personally destroyed maybe five of my vacations.” Marshall’s former coach; his wife; his mother; and his psychiatrist, Dr. John Gunderson of McLean Hospital in Belmont, Mass., were all interviewed on the show.

The narrator for “A Football Life” described Marshall’s behavior as erratic, both on and off the field. Film clips were shown of Marshall losing his temper, kicking the ball off the field during a penalty, and celebrating excessively. His mother referred to his outbursts as “hissy fits,” and she noted, “We were all under the impression Brandon could control this.”

Despite his talent as a wide receiver – while playing for the Broncos, Marshall caught more than 100 passes in each of three consecutive seasons – the Broncos traded him to the Miami Dolphins. His career with the Broncos had been marked by a brief suspension for charges of drunk driving and domestic violence, and Marshall had had numerous arrests over the years. He finally was required to have a psychiatric assessment, and Marshall flew to Massachusetts for a day-long evaluation with Dr. Gunderson. Dr. Gunderson described Marshall at that meeting as “hostile and nondisclosing.”

In Miami, Marshall’s behavior continued to be a source of contention. His girlfriend, Michi, described him as remote and withdrawn. After a domestic dispute in which she was charged with stabbing him – charges that both denied and were later dropped – Marshall returned to see Dr. Gunderson and dedicated 3 months of his off-season to getting treatment.

Dr. Gunderson noted that on his return visit, “He was troubled enough by his behaviors and the difficulties they were causing for him.”

With a diagnosis of borderline personality disorder, Marshall became invested in learning about the disorder and devoted his days to intensive treatment, which included group therapy. He discussed the difficulties he has regulating his emotions and noted that he now had strategies to help him maintain control. Cutler noted that Marshall still loses his cool, but he quickly regains his composure, while in the past he could stay angry for days.

The rest of the show went on to document Marshall’s successes. He gained better control of his temper and became less difficult to work with. Coach Tony Sparano was interviewed, and both he and Marshall talked of Sparano’s role in providing emotional support to the football player. He was offered a $30 million contract extension with the Bears. He and Michi married, started the Brandon Marshall Foundation to support mental health education and treatment, and the couple announced in September that they are expecting twins.

Dr. Gunderson noted that Brandon Marshall’s openness about his disorder does a great deal to alleviate the stigma associated with borderline personality disorder.

“He’s an articulate and charismatic male football player,” he said. “This takes it out of the realm of something that’s about weak people.”

The special did not talk about whether Marshall was taking medications – it was implied that he wasn’t – or if he has continued in treatment. We think of borderline personality disorder as being resistant to treatments, and certainly not as a disorder that can be fixed with 3 months of treatment. It was noted that Marshall has some unusual assets in addition to his charismatic personality: He has a vocation he loves and is good at, and he has supportive relationships. A clip was shown of an appearance he and Michi had made on “The View,” where he credited her support as being key to his success.

As psychiatrists, there is a delicate balance when treating patients with personality disorders. On the one hand, we want them to take ownership for their behaviors in the hopes that they will be able to gain some control over them. To balance this, however, personality disorders can be as crippling as any illness we treat in psychiatry, and the prognosis for some people is dismal. While it may be helpful to have a diagnosis and an explanation, it’s not beneficial if the patient sees himself as the victim of an untreatable condition. The television special on Brandon Marshall did a wonderful job of presenting this disorder with a balance – as a problem that happens to people, perhaps because of their difficult childhoods – but one that the individual can learn to take control of in an empowering way.

We might imagine this remains an ongoing struggle for Marshall, not one that was treated and fixed. I, however, enjoyed watching an NFL production with a positive spin on what we think of as being such a devastating psychiatric disorder.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

I am what you’d call an unwilling sports fan – and then just barely – in that I reside in a family where everyone else is riveted by sports, and by football in particular. The National Football League is the backdrop to my home life on Sundays, Mondays, and Thursdays, with Saturday reserved for college football, all the more so since both of my children have attended Big 10 universities. With that as a background, I was delighted when the Sept. 19 episode of the NFL’s “A Football Life,” focused on Brandon Marshall, the Chicago Bears wide receiver who has talked publicly about his personal struggles with borderline personality disorder.

While many psychiatric disorders are stigmatized by people who are unfamiliar with them, borderline personality disorder is likely the illness that gets most stigmatized within our profession. “Borderline” or “Cluster B” are sometimes uttered as code, to mean that a patient is difficult to work with, unlikeable, or perhaps even manipulative. We often blame patients for their behaviors in ways that we don’t when a patient is ill with an Axis I disorder, and few psychiatrists relish the opportunity to work with patients who have borderline personality disorder.

The television episode focused on Marshall’s football career, his legal struggles, and his interpersonal relationships both on and off the playing field. There were spotlights on many of the people who were affected by his troubling behavior. Marshall described his relationship with his best friend and quarterback, Jay Cutler, as, “We’re the couple that really love each other but shouldn’t be together.”

Cutler was interviewed. He described Marshall as an emotional man who loved media attention and who would lose his temper and hang on to grudges. They first played together for the Denver Broncos, and now both men play for the Chicago Bears.

Marshall’s agent was interviewed and made the point that Marshall had “…personally destroyed maybe five of my vacations.” Marshall’s former coach; his wife; his mother; and his psychiatrist, Dr. John Gunderson of McLean Hospital in Belmont, Mass., were all interviewed on the show.

The narrator for “A Football Life” described Marshall’s behavior as erratic, both on and off the field. Film clips were shown of Marshall losing his temper, kicking the ball off the field during a penalty, and celebrating excessively. His mother referred to his outbursts as “hissy fits,” and she noted, “We were all under the impression Brandon could control this.”

Despite his talent as a wide receiver – while playing for the Broncos, Marshall caught more than 100 passes in each of three consecutive seasons – the Broncos traded him to the Miami Dolphins. His career with the Broncos had been marked by a brief suspension for charges of drunk driving and domestic violence, and Marshall had had numerous arrests over the years. He finally was required to have a psychiatric assessment, and Marshall flew to Massachusetts for a day-long evaluation with Dr. Gunderson. Dr. Gunderson described Marshall at that meeting as “hostile and nondisclosing.”

In Miami, Marshall’s behavior continued to be a source of contention. His girlfriend, Michi, described him as remote and withdrawn. After a domestic dispute in which she was charged with stabbing him – charges that both denied and were later dropped – Marshall returned to see Dr. Gunderson and dedicated 3 months of his off-season to getting treatment.

Dr. Gunderson noted that on his return visit, “He was troubled enough by his behaviors and the difficulties they were causing for him.”

With a diagnosis of borderline personality disorder, Marshall became invested in learning about the disorder and devoted his days to intensive treatment, which included group therapy. He discussed the difficulties he has regulating his emotions and noted that he now had strategies to help him maintain control. Cutler noted that Marshall still loses his cool, but he quickly regains his composure, while in the past he could stay angry for days.

The rest of the show went on to document Marshall’s successes. He gained better control of his temper and became less difficult to work with. Coach Tony Sparano was interviewed, and both he and Marshall talked of Sparano’s role in providing emotional support to the football player. He was offered a $30 million contract extension with the Bears. He and Michi married, started the Brandon Marshall Foundation to support mental health education and treatment, and the couple announced in September that they are expecting twins.

Dr. Gunderson noted that Brandon Marshall’s openness about his disorder does a great deal to alleviate the stigma associated with borderline personality disorder.

“He’s an articulate and charismatic male football player,” he said. “This takes it out of the realm of something that’s about weak people.”

The special did not talk about whether Marshall was taking medications – it was implied that he wasn’t – or if he has continued in treatment. We think of borderline personality disorder as being resistant to treatments, and certainly not as a disorder that can be fixed with 3 months of treatment. It was noted that Marshall has some unusual assets in addition to his charismatic personality: He has a vocation he loves and is good at, and he has supportive relationships. A clip was shown of an appearance he and Michi had made on “The View,” where he credited her support as being key to his success.

As psychiatrists, there is a delicate balance when treating patients with personality disorders. On the one hand, we want them to take ownership for their behaviors in the hopes that they will be able to gain some control over them. To balance this, however, personality disorders can be as crippling as any illness we treat in psychiatry, and the prognosis for some people is dismal. While it may be helpful to have a diagnosis and an explanation, it’s not beneficial if the patient sees himself as the victim of an untreatable condition. The television special on Brandon Marshall did a wonderful job of presenting this disorder with a balance – as a problem that happens to people, perhaps because of their difficult childhoods – but one that the individual can learn to take control of in an empowering way.

We might imagine this remains an ongoing struggle for Marshall, not one that was treated and fixed. I, however, enjoyed watching an NFL production with a positive spin on what we think of as being such a devastating psychiatric disorder.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

I am what you’d call an unwilling sports fan – and then just barely – in that I reside in a family where everyone else is riveted by sports, and by football in particular. The National Football League is the backdrop to my home life on Sundays, Mondays, and Thursdays, with Saturday reserved for college football, all the more so since both of my children have attended Big 10 universities. With that as a background, I was delighted when the Sept. 19 episode of the NFL’s “A Football Life,” focused on Brandon Marshall, the Chicago Bears wide receiver who has talked publicly about his personal struggles with borderline personality disorder.

While many psychiatric disorders are stigmatized by people who are unfamiliar with them, borderline personality disorder is likely the illness that gets most stigmatized within our profession. “Borderline” or “Cluster B” are sometimes uttered as code, to mean that a patient is difficult to work with, unlikeable, or perhaps even manipulative. We often blame patients for their behaviors in ways that we don’t when a patient is ill with an Axis I disorder, and few psychiatrists relish the opportunity to work with patients who have borderline personality disorder.

The television episode focused on Marshall’s football career, his legal struggles, and his interpersonal relationships both on and off the playing field. There were spotlights on many of the people who were affected by his troubling behavior. Marshall described his relationship with his best friend and quarterback, Jay Cutler, as, “We’re the couple that really love each other but shouldn’t be together.”

Cutler was interviewed. He described Marshall as an emotional man who loved media attention and who would lose his temper and hang on to grudges. They first played together for the Denver Broncos, and now both men play for the Chicago Bears.

Marshall’s agent was interviewed and made the point that Marshall had “…personally destroyed maybe five of my vacations.” Marshall’s former coach; his wife; his mother; and his psychiatrist, Dr. John Gunderson of McLean Hospital in Belmont, Mass., were all interviewed on the show.

The narrator for “A Football Life” described Marshall’s behavior as erratic, both on and off the field. Film clips were shown of Marshall losing his temper, kicking the ball off the field during a penalty, and celebrating excessively. His mother referred to his outbursts as “hissy fits,” and she noted, “We were all under the impression Brandon could control this.”

Despite his talent as a wide receiver – while playing for the Broncos, Marshall caught more than 100 passes in each of three consecutive seasons – the Broncos traded him to the Miami Dolphins. His career with the Broncos had been marked by a brief suspension for charges of drunk driving and domestic violence, and Marshall had had numerous arrests over the years. He finally was required to have a psychiatric assessment, and Marshall flew to Massachusetts for a day-long evaluation with Dr. Gunderson. Dr. Gunderson described Marshall at that meeting as “hostile and nondisclosing.”

In Miami, Marshall’s behavior continued to be a source of contention. His girlfriend, Michi, described him as remote and withdrawn. After a domestic dispute in which she was charged with stabbing him – charges that both denied and were later dropped – Marshall returned to see Dr. Gunderson and dedicated 3 months of his off-season to getting treatment.

Dr. Gunderson noted that on his return visit, “He was troubled enough by his behaviors and the difficulties they were causing for him.”

With a diagnosis of borderline personality disorder, Marshall became invested in learning about the disorder and devoted his days to intensive treatment, which included group therapy. He discussed the difficulties he has regulating his emotions and noted that he now had strategies to help him maintain control. Cutler noted that Marshall still loses his cool, but he quickly regains his composure, while in the past he could stay angry for days.

The rest of the show went on to document Marshall’s successes. He gained better control of his temper and became less difficult to work with. Coach Tony Sparano was interviewed, and both he and Marshall talked of Sparano’s role in providing emotional support to the football player. He was offered a $30 million contract extension with the Bears. He and Michi married, started the Brandon Marshall Foundation to support mental health education and treatment, and the couple announced in September that they are expecting twins.

Dr. Gunderson noted that Brandon Marshall’s openness about his disorder does a great deal to alleviate the stigma associated with borderline personality disorder.

“He’s an articulate and charismatic male football player,” he said. “This takes it out of the realm of something that’s about weak people.”

The special did not talk about whether Marshall was taking medications – it was implied that he wasn’t – or if he has continued in treatment. We think of borderline personality disorder as being resistant to treatments, and certainly not as a disorder that can be fixed with 3 months of treatment. It was noted that Marshall has some unusual assets in addition to his charismatic personality: He has a vocation he loves and is good at, and he has supportive relationships. A clip was shown of an appearance he and Michi had made on “The View,” where he credited her support as being key to his success.

As psychiatrists, there is a delicate balance when treating patients with personality disorders. On the one hand, we want them to take ownership for their behaviors in the hopes that they will be able to gain some control over them. To balance this, however, personality disorders can be as crippling as any illness we treat in psychiatry, and the prognosis for some people is dismal. While it may be helpful to have a diagnosis and an explanation, it’s not beneficial if the patient sees himself as the victim of an untreatable condition. The television special on Brandon Marshall did a wonderful job of presenting this disorder with a balance – as a problem that happens to people, perhaps because of their difficult childhoods – but one that the individual can learn to take control of in an empowering way.

We might imagine this remains an ongoing struggle for Marshall, not one that was treated and fixed. I, however, enjoyed watching an NFL production with a positive spin on what we think of as being such a devastating psychiatric disorder.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

I struggled to decide where to begin this week’s column in the wake of news that a Belgian inmate had been granted his request for physician-assisted suicide. Beyond stifling an instinctive “oh my god” response, I felt an immediate regret that I predicted something like this would happen eventually when I wrote about state laws regarding assisted suicide for a previous column. I just didn’t expect it to happen quite so soon, or to involve a prison inmate.

According to an Associated Press story published in the Washington Post, inmate Frank Van Den Bleeken had served almost 30 years for the rape and murder of an unspecified number of women, and had requested euthanasia on the basis of having a mental condition deemed incurable by the Belgian courts. The story didn’t specify exactly what that condition was, or why it was untreatable, but the inmate alleged that he couldn’t live with the knowledge that he would be a danger to society again upon release. I’m surprised at this newly developed sense of conscience, since it apparently wasn’t enough to prevent him from committing the crimes in the first place. If his incurable condition was sociopathy, then some intervention must have worked to lead to this remarkable development of empathy. Setting skepticism aside, the case does raise serious concerns for psychiatrists working in jails and prisons.

