Shrink Rap News

Nonforensic psychiatrists in private practice rarely expect to be dealing with patients involved in the correctional system, but unexpected things happen even with the most carefully chosen patients. I’m writing this column to offer guidance to clinicians facing this situation for the first time, based upon the most common questions I get asked.

The most common situation I hear about is that a patient has missed an appointment, and the clinician hears from a family member that the patient has been arrested. The conscientious doctor wants to make sure that his seriously mentally ill client doesn’t experience an interruption in treatment, and that an appointment will be ready after release. The first challenge is to locate the patient.

In small communities, or when a family member was present at the time of arrest, it’s relatively easy to figure out which detention center or jail the patient was taken to. If the patient was arrested in a large urban area, or even out of state, this can be more of a challenge. Fortunately, many states and even now some local county or city jurisdictions have inmate locator web pages. The website will provide search capabilities to identify anyone currently in custody, and will generally provide a unique booking or inmate number that should be used in any facility communication, along with a date of birth and the address of the facility. Be aware that a large jail with high turnover may not have real-time data capability, meaning that new arrests may not show up on the website for 24 hours.

For psychiatrists who spend a lot of time tracking down their patients in custody, there is even an iPhone- and Android-compatible app called MobilePatrol, which provides a convenient interface to many inmate locator databases nationwide. MobilePatrol does not provide information about charges or date of birth, so it’s mainly useful if the patient can be identified by age and has a unique name.

The next step is to ensure that the patient has been identified as needing psychiatric care within the facility. Almost all jails and prisons now have routine multilevel screens to identify arrestees with chronic medical or mental health needs, and to assess suicide risk at intake. This is required by any jail or prison accredited by the National Commission on Correctional Health Care. Nevertheless, some patients are reluctant to self-identify out of fear they might be inappropriately or precipitously thrown into a suicide observation cell.

When it comes to transmitting information to a correctional facility, don’t rely on custody staff. They aren’t clinicians, they change with every shift, and they won’t know what questions to ask about the patient. This includes the warden’s office. The best thing to do is call the psychology department to transmit the patient’s name, date of birth, jail or prison number, and any pertinent clinical information. Don’t rely on an administrative assistant or nonmedical therapist to do this for you – I can’t tell you the number of times I’ve gotten a message that "...John Doe is in your jail and he needs to be seen..." with absolutely no information about medication names, dosage, and frequency, or even a diagnosis! An initial phone call will ensure that the patient is found within the facility and scheduled to see the institutional psychiatrist.

Follow the phone call up with a letter. This will ensure that the clinical information is still available on the day the psychiatrist comes in, and for the next institutional physician if the patient is transferred to another facility. The letter should summarize pertinent symptoms, violence or suicide risk factors, and previous medication trials. The past med trial information is particularly important for correctional psychiatrists, given that many jails and prisons require "fail-first" prescribing policies. Outside documentation that supports a current nonformulary medication regimen can be crucial to ensuring a smooth transition of care. But please, resist the temptation to reprimand the correctional psychiatrist in advance for making a medication change – there are many valid clinical reasons for a correctional psychiatrist to alter a treatment regimen upon arrest that have nothing to do with formulary issues.

Finally, encourage the patient’s family members to maintain contact with their incarcerated loved one if that relationship is healthy and supportive. No one knows a patient better than those in his own household, and a family member can be particularly sensitive to early signs of relapse sometimes through nothing more than a patient’s tone of voice during a phone call. Give the primary caregivers contact information for the institutional psychology department and encourage them to call if they observe anything concerning during a visit or court appearance. Court dates are particularly stressful times and may serve as a crisis point for a suicidal inmate. Having an extra pair of eyes on the scene could be lifesaving.

Once the patient has been identified and referred, and treatment started, your job is done until release. For misdemeanor offenders in local detention, this could take place within days or a few weeks, or even the day of arrest if the patient is able to make bail. Following the steps I’ve recommended to ensure continuity of care will help your patient return to you in at least as good a condition as when he came in.

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.

Nonforensic psychiatrists in private practice rarely expect to be dealing with patients involved in the correctional system, but unexpected things happen even with the most carefully chosen patients. I’m writing this column to offer guidance to clinicians facing this situation for the first time, based upon the most common questions I get asked.

The most common situation I hear about is that a patient has missed an appointment, and the clinician hears from a family member that the patient has been arrested. The conscientious doctor wants to make sure that his seriously mentally ill client doesn’t experience an interruption in treatment, and that an appointment will be ready after release. The first challenge is to locate the patient.

In small communities, or when a family member was present at the time of arrest, it’s relatively easy to figure out which detention center or jail the patient was taken to. If the patient was arrested in a large urban area, or even out of state, this can be more of a challenge. Fortunately, many states and even now some local county or city jurisdictions have inmate locator web pages. The website will provide search capabilities to identify anyone currently in custody, and will generally provide a unique booking or inmate number that should be used in any facility communication, along with a date of birth and the address of the facility. Be aware that a large jail with high turnover may not have real-time data capability, meaning that new arrests may not show up on the website for 24 hours.

For psychiatrists who spend a lot of time tracking down their patients in custody, there is even an iPhone- and Android-compatible app called MobilePatrol, which provides a convenient interface to many inmate locator databases nationwide. MobilePatrol does not provide information about charges or date of birth, so it’s mainly useful if the patient can be identified by age and has a unique name.

The next step is to ensure that the patient has been identified as needing psychiatric care within the facility. Almost all jails and prisons now have routine multilevel screens to identify arrestees with chronic medical or mental health needs, and to assess suicide risk at intake. This is required by any jail or prison accredited by the National Commission on Correctional Health Care. Nevertheless, some patients are reluctant to self-identify out of fear they might be inappropriately or precipitously thrown into a suicide observation cell.

When it comes to transmitting information to a correctional facility, don’t rely on custody staff. They aren’t clinicians, they change with every shift, and they won’t know what questions to ask about the patient. This includes the warden’s office. The best thing to do is call the psychology department to transmit the patient’s name, date of birth, jail or prison number, and any pertinent clinical information. Don’t rely on an administrative assistant or nonmedical therapist to do this for you – I can’t tell you the number of times I’ve gotten a message that "...John Doe is in your jail and he needs to be seen..." with absolutely no information about medication names, dosage, and frequency, or even a diagnosis! An initial phone call will ensure that the patient is found within the facility and scheduled to see the institutional psychiatrist.

Follow the phone call up with a letter. This will ensure that the clinical information is still available on the day the psychiatrist comes in, and for the next institutional physician if the patient is transferred to another facility. The letter should summarize pertinent symptoms, violence or suicide risk factors, and previous medication trials. The past med trial information is particularly important for correctional psychiatrists, given that many jails and prisons require "fail-first" prescribing policies. Outside documentation that supports a current nonformulary medication regimen can be crucial to ensuring a smooth transition of care. But please, resist the temptation to reprimand the correctional psychiatrist in advance for making a medication change – there are many valid clinical reasons for a correctional psychiatrist to alter a treatment regimen upon arrest that have nothing to do with formulary issues.

Finally, encourage the patient’s family members to maintain contact with their incarcerated loved one if that relationship is healthy and supportive. No one knows a patient better than those in his own household, and a family member can be particularly sensitive to early signs of relapse sometimes through nothing more than a patient’s tone of voice during a phone call. Give the primary caregivers contact information for the institutional psychology department and encourage them to call if they observe anything concerning during a visit or court appearance. Court dates are particularly stressful times and may serve as a crisis point for a suicidal inmate. Having an extra pair of eyes on the scene could be lifesaving.

Once the patient has been identified and referred, and treatment started, your job is done until release. For misdemeanor offenders in local detention, this could take place within days or a few weeks, or even the day of arrest if the patient is able to make bail. Following the steps I’ve recommended to ensure continuity of care will help your patient return to you in at least as good a condition as when he came in.

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.

Nonforensic psychiatrists in private practice rarely expect to be dealing with patients involved in the correctional system, but unexpected things happen even with the most carefully chosen patients. I’m writing this column to offer guidance to clinicians facing this situation for the first time, based upon the most common questions I get asked.

The most common situation I hear about is that a patient has missed an appointment, and the clinician hears from a family member that the patient has been arrested. The conscientious doctor wants to make sure that his seriously mentally ill client doesn’t experience an interruption in treatment, and that an appointment will be ready after release. The first challenge is to locate the patient.

In small communities, or when a family member was present at the time of arrest, it’s relatively easy to figure out which detention center or jail the patient was taken to. If the patient was arrested in a large urban area, or even out of state, this can be more of a challenge. Fortunately, many states and even now some local county or city jurisdictions have inmate locator web pages. The website will provide search capabilities to identify anyone currently in custody, and will generally provide a unique booking or inmate number that should be used in any facility communication, along with a date of birth and the address of the facility. Be aware that a large jail with high turnover may not have real-time data capability, meaning that new arrests may not show up on the website for 24 hours.

For psychiatrists who spend a lot of time tracking down their patients in custody, there is even an iPhone- and Android-compatible app called MobilePatrol, which provides a convenient interface to many inmate locator databases nationwide. MobilePatrol does not provide information about charges or date of birth, so it’s mainly useful if the patient can be identified by age and has a unique name.

The next step is to ensure that the patient has been identified as needing psychiatric care within the facility. Almost all jails and prisons now have routine multilevel screens to identify arrestees with chronic medical or mental health needs, and to assess suicide risk at intake. This is required by any jail or prison accredited by the National Commission on Correctional Health Care. Nevertheless, some patients are reluctant to self-identify out of fear they might be inappropriately or precipitously thrown into a suicide observation cell.

When it comes to transmitting information to a correctional facility, don’t rely on custody staff. They aren’t clinicians, they change with every shift, and they won’t know what questions to ask about the patient. This includes the warden’s office. The best thing to do is call the psychology department to transmit the patient’s name, date of birth, jail or prison number, and any pertinent clinical information. Don’t rely on an administrative assistant or nonmedical therapist to do this for you – I can’t tell you the number of times I’ve gotten a message that "...John Doe is in your jail and he needs to be seen..." with absolutely no information about medication names, dosage, and frequency, or even a diagnosis! An initial phone call will ensure that the patient is found within the facility and scheduled to see the institutional psychiatrist.

Follow the phone call up with a letter. This will ensure that the clinical information is still available on the day the psychiatrist comes in, and for the next institutional physician if the patient is transferred to another facility. The letter should summarize pertinent symptoms, violence or suicide risk factors, and previous medication trials. The past med trial information is particularly important for correctional psychiatrists, given that many jails and prisons require "fail-first" prescribing policies. Outside documentation that supports a current nonformulary medication regimen can be crucial to ensuring a smooth transition of care. But please, resist the temptation to reprimand the correctional psychiatrist in advance for making a medication change – there are many valid clinical reasons for a correctional psychiatrist to alter a treatment regimen upon arrest that have nothing to do with formulary issues.

Finally, encourage the patient’s family members to maintain contact with their incarcerated loved one if that relationship is healthy and supportive. No one knows a patient better than those in his own household, and a family member can be particularly sensitive to early signs of relapse sometimes through nothing more than a patient’s tone of voice during a phone call. Give the primary caregivers contact information for the institutional psychology department and encourage them to call if they observe anything concerning during a visit or court appearance. Court dates are particularly stressful times and may serve as a crisis point for a suicidal inmate. Having an extra pair of eyes on the scene could be lifesaving.

Once the patient has been identified and referred, and treatment started, your job is done until release. For misdemeanor offenders in local detention, this could take place within days or a few weeks, or even the day of arrest if the patient is able to make bail. Following the steps I’ve recommended to ensure continuity of care will help your patient return to you in at least as good a condition as when he came in.

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.

When I was in high school, one of my friends told me he intended to kill another one of my friends. It was a different day and age back then, and with more than 4,000 students, my high school was rather large and impersonal – it was easy to get lost in the crowd.

"Juan" (not his real name) confided in me that he wanted to kill "Joe" (also not his real name), which I found a bit odd. Joe was well liked but not did really stand out. Juan was perhaps quieter and more studious, but he also did not stand out. Both boys had friends, did well in school, and were not obviously troubled. When I asked Juan why he wanted to kill Joe, he responded, "Because he’s the all-American boy."

I worried about this. I told my mother, and I told a teacher I trusted. No one knew what to do, and Juan’s plan did not sound feasible. He was going to bring a knife to school in a folder, and when Joe was walking in a crowded hallway, Juan would walk behind him and thrust out the folder to sent the knife flying. The physics of this just didn’t make sense to me, and I didn’t see how the knife would gain enough momentum to travel very far, much less penetrate a person through their clothes. Feasible, or not, however, the equation changed on a day that Juan and I were sitting together in the back row of Latin class. Juan opened his calculus book and showed me the butcher knife.

I excused myself from class, went to a pay phone, and called my mother. She called the school, the principal called the police, and Juan was quietly removed from school when the period ended. It would be hard to imagine that a teenager who plotted the murder of another student, by illogical means for an illogical reason, wasn’t emotionally disturbed. I don’t know what happens to someone like Juan in 2014 – I’m thinking nothing good – but let me tell you what happened to Juan in the late 1970s.

Juan was out of high school for 6 weeks. I heard he had psychological testing, but aside from that, I have no idea what transpired. One of his friends told me it was a joke. He returned to high school, never said another word to me, graduated, and attended an Ivy League university – one of several prestigious schools to which he gained admission. A Google search reveals that Juan later earned a graduate degree and works as an executive making a six-figure salary. (Isn’t Google great?) He’s an adjunct professor at a college where he gets glowing reviews on RateMyProfessors.com. He was elected to serve on a local government committee. He’s married and has children. Compliments of Facebook, I know that he continues to have contact with high school friends.

From what I can tell, Juan’s brief period of being a disturbed adolescent did not progress to a life defined by chronic mental illness, and he did not go on to become a violent felon. I have no idea if I did Juan a favor, prevented a murder, got him much-needed treatment, or simply added an embarrassing diversion to his life. I don’t know if he ever really would have harmed Joe, or if it was in fact a joke designed to yank my chain.

Apparently, my threshold is on the low side, and not long ago I called a friend late one night and insisted she check on her teenager when a Facebook post struck me as alarming and a bit too final. The response I got was, "They were lyrics from a song and you’re overreacting." So be it. I called the mother and not the National Guard, and if the teen had become a statistic, I would have regretted not reacting.

I did wonder, while writing this article, how it would be received if I were to contact Juan and ask his thoughts on those events decades ago. Somehow, it seemed best not to uncover old wounds.

The media talk about the dangerously mentally ill as though they are a separate breed of humans, ones who can be easily distinguished by simply assessing who stands on which side of a well-marked "us-versus-them" line. Human beings, especially young human beings, may go through phases, and they may struggle with controlling their emotions, behaviors, and impulses and with finding their identity at a time in life when fitting in has undue importance. Some of them, no doubt, have these crises in the throes of an acute episode of mental distress – illness, if you’d prefer – and others do so at the genesis of what will prove to be a chronic and persistent psychiatric disorder. It may not be clear at any given moment who is going through a phase, who is suffering from an acute episode of mental illness, and who is beginning their course of a severe and persistent disorder.

