Shrink Rap News

The year is not even halfway through, but I’ve figured out that 2013 is not the year of the psychiatrist. In January, we started with our first three letters: CPT. I, like many other psychiatrists, had to learn how to use the Current Procedural Terminology to bill for my services, a process that took a great deal of time and entailed rethinking about how I conduct my therapy sessions, compose my progress notes, and issue my insurance forms -- and required an investment that does nothing to improve the quality of care I render to patients. If anything, the process has worn me, as I’ve struggled to figure out how I handle a patient who is a few minutes late to a session in a landscape where 1 minute of psychotherapy makes a substantial difference in reimbursement.

I don’t participate with insurance panels, and I feel I should code in such a way that maximizes my patient's reimbursement while accurately characterizing the one of 15 possible ways to code the hour session, but I still haven’t figured out the nuances of telling a patient that because he was stuck in traffic for a few minutes, we won’t have time for the full 53 minutes of therapy after the time allotted for evaluation and management, and so I’ll need to down code and he’ll be reimbursed less for this week’s session than for last week’s.

My colleagues tell me that I’m missing great opportunities to explore these “grist for the mill” opportunities. The mill sometimes grinds me down, and instead, I sometimes sympathize with the patients’ struggles with the construction issues on my block and the parking challenges they face since a large restaurant across the street has reopened after a devastating fire last year. I run over and skip breaks between patients, grab a handful of nuts for lunch, and leave all my notes until the end of the day.

That was January. This month, we’ll see the next alphabet change when the DSM-5 unveils and clinical practice changes once again. If not clinical practice, then clinical paperwork, as I figure out what code now best captures the patients I’ve been calling “NOS,” because those particular letters have worked okay until now.

The first challenge will be to figure out exactly when the insurance companies will begin refusing claims with the old codes and when they will implement the new codes, what numbers will best substitute, and there will be yet another block of time to re-program my billing software. Okay, I admit, I’m getting faster at setting codes. 

In June, I’m scheduled to begin the process of learning to use another set of alphabetic psychiatric technologies. For 2 days next month, I will be out of the clinic and into the classroom to learn the latest and greatest in doctor must-dos: the EMR – the Electronic Medical Record – and more alphabetically specific, EPIC. I don’t know what EPIC stands for, nor do I need to, but I’m a bit worried that the conversion is going to be difficult. I don’t think it will help that I only work in the clinic for 4 hours a week, and I found that gave me a much longer learning curve for getting comfortable with e-prescribing, compared with the psychiatrists who work in clinic full-time.

Change is sometimes hard, and if I had a say, I’d rather it trickled in than came in a series of sequential storms. I’m whining. I know I’m whining, and as we lag our way out of a recession, I have had the fortune to be in a career I love, with no fears of unemployment. My days may include a few moments of swearing at computer screens and unwelcome adjustments to unwelcome changes, but the work I do with patients remains rewarding. Ah, indoor work with no heavy lifting, though certainly there are days where the responsibility weighs heavy. I’ll stop whining now, and perhaps 2014 can be the year of the psychiatrist, once we figure out the ACA, (also known as the Affordable Care Act, or Obamacare), that is.

<[QM]>—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011).

The year is not even halfway through, but I’ve figured out that 2013 is not the year of the psychiatrist. In January, we started with our first three letters: CPT. I, like many other psychiatrists, had to learn how to use the Current Procedural Terminology to bill for my services, a process that took a great deal of time and entailed rethinking about how I conduct my therapy sessions, compose my progress notes, and issue my insurance forms -- and required an investment that does nothing to improve the quality of care I render to patients. If anything, the process has worn me, as I’ve struggled to figure out how I handle a patient who is a few minutes late to a session in a landscape where 1 minute of psychotherapy makes a substantial difference in reimbursement.

I don’t participate with insurance panels, and I feel I should code in such a way that maximizes my patient's reimbursement while accurately characterizing the one of 15 possible ways to code the hour session, but I still haven’t figured out the nuances of telling a patient that because he was stuck in traffic for a few minutes, we won’t have time for the full 53 minutes of therapy after the time allotted for evaluation and management, and so I’ll need to down code and he’ll be reimbursed less for this week’s session than for last week’s.

My colleagues tell me that I’m missing great opportunities to explore these “grist for the mill” opportunities. The mill sometimes grinds me down, and instead, I sometimes sympathize with the patients’ struggles with the construction issues on my block and the parking challenges they face since a large restaurant across the street has reopened after a devastating fire last year. I run over and skip breaks between patients, grab a handful of nuts for lunch, and leave all my notes until the end of the day.

That was January. This month, we’ll see the next alphabet change when the DSM-5 unveils and clinical practice changes once again. If not clinical practice, then clinical paperwork, as I figure out what code now best captures the patients I’ve been calling “NOS,” because those particular letters have worked okay until now.

The first challenge will be to figure out exactly when the insurance companies will begin refusing claims with the old codes and when they will implement the new codes, what numbers will best substitute, and there will be yet another block of time to re-program my billing software. Okay, I admit, I’m getting faster at setting codes. 

In June, I’m scheduled to begin the process of learning to use another set of alphabetic psychiatric technologies. For 2 days next month, I will be out of the clinic and into the classroom to learn the latest and greatest in doctor must-dos: the EMR – the Electronic Medical Record – and more alphabetically specific, EPIC. I don’t know what EPIC stands for, nor do I need to, but I’m a bit worried that the conversion is going to be difficult. I don’t think it will help that I only work in the clinic for 4 hours a week, and I found that gave me a much longer learning curve for getting comfortable with e-prescribing, compared with the psychiatrists who work in clinic full-time.

Change is sometimes hard, and if I had a say, I’d rather it trickled in than came in a series of sequential storms. I’m whining. I know I’m whining, and as we lag our way out of a recession, I have had the fortune to be in a career I love, with no fears of unemployment. My days may include a few moments of swearing at computer screens and unwelcome adjustments to unwelcome changes, but the work I do with patients remains rewarding. Ah, indoor work with no heavy lifting, though certainly there are days where the responsibility weighs heavy. I’ll stop whining now, and perhaps 2014 can be the year of the psychiatrist, once we figure out the ACA, (also known as the Affordable Care Act, or Obamacare), that is.

<[QM]>—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011).

The year is not even halfway through, but I’ve figured out that 2013 is not the year of the psychiatrist. In January, we started with our first three letters: CPT. I, like many other psychiatrists, had to learn how to use the Current Procedural Terminology to bill for my services, a process that took a great deal of time and entailed rethinking about how I conduct my therapy sessions, compose my progress notes, and issue my insurance forms -- and required an investment that does nothing to improve the quality of care I render to patients. If anything, the process has worn me, as I’ve struggled to figure out how I handle a patient who is a few minutes late to a session in a landscape where 1 minute of psychotherapy makes a substantial difference in reimbursement.

I don’t participate with insurance panels, and I feel I should code in such a way that maximizes my patient's reimbursement while accurately characterizing the one of 15 possible ways to code the hour session, but I still haven’t figured out the nuances of telling a patient that because he was stuck in traffic for a few minutes, we won’t have time for the full 53 minutes of therapy after the time allotted for evaluation and management, and so I’ll need to down code and he’ll be reimbursed less for this week’s session than for last week’s.

My colleagues tell me that I’m missing great opportunities to explore these “grist for the mill” opportunities. The mill sometimes grinds me down, and instead, I sometimes sympathize with the patients’ struggles with the construction issues on my block and the parking challenges they face since a large restaurant across the street has reopened after a devastating fire last year. I run over and skip breaks between patients, grab a handful of nuts for lunch, and leave all my notes until the end of the day.

That was January. This month, we’ll see the next alphabet change when the DSM-5 unveils and clinical practice changes once again. If not clinical practice, then clinical paperwork, as I figure out what code now best captures the patients I’ve been calling “NOS,” because those particular letters have worked okay until now.

The first challenge will be to figure out exactly when the insurance companies will begin refusing claims with the old codes and when they will implement the new codes, what numbers will best substitute, and there will be yet another block of time to re-program my billing software. Okay, I admit, I’m getting faster at setting codes. 

In June, I’m scheduled to begin the process of learning to use another set of alphabetic psychiatric technologies. For 2 days next month, I will be out of the clinic and into the classroom to learn the latest and greatest in doctor must-dos: the EMR – the Electronic Medical Record – and more alphabetically specific, EPIC. I don’t know what EPIC stands for, nor do I need to, but I’m a bit worried that the conversion is going to be difficult. I don’t think it will help that I only work in the clinic for 4 hours a week, and I found that gave me a much longer learning curve for getting comfortable with e-prescribing, compared with the psychiatrists who work in clinic full-time.

Change is sometimes hard, and if I had a say, I’d rather it trickled in than came in a series of sequential storms. I’m whining. I know I’m whining, and as we lag our way out of a recession, I have had the fortune to be in a career I love, with no fears of unemployment. My days may include a few moments of swearing at computer screens and unwelcome adjustments to unwelcome changes, but the work I do with patients remains rewarding. Ah, indoor work with no heavy lifting, though certainly there are days where the responsibility weighs heavy. I’ll stop whining now, and perhaps 2014 can be the year of the psychiatrist, once we figure out the ACA, (also known as the Affordable Care Act, or Obamacare), that is.

<[QM]>—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011).

Before I worked in corrections, what I knew about organized crime was limited to reruns of “The Godfather” and later episodes of “The Sopranos.” Little did I know that crime rings would eventually become part of my day-to-day clinical life.

Recently, my local jail was shaken with the news that 25 people, including 13 correctional officers, had been federally indicted as a result of a 2-year-long investigation into corruption within the detention center. Several members of the Black Guerilla Family were charged with drug distribution and money laundering, as well as witness tampering and other offenses, all directed from within the facility. What made the allegations particularly shocking was the fact that the alleged leader also had sexual relations with female correctional officers while incarcerated and impregnated four of them.

While I would like to say that this was a shock to me, the unfortunate truth is that I’ve watched the gradual infiltration of gangs into the state prison system over the last several years. My clinic patients discuss their concerns about gangs and institutional security. Some are former gang members, some gang informants. Most are careful to keep their confidences well circumscribed, talking only about general concerns or issues without ever giving enough detail to trigger a reporting duty and without giving up specific names. They talk about the frustration of being denied jobs on the tier or being the last to get on the phone when these opportunities are controlled by gang members on the unit. They talk about being pressured to hold contraband or transmit messages to and from free society. They talk about being caught in the cross-fire of rivalries and turf issues.