Adopted in 2002, the Belgian law defines euthanasia as “intentionally terminating life by someone other than the person concerned, at the latter’s request.” The individual making the request must do so competently and without external pressure if his condition is “constant and medically futile,” leading to “unbearable physical or mental suffering that cannot be alleviated.” A physician cannot be compelled to perform the killing but must notify the patient of the refusal and must forward the patient’s medical record to another physician of the patient’s choosing.

It seems we’ve arrived at a strange mirror-inverse world of medicine in correctional health care now. Given that the World Health Organization has proscribed the force feeding of prisoners, a correctional physician may not only be forbidden from intervening to save a life, he may also be called upon to intentionally end one. If there were ever a situation that calls for scrupulous medical integrity, this is it.

I’m not shocked by the thought that an inmate might request suicide. Most prisoners are young, are male, and have active substance use disorders – three commonly accepted risk factors for suicide – even before walking into the facility. What concerns me more is the thought that in all likelihood, requests for assisted suicide by prisoners are going to be considered less carefully than those by noncriminals. Given the horrific nature of some offenses, it would be easy to imagine a court turning a semiblind eye to other factors influencing a request to die. It would be easy to view suicide as a rational choice for someone serving a life term, rather than as a product of a treatable psychiatric condition. Courts might also be unwilling to examine the underlying conditions of confinement or an institutional culture that would lead one to accept death as a viable alternative to life in a threatening or inhumane environment. Prisoners are also less likely to have outside supports or involved family members to provide more factual context to the decision to seek physician-assisted suicide, or to challenge the competence of the petitioner. The institution itself might be unwilling to acknowledge inadequate health care services, or lack of palliative care, for terminally ill prisoners.

Belgium and the Netherlands have expanded physician-assisted suicide processes far beyond anything presently contemplated here in the United States, but petitions for assisted suicide have been increasing there year after year, and an increasing number of American states have been considering this legislation. As the Van Den Bleeken case illustrates, only the professional integrity of physicians may stand between poorly considered laws and a select group of vulnerable human beings.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I struggled to decide where to begin this week’s column in the wake of news that a Belgian inmate had been granted his request for physician-assisted suicide. Beyond stifling an instinctive “oh my god” response, I felt an immediate regret that I predicted something like this would happen eventually when I wrote about state laws regarding assisted suicide for a previous column. I just didn’t expect it to happen quite so soon, or to involve a prison inmate.

According to an Associated Press story published in the Washington Post, inmate Frank Van Den Bleeken had served almost 30 years for the rape and murder of an unspecified number of women, and had requested euthanasia on the basis of having a mental condition deemed incurable by the Belgian courts. The story didn’t specify exactly what that condition was, or why it was untreatable, but the inmate alleged that he couldn’t live with the knowledge that he would be a danger to society again upon release. I’m surprised at this newly developed sense of conscience, since it apparently wasn’t enough to prevent him from committing the crimes in the first place. If his incurable condition was sociopathy, then some intervention must have worked to lead to this remarkable development of empathy. Setting skepticism aside, the case does raise serious concerns for psychiatrists working in jails and prisons.

Adopted in 2002, the Belgian law defines euthanasia as “intentionally terminating life by someone other than the person concerned, at the latter’s request.” The individual making the request must do so competently and without external pressure if his condition is “constant and medically futile,” leading to “unbearable physical or mental suffering that cannot be alleviated.” A physician cannot be compelled to perform the killing but must notify the patient of the refusal and must forward the patient’s medical record to another physician of the patient’s choosing.

It seems we’ve arrived at a strange mirror-inverse world of medicine in correctional health care now. Given that the World Health Organization has proscribed the force feeding of prisoners, a correctional physician may not only be forbidden from intervening to save a life, he may also be called upon to intentionally end one. If there were ever a situation that calls for scrupulous medical integrity, this is it.

I’m not shocked by the thought that an inmate might request suicide. Most prisoners are young, are male, and have active substance use disorders – three commonly accepted risk factors for suicide – even before walking into the facility. What concerns me more is the thought that in all likelihood, requests for assisted suicide by prisoners are going to be considered less carefully than those by noncriminals. Given the horrific nature of some offenses, it would be easy to imagine a court turning a semiblind eye to other factors influencing a request to die. It would be easy to view suicide as a rational choice for someone serving a life term, rather than as a product of a treatable psychiatric condition. Courts might also be unwilling to examine the underlying conditions of confinement or an institutional culture that would lead one to accept death as a viable alternative to life in a threatening or inhumane environment. Prisoners are also less likely to have outside supports or involved family members to provide more factual context to the decision to seek physician-assisted suicide, or to challenge the competence of the petitioner. The institution itself might be unwilling to acknowledge inadequate health care services, or lack of palliative care, for terminally ill prisoners.

Belgium and the Netherlands have expanded physician-assisted suicide processes far beyond anything presently contemplated here in the United States, but petitions for assisted suicide have been increasing there year after year, and an increasing number of American states have been considering this legislation. As the Van Den Bleeken case illustrates, only the professional integrity of physicians may stand between poorly considered laws and a select group of vulnerable human beings.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

I struggled to decide where to begin this week’s column in the wake of news that a Belgian inmate had been granted his request for physician-assisted suicide. Beyond stifling an instinctive “oh my god” response, I felt an immediate regret that I predicted something like this would happen eventually when I wrote about state laws regarding assisted suicide for a previous column. I just didn’t expect it to happen quite so soon, or to involve a prison inmate.

According to an Associated Press story published in the Washington Post, inmate Frank Van Den Bleeken had served almost 30 years for the rape and murder of an unspecified number of women, and had requested euthanasia on the basis of having a mental condition deemed incurable by the Belgian courts. The story didn’t specify exactly what that condition was, or why it was untreatable, but the inmate alleged that he couldn’t live with the knowledge that he would be a danger to society again upon release. I’m surprised at this newly developed sense of conscience, since it apparently wasn’t enough to prevent him from committing the crimes in the first place. If his incurable condition was sociopathy, then some intervention must have worked to lead to this remarkable development of empathy. Setting skepticism aside, the case does raise serious concerns for psychiatrists working in jails and prisons.

Adopted in 2002, the Belgian law defines euthanasia as “intentionally terminating life by someone other than the person concerned, at the latter’s request.” The individual making the request must do so competently and without external pressure if his condition is “constant and medically futile,” leading to “unbearable physical or mental suffering that cannot be alleviated.” A physician cannot be compelled to perform the killing but must notify the patient of the refusal and must forward the patient’s medical record to another physician of the patient’s choosing.

It seems we’ve arrived at a strange mirror-inverse world of medicine in correctional health care now. Given that the World Health Organization has proscribed the force feeding of prisoners, a correctional physician may not only be forbidden from intervening to save a life, he may also be called upon to intentionally end one. If there were ever a situation that calls for scrupulous medical integrity, this is it.

I’m not shocked by the thought that an inmate might request suicide. Most prisoners are young, are male, and have active substance use disorders – three commonly accepted risk factors for suicide – even before walking into the facility. What concerns me more is the thought that in all likelihood, requests for assisted suicide by prisoners are going to be considered less carefully than those by noncriminals. Given the horrific nature of some offenses, it would be easy to imagine a court turning a semiblind eye to other factors influencing a request to die. It would be easy to view suicide as a rational choice for someone serving a life term, rather than as a product of a treatable psychiatric condition. Courts might also be unwilling to examine the underlying conditions of confinement or an institutional culture that would lead one to accept death as a viable alternative to life in a threatening or inhumane environment. Prisoners are also less likely to have outside supports or involved family members to provide more factual context to the decision to seek physician-assisted suicide, or to challenge the competence of the petitioner. The institution itself might be unwilling to acknowledge inadequate health care services, or lack of palliative care, for terminally ill prisoners.

Belgium and the Netherlands have expanded physician-assisted suicide processes far beyond anything presently contemplated here in the United States, but petitions for assisted suicide have been increasing there year after year, and an increasing number of American states have been considering this legislation. As the Van Den Bleeken case illustrates, only the professional integrity of physicians may stand between poorly considered laws and a select group of vulnerable human beings.

Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

National Suicide Prevention Day fell on Sept. 10 this year, surrounded by National Suicide Prevention Week Sept. 8-14. The conversation, as I’m sure everyone noticed, was focused on the suicide of actor Robin Williams. As we move out a few weeks, my patients – especially those who have contemplated ending their own lives – continue to talk about this tragic loss.

The fear is that the suicide of a celebrity will lead to an increase in the suicide rate in the general public – copycat suicides, if you will. In the month after Marilyn Monroe died of an overdose in 1962, the suicide rate rose by more than 10%. On the other hand, the death of a celebrity may lead to a decrease in the suicide rate, as happened after Kurt Cobain’s death from a self-inflicted gunshot wound in 1994. In the period after Cobain’s death, an effort was made to publicize resources for those who need help. The suicide rate dropped, while calls to hotlines rose.

After Robin Williams’ death, my own social media feeds were full of ads for the National Suicide Prevention Lifeline (NSPL), a hotline with the number 1-800-273-TALK. There are other hotlines, but this was the one I saw most. I wanted to learn about suicide hotlines, so I did a few things: I asked readers of our Shrink Rap blog to tell me about their experiences, and I called the hotline myself to see if I could learn about the structure of the organization, what resources they had to offer a distraught caller, and whether there had been a change in the number of calls they’d received in the time following Mr. Williams’ death.

I called from my cell phone, which is registered in Maryland, while sitting in my home in Baltimore City. The call was routed to Grassroots Crisis Intervention Center in Columbia, Md. Google Maps tells me the center is 25 miles from my house, and it would take me 32 minutes to drive there. In addition to being part of a network of 160 hotline centers across the country, Grassroots has a walk-in crisis center and a mobile treatment center, and is adjacent to a homeless shelter.

“Most of the people who call the National Suicide Prevention Lifeline are suicidal,” said Nicole DeChirico, director of crisis intervention services for Grassroots. “There is a gradation in suicidal thinking, but about 90% of our callers are considering it.”

“We first form rapport, and then we try to quickly assess if an attempt has already been made, and if they are in any danger. We use the assessment of suicidality that is put out by the NSPL. It’s a structured template that is used as a guideline.”

Ms. DeChirico noted that the people who man the hotlines have bachelor’s or master’s degrees – often in psychology, social work, counseling, or education. If feasible, a Safety Planning Intervention is implemented, based on the work of Barbara Stanley, Ph.D., at Columbia University in New York.

“We talk to people about what they need to do to feel safe. If they allow it, we set up a follow-up call. Of the total number of people who have attempted suicide once in the past and lived, 90%-96% never go on to attempt suicide again,” Ms. DeChirico noted. Suicide is a time-limited acute crisis.”

The Grassroots team can see patients on site while they wait for appointments with an outpatient clinician, and can send a mobile crisis team to those who need it if they are in the county served by the organization. I wondered if all 160 agencies that received calls from the NSPL could also provide crisis services.

Marcia Epstein, LMSW, was director of the Headquarters Counseling Center in Lawrence, Kan., from 1979 to 2013. The center became part of the first national suicide prevention hotline network, the National Hopeline Network, 1-800-SUICIDE, in 2001, and then became part of the National Suicide Prevention Lifeline, 1-800-274-TALK (8255), when that network began in January 2005.

“The types of programs and agencies which are part of NSPL vary greatly. The accreditation that allows them to be part of the NSPL network also varies. Some centers are staffed totally by licensed mental health therapists, while others might include trained volunteers and paid counselors who have no professional degree or licensure. Service may be delivered by phone, as well as in person, by text, and by live chat. In person might be on site or through mobile crisis outreach. Some centers are part of other organizations, while others are free-standing, and some serve entire states, while others serve geographically smaller regions,” Ms. Epstein explained in a series of e-mails. She noted that some centers assess and refer, while others, like Grassroots, are able to provide more counseling.

“So if it sounds like I’m saying there is little consistency between centers, yes, that is my experience. But the centers all bring strong commitment to preventing suicide.”

Ms. Epstein continued to discuss the power of the work done with hotline callers.

“The really helpful counseling comes from the heart, from connecting to people with caring and respect and patience, and using our skills in helping them stay safer through the crisis and then, when needed, to stay safer in the long run. It takes a lot of bravery from the people letting us help. And it takes a lot of creativity and flexibility in coming up together with realistic plans to support safety.”

I was curious about the patient response, and I found that was mixed. It was also notable that different patients found different forms of communication to be helpful.

A woman who identified herself only as “Virginia Woolf” wrote, “I have contacted the Samaritans on the [email protected] line because I could write to them via e-mail. I don’t like phones and I also know too many of the counselors on the local crisis line. Each time I was definitely close to suicide. I was in despair and I had the means at hand. I think what stopped me was knowing they would reply. They always did, within a few hours, but waiting for their reply kept me safe.”

Not every response was as positive.

One writer noted, “It was not a productive, supportive, or empathetic person. I felt like she was arrogant, judgmental, and didn’t really care about why I was calling.” The same writer, however, was able to find solace elsewhere. “I have texted CrisisChat and it was an excellent chat and I did feel better.”

Finally, Ms. DeChirico sent me information about the call volume from our local NPSL center in Columbia. From July 1, 2013, to July 31, 2014, the Lifeline received an average of 134 calls per month. December had the highest number of calls, with 163, while August had the lowest with 118. September, February, and April all had 120 calls or fewer.

Robin Williams died on Aug. 11, 2014, and the center received 200 calls in August – a 49% increase over the average volume. Hopefully, we’ll end up seeing a decline in suicide in the months following Mr. Williams’ tragic death.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

National Suicide Prevention Day fell on Sept. 10 this year, surrounded by National Suicide Prevention Week Sept. 8-14. The conversation, as I’m sure everyone noticed, was focused on the suicide of actor Robin Williams. As we move out a few weeks, my patients – especially those who have contemplated ending their own lives – continue to talk about this tragic loss.

The fear is that the suicide of a celebrity will lead to an increase in the suicide rate in the general public – copycat suicides, if you will. In the month after Marilyn Monroe died of an overdose in 1962, the suicide rate rose by more than 10%. On the other hand, the death of a celebrity may lead to a decrease in the suicide rate, as happened after Kurt Cobain’s death from a self-inflicted gunshot wound in 1994. In the period after Cobain’s death, an effort was made to publicize resources for those who need help. The suicide rate dropped, while calls to hotlines rose.

After Robin Williams’ death, my own social media feeds were full of ads for the National Suicide Prevention Lifeline (NSPL), a hotline with the number 1-800-273-TALK. There are other hotlines, but this was the one I saw most. I wanted to learn about suicide hotlines, so I did a few things: I asked readers of our Shrink Rap blog to tell me about their experiences, and I called the hotline myself to see if I could learn about the structure of the organization, what resources they had to offer a distraught caller, and whether there had been a change in the number of calls they’d received in the time following Mr. Williams’ death.

I called from my cell phone, which is registered in Maryland, while sitting in my home in Baltimore City. The call was routed to Grassroots Crisis Intervention Center in Columbia, Md. Google Maps tells me the center is 25 miles from my house, and it would take me 32 minutes to drive there. In addition to being part of a network of 160 hotline centers across the country, Grassroots has a walk-in crisis center and a mobile treatment center, and is adjacent to a homeless shelter.