Still, there are those who want to neatly categorize those with "serious" mental illness so that we can focus more of our resources on their needs and not on those who they deem to be the "worried well." Juan, it appears, did not fall into that category of chronically or persistently mentally ill. Similarly, all of us know chaotic, misbehaving, and even suicidal teenagers who go on to live productive lives. Does that designation matter if those not-so-seriously (or not-so-obviously) mentally ill individuals kill someone or die during their brief moments of emotional turbulence?

It seems to me that the goal is to keep people safe and help usher them through difficult periods in their lives, regardless of any diagnostic certainty or severity. I would contend that the mentally healthy among us also are subject to impulsive, distressed, and dangerous moments and that the world does not always neatly divide people into proper categorical entities.

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

When I was in high school, one of my friends told me he intended to kill another one of my friends. It was a different day and age back then, and with more than 4,000 students, my high school was rather large and impersonal – it was easy to get lost in the crowd.

"Juan" (not his real name) confided in me that he wanted to kill "Joe" (also not his real name), which I found a bit odd. Joe was well liked but not did really stand out. Juan was perhaps quieter and more studious, but he also did not stand out. Both boys had friends, did well in school, and were not obviously troubled. When I asked Juan why he wanted to kill Joe, he responded, "Because he’s the all-American boy."

I worried about this. I told my mother, and I told a teacher I trusted. No one knew what to do, and Juan’s plan did not sound feasible. He was going to bring a knife to school in a folder, and when Joe was walking in a crowded hallway, Juan would walk behind him and thrust out the folder to sent the knife flying. The physics of this just didn’t make sense to me, and I didn’t see how the knife would gain enough momentum to travel very far, much less penetrate a person through their clothes. Feasible, or not, however, the equation changed on a day that Juan and I were sitting together in the back row of Latin class. Juan opened his calculus book and showed me the butcher knife.

I excused myself from class, went to a pay phone, and called my mother. She called the school, the principal called the police, and Juan was quietly removed from school when the period ended. It would be hard to imagine that a teenager who plotted the murder of another student, by illogical means for an illogical reason, wasn’t emotionally disturbed. I don’t know what happens to someone like Juan in 2014 – I’m thinking nothing good – but let me tell you what happened to Juan in the late 1970s.

Juan was out of high school for 6 weeks. I heard he had psychological testing, but aside from that, I have no idea what transpired. One of his friends told me it was a joke. He returned to high school, never said another word to me, graduated, and attended an Ivy League university – one of several prestigious schools to which he gained admission. A Google search reveals that Juan later earned a graduate degree and works as an executive making a six-figure salary. (Isn’t Google great?) He’s an adjunct professor at a college where he gets glowing reviews on RateMyProfessors.com. He was elected to serve on a local government committee. He’s married and has children. Compliments of Facebook, I know that he continues to have contact with high school friends.

From what I can tell, Juan’s brief period of being a disturbed adolescent did not progress to a life defined by chronic mental illness, and he did not go on to become a violent felon. I have no idea if I did Juan a favor, prevented a murder, got him much-needed treatment, or simply added an embarrassing diversion to his life. I don’t know if he ever really would have harmed Joe, or if it was in fact a joke designed to yank my chain.

Apparently, my threshold is on the low side, and not long ago I called a friend late one night and insisted she check on her teenager when a Facebook post struck me as alarming and a bit too final. The response I got was, "They were lyrics from a song and you’re overreacting." So be it. I called the mother and not the National Guard, and if the teen had become a statistic, I would have regretted not reacting.

I did wonder, while writing this article, how it would be received if I were to contact Juan and ask his thoughts on those events decades ago. Somehow, it seemed best not to uncover old wounds.

The media talk about the dangerously mentally ill as though they are a separate breed of humans, ones who can be easily distinguished by simply assessing who stands on which side of a well-marked "us-versus-them" line. Human beings, especially young human beings, may go through phases, and they may struggle with controlling their emotions, behaviors, and impulses and with finding their identity at a time in life when fitting in has undue importance. Some of them, no doubt, have these crises in the throes of an acute episode of mental distress – illness, if you’d prefer – and others do so at the genesis of what will prove to be a chronic and persistent psychiatric disorder. It may not be clear at any given moment who is going through a phase, who is suffering from an acute episode of mental illness, and who is beginning their course of a severe and persistent disorder.

Still, there are those who want to neatly categorize those with "serious" mental illness so that we can focus more of our resources on their needs and not on those who they deem to be the "worried well." Juan, it appears, did not fall into that category of chronically or persistently mentally ill. Similarly, all of us know chaotic, misbehaving, and even suicidal teenagers who go on to live productive lives. Does that designation matter if those not-so-seriously (or not-so-obviously) mentally ill individuals kill someone or die during their brief moments of emotional turbulence?

It seems to me that the goal is to keep people safe and help usher them through difficult periods in their lives, regardless of any diagnostic certainty or severity. I would contend that the mentally healthy among us also are subject to impulsive, distressed, and dangerous moments and that the world does not always neatly divide people into proper categorical entities.

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

When I was in high school, one of my friends told me he intended to kill another one of my friends. It was a different day and age back then, and with more than 4,000 students, my high school was rather large and impersonal – it was easy to get lost in the crowd.

"Juan" (not his real name) confided in me that he wanted to kill "Joe" (also not his real name), which I found a bit odd. Joe was well liked but not did really stand out. Juan was perhaps quieter and more studious, but he also did not stand out. Both boys had friends, did well in school, and were not obviously troubled. When I asked Juan why he wanted to kill Joe, he responded, "Because he’s the all-American boy."

I worried about this. I told my mother, and I told a teacher I trusted. No one knew what to do, and Juan’s plan did not sound feasible. He was going to bring a knife to school in a folder, and when Joe was walking in a crowded hallway, Juan would walk behind him and thrust out the folder to sent the knife flying. The physics of this just didn’t make sense to me, and I didn’t see how the knife would gain enough momentum to travel very far, much less penetrate a person through their clothes. Feasible, or not, however, the equation changed on a day that Juan and I were sitting together in the back row of Latin class. Juan opened his calculus book and showed me the butcher knife.

I excused myself from class, went to a pay phone, and called my mother. She called the school, the principal called the police, and Juan was quietly removed from school when the period ended. It would be hard to imagine that a teenager who plotted the murder of another student, by illogical means for an illogical reason, wasn’t emotionally disturbed. I don’t know what happens to someone like Juan in 2014 – I’m thinking nothing good – but let me tell you what happened to Juan in the late 1970s.

Juan was out of high school for 6 weeks. I heard he had psychological testing, but aside from that, I have no idea what transpired. One of his friends told me it was a joke. He returned to high school, never said another word to me, graduated, and attended an Ivy League university – one of several prestigious schools to which he gained admission. A Google search reveals that Juan later earned a graduate degree and works as an executive making a six-figure salary. (Isn’t Google great?) He’s an adjunct professor at a college where he gets glowing reviews on RateMyProfessors.com. He was elected to serve on a local government committee. He’s married and has children. Compliments of Facebook, I know that he continues to have contact with high school friends.

From what I can tell, Juan’s brief period of being a disturbed adolescent did not progress to a life defined by chronic mental illness, and he did not go on to become a violent felon. I have no idea if I did Juan a favor, prevented a murder, got him much-needed treatment, or simply added an embarrassing diversion to his life. I don’t know if he ever really would have harmed Joe, or if it was in fact a joke designed to yank my chain.

Apparently, my threshold is on the low side, and not long ago I called a friend late one night and insisted she check on her teenager when a Facebook post struck me as alarming and a bit too final. The response I got was, "They were lyrics from a song and you’re overreacting." So be it. I called the mother and not the National Guard, and if the teen had become a statistic, I would have regretted not reacting.

I did wonder, while writing this article, how it would be received if I were to contact Juan and ask his thoughts on those events decades ago. Somehow, it seemed best not to uncover old wounds.

The media talk about the dangerously mentally ill as though they are a separate breed of humans, ones who can be easily distinguished by simply assessing who stands on which side of a well-marked "us-versus-them" line. Human beings, especially young human beings, may go through phases, and they may struggle with controlling their emotions, behaviors, and impulses and with finding their identity at a time in life when fitting in has undue importance. Some of them, no doubt, have these crises in the throes of an acute episode of mental distress – illness, if you’d prefer – and others do so at the genesis of what will prove to be a chronic and persistent psychiatric disorder. It may not be clear at any given moment who is going through a phase, who is suffering from an acute episode of mental illness, and who is beginning their course of a severe and persistent disorder.

Still, there are those who want to neatly categorize those with "serious" mental illness so that we can focus more of our resources on their needs and not on those who they deem to be the "worried well." Juan, it appears, did not fall into that category of chronically or persistently mentally ill. Similarly, all of us know chaotic, misbehaving, and even suicidal teenagers who go on to live productive lives. Does that designation matter if those not-so-seriously (or not-so-obviously) mentally ill individuals kill someone or die during their brief moments of emotional turbulence?

It seems to me that the goal is to keep people safe and help usher them through difficult periods in their lives, regardless of any diagnostic certainty or severity. I would contend that the mentally healthy among us also are subject to impulsive, distressed, and dangerous moments and that the world does not always neatly divide people into proper categorical entities.

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

Lately, I've been busy wading through a heavily publicized study that was published this month in the Lancet. In their paper, "Antipsychotics, mood stabilisers and risk of violent crime," Dr. Seena Fazel and his associates linked Swedish national registers to compare rates of violent crime among 82,647 male and female psychiatric patients to assess the effect of medication on this outcome.

The study made quite a splash in the news, because the outcome was almost too good to be true. There was a 64% reduction in violent crime among patients who had been prescribed any antipsychotic or mood stabilizer, compared with those taking other psychotropics. The reduction in violence for those taking neuroleptics and mood stabilizers was 45% and 24%, respectively. Selective serotonin reuptake inhibitors (SSRIs) had no apparent effect on crime (Lancet 2014 [doi:10.1016/S0140-6736(14)60379-2]).
Given our American anxiety over spree shooters and other high-profile crimes allegedly committed by untreated psychiatric patients, this study clearly deserves some scrutiny to thoroughly understand the findings, limitations, and other factors that could limit generalizability to the United States.

The authors compared mental health treatment registries with the national criminal history database. They looked at the rate and types of crimes committed by psychiatric patients when they were in and out of treatment. The "in-treatment" time interval was defined as the time between two or more prescriptions, as long as the prescriptions were no more than 4 months apart. Individuals who had only been given one script [prescription] were excluded. The outcome measure was any criminal conviction. The conviction outcome was based upon the date the offense took place, not the date of conviction. Individuals were excluded if the offense date was unknown.

A within-individual analysis showed significant reduction in all crimes, including violent crime, drug-related crime, and less severe crimes, during times when patients were prescribed medication, compared with medication-free intervals. When medicated, the rate of violent crime did not differ between patients with and without a history of violent offenses when diagnosis was not considered. When the analysis was limited to people with schizophrenia, bipolar disorder, or other psychotic disorders, the prescription of neuroleptics significantly reduced violent crime for both men and women.

For bipolar disorder, mood stabilizing medication reduced violent crime for men but not for women. The SSRI-medicated group was used as a control, to account for the general effect of contact with the mental health system and non-medication interventions related to this, and there was no effect on violent crime with this class of medication.

Now on to the limitations. Medication adherence was not assessed and could not be verified apart from patients given depot neuroleptics. The overall rate of violent crime was low, as would be expected. Only 6% of men and 1% of the women committed a violent crime. The numbers were so low that the study could not statistically assess the impact of violent crime history among patients diagnosed with psychosis. This is a small but crucial finding that did not make the traditional media coverage of this study.

Also, only 40% of those patients taking antipsychotics and mood stabilizers had a diagnosis of schizophrenia, other psychosis, or bipolar disorder, suggesting that, in Sweden, these medications might be prescribed for other indications such as characterologic low frustration tolerance or irritability. The analysis did not look at impact on violent crime by personality disorder diagnosis.

The authors acknowledged that their research could not prove a causal link between psychiatric illness and violence, another important conclusion that was not mentioned in traditional media coverage. In Sweden, mental illness cannot be used to prevent or mitigate a criminal conviction, so any connection between psychiatric symptoms and crime in this population can't be determined. The study also did not consider which subjects, if any, were taking medication or in treatment under court-mandated conditions.

As legislators and advocacy groups push to strengthen involuntary treatment laws, there is a risk that "bottom line" media coverage of research like this may inappropriately sway public opinion. Psychiatrists should be prepared to respond to proposed policies based on inaccurate interpretation of research.

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.

Lately, I've been busy wading through a heavily publicized study that was published this month in the Lancet. In their paper, "Antipsychotics, mood stabilisers and risk of violent crime," Dr. Seena Fazel and his associates linked Swedish national registers to compare rates of violent crime among 82,647 male and female psychiatric patients to assess the effect of medication on this outcome.

The study made quite a splash in the news, because the outcome was almost too good to be true. There was a 64% reduction in violent crime among patients who had been prescribed any antipsychotic or mood stabilizer, compared with those taking other psychotropics. The reduction in violence for those taking neuroleptics and mood stabilizers was 45% and 24%, respectively. Selective serotonin reuptake inhibitors (SSRIs) had no apparent effect on crime (Lancet 2014 [doi:10.1016/S0140-6736(14)60379-2]).
Given our American anxiety over spree shooters and other high-profile crimes allegedly committed by untreated psychiatric patients, this study clearly deserves some scrutiny to thoroughly understand the findings, limitations, and other factors that could limit generalizability to the United States.

The authors compared mental health treatment registries with the national criminal history database. They looked at the rate and types of crimes committed by psychiatric patients when they were in and out of treatment. The "in-treatment" time interval was defined as the time between two or more prescriptions, as long as the prescriptions were no more than 4 months apart. Individuals who had only been given one script [prescription] were excluded. The outcome measure was any criminal conviction. The conviction outcome was based upon the date the offense took place, not the date of conviction. Individuals were excluded if the offense date was unknown.

A within-individual analysis showed significant reduction in all crimes, including violent crime, drug-related crime, and less severe crimes, during times when patients were prescribed medication, compared with medication-free intervals. When medicated, the rate of violent crime did not differ between patients with and without a history of violent offenses when diagnosis was not considered. When the analysis was limited to people with schizophrenia, bipolar disorder, or other psychotic disorders, the prescription of neuroleptics significantly reduced violent crime for both men and women.

For bipolar disorder, mood stabilizing medication reduced violent crime for men but not for women. The SSRI-medicated group was used as a control, to account for the general effect of contact with the mental health system and non-medication interventions related to this, and there was no effect on violent crime with this class of medication.