Rarely, they talk about being the target of a gang contract killing. An inmate condemned to death by a gang is one of the most frightened prison patients I’ve ever encountered. He is frightened for himself but also for his family, who might be at risk as well. In this situation, the guilt of incarceration is compounded by the guilt and fear of being unable to protect a loved one.

When an inmate tells me these things, I have to question why they entrust me with this information. Sometimes the reason is simply that they need to tell someone trustworthy who can be counted on to keep a confidence. Sometimes the purpose is to get placed in a housing unit or moved to a facility that he deems safe. Sometimes he wants me to contact a prosecutor or outside investigator who has promised protection or release in return for cooperation.

Rarely, a patient wants the information passed along to command staff without any promise of reward or any gain in return. He wants the information forwarded to prison administration through mental health staff, because this is less likely to be overheard or intercepted by front line tier officers. When a patient wants to turn informant, I talk openly with him about the potential hazards, although he’s usually always thought this through on his own long before our appointment. Once I’m sure he understands the risks and consequences, I will contact the institutional security chief.

Many correctional systems have a designated gang intelligence officer or security threat group who collect information about organized criminal activities within the institution. They will verify the accuracy of an inmate’s information then take appropriate steps to protect that inmate through institutional transfer – either within the system or out of state. If an inmate returns to the system later, they also take appropriate steps to ensure that he is not sent back to a facility where he was known as an actual or suspected informant, or where he was targeted during a previous incarceration.

As state delegates gear up to hold a hearing on jail corruption and the governor plans legislation to crack down on penalties for institutional contraband, I wonder how many of my colleagues may be working with jail or prison patients with gang connections. Knowing what concerns to expect and what advice to give a detained patient may soon become part of the correctional health care training curriculum.

 —Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.

Before I worked in corrections, what I knew about organized crime was limited to reruns of “The Godfather” and later episodes of “The Sopranos.” Little did I know that crime rings would eventually become part of my day-to-day clinical life.

Recently, my local jail was shaken with the news that 25 people, including 13 correctional officers, had been federally indicted as a result of a 2-year-long investigation into corruption within the detention center. Several members of the Black Guerilla Family were charged with drug distribution and money laundering, as well as witness tampering and other offenses, all directed from within the facility. What made the allegations particularly shocking was the fact that the alleged leader also had sexual relations with female correctional officers while incarcerated and impregnated four of them.

While I would like to say that this was a shock to me, the unfortunate truth is that I’ve watched the gradual infiltration of gangs into the state prison system over the last several years. My clinic patients discuss their concerns about gangs and institutional security. Some are former gang members, some gang informants. Most are careful to keep their confidences well circumscribed, talking only about general concerns or issues without ever giving enough detail to trigger a reporting duty and without giving up specific names. They talk about the frustration of being denied jobs on the tier or being the last to get on the phone when these opportunities are controlled by gang members on the unit. They talk about being pressured to hold contraband or transmit messages to and from free society. They talk about being caught in the cross-fire of rivalries and turf issues.

Rarely, they talk about being the target of a gang contract killing. An inmate condemned to death by a gang is one of the most frightened prison patients I’ve ever encountered. He is frightened for himself but also for his family, who might be at risk as well. In this situation, the guilt of incarceration is compounded by the guilt and fear of being unable to protect a loved one.

When an inmate tells me these things, I have to question why they entrust me with this information. Sometimes the reason is simply that they need to tell someone trustworthy who can be counted on to keep a confidence. Sometimes the purpose is to get placed in a housing unit or moved to a facility that he deems safe. Sometimes he wants me to contact a prosecutor or outside investigator who has promised protection or release in return for cooperation.

Rarely, a patient wants the information passed along to command staff without any promise of reward or any gain in return. He wants the information forwarded to prison administration through mental health staff, because this is less likely to be overheard or intercepted by front line tier officers. When a patient wants to turn informant, I talk openly with him about the potential hazards, although he’s usually always thought this through on his own long before our appointment. Once I’m sure he understands the risks and consequences, I will contact the institutional security chief.

Many correctional systems have a designated gang intelligence officer or security threat group who collect information about organized criminal activities within the institution. They will verify the accuracy of an inmate’s information then take appropriate steps to protect that inmate through institutional transfer – either within the system or out of state. If an inmate returns to the system later, they also take appropriate steps to ensure that he is not sent back to a facility where he was known as an actual or suspected informant, or where he was targeted during a previous incarceration.

As state delegates gear up to hold a hearing on jail corruption and the governor plans legislation to crack down on penalties for institutional contraband, I wonder how many of my colleagues may be working with jail or prison patients with gang connections. Knowing what concerns to expect and what advice to give a detained patient may soon become part of the correctional health care training curriculum.

 —Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.

Before I worked in corrections, what I knew about organized crime was limited to reruns of “The Godfather” and later episodes of “The Sopranos.” Little did I know that crime rings would eventually become part of my day-to-day clinical life.

Recently, my local jail was shaken with the news that 25 people, including 13 correctional officers, had been federally indicted as a result of a 2-year-long investigation into corruption within the detention center. Several members of the Black Guerilla Family were charged with drug distribution and money laundering, as well as witness tampering and other offenses, all directed from within the facility. What made the allegations particularly shocking was the fact that the alleged leader also had sexual relations with female correctional officers while incarcerated and impregnated four of them.

While I would like to say that this was a shock to me, the unfortunate truth is that I’ve watched the gradual infiltration of gangs into the state prison system over the last several years. My clinic patients discuss their concerns about gangs and institutional security. Some are former gang members, some gang informants. Most are careful to keep their confidences well circumscribed, talking only about general concerns or issues without ever giving enough detail to trigger a reporting duty and without giving up specific names. They talk about the frustration of being denied jobs on the tier or being the last to get on the phone when these opportunities are controlled by gang members on the unit. They talk about being pressured to hold contraband or transmit messages to and from free society. They talk about being caught in the cross-fire of rivalries and turf issues.

Rarely, they talk about being the target of a gang contract killing. An inmate condemned to death by a gang is one of the most frightened prison patients I’ve ever encountered. He is frightened for himself but also for his family, who might be at risk as well. In this situation, the guilt of incarceration is compounded by the guilt and fear of being unable to protect a loved one.

When an inmate tells me these things, I have to question why they entrust me with this information. Sometimes the reason is simply that they need to tell someone trustworthy who can be counted on to keep a confidence. Sometimes the purpose is to get placed in a housing unit or moved to a facility that he deems safe. Sometimes he wants me to contact a prosecutor or outside investigator who has promised protection or release in return for cooperation.

Rarely, a patient wants the information passed along to command staff without any promise of reward or any gain in return. He wants the information forwarded to prison administration through mental health staff, because this is less likely to be overheard or intercepted by front line tier officers. When a patient wants to turn informant, I talk openly with him about the potential hazards, although he’s usually always thought this through on his own long before our appointment. Once I’m sure he understands the risks and consequences, I will contact the institutional security chief.

Many correctional systems have a designated gang intelligence officer or security threat group who collect information about organized criminal activities within the institution. They will verify the accuracy of an inmate’s information then take appropriate steps to protect that inmate through institutional transfer – either within the system or out of state. If an inmate returns to the system later, they also take appropriate steps to ensure that he is not sent back to a facility where he was known as an actual or suspected informant, or where he was targeted during a previous incarceration.

As state delegates gear up to hold a hearing on jail corruption and the governor plans legislation to crack down on penalties for institutional contraband, I wonder how many of my colleagues may be working with jail or prison patients with gang connections. Knowing what concerns to expect and what advice to give a detained patient may soon become part of the correctional health care training curriculum.

 —Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.

Mental illness and mental health have been in the headlines and in the legislative discussions across the country over the past few months. For good or bad, the Newtown massacre has resulted in focused national discussions on three topics: access to firearms, schools, and mental illness.

In Maryland, our annual 90-day legislative session just ended, during which we saw the highest number of mental health-related bills in 8 years, and double the number from last year. The number of gun-related bills more than doubled. Most states are seeing the same patterns in their deliberative bodies.

The annual meeting of the American Psychiatric Association is next month in San Francisco, and the APA’s own deliberative body, the Assembly, will be meeting for three days starting May 17. It also will be discussing numerous bills, called “Action Papers,” about gun violence.

There are 29 Action Papers this session: seven on guns/violence; four each on membership/finances and public health issues; three on elections/governance; two each on health IT, maintenance of certification, the health care system, and training; and one each on the DSM, awards, and reinstating an expired position paper. Five of the Action Papers on guns and violence came from the Connecticut Psychiatric Society. One proposes that the APA oppose laws mandating that mental health professionals formally report patients who are a danger to themselves or others, using clinical discretion instead.

Another proposes that the APA oppose laws that prohibit physicians from asking patients about access to firearms, as six states are either considering or have already passed such a law. One echoes Dr. Paul Appelbaum’s call for a Presidential Commission to develop a vision for mental health care, also calling for steps toward early intervention, a system for responding to key mental health issues, and approaches to sensible firearm regulation. Another Action Paper supports the statements of APA President Dilip Jeste, M.D., to the U.S. Congress educating them that violence is not an inherent characteristic of people with mental illness. Another calls for support for the Centers for Disease Control and Prevention and the Institute of Medicine to address research and education on gun violence. A final one proposes an ad hoc work group on gun violence (which already has begun meeting).

There is an Action Paper calling for access to DSM-5 teaching materials for District Branches; one that adds voluntary contributions to the dues statements; and another that would change the process for APA members to vote on a referendum. Another one (mine) calls for changes that would permit candidates for APA office to hold town hall-style discussions on the electronic communication platforms (listservs, Google Groups, message boards, etc.) used by District Branches. The current rules do not allow local discussions like this, only on the Member-to-Member (M2M) listserv.

Several other Action Papers address issues that impact the organization and its members. One calls for significantly increased funding and reorganization of APA components to enhance communication and public relations. Another calls for advocating that all Health Insurance Exchanges must include all CPT codes and must use Medicare’s RVU system as a basis of determining allowable fees. Other papers address human trafficking, polypharmacy, self-defense training for members-in-training (MITs), MOC, HL7 health IT standards, United Nations participation, and an Early Career Psychiatrist (ECP) track at the Annual Meeting.

APA members are encouraged to share their thoughts on these topics with their elected Assembly Representative or Deputy Representative prior to the meeting next month.