“Most of the people who call the National Suicide Prevention Lifeline are suicidal,” said Nicole DeChirico, director of crisis intervention services for Grassroots. “There is a gradation in suicidal thinking, but about 90% of our callers are considering it.”

“We first form rapport, and then we try to quickly assess if an attempt has already been made, and if they are in any danger. We use the assessment of suicidality that is put out by the NSPL. It’s a structured template that is used as a guideline.”

Ms. DeChirico noted that the people who man the hotlines have bachelor’s or master’s degrees – often in psychology, social work, counseling, or education. If feasible, a Safety Planning Intervention is implemented, based on the work of Barbara Stanley, Ph.D., at Columbia University in New York.

“We talk to people about what they need to do to feel safe. If they allow it, we set up a follow-up call. Of the total number of people who have attempted suicide once in the past and lived, 90%-96% never go on to attempt suicide again,” Ms. DeChirico noted. Suicide is a time-limited acute crisis.”

The Grassroots team can see patients on site while they wait for appointments with an outpatient clinician, and can send a mobile crisis team to those who need it if they are in the county served by the organization. I wondered if all 160 agencies that received calls from the NSPL could also provide crisis services.

Marcia Epstein, LMSW, was director of the Headquarters Counseling Center in Lawrence, Kan., from 1979 to 2013. The center became part of the first national suicide prevention hotline network, the National Hopeline Network, 1-800-SUICIDE, in 2001, and then became part of the National Suicide Prevention Lifeline, 1-800-274-TALK (8255), when that network began in January 2005.

“The types of programs and agencies which are part of NSPL vary greatly. The accreditation that allows them to be part of the NSPL network also varies. Some centers are staffed totally by licensed mental health therapists, while others might include trained volunteers and paid counselors who have no professional degree or licensure. Service may be delivered by phone, as well as in person, by text, and by live chat. In person might be on site or through mobile crisis outreach. Some centers are part of other organizations, while others are free-standing, and some serve entire states, while others serve geographically smaller regions,” Ms. Epstein explained in a series of e-mails. She noted that some centers assess and refer, while others, like Grassroots, are able to provide more counseling.

“So if it sounds like I’m saying there is little consistency between centers, yes, that is my experience. But the centers all bring strong commitment to preventing suicide.”

Ms. Epstein continued to discuss the power of the work done with hotline callers.

“The really helpful counseling comes from the heart, from connecting to people with caring and respect and patience, and using our skills in helping them stay safer through the crisis and then, when needed, to stay safer in the long run. It takes a lot of bravery from the people letting us help. And it takes a lot of creativity and flexibility in coming up together with realistic plans to support safety.”

I was curious about the patient response, and I found that was mixed. It was also notable that different patients found different forms of communication to be helpful.

A woman who identified herself only as “Virginia Woolf” wrote, “I have contacted the Samaritans on the [email protected] line because I could write to them via e-mail. I don’t like phones and I also know too many of the counselors on the local crisis line. Each time I was definitely close to suicide. I was in despair and I had the means at hand. I think what stopped me was knowing they would reply. They always did, within a few hours, but waiting for their reply kept me safe.”

Not every response was as positive.

One writer noted, “It was not a productive, supportive, or empathetic person. I felt like she was arrogant, judgmental, and didn’t really care about why I was calling.” The same writer, however, was able to find solace elsewhere. “I have texted CrisisChat and it was an excellent chat and I did feel better.”

Finally, Ms. DeChirico sent me information about the call volume from our local NPSL center in Columbia. From July 1, 2013, to July 31, 2014, the Lifeline received an average of 134 calls per month. December had the highest number of calls, with 163, while August had the lowest with 118. September, February, and April all had 120 calls or fewer.

Robin Williams died on Aug. 11, 2014, and the center received 200 calls in August – a 49% increase over the average volume. Hopefully, we’ll end up seeing a decline in suicide in the months following Mr. Williams’ tragic death.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

National Suicide Prevention Day fell on Sept. 10 this year, surrounded by National Suicide Prevention Week Sept. 8-14. The conversation, as I’m sure everyone noticed, was focused on the suicide of actor Robin Williams. As we move out a few weeks, my patients – especially those who have contemplated ending their own lives – continue to talk about this tragic loss.

The fear is that the suicide of a celebrity will lead to an increase in the suicide rate in the general public – copycat suicides, if you will. In the month after Marilyn Monroe died of an overdose in 1962, the suicide rate rose by more than 10%. On the other hand, the death of a celebrity may lead to a decrease in the suicide rate, as happened after Kurt Cobain’s death from a self-inflicted gunshot wound in 1994. In the period after Cobain’s death, an effort was made to publicize resources for those who need help. The suicide rate dropped, while calls to hotlines rose.

After Robin Williams’ death, my own social media feeds were full of ads for the National Suicide Prevention Lifeline (NSPL), a hotline with the number 1-800-273-TALK. There are other hotlines, but this was the one I saw most. I wanted to learn about suicide hotlines, so I did a few things: I asked readers of our Shrink Rap blog to tell me about their experiences, and I called the hotline myself to see if I could learn about the structure of the organization, what resources they had to offer a distraught caller, and whether there had been a change in the number of calls they’d received in the time following Mr. Williams’ death.

I called from my cell phone, which is registered in Maryland, while sitting in my home in Baltimore City. The call was routed to Grassroots Crisis Intervention Center in Columbia, Md. Google Maps tells me the center is 25 miles from my house, and it would take me 32 minutes to drive there. In addition to being part of a network of 160 hotline centers across the country, Grassroots has a walk-in crisis center and a mobile treatment center, and is adjacent to a homeless shelter.

“Most of the people who call the National Suicide Prevention Lifeline are suicidal,” said Nicole DeChirico, director of crisis intervention services for Grassroots. “There is a gradation in suicidal thinking, but about 90% of our callers are considering it.”

“We first form rapport, and then we try to quickly assess if an attempt has already been made, and if they are in any danger. We use the assessment of suicidality that is put out by the NSPL. It’s a structured template that is used as a guideline.”

Ms. DeChirico noted that the people who man the hotlines have bachelor’s or master’s degrees – often in psychology, social work, counseling, or education. If feasible, a Safety Planning Intervention is implemented, based on the work of Barbara Stanley, Ph.D., at Columbia University in New York.

“We talk to people about what they need to do to feel safe. If they allow it, we set up a follow-up call. Of the total number of people who have attempted suicide once in the past and lived, 90%-96% never go on to attempt suicide again,” Ms. DeChirico noted. Suicide is a time-limited acute crisis.”

The Grassroots team can see patients on site while they wait for appointments with an outpatient clinician, and can send a mobile crisis team to those who need it if they are in the county served by the organization. I wondered if all 160 agencies that received calls from the NSPL could also provide crisis services.

Marcia Epstein, LMSW, was director of the Headquarters Counseling Center in Lawrence, Kan., from 1979 to 2013. The center became part of the first national suicide prevention hotline network, the National Hopeline Network, 1-800-SUICIDE, in 2001, and then became part of the National Suicide Prevention Lifeline, 1-800-274-TALK (8255), when that network began in January 2005.

“The types of programs and agencies which are part of NSPL vary greatly. The accreditation that allows them to be part of the NSPL network also varies. Some centers are staffed totally by licensed mental health therapists, while others might include trained volunteers and paid counselors who have no professional degree or licensure. Service may be delivered by phone, as well as in person, by text, and by live chat. In person might be on site or through mobile crisis outreach. Some centers are part of other organizations, while others are free-standing, and some serve entire states, while others serve geographically smaller regions,” Ms. Epstein explained in a series of e-mails. She noted that some centers assess and refer, while others, like Grassroots, are able to provide more counseling.

“So if it sounds like I’m saying there is little consistency between centers, yes, that is my experience. But the centers all bring strong commitment to preventing suicide.”

Ms. Epstein continued to discuss the power of the work done with hotline callers.

“The really helpful counseling comes from the heart, from connecting to people with caring and respect and patience, and using our skills in helping them stay safer through the crisis and then, when needed, to stay safer in the long run. It takes a lot of bravery from the people letting us help. And it takes a lot of creativity and flexibility in coming up together with realistic plans to support safety.”

I was curious about the patient response, and I found that was mixed. It was also notable that different patients found different forms of communication to be helpful.

A woman who identified herself only as “Virginia Woolf” wrote, “I have contacted the Samaritans on the [email protected] line because I could write to them via e-mail. I don’t like phones and I also know too many of the counselors on the local crisis line. Each time I was definitely close to suicide. I was in despair and I had the means at hand. I think what stopped me was knowing they would reply. They always did, within a few hours, but waiting for their reply kept me safe.”

Not every response was as positive.

One writer noted, “It was not a productive, supportive, or empathetic person. I felt like she was arrogant, judgmental, and didn’t really care about why I was calling.” The same writer, however, was able to find solace elsewhere. “I have texted CrisisChat and it was an excellent chat and I did feel better.”

Finally, Ms. DeChirico sent me information about the call volume from our local NPSL center in Columbia. From July 1, 2013, to July 31, 2014, the Lifeline received an average of 134 calls per month. December had the highest number of calls, with 163, while August had the lowest with 118. September, February, and April all had 120 calls or fewer.

Robin Williams died on Aug. 11, 2014, and the center received 200 calls in August – a 49% increase over the average volume. Hopefully, we’ll end up seeing a decline in suicide in the months following Mr. Williams’ tragic death.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

Ever since the 2001 attack on the World Trade Center, I have associated a bright, sunny day with disaster. I vividly remember what a beautiful morning that was -- a crystal blue cloudless sky, low humidity, and a cool, comfortable temperature. Who could be unhappy on such a marvelous day?

On the other hand, my experience living in a northern climate taught me that winter was another story. Getting up in the dark to go to school or work was a miserable experience, followed by coming home in the dark and endless hours of biting cold and bitter nights. I was not surprised to learn later in my residency training about seasonal affective disorder and about the effects of light on mood. With this background, I felt primed to write a column about a new study, "Direct Effect of Sunshine on Suicide" (JAMA Psychiatry 2014 Sept. 10 [doi:10.1001/jamapsychiatry.2014.1198]).

In this study, investigators looked at public records of confirmed suicides in Austria between January 1970 and May 2010.They gathered 40 years of daily sunlight data from 86 meteorological stations. The amount of sunlight was defined as the duration of time that light intensity was higher than 120 watts per square meter, which apparently is the amount of light typically seen just after sunrise or just before sunset. Using this information, they compared daily suicide rates with the average daily duration of sunshine. Since sunlight varies in both duration and intensity over the seasons, the researchers used statistical methods to compensate for this, which distinguished this work from previous similar suicide studies. The authors then compared suicide rates by gender and method.

There were 69,462 suicide deaths, the majority through violent means such as hanging, drowning, shooting, or jumping. Only a quarter of the deaths were through nonviolent means such as poisoning. A significant correlation was found between the daily suicide rate and the daily duration of sunshine, but the surprising result was that sunshine appeared to have both a provocative and a palliative effect. Suicide rates climbed with increasing sunshine during the 10 days leading up to a suicide for suicides as a whole, for suicide through violent means, and for women. Sunlight had no effect on suicides for nonviolent deaths.

As a group, there was a negative correlation with deaths for the 14-60 days prior to a given suicide. Violent suicides were less likely during this time. The effects of sunshine also were specific to gender. There was a negative correlation, or apparently a protective effect, for men but not for women in the preceding 14-60 days.

Many physiologic reasons explain why light can affect mood, such as disruption of circadian rhythms and altered melatonin levels, or disturbances in serotonin or monoamine systems. There have also been social explanations for why suicides show seasonal variation. The "winter blues" have been explained by the stress of holiday preparation and its associated high expectations, family conflict, and increased alcohol use around this time. The authors concluded that one reason sunlight may increase suicide rates is that sunlight may improve motivation before lifting mood, giving a person the impetus to act on self-destructive impulses.

How this relates to the use of light boxes to treat seasonal affective disorder remains to be seen. Traditionally, this intervention is favored because of the relatively few associated hazards and side effects compared to pharmacotherapy. This risk-benefit ratio may need to be reassessed as more studies address the sunlight-suicide connection. Still, given that these devices are not Food and Drug Administration‑regulated or approved, I doubt we will be seeing the equivalent of a “black box” warning anytime in the near future.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Ever since the 2001 attack on the World Trade Center, I have associated a bright, sunny day with disaster. I vividly remember what a beautiful morning that was -- a crystal blue cloudless sky, low humidity, and a cool, comfortable temperature. Who could be unhappy on such a marvelous day?

On the other hand, my experience living in a northern climate taught me that winter was another story. Getting up in the dark to go to school or work was a miserable experience, followed by coming home in the dark and endless hours of biting cold and bitter nights. I was not surprised to learn later in my residency training about seasonal affective disorder and about the effects of light on mood. With this background, I felt primed to write a column about a new study, "Direct Effect of Sunshine on Suicide" (JAMA Psychiatry 2014 Sept. 10 [doi:10.1001/jamapsychiatry.2014.1198]).

In this study, investigators looked at public records of confirmed suicides in Austria between January 1970 and May 2010.They gathered 40 years of daily sunlight data from 86 meteorological stations. The amount of sunlight was defined as the duration of time that light intensity was higher than 120 watts per square meter, which apparently is the amount of light typically seen just after sunrise or just before sunset. Using this information, they compared daily suicide rates with the average daily duration of sunshine. Since sunlight varies in both duration and intensity over the seasons, the researchers used statistical methods to compensate for this, which distinguished this work from previous similar suicide studies. The authors then compared suicide rates by gender and method.

There were 69,462 suicide deaths, the majority through violent means such as hanging, drowning, shooting, or jumping. Only a quarter of the deaths were through nonviolent means such as poisoning. A significant correlation was found between the daily suicide rate and the daily duration of sunshine, but the surprising result was that sunshine appeared to have both a provocative and a palliative effect. Suicide rates climbed with increasing sunshine during the 10 days leading up to a suicide for suicides as a whole, for suicide through violent means, and for women. Sunlight had no effect on suicides for nonviolent deaths.

As a group, there was a negative correlation with deaths for the 14-60 days prior to a given suicide. Violent suicides were less likely during this time. The effects of sunshine also were specific to gender. There was a negative correlation, or apparently a protective effect, for men but not for women in the preceding 14-60 days.

Many physiologic reasons explain why light can affect mood, such as disruption of circadian rhythms and altered melatonin levels, or disturbances in serotonin or monoamine systems. There have also been social explanations for why suicides show seasonal variation. The "winter blues" have been explained by the stress of holiday preparation and its associated high expectations, family conflict, and increased alcohol use around this time. The authors concluded that one reason sunlight may increase suicide rates is that sunlight may improve motivation before lifting mood, giving a person the impetus to act on self-destructive impulses.