Now on to the limitations. Medication adherence was not assessed and could not be verified apart from patients given depot neuroleptics. The overall rate of violent crime was low, as would be expected. Only 6% of men and 1% of the women committed a violent crime. The numbers were so low that the study could not statistically assess the impact of violent crime history among patients diagnosed with psychosis. This is a small but crucial finding that did not make the traditional media coverage of this study.

Also, only 40% of those patients taking antipsychotics and mood stabilizers had a diagnosis of schizophrenia, other psychosis, or bipolar disorder, suggesting that, in Sweden, these medications might be prescribed for other indications such as characterologic low frustration tolerance or irritability. The analysis did not look at impact on violent crime by personality disorder diagnosis.

The authors acknowledged that their research could not prove a causal link between psychiatric illness and violence, another important conclusion that was not mentioned in traditional media coverage. In Sweden, mental illness cannot be used to prevent or mitigate a criminal conviction, so any connection between psychiatric symptoms and crime in this population can't be determined. The study also did not consider which subjects, if any, were taking medication or in treatment under court-mandated conditions.

As legislators and advocacy groups push to strengthen involuntary treatment laws, there is a risk that "bottom line" media coverage of research like this may inappropriately sway public opinion. Psychiatrists should be prepared to respond to proposed policies based on inaccurate interpretation of research.

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.

Lately, I've been busy wading through a heavily publicized study that was published this month in the Lancet. In their paper, "Antipsychotics, mood stabilisers and risk of violent crime," Dr. Seena Fazel and his associates linked Swedish national registers to compare rates of violent crime among 82,647 male and female psychiatric patients to assess the effect of medication on this outcome.

The study made quite a splash in the news, because the outcome was almost too good to be true. There was a 64% reduction in violent crime among patients who had been prescribed any antipsychotic or mood stabilizer, compared with those taking other psychotropics. The reduction in violence for those taking neuroleptics and mood stabilizers was 45% and 24%, respectively. Selective serotonin reuptake inhibitors (SSRIs) had no apparent effect on crime (Lancet 2014 [doi:10.1016/S0140-6736(14)60379-2]).
Given our American anxiety over spree shooters and other high-profile crimes allegedly committed by untreated psychiatric patients, this study clearly deserves some scrutiny to thoroughly understand the findings, limitations, and other factors that could limit generalizability to the United States.

The authors compared mental health treatment registries with the national criminal history database. They looked at the rate and types of crimes committed by psychiatric patients when they were in and out of treatment. The "in-treatment" time interval was defined as the time between two or more prescriptions, as long as the prescriptions were no more than 4 months apart. Individuals who had only been given one script [prescription] were excluded. The outcome measure was any criminal conviction. The conviction outcome was based upon the date the offense took place, not the date of conviction. Individuals were excluded if the offense date was unknown.

A within-individual analysis showed significant reduction in all crimes, including violent crime, drug-related crime, and less severe crimes, during times when patients were prescribed medication, compared with medication-free intervals. When medicated, the rate of violent crime did not differ between patients with and without a history of violent offenses when diagnosis was not considered. When the analysis was limited to people with schizophrenia, bipolar disorder, or other psychotic disorders, the prescription of neuroleptics significantly reduced violent crime for both men and women.

For bipolar disorder, mood stabilizing medication reduced violent crime for men but not for women. The SSRI-medicated group was used as a control, to account for the general effect of contact with the mental health system and non-medication interventions related to this, and there was no effect on violent crime with this class of medication.

Now on to the limitations. Medication adherence was not assessed and could not be verified apart from patients given depot neuroleptics. The overall rate of violent crime was low, as would be expected. Only 6% of men and 1% of the women committed a violent crime. The numbers were so low that the study could not statistically assess the impact of violent crime history among patients diagnosed with psychosis. This is a small but crucial finding that did not make the traditional media coverage of this study.

Also, only 40% of those patients taking antipsychotics and mood stabilizers had a diagnosis of schizophrenia, other psychosis, or bipolar disorder, suggesting that, in Sweden, these medications might be prescribed for other indications such as characterologic low frustration tolerance or irritability. The analysis did not look at impact on violent crime by personality disorder diagnosis.

The authors acknowledged that their research could not prove a causal link between psychiatric illness and violence, another important conclusion that was not mentioned in traditional media coverage. In Sweden, mental illness cannot be used to prevent or mitigate a criminal conviction, so any connection between psychiatric symptoms and crime in this population can't be determined. The study also did not consider which subjects, if any, were taking medication or in treatment under court-mandated conditions.

As legislators and advocacy groups push to strengthen involuntary treatment laws, there is a risk that "bottom line" media coverage of research like this may inappropriately sway public opinion. Psychiatrists should be prepared to respond to proposed policies based on inaccurate interpretation of research.

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.

Like many of you, I’m currently in New York City for 5 days of psychiatry and psychiatrists, 24/7. I’m hoping there will be a bagel with lox in there somewhere as well.

I wanted to talk about one section of Rep. Tim Murphy’s (R-Pa.) proposed legislation, H.R. 3717, the Helping Families in Mental Health Crisis Act. If you’re not familiar with it, the legislation intends to overhaul a broken mental health system in the United States. One component of the bill, Section 301 located on page 44, deals with modifying HIPAA such that mental health providers can speak with caregivers and family members. Rep. Murphy – who is also a psychologist – has noted in his television appearance and in public testimony that HIPAA is misinterpreted such that families are sometimes told they may not provide historical information about the patient. HIPAA does not actually prevent a mental health professional from listening to anyone’s free speech, but there seem to be times when the involved parties believe this is the case.

In addition, Rep. Murphy noted that HIPAA prevents clinicians from releasing information to caretakers that might help in providing for outpatient care – specifically for releasing medication information and follow-up appointments to those who may be responsible for helping patients negotiate these crucial items.

The proposed legislation reads:

"Caregiver Access to Information: ...to an individual with a serious mental illness who does not provide consent for the disclosure of protected health information to a caregiver of such individual, the caregiver shall be treated by a covered entity as a personal representative ... when the provider furnishing services to the individual reasonably believes it is necessary for protected health information of the individual to be made available to the caregiver in order to protect the health, safety, or welfare of such individuals or the safety of one or more other individuals."

The bill goes on to define "caregiver" as an immediate family member, an individual who assumes primary responsibility for providing for the patient’s basic needs, or a personal representative as determined by law. I think we all agree that collaboration and communication are essential to the care of our patients, and so I applaud these efforts. I worry, however, about the unintended consequences and what roads this might lead us down.

Long before we had HIPAA, we had requirements for patient confidentiality. I, like Rep. Murphy, believe that HIPAA gets distorted. "We need to let your family know your discharge medications and follow-up appointments," is not often met with resistance, but if it is, shouldn’t that be respected? What if patients have valid reasons for not wanting family to know their medications? What if they feel their family is too intrusive, or is part of the problem? Such legislation might suggest that the family is always right and the patient is always wrong.

While the intent (as I’ve understood it from Rep. Murphy’s speeches) is to allow hospitals to tell families, "Yes, your loved [one] has been admitted to our inpatient unit," or to allow well-negotiated follow-up to prevent relapse, might such legislation lead patients to believe that the content of their discussions with mental health professionals can be relayed to others against their will? Might it serve as one more reason for a troubled individual to avoid care?

From a psychiatrist’s point of view, I might be concerned that I would agree with a patient that information should not be released to family, and nothing about this law would then force me to release it. But would family members feel the law says otherwise? Will they contend, "My family member is mentally ill so HIPAA does not apply, and you must release information to me?" While any given psychiatrist might choose not to release information on any given patient, I wonder if this might be setting us up to be at odds with families, and that would not be a good thing. Much as I’m no fan of HIPAA for many reasons, people do understand the concept that confidentiality is required by law. Perhaps I’m reading too much into this?

Finally, we all agree that eliminating stigma is a good thing when it comes to facilitating voluntary care for those who might need it. But I wonder if we can say that people with mental illnesses are just like everyone else, that this is a medical condition just like other conditions, but for this select group of people they lose their right to privacy, much as children have no right to medical privacy. Might that add to the stigma of mental illness?

I don’t have an answer. I believe the intentions of the Helping Families in Mental Health Crisis Act are good, and I believe they target weaknesses in our system. But I also worry that the legislation might create as many problems as it might fix.

The comments feature of the Clinical Psychiatry News website is turned off for the moment, and I would love to hear your thoughts. Please do e-mail with your comments; I can be reached at [email protected], or you may comment on a similar post here.

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

Like many of you, I’m currently in New York City for 5 days of psychiatry and psychiatrists, 24/7. I’m hoping there will be a bagel with lox in there somewhere as well.

I wanted to talk about one section of Rep. Tim Murphy’s (R-Pa.) proposed legislation, H.R. 3717, the Helping Families in Mental Health Crisis Act. If you’re not familiar with it, the legislation intends to overhaul a broken mental health system in the United States. One component of the bill, Section 301 located on page 44, deals with modifying HIPAA such that mental health providers can speak with caregivers and family members. Rep. Murphy – who is also a psychologist – has noted in his television appearance and in public testimony that HIPAA is misinterpreted such that families are sometimes told they may not provide historical information about the patient. HIPAA does not actually prevent a mental health professional from listening to anyone’s free speech, but there seem to be times when the involved parties believe this is the case.

In addition, Rep. Murphy noted that HIPAA prevents clinicians from releasing information to caretakers that might help in providing for outpatient care – specifically for releasing medication information and follow-up appointments to those who may be responsible for helping patients negotiate these crucial items.

The proposed legislation reads:

"Caregiver Access to Information: ...to an individual with a serious mental illness who does not provide consent for the disclosure of protected health information to a caregiver of such individual, the caregiver shall be treated by a covered entity as a personal representative ... when the provider furnishing services to the individual reasonably believes it is necessary for protected health information of the individual to be made available to the caregiver in order to protect the health, safety, or welfare of such individuals or the safety of one or more other individuals."

The bill goes on to define "caregiver" as an immediate family member, an individual who assumes primary responsibility for providing for the patient’s basic needs, or a personal representative as determined by law. I think we all agree that collaboration and communication are essential to the care of our patients, and so I applaud these efforts. I worry, however, about the unintended consequences and what roads this might lead us down.

Long before we had HIPAA, we had requirements for patient confidentiality. I, like Rep. Murphy, believe that HIPAA gets distorted. "We need to let your family know your discharge medications and follow-up appointments," is not often met with resistance, but if it is, shouldn’t that be respected? What if patients have valid reasons for not wanting family to know their medications? What if they feel their family is too intrusive, or is part of the problem? Such legislation might suggest that the family is always right and the patient is always wrong.

While the intent (as I’ve understood it from Rep. Murphy’s speeches) is to allow hospitals to tell families, "Yes, your loved [one] has been admitted to our inpatient unit," or to allow well-negotiated follow-up to prevent relapse, might such legislation lead patients to believe that the content of their discussions with mental health professionals can be relayed to others against their will? Might it serve as one more reason for a troubled individual to avoid care?

From a psychiatrist’s point of view, I might be concerned that I would agree with a patient that information should not be released to family, and nothing about this law would then force me to release it. But would family members feel the law says otherwise? Will they contend, "My family member is mentally ill so HIPAA does not apply, and you must release information to me?" While any given psychiatrist might choose not to release information on any given patient, I wonder if this might be setting us up to be at odds with families, and that would not be a good thing. Much as I’m no fan of HIPAA for many reasons, people do understand the concept that confidentiality is required by law. Perhaps I’m reading too much into this?

Finally, we all agree that eliminating stigma is a good thing when it comes to facilitating voluntary care for those who might need it. But I wonder if we can say that people with mental illnesses are just like everyone else, that this is a medical condition just like other conditions, but for this select group of people they lose their right to privacy, much as children have no right to medical privacy. Might that add to the stigma of mental illness?

I don’t have an answer. I believe the intentions of the Helping Families in Mental Health Crisis Act are good, and I believe they target weaknesses in our system. But I also worry that the legislation might create as many problems as it might fix.

The comments feature of the Clinical Psychiatry News website is turned off for the moment, and I would love to hear your thoughts. Please do e-mail with your comments; I can be reached at [email protected], or you may comment on a similar post here.

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

Like many of you, I’m currently in New York City for 5 days of psychiatry and psychiatrists, 24/7. I’m hoping there will be a bagel with lox in there somewhere as well.

I wanted to talk about one section of Rep. Tim Murphy’s (R-Pa.) proposed legislation, H.R. 3717, the Helping Families in Mental Health Crisis Act. If you’re not familiar with it, the legislation intends to overhaul a broken mental health system in the United States. One component of the bill, Section 301 located on page 44, deals with modifying HIPAA such that mental health providers can speak with caregivers and family members. Rep. Murphy – who is also a psychologist – has noted in his television appearance and in public testimony that HIPAA is misinterpreted such that families are sometimes told they may not provide historical information about the patient. HIPAA does not actually prevent a mental health professional from listening to anyone’s free speech, but there seem to be times when the involved parties believe this is the case.

In addition, Rep. Murphy noted that HIPAA prevents clinicians from releasing information to caretakers that might help in providing for outpatient care – specifically for releasing medication information and follow-up appointments to those who may be responsible for helping patients negotiate these crucial items.

The proposed legislation reads:

"Caregiver Access to Information: ...to an individual with a serious mental illness who does not provide consent for the disclosure of protected health information to a caregiver of such individual, the caregiver shall be treated by a covered entity as a personal representative ... when the provider furnishing services to the individual reasonably believes it is necessary for protected health information of the individual to be made available to the caregiver in order to protect the health, safety, or welfare of such individuals or the safety of one or more other individuals."

The bill goes on to define "caregiver" as an immediate family member, an individual who assumes primary responsibility for providing for the patient’s basic needs, or a personal representative as determined by law. I think we all agree that collaboration and communication are essential to the care of our patients, and so I applaud these efforts. I worry, however, about the unintended consequences and what roads this might lead us down.

Long before we had HIPAA, we had requirements for patient confidentiality. I, like Rep. Murphy, believe that HIPAA gets distorted. "We need to let your family know your discharge medications and follow-up appointments," is not often met with resistance, but if it is, shouldn’t that be respected? What if patients have valid reasons for not wanting family to know their medications? What if they feel their family is too intrusive, or is part of the problem? Such legislation might suggest that the family is always right and the patient is always wrong.

While the intent (as I’ve understood it from Rep. Murphy’s speeches) is to allow hospitals to tell families, "Yes, your loved [one] has been admitted to our inpatient unit," or to allow well-negotiated follow-up to prevent relapse, might such legislation lead patients to believe that the content of their discussions with mental health professionals can be relayed to others against their will? Might it serve as one more reason for a troubled individual to avoid care?

From a psychiatrist’s point of view, I might be concerned that I would agree with a patient that information should not be released to family, and nothing about this law would then force me to release it. But would family members feel the law says otherwise? Will they contend, "My family member is mentally ill so HIPAA does not apply, and you must release information to me?" While any given psychiatrist might choose not to release information on any given patient, I wonder if this might be setting us up to be at odds with families, and that would not be a good thing. Much as I’m no fan of HIPAA for many reasons, people do understand the concept that confidentiality is required by law. Perhaps I’m reading too much into this?