The Assembly meets twice annually and is comprised of representatives from each of its 75 district branches in Canada and the United States, as well as members who represent minority/underrepresented groups, MITs, ECPs, allied organizations, and from each of the seven Areas. All 231 Assembly Representatives are elected by their constituents, and District Branches that have more APA members have more elected Representatives.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is president of Fuse Health Strategies, chair of the department of psychiatry at the Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at drdavissATgmail.com and on the My Three Shrinks podcast.

Mental illness and mental health have been in the headlines and in the legislative discussions across the country over the past few months. For good or bad, the Newtown massacre has resulted in focused national discussions on three topics: access to firearms, schools, and mental illness.

In Maryland, our annual 90-day legislative session just ended, during which we saw the highest number of mental health-related bills in 8 years, and double the number from last year. The number of gun-related bills more than doubled. Most states are seeing the same patterns in their deliberative bodies.

The annual meeting of the American Psychiatric Association is next month in San Francisco, and the APA’s own deliberative body, the Assembly, will be meeting for three days starting May 17. It also will be discussing numerous bills, called “Action Papers,” about gun violence.

There are 29 Action Papers this session: seven on guns/violence; four each on membership/finances and public health issues; three on elections/governance; two each on health IT, maintenance of certification, the health care system, and training; and one each on the DSM, awards, and reinstating an expired position paper. Five of the Action Papers on guns and violence came from the Connecticut Psychiatric Society. One proposes that the APA oppose laws mandating that mental health professionals formally report patients who are a danger to themselves or others, using clinical discretion instead.

Another proposes that the APA oppose laws that prohibit physicians from asking patients about access to firearms, as six states are either considering or have already passed such a law. One echoes Dr. Paul Appelbaum’s call for a Presidential Commission to develop a vision for mental health care, also calling for steps toward early intervention, a system for responding to key mental health issues, and approaches to sensible firearm regulation. Another Action Paper supports the statements of APA President Dilip Jeste, M.D., to the U.S. Congress educating them that violence is not an inherent characteristic of people with mental illness. Another calls for support for the Centers for Disease Control and Prevention and the Institute of Medicine to address research and education on gun violence. A final one proposes an ad hoc work group on gun violence (which already has begun meeting).

There is an Action Paper calling for access to DSM-5 teaching materials for District Branches; one that adds voluntary contributions to the dues statements; and another that would change the process for APA members to vote on a referendum. Another one (mine) calls for changes that would permit candidates for APA office to hold town hall-style discussions on the electronic communication platforms (listservs, Google Groups, message boards, etc.) used by District Branches. The current rules do not allow local discussions like this, only on the Member-to-Member (M2M) listserv.

Several other Action Papers address issues that impact the organization and its members. One calls for significantly increased funding and reorganization of APA components to enhance communication and public relations. Another calls for advocating that all Health Insurance Exchanges must include all CPT codes and must use Medicare’s RVU system as a basis of determining allowable fees. Other papers address human trafficking, polypharmacy, self-defense training for members-in-training (MITs), MOC, HL7 health IT standards, United Nations participation, and an Early Career Psychiatrist (ECP) track at the Annual Meeting.

APA members are encouraged to share their thoughts on these topics with their elected Assembly Representative or Deputy Representative prior to the meeting next month.

The Assembly meets twice annually and is comprised of representatives from each of its 75 district branches in Canada and the United States, as well as members who represent minority/underrepresented groups, MITs, ECPs, allied organizations, and from each of the seven Areas. All 231 Assembly Representatives are elected by their constituents, and District Branches that have more APA members have more elected Representatives.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is president of Fuse Health Strategies, chair of the department of psychiatry at the Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at drdavissATgmail.com and on the My Three Shrinks podcast.

Mental illness and mental health have been in the headlines and in the legislative discussions across the country over the past few months. For good or bad, the Newtown massacre has resulted in focused national discussions on three topics: access to firearms, schools, and mental illness.

In Maryland, our annual 90-day legislative session just ended, during which we saw the highest number of mental health-related bills in 8 years, and double the number from last year. The number of gun-related bills more than doubled. Most states are seeing the same patterns in their deliberative bodies.

The annual meeting of the American Psychiatric Association is next month in San Francisco, and the APA’s own deliberative body, the Assembly, will be meeting for three days starting May 17. It also will be discussing numerous bills, called “Action Papers,” about gun violence.

There are 29 Action Papers this session: seven on guns/violence; four each on membership/finances and public health issues; three on elections/governance; two each on health IT, maintenance of certification, the health care system, and training; and one each on the DSM, awards, and reinstating an expired position paper. Five of the Action Papers on guns and violence came from the Connecticut Psychiatric Society. One proposes that the APA oppose laws mandating that mental health professionals formally report patients who are a danger to themselves or others, using clinical discretion instead.

Another proposes that the APA oppose laws that prohibit physicians from asking patients about access to firearms, as six states are either considering or have already passed such a law. One echoes Dr. Paul Appelbaum’s call for a Presidential Commission to develop a vision for mental health care, also calling for steps toward early intervention, a system for responding to key mental health issues, and approaches to sensible firearm regulation. Another Action Paper supports the statements of APA President Dilip Jeste, M.D., to the U.S. Congress educating them that violence is not an inherent characteristic of people with mental illness. Another calls for support for the Centers for Disease Control and Prevention and the Institute of Medicine to address research and education on gun violence. A final one proposes an ad hoc work group on gun violence (which already has begun meeting).

There is an Action Paper calling for access to DSM-5 teaching materials for District Branches; one that adds voluntary contributions to the dues statements; and another that would change the process for APA members to vote on a referendum. Another one (mine) calls for changes that would permit candidates for APA office to hold town hall-style discussions on the electronic communication platforms (listservs, Google Groups, message boards, etc.) used by District Branches. The current rules do not allow local discussions like this, only on the Member-to-Member (M2M) listserv.

Several other Action Papers address issues that impact the organization and its members. One calls for significantly increased funding and reorganization of APA components to enhance communication and public relations. Another calls for advocating that all Health Insurance Exchanges must include all CPT codes and must use Medicare’s RVU system as a basis of determining allowable fees. Other papers address human trafficking, polypharmacy, self-defense training for members-in-training (MITs), MOC, HL7 health IT standards, United Nations participation, and an Early Career Psychiatrist (ECP) track at the Annual Meeting.

APA members are encouraged to share their thoughts on these topics with their elected Assembly Representative or Deputy Representative prior to the meeting next month.

The Assembly meets twice annually and is comprised of representatives from each of its 75 district branches in Canada and the United States, as well as members who represent minority/underrepresented groups, MITs, ECPs, allied organizations, and from each of the seven Areas. All 231 Assembly Representatives are elected by their constituents, and District Branches that have more APA members have more elected Representatives.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is president of Fuse Health Strategies, chair of the department of psychiatry at the Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found at drdavissATgmail.com and on the My Three Shrinks podcast.

Like many, I spent Friday night riveted to the television, waiting for the authorities to locate and capture Suspect No. 2 in the Boston Marathon bombings. Terrorist events are not about psychiatry, but like everyone else, I felt overwhelmingly sad.

I was sad for the victims of the explosions, for the young MIT police officer who was killed in the gunfight, for the teenage terrorist and his brother who surrendered their promising futures for the senseless sake of taking innocent lives, and for the entire town of West, Tex., where a fertilizer plant had exploded on Wednesday.

I simultaneously felt sad for the Maryland teenager who was killed by a hit-and-run driver while walking with friends, for the three people murdered in Baltimore last week, and for the local teenager whose tragic suicide has been kept so quiet. None of those losses received attention from Anderson Cooper or Wolf Blitzer, but their lives are gone, nonetheless. And all of these tragedies come as we continue to mourn the horror of Sandy Hook, and just months after so many people died at a movie theater in Aurora.

As much as I feel profound sadness for the victims, I also ache for the mothers of both the victims and the criminals, and in the situations where the perpetrators have been suffered from mental illness, I also feel sympathy for their psychiatrists. The roles of mother and psychiatrist are ones I know well.

When a child behaves in an unseemly way, regardless of whether the transgression is minor or catastrophic, the first people who come into question are the parents, the mother in particular. When a child grows up well, parents are quick to take credit; their love, attention, and ability to raise children with the precise formula of discipline and acceptance are what produced such a fine product of a human being. When children waiver from the path, their parents may blame biology, a difficult temperament, or outside influences. In some circumstances, the child is deemed a “bad seed.” The outside world, however, is quick to blame the parents.

When my children were young, I knew a great deal about how to be a good parent. When they became teenagers, I was quickly humbled and often wished they had arrived in this world with instruction manuals. I have been blessed with wonderful children, but I am never so sure that I want the world to judge my parenting by the things they post on Facebook or the clothing they choose to wear in public. Ah, tell them not to do that, a bystander might say – one with particularly compliant teenagers –  but I’ve learned that controlling another human being’s action is easier said than done, and sometimes it is close to impossible. Obviously, a teenager’s inopportune grunt or jeans that rest a bit too low are not events one should compare to mass murderers, but my helplessness in effecting precise cause and effect with my parental skills has left me feeling that it’s not as simple as following a formula.

In much the same way, if the perpetrator of an atrocious act has a mental illness, the psychiatrist is scrutinized. Did the doctor ask the right questions? Did she take any threatening comments seriously enough? Did she warn those who might be warned? Were the medicines pushed to high enough doses? Was the patient hospitalized? For long enough? Even if it was all done precisely right by psychiatric standards, the public has their own measures and often believe that more should have been done. We all live with just a little fear that a patient might suicide, or end up on a national news story. Even when it’s predictable, there is only so much we can do in an attempt to alter the outcome.

Certainly, there are terrible, negligent, and abusive parents, just as there are psychiatrists who rush through their day with little regard for whether they are considering standards of care and giving enough consideration to a patient’s potential to harm themselves or others. In those cases, my sympathy wanes. Since I spend a lot of time thinking about how I could be both an excellent parent and an excellent psychiatrist, I’m well aware that there is an element of luck to both endeavors. Often, kind and attentive parents have good kids, and conscientious psychiatrists have good outcomes. Sometimes, however, major mistakes are made, and things turn our well anyway; people can be very resilient. Horrible parents sometimes produce wonderful children, while shoddy psychiatrists get lucky. Other times, a single mistake can lead to a disastrous result.