How this relates to the use of light boxes to treat seasonal affective disorder remains to be seen. Traditionally, this intervention is favored because of the relatively few associated hazards and side effects compared to pharmacotherapy. This risk-benefit ratio may need to be reassessed as more studies address the sunlight-suicide connection. Still, given that these devices are not Food and Drug Administration‑regulated or approved, I doubt we will be seeing the equivalent of a “black box” warning anytime in the near future.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Ever since the 2001 attack on the World Trade Center, I have associated a bright, sunny day with disaster. I vividly remember what a beautiful morning that was -- a crystal blue cloudless sky, low humidity, and a cool, comfortable temperature. Who could be unhappy on such a marvelous day?

On the other hand, my experience living in a northern climate taught me that winter was another story. Getting up in the dark to go to school or work was a miserable experience, followed by coming home in the dark and endless hours of biting cold and bitter nights. I was not surprised to learn later in my residency training about seasonal affective disorder and about the effects of light on mood. With this background, I felt primed to write a column about a new study, "Direct Effect of Sunshine on Suicide" (JAMA Psychiatry 2014 Sept. 10 [doi:10.1001/jamapsychiatry.2014.1198]).

In this study, investigators looked at public records of confirmed suicides in Austria between January 1970 and May 2010.They gathered 40 years of daily sunlight data from 86 meteorological stations. The amount of sunlight was defined as the duration of time that light intensity was higher than 120 watts per square meter, which apparently is the amount of light typically seen just after sunrise or just before sunset. Using this information, they compared daily suicide rates with the average daily duration of sunshine. Since sunlight varies in both duration and intensity over the seasons, the researchers used statistical methods to compensate for this, which distinguished this work from previous similar suicide studies. The authors then compared suicide rates by gender and method.

There were 69,462 suicide deaths, the majority through violent means such as hanging, drowning, shooting, or jumping. Only a quarter of the deaths were through nonviolent means such as poisoning. A significant correlation was found between the daily suicide rate and the daily duration of sunshine, but the surprising result was that sunshine appeared to have both a provocative and a palliative effect. Suicide rates climbed with increasing sunshine during the 10 days leading up to a suicide for suicides as a whole, for suicide through violent means, and for women. Sunlight had no effect on suicides for nonviolent deaths.

As a group, there was a negative correlation with deaths for the 14-60 days prior to a given suicide. Violent suicides were less likely during this time. The effects of sunshine also were specific to gender. There was a negative correlation, or apparently a protective effect, for men but not for women in the preceding 14-60 days.

Many physiologic reasons explain why light can affect mood, such as disruption of circadian rhythms and altered melatonin levels, or disturbances in serotonin or monoamine systems. There have also been social explanations for why suicides show seasonal variation. The "winter blues" have been explained by the stress of holiday preparation and its associated high expectations, family conflict, and increased alcohol use around this time. The authors concluded that one reason sunlight may increase suicide rates is that sunlight may improve motivation before lifting mood, giving a person the impetus to act on self-destructive impulses.

How this relates to the use of light boxes to treat seasonal affective disorder remains to be seen. Traditionally, this intervention is favored because of the relatively few associated hazards and side effects compared to pharmacotherapy. This risk-benefit ratio may need to be reassessed as more studies address the sunlight-suicide connection. Still, given that these devices are not Food and Drug Administration‑regulated or approved, I doubt we will be seeing the equivalent of a “black box” warning anytime in the near future.

Dr. Hanson is a forensic psychiatrist and coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work.” The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson's employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Over the past few days, an article has circulated about a 23-year-old middle school teacher in Cambridge, Md., who was suspended from his job because of two futuristic novels he wrote, including one about a school massacre 900 years in the future. The story was reported in The Atlantic under the headline, "In Maryland, a Soviet-Style Punishment for a Novelist."

The article, by Jeffrey Goldberg, said the young teacher had self-published his novels some time ago under a pseudonym. In addition to his being suspended, an "emergency medical evaluation" was ordered, his house was searched, and the school was swept for bombs by K-9 dogs. No charges have been filed as of this writing.

This response was deemed an "overreaction," and certainly has been good for book sales but probably not so much for the young man’s teaching career. The idea that artistic expression must conform to a specific standard or jeopardize one’s job leaves those with creative pursuits to worry and civil rights advocates to protest.

Soon after, the Los Angeles Times published an article stating that the issue was not the novels – the school knew about those in 2012 – but rather the content of a four-page letter the teacher had written to the school board suggesting that the teacher was suffering from some type of psychiatric condition and might have included indications that he was suicidal or dangerous. With this information, it was not as clear if the police response was an overreaction, and such determinations are generally made in hindsight: If a bomb is found, the decision was heroic, if not, it was an overreaction and a civil rights violation.

The case reminded me of the story about a New York City police officer who had Internet discussions about his desire to cook and eat women, including his ex-wife. While the officer never ate anyone, he was part of an online community called the Dark Fetish Network, which has of tens of thousands of registered users who discuss violent sexual fantasies. The officer, known in the media frenzy as Cannibal Cop, lost his job and was convicted of plotting to kidnap, a crime that could carry a life sentence. He reportedly had graphic discussions of plans to kill, roast, and eat specified victims, and he claimed that he had the means to do so. An investigation revealed that he did not own the implements that would enable him to carry out such a plan. His lawyer insisted that he was engaged in a role-playing fantasy, but he was convicted by a jury in 2012. In July, his conviction was overturned and he was released on bond. By that time, Cannibal Cop had served a year and a half in prison, with several months of it in solitary confinement.

Situations in which a person has done nothing illegal but has spoken or written words that indicate he or she might be a threat to public safety are fraught with concerns. While violent fantasies might be seen as "creepy" at a minimum, the criminal justice system is left to decide where the line is between fantasy and plan, and when a real threat exists. A person has the right to his dark fantasies, and the First Amendment right to free speech allows for discussion of those fantasies, while artistic endeavors allow for their expression. At the same time, if there are named or presumed victims, those individuals should not have to live with the terror of wondering if the fantasizer is going to act on the fantasies.

Invariably, psychiatrists end up being involved, even if the individual in question has no psychiatric history or obvious diagnosis. In a New York magazine article about the police officer titled, "A Dangerous Mind," Robert Kolker noted: "Pre-crime and psychiatry often go hand in hand. Legal instruments like institutionalization and sex-offender registration all share the goal of preventing crime from taking place, and for better or worse, they’re based on a psychiatric rationale."

As we all know, it can be difficult – if not impossible – to distinguish those who are having fantasies from those who are planning to commit a dangerous act. As psychiatrists, we deal with this uncertainty for patients who have suicidal thoughts on a regular basis. Often, even the patients don’t know for sure if they will act on their impulses. Fantasies that involve harming others are more unusual in clinical practice, and our risk assessment often begins with the stated intent of the individual. Our strongest predictor of future behavior continues to be past behavior, and neither the teacher nor the police officer in the stories above had criminal records.

To make it even more confusing, the Internet has added to the uncertainty; people have always had dangerous and fetishistic fantasies, but now there are ways others can learn the content of what was once very private. The risk, of course, is that fantasies and artistic endeavors become subject to both psychiatric scrutiny and criminal prosecution in a way that threatens civil rights and squelches creativity.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore:The Johns Hopkins University Press, 2011).

Over the past few days, an article has circulated about a 23-year-old middle school teacher in Cambridge, Md., who was suspended from his job because of two futuristic novels he wrote, including one about a school massacre 900 years in the future. The story was reported in The Atlantic under the headline, "In Maryland, a Soviet-Style Punishment for a Novelist."

The article, by Jeffrey Goldberg, said the young teacher had self-published his novels some time ago under a pseudonym. In addition to his being suspended, an "emergency medical evaluation" was ordered, his house was searched, and the school was swept for bombs by K-9 dogs. No charges have been filed as of this writing.

This response was deemed an "overreaction," and certainly has been good for book sales but probably not so much for the young man’s teaching career. The idea that artistic expression must conform to a specific standard or jeopardize one’s job leaves those with creative pursuits to worry and civil rights advocates to protest.

Soon after, the Los Angeles Times published an article stating that the issue was not the novels – the school knew about those in 2012 – but rather the content of a four-page letter the teacher had written to the school board suggesting that the teacher was suffering from some type of psychiatric condition and might have included indications that he was suicidal or dangerous. With this information, it was not as clear if the police response was an overreaction, and such determinations are generally made in hindsight: If a bomb is found, the decision was heroic, if not, it was an overreaction and a civil rights violation.

The case reminded me of the story about a New York City police officer who had Internet discussions about his desire to cook and eat women, including his ex-wife. While the officer never ate anyone, he was part of an online community called the Dark Fetish Network, which has of tens of thousands of registered users who discuss violent sexual fantasies. The officer, known in the media frenzy as Cannibal Cop, lost his job and was convicted of plotting to kidnap, a crime that could carry a life sentence. He reportedly had graphic discussions of plans to kill, roast, and eat specified victims, and he claimed that he had the means to do so. An investigation revealed that he did not own the implements that would enable him to carry out such a plan. His lawyer insisted that he was engaged in a role-playing fantasy, but he was convicted by a jury in 2012. In July, his conviction was overturned and he was released on bond. By that time, Cannibal Cop had served a year and a half in prison, with several months of it in solitary confinement.

Situations in which a person has done nothing illegal but has spoken or written words that indicate he or she might be a threat to public safety are fraught with concerns. While violent fantasies might be seen as "creepy" at a minimum, the criminal justice system is left to decide where the line is between fantasy and plan, and when a real threat exists. A person has the right to his dark fantasies, and the First Amendment right to free speech allows for discussion of those fantasies, while artistic endeavors allow for their expression. At the same time, if there are named or presumed victims, those individuals should not have to live with the terror of wondering if the fantasizer is going to act on the fantasies.

Invariably, psychiatrists end up being involved, even if the individual in question has no psychiatric history or obvious diagnosis. In a New York magazine article about the police officer titled, "A Dangerous Mind," Robert Kolker noted: "Pre-crime and psychiatry often go hand in hand. Legal instruments like institutionalization and sex-offender registration all share the goal of preventing crime from taking place, and for better or worse, they’re based on a psychiatric rationale."

As we all know, it can be difficult – if not impossible – to distinguish those who are having fantasies from those who are planning to commit a dangerous act. As psychiatrists, we deal with this uncertainty for patients who have suicidal thoughts on a regular basis. Often, even the patients don’t know for sure if they will act on their impulses. Fantasies that involve harming others are more unusual in clinical practice, and our risk assessment often begins with the stated intent of the individual. Our strongest predictor of future behavior continues to be past behavior, and neither the teacher nor the police officer in the stories above had criminal records.

To make it even more confusing, the Internet has added to the uncertainty; people have always had dangerous and fetishistic fantasies, but now there are ways others can learn the content of what was once very private. The risk, of course, is that fantasies and artistic endeavors become subject to both psychiatric scrutiny and criminal prosecution in a way that threatens civil rights and squelches creativity.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore:The Johns Hopkins University Press, 2011).

Over the past few days, an article has circulated about a 23-year-old middle school teacher in Cambridge, Md., who was suspended from his job because of two futuristic novels he wrote, including one about a school massacre 900 years in the future. The story was reported in The Atlantic under the headline, "In Maryland, a Soviet-Style Punishment for a Novelist."

The article, by Jeffrey Goldberg, said the young teacher had self-published his novels some time ago under a pseudonym. In addition to his being suspended, an "emergency medical evaluation" was ordered, his house was searched, and the school was swept for bombs by K-9 dogs. No charges have been filed as of this writing.

This response was deemed an "overreaction," and certainly has been good for book sales but probably not so much for the young man’s teaching career. The idea that artistic expression must conform to a specific standard or jeopardize one’s job leaves those with creative pursuits to worry and civil rights advocates to protest.

Soon after, the Los Angeles Times published an article stating that the issue was not the novels – the school knew about those in 2012 – but rather the content of a four-page letter the teacher had written to the school board suggesting that the teacher was suffering from some type of psychiatric condition and might have included indications that he was suicidal or dangerous. With this information, it was not as clear if the police response was an overreaction, and such determinations are generally made in hindsight: If a bomb is found, the decision was heroic, if not, it was an overreaction and a civil rights violation.

The case reminded me of the story about a New York City police officer who had Internet discussions about his desire to cook and eat women, including his ex-wife. While the officer never ate anyone, he was part of an online community called the Dark Fetish Network, which has of tens of thousands of registered users who discuss violent sexual fantasies. The officer, known in the media frenzy as Cannibal Cop, lost his job and was convicted of plotting to kidnap, a crime that could carry a life sentence. He reportedly had graphic discussions of plans to kill, roast, and eat specified victims, and he claimed that he had the means to do so. An investigation revealed that he did not own the implements that would enable him to carry out such a plan. His lawyer insisted that he was engaged in a role-playing fantasy, but he was convicted by a jury in 2012. In July, his conviction was overturned and he was released on bond. By that time, Cannibal Cop had served a year and a half in prison, with several months of it in solitary confinement.

Situations in which a person has done nothing illegal but has spoken or written words that indicate he or she might be a threat to public safety are fraught with concerns. While violent fantasies might be seen as "creepy" at a minimum, the criminal justice system is left to decide where the line is between fantasy and plan, and when a real threat exists. A person has the right to his dark fantasies, and the First Amendment right to free speech allows for discussion of those fantasies, while artistic endeavors allow for their expression. At the same time, if there are named or presumed victims, those individuals should not have to live with the terror of wondering if the fantasizer is going to act on the fantasies.

Invariably, psychiatrists end up being involved, even if the individual in question has no psychiatric history or obvious diagnosis. In a New York magazine article about the police officer titled, "A Dangerous Mind," Robert Kolker noted: "Pre-crime and psychiatry often go hand in hand. Legal instruments like institutionalization and sex-offender registration all share the goal of preventing crime from taking place, and for better or worse, they’re based on a psychiatric rationale."

As we all know, it can be difficult – if not impossible – to distinguish those who are having fantasies from those who are planning to commit a dangerous act. As psychiatrists, we deal with this uncertainty for patients who have suicidal thoughts on a regular basis. Often, even the patients don’t know for sure if they will act on their impulses. Fantasies that involve harming others are more unusual in clinical practice, and our risk assessment often begins with the stated intent of the individual. Our strongest predictor of future behavior continues to be past behavior, and neither the teacher nor the police officer in the stories above had criminal records.

To make it even more confusing, the Internet has added to the uncertainty; people have always had dangerous and fetishistic fantasies, but now there are ways others can learn the content of what was once very private. The risk, of course, is that fantasies and artistic endeavors become subject to both psychiatric scrutiny and criminal prosecution in a way that threatens civil rights and squelches creativity.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore:The Johns Hopkins University Press, 2011).