Finally, we all agree that eliminating stigma is a good thing when it comes to facilitating voluntary care for those who might need it. But I wonder if we can say that people with mental illnesses are just like everyone else, that this is a medical condition just like other conditions, but for this select group of people they lose their right to privacy, much as children have no right to medical privacy. Might that add to the stigma of mental illness?

I don’t have an answer. I believe the intentions of the Helping Families in Mental Health Crisis Act are good, and I believe they target weaknesses in our system. But I also worry that the legislation might create as many problems as it might fix.

The comments feature of the Clinical Psychiatry News website is turned off for the moment, and I would love to hear your thoughts. Please do e-mail with your comments; I can be reached at [email protected], or you may comment on a similar post here.

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

The Treatment Advocacy Center has released an update of a national survey of prison and jail involuntary treatment policies in its 116-page report, "The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey."

The survey was a replication of a previous study done in 2008. The purpose of the study was to compare treatment bed capacity and the numbers of seriously mentally ill patients housed within a state’s correctional system versus its public mental health system, and to promote the use of involuntary treatment procedures within correctional facilities.

To prepare the report, the center gathered data from each state prison system, as well as from non–randomly selected jails, regarding total bed capacity and the percentage of seriously mentally ill prisoners housed in the correctional system. Information about nonemergency involuntary medication procedures was gathered from prison websites or through Freedom of Information requests. For jails, some policies were obtained or clarified from administrative personnel or mental health professionals within the facility. Information about available psychiatric state hospital beds was gathered from a previous TAC report on state per-capita treatment capacity.

The new report found that the ratio of seriously mentally ill patients housed in correctional facilities versus state hospitals has increased substantially since 2008. Then, the ratio was 3:1. Currently, the ratio is 10 patients held in jail or prison for every single patient in a state hospital. This is clearly a significant change, which TAC attributes to closure of state hospital beds and failure to implement outpatient commitment laws.

As I’ve said in previous columns, I’m reluctant to attribute the incarceration of mentally ill people solely to mental illness. I’m uncomfortable with a reductionist hypothesis that overlooks the whole person. All of my prison patients have challenges common to many non–mentally ill prisoners: substance abuse, lack of social supports, illiteracy, poor vocational skills, and poverty. Psychiatric patients also suffer the baser instincts common to all humanity: fear, greed, and jealous rage. Changes in laws governing sentencing also will affect all offenders, regardless of psychiatric status. Psychiatric medication, voluntary or involuntary, is not the sole answer to the problem of criminality and will do nothing to address these other issues.

Nevertheless, I agree with the majority of the TAC report recommendations, and I applaud the emphasis placed upon expanded use of mental health courts and crisis intervention teams (CIT) to avert incarceration. The recommendation to screen prisoners for mental illness is already mandated by the National Commission on Correctional Health Care (NCCHC) for any accredited facility. According to a 1994 national survey by Dr. Jeffrey L. Metzner and associates, all prisons systems provided either reception or prompt intake mental health screening to all newly admitted intakes (Bull. Am. Acad. Psychiatry Law 1994;22:451-7). Twenty-six percent of the prison systems exceeded screening standards recommended by the American Psychiatric Association. This is good news.

The TAC report also recommended mandatory release planning. Systematic release planning is a challenge to implement for most correctional systems for several reasons. In jail, release may be contingent upon the outcome of a trial and is therefore unpredictable. If the trial is postponed, a valuable community treatment slot is tied up for a patient who will never arrive. Conversely, failure to plan prior to a court date might leave a prisoner on the street directly from court with no aftercare. Nevertheless, states are beginning to realize the cost and public safety benefit of release plans that integrate medical, mental health, and substance abuse services.

One recent outcome study showed that more than half of released prisoners stayed in treatment in the community when an in-reach program provided integrated release planning services, and that annual criminal charges dropped by more than 50% in the year following engagement. More good news.

Finally, a minor quibble. My own state, Maryland, was cited in the report as one of the few states in which the involuntary treatment of inmates is most difficult because of the requirement to transfer the inmate to a hospital first. What the TAC failed to mention was that, in Maryland, the involuntary medication process was substantially undermined by case law. In 2006, the Maryland Court of Appeals decided in Department of Health and Mental Hygiene v. Anthony Kelly that involuntary medication only can be administered if the patient demonstrates dangerousness within the institution. Given this restriction, involuntary medication could not be administered on a nonemergency basis even in a correctional facility.

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.

The Treatment Advocacy Center has released an update of a national survey of prison and jail involuntary treatment policies in its 116-page report, "The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey."

The survey was a replication of a previous study done in 2008. The purpose of the study was to compare treatment bed capacity and the numbers of seriously mentally ill patients housed within a state’s correctional system versus its public mental health system, and to promote the use of involuntary treatment procedures within correctional facilities.

To prepare the report, the center gathered data from each state prison system, as well as from non–randomly selected jails, regarding total bed capacity and the percentage of seriously mentally ill prisoners housed in the correctional system. Information about nonemergency involuntary medication procedures was gathered from prison websites or through Freedom of Information requests. For jails, some policies were obtained or clarified from administrative personnel or mental health professionals within the facility. Information about available psychiatric state hospital beds was gathered from a previous TAC report on state per-capita treatment capacity.

The new report found that the ratio of seriously mentally ill patients housed in correctional facilities versus state hospitals has increased substantially since 2008. Then, the ratio was 3:1. Currently, the ratio is 10 patients held in jail or prison for every single patient in a state hospital. This is clearly a significant change, which TAC attributes to closure of state hospital beds and failure to implement outpatient commitment laws.

As I’ve said in previous columns, I’m reluctant to attribute the incarceration of mentally ill people solely to mental illness. I’m uncomfortable with a reductionist hypothesis that overlooks the whole person. All of my prison patients have challenges common to many non–mentally ill prisoners: substance abuse, lack of social supports, illiteracy, poor vocational skills, and poverty. Psychiatric patients also suffer the baser instincts common to all humanity: fear, greed, and jealous rage. Changes in laws governing sentencing also will affect all offenders, regardless of psychiatric status. Psychiatric medication, voluntary or involuntary, is not the sole answer to the problem of criminality and will do nothing to address these other issues.

Nevertheless, I agree with the majority of the TAC report recommendations, and I applaud the emphasis placed upon expanded use of mental health courts and crisis intervention teams (CIT) to avert incarceration. The recommendation to screen prisoners for mental illness is already mandated by the National Commission on Correctional Health Care (NCCHC) for any accredited facility. According to a 1994 national survey by Dr. Jeffrey L. Metzner and associates, all prisons systems provided either reception or prompt intake mental health screening to all newly admitted intakes (Bull. Am. Acad. Psychiatry Law 1994;22:451-7). Twenty-six percent of the prison systems exceeded screening standards recommended by the American Psychiatric Association. This is good news.

The TAC report also recommended mandatory release planning. Systematic release planning is a challenge to implement for most correctional systems for several reasons. In jail, release may be contingent upon the outcome of a trial and is therefore unpredictable. If the trial is postponed, a valuable community treatment slot is tied up for a patient who will never arrive. Conversely, failure to plan prior to a court date might leave a prisoner on the street directly from court with no aftercare. Nevertheless, states are beginning to realize the cost and public safety benefit of release plans that integrate medical, mental health, and substance abuse services.

One recent outcome study showed that more than half of released prisoners stayed in treatment in the community when an in-reach program provided integrated release planning services, and that annual criminal charges dropped by more than 50% in the year following engagement. More good news.

Finally, a minor quibble. My own state, Maryland, was cited in the report as one of the few states in which the involuntary treatment of inmates is most difficult because of the requirement to transfer the inmate to a hospital first. What the TAC failed to mention was that, in Maryland, the involuntary medication process was substantially undermined by case law. In 2006, the Maryland Court of Appeals decided in Department of Health and Mental Hygiene v. Anthony Kelly that involuntary medication only can be administered if the patient demonstrates dangerousness within the institution. Given this restriction, involuntary medication could not be administered on a nonemergency basis even in a correctional facility.

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.

The Treatment Advocacy Center has released an update of a national survey of prison and jail involuntary treatment policies in its 116-page report, "The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey."

The survey was a replication of a previous study done in 2008. The purpose of the study was to compare treatment bed capacity and the numbers of seriously mentally ill patients housed within a state’s correctional system versus its public mental health system, and to promote the use of involuntary treatment procedures within correctional facilities.

To prepare the report, the center gathered data from each state prison system, as well as from non–randomly selected jails, regarding total bed capacity and the percentage of seriously mentally ill prisoners housed in the correctional system. Information about nonemergency involuntary medication procedures was gathered from prison websites or through Freedom of Information requests. For jails, some policies were obtained or clarified from administrative personnel or mental health professionals within the facility. Information about available psychiatric state hospital beds was gathered from a previous TAC report on state per-capita treatment capacity.

The new report found that the ratio of seriously mentally ill patients housed in correctional facilities versus state hospitals has increased substantially since 2008. Then, the ratio was 3:1. Currently, the ratio is 10 patients held in jail or prison for every single patient in a state hospital. This is clearly a significant change, which TAC attributes to closure of state hospital beds and failure to implement outpatient commitment laws.

As I’ve said in previous columns, I’m reluctant to attribute the incarceration of mentally ill people solely to mental illness. I’m uncomfortable with a reductionist hypothesis that overlooks the whole person. All of my prison patients have challenges common to many non–mentally ill prisoners: substance abuse, lack of social supports, illiteracy, poor vocational skills, and poverty. Psychiatric patients also suffer the baser instincts common to all humanity: fear, greed, and jealous rage. Changes in laws governing sentencing also will affect all offenders, regardless of psychiatric status. Psychiatric medication, voluntary or involuntary, is not the sole answer to the problem of criminality and will do nothing to address these other issues.

Nevertheless, I agree with the majority of the TAC report recommendations, and I applaud the emphasis placed upon expanded use of mental health courts and crisis intervention teams (CIT) to avert incarceration. The recommendation to screen prisoners for mental illness is already mandated by the National Commission on Correctional Health Care (NCCHC) for any accredited facility. According to a 1994 national survey by Dr. Jeffrey L. Metzner and associates, all prisons systems provided either reception or prompt intake mental health screening to all newly admitted intakes (Bull. Am. Acad. Psychiatry Law 1994;22:451-7). Twenty-six percent of the prison systems exceeded screening standards recommended by the American Psychiatric Association. This is good news.

The TAC report also recommended mandatory release planning. Systematic release planning is a challenge to implement for most correctional systems for several reasons. In jail, release may be contingent upon the outcome of a trial and is therefore unpredictable. If the trial is postponed, a valuable community treatment slot is tied up for a patient who will never arrive. Conversely, failure to plan prior to a court date might leave a prisoner on the street directly from court with no aftercare. Nevertheless, states are beginning to realize the cost and public safety benefit of release plans that integrate medical, mental health, and substance abuse services.

One recent outcome study showed that more than half of released prisoners stayed in treatment in the community when an in-reach program provided integrated release planning services, and that annual criminal charges dropped by more than 50% in the year following engagement. More good news.

Finally, a minor quibble. My own state, Maryland, was cited in the report as one of the few states in which the involuntary treatment of inmates is most difficult because of the requirement to transfer the inmate to a hospital first. What the TAC failed to mention was that, in Maryland, the involuntary medication process was substantially undermined by case law. In 2006, the Maryland Court of Appeals decided in Department of Health and Mental Hygiene v. Anthony Kelly that involuntary medication only can be administered if the patient demonstrates dangerousness within the institution. Given this restriction, involuntary medication could not be administered on a nonemergency basis even in a correctional facility.

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.

Despite protests from the American Medical Association, on Wednesday, April 9, the Obama administration made public payments to 880,000 Medicare providers. The data, released by the Centers for Medicare & Medicaid Services, include the clinician's name; specialty; address; and a breakdown of the number of patients who received each itemized service, the number of services rendered, the average amount billed per CPT code, and the average amount paid; along with the physician's total Medicare reimbursement for 2012. The data are easily accessible, and major newspapers have included look-up tools on their websites to allow for easy access to the data.

Through a discussion on the Maryland Psychiatric Society listserv, the opinions of several psychiatrists were solicited. From this, I learned that psychiatrists in my metro area have had mixed responses to the release of this information. Jesse Hellman, a psychiatrist in private practice in Towson, Md., notes: "This was a major privacy violation. Publishing the payments to individual physicians was a blunder. It should never have happened. Relevant data might have been released in another form."

Brian Crowley, a psychiatrist in practice in Washington, feels otherwise. "Personally, I'm in favor of the publication. It is of interest that most of the money goes to a few doctors, I believe, and may help planning. I believe the transparency is likely a good thing."

Roger Peele, a psychiatrist in Rockville, Md., agreed. "Even though misleading in some ways, and even though it might decrease the willingness of a few to be part of Medicare, it adds weight to the argument for a more rational payment system for physicians."

Robert Roca, vice president and medical director of Sheppard Pratt Health Systems added that he’d heard a journalist with expertise about this issue speaking on National Public Radio. "They don’t see this as a privacy issue. Their argument is that these are public dollars and that the public is entitled to know how and where they are spent. Unfortunately, the question of whether detailed information about payment of public dollars for other goods or services should be readily available to the public did not come up."

Steve Daviss, president of FUSE Health Strategies, had a lot to say about making the data public: "Put me in the 'transparency is good' camp. I see this less from a privacy of the doctor viewpoint, but rather from the perspectives of open government, and that this sort of data feedback mechanism is needed for proper homeostasis of our health care system.

"The U.S. spends twice as much per person on health care as any other country – double! – yet, we are not getting twice the health outcomes. When the CMS [Centers for Medicare & Medicaid Services] released this sort of data for hospitals, only then could we see the huge disparity in billing practices across the country. This sort of data about physicians will help demonstrate similar discrepancies, not just the 0.1% of physicians making millions on senior cataract surgery or whatever, but the shortages. There are many explanations for the odd data bits, which provide us a great opportunity to educate our patients and our policy makers.

"I don’t really see the danger," Dr. Daviss continued. "Where I do see the danger is in preventing people from understanding how much health care costs, where the money goes, and how to comparison shop. The next step (maybe it should have been the first) is to also share aggregate quality data, patient experience data, and comorbidity data. Then people will begin to connect the dots and have the information needed to make better health care decisions."

Laurie Orgel, a psychiatrist in private practice in Towson, countered, "I suppose we can look at this as a privacy issue, but there is the issue of relevance. What does it get anyone? Yes, there will be those of us who note the minority who get huge reimbursements, but I suspect that will just tarnish the rest of us rather than be understood as ‘a few outliers.’ Does this information really help planning?"

Kery Hummel, executive director of the Maryland Psychiatric Society, said, "I also wonder why some people have such considerable amounts and others such small amounts." He was quick to point out that the list included income earned for a psychiatrist, still listed at a Maryland address, who had moved out of state several years before.