Do we think the mother of the Newtown shooter would have gone to bed that night leaving guns accessible if she’d had even the slightest inkling that her son would kill her, much less innocent young children? We are all subject to moments of poor judgment, or of hoping the suicidal patient we opted not to hospitalize will make it through the night. Parents and psychiatrists both want luck to be on their side.

I like to believe that most parents try to do their best by their children, and most psychiatrists try to do their best by their patients. And when awful things happen, I feel badly for the mothers of both the victims and the perpetrators, and for the psychiatrists. It’s a myth – and a burden – we hold that any of us can completely control the behavior of another human being.

<[QM—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011).

Like many, I spent Friday night riveted to the television, waiting for the authorities to locate and capture Suspect No. 2 in the Boston Marathon bombings. Terrorist events are not about psychiatry, but like everyone else, I felt overwhelmingly sad.

I was sad for the victims of the explosions, for the young MIT police officer who was killed in the gunfight, for the teenage terrorist and his brother who surrendered their promising futures for the senseless sake of taking innocent lives, and for the entire town of West, Tex., where a fertilizer plant had exploded on Wednesday.

I simultaneously felt sad for the Maryland teenager who was killed by a hit-and-run driver while walking with friends, for the three people murdered in Baltimore last week, and for the local teenager whose tragic suicide has been kept so quiet. None of those losses received attention from Anderson Cooper or Wolf Blitzer, but their lives are gone, nonetheless. And all of these tragedies come as we continue to mourn the horror of Sandy Hook, and just months after so many people died at a movie theater in Aurora.

As much as I feel profound sadness for the victims, I also ache for the mothers of both the victims and the criminals, and in the situations where the perpetrators have been suffered from mental illness, I also feel sympathy for their psychiatrists. The roles of mother and psychiatrist are ones I know well.

When a child behaves in an unseemly way, regardless of whether the transgression is minor or catastrophic, the first people who come into question are the parents, the mother in particular. When a child grows up well, parents are quick to take credit; their love, attention, and ability to raise children with the precise formula of discipline and acceptance are what produced such a fine product of a human being. When children waiver from the path, their parents may blame biology, a difficult temperament, or outside influences. In some circumstances, the child is deemed a “bad seed.” The outside world, however, is quick to blame the parents.

When my children were young, I knew a great deal about how to be a good parent. When they became teenagers, I was quickly humbled and often wished they had arrived in this world with instruction manuals. I have been blessed with wonderful children, but I am never so sure that I want the world to judge my parenting by the things they post on Facebook or the clothing they choose to wear in public. Ah, tell them not to do that, a bystander might say – one with particularly compliant teenagers –  but I’ve learned that controlling another human being’s action is easier said than done, and sometimes it is close to impossible. Obviously, a teenager’s inopportune grunt or jeans that rest a bit too low are not events one should compare to mass murderers, but my helplessness in effecting precise cause and effect with my parental skills has left me feeling that it’s not as simple as following a formula.

In much the same way, if the perpetrator of an atrocious act has a mental illness, the psychiatrist is scrutinized. Did the doctor ask the right questions? Did she take any threatening comments seriously enough? Did she warn those who might be warned? Were the medicines pushed to high enough doses? Was the patient hospitalized? For long enough? Even if it was all done precisely right by psychiatric standards, the public has their own measures and often believe that more should have been done. We all live with just a little fear that a patient might suicide, or end up on a national news story. Even when it’s predictable, there is only so much we can do in an attempt to alter the outcome.

Certainly, there are terrible, negligent, and abusive parents, just as there are psychiatrists who rush through their day with little regard for whether they are considering standards of care and giving enough consideration to a patient’s potential to harm themselves or others. In those cases, my sympathy wanes. Since I spend a lot of time thinking about how I could be both an excellent parent and an excellent psychiatrist, I’m well aware that there is an element of luck to both endeavors. Often, kind and attentive parents have good kids, and conscientious psychiatrists have good outcomes. Sometimes, however, major mistakes are made, and things turn our well anyway; people can be very resilient. Horrible parents sometimes produce wonderful children, while shoddy psychiatrists get lucky. Other times, a single mistake can lead to a disastrous result.

Do we think the mother of the Newtown shooter would have gone to bed that night leaving guns accessible if she’d had even the slightest inkling that her son would kill her, much less innocent young children? We are all subject to moments of poor judgment, or of hoping the suicidal patient we opted not to hospitalize will make it through the night. Parents and psychiatrists both want luck to be on their side.

I like to believe that most parents try to do their best by their children, and most psychiatrists try to do their best by their patients. And when awful things happen, I feel badly for the mothers of both the victims and the perpetrators, and for the psychiatrists. It’s a myth – and a burden – we hold that any of us can completely control the behavior of another human being.

<[QM—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011).

Like many, I spent Friday night riveted to the television, waiting for the authorities to locate and capture Suspect No. 2 in the Boston Marathon bombings. Terrorist events are not about psychiatry, but like everyone else, I felt overwhelmingly sad.

I was sad for the victims of the explosions, for the young MIT police officer who was killed in the gunfight, for the teenage terrorist and his brother who surrendered their promising futures for the senseless sake of taking innocent lives, and for the entire town of West, Tex., where a fertilizer plant had exploded on Wednesday.

I simultaneously felt sad for the Maryland teenager who was killed by a hit-and-run driver while walking with friends, for the three people murdered in Baltimore last week, and for the local teenager whose tragic suicide has been kept so quiet. None of those losses received attention from Anderson Cooper or Wolf Blitzer, but their lives are gone, nonetheless. And all of these tragedies come as we continue to mourn the horror of Sandy Hook, and just months after so many people died at a movie theater in Aurora.

As much as I feel profound sadness for the victims, I also ache for the mothers of both the victims and the criminals, and in the situations where the perpetrators have been suffered from mental illness, I also feel sympathy for their psychiatrists. The roles of mother and psychiatrist are ones I know well.

When a child behaves in an unseemly way, regardless of whether the transgression is minor or catastrophic, the first people who come into question are the parents, the mother in particular. When a child grows up well, parents are quick to take credit; their love, attention, and ability to raise children with the precise formula of discipline and acceptance are what produced such a fine product of a human being. When children waiver from the path, their parents may blame biology, a difficult temperament, or outside influences. In some circumstances, the child is deemed a “bad seed.” The outside world, however, is quick to blame the parents.

When my children were young, I knew a great deal about how to be a good parent. When they became teenagers, I was quickly humbled and often wished they had arrived in this world with instruction manuals. I have been blessed with wonderful children, but I am never so sure that I want the world to judge my parenting by the things they post on Facebook or the clothing they choose to wear in public. Ah, tell them not to do that, a bystander might say – one with particularly compliant teenagers –  but I’ve learned that controlling another human being’s action is easier said than done, and sometimes it is close to impossible. Obviously, a teenager’s inopportune grunt or jeans that rest a bit too low are not events one should compare to mass murderers, but my helplessness in effecting precise cause and effect with my parental skills has left me feeling that it’s not as simple as following a formula.

In much the same way, if the perpetrator of an atrocious act has a mental illness, the psychiatrist is scrutinized. Did the doctor ask the right questions? Did she take any threatening comments seriously enough? Did she warn those who might be warned? Were the medicines pushed to high enough doses? Was the patient hospitalized? For long enough? Even if it was all done precisely right by psychiatric standards, the public has their own measures and often believe that more should have been done. We all live with just a little fear that a patient might suicide, or end up on a national news story. Even when it’s predictable, there is only so much we can do in an attempt to alter the outcome.

Certainly, there are terrible, negligent, and abusive parents, just as there are psychiatrists who rush through their day with little regard for whether they are considering standards of care and giving enough consideration to a patient’s potential to harm themselves or others. In those cases, my sympathy wanes. Since I spend a lot of time thinking about how I could be both an excellent parent and an excellent psychiatrist, I’m well aware that there is an element of luck to both endeavors. Often, kind and attentive parents have good kids, and conscientious psychiatrists have good outcomes. Sometimes, however, major mistakes are made, and things turn our well anyway; people can be very resilient. Horrible parents sometimes produce wonderful children, while shoddy psychiatrists get lucky. Other times, a single mistake can lead to a disastrous result.

Do we think the mother of the Newtown shooter would have gone to bed that night leaving guns accessible if she’d had even the slightest inkling that her son would kill her, much less innocent young children? We are all subject to moments of poor judgment, or of hoping the suicidal patient we opted not to hospitalize will make it through the night. Parents and psychiatrists both want luck to be on their side.

I like to believe that most parents try to do their best by their children, and most psychiatrists try to do their best by their patients. And when awful things happen, I feel badly for the mothers of both the victims and the perpetrators, and for the psychiatrists. It’s a myth – and a burden – we hold that any of us can completely control the behavior of another human being.

<[QM—Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011).

Prison violence has been on my mind recently due to an article in my local newspaper about the high rate of homicide in the Maryland prison system, which has one of the highest rates in the country –  although assault rates between prisoners has actually decreased by 47% over the last 6 years. Inevitably, people link prison violence either to some failure in prison administration or to a lack of correctional mental health services. In my experience, neither explanation alone suffices.

While most people imagine a prison as a “Lord of the Flies” environment where the fittest survive and rule, in fact, there are strict principles of etiquette that every experienced inmate lives by. These are: keep your cell or “home” clean, pay back your debts to your cellmate, wipe the toilet clean after each use, don’t talk too much, and always apologize after any burp or fart. And as much as possible, try not to snore.

Prison etiquette isn't followed out of courtesy so much as out of a mutual desire to avoid confrontations that could lead to fights and disciplinary segregation. Newly received inmates generally have experience in a local detention center first, where they learn this etiquette. They also learn that a correctional facility has rules and expectations, and that violating those rules through violence will have clearly spelled out consequences.

The most common cause of violence between inmates that I’ve seen is a persistent failure to follow prison courtesy between cellmates. This has very little to do with prison administration, and it’s nothing that your average correctional officer on the tier can predict or prevent.

In addition to lifestyle or etiquette-based conflicts, there are other rational motives for violence. Certain aggressive behaviors, such as throwing urine or feces or making violent threats, are a standard form of protest behavior within the correctional environment. These behaviors are so commonly accepted as “normal” prison aggression that they typically don’t trigger a referral for mental health evaluation and are handled entirely within the prison disciplinary process.

When a small inmate ”proves” his toughness by assaulting a larger and physically more imposing inmate, violence can be adaptive and protective by deterring harassment from others. By demonstrating a willingness to stand up for oneself, the inmate also increases his status on the tier, which in turn will improve his access to privileges and resources such as telephone calls and paid jobs within the facility.