The news last night was tragic: Robin Williams has died of an apparent suicide at the early age of 63. I saw the news and felt overwhelmingly sad. Really? He was a tremendous actor, a creative genius by any account, a man who I imagined had everything – talent, wealth, fame, the wonderful ability to make people laugh and to brighten lives. Such people also get draped with love and admiration, though certainly at a price. For what it’s worth, Robin Williams has been open about the fact that he’s struggled with both depression and addiction, but the complete story is never the one that gets told by the media.

Courtesy Wikimedia Commons/John J. Kruzel/Creative Commons License

Twitter started with 140-character links to suicide hotlines and suicide awareness, to statements about how depression is a treatable illness – Is it always? – and I hit retweet on a comment stating:" We’re never going to get anywhere till we take seriously that depression is an illness, not a weakness" and several people retweeted my retweet. I’m not sure why I did this; I don’t think that most people still think of mood disorders as a "weakness," or that those who do might change their minds because of a tweet. And I don’t think that suicide does anything to reduce stigma.

One psychiatrist friend tweeted a comment about how one should never ask someone why they are depressed, I guess because the "why?" implies something other than because biology dictated it, but if you’ve ever spoken to a person suffering from depression, you know that it comes in all shades of severity and that people often write a story to explain it. Sometimes that story is right: I’m depressed because of a breakup, or because I don’t have a job now, or because of ongoing work stress – and indeed, the person suffering often feels better after talking about the situation, after getting a new boyfriend or a new job, or after their boss moves to Zimbabwe.

I’m convinced that treatment works best when psychotherapy is combined with medication (if indicated), and while medicines are a miracle for some, they aren’t for others. As psychiatrists, we certainly see a good deal of treatment-resistant depression. And yes, the antipsychiatry faction may postulate that it is the treatment – the medications, specifically – that cause people to kill themselves and others, but I will leave you with the idea that the science just doesn’t support that. Certainly, they aren’t for everyone, but clinically, I have seen medications do more good than harm in clinical practice overall.

I know nothing about Robin Williams beyond what I’ve read in the media, and I know that the media reports are often incomplete and distorted. I do imagine that Mr. Williams had the resources to get good care and that he may well have had treatment for depression since he was open about his struggle. His story will be used to say: "Get help," and if you’re feeling suicidal and aren’t getting help, please do so. If you’re feeling suicidal and "help" isn’t making you feel better, please consider getting a second opinion or a different kind of help.

The tragic thing about suicide is that it’s a permanent answer to what is often a temporary problem.

Sometimes, I imagine that there are people who have tried and tried to get help and that their pain remains so unbearable for so long that suicide offers them the only possible relief – if such a thing is even to be had given that we don’t what comes next and some religions will say that suicide leads to nowhere good. Even if it provides relief to the person involved, it comes with the cost of leaving those who remain in horrible pain. Sadly, depressed people sometimes imagine that the world will be better off without them, and often that idea is just not true.

I hope that Robin Williams is in a better place, for his sake. I hope that before he ended his life, he tried every possible treatment option, and that this wasn’t an impulsive decision, or one based on an episodic relapse of either depression or substance abuse – a relapse that may have resolved and let him live for decades more. I hope his wife and children and all the people who knew and loved him will eventually find some peace. His death, however, is not simply a personal one because he touched us all with his talent and his charisma. What a tragic loss.

Dr. Miller also posted a version http://bit.ly/1kyO1a7 of this piece on the Shrink Rap News website. She is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

The news last night was tragic: Robin Williams has died of an apparent suicide at the early age of 63. I saw the news and felt overwhelmingly sad. Really? He was a tremendous actor, a creative genius by any account, a man who I imagined had everything – talent, wealth, fame, the wonderful ability to make people laugh and to brighten lives. Such people also get draped with love and admiration, though certainly at a price. For what it’s worth, Robin Williams has been open about the fact that he’s struggled with both depression and addiction, but the complete story is never the one that gets told by the media.

Courtesy Wikimedia Commons/John J. Kruzel/Creative Commons License

Twitter started with 140-character links to suicide hotlines and suicide awareness, to statements about how depression is a treatable illness – Is it always? – and I hit retweet on a comment stating:" We’re never going to get anywhere till we take seriously that depression is an illness, not a weakness" and several people retweeted my retweet. I’m not sure why I did this; I don’t think that most people still think of mood disorders as a "weakness," or that those who do might change their minds because of a tweet. And I don’t think that suicide does anything to reduce stigma.

One psychiatrist friend tweeted a comment about how one should never ask someone why they are depressed, I guess because the "why?" implies something other than because biology dictated it, but if you’ve ever spoken to a person suffering from depression, you know that it comes in all shades of severity and that people often write a story to explain it. Sometimes that story is right: I’m depressed because of a breakup, or because I don’t have a job now, or because of ongoing work stress – and indeed, the person suffering often feels better after talking about the situation, after getting a new boyfriend or a new job, or after their boss moves to Zimbabwe.

I’m convinced that treatment works best when psychotherapy is combined with medication (if indicated), and while medicines are a miracle for some, they aren’t for others. As psychiatrists, we certainly see a good deal of treatment-resistant depression. And yes, the antipsychiatry faction may postulate that it is the treatment – the medications, specifically – that cause people to kill themselves and others, but I will leave you with the idea that the science just doesn’t support that. Certainly, they aren’t for everyone, but clinically, I have seen medications do more good than harm in clinical practice overall.

I know nothing about Robin Williams beyond what I’ve read in the media, and I know that the media reports are often incomplete and distorted. I do imagine that Mr. Williams had the resources to get good care and that he may well have had treatment for depression since he was open about his struggle. His story will be used to say: "Get help," and if you’re feeling suicidal and aren’t getting help, please do so. If you’re feeling suicidal and "help" isn’t making you feel better, please consider getting a second opinion or a different kind of help.

The tragic thing about suicide is that it’s a permanent answer to what is often a temporary problem.

Sometimes, I imagine that there are people who have tried and tried to get help and that their pain remains so unbearable for so long that suicide offers them the only possible relief – if such a thing is even to be had given that we don’t what comes next and some religions will say that suicide leads to nowhere good. Even if it provides relief to the person involved, it comes with the cost of leaving those who remain in horrible pain. Sadly, depressed people sometimes imagine that the world will be better off without them, and often that idea is just not true.

I hope that Robin Williams is in a better place, for his sake. I hope that before he ended his life, he tried every possible treatment option, and that this wasn’t an impulsive decision, or one based on an episodic relapse of either depression or substance abuse – a relapse that may have resolved and let him live for decades more. I hope his wife and children and all the people who knew and loved him will eventually find some peace. His death, however, is not simply a personal one because he touched us all with his talent and his charisma. What a tragic loss.

Dr. Miller also posted a version http://bit.ly/1kyO1a7 of this piece on the Shrink Rap News website. She is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

The news last night was tragic: Robin Williams has died of an apparent suicide at the early age of 63. I saw the news and felt overwhelmingly sad. Really? He was a tremendous actor, a creative genius by any account, a man who I imagined had everything – talent, wealth, fame, the wonderful ability to make people laugh and to brighten lives. Such people also get draped with love and admiration, though certainly at a price. For what it’s worth, Robin Williams has been open about the fact that he’s struggled with both depression and addiction, but the complete story is never the one that gets told by the media.

Courtesy Wikimedia Commons/John J. Kruzel/Creative Commons License

Twitter started with 140-character links to suicide hotlines and suicide awareness, to statements about how depression is a treatable illness – Is it always? – and I hit retweet on a comment stating:" We’re never going to get anywhere till we take seriously that depression is an illness, not a weakness" and several people retweeted my retweet. I’m not sure why I did this; I don’t think that most people still think of mood disorders as a "weakness," or that those who do might change their minds because of a tweet. And I don’t think that suicide does anything to reduce stigma.

One psychiatrist friend tweeted a comment about how one should never ask someone why they are depressed, I guess because the "why?" implies something other than because biology dictated it, but if you’ve ever spoken to a person suffering from depression, you know that it comes in all shades of severity and that people often write a story to explain it. Sometimes that story is right: I’m depressed because of a breakup, or because I don’t have a job now, or because of ongoing work stress – and indeed, the person suffering often feels better after talking about the situation, after getting a new boyfriend or a new job, or after their boss moves to Zimbabwe.

I’m convinced that treatment works best when psychotherapy is combined with medication (if indicated), and while medicines are a miracle for some, they aren’t for others. As psychiatrists, we certainly see a good deal of treatment-resistant depression. And yes, the antipsychiatry faction may postulate that it is the treatment – the medications, specifically – that cause people to kill themselves and others, but I will leave you with the idea that the science just doesn’t support that. Certainly, they aren’t for everyone, but clinically, I have seen medications do more good than harm in clinical practice overall.

I know nothing about Robin Williams beyond what I’ve read in the media, and I know that the media reports are often incomplete and distorted. I do imagine that Mr. Williams had the resources to get good care and that he may well have had treatment for depression since he was open about his struggle. His story will be used to say: "Get help," and if you’re feeling suicidal and aren’t getting help, please do so. If you’re feeling suicidal and "help" isn’t making you feel better, please consider getting a second opinion or a different kind of help.

The tragic thing about suicide is that it’s a permanent answer to what is often a temporary problem.

Sometimes, I imagine that there are people who have tried and tried to get help and that their pain remains so unbearable for so long that suicide offers them the only possible relief – if such a thing is even to be had given that we don’t what comes next and some religions will say that suicide leads to nowhere good. Even if it provides relief to the person involved, it comes with the cost of leaving those who remain in horrible pain. Sadly, depressed people sometimes imagine that the world will be better off without them, and often that idea is just not true.

I hope that Robin Williams is in a better place, for his sake. I hope that before he ended his life, he tried every possible treatment option, and that this wasn’t an impulsive decision, or one based on an episodic relapse of either depression or substance abuse – a relapse that may have resolved and let him live for decades more. I hope his wife and children and all the people who knew and loved him will eventually find some peace. His death, however, is not simply a personal one because he touched us all with his talent and his charisma. What a tragic loss.

Dr. Miller also posted a version http://bit.ly/1kyO1a7 of this piece on the Shrink Rap News website. She is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

The news has been filled lately with stories of violence within correctional facilities, often involving prisoners or detainees who are alleged to have mental illness. The California prison system recently announced an initiative to reduce the use of force against mentally ill prisoners and to require correctional officers to consider an inmate’s mental health status prior to any use of force.

This is an excellent initiative, and close collaboration between security and mental health services is crucial for effective treatment of some mentally ill offenders.

However, this would be a good time to remember that not all seriously mentally ill prisoners are disruptive and that violence is a behavior rather than a diagnostic criterion. The nonsymptomatic causes of violence are important to consider as well: Is the inmate defending himself from attack by more aggressive peers? Is he taking a stand and making a display of force in order to make the point that he won’t be intimidated? Is he delirious from an unrecognized or treated medical condition? Is he having a seizure, suffering from withdrawal, or medically compromised in some other way? Or is the violence instrumental, a means to an end by a sociopathic inmate who needs to enforce his chain of command or protect his prison drug distribution channels? While for some, violence may be an outward sign of psychosis, for others it’s part of the cost of doing business.

In addition to looking at violence on an individual level, we also need to consider it from an institutional perspective. Violence may be a sign that there are serious problems not only on an individual level but possibly on an institutional one as well. Increased sensitivity to the mental status of the prisoner is only one piece of the puzzle.

Correctional officers are exposed to an environment unlike anything most civilians can imagine. They are exposed daily to threats, actual or implied assault, harassment, and sometimes even flying bodily fluids. When the prison budget doesn’t keep up with the daily institutional census, they may be required to work repeated overtime shifts or to work on tiers in which they are greatly outnumbered by the prisoners they are supposed to supervise and protect. Even when a correctional officer is not directly the subject of violence, the officer is required to respond to traumatic events like inmate-on-inmate assaults or completed suicides.

It’s not surprising, then, that many new officers leave the profession within the first 5 years, and that those who stay longer may be prone to stress-related absenteeism, substance abuse, and depression. Officers (or "guards" as the traditional media repeatedly misidentifies them) who show a change in personality or an unusually low tolerance for inmate misbehavior may be showing early signs of posttraumatic stress disorder or clinical depression. If this is being taken out on an inmate, it may also be a problem at home, leading to relationship problems or domestic violence. Officers who are cruel to a prisoner may not be particularly pleasant to civilian staff, either.

Changing a violent prison environment requires more than additional staff training and another redundant prison directive about the use of force. It requires change in a prison culture that values toughness and bravado. Access to mental health should be rapid and confidential, and not seen as an indication that an officer wants an "easy way out" through medical retirement. Security and psychiatry must work together for the care of the prisoner, but they also need to work on behalf of one another.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health & Mental Hygiene or the Maryland State Division of Correction.

The news has been filled lately with stories of violence within correctional facilities, often involving prisoners or detainees who are alleged to have mental illness. The California prison system recently announced an initiative to reduce the use of force against mentally ill prisoners and to require correctional officers to consider an inmate’s mental health status prior to any use of force.

This is an excellent initiative, and close collaboration between security and mental health services is crucial for effective treatment of some mentally ill offenders.

However, this would be a good time to remember that not all seriously mentally ill prisoners are disruptive and that violence is a behavior rather than a diagnostic criterion. The nonsymptomatic causes of violence are important to consider as well: Is the inmate defending himself from attack by more aggressive peers? Is he taking a stand and making a display of force in order to make the point that he won’t be intimidated? Is he delirious from an unrecognized or treated medical condition? Is he having a seizure, suffering from withdrawal, or medically compromised in some other way? Or is the violence instrumental, a means to an end by a sociopathic inmate who needs to enforce his chain of command or protect his prison drug distribution channels? While for some, violence may be an outward sign of psychosis, for others it’s part of the cost of doing business.

In addition to looking at violence on an individual level, we also need to consider it from an institutional perspective. Violence may be a sign that there are serious problems not only on an individual level but possibly on an institutional one as well. Increased sensitivity to the mental status of the prisoner is only one piece of the puzzle.

Correctional officers are exposed to an environment unlike anything most civilians can imagine. They are exposed daily to threats, actual or implied assault, harassment, and sometimes even flying bodily fluids. When the prison budget doesn’t keep up with the daily institutional census, they may be required to work repeated overtime shifts or to work on tiers in which they are greatly outnumbered by the prisoners they are supposed to supervise and protect. Even when a correctional officer is not directly the subject of violence, the officer is required to respond to traumatic events like inmate-on-inmate assaults or completed suicides.

It’s not surprising, then, that many new officers leave the profession within the first 5 years, and that those who stay longer may be prone to stress-related absenteeism, substance abuse, and depression. Officers (or "guards" as the traditional media repeatedly misidentifies them) who show a change in personality or an unusually low tolerance for inmate misbehavior may be showing early signs of posttraumatic stress disorder or clinical depression. If this is being taken out on an inmate, it may also be a problem at home, leading to relationship problems or domestic violence. Officers who are cruel to a prisoner may not be particularly pleasant to civilian staff, either.