Whether it's a violation of a doctor’s privacy to have the details of his practice and incomes easily accessible to the public, and whether this degree of transparency adds value when it comes to making health care more efficient with better outcomes, will be seen over time. In terms of capturing fraud, one might think that the CMS always had access to this data, and if it's an outlier for a physician to receive $21 million in Medicare dollars, then that should have been known without the need to make that information public. Notably, the data, even if completely correct, don’t tell the full picture of American health care dollars, as it doesn’t capture the practice habits of those who have opted out, or any transactions that are not provided through the Medicare program. The statistics, by definition, are skewed to reflect the practice habits of participating physicians who treat senior citizens and the disabled.

Finally, and as a bit of a humorous aside, having the data available does enable some interesting statistical analysis. One day after the data went public, Brian Reid published an article on the widely read medical blog KevinMD. In "Doctors who tweet aren’t ones who bill Medicare for millions," Mr. Reid said,"First, we created a list of doctors who appeared both in the dataset of Medicare providers and our MDigitalLife database of verified doctors in the United States with Twitter handles: 8,000 doctors who both used Twitter and received Medicare payments. We compared that group to the top 14,000 or so providers in the Medicare dataset (every single person who received $500,000 or more from the Medicare). There wasn't a lot of overlap. Only 230 docs made both the top-tweeter and the top-biller list. And among the real outliers – the top 1,000 recipients of Medicare dollars – only 13 were on Twitter, with a measly median follower count of 112. What’s more, there was an inverse association between Twitter followers and money received from Medicare."

Typically, I might end an article by asking readers to follow me on Twitter, but today I think I'll opt for a shot at higher reimbursement.

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

Despite protests from the American Medical Association, on Wednesday, April 9, the Obama administration made public payments to 880,000 Medicare providers. The data, released by the Centers for Medicare & Medicaid Services, include the clinician's name; specialty; address; and a breakdown of the number of patients who received each itemized service, the number of services rendered, the average amount billed per CPT code, and the average amount paid; along with the physician's total Medicare reimbursement for 2012. The data are easily accessible, and major newspapers have included look-up tools on their websites to allow for easy access to the data.

Through a discussion on the Maryland Psychiatric Society listserv, the opinions of several psychiatrists were solicited. From this, I learned that psychiatrists in my metro area have had mixed responses to the release of this information. Jesse Hellman, a psychiatrist in private practice in Towson, Md., notes: "This was a major privacy violation. Publishing the payments to individual physicians was a blunder. It should never have happened. Relevant data might have been released in another form."

Brian Crowley, a psychiatrist in practice in Washington, feels otherwise. "Personally, I'm in favor of the publication. It is of interest that most of the money goes to a few doctors, I believe, and may help planning. I believe the transparency is likely a good thing."

Roger Peele, a psychiatrist in Rockville, Md., agreed. "Even though misleading in some ways, and even though it might decrease the willingness of a few to be part of Medicare, it adds weight to the argument for a more rational payment system for physicians."

Robert Roca, vice president and medical director of Sheppard Pratt Health Systems added that he’d heard a journalist with expertise about this issue speaking on National Public Radio. "They don’t see this as a privacy issue. Their argument is that these are public dollars and that the public is entitled to know how and where they are spent. Unfortunately, the question of whether detailed information about payment of public dollars for other goods or services should be readily available to the public did not come up."

Steve Daviss, president of FUSE Health Strategies, had a lot to say about making the data public: "Put me in the 'transparency is good' camp. I see this less from a privacy of the doctor viewpoint, but rather from the perspectives of open government, and that this sort of data feedback mechanism is needed for proper homeostasis of our health care system.

"The U.S. spends twice as much per person on health care as any other country – double! – yet, we are not getting twice the health outcomes. When the CMS [Centers for Medicare & Medicaid Services] released this sort of data for hospitals, only then could we see the huge disparity in billing practices across the country. This sort of data about physicians will help demonstrate similar discrepancies, not just the 0.1% of physicians making millions on senior cataract surgery or whatever, but the shortages. There are many explanations for the odd data bits, which provide us a great opportunity to educate our patients and our policy makers.

"I don’t really see the danger," Dr. Daviss continued. "Where I do see the danger is in preventing people from understanding how much health care costs, where the money goes, and how to comparison shop. The next step (maybe it should have been the first) is to also share aggregate quality data, patient experience data, and comorbidity data. Then people will begin to connect the dots and have the information needed to make better health care decisions."

Laurie Orgel, a psychiatrist in private practice in Towson, countered, "I suppose we can look at this as a privacy issue, but there is the issue of relevance. What does it get anyone? Yes, there will be those of us who note the minority who get huge reimbursements, but I suspect that will just tarnish the rest of us rather than be understood as ‘a few outliers.’ Does this information really help planning?"

Kery Hummel, executive director of the Maryland Psychiatric Society, said, "I also wonder why some people have such considerable amounts and others such small amounts." He was quick to point out that the list included income earned for a psychiatrist, still listed at a Maryland address, who had moved out of state several years before.

Whether it's a violation of a doctor’s privacy to have the details of his practice and incomes easily accessible to the public, and whether this degree of transparency adds value when it comes to making health care more efficient with better outcomes, will be seen over time. In terms of capturing fraud, one might think that the CMS always had access to this data, and if it's an outlier for a physician to receive $21 million in Medicare dollars, then that should have been known without the need to make that information public. Notably, the data, even if completely correct, don’t tell the full picture of American health care dollars, as it doesn’t capture the practice habits of those who have opted out, or any transactions that are not provided through the Medicare program. The statistics, by definition, are skewed to reflect the practice habits of participating physicians who treat senior citizens and the disabled.

Finally, and as a bit of a humorous aside, having the data available does enable some interesting statistical analysis. One day after the data went public, Brian Reid published an article on the widely read medical blog KevinMD. In "Doctors who tweet aren’t ones who bill Medicare for millions," Mr. Reid said,"First, we created a list of doctors who appeared both in the dataset of Medicare providers and our MDigitalLife database of verified doctors in the United States with Twitter handles: 8,000 doctors who both used Twitter and received Medicare payments. We compared that group to the top 14,000 or so providers in the Medicare dataset (every single person who received $500,000 or more from the Medicare). There wasn't a lot of overlap. Only 230 docs made both the top-tweeter and the top-biller list. And among the real outliers – the top 1,000 recipients of Medicare dollars – only 13 were on Twitter, with a measly median follower count of 112. What’s more, there was an inverse association between Twitter followers and money received from Medicare."

Typically, I might end an article by asking readers to follow me on Twitter, but today I think I'll opt for a shot at higher reimbursement.

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

Despite protests from the American Medical Association, on Wednesday, April 9, the Obama administration made public payments to 880,000 Medicare providers. The data, released by the Centers for Medicare & Medicaid Services, include the clinician's name; specialty; address; and a breakdown of the number of patients who received each itemized service, the number of services rendered, the average amount billed per CPT code, and the average amount paid; along with the physician's total Medicare reimbursement for 2012. The data are easily accessible, and major newspapers have included look-up tools on their websites to allow for easy access to the data.

Through a discussion on the Maryland Psychiatric Society listserv, the opinions of several psychiatrists were solicited. From this, I learned that psychiatrists in my metro area have had mixed responses to the release of this information. Jesse Hellman, a psychiatrist in private practice in Towson, Md., notes: "This was a major privacy violation. Publishing the payments to individual physicians was a blunder. It should never have happened. Relevant data might have been released in another form."

Brian Crowley, a psychiatrist in practice in Washington, feels otherwise. "Personally, I'm in favor of the publication. It is of interest that most of the money goes to a few doctors, I believe, and may help planning. I believe the transparency is likely a good thing."

Roger Peele, a psychiatrist in Rockville, Md., agreed. "Even though misleading in some ways, and even though it might decrease the willingness of a few to be part of Medicare, it adds weight to the argument for a more rational payment system for physicians."

Robert Roca, vice president and medical director of Sheppard Pratt Health Systems added that he’d heard a journalist with expertise about this issue speaking on National Public Radio. "They don’t see this as a privacy issue. Their argument is that these are public dollars and that the public is entitled to know how and where they are spent. Unfortunately, the question of whether detailed information about payment of public dollars for other goods or services should be readily available to the public did not come up."

Steve Daviss, president of FUSE Health Strategies, had a lot to say about making the data public: "Put me in the 'transparency is good' camp. I see this less from a privacy of the doctor viewpoint, but rather from the perspectives of open government, and that this sort of data feedback mechanism is needed for proper homeostasis of our health care system.

"The U.S. spends twice as much per person on health care as any other country – double! – yet, we are not getting twice the health outcomes. When the CMS [Centers for Medicare & Medicaid Services] released this sort of data for hospitals, only then could we see the huge disparity in billing practices across the country. This sort of data about physicians will help demonstrate similar discrepancies, not just the 0.1% of physicians making millions on senior cataract surgery or whatever, but the shortages. There are many explanations for the odd data bits, which provide us a great opportunity to educate our patients and our policy makers.

"I don’t really see the danger," Dr. Daviss continued. "Where I do see the danger is in preventing people from understanding how much health care costs, where the money goes, and how to comparison shop. The next step (maybe it should have been the first) is to also share aggregate quality data, patient experience data, and comorbidity data. Then people will begin to connect the dots and have the information needed to make better health care decisions."

Laurie Orgel, a psychiatrist in private practice in Towson, countered, "I suppose we can look at this as a privacy issue, but there is the issue of relevance. What does it get anyone? Yes, there will be those of us who note the minority who get huge reimbursements, but I suspect that will just tarnish the rest of us rather than be understood as ‘a few outliers.’ Does this information really help planning?"

Kery Hummel, executive director of the Maryland Psychiatric Society, said, "I also wonder why some people have such considerable amounts and others such small amounts." He was quick to point out that the list included income earned for a psychiatrist, still listed at a Maryland address, who had moved out of state several years before.

Whether it's a violation of a doctor’s privacy to have the details of his practice and incomes easily accessible to the public, and whether this degree of transparency adds value when it comes to making health care more efficient with better outcomes, will be seen over time. In terms of capturing fraud, one might think that the CMS always had access to this data, and if it's an outlier for a physician to receive $21 million in Medicare dollars, then that should have been known without the need to make that information public. Notably, the data, even if completely correct, don’t tell the full picture of American health care dollars, as it doesn’t capture the practice habits of those who have opted out, or any transactions that are not provided through the Medicare program. The statistics, by definition, are skewed to reflect the practice habits of participating physicians who treat senior citizens and the disabled.

Finally, and as a bit of a humorous aside, having the data available does enable some interesting statistical analysis. One day after the data went public, Brian Reid published an article on the widely read medical blog KevinMD. In "Doctors who tweet aren’t ones who bill Medicare for millions," Mr. Reid said,"First, we created a list of doctors who appeared both in the dataset of Medicare providers and our MDigitalLife database of verified doctors in the United States with Twitter handles: 8,000 doctors who both used Twitter and received Medicare payments. We compared that group to the top 14,000 or so providers in the Medicare dataset (every single person who received $500,000 or more from the Medicare). There wasn't a lot of overlap. Only 230 docs made both the top-tweeter and the top-biller list. And among the real outliers – the top 1,000 recipients of Medicare dollars – only 13 were on Twitter, with a measly median follower count of 112. What’s more, there was an inverse association between Twitter followers and money received from Medicare."

Typically, I might end an article by asking readers to follow me on Twitter, but today I think I'll opt for a shot at higher reimbursement.

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

In the jail cell I had appropriated as an office, the toilet was broken. The metal toilet bowl was wrapped carelessly in heavy plastic and the plastic was anchored in place by gray duct tape. The window opened hopefully to about 4 inches, just enough to let in the August humidity. Outside, the temperature reached 90 F. Inside the cell, the temperature was easily over 100° F. I was wilting, my patients were wilting, and I left the building at the end of the morning soaked in sweat carrying stacks of damp paper. For the first time since I was an intern, I donned a pair of surgical scrubs because the building was too intolerable for wearing street clothes. This was the legacy of my jail. The facility was opened in 1859, well before the invention of modern heating and air conditioning.

Thanks to the intervention of the Department of Justice, some improvements were made. Certain tiers were given air-conditioning units and designated for the housing of inmates vulnerable to heat exhaustion. Intake procedures were modified to identify and stratify new detainees according to their medical needs and heat tolerance. Inmates were given education on the symptoms of heat exhaustion and how to prevent it. Eventually summer passed, and I was able to lose the surgical scrubs and slip back into street clothes.

Yet the remaining need for a new jail was obvious to anyone working in the facility or incarcerated there. A recent legislative inquiry pointed out the security risks posed by the antiquated tier structures and other hazards. In the report published later, the cost of a new jail was estimated to be $553 million.

The protest started almost immediately. People wrote to the local newspaper to object to the idea of spending money on incarceration rather than crime prevention. Advocacy groups carved out territorial niches to promote diversion of juveniles, pregnant women, and the mentally ill, apparently leaving any prisoner who didn’t fit into one of those categories to fend for himself. In the end, the jail – which opened at a time when there were only 33 states in the union, the year that "A Tale of Two Cities" and "On the Origin of Species" were published, and when the works of Johannes Brahms were being heard for the first time – remained untouched.

These memories returned quickly after reading a recent New York Times story about a homeless veteran with mental illness who died in his jail cell, presumably because of excessive heat. The man had been incarcerated for a misdemeanor and held only because he couldn’t make bail. The fact that this happened in winter tells me a lot about the nature of the facility’s heating and ventilation system.

The first thing that struck me about this story was the need to invoke certain adjectives, as though readers would not care about the story if the prisoner who died was not mentally ill or was not a veteran. There may be some truth to that concern. When it comes to prison reform, I’ve seen the tendency within psychiatry to limit discussions only to conditions as they affect the mentally ill. This was not always the case. Dr. Benjamin Rush, founder of Pennsylvania Hospital, also founded one of the first prison reformation societies. He advocated humane care for everyone in the facility, not just a certain faction.

Unless someone figures out how to "cure" crime, we will always need jails and prisons. Building a new facility is neither a failure nor a waste of resources. It may be the beginning of a long-term commitment to rehabilitation.

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.

In the jail cell I had appropriated as an office, the toilet was broken. The metal toilet bowl was wrapped carelessly in heavy plastic and the plastic was anchored in place by gray duct tape. The window opened hopefully to about 4 inches, just enough to let in the August humidity. Outside, the temperature reached 90 F. Inside the cell, the temperature was easily over 100° F. I was wilting, my patients were wilting, and I left the building at the end of the morning soaked in sweat carrying stacks of damp paper. For the first time since I was an intern, I donned a pair of surgical scrubs because the building was too intolerable for wearing street clothes. This was the legacy of my jail. The facility was opened in 1859, well before the invention of modern heating and air conditioning.