Similarly, violence between neighborhood rivals or known prison gang members is typical of instrumental aggression to maintain order on a tier or to further criminal activities within the facility. If these rivalries are known to investigators, the violent prisoner would not typically be referred for psychiatric evaluation.

In contrast, sexually threatening behavior or repetitively assaultive behavior, or assaults that are indiscriminately directed against both officers and inmates, could trigger a consult to the prison psychology department.

The key to determining rational or instrumental violence from symptomatic violence is a careful mental status examination and history. Some violence-related questions that are unique to correctional practice are:

• Is the victim known to the inmate? What is their previous relationship? Do they have known gang or neighborhood rivalries and affiliations?

• What is the inmate’s previous adjustment history? Has he been moved to the facility from a lower security setting and if so, why? Does he have identified enemies within the facility?

• What is the inmate’s preferred housing status? Does he have a history of requesting segregated confinement voluntarily?

• Where is the inmate’s family? Is there a higher security facility located closer to them, and would a disciplinary transfer facilitate family contact?

• Does the inmate have a history of aggression directed toward authority figures, particularly in early development?

• Does the inmate have a history of persecution by other inmates? Is he a known informant or drug user within the facility? Does he owe gambling or other debts?

New onset violence is of particular concern, and may indicate a recent psychosocial stressor, mental illness, substance intoxication, or an undetected medical condition. While substance abuse is less likely in the correctional environment, use of stimulants or hallucinations, or even the newer synthetic cannabinoids, has been known to trigger aggression in previously well-adjusted inmates.

The cause of violent behavior and any related diagnosis usually can be identified through careful history and observation. Rarely, a transfer for admission or diagnostic work-up may be indicated. There is a substantial body of literature on the pharmacologic management of violence, and most medication interventions are available in a standard correctional formulary.

Anticonvulsants or lithium are commonly used, with the short-term addition of a neuroleptic if the violence is due to a primary psychotic disorder or mania. Regardless of the medication choice, it is important to clearly document the condition and indication for the medication to avoid allegations that pharmacologic interventions are being used for disciplinary reasons or merely to “keep the inmate quiet.”

After the acute crisis is resolved, the inmate can be offered additional follow-up for supportive counseling, crisis intervention as needed, as well as education about anger management skills.

The use of behavior modification plans, while helpful, can be somewhat controversial if the terms are overly restrictive or harsh. Such plans have led to court challenges over legal and ethical concerns. The plan should be carefully constructed to allow for inmate input into the terms and conditions, and explained in detail along with the rationale for each contingency. Voluntary participation in plan development is more likely to lead to a successful outcome and to withstand challenge by outside agencies.

The use of solitary confinement or segregated housing is controversial. However, when used temporarily in conjunction with psychiatric evaluation and intervention, solitary confinement can be an essential tool to protect both staff and other prisoners.

—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.

Prison violence has been on my mind recently due to an article in my local newspaper about the high rate of homicide in the Maryland prison system, which has one of the highest rates in the country –  although assault rates between prisoners has actually decreased by 47% over the last 6 years. Inevitably, people link prison violence either to some failure in prison administration or to a lack of correctional mental health services. In my experience, neither explanation alone suffices.

While most people imagine a prison as a “Lord of the Flies” environment where the fittest survive and rule, in fact, there are strict principles of etiquette that every experienced inmate lives by. These are: keep your cell or “home” clean, pay back your debts to your cellmate, wipe the toilet clean after each use, don’t talk too much, and always apologize after any burp or fart. And as much as possible, try not to snore.

Prison etiquette isn't followed out of courtesy so much as out of a mutual desire to avoid confrontations that could lead to fights and disciplinary segregation. Newly received inmates generally have experience in a local detention center first, where they learn this etiquette. They also learn that a correctional facility has rules and expectations, and that violating those rules through violence will have clearly spelled out consequences.

The most common cause of violence between inmates that I’ve seen is a persistent failure to follow prison courtesy between cellmates. This has very little to do with prison administration, and it’s nothing that your average correctional officer on the tier can predict or prevent.

In addition to lifestyle or etiquette-based conflicts, there are other rational motives for violence. Certain aggressive behaviors, such as throwing urine or feces or making violent threats, are a standard form of protest behavior within the correctional environment. These behaviors are so commonly accepted as “normal” prison aggression that they typically don’t trigger a referral for mental health evaluation and are handled entirely within the prison disciplinary process.

When a small inmate ”proves” his toughness by assaulting a larger and physically more imposing inmate, violence can be adaptive and protective by deterring harassment from others. By demonstrating a willingness to stand up for oneself, the inmate also increases his status on the tier, which in turn will improve his access to privileges and resources such as telephone calls and paid jobs within the facility.

Similarly, violence between neighborhood rivals or known prison gang members is typical of instrumental aggression to maintain order on a tier or to further criminal activities within the facility. If these rivalries are known to investigators, the violent prisoner would not typically be referred for psychiatric evaluation.

In contrast, sexually threatening behavior or repetitively assaultive behavior, or assaults that are indiscriminately directed against both officers and inmates, could trigger a consult to the prison psychology department.

The key to determining rational or instrumental violence from symptomatic violence is a careful mental status examination and history. Some violence-related questions that are unique to correctional practice are:

• Is the victim known to the inmate? What is their previous relationship? Do they have known gang or neighborhood rivalries and affiliations?

• What is the inmate’s previous adjustment history? Has he been moved to the facility from a lower security setting and if so, why? Does he have identified enemies within the facility?

• What is the inmate’s preferred housing status? Does he have a history of requesting segregated confinement voluntarily?

• Where is the inmate’s family? Is there a higher security facility located closer to them, and would a disciplinary transfer facilitate family contact?

• Does the inmate have a history of aggression directed toward authority figures, particularly in early development?

• Does the inmate have a history of persecution by other inmates? Is he a known informant or drug user within the facility? Does he owe gambling or other debts?

New onset violence is of particular concern, and may indicate a recent psychosocial stressor, mental illness, substance intoxication, or an undetected medical condition. While substance abuse is less likely in the correctional environment, use of stimulants or hallucinations, or even the newer synthetic cannabinoids, has been known to trigger aggression in previously well-adjusted inmates.

The cause of violent behavior and any related diagnosis usually can be identified through careful history and observation. Rarely, a transfer for admission or diagnostic work-up may be indicated. There is a substantial body of literature on the pharmacologic management of violence, and most medication interventions are available in a standard correctional formulary.

Anticonvulsants or lithium are commonly used, with the short-term addition of a neuroleptic if the violence is due to a primary psychotic disorder or mania. Regardless of the medication choice, it is important to clearly document the condition and indication for the medication to avoid allegations that pharmacologic interventions are being used for disciplinary reasons or merely to “keep the inmate quiet.”

After the acute crisis is resolved, the inmate can be offered additional follow-up for supportive counseling, crisis intervention as needed, as well as education about anger management skills.

The use of behavior modification plans, while helpful, can be somewhat controversial if the terms are overly restrictive or harsh. Such plans have led to court challenges over legal and ethical concerns. The plan should be carefully constructed to allow for inmate input into the terms and conditions, and explained in detail along with the rationale for each contingency. Voluntary participation in plan development is more likely to lead to a successful outcome and to withstand challenge by outside agencies.

The use of solitary confinement or segregated housing is controversial. However, when used temporarily in conjunction with psychiatric evaluation and intervention, solitary confinement can be an essential tool to protect both staff and other prisoners.

—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.

Prison violence has been on my mind recently due to an article in my local newspaper about the high rate of homicide in the Maryland prison system, which has one of the highest rates in the country –  although assault rates between prisoners has actually decreased by 47% over the last 6 years. Inevitably, people link prison violence either to some failure in prison administration or to a lack of correctional mental health services. In my experience, neither explanation alone suffices.

While most people imagine a prison as a “Lord of the Flies” environment where the fittest survive and rule, in fact, there are strict principles of etiquette that every experienced inmate lives by. These are: keep your cell or “home” clean, pay back your debts to your cellmate, wipe the toilet clean after each use, don’t talk too much, and always apologize after any burp or fart. And as much as possible, try not to snore.

Prison etiquette isn't followed out of courtesy so much as out of a mutual desire to avoid confrontations that could lead to fights and disciplinary segregation. Newly received inmates generally have experience in a local detention center first, where they learn this etiquette. They also learn that a correctional facility has rules and expectations, and that violating those rules through violence will have clearly spelled out consequences.

The most common cause of violence between inmates that I’ve seen is a persistent failure to follow prison courtesy between cellmates. This has very little to do with prison administration, and it’s nothing that your average correctional officer on the tier can predict or prevent.

In addition to lifestyle or etiquette-based conflicts, there are other rational motives for violence. Certain aggressive behaviors, such as throwing urine or feces or making violent threats, are a standard form of protest behavior within the correctional environment. These behaviors are so commonly accepted as “normal” prison aggression that they typically don’t trigger a referral for mental health evaluation and are handled entirely within the prison disciplinary process.

When a small inmate ”proves” his toughness by assaulting a larger and physically more imposing inmate, violence can be adaptive and protective by deterring harassment from others. By demonstrating a willingness to stand up for oneself, the inmate also increases his status on the tier, which in turn will improve his access to privileges and resources such as telephone calls and paid jobs within the facility.

Similarly, violence between neighborhood rivals or known prison gang members is typical of instrumental aggression to maintain order on a tier or to further criminal activities within the facility. If these rivalries are known to investigators, the violent prisoner would not typically be referred for psychiatric evaluation.

In contrast, sexually threatening behavior or repetitively assaultive behavior, or assaults that are indiscriminately directed against both officers and inmates, could trigger a consult to the prison psychology department.

The key to determining rational or instrumental violence from symptomatic violence is a careful mental status examination and history. Some violence-related questions that are unique to correctional practice are:

• Is the victim known to the inmate? What is their previous relationship? Do they have known gang or neighborhood rivalries and affiliations?

• What is the inmate’s previous adjustment history? Has he been moved to the facility from a lower security setting and if so, why? Does he have identified enemies within the facility?

• What is the inmate’s preferred housing status? Does he have a history of requesting segregated confinement voluntarily?

• Where is the inmate’s family? Is there a higher security facility located closer to them, and would a disciplinary transfer facilitate family contact?