Changing a violent prison environment requires more than additional staff training and another redundant prison directive about the use of force. It requires change in a prison culture that values toughness and bravado. Access to mental health should be rapid and confidential, and not seen as an indication that an officer wants an "easy way out" through medical retirement. Security and psychiatry must work together for the care of the prisoner, but they also need to work on behalf of one another.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health & Mental Hygiene or the Maryland State Division of Correction.

The news has been filled lately with stories of violence within correctional facilities, often involving prisoners or detainees who are alleged to have mental illness. The California prison system recently announced an initiative to reduce the use of force against mentally ill prisoners and to require correctional officers to consider an inmate’s mental health status prior to any use of force.

This is an excellent initiative, and close collaboration between security and mental health services is crucial for effective treatment of some mentally ill offenders.

However, this would be a good time to remember that not all seriously mentally ill prisoners are disruptive and that violence is a behavior rather than a diagnostic criterion. The nonsymptomatic causes of violence are important to consider as well: Is the inmate defending himself from attack by more aggressive peers? Is he taking a stand and making a display of force in order to make the point that he won’t be intimidated? Is he delirious from an unrecognized or treated medical condition? Is he having a seizure, suffering from withdrawal, or medically compromised in some other way? Or is the violence instrumental, a means to an end by a sociopathic inmate who needs to enforce his chain of command or protect his prison drug distribution channels? While for some, violence may be an outward sign of psychosis, for others it’s part of the cost of doing business.

In addition to looking at violence on an individual level, we also need to consider it from an institutional perspective. Violence may be a sign that there are serious problems not only on an individual level but possibly on an institutional one as well. Increased sensitivity to the mental status of the prisoner is only one piece of the puzzle.

Correctional officers are exposed to an environment unlike anything most civilians can imagine. They are exposed daily to threats, actual or implied assault, harassment, and sometimes even flying bodily fluids. When the prison budget doesn’t keep up with the daily institutional census, they may be required to work repeated overtime shifts or to work on tiers in which they are greatly outnumbered by the prisoners they are supposed to supervise and protect. Even when a correctional officer is not directly the subject of violence, the officer is required to respond to traumatic events like inmate-on-inmate assaults or completed suicides.

It’s not surprising, then, that many new officers leave the profession within the first 5 years, and that those who stay longer may be prone to stress-related absenteeism, substance abuse, and depression. Officers (or "guards" as the traditional media repeatedly misidentifies them) who show a change in personality or an unusually low tolerance for inmate misbehavior may be showing early signs of posttraumatic stress disorder or clinical depression. If this is being taken out on an inmate, it may also be a problem at home, leading to relationship problems or domestic violence. Officers who are cruel to a prisoner may not be particularly pleasant to civilian staff, either.

Changing a violent prison environment requires more than additional staff training and another redundant prison directive about the use of force. It requires change in a prison culture that values toughness and bravado. Access to mental health should be rapid and confidential, and not seen as an indication that an officer wants an "easy way out" through medical retirement. Security and psychiatry must work together for the care of the prisoner, but they also need to work on behalf of one another.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health & Mental Hygiene or the Maryland State Division of Correction.

A Clinical Psychiatry News reader wrote in recently to object to the use of the term "shrink" in our column name. The writer noted, "We spend a lot of time trying to destigmatize the field, then use terms like this among ourselves. It’s odd and offensive." The feedback made me pause and wonder to myself if the term "shrink" is, in fact, stigmatizing.

Let me first give a little history of the decision to name our column "Shrink Rap News." In 2006, I was sitting at the kitchen table and decided I wanted a blog. I didn’t know what a blog actually was, but I wanted one. I went to blogger.com to set up a free website and was asked what I’d like to call my blog. On an impulse, I titled it "Shrink Rap." There was no debate or consideration, and no consultation. I liked the play on words with "shrink wrap," which is used for food storage, and I liked the connotation of psychiatrists talking, or "rapping." In a matter of hours, my impulsive thought was turned into the Shrink Rap blog.

Over the next few days, I invited Dr. Steve Daviss and Dr. Annette Hanson to join me in this venture, and Shrink Rap has continued to publish regular blog posts for 8.5 years now. Steve initially balked at the use of "shrink," but when he went to start our podcast, he titled it "My Three Shrinks" and modified the logo from an old television show, "My Three Sons." When we went to title our book, I wanted to call it "Off the Couch," but I was told that there was no room for couches anywhere. After many months of lively debate, we ended up in a restaurant with our editor and a whiteboard, and by the end of the evening we were back at Shrink Rap for a title for the book.

When Clinical Psychiatry News and Psychology Today approached us to write for their sites, we decided to remain with an image that was working for us, and used Shrink Rap News and Shrink Rap Today for column titles. Because the term may imply something less than a serious look at psychiatric issues, the umbrella name for all our endeavors is The Accessible Psychiatry Project.

So, is the term "shrink" actually stigmatizing? When I think of words as being part of stigma, I think of racial and religious slurs, and those induce a visceral response of disgust in me. For whatever reason, I personally don’t have a clear negative association to the term "shrink" or even "headshrinker." To me, it evokes something lighthearted and includes having a sense of humor about the field. I imagine if psychiatrists ever had actually shrunken heads, I might feel differently. Others may well have another response to the term, but the emotional link to something negative is just not there for me.

From a site called World Wide Words – Investigating the English Language Across the Globe, which is devoted to linguistics and run by a British etymologist, I found the following history of the term "headshrinker":

The original meaning of the term head-shrinker was in reference to a member of a group in Amazonia, the Jivaro, who preserved the heads of their enemies by stripping the skin from the skull, which resulted in a shrunken mummified remnant the size of a fist. The term isn’t that old – it’s first recorded from 1926.

All the early evidence suggests that the person who invented the psychiatrist sense worked in the movies (no jokes please). We have to assume that the term came about because people regarded the process of psychiatry as being like head-shrinking because it reduced the size of the swollen egos so common in show business. Or perhaps they were suspicious about what psychiatrists actually did to their heads and how they did it and so made a joke to relieve the tension.

The earliest example we have is from an article in Time in November 1950 to which an editor has helpfully added a footnote to say that head-shrinker was Hollywood jargon for a psychiatrist. The term afterward became moderately popular, in part because it was used in the film Rebel Without a Cause in 1955. Robert Heinlein felt his readers needed it to be explained when he introduced it in "Time for the Stars" in 1956: " ‘Dr. Devereaux is the boss head-shrinker.’ I looked puzzled and Uncle Steve went on, ‘You don’t savvy? Psychiatrist.’ " By the time it turns up in West Side Story on Broadway in 1957, it was becoming established.

Shrink, the abbreviation, became popular in the United States in the 1970s, though it had first appeared in one of Thomas Pynchon’s books, "The Crying of Lot 49," in 1965, and there is anecdotal evidence that it was around earlier, which is only to be expected of a slang term that would have been mainly transmitted through the spoken word in its earliest days.

The issue of stigma in mental health has gotten a lot of attention as being one reason that people who have difficulties may not seek help. Certainly, words can be powerful, but I wonder if the term "shrink" might actually be easier for patients to use? "I’m going to see my shrink," might imply a visit with any number of mental health professionals and might disassociate it from the implication that the patient is going to see a psychiatrist for treatment of a mental illness, a condition that the media is all too happy to tell us causes people to commit mass murders.

"Shrink" may have a disparaging tone to it, or it may have a ring of affection, depending on the context. Certainly, there are many negative associations and jokes related to being an attorney, and one friend told me that his son was "going to the dark side" when the son applied to law school. Still, there is no stigma associated with having an appointment with one’s lawyer, leading me to believe that a profession can be stigmatized without stigmatizing the clientele.

Some words have taken on a pervasively negative meaning; others are harder to capture. After 8 years, Shrink Rap is now a platform for our writing, invested with its own meanings to us and our readers. The psychiatrist who wrote in to say it is offensive, odd, and stigmatizing certainly has a different set of associations to the word then we do, or we would never have let this be a title for our work.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A Clinical Psychiatry News reader wrote in recently to object to the use of the term "shrink" in our column name. The writer noted, "We spend a lot of time trying to destigmatize the field, then use terms like this among ourselves. It’s odd and offensive." The feedback made me pause and wonder to myself if the term "shrink" is, in fact, stigmatizing.

Let me first give a little history of the decision to name our column "Shrink Rap News." In 2006, I was sitting at the kitchen table and decided I wanted a blog. I didn’t know what a blog actually was, but I wanted one. I went to blogger.com to set up a free website and was asked what I’d like to call my blog. On an impulse, I titled it "Shrink Rap." There was no debate or consideration, and no consultation. I liked the play on words with "shrink wrap," which is used for food storage, and I liked the connotation of psychiatrists talking, or "rapping." In a matter of hours, my impulsive thought was turned into the Shrink Rap blog.

Over the next few days, I invited Dr. Steve Daviss and Dr. Annette Hanson to join me in this venture, and Shrink Rap has continued to publish regular blog posts for 8.5 years now. Steve initially balked at the use of "shrink," but when he went to start our podcast, he titled it "My Three Shrinks" and modified the logo from an old television show, "My Three Sons." When we went to title our book, I wanted to call it "Off the Couch," but I was told that there was no room for couches anywhere. After many months of lively debate, we ended up in a restaurant with our editor and a whiteboard, and by the end of the evening we were back at Shrink Rap for a title for the book.

When Clinical Psychiatry News and Psychology Today approached us to write for their sites, we decided to remain with an image that was working for us, and used Shrink Rap News and Shrink Rap Today for column titles. Because the term may imply something less than a serious look at psychiatric issues, the umbrella name for all our endeavors is The Accessible Psychiatry Project.

So, is the term "shrink" actually stigmatizing? When I think of words as being part of stigma, I think of racial and religious slurs, and those induce a visceral response of disgust in me. For whatever reason, I personally don’t have a clear negative association to the term "shrink" or even "headshrinker." To me, it evokes something lighthearted and includes having a sense of humor about the field. I imagine if psychiatrists ever had actually shrunken heads, I might feel differently. Others may well have another response to the term, but the emotional link to something negative is just not there for me.

From a site called World Wide Words – Investigating the English Language Across the Globe, which is devoted to linguistics and run by a British etymologist, I found the following history of the term "headshrinker":

The original meaning of the term head-shrinker was in reference to a member of a group in Amazonia, the Jivaro, who preserved the heads of their enemies by stripping the skin from the skull, which resulted in a shrunken mummified remnant the size of a fist. The term isn’t that old – it’s first recorded from 1926.

All the early evidence suggests that the person who invented the psychiatrist sense worked in the movies (no jokes please). We have to assume that the term came about because people regarded the process of psychiatry as being like head-shrinking because it reduced the size of the swollen egos so common in show business. Or perhaps they were suspicious about what psychiatrists actually did to their heads and how they did it and so made a joke to relieve the tension.

The earliest example we have is from an article in Time in November 1950 to which an editor has helpfully added a footnote to say that head-shrinker was Hollywood jargon for a psychiatrist. The term afterward became moderately popular, in part because it was used in the film Rebel Without a Cause in 1955. Robert Heinlein felt his readers needed it to be explained when he introduced it in "Time for the Stars" in 1956: " ‘Dr. Devereaux is the boss head-shrinker.’ I looked puzzled and Uncle Steve went on, ‘You don’t savvy? Psychiatrist.’ " By the time it turns up in West Side Story on Broadway in 1957, it was becoming established.

Shrink, the abbreviation, became popular in the United States in the 1970s, though it had first appeared in one of Thomas Pynchon’s books, "The Crying of Lot 49," in 1965, and there is anecdotal evidence that it was around earlier, which is only to be expected of a slang term that would have been mainly transmitted through the spoken word in its earliest days.

The issue of stigma in mental health has gotten a lot of attention as being one reason that people who have difficulties may not seek help. Certainly, words can be powerful, but I wonder if the term "shrink" might actually be easier for patients to use? "I’m going to see my shrink," might imply a visit with any number of mental health professionals and might disassociate it from the implication that the patient is going to see a psychiatrist for treatment of a mental illness, a condition that the media is all too happy to tell us causes people to commit mass murders.

"Shrink" may have a disparaging tone to it, or it may have a ring of affection, depending on the context. Certainly, there are many negative associations and jokes related to being an attorney, and one friend told me that his son was "going to the dark side" when the son applied to law school. Still, there is no stigma associated with having an appointment with one’s lawyer, leading me to believe that a profession can be stigmatized without stigmatizing the clientele.

Some words have taken on a pervasively negative meaning; others are harder to capture. After 8 years, Shrink Rap is now a platform for our writing, invested with its own meanings to us and our readers. The psychiatrist who wrote in to say it is offensive, odd, and stigmatizing certainly has a different set of associations to the word then we do, or we would never have let this be a title for our work.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A Clinical Psychiatry News reader wrote in recently to object to the use of the term "shrink" in our column name. The writer noted, "We spend a lot of time trying to destigmatize the field, then use terms like this among ourselves. It’s odd and offensive." The feedback made me pause and wonder to myself if the term "shrink" is, in fact, stigmatizing.

Let me first give a little history of the decision to name our column "Shrink Rap News." In 2006, I was sitting at the kitchen table and decided I wanted a blog. I didn’t know what a blog actually was, but I wanted one. I went to blogger.com to set up a free website and was asked what I’d like to call my blog. On an impulse, I titled it "Shrink Rap." There was no debate or consideration, and no consultation. I liked the play on words with "shrink wrap," which is used for food storage, and I liked the connotation of psychiatrists talking, or "rapping." In a matter of hours, my impulsive thought was turned into the Shrink Rap blog.

Over the next few days, I invited Dr. Steve Daviss and Dr. Annette Hanson to join me in this venture, and Shrink Rap has continued to publish regular blog posts for 8.5 years now. Steve initially balked at the use of "shrink," but when he went to start our podcast, he titled it "My Three Shrinks" and modified the logo from an old television show, "My Three Sons." When we went to title our book, I wanted to call it "Off the Couch," but I was told that there was no room for couches anywhere. After many months of lively debate, we ended up in a restaurant with our editor and a whiteboard, and by the end of the evening we were back at Shrink Rap for a title for the book.

When Clinical Psychiatry News and Psychology Today approached us to write for their sites, we decided to remain with an image that was working for us, and used Shrink Rap News and Shrink Rap Today for column titles. Because the term may imply something less than a serious look at psychiatric issues, the umbrella name for all our endeavors is The Accessible Psychiatry Project.

So, is the term "shrink" actually stigmatizing? When I think of words as being part of stigma, I think of racial and religious slurs, and those induce a visceral response of disgust in me. For whatever reason, I personally don’t have a clear negative association to the term "shrink" or even "headshrinker." To me, it evokes something lighthearted and includes having a sense of humor about the field. I imagine if psychiatrists ever had actually shrunken heads, I might feel differently. Others may well have another response to the term, but the emotional link to something negative is just not there for me.