Thanks to the intervention of the Department of Justice, some improvements were made. Certain tiers were given air-conditioning units and designated for the housing of inmates vulnerable to heat exhaustion. Intake procedures were modified to identify and stratify new detainees according to their medical needs and heat tolerance. Inmates were given education on the symptoms of heat exhaustion and how to prevent it. Eventually summer passed, and I was able to lose the surgical scrubs and slip back into street clothes.

Yet the remaining need for a new jail was obvious to anyone working in the facility or incarcerated there. A recent legislative inquiry pointed out the security risks posed by the antiquated tier structures and other hazards. In the report published later, the cost of a new jail was estimated to be $553 million.

The protest started almost immediately. People wrote to the local newspaper to object to the idea of spending money on incarceration rather than crime prevention. Advocacy groups carved out territorial niches to promote diversion of juveniles, pregnant women, and the mentally ill, apparently leaving any prisoner who didn’t fit into one of those categories to fend for himself. In the end, the jail – which opened at a time when there were only 33 states in the union, the year that "A Tale of Two Cities" and "On the Origin of Species" were published, and when the works of Johannes Brahms were being heard for the first time – remained untouched.

These memories returned quickly after reading a recent New York Times story about a homeless veteran with mental illness who died in his jail cell, presumably because of excessive heat. The man had been incarcerated for a misdemeanor and held only because he couldn’t make bail. The fact that this happened in winter tells me a lot about the nature of the facility’s heating and ventilation system.

The first thing that struck me about this story was the need to invoke certain adjectives, as though readers would not care about the story if the prisoner who died was not mentally ill or was not a veteran. There may be some truth to that concern. When it comes to prison reform, I’ve seen the tendency within psychiatry to limit discussions only to conditions as they affect the mentally ill. This was not always the case. Dr. Benjamin Rush, founder of Pennsylvania Hospital, also founded one of the first prison reformation societies. He advocated humane care for everyone in the facility, not just a certain faction.

Unless someone figures out how to "cure" crime, we will always need jails and prisons. Building a new facility is neither a failure nor a waste of resources. It may be the beginning of a long-term commitment to rehabilitation.

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.

In the jail cell I had appropriated as an office, the toilet was broken. The metal toilet bowl was wrapped carelessly in heavy plastic and the plastic was anchored in place by gray duct tape. The window opened hopefully to about 4 inches, just enough to let in the August humidity. Outside, the temperature reached 90 F. Inside the cell, the temperature was easily over 100° F. I was wilting, my patients were wilting, and I left the building at the end of the morning soaked in sweat carrying stacks of damp paper. For the first time since I was an intern, I donned a pair of surgical scrubs because the building was too intolerable for wearing street clothes. This was the legacy of my jail. The facility was opened in 1859, well before the invention of modern heating and air conditioning.

Thanks to the intervention of the Department of Justice, some improvements were made. Certain tiers were given air-conditioning units and designated for the housing of inmates vulnerable to heat exhaustion. Intake procedures were modified to identify and stratify new detainees according to their medical needs and heat tolerance. Inmates were given education on the symptoms of heat exhaustion and how to prevent it. Eventually summer passed, and I was able to lose the surgical scrubs and slip back into street clothes.

Yet the remaining need for a new jail was obvious to anyone working in the facility or incarcerated there. A recent legislative inquiry pointed out the security risks posed by the antiquated tier structures and other hazards. In the report published later, the cost of a new jail was estimated to be $553 million.

The protest started almost immediately. People wrote to the local newspaper to object to the idea of spending money on incarceration rather than crime prevention. Advocacy groups carved out territorial niches to promote diversion of juveniles, pregnant women, and the mentally ill, apparently leaving any prisoner who didn’t fit into one of those categories to fend for himself. In the end, the jail – which opened at a time when there were only 33 states in the union, the year that "A Tale of Two Cities" and "On the Origin of Species" were published, and when the works of Johannes Brahms were being heard for the first time – remained untouched.

These memories returned quickly after reading a recent New York Times story about a homeless veteran with mental illness who died in his jail cell, presumably because of excessive heat. The man had been incarcerated for a misdemeanor and held only because he couldn’t make bail. The fact that this happened in winter tells me a lot about the nature of the facility’s heating and ventilation system.

The first thing that struck me about this story was the need to invoke certain adjectives, as though readers would not care about the story if the prisoner who died was not mentally ill or was not a veteran. There may be some truth to that concern. When it comes to prison reform, I’ve seen the tendency within psychiatry to limit discussions only to conditions as they affect the mentally ill. This was not always the case. Dr. Benjamin Rush, founder of Pennsylvania Hospital, also founded one of the first prison reformation societies. He advocated humane care for everyone in the facility, not just a certain faction.

Unless someone figures out how to "cure" crime, we will always need jails and prisons. Building a new facility is neither a failure nor a waste of resources. It may be the beginning of a long-term commitment to rehabilitation.

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.

Late in February, I drove to Annapolis, Md., to listen to testimony being given to our state’s Senate Finance Committee on a number of proposed bills relating to involuntary treatments. But this article is not going to be about those bills or the fuss that played out around them, but rather about what happened when I arrived a bit early and heard testimony on another piece of legislation that had nothing to do with psychiatry and everything to do with being human.

Ten bills were scheduled for public testimony that afternoon, and I arrived shortly after 1 p.m. to a hearing room in which there was standing room only. There are 11 members of the Senate Finance Committee; 10 were present, and I’m going to guess there were more than100 people in the room waiting to testify. The only other time I had gone to listen to public testimony was last year for Gov. Martin O’Malley’s Firearm Safety Act, and for that piece of legislation, 1,300 people were there to testify, the large majority of them being Second Amendment activists who were there to oppose the bill.

The legislation in question (the one I did not come to hear about) was Senate Bill 654. The description of that bill reads:

"This bill requires the Department of Health and Mental Hygiene to identify up-to-date, evidence-based, written information about Down syndrome. This information must be provided to health care facilities and providers, who must provide the information to expectant parents who receive a prenatal test result for Down syndrome and parents of a child diagnosed with Down syndrome."

My first thought was this is a standard of care issue, something to be addressed by the specialties involved, not something that should be the subject of legislation. We don’t really want to have condition-specific laws mandating what physicians must tell their patients, do we? Where would it stop: Would legislation be written for every disorder? Shouldn’t the clinician who knows the family determine what information is best for each individual and with what timing? Never mind the nuance of figuring out exactly what is "up to date" and what is not. And it’s not as though the parents couldn’t search for the information themselves – certainly there must be resources online.

Then the testimony began. There were women whose children had been diagnosed, generally in utero, before the time when one could Google the condition and search for available resources. They told stories of asking for resources, only to be told that their clinicians didn’t know of any. And they told stories of being counseled to abort after they wanted to continue with the pregnancy. They discussed how shocked and alone they felt, and how insensitive the care they received was. In addition, they talked about the value their children added to the world. And then the adult children with Down syndrome also testified. In a way, I felt like it was testimony for the rights of these people to be here, more so perhaps than testimony to require clinicians to give out the appropriate pamphlets.

Representatives from MedChi (the Maryland State Medical Society) and the Department of Health and Mental Hygiene also testified. While neither was opposed to the creation of lists and websites of resources and educational information, they did object to the mandate that the clinician must give the information at a specific time. What if the clinician felt it was not in that patient’s best interest to distribute the information to a specific patient or at a specific time? Perhaps it wasn’t there, but I heard the unspoken concern that the clinician might be subject to sanctions or accusations of malpractice if they neglected to distribute the information as required by law if the legislation passed. The Down syndrome information supporters said they had already gone office to office to provide pamphlets and information to clinicians, which were then placed in a drawer and not distributed. They objected to language that would change "must" to "may" with the idea that it wasn’t strong enough to move clinicians to action.

Another bill also caught my attention this year, although I was not present for any public testimony. Delegate Robert A. Costa proposed House Bill 279, legislation that would forbid a physician from charging or filing an insurance claim for any appointment that began more than 30 minutes from the scheduled time. The legislation did allow for an exclusion for emergencies, if the doctor presented an "emergency services verification number" to the patient, but it did not take into account that an appointment might start late because the patient was late!

Regardless of whether the legislation proposed by these two bills makes sense as something for lawmakers to address, and regardless of how practical they are in terms of both their intended and unintended consequences, the message of such legislation is clear: They represent distress at insensitive care and an attempt to legislate kindness. The message comes through that clinicians can’t be trusted to do what’s right, and laws must be passed to make sure they practice in a thoughtful and considerate manner. It would be nice to have some reasonable conclusion about how to rectify these situations without having legislators tell medical professionals how to practice. I don’t have an answer here, but I believe that passing more laws will create its own negative fallout, and we need to find a better route to kindness.

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

[email protected]

Late in February, I drove to Annapolis, Md., to listen to testimony being given to our state’s Senate Finance Committee on a number of proposed bills relating to involuntary treatments. But this article is not going to be about those bills or the fuss that played out around them, but rather about what happened when I arrived a bit early and heard testimony on another piece of legislation that had nothing to do with psychiatry and everything to do with being human.

Ten bills were scheduled for public testimony that afternoon, and I arrived shortly after 1 p.m. to a hearing room in which there was standing room only. There are 11 members of the Senate Finance Committee; 10 were present, and I’m going to guess there were more than100 people in the room waiting to testify. The only other time I had gone to listen to public testimony was last year for Gov. Martin O’Malley’s Firearm Safety Act, and for that piece of legislation, 1,300 people were there to testify, the large majority of them being Second Amendment activists who were there to oppose the bill.

The legislation in question (the one I did not come to hear about) was Senate Bill 654. The description of that bill reads:

"This bill requires the Department of Health and Mental Hygiene to identify up-to-date, evidence-based, written information about Down syndrome. This information must be provided to health care facilities and providers, who must provide the information to expectant parents who receive a prenatal test result for Down syndrome and parents of a child diagnosed with Down syndrome."

My first thought was this is a standard of care issue, something to be addressed by the specialties involved, not something that should be the subject of legislation. We don’t really want to have condition-specific laws mandating what physicians must tell their patients, do we? Where would it stop: Would legislation be written for every disorder? Shouldn’t the clinician who knows the family determine what information is best for each individual and with what timing? Never mind the nuance of figuring out exactly what is "up to date" and what is not. And it’s not as though the parents couldn’t search for the information themselves – certainly there must be resources online.

Then the testimony began. There were women whose children had been diagnosed, generally in utero, before the time when one could Google the condition and search for available resources. They told stories of asking for resources, only to be told that their clinicians didn’t know of any. And they told stories of being counseled to abort after they wanted to continue with the pregnancy. They discussed how shocked and alone they felt, and how insensitive the care they received was. In addition, they talked about the value their children added to the world. And then the adult children with Down syndrome also testified. In a way, I felt like it was testimony for the rights of these people to be here, more so perhaps than testimony to require clinicians to give out the appropriate pamphlets.

Representatives from MedChi (the Maryland State Medical Society) and the Department of Health and Mental Hygiene also testified. While neither was opposed to the creation of lists and websites of resources and educational information, they did object to the mandate that the clinician must give the information at a specific time. What if the clinician felt it was not in that patient’s best interest to distribute the information to a specific patient or at a specific time? Perhaps it wasn’t there, but I heard the unspoken concern that the clinician might be subject to sanctions or accusations of malpractice if they neglected to distribute the information as required by law if the legislation passed. The Down syndrome information supporters said they had already gone office to office to provide pamphlets and information to clinicians, which were then placed in a drawer and not distributed. They objected to language that would change "must" to "may" with the idea that it wasn’t strong enough to move clinicians to action.

Another bill also caught my attention this year, although I was not present for any public testimony. Delegate Robert A. Costa proposed House Bill 279, legislation that would forbid a physician from charging or filing an insurance claim for any appointment that began more than 30 minutes from the scheduled time. The legislation did allow for an exclusion for emergencies, if the doctor presented an "emergency services verification number" to the patient, but it did not take into account that an appointment might start late because the patient was late!

Regardless of whether the legislation proposed by these two bills makes sense as something for lawmakers to address, and regardless of how practical they are in terms of both their intended and unintended consequences, the message of such legislation is clear: They represent distress at insensitive care and an attempt to legislate kindness. The message comes through that clinicians can’t be trusted to do what’s right, and laws must be passed to make sure they practice in a thoughtful and considerate manner. It would be nice to have some reasonable conclusion about how to rectify these situations without having legislators tell medical professionals how to practice. I don’t have an answer here, but I believe that passing more laws will create its own negative fallout, and we need to find a better route to kindness.

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

[email protected]

Late in February, I drove to Annapolis, Md., to listen to testimony being given to our state’s Senate Finance Committee on a number of proposed bills relating to involuntary treatments. But this article is not going to be about those bills or the fuss that played out around them, but rather about what happened when I arrived a bit early and heard testimony on another piece of legislation that had nothing to do with psychiatry and everything to do with being human.

Ten bills were scheduled for public testimony that afternoon, and I arrived shortly after 1 p.m. to a hearing room in which there was standing room only. There are 11 members of the Senate Finance Committee; 10 were present, and I’m going to guess there were more than100 people in the room waiting to testify. The only other time I had gone to listen to public testimony was last year for Gov. Martin O’Malley’s Firearm Safety Act, and for that piece of legislation, 1,300 people were there to testify, the large majority of them being Second Amendment activists who were there to oppose the bill.

The legislation in question (the one I did not come to hear about) was Senate Bill 654. The description of that bill reads:

"This bill requires the Department of Health and Mental Hygiene to identify up-to-date, evidence-based, written information about Down syndrome. This information must be provided to health care facilities and providers, who must provide the information to expectant parents who receive a prenatal test result for Down syndrome and parents of a child diagnosed with Down syndrome."

My first thought was this is a standard of care issue, something to be addressed by the specialties involved, not something that should be the subject of legislation. We don’t really want to have condition-specific laws mandating what physicians must tell their patients, do we? Where would it stop: Would legislation be written for every disorder? Shouldn’t the clinician who knows the family determine what information is best for each individual and with what timing? Never mind the nuance of figuring out exactly what is "up to date" and what is not. And it’s not as though the parents couldn’t search for the information themselves – certainly there must be resources online.

Then the testimony began. There were women whose children had been diagnosed, generally in utero, before the time when one could Google the condition and search for available resources. They told stories of asking for resources, only to be told that their clinicians didn’t know of any. And they told stories of being counseled to abort after they wanted to continue with the pregnancy. They discussed how shocked and alone they felt, and how insensitive the care they received was. In addition, they talked about the value their children added to the world. And then the adult children with Down syndrome also testified. In a way, I felt like it was testimony for the rights of these people to be here, more so perhaps than testimony to require clinicians to give out the appropriate pamphlets.

Representatives from MedChi (the Maryland State Medical Society) and the Department of Health and Mental Hygiene also testified. While neither was opposed to the creation of lists and websites of resources and educational information, they did object to the mandate that the clinician must give the information at a specific time. What if the clinician felt it was not in that patient’s best interest to distribute the information to a specific patient or at a specific time? Perhaps it wasn’t there, but I heard the unspoken concern that the clinician might be subject to sanctions or accusations of malpractice if they neglected to distribute the information as required by law if the legislation passed. The Down syndrome information supporters said they had already gone office to office to provide pamphlets and information to clinicians, which were then placed in a drawer and not distributed. They objected to language that would change "must" to "may" with the idea that it wasn’t strong enough to move clinicians to action.