• Does the inmate have a history of aggression directed toward authority figures, particularly in early development?

• Does the inmate have a history of persecution by other inmates? Is he a known informant or drug user within the facility? Does he owe gambling or other debts?

New onset violence is of particular concern, and may indicate a recent psychosocial stressor, mental illness, substance intoxication, or an undetected medical condition. While substance abuse is less likely in the correctional environment, use of stimulants or hallucinations, or even the newer synthetic cannabinoids, has been known to trigger aggression in previously well-adjusted inmates.

The cause of violent behavior and any related diagnosis usually can be identified through careful history and observation. Rarely, a transfer for admission or diagnostic work-up may be indicated. There is a substantial body of literature on the pharmacologic management of violence, and most medication interventions are available in a standard correctional formulary.

Anticonvulsants or lithium are commonly used, with the short-term addition of a neuroleptic if the violence is due to a primary psychotic disorder or mania. Regardless of the medication choice, it is important to clearly document the condition and indication for the medication to avoid allegations that pharmacologic interventions are being used for disciplinary reasons or merely to “keep the inmate quiet.”

After the acute crisis is resolved, the inmate can be offered additional follow-up for supportive counseling, crisis intervention as needed, as well as education about anger management skills.

The use of behavior modification plans, while helpful, can be somewhat controversial if the terms are overly restrictive or harsh. Such plans have led to court challenges over legal and ethical concerns. The plan should be carefully constructed to allow for inmate input into the terms and conditions, and explained in detail along with the rationale for each contingency. Voluntary participation in plan development is more likely to lead to a successful outcome and to withstand challenge by outside agencies.

The use of solitary confinement or segregated housing is controversial. However, when used temporarily in conjunction with psychiatric evaluation and intervention, solitary confinement can be an essential tool to protect both staff and other prisoners.

—Annette Hanson, M.D.

Dr. Hanson is a forensic psychiatrist and co-author 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.

If you’ve been following our columns for the past few weeks, you’ll note that we’ve been interested in the ongoing gun control legislation in Maryland as it pertains to those with psychiatric disorders.

My co-columnist, Dr. Anne Hanson, likes the metaphor that this legislation, as it pertains to intersection of gun ownership rights and mental illness, is like the Wicked Witch of the West and notes, “Things must be done carefully.” I’ve come to think of these laws as being similar to the boardwalk game, Whack-A-Mole. In Maryland, the Firearms Act of 2013 is being debated as I type – our legislative session ends on Monday. The legislation, as put forth by Gov. O’Malley and his administration, does not include a requirement to report dangerous patients to the state, but individual legislators have supported first a bill, then an amendment, to mandate legislation with wording similar to what has passed as part of the New York SAFE Act. Each time we believe the issue is dead, it pops up again, only to get whacked down and then resurface from another unexpected hole. I’m hopeful that it has died a final death and that mandatory reporting will not make its way into Maryland.

Why are legislators proposing laws where there is no clear benefit to the community? There are no data to support either the idea that reporting “likely to be dangerous people” to a federal database for the purpose of revoking firearms permits or preventing such permits from being issued will make us safer, and the fear is that such legislation will deter dangerous individuals from seeking treatment. Our legislators have deemed this “the chilling effect” and with such a label, they’ve acknowledged the possibility and can then minimize it. On the other hand, we don’t know for sure that such legislation won’t make us all safer; there simply are no data. What we do know is that the New York Veterans Administration has publicly stated that it will not comply with the reporting requirement, and that a New York firearms site has announced that doctor-patient confidentiality is gone and people should be careful about what they say to their therapists.

Why would any Maryland legislator support such measures, given that they may deter people from seeking treatment? Since my own delegate was a co-sponsor of the bill to require mandatory reporting of patients who are likely to be dangerous, I went to speak with him about it. His response was that this was the recommendation of the Task Force to Study Access of Individuals With Mental Illness to Regulated Firearms. What’s really interesting about this recommendation is that of the 17 members on the task force, there was only one psychiatrist – an administrator for the Department of Health and Mental Hygiene whose role was to represent the state. Many organizations were represented, but mental health clinicians of all flavors were notably missing. While the Maryland Psychiatric Society did not have a seat at the table, the Associated Gun Clubs of Baltimore and Maryland Shall Issue (a citizens’ defense league) were both represented. That’s right, our state had a mental health task force where the gun activists had a larger voice then the psychiatrists. I’ll leave it to you to decide if that makes any sense.

As much as I believe that mandatory reporting of those “likely to be dangerous” to an FBI database by mental health professionals is a bad idea, I don’t know that it is. There is simply no research on this. It’s interesting that our state task force also suggested that firearms be seized from dangerous people – a measure that might be welcome by clinicians worried about a patient’s safety – but this recommendation did not influence any proposed legislation.

Toward the purpose of understanding what data are out there to inform our laws, I want to put in a quick plug for Reducing Gun Violence in America: Informing Policy with Evidence and Analysis, edited by Daniel W. Webster and Jon S. Vernick of the Center for Gun Policy and Research at the Johns Hopkins Bloomberg School of Public Health. In the aftermath of the Sandy Hook Tragedy, Webster and Vernick put together a volume that includes extensive reviews of the available literature on firearms research. One chapter is devoted to mental health research, and two of the seven co-authors of that chapter are psychiatrists. The book is the result of the Summit on Reducing Gun Violence in America, held Jan. 14-15 at Johns Hopkins.

The book became available with surprising speed. Kathy Alexander, a publicity manager for JHUP told me, “While most of our manuscripts (as a whole) are reviewed by scholars in the field, this time we had multiple scholars reviewing chapters at the same time to speed up the process and to have those sections reviewed by those scholars that follow that particular angle. It was really amazing. In the scramble to get the summit and the accompanying book out, our employees gave up vacations, angered family members during the holidays, and obviously lost some sleep.” The result, however, is a wonderful, state-of-the art review of what we do and don’t know about gun violence, and while a single chapter is devoted to mental disorders, the topics of suicide and dangerousness are prominent throughout the manuscript.

When it comes to legislation regarding those with psychiatric disorders, we need a few improvements. We need to be guided by the available research, not by emotions, and we need psychiatry – as represented by those who actually treat patients – to have a voice in discussing the clinical implications.

<[QM]>--Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011)

If you’ve been following our columns for the past few weeks, you’ll note that we’ve been interested in the ongoing gun control legislation in Maryland as it pertains to those with psychiatric disorders.

My co-columnist, Dr. Anne Hanson, likes the metaphor that this legislation, as it pertains to intersection of gun ownership rights and mental illness, is like the Wicked Witch of the West and notes, “Things must be done carefully.” I’ve come to think of these laws as being similar to the boardwalk game, Whack-A-Mole. In Maryland, the Firearms Act of 2013 is being debated as I type – our legislative session ends on Monday. The legislation, as put forth by Gov. O’Malley and his administration, does not include a requirement to report dangerous patients to the state, but individual legislators have supported first a bill, then an amendment, to mandate legislation with wording similar to what has passed as part of the New York SAFE Act. Each time we believe the issue is dead, it pops up again, only to get whacked down and then resurface from another unexpected hole. I’m hopeful that it has died a final death and that mandatory reporting will not make its way into Maryland.

Why are legislators proposing laws where there is no clear benefit to the community? There are no data to support either the idea that reporting “likely to be dangerous people” to a federal database for the purpose of revoking firearms permits or preventing such permits from being issued will make us safer, and the fear is that such legislation will deter dangerous individuals from seeking treatment. Our legislators have deemed this “the chilling effect” and with such a label, they’ve acknowledged the possibility and can then minimize it. On the other hand, we don’t know for sure that such legislation won’t make us all safer; there simply are no data. What we do know is that the New York Veterans Administration has publicly stated that it will not comply with the reporting requirement, and that a New York firearms site has announced that doctor-patient confidentiality is gone and people should be careful about what they say to their therapists.

Why would any Maryland legislator support such measures, given that they may deter people from seeking treatment? Since my own delegate was a co-sponsor of the bill to require mandatory reporting of patients who are likely to be dangerous, I went to speak with him about it. His response was that this was the recommendation of the Task Force to Study Access of Individuals With Mental Illness to Regulated Firearms. What’s really interesting about this recommendation is that of the 17 members on the task force, there was only one psychiatrist – an administrator for the Department of Health and Mental Hygiene whose role was to represent the state. Many organizations were represented, but mental health clinicians of all flavors were notably missing. While the Maryland Psychiatric Society did not have a seat at the table, the Associated Gun Clubs of Baltimore and Maryland Shall Issue (a citizens’ defense league) were both represented. That’s right, our state had a mental health task force where the gun activists had a larger voice then the psychiatrists. I’ll leave it to you to decide if that makes any sense.

As much as I believe that mandatory reporting of those “likely to be dangerous” to an FBI database by mental health professionals is a bad idea, I don’t know that it is. There is simply no research on this. It’s interesting that our state task force also suggested that firearms be seized from dangerous people – a measure that might be welcome by clinicians worried about a patient’s safety – but this recommendation did not influence any proposed legislation.

Toward the purpose of understanding what data are out there to inform our laws, I want to put in a quick plug for Reducing Gun Violence in America: Informing Policy with Evidence and Analysis, edited by Daniel W. Webster and Jon S. Vernick of the Center for Gun Policy and Research at the Johns Hopkins Bloomberg School of Public Health. In the aftermath of the Sandy Hook Tragedy, Webster and Vernick put together a volume that includes extensive reviews of the available literature on firearms research. One chapter is devoted to mental health research, and two of the seven co-authors of that chapter are psychiatrists. The book is the result of the Summit on Reducing Gun Violence in America, held Jan. 14-15 at Johns Hopkins.

The book became available with surprising speed. Kathy Alexander, a publicity manager for JHUP told me, “While most of our manuscripts (as a whole) are reviewed by scholars in the field, this time we had multiple scholars reviewing chapters at the same time to speed up the process and to have those sections reviewed by those scholars that follow that particular angle. It was really amazing. In the scramble to get the summit and the accompanying book out, our employees gave up vacations, angered family members during the holidays, and obviously lost some sleep.” The result, however, is a wonderful, state-of-the art review of what we do and don’t know about gun violence, and while a single chapter is devoted to mental disorders, the topics of suicide and dangerousness are prominent throughout the manuscript.

When it comes to legislation regarding those with psychiatric disorders, we need a few improvements. We need to be guided by the available research, not by emotions, and we need psychiatry – as represented by those who actually treat patients – to have a voice in discussing the clinical implications.