From a site called World Wide Words – Investigating the English Language Across the Globe, which is devoted to linguistics and run by a British etymologist, I found the following history of the term "headshrinker":

The original meaning of the term head-shrinker was in reference to a member of a group in Amazonia, the Jivaro, who preserved the heads of their enemies by stripping the skin from the skull, which resulted in a shrunken mummified remnant the size of a fist. The term isn’t that old – it’s first recorded from 1926.

All the early evidence suggests that the person who invented the psychiatrist sense worked in the movies (no jokes please). We have to assume that the term came about because people regarded the process of psychiatry as being like head-shrinking because it reduced the size of the swollen egos so common in show business. Or perhaps they were suspicious about what psychiatrists actually did to their heads and how they did it and so made a joke to relieve the tension.

The earliest example we have is from an article in Time in November 1950 to which an editor has helpfully added a footnote to say that head-shrinker was Hollywood jargon for a psychiatrist. The term afterward became moderately popular, in part because it was used in the film Rebel Without a Cause in 1955. Robert Heinlein felt his readers needed it to be explained when he introduced it in "Time for the Stars" in 1956: " ‘Dr. Devereaux is the boss head-shrinker.’ I looked puzzled and Uncle Steve went on, ‘You don’t savvy? Psychiatrist.’ " By the time it turns up in West Side Story on Broadway in 1957, it was becoming established.

Shrink, the abbreviation, became popular in the United States in the 1970s, though it had first appeared in one of Thomas Pynchon’s books, "The Crying of Lot 49," in 1965, and there is anecdotal evidence that it was around earlier, which is only to be expected of a slang term that would have been mainly transmitted through the spoken word in its earliest days.

The issue of stigma in mental health has gotten a lot of attention as being one reason that people who have difficulties may not seek help. Certainly, words can be powerful, but I wonder if the term "shrink" might actually be easier for patients to use? "I’m going to see my shrink," might imply a visit with any number of mental health professionals and might disassociate it from the implication that the patient is going to see a psychiatrist for treatment of a mental illness, a condition that the media is all too happy to tell us causes people to commit mass murders.

"Shrink" may have a disparaging tone to it, or it may have a ring of affection, depending on the context. Certainly, there are many negative associations and jokes related to being an attorney, and one friend told me that his son was "going to the dark side" when the son applied to law school. Still, there is no stigma associated with having an appointment with one’s lawyer, leading me to believe that a profession can be stigmatized without stigmatizing the clientele.

Some words have taken on a pervasively negative meaning; others are harder to capture. After 8 years, Shrink Rap is now a platform for our writing, invested with its own meanings to us and our readers. The psychiatrist who wrote in to say it is offensive, odd, and stigmatizing certainly has a different set of associations to the word then we do, or we would never have let this be a title for our work.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Under British common law, suicide was a felony if committed by a person "in the years of discretion," in other words, by an adult, who was "of sound mind." An adult who killed himself while insane was not considered a criminal. While the offender obviously could not be punished, he also could not be buried in hallowed ground, and all of his property was seized by the crown. Surviving family members were not allowed to inherit.

While no state defines suicide itself as a crime by statute, there are still common law and statutory prohibitions against aiding or abetting, or encouraging, a suicide. Laws surrounding assisted suicide might seem remote or irrelevant now, but clinicians should be aware that this is changing on an almost monthly basis, and impetus is building through the support of various advocacy groups, such as Compassion & Choices, Final Exit Network,and the Euthanasia Research and Guidance Organization (ERGO).

My own interest in this topic was spurred when a recent Maryland gubernatorial candidate ran on a platform that included a plan to introduce legislation to allow physician-assisted suicide. Presently, our state defines assisted suicide as a felony offense punishable by 1 year of incarceration and a $10,000 fine, and there have been two criminal prosecutions for assisted suicide in recent years.

Nationally, 39 states have prohibitions against assisted suicide defined either by specific statute or contained within the definition of manslaughter. Some states ban assisted suicide by case law, some through the adoption of common law. Presently, five states allow physician-assisted suicide. Oregon, Washington, and Montana were among the first states to allow this. New Mexico and Vermont adopted legislation this year in January and May, respectively.

Most states have modeled their laws after the original physician-assisted suicide law, Oregon’s Death With Dignity Act. For psychiatrists involved in legislative affairs, familiarity with this law is essential.

Under the Death With Dignity Act, a person might be eligible to request physician aid in dying if he is an adult resident of the state, is able to make and communicate medical decisions, and has a 6-month prognosis as medically confirmed by two physicians. The patient must make an initial oral and written request, then repeat the oral request no sooner than 15 days later. The written request must be submitted on a state-mandated form witnessed by two people who can neither be blood relatives nor estate benefactors.

There is a requirement for informed consent, specifically that the person must know his medical diagnosis as well as the risk of taking the life-ending medication and the expected result of this act. There must be documented consideration of alternatives to suicide.

While there is a statutory mandate to refer patients for counseling if depression is suspected, there is no requirement that the patient seeking suicide be screened for this disorder or even have a capacity assessment performed by a psychiatrist.

Out of curiosity, I copied the text of the physician-assisted suicide request form through two text analyzing applications to determine the readability of the document. My two tests revealed that the form required between a 12th grade to college-level reading comprehension level. For comparison purposes, my average prison clinic patient has a 9th-grade education with a 6th-grade reading level.

The most easily understood sentence in the entire document was the instruction at the bottom of the form: "PLEASE MAKE A COPY OF THIS FORM TO KEEP IN YOUR HOME."

This makes sense when you consider the demographics of those who seek physician-assisted suicide in Oregon. Most were white, college educated, over age 65 years, and suffered from cancer or chronic respiratory disease. Since the law was passed, 752 out of 1,173 people, or 64% of those given prescriptions, ended their lives. Only 2 of the 71 people who died in 2013 were referred for psychiatric or psychological evaluation. Most died of suicide within the year; however, some died the following year.

Without discussing the merits and controversy of physician-assisted suicide per se, we can at least identify some obvious weaknesses in copy-and-paste legislation between states. A law that appears tailored for an educated majority culture, which accepts capacity at face value despite clearly concerning circumstances, would at least require substantial revision for a region with high rates of illiteracy or mental illness.

Other questions also are looming on the horizon: Should qualifying conditions be limited to medical conditions only? Could an advance directive include an option to request assisted suicide proactively, prior to a 6-month prognosis, or could it be requested through a designated proxy? If a patient has both a psychiatric disorder and a terminal medical condition, should laws for involuntary psychiatric care still apply?

Dr. Lawrence Egbert, retired anesthesiologist and former medical director of Final Exit Network, foretold these questions in a Washington Post interview in which he stated he "is also willing, in extreme cases, he says, to serve as an ‘exit guide’ for patients who have suffered from depression for extended periods of time."

Only time will tell how these issues play out, but with some background on the topic our profession can at least begin the discussion.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Under British common law, suicide was a felony if committed by a person "in the years of discretion," in other words, by an adult, who was "of sound mind." An adult who killed himself while insane was not considered a criminal. While the offender obviously could not be punished, he also could not be buried in hallowed ground, and all of his property was seized by the crown. Surviving family members were not allowed to inherit.

While no state defines suicide itself as a crime by statute, there are still common law and statutory prohibitions against aiding or abetting, or encouraging, a suicide. Laws surrounding assisted suicide might seem remote or irrelevant now, but clinicians should be aware that this is changing on an almost monthly basis, and impetus is building through the support of various advocacy groups, such as Compassion & Choices, Final Exit Network,and the Euthanasia Research and Guidance Organization (ERGO).

My own interest in this topic was spurred when a recent Maryland gubernatorial candidate ran on a platform that included a plan to introduce legislation to allow physician-assisted suicide. Presently, our state defines assisted suicide as a felony offense punishable by 1 year of incarceration and a $10,000 fine, and there have been two criminal prosecutions for assisted suicide in recent years.

Nationally, 39 states have prohibitions against assisted suicide defined either by specific statute or contained within the definition of manslaughter. Some states ban assisted suicide by case law, some through the adoption of common law. Presently, five states allow physician-assisted suicide. Oregon, Washington, and Montana were among the first states to allow this. New Mexico and Vermont adopted legislation this year in January and May, respectively.

Most states have modeled their laws after the original physician-assisted suicide law, Oregon’s Death With Dignity Act. For psychiatrists involved in legislative affairs, familiarity with this law is essential.

Under the Death With Dignity Act, a person might be eligible to request physician aid in dying if he is an adult resident of the state, is able to make and communicate medical decisions, and has a 6-month prognosis as medically confirmed by two physicians. The patient must make an initial oral and written request, then repeat the oral request no sooner than 15 days later. The written request must be submitted on a state-mandated form witnessed by two people who can neither be blood relatives nor estate benefactors.

There is a requirement for informed consent, specifically that the person must know his medical diagnosis as well as the risk of taking the life-ending medication and the expected result of this act. There must be documented consideration of alternatives to suicide.

While there is a statutory mandate to refer patients for counseling if depression is suspected, there is no requirement that the patient seeking suicide be screened for this disorder or even have a capacity assessment performed by a psychiatrist.

Out of curiosity, I copied the text of the physician-assisted suicide request form through two text analyzing applications to determine the readability of the document. My two tests revealed that the form required between a 12th grade to college-level reading comprehension level. For comparison purposes, my average prison clinic patient has a 9th-grade education with a 6th-grade reading level.

The most easily understood sentence in the entire document was the instruction at the bottom of the form: "PLEASE MAKE A COPY OF THIS FORM TO KEEP IN YOUR HOME."

This makes sense when you consider the demographics of those who seek physician-assisted suicide in Oregon. Most were white, college educated, over age 65 years, and suffered from cancer or chronic respiratory disease. Since the law was passed, 752 out of 1,173 people, or 64% of those given prescriptions, ended their lives. Only 2 of the 71 people who died in 2013 were referred for psychiatric or psychological evaluation. Most died of suicide within the year; however, some died the following year.

Without discussing the merits and controversy of physician-assisted suicide per se, we can at least identify some obvious weaknesses in copy-and-paste legislation between states. A law that appears tailored for an educated majority culture, which accepts capacity at face value despite clearly concerning circumstances, would at least require substantial revision for a region with high rates of illiteracy or mental illness.

Other questions also are looming on the horizon: Should qualifying conditions be limited to medical conditions only? Could an advance directive include an option to request assisted suicide proactively, prior to a 6-month prognosis, or could it be requested through a designated proxy? If a patient has both a psychiatric disorder and a terminal medical condition, should laws for involuntary psychiatric care still apply?

Dr. Lawrence Egbert, retired anesthesiologist and former medical director of Final Exit Network, foretold these questions in a Washington Post interview in which he stated he "is also willing, in extreme cases, he says, to serve as an ‘exit guide’ for patients who have suffered from depression for extended periods of time."

Only time will tell how these issues play out, but with some background on the topic our profession can at least begin the discussion.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Under British common law, suicide was a felony if committed by a person "in the years of discretion," in other words, by an adult, who was "of sound mind." An adult who killed himself while insane was not considered a criminal. While the offender obviously could not be punished, he also could not be buried in hallowed ground, and all of his property was seized by the crown. Surviving family members were not allowed to inherit.

While no state defines suicide itself as a crime by statute, there are still common law and statutory prohibitions against aiding or abetting, or encouraging, a suicide. Laws surrounding assisted suicide might seem remote or irrelevant now, but clinicians should be aware that this is changing on an almost monthly basis, and impetus is building through the support of various advocacy groups, such as Compassion & Choices, Final Exit Network,and the Euthanasia Research and Guidance Organization (ERGO).

My own interest in this topic was spurred when a recent Maryland gubernatorial candidate ran on a platform that included a plan to introduce legislation to allow physician-assisted suicide. Presently, our state defines assisted suicide as a felony offense punishable by 1 year of incarceration and a $10,000 fine, and there have been two criminal prosecutions for assisted suicide in recent years.

Nationally, 39 states have prohibitions against assisted suicide defined either by specific statute or contained within the definition of manslaughter. Some states ban assisted suicide by case law, some through the adoption of common law. Presently, five states allow physician-assisted suicide. Oregon, Washington, and Montana were among the first states to allow this. New Mexico and Vermont adopted legislation this year in January and May, respectively.

Most states have modeled their laws after the original physician-assisted suicide law, Oregon’s Death With Dignity Act. For psychiatrists involved in legislative affairs, familiarity with this law is essential.

Under the Death With Dignity Act, a person might be eligible to request physician aid in dying if he is an adult resident of the state, is able to make and communicate medical decisions, and has a 6-month prognosis as medically confirmed by two physicians. The patient must make an initial oral and written request, then repeat the oral request no sooner than 15 days later. The written request must be submitted on a state-mandated form witnessed by two people who can neither be blood relatives nor estate benefactors.

There is a requirement for informed consent, specifically that the person must know his medical diagnosis as well as the risk of taking the life-ending medication and the expected result of this act. There must be documented consideration of alternatives to suicide.

While there is a statutory mandate to refer patients for counseling if depression is suspected, there is no requirement that the patient seeking suicide be screened for this disorder or even have a capacity assessment performed by a psychiatrist.

Out of curiosity, I copied the text of the physician-assisted suicide request form through two text analyzing applications to determine the readability of the document. My two tests revealed that the form required between a 12th grade to college-level reading comprehension level. For comparison purposes, my average prison clinic patient has a 9th-grade education with a 6th-grade reading level.

The most easily understood sentence in the entire document was the instruction at the bottom of the form: "PLEASE MAKE A COPY OF THIS FORM TO KEEP IN YOUR HOME."

This makes sense when you consider the demographics of those who seek physician-assisted suicide in Oregon. Most were white, college educated, over age 65 years, and suffered from cancer or chronic respiratory disease. Since the law was passed, 752 out of 1,173 people, or 64% of those given prescriptions, ended their lives. Only 2 of the 71 people who died in 2013 were referred for psychiatric or psychological evaluation. Most died of suicide within the year; however, some died the following year.

Without discussing the merits and controversy of physician-assisted suicide per se, we can at least identify some obvious weaknesses in copy-and-paste legislation between states. A law that appears tailored for an educated majority culture, which accepts capacity at face value despite clearly concerning circumstances, would at least require substantial revision for a region with high rates of illiteracy or mental illness.

Other questions also are looming on the horizon: Should qualifying conditions be limited to medical conditions only? Could an advance directive include an option to request assisted suicide proactively, prior to a 6-month prognosis, or could it be requested through a designated proxy? If a patient has both a psychiatric disorder and a terminal medical condition, should laws for involuntary psychiatric care still apply?

Dr. Lawrence Egbert, retired anesthesiologist and former medical director of Final Exit Network, foretold these questions in a Washington Post interview in which he stated he "is also willing, in extreme cases, he says, to serve as an ‘exit guide’ for patients who have suffered from depression for extended periods of time."

Only time will tell how these issues play out, but with some background on the topic our profession can at least begin the discussion.