Another bill also caught my attention this year, although I was not present for any public testimony. Delegate Robert A. Costa proposed House Bill 279, legislation that would forbid a physician from charging or filing an insurance claim for any appointment that began more than 30 minutes from the scheduled time. The legislation did allow for an exclusion for emergencies, if the doctor presented an "emergency services verification number" to the patient, but it did not take into account that an appointment might start late because the patient was late!

Regardless of whether the legislation proposed by these two bills makes sense as something for lawmakers to address, and regardless of how practical they are in terms of both their intended and unintended consequences, the message of such legislation is clear: They represent distress at insensitive care and an attempt to legislate kindness. The message comes through that clinicians can’t be trusted to do what’s right, and laws must be passed to make sure they practice in a thoughtful and considerate manner. It would be nice to have some reasonable conclusion about how to rectify these situations without having legislators tell medical professionals how to practice. I don’t have an answer here, but I believe that passing more laws will create its own negative fallout, and we need to find a better route to kindness.

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

[email protected]

Recently, the Senate Judiciary Committee heard testimony regarding the use of solitary confinement in the Federal Bureau of Prisons. This was the second hearing on this issue, which featured testimony from the director of the federal system, from several human rights organizations, from state prison officials, and from former inmates themselves. Although one of the main concerns of the hearing was the psychological effects of solitary confinement, only one of the 11 speakers was a mental health professional. Psychology professor Craig Haney, Ph.D., has spent 30 years studying the effects of solitary confinement; however, by his own testimony, he did this primarily as an expert witness retained in the context of correctional litigation. None of those offering testimony was a mental health professional actively involved in the treatment of segregated prisoners. In fact, according to the curriculum vitae that Dr. Haney filed in his capacity as an expert in the California prison overcrowding case, Dr. Haney has never worked in a jail or a prison.

During the hearing, Sen. Al Franken (D-Minn.) made a reference to the risks some inmates posed to prison "guards." For those readers who have never worked in corrections, this is a tremendous faux pas. A "guard" is a generic term for a civilian hired by a private company or business who is given minimal training, slapped into a uniform, and told to stand watch over something. A correctional officer is a law enforcement professional who is trained, regulated, and monitored by the state. A correctional officer is a professional with a code of ethics and who is granted police powers, including the right to use deadly force. Confusing a correctional officer with a "guard" is like mistaking a Navy Seal for a Boy Scout.

So we have a hearing about the psychological effects of confinement in which a psychologist with no correctional experience is testifying before a senator who is not familiar with even basic correctional training standards. What could possibly go wrong?

This topic is close to my heart lately, because there is a bill currently before the Maryland General Assembly to study the use of solitary confinement in our prison system. I’ve read the bill, I’ve listened to the testimony, and I have a few opinions on the issue myself.

First, a few stipulations and clarifications. People involved in this issue tend to confuse terminology related to restricted housing within a correctional facility. The term "solitary confinement" traditionally means a housing situation in which the inmate is placed alone in a cell. The term "administrative segregation" or "ad seg" is sometimes used interchangeably with "disciplinary segregation," although this is not accurate. Disciplinary segregation means that the inmate is removed from the general population because of a rule violation. Inmates on disciplinary segregation are often barred from owning certain property like a television or radio. Visiting privileges and phone calls may also be restricted as a punishment.

In contrast, an inmate could be placed on administrative segregation for nondisciplinary reasons if the prisoner requires medical isolation temporarily, if the inmate voluntarily requests special housing, or if there is a need for protective custody. In this case, the inmate is still allowed to own property, and he retains basic visiting and telephone privileges. In all cases, there is time allowed out of the cell for exercise and recreation. There is also still access to medical and mental health services.

Regarding the stipulations, I don’t question that the prevalence of mental illness among prisoners will be high in a facility that is designated as maximum security or in a control unit prison. I also agree that solitary confinement, or housing without a cellmate, is a bad idea for a prisoner who is deemed a high suicide risk. I agree that boredom and lack of activity are generally a very bad thing for anyone, prisoner or not, and that we shouldn’t keep prisoners on segregation status longer than is necessary to accomplish the intended purpose of the housing.

Here’s where the agreement ends: I don’t think restricted housing is automatically and consistently bad for everyone, and I certainly don’t agree that the segregated housing itself causes whatever mental disturbance may be present. Association does not prove cause and effect, and the number of well-designed, controlled studies of this issue are too few and far between to allow a causal link to be drawn. I realize that this goes against the grain of most court findings on this issue, but that’s the state of the science. I was not surprised to see that the proponents of the solitary confinement bill didn’t mention contradictory evidence. Few journalists in the traditional media have, either.

I think when it comes to dictating prison policy, our legislators need to realize how dangerous our prison systems have become. According to the Bureau of Justice Statistics, between 2001 and 2011, the number of murders in American prisons increased by 79%. During that time my own state ranked second in the country in per capita prison murders. According to the testimony by the federal prison director, 47% of the inmates confined in the Florence SuperMax facility – the institution at the heart of the latest class action suit over solitary confinement – are there for killing another prisoner or staff member while incarcerated. Some of them have killed more than once. If one of my patients tells me that he feels safer in segregated housing and wants to be there, I’m not going to question that, and I hope no outside politician or advocacy group is going to criticize that intervention.

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, the Senate Judiciary Committee heard testimony regarding the use of solitary confinement in the Federal Bureau of Prisons. This was the second hearing on this issue, which featured testimony from the director of the federal system, from several human rights organizations, from state prison officials, and from former inmates themselves. Although one of the main concerns of the hearing was the psychological effects of solitary confinement, only one of the 11 speakers was a mental health professional. Psychology professor Craig Haney, Ph.D., has spent 30 years studying the effects of solitary confinement; however, by his own testimony, he did this primarily as an expert witness retained in the context of correctional litigation. None of those offering testimony was a mental health professional actively involved in the treatment of segregated prisoners. In fact, according to the curriculum vitae that Dr. Haney filed in his capacity as an expert in the California prison overcrowding case, Dr. Haney has never worked in a jail or a prison.

During the hearing, Sen. Al Franken (D-Minn.) made a reference to the risks some inmates posed to prison "guards." For those readers who have never worked in corrections, this is a tremendous faux pas. A "guard" is a generic term for a civilian hired by a private company or business who is given minimal training, slapped into a uniform, and told to stand watch over something. A correctional officer is a law enforcement professional who is trained, regulated, and monitored by the state. A correctional officer is a professional with a code of ethics and who is granted police powers, including the right to use deadly force. Confusing a correctional officer with a "guard" is like mistaking a Navy Seal for a Boy Scout.

So we have a hearing about the psychological effects of confinement in which a psychologist with no correctional experience is testifying before a senator who is not familiar with even basic correctional training standards. What could possibly go wrong?

This topic is close to my heart lately, because there is a bill currently before the Maryland General Assembly to study the use of solitary confinement in our prison system. I’ve read the bill, I’ve listened to the testimony, and I have a few opinions on the issue myself.

First, a few stipulations and clarifications. People involved in this issue tend to confuse terminology related to restricted housing within a correctional facility. The term "solitary confinement" traditionally means a housing situation in which the inmate is placed alone in a cell. The term "administrative segregation" or "ad seg" is sometimes used interchangeably with "disciplinary segregation," although this is not accurate. Disciplinary segregation means that the inmate is removed from the general population because of a rule violation. Inmates on disciplinary segregation are often barred from owning certain property like a television or radio. Visiting privileges and phone calls may also be restricted as a punishment.

In contrast, an inmate could be placed on administrative segregation for nondisciplinary reasons if the prisoner requires medical isolation temporarily, if the inmate voluntarily requests special housing, or if there is a need for protective custody. In this case, the inmate is still allowed to own property, and he retains basic visiting and telephone privileges. In all cases, there is time allowed out of the cell for exercise and recreation. There is also still access to medical and mental health services.

Regarding the stipulations, I don’t question that the prevalence of mental illness among prisoners will be high in a facility that is designated as maximum security or in a control unit prison. I also agree that solitary confinement, or housing without a cellmate, is a bad idea for a prisoner who is deemed a high suicide risk. I agree that boredom and lack of activity are generally a very bad thing for anyone, prisoner or not, and that we shouldn’t keep prisoners on segregation status longer than is necessary to accomplish the intended purpose of the housing.

Here’s where the agreement ends: I don’t think restricted housing is automatically and consistently bad for everyone, and I certainly don’t agree that the segregated housing itself causes whatever mental disturbance may be present. Association does not prove cause and effect, and the number of well-designed, controlled studies of this issue are too few and far between to allow a causal link to be drawn. I realize that this goes against the grain of most court findings on this issue, but that’s the state of the science. I was not surprised to see that the proponents of the solitary confinement bill didn’t mention contradictory evidence. Few journalists in the traditional media have, either.

I think when it comes to dictating prison policy, our legislators need to realize how dangerous our prison systems have become. According to the Bureau of Justice Statistics, between 2001 and 2011, the number of murders in American prisons increased by 79%. During that time my own state ranked second in the country in per capita prison murders. According to the testimony by the federal prison director, 47% of the inmates confined in the Florence SuperMax facility – the institution at the heart of the latest class action suit over solitary confinement – are there for killing another prisoner or staff member while incarcerated. Some of them have killed more than once. If one of my patients tells me that he feels safer in segregated housing and wants to be there, I’m not going to question that, and I hope no outside politician or advocacy group is going to criticize that intervention.

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, the Senate Judiciary Committee heard testimony regarding the use of solitary confinement in the Federal Bureau of Prisons. This was the second hearing on this issue, which featured testimony from the director of the federal system, from several human rights organizations, from state prison officials, and from former inmates themselves. Although one of the main concerns of the hearing was the psychological effects of solitary confinement, only one of the 11 speakers was a mental health professional. Psychology professor Craig Haney, Ph.D., has spent 30 years studying the effects of solitary confinement; however, by his own testimony, he did this primarily as an expert witness retained in the context of correctional litigation. None of those offering testimony was a mental health professional actively involved in the treatment of segregated prisoners. In fact, according to the curriculum vitae that Dr. Haney filed in his capacity as an expert in the California prison overcrowding case, Dr. Haney has never worked in a jail or a prison.

During the hearing, Sen. Al Franken (D-Minn.) made a reference to the risks some inmates posed to prison "guards." For those readers who have never worked in corrections, this is a tremendous faux pas. A "guard" is a generic term for a civilian hired by a private company or business who is given minimal training, slapped into a uniform, and told to stand watch over something. A correctional officer is a law enforcement professional who is trained, regulated, and monitored by the state. A correctional officer is a professional with a code of ethics and who is granted police powers, including the right to use deadly force. Confusing a correctional officer with a "guard" is like mistaking a Navy Seal for a Boy Scout.

So we have a hearing about the psychological effects of confinement in which a psychologist with no correctional experience is testifying before a senator who is not familiar with even basic correctional training standards. What could possibly go wrong?

This topic is close to my heart lately, because there is a bill currently before the Maryland General Assembly to study the use of solitary confinement in our prison system. I’ve read the bill, I’ve listened to the testimony, and I have a few opinions on the issue myself.

First, a few stipulations and clarifications. People involved in this issue tend to confuse terminology related to restricted housing within a correctional facility. The term "solitary confinement" traditionally means a housing situation in which the inmate is placed alone in a cell. The term "administrative segregation" or "ad seg" is sometimes used interchangeably with "disciplinary segregation," although this is not accurate. Disciplinary segregation means that the inmate is removed from the general population because of a rule violation. Inmates on disciplinary segregation are often barred from owning certain property like a television or radio. Visiting privileges and phone calls may also be restricted as a punishment.

In contrast, an inmate could be placed on administrative segregation for nondisciplinary reasons if the prisoner requires medical isolation temporarily, if the inmate voluntarily requests special housing, or if there is a need for protective custody. In this case, the inmate is still allowed to own property, and he retains basic visiting and telephone privileges. In all cases, there is time allowed out of the cell for exercise and recreation. There is also still access to medical and mental health services.

Regarding the stipulations, I don’t question that the prevalence of mental illness among prisoners will be high in a facility that is designated as maximum security or in a control unit prison. I also agree that solitary confinement, or housing without a cellmate, is a bad idea for a prisoner who is deemed a high suicide risk. I agree that boredom and lack of activity are generally a very bad thing for anyone, prisoner or not, and that we shouldn’t keep prisoners on segregation status longer than is necessary to accomplish the intended purpose of the housing.

Here’s where the agreement ends: I don’t think restricted housing is automatically and consistently bad for everyone, and I certainly don’t agree that the segregated housing itself causes whatever mental disturbance may be present. Association does not prove cause and effect, and the number of well-designed, controlled studies of this issue are too few and far between to allow a causal link to be drawn. I realize that this goes against the grain of most court findings on this issue, but that’s the state of the science. I was not surprised to see that the proponents of the solitary confinement bill didn’t mention contradictory evidence. Few journalists in the traditional media have, either.

I think when it comes to dictating prison policy, our legislators need to realize how dangerous our prison systems have become. According to the Bureau of Justice Statistics, between 2001 and 2011, the number of murders in American prisons increased by 79%. During that time my own state ranked second in the country in per capita prison murders. According to the testimony by the federal prison director, 47% of the inmates confined in the Florence SuperMax facility – the institution at the heart of the latest class action suit over solitary confinement – are there for killing another prisoner or staff member while incarcerated. Some of them have killed more than once. If one of my patients tells me that he feels safer in segregated housing and wants to be there, I’m not going to question that, and I hope no outside politician or advocacy group is going to criticize that intervention.

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.

In my last column, I summarized a lecture given by Jeffrey Swanson, Ph.D., a medical sociologist who studies outcomes with outpatient civil commitment. Several readers posted comments, including a very articulate letter from Evelyn Burton, a patient advocate who is on the Public Policy Committee of the National Alliance on Mental Illness–Maryland (NAMI MD).

Ms. Burton, along with one or two other commenters, believed that I missed the point of "assisted outpatient treatment" (AOT) and did not understand the target population; and I will contend that, with 20 years of experience in four community mental health centers, including Baltimore’s Health Care for the Homeless, I do understand that there are some people who might do better if forced to undergo treatment. I also understand that the consequences of untreated mental illness can be both trying and tragic for the patients and their families.

Because Maryland has not legalized forced outpatient care, I do not have experience with this, and I was struck by the fact that Dr. Swanson felt that much of the benefit of forcing treatment could be explained by the way AOT obligates society to the patient by granting these patients case management services, housing, and access to mental health care – things that society is not obligated to provide for those with severe psychotic disorders who willingly seek care. Done poorly, AOT is often unenforceable and poorly funded, and laws may be written such that the intended target population – the sickest, most psychotic members of society who cycle in and out of hospitals due to their noncompliance – are not clearly identified as those to receive "assisted" treatment.