<[QM]>--Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011)

If you’ve been following our columns for the past few weeks, you’ll note that we’ve been interested in the ongoing gun control legislation in Maryland as it pertains to those with psychiatric disorders.

My co-columnist, Dr. Anne Hanson, likes the metaphor that this legislation, as it pertains to intersection of gun ownership rights and mental illness, is like the Wicked Witch of the West and notes, “Things must be done carefully.” I’ve come to think of these laws as being similar to the boardwalk game, Whack-A-Mole. In Maryland, the Firearms Act of 2013 is being debated as I type – our legislative session ends on Monday. The legislation, as put forth by Gov. O’Malley and his administration, does not include a requirement to report dangerous patients to the state, but individual legislators have supported first a bill, then an amendment, to mandate legislation with wording similar to what has passed as part of the New York SAFE Act. Each time we believe the issue is dead, it pops up again, only to get whacked down and then resurface from another unexpected hole. I’m hopeful that it has died a final death and that mandatory reporting will not make its way into Maryland.

Why are legislators proposing laws where there is no clear benefit to the community? There are no data to support either the idea that reporting “likely to be dangerous people” to a federal database for the purpose of revoking firearms permits or preventing such permits from being issued will make us safer, and the fear is that such legislation will deter dangerous individuals from seeking treatment. Our legislators have deemed this “the chilling effect” and with such a label, they’ve acknowledged the possibility and can then minimize it. On the other hand, we don’t know for sure that such legislation won’t make us all safer; there simply are no data. What we do know is that the New York Veterans Administration has publicly stated that it will not comply with the reporting requirement, and that a New York firearms site has announced that doctor-patient confidentiality is gone and people should be careful about what they say to their therapists.

Why would any Maryland legislator support such measures, given that they may deter people from seeking treatment? Since my own delegate was a co-sponsor of the bill to require mandatory reporting of patients who are likely to be dangerous, I went to speak with him about it. His response was that this was the recommendation of the Task Force to Study Access of Individuals With Mental Illness to Regulated Firearms. What’s really interesting about this recommendation is that of the 17 members on the task force, there was only one psychiatrist – an administrator for the Department of Health and Mental Hygiene whose role was to represent the state. Many organizations were represented, but mental health clinicians of all flavors were notably missing. While the Maryland Psychiatric Society did not have a seat at the table, the Associated Gun Clubs of Baltimore and Maryland Shall Issue (a citizens’ defense league) were both represented. That’s right, our state had a mental health task force where the gun activists had a larger voice then the psychiatrists. I’ll leave it to you to decide if that makes any sense.

As much as I believe that mandatory reporting of those “likely to be dangerous” to an FBI database by mental health professionals is a bad idea, I don’t know that it is. There is simply no research on this. It’s interesting that our state task force also suggested that firearms be seized from dangerous people – a measure that might be welcome by clinicians worried about a patient’s safety – but this recommendation did not influence any proposed legislation.

Toward the purpose of understanding what data are out there to inform our laws, I want to put in a quick plug for Reducing Gun Violence in America: Informing Policy with Evidence and Analysis, edited by Daniel W. Webster and Jon S. Vernick of the Center for Gun Policy and Research at the Johns Hopkins Bloomberg School of Public Health. In the aftermath of the Sandy Hook Tragedy, Webster and Vernick put together a volume that includes extensive reviews of the available literature on firearms research. One chapter is devoted to mental health research, and two of the seven co-authors of that chapter are psychiatrists. The book is the result of the Summit on Reducing Gun Violence in America, held Jan. 14-15 at Johns Hopkins.

The book became available with surprising speed. Kathy Alexander, a publicity manager for JHUP told me, “While most of our manuscripts (as a whole) are reviewed by scholars in the field, this time we had multiple scholars reviewing chapters at the same time to speed up the process and to have those sections reviewed by those scholars that follow that particular angle. It was really amazing. In the scramble to get the summit and the accompanying book out, our employees gave up vacations, angered family members during the holidays, and obviously lost some sleep.” The result, however, is a wonderful, state-of-the art review of what we do and don’t know about gun violence, and while a single chapter is devoted to mental disorders, the topics of suicide and dangerousness are prominent throughout the manuscript.

When it comes to legislation regarding those with psychiatric disorders, we need a few improvements. We need to be guided by the available research, not by emotions, and we need psychiatry – as represented by those who actually treat patients – to have a voice in discussing the clinical implications.

<[QM]>--Dinah Miller, M.D.

Dr. Miller is co-author of Shrink Rap: Three Psychiatrists Explain Their Work (Johns Hopkins University Press, 2011)

With barely a week left in the current legislative session, I feel a bit like a marathoner entering the home stretch. Like many states, Maryland faced a flurry of bills aimed at reducing gun violence and the risk of violence posed by certain psychiatric patients.

We dealt with laws regarding the mandatory reporting of potentially violent patients, laws to take guns away from certain psychiatric patients, liberalization of emergency evaluation and civil commitment procedures, as well as involuntary medication laws. We saw laws designed to prevent the release of insanity acquittees by creating a second, redundant review process. At times, it seemed that all of public policy was aligned to single out the people in our care. Frankly, it was exhausting.

In addition to screening and previewing hundreds of bills with the help of our lobbyist, we had to consider the history and intended purpose of each bill, the motivation of the sponsors, the stances of various interest groups, and the implications for clinical practice. We volunteered countless hours of time spent in conference calls, meetings, and the review of draft amendments.

I began to wish that I had a magic wand that I could swish while shouting the Harry Potter-esque charm “excretus ablatus!” which would magically revamp the bill to exclude excess or ambiguous language and send it flying through committee and both houses with the speed and precision of a Department of Defense drone. Either that or make the bill disappear completely.

Alas, there was no magic wand and no spell that could fix some of the proposed bills I reviewed and no way to make them disappear. Instead, I learned a number of valuable lessons about the legislative process.

The first thing I learned was that the Wicked Witch of the West was right. When she was attempting to confiscate Dorothy's magic slippers, she uttered a maxim I found myself repeating to myself over several proposed laws: "These things must be done carefully." A good bill is shaped through careful deliberation with the input of many stakeholders, not cobbled together in a hodgepodge of rushed amendments. A rushed compromise law runs the risk of making things worse rather than better and may result in a challenge that throws the existing law out completely.

Second, there must be a consideration of the risk of compromise versus the risk of drawing a line in the sand. While the ability to compromise is often considered to be a positive quality, where our patients are concerned this can lead down a slippery slope of an even worse compromise later. Psychiatry has dealt with this slippery slope with regard to mandatory reporting of child abuse. Mandatory reporting laws evolved into criminal sanctions for failure to report. A similar risk could arise with regard to mandatory reporting of psychiatric patients. We must actively resist this criminalization of our profession as well as the stigma imposed upon our patients.

The last point is one I am careful to pass on to my students, which is the importance of active involvement in one’s professional organization. At a time when the American Psychiatric Association is under attack for problems associated with the DSM-5 and changes in CPT coding, psychiatrists may forget the importance of the district branch. District branches are crucial to the day-to-day regulation of clinical practice and for patient advocacy. Unfortunately, much of this work is done behind the scenes with little fanfare or public acknowledgment. Like a well-designed car, the only time people think about how it works is when there is a mishap. In the case of legislation, if all goes well, members are unaware that there is actually a lot going on “under the hood.”

Dr. Hanson is a forensic psychiatrist and co-author 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.

With barely a week left in the current legislative session, I feel a bit like a marathoner entering the home stretch. Like many states, Maryland faced a flurry of bills aimed at reducing gun violence and the risk of violence posed by certain psychiatric patients.

We dealt with laws regarding the mandatory reporting of potentially violent patients, laws to take guns away from certain psychiatric patients, liberalization of emergency evaluation and civil commitment procedures, as well as involuntary medication laws. We saw laws designed to prevent the release of insanity acquittees by creating a second, redundant review process. At times, it seemed that all of public policy was aligned to single out the people in our care. Frankly, it was exhausting.

In addition to screening and previewing hundreds of bills with the help of our lobbyist, we had to consider the history and intended purpose of each bill, the motivation of the sponsors, the stances of various interest groups, and the implications for clinical practice. We volunteered countless hours of time spent in conference calls, meetings, and the review of draft amendments.

I began to wish that I had a magic wand that I could swish while shouting the Harry Potter-esque charm “excretus ablatus!” which would magically revamp the bill to exclude excess or ambiguous language and send it flying through committee and both houses with the speed and precision of a Department of Defense drone. Either that or make the bill disappear completely.

Alas, there was no magic wand and no spell that could fix some of the proposed bills I reviewed and no way to make them disappear. Instead, I learned a number of valuable lessons about the legislative process.

The first thing I learned was that the Wicked Witch of the West was right. When she was attempting to confiscate Dorothy's magic slippers, she uttered a maxim I found myself repeating to myself over several proposed laws: "These things must be done carefully." A good bill is shaped through careful deliberation with the input of many stakeholders, not cobbled together in a hodgepodge of rushed amendments. A rushed compromise law runs the risk of making things worse rather than better and may result in a challenge that throws the existing law out completely.

Second, there must be a consideration of the risk of compromise versus the risk of drawing a line in the sand. While the ability to compromise is often considered to be a positive quality, where our patients are concerned this can lead down a slippery slope of an even worse compromise later. Psychiatry has dealt with this slippery slope with regard to mandatory reporting of child abuse. Mandatory reporting laws evolved into criminal sanctions for failure to report. A similar risk could arise with regard to mandatory reporting of psychiatric patients. We must actively resist this criminalization of our profession as well as the stigma imposed upon our patients.

The last point is one I am careful to pass on to my students, which is the importance of active involvement in one’s professional organization. At a time when the American Psychiatric Association is under attack for problems associated with the DSM-5 and changes in CPT coding, psychiatrists may forget the importance of the district branch. District branches are crucial to the day-to-day regulation of clinical practice and for patient advocacy. Unfortunately, much of this work is done behind the scenes with little fanfare or public acknowledgment. Like a well-designed car, the only time people think about how it works is when there is a mishap. In the case of legislation, if all goes well, members are unaware that there is actually a lot going on “under the hood.”

Dr. Hanson is a forensic psychiatrist and co-author 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.

With barely a week left in the current legislative session, I feel a bit like a marathoner entering the home stretch. Like many states, Maryland faced a flurry of bills aimed at reducing gun violence and the risk of violence posed by certain psychiatric patients.