Dr. Hanson is a forensic psychiatrist and coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011). The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.

Recently, I put up a post on our main Shrink Rap blog titled, "Is it okay to shrink your sister in an emergency?" Given how difficult it can be to get an appointment with a psychiatrist, I wondered about the ethics of prescribing psychotropics to a distressed family member when other options are limited.

First, I created a fictional scenario. Sister Lucy was treated for panic disorder 5 years ago. She took a benzodiazepine for a few weeks, an SSRI for a year, and went to psychotherapy. Her symptoms resolved, and she was able to terminate treatment with the blessing of her psychiatrist. Last year, Lucy moved to a new state and, being generally healthy, she has not yet established relationships with primary care providers. So with no physician, in a new state, Lucy had a recurrence of her panic disorder. She was initially seen in an emergency department, given a small supply of Ativan (lorazepam), and instructions to see a psychiatrist.

Lucy called around, and the earliest appointment she could get was 6 weeks away. She tried a handful of psychiatrists, but she did not call every psychiatrist in town. Most of the ones she tried were not taking new patients, and the voice mail systems of each mental health group were time consuming and frustrating, some cut her off, and no one had any more immediate response than to go to the ED if it were an emergency, and Lucy had already done that. Her brother, a psychiatrist in another state, came to visit for the weekend, and he witnessed several of her panic attacks. He had no more luck finding a psychiatrist for her. Lucy visited an urgent care center, where she was restarted on the SSRI and given more of the Ativan. But at the drugstore, she noticed she was given a 2-week supply and this would not last until the scheduled appointment.

So I asked our blog readers if it was okay for the brother to write prescriptions to hold his sister over until her scheduled appointment. The other options would have been for her to continue to suffer, to see if she could find another form of treatment more quickly, to return to the urgent care center on a continual basis and hope they would provide more medication, or to find a new primary care doctor who could prescribe in the meantime. Lucy didn’t know if this would be any easier. The psychiatrist who saw her 5 years ago before she moved would not be comfortable resuming medications without seeing her, but just in case there was any doubt, he retired, moved to North Korea, and died in a freak accident where he was swept up by a street cleaner so that option was not on the table (fictional characters can lead interesting and tragic lives).

Readers wrote in with a variety of thoughts. One psychiatrist empathized; she had a very depressed relative, and she debated providing medication samples in the interim while the relative waited to get in with a mental health professional. Another psychiatrist had seen too many patients become addicted to prescription benzodiazepines and suggested that this might start a cycle where Sister Lucy would pester brother psychiatrist for more medication in the future. Most of the psychiatrists felt that if a reasonable effort were made to obtain care and the barriers were valid, then it was a tough situation, but ultimately they felt it was okay to resume medications that previously had worked and been tolerated, for a limited period of time, since Lucy was symptomatic and this constituted an emergency.

The patients who wrote in were less forgiving, overall. Several insisted it was easy enough to find a primary care doctor within days, and a primary care doctor would certainly prescribe the medications. I was told that all one has to do is call one’s insurance company, so, curious, I called mine and got two names. The first one had a message saying staff was not in on Wednesday and the caller should try back tomorrow. I didn’t. The second one instructed me to leave a message that would be returned within 24 hours. It wasn’t. I e-mailed my own primary care doctor to ask when the next new patient appointment was – this physician charges a practice fee (too low to be considered "concierge," but high enough to enable a lower caseload). The response I received is that the practice is full. I e-mailed a friend who is a wonderful primary care doctor but takes no health insurance and has opted out of Medicare, and he had an opening the following week. I, however, had insider knowledge that a random newcomer to town might not have, and the insurance companies would certainly not be referring urgent cases to this out-of-network doctor. And all this assumes that any doc will do; there is no allowance here for the idea of waiting for a psychiatrist or internist who might come highly recommended or have subspecialty training.

I was left to say that it wasn’t easy to find a psychiatrist or a primary care doctor on demand when one is new in town and in a state of emotional distress. Again, I was told otherwise! I learned about a service called ZocDoc.com where you can make a next day appointment with a physician, simply by giving your Zip code, insurance, and specialty desired. Interesting, as I do this all the time with an App called OpenTable to schedule reservations at restaurants. Why not doctors’ appointments?

So it was late, and I tried to schedule a next day appointment with a primary care doc. It worked! Only I didn’t really want the appointment; what I wanted was information to write my article for Clinical Psychiatry News this week. I dialed the doctor to cancel the appointment, and instead of getting an office machine, I got the actual doctor – and he even sounded like a nice guy. He couldn’t cancel my appointment, but I then realized that, like OpenTable, there was a button to push to cancel the appointment, and I did that. I looked for psychiatrists, and there weren’t many with next day appointments – perhaps one – nearby, but if I would drive 30 miles or so to the next major city, I could get an appointment very soon, and certainly within a couple of weeks. Interesting. I learned something new!

So I wondered about Sister Lucy, and I decided she lives in Boise, Idaho, a place I’ve never been to and whose availability of medical care I know nothing about. The ZocDoc site there is not active, and so poor Lucy is back to her original problem, and I am left to the original question: Should her brother prescribe her medications?

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

Recently, I put up a post on our main Shrink Rap blog titled, "Is it okay to shrink your sister in an emergency?" Given how difficult it can be to get an appointment with a psychiatrist, I wondered about the ethics of prescribing psychotropics to a distressed family member when other options are limited.

First, I created a fictional scenario. Sister Lucy was treated for panic disorder 5 years ago. She took a benzodiazepine for a few weeks, an SSRI for a year, and went to psychotherapy. Her symptoms resolved, and she was able to terminate treatment with the blessing of her psychiatrist. Last year, Lucy moved to a new state and, being generally healthy, she has not yet established relationships with primary care providers. So with no physician, in a new state, Lucy had a recurrence of her panic disorder. She was initially seen in an emergency department, given a small supply of Ativan (lorazepam), and instructions to see a psychiatrist.

Lucy called around, and the earliest appointment she could get was 6 weeks away. She tried a handful of psychiatrists, but she did not call every psychiatrist in town. Most of the ones she tried were not taking new patients, and the voice mail systems of each mental health group were time consuming and frustrating, some cut her off, and no one had any more immediate response than to go to the ED if it were an emergency, and Lucy had already done that. Her brother, a psychiatrist in another state, came to visit for the weekend, and he witnessed several of her panic attacks. He had no more luck finding a psychiatrist for her. Lucy visited an urgent care center, where she was restarted on the SSRI and given more of the Ativan. But at the drugstore, she noticed she was given a 2-week supply and this would not last until the scheduled appointment.

So I asked our blog readers if it was okay for the brother to write prescriptions to hold his sister over until her scheduled appointment. The other options would have been for her to continue to suffer, to see if she could find another form of treatment more quickly, to return to the urgent care center on a continual basis and hope they would provide more medication, or to find a new primary care doctor who could prescribe in the meantime. Lucy didn’t know if this would be any easier. The psychiatrist who saw her 5 years ago before she moved would not be comfortable resuming medications without seeing her, but just in case there was any doubt, he retired, moved to North Korea, and died in a freak accident where he was swept up by a street cleaner so that option was not on the table (fictional characters can lead interesting and tragic lives).

Readers wrote in with a variety of thoughts. One psychiatrist empathized; she had a very depressed relative, and she debated providing medication samples in the interim while the relative waited to get in with a mental health professional. Another psychiatrist had seen too many patients become addicted to prescription benzodiazepines and suggested that this might start a cycle where Sister Lucy would pester brother psychiatrist for more medication in the future. Most of the psychiatrists felt that if a reasonable effort were made to obtain care and the barriers were valid, then it was a tough situation, but ultimately they felt it was okay to resume medications that previously had worked and been tolerated, for a limited period of time, since Lucy was symptomatic and this constituted an emergency.

The patients who wrote in were less forgiving, overall. Several insisted it was easy enough to find a primary care doctor within days, and a primary care doctor would certainly prescribe the medications. I was told that all one has to do is call one’s insurance company, so, curious, I called mine and got two names. The first one had a message saying staff was not in on Wednesday and the caller should try back tomorrow. I didn’t. The second one instructed me to leave a message that would be returned within 24 hours. It wasn’t. I e-mailed my own primary care doctor to ask when the next new patient appointment was – this physician charges a practice fee (too low to be considered "concierge," but high enough to enable a lower caseload). The response I received is that the practice is full. I e-mailed a friend who is a wonderful primary care doctor but takes no health insurance and has opted out of Medicare, and he had an opening the following week. I, however, had insider knowledge that a random newcomer to town might not have, and the insurance companies would certainly not be referring urgent cases to this out-of-network doctor. And all this assumes that any doc will do; there is no allowance here for the idea of waiting for a psychiatrist or internist who might come highly recommended or have subspecialty training.

I was left to say that it wasn’t easy to find a psychiatrist or a primary care doctor on demand when one is new in town and in a state of emotional distress. Again, I was told otherwise! I learned about a service called ZocDoc.com where you can make a next day appointment with a physician, simply by giving your Zip code, insurance, and specialty desired. Interesting, as I do this all the time with an App called OpenTable to schedule reservations at restaurants. Why not doctors’ appointments?

So it was late, and I tried to schedule a next day appointment with a primary care doc. It worked! Only I didn’t really want the appointment; what I wanted was information to write my article for Clinical Psychiatry News this week. I dialed the doctor to cancel the appointment, and instead of getting an office machine, I got the actual doctor – and he even sounded like a nice guy. He couldn’t cancel my appointment, but I then realized that, like OpenTable, there was a button to push to cancel the appointment, and I did that. I looked for psychiatrists, and there weren’t many with next day appointments – perhaps one – nearby, but if I would drive 30 miles or so to the next major city, I could get an appointment very soon, and certainly within a couple of weeks. Interesting. I learned something new!

So I wondered about Sister Lucy, and I decided she lives in Boise, Idaho, a place I’ve never been to and whose availability of medical care I know nothing about. The ZocDoc site there is not active, and so poor Lucy is back to her original problem, and I am left to the original question: Should her brother prescribe her medications?

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

Recently, I put up a post on our main Shrink Rap blog titled, "Is it okay to shrink your sister in an emergency?" Given how difficult it can be to get an appointment with a psychiatrist, I wondered about the ethics of prescribing psychotropics to a distressed family member when other options are limited.

First, I created a fictional scenario. Sister Lucy was treated for panic disorder 5 years ago. She took a benzodiazepine for a few weeks, an SSRI for a year, and went to psychotherapy. Her symptoms resolved, and she was able to terminate treatment with the blessing of her psychiatrist. Last year, Lucy moved to a new state and, being generally healthy, she has not yet established relationships with primary care providers. So with no physician, in a new state, Lucy had a recurrence of her panic disorder. She was initially seen in an emergency department, given a small supply of Ativan (lorazepam), and instructions to see a psychiatrist.

Lucy called around, and the earliest appointment she could get was 6 weeks away. She tried a handful of psychiatrists, but she did not call every psychiatrist in town. Most of the ones she tried were not taking new patients, and the voice mail systems of each mental health group were time consuming and frustrating, some cut her off, and no one had any more immediate response than to go to the ED if it were an emergency, and Lucy had already done that. Her brother, a psychiatrist in another state, came to visit for the weekend, and he witnessed several of her panic attacks. He had no more luck finding a psychiatrist for her. Lucy visited an urgent care center, where she was restarted on the SSRI and given more of the Ativan. But at the drugstore, she noticed she was given a 2-week supply and this would not last until the scheduled appointment.

So I asked our blog readers if it was okay for the brother to write prescriptions to hold his sister over until her scheduled appointment. The other options would have been for her to continue to suffer, to see if she could find another form of treatment more quickly, to return to the urgent care center on a continual basis and hope they would provide more medication, or to find a new primary care doctor who could prescribe in the meantime. Lucy didn’t know if this would be any easier. The psychiatrist who saw her 5 years ago before she moved would not be comfortable resuming medications without seeing her, but just in case there was any doubt, he retired, moved to North Korea, and died in a freak accident where he was swept up by a street cleaner so that option was not on the table (fictional characters can lead interesting and tragic lives).

Readers wrote in with a variety of thoughts. One psychiatrist empathized; she had a very depressed relative, and she debated providing medication samples in the interim while the relative waited to get in with a mental health professional. Another psychiatrist had seen too many patients become addicted to prescription benzodiazepines and suggested that this might start a cycle where Sister Lucy would pester brother psychiatrist for more medication in the future. Most of the psychiatrists felt that if a reasonable effort were made to obtain care and the barriers were valid, then it was a tough situation, but ultimately they felt it was okay to resume medications that previously had worked and been tolerated, for a limited period of time, since Lucy was symptomatic and this constituted an emergency.

The patients who wrote in were less forgiving, overall. Several insisted it was easy enough to find a primary care doctor within days, and a primary care doctor would certainly prescribe the medications. I was told that all one has to do is call one’s insurance company, so, curious, I called mine and got two names. The first one had a message saying staff was not in on Wednesday and the caller should try back tomorrow. I didn’t. The second one instructed me to leave a message that would be returned within 24 hours. It wasn’t. I e-mailed my own primary care doctor to ask when the next new patient appointment was – this physician charges a practice fee (too low to be considered "concierge," but high enough to enable a lower caseload). The response I received is that the practice is full. I e-mailed a friend who is a wonderful primary care doctor but takes no health insurance and has opted out of Medicare, and he had an opening the following week. I, however, had insider knowledge that a random newcomer to town might not have, and the insurance companies would certainly not be referring urgent cases to this out-of-network doctor. And all this assumes that any doc will do; there is no allowance here for the idea of waiting for a psychiatrist or internist who might come highly recommended or have subspecialty training.

I was left to say that it wasn’t easy to find a psychiatrist or a primary care doctor on demand when one is new in town and in a state of emotional distress. Again, I was told otherwise! I learned about a service called ZocDoc.com where you can make a next day appointment with a physician, simply by giving your Zip code, insurance, and specialty desired. Interesting, as I do this all the time with an App called OpenTable to schedule reservations at restaurants. Why not doctors’ appointments?

So it was late, and I tried to schedule a next day appointment with a primary care doc. It worked! Only I didn’t really want the appointment; what I wanted was information to write my article for Clinical Psychiatry News this week. I dialed the doctor to cancel the appointment, and instead of getting an office machine, I got the actual doctor – and he even sounded like a nice guy. He couldn’t cancel my appointment, but I then realized that, like OpenTable, there was a button to push to cancel the appointment, and I did that. I looked for psychiatrists, and there weren’t many with next day appointments – perhaps one – nearby, but if I would drive 30 miles or so to the next major city, I could get an appointment very soon, and certainly within a couple of weeks. Interesting. I learned something new!

So I wondered about Sister Lucy, and I decided she lives in Boise, Idaho, a place I’ve never been to and whose availability of medical care I know nothing about. The ZocDoc site there is not active, and so poor Lucy is back to her original problem, and I am left to the original question: Should her brother prescribe her medications?

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).