While we may agree or disagree as to whether AOT is helpful and under what circumstances and whether it benefits those who might otherwise end up on the streets, in jail, or dead, the truth is that states with AOT still have psychotic people living on the streets and eating from the garbage. AOT has not proven to be a panacea for homelessness, suicide, or wasted lives. I realize that to a parent who fears her child might join those ranks, the heartbreak is immense, and the anecdotes about forced treatment offer hope.

I have no doubt that there are times when AOT, together with its attendant services, provides a lifeline. It’s unfortunate – if not disgraceful – that these services are not routinely provided to our sickest members of society. Still, it’s important to make sure that any given patient’s civil rights be considered. I’m also well aware that there are people who believe that a discussion of civil rights has no place in the treatment of psychosis, and there we will need to respectfully disagree.

While Ms. Burton’s heartfelt letter was articulate and compelling, I have to say that I was taken back by one paragraph. I expressed concern that patients do not generally endorse involuntary treatments, and I suggested that we need to look at why the treatments we offer are not palatable to those receiving forced care.

Ms. Burton responded:

"You do not need to waste your time trying to figure out why your treatment is not palatable to this particular group of individuals. NAMI MD families can tell you, you are asking the wrong question. It has nothing to do with palatable services and everything to do with anosognosia."

I was baffled by this. Compliant patients with good insight complain about side effects. If they take antipsychotic medications, they sometimes feel sedated, and they are told of the risks of weight gain, diabetes, and hyperlipidemia, conditions that can decrease both the quality and length of their lives. Sometimes we have little choice and are left to say that we believe the benefit to the patient is worth the trade-off, but with voluntary patients, the ultimate decision is theirs. Sometimes patients talk with their feet. Sometimes they fare better without medications, therapy, and the other treatments we have to offer, and sometimes they fare catastrophically worse. If they always did better, lived fuller, healthier, happier, and longer lives with the treatments we offer, the choice would be simple. Unfortunately, the medications we offer to treat psychosis are not benign.

The idea that "anosognosia," or simply lack of insight, is the pivotal issue, is a difficult one. People with substance abuse disorders, especially alcoholism and cannabis abuse, may insist that their use of these intoxicants is consistent with the societal norms around them and deny that it’s a problem, despite the difficulties it brings to them. And people with major mental illnesses may deny their existence, but still come to appointments and take prescribed medications. Patients can lack insight at one point in time and gain it later. The issue should not be the patient’s insight, because that label may be stamped on anyone who simply disagrees with their diagnosis or treatment recommendations.

The risk of labeling people with anosognosia is that we might cease to see them as humans, that we might write off their resistance to treatment as simply an inability to know what’s best for them, in a way that enables us to close our ears to what may well be their valid concerns. It may become too easy to say that the court order calls for the medications, and changing doses or medications to alter the risks or the side-effect profile is no longer part of the effort. Such a mind-set may lead the psychiatrist to complacence and disregard for the patient’s concerns.

Why take the time to know the patient, to develop rapport, to convince the patient to come to therapy and to try medications on his terms, when a court order might cut all those corners and a nurse can administer an injection? That’s not the targeted group of patients, you say, that’s not whom AOT captures. If we’re not careful – if we feel that addressing the concerns of our patients is simply a "waste of time" because, after all, they have no insight – then we risk losing sight of what needs to be our real goal: helping patients to live the lives they want to live in productive and meaningful ways. Forcing treatment may get one person help at a particular period in time, but it comes with a cost: It leaves some patients afraid to seek voluntary care for fear of what may occur down the line, and it stigmatizes our profession. Finally, it makes us the adversaries of the patients we serve.

It would be easy to read this and think I’m against involuntary outpatient treatment, and that’s not completely true (ah, it’s mostly true). If involuntary treatment is limited to those patients who cycle in and out of hospitals and jails because of noncompliance, who become dangerous when ill, for whom treatment has proven to be effective, and who have failed thoughtful attempts at voluntary care, then forced care with its array of ancillary services and housing provisions may be a reasonable resource, regardless of the patient’s level of insight. Still, I remain interested in making our treatments more palatable to all of our patients – those who are forced into care as well as those who come willingly – and I believe it’s a mistake to see that effort as a waste of anyone’s time.

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

In my last column, I summarized a lecture given by Jeffrey Swanson, Ph.D., a medical sociologist who studies outcomes with outpatient civil commitment. Several readers posted comments, including a very articulate letter from Evelyn Burton, a patient advocate who is on the Public Policy Committee of the National Alliance on Mental Illness–Maryland (NAMI MD).

Ms. Burton, along with one or two other commenters, believed that I missed the point of "assisted outpatient treatment" (AOT) and did not understand the target population; and I will contend that, with 20 years of experience in four community mental health centers, including Baltimore’s Health Care for the Homeless, I do understand that there are some people who might do better if forced to undergo treatment. I also understand that the consequences of untreated mental illness can be both trying and tragic for the patients and their families.

Because Maryland has not legalized forced outpatient care, I do not have experience with this, and I was struck by the fact that Dr. Swanson felt that much of the benefit of forcing treatment could be explained by the way AOT obligates society to the patient by granting these patients case management services, housing, and access to mental health care – things that society is not obligated to provide for those with severe psychotic disorders who willingly seek care. Done poorly, AOT is often unenforceable and poorly funded, and laws may be written such that the intended target population – the sickest, most psychotic members of society who cycle in and out of hospitals due to their noncompliance – are not clearly identified as those to receive "assisted" treatment.

While we may agree or disagree as to whether AOT is helpful and under what circumstances and whether it benefits those who might otherwise end up on the streets, in jail, or dead, the truth is that states with AOT still have psychotic people living on the streets and eating from the garbage. AOT has not proven to be a panacea for homelessness, suicide, or wasted lives. I realize that to a parent who fears her child might join those ranks, the heartbreak is immense, and the anecdotes about forced treatment offer hope.

I have no doubt that there are times when AOT, together with its attendant services, provides a lifeline. It’s unfortunate – if not disgraceful – that these services are not routinely provided to our sickest members of society. Still, it’s important to make sure that any given patient’s civil rights be considered. I’m also well aware that there are people who believe that a discussion of civil rights has no place in the treatment of psychosis, and there we will need to respectfully disagree.

While Ms. Burton’s heartfelt letter was articulate and compelling, I have to say that I was taken back by one paragraph. I expressed concern that patients do not generally endorse involuntary treatments, and I suggested that we need to look at why the treatments we offer are not palatable to those receiving forced care.

Ms. Burton responded:

"You do not need to waste your time trying to figure out why your treatment is not palatable to this particular group of individuals. NAMI MD families can tell you, you are asking the wrong question. It has nothing to do with palatable services and everything to do with anosognosia."

I was baffled by this. Compliant patients with good insight complain about side effects. If they take antipsychotic medications, they sometimes feel sedated, and they are told of the risks of weight gain, diabetes, and hyperlipidemia, conditions that can decrease both the quality and length of their lives. Sometimes we have little choice and are left to say that we believe the benefit to the patient is worth the trade-off, but with voluntary patients, the ultimate decision is theirs. Sometimes patients talk with their feet. Sometimes they fare better without medications, therapy, and the other treatments we have to offer, and sometimes they fare catastrophically worse. If they always did better, lived fuller, healthier, happier, and longer lives with the treatments we offer, the choice would be simple. Unfortunately, the medications we offer to treat psychosis are not benign.

The idea that "anosognosia," or simply lack of insight, is the pivotal issue, is a difficult one. People with substance abuse disorders, especially alcoholism and cannabis abuse, may insist that their use of these intoxicants is consistent with the societal norms around them and deny that it’s a problem, despite the difficulties it brings to them. And people with major mental illnesses may deny their existence, but still come to appointments and take prescribed medications. Patients can lack insight at one point in time and gain it later. The issue should not be the patient’s insight, because that label may be stamped on anyone who simply disagrees with their diagnosis or treatment recommendations.

The risk of labeling people with anosognosia is that we might cease to see them as humans, that we might write off their resistance to treatment as simply an inability to know what’s best for them, in a way that enables us to close our ears to what may well be their valid concerns. It may become too easy to say that the court order calls for the medications, and changing doses or medications to alter the risks or the side-effect profile is no longer part of the effort. Such a mind-set may lead the psychiatrist to complacence and disregard for the patient’s concerns.

Why take the time to know the patient, to develop rapport, to convince the patient to come to therapy and to try medications on his terms, when a court order might cut all those corners and a nurse can administer an injection? That’s not the targeted group of patients, you say, that’s not whom AOT captures. If we’re not careful – if we feel that addressing the concerns of our patients is simply a "waste of time" because, after all, they have no insight – then we risk losing sight of what needs to be our real goal: helping patients to live the lives they want to live in productive and meaningful ways. Forcing treatment may get one person help at a particular period in time, but it comes with a cost: It leaves some patients afraid to seek voluntary care for fear of what may occur down the line, and it stigmatizes our profession. Finally, it makes us the adversaries of the patients we serve.

It would be easy to read this and think I’m against involuntary outpatient treatment, and that’s not completely true (ah, it’s mostly true). If involuntary treatment is limited to those patients who cycle in and out of hospitals and jails because of noncompliance, who become dangerous when ill, for whom treatment has proven to be effective, and who have failed thoughtful attempts at voluntary care, then forced care with its array of ancillary services and housing provisions may be a reasonable resource, regardless of the patient’s level of insight. Still, I remain interested in making our treatments more palatable to all of our patients – those who are forced into care as well as those who come willingly – and I believe it’s a mistake to see that effort as a waste of anyone’s time.

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

In my last column, I summarized a lecture given by Jeffrey Swanson, Ph.D., a medical sociologist who studies outcomes with outpatient civil commitment. Several readers posted comments, including a very articulate letter from Evelyn Burton, a patient advocate who is on the Public Policy Committee of the National Alliance on Mental Illness–Maryland (NAMI MD).

Ms. Burton, along with one or two other commenters, believed that I missed the point of "assisted outpatient treatment" (AOT) and did not understand the target population; and I will contend that, with 20 years of experience in four community mental health centers, including Baltimore’s Health Care for the Homeless, I do understand that there are some people who might do better if forced to undergo treatment. I also understand that the consequences of untreated mental illness can be both trying and tragic for the patients and their families.

Because Maryland has not legalized forced outpatient care, I do not have experience with this, and I was struck by the fact that Dr. Swanson felt that much of the benefit of forcing treatment could be explained by the way AOT obligates society to the patient by granting these patients case management services, housing, and access to mental health care – things that society is not obligated to provide for those with severe psychotic disorders who willingly seek care. Done poorly, AOT is often unenforceable and poorly funded, and laws may be written such that the intended target population – the sickest, most psychotic members of society who cycle in and out of hospitals due to their noncompliance – are not clearly identified as those to receive "assisted" treatment.

While we may agree or disagree as to whether AOT is helpful and under what circumstances and whether it benefits those who might otherwise end up on the streets, in jail, or dead, the truth is that states with AOT still have psychotic people living on the streets and eating from the garbage. AOT has not proven to be a panacea for homelessness, suicide, or wasted lives. I realize that to a parent who fears her child might join those ranks, the heartbreak is immense, and the anecdotes about forced treatment offer hope.

I have no doubt that there are times when AOT, together with its attendant services, provides a lifeline. It’s unfortunate – if not disgraceful – that these services are not routinely provided to our sickest members of society. Still, it’s important to make sure that any given patient’s civil rights be considered. I’m also well aware that there are people who believe that a discussion of civil rights has no place in the treatment of psychosis, and there we will need to respectfully disagree.

While Ms. Burton’s heartfelt letter was articulate and compelling, I have to say that I was taken back by one paragraph. I expressed concern that patients do not generally endorse involuntary treatments, and I suggested that we need to look at why the treatments we offer are not palatable to those receiving forced care.

Ms. Burton responded:

"You do not need to waste your time trying to figure out why your treatment is not palatable to this particular group of individuals. NAMI MD families can tell you, you are asking the wrong question. It has nothing to do with palatable services and everything to do with anosognosia."

I was baffled by this. Compliant patients with good insight complain about side effects. If they take antipsychotic medications, they sometimes feel sedated, and they are told of the risks of weight gain, diabetes, and hyperlipidemia, conditions that can decrease both the quality and length of their lives. Sometimes we have little choice and are left to say that we believe the benefit to the patient is worth the trade-off, but with voluntary patients, the ultimate decision is theirs. Sometimes patients talk with their feet. Sometimes they fare better without medications, therapy, and the other treatments we have to offer, and sometimes they fare catastrophically worse. If they always did better, lived fuller, healthier, happier, and longer lives with the treatments we offer, the choice would be simple. Unfortunately, the medications we offer to treat psychosis are not benign.

The idea that "anosognosia," or simply lack of insight, is the pivotal issue, is a difficult one. People with substance abuse disorders, especially alcoholism and cannabis abuse, may insist that their use of these intoxicants is consistent with the societal norms around them and deny that it’s a problem, despite the difficulties it brings to them. And people with major mental illnesses may deny their existence, but still come to appointments and take prescribed medications. Patients can lack insight at one point in time and gain it later. The issue should not be the patient’s insight, because that label may be stamped on anyone who simply disagrees with their diagnosis or treatment recommendations.

The risk of labeling people with anosognosia is that we might cease to see them as humans, that we might write off their resistance to treatment as simply an inability to know what’s best for them, in a way that enables us to close our ears to what may well be their valid concerns. It may become too easy to say that the court order calls for the medications, and changing doses or medications to alter the risks or the side-effect profile is no longer part of the effort. Such a mind-set may lead the psychiatrist to complacence and disregard for the patient’s concerns.

Why take the time to know the patient, to develop rapport, to convince the patient to come to therapy and to try medications on his terms, when a court order might cut all those corners and a nurse can administer an injection? That’s not the targeted group of patients, you say, that’s not whom AOT captures. If we’re not careful – if we feel that addressing the concerns of our patients is simply a "waste of time" because, after all, they have no insight – then we risk losing sight of what needs to be our real goal: helping patients to live the lives they want to live in productive and meaningful ways. Forcing treatment may get one person help at a particular period in time, but it comes with a cost: It leaves some patients afraid to seek voluntary care for fear of what may occur down the line, and it stigmatizes our profession. Finally, it makes us the adversaries of the patients we serve.

It would be easy to read this and think I’m against involuntary outpatient treatment, and that’s not completely true (ah, it’s mostly true). If involuntary treatment is limited to those patients who cycle in and out of hospitals and jails because of noncompliance, who become dangerous when ill, for whom treatment has proven to be effective, and who have failed thoughtful attempts at voluntary care, then forced care with its array of ancillary services and housing provisions may be a reasonable resource, regardless of the patient’s level of insight. Still, I remain interested in making our treatments more palatable to all of our patients – those who are forced into care as well as those who come willingly – and I believe it’s a mistake to see that effort as a waste of anyone’s time.

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