We dealt with laws regarding the mandatory reporting of potentially violent patients, laws to take guns away from certain psychiatric patients, liberalization of emergency evaluation and civil commitment procedures, as well as involuntary medication laws. We saw laws designed to prevent the release of insanity acquittees by creating a second, redundant review process. At times, it seemed that all of public policy was aligned to single out the people in our care. Frankly, it was exhausting.

In addition to screening and previewing hundreds of bills with the help of our lobbyist, we had to consider the history and intended purpose of each bill, the motivation of the sponsors, the stances of various interest groups, and the implications for clinical practice. We volunteered countless hours of time spent in conference calls, meetings, and the review of draft amendments.

I began to wish that I had a magic wand that I could swish while shouting the Harry Potter-esque charm “excretus ablatus!” which would magically revamp the bill to exclude excess or ambiguous language and send it flying through committee and both houses with the speed and precision of a Department of Defense drone. Either that or make the bill disappear completely.

Alas, there was no magic wand and no spell that could fix some of the proposed bills I reviewed and no way to make them disappear. Instead, I learned a number of valuable lessons about the legislative process.

The first thing I learned was that the Wicked Witch of the West was right. When she was attempting to confiscate Dorothy's magic slippers, she uttered a maxim I found myself repeating to myself over several proposed laws: "These things must be done carefully." A good bill is shaped through careful deliberation with the input of many stakeholders, not cobbled together in a hodgepodge of rushed amendments. A rushed compromise law runs the risk of making things worse rather than better and may result in a challenge that throws the existing law out completely.

Second, there must be a consideration of the risk of compromise versus the risk of drawing a line in the sand. While the ability to compromise is often considered to be a positive quality, where our patients are concerned this can lead down a slippery slope of an even worse compromise later. Psychiatry has dealt with this slippery slope with regard to mandatory reporting of child abuse. Mandatory reporting laws evolved into criminal sanctions for failure to report. A similar risk could arise with regard to mandatory reporting of psychiatric patients. We must actively resist this criminalization of our profession as well as the stigma imposed upon our patients.

The last point is one I am careful to pass on to my students, which is the importance of active involvement in one’s professional organization. At a time when the American Psychiatric Association is under attack for problems associated with the DSM-5 and changes in CPT coding, psychiatrists may forget the importance of the district branch. District branches are crucial to the day-to-day regulation of clinical practice and for patient advocacy. Unfortunately, much of this work is done behind the scenes with little fanfare or public acknowledgment. Like a well-designed car, the only time people think about how it works is when there is a mishap. In the case of legislation, if all goes well, members are unaware that there is actually a lot going on “under the hood.”

Dr. Hanson is a forensic psychiatrist and co-author 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.

The American Psychiatric Association (APA) started working with insurance companies prior to the new CPT codes taking effect. Some have responded by making the appropriate adjustments so that patients and psychiatrists billing for E&M codes (Evaluation & Management) as well as the new psychotherapy codes are paid properly and fairly. In most cases, when this is paid according to the law – including the parity law – the payments are higher than they were before the codes went into effect on Jan. 1, 2013.

However, there are still many insurance companies that have either ignored the law, or, more malignantly, have taken advantage of the situation by paying patients and physicians even less money for needed mental health and addiction treatment than they did before Jan. 1. Many psychiatrists, state psychiatric societies, and the APA are fighting with the payers to correct this improper, even illegal, corporate behavior.

Psychiatrists across the country have been confused and angered by this behavior, some even blaming the APA for supporting the changes. However, most are now realizing that it is the insurance companies that are playing games. Well, the games are over, the gloves are off, and the complaints and lawsuits are beginning to fly.

In January, the Centers for Medicare and Medicaid issued a strongly worded statement to state health officers that their Medicaid plans need to be compliant with Parity.

On March 11, the New York State Psychiatric Association filed a federal lawsuit against UnitedHealth contending that it systematically discriminates against people with mental illness by limiting, delaying, and denying care, including discriminatory payment practices.

On March 14, the APA, Connecticut Psychiatric Society, and Connecticut State Medical Society sent a letter to Anthem Blue Cross, which they believe is “violating state and federal laws and regulations, including the Mental Health Parity and Addiction Equity Act (MHPAEA), the Connecticut Parity Law, HIPAA, and the Unfair Insurance and Unfair Trade Practices laws as they pertain to the treatment of patients with a mental or substance use disorder.”

Sam Muszynski, director of APA’s Office of Healthcare Systems and Financing, enumerated the problems being seen across the country:

“Unfortunately, the apparent inability of many payers to at least maintain the reimbursement levels psychiatrists were receiving in 2012 has created a number of problems for APA members and their patients. The problems seem to differ from plan to plan and even from psychiatrist to psychiatrist within a plan’s network. Some of the issues the Office of Healthcare Systems has heard about with some regularity are:

• Plans’ inability to process the two codes now needed to represent psychotherapy with medical evaluation and management (E/M), previously coding using one code with minimal value given to the E/M, which is often a major part of psychiatric care. There are variations on this with some plans paying only for the E/M code, while others pay only for the psychotherapy code.

• Plans paying for the two codes, but at such reduced fees that psychiatrists are receiving less than they did for providing the same services in 2012 when they had no means of accurately representing the E/M work they performed.

• Plans charging patients two co-pays for a visit with a psychiatrist because two codes are used to record the visit – something that never occurs with visits to primary care physicians who often use several codes for apatient encounter.

• Plans requiring prior authorization for the use of E/M codes 99214 and 99215.

• Plans not paying anything at all because of computer problems with processing the claims.

• Plans refusing to recognize and/or pay for the psychotherapy add-on codes (90833, 90836, and 90838).

“We have an ongoing program of liaison with payers regarding these issues and are launching a new focused effort aimed at amelioration,” Muszynski said. “Where resolution is not forthcoming, the APA will commence an even more focused action with the problem payers and will consider all appropriate options as necessary.”

We need to get lawsuits against this illegal behavior blossoming in every state. The best thing we can do is to complain to the payers, our state psychiatric societies, our state insurance administrations, and our elected officials. Add your voice to the strength of the APA by sending it your evidence of improper or illegal insurance discrimination. See the box for more information.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on at drdavisATgmail.com, and  and on the Shrink Rap blog.

The American Psychiatric Association (APA) started working with insurance companies prior to the new CPT codes taking effect. Some have responded by making the appropriate adjustments so that patients and psychiatrists billing for E&M codes (Evaluation & Management) as well as the new psychotherapy codes are paid properly and fairly. In most cases, when this is paid according to the law – including the parity law – the payments are higher than they were before the codes went into effect on Jan. 1, 2013.

However, there are still many insurance companies that have either ignored the law, or, more malignantly, have taken advantage of the situation by paying patients and physicians even less money for needed mental health and addiction treatment than they did before Jan. 1. Many psychiatrists, state psychiatric societies, and the APA are fighting with the payers to correct this improper, even illegal, corporate behavior.

Psychiatrists across the country have been confused and angered by this behavior, some even blaming the APA for supporting the changes. However, most are now realizing that it is the insurance companies that are playing games. Well, the games are over, the gloves are off, and the complaints and lawsuits are beginning to fly.

In January, the Centers for Medicare and Medicaid issued a strongly worded statement to state health officers that their Medicaid plans need to be compliant with Parity.

On March 11, the New York State Psychiatric Association filed a federal lawsuit against UnitedHealth contending that it systematically discriminates against people with mental illness by limiting, delaying, and denying care, including discriminatory payment practices.

On March 14, the APA, Connecticut Psychiatric Society, and Connecticut State Medical Society sent a letter to Anthem Blue Cross, which they believe is “violating state and federal laws and regulations, including the Mental Health Parity and Addiction Equity Act (MHPAEA), the Connecticut Parity Law, HIPAA, and the Unfair Insurance and Unfair Trade Practices laws as they pertain to the treatment of patients with a mental or substance use disorder.”

Sam Muszynski, director of APA’s Office of Healthcare Systems and Financing, enumerated the problems being seen across the country:

“Unfortunately, the apparent inability of many payers to at least maintain the reimbursement levels psychiatrists were receiving in 2012 has created a number of problems for APA members and their patients. The problems seem to differ from plan to plan and even from psychiatrist to psychiatrist within a plan’s network. Some of the issues the Office of Healthcare Systems has heard about with some regularity are:

• Plans’ inability to process the two codes now needed to represent psychotherapy with medical evaluation and management (E/M), previously coding using one code with minimal value given to the E/M, which is often a major part of psychiatric care. There are variations on this with some plans paying only for the E/M code, while others pay only for the psychotherapy code.

• Plans paying for the two codes, but at such reduced fees that psychiatrists are receiving less than they did for providing the same services in 2012 when they had no means of accurately representing the E/M work they performed.

• Plans charging patients two co-pays for a visit with a psychiatrist because two codes are used to record the visit – something that never occurs with visits to primary care physicians who often use several codes for apatient encounter.

• Plans requiring prior authorization for the use of E/M codes 99214 and 99215.

• Plans not paying anything at all because of computer problems with processing the claims.

• Plans refusing to recognize and/or pay for the psychotherapy add-on codes (90833, 90836, and 90838).

“We have an ongoing program of liaison with payers regarding these issues and are launching a new focused effort aimed at amelioration,” Muszynski said. “Where resolution is not forthcoming, the APA will commence an even more focused action with the problem payers and will consider all appropriate options as necessary.”

We need to get lawsuits against this illegal behavior blossoming in every state. The best thing we can do is to complain to the payers, our state psychiatric societies, our state insurance administrations, and our elected officials. Add your voice to the strength of the APA by sending it your evidence of improper or illegal insurance discrimination. See the box for more information.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on at drdavisATgmail.com, and  and on the Shrink Rap blog.

The American Psychiatric Association (APA) started working with insurance companies prior to the new CPT codes taking effect. Some have responded by making the appropriate adjustments so that patients and psychiatrists billing for E&M codes (Evaluation & Management) as well as the new psychotherapy codes are paid properly and fairly. In most cases, when this is paid according to the law – including the parity law – the payments are higher than they were before the codes went into effect on Jan. 1, 2013.

However, there are still many insurance companies that have either ignored the law, or, more malignantly, have taken advantage of the situation by paying patients and physicians even less money for needed mental health and addiction treatment than they did before Jan. 1. Many psychiatrists, state psychiatric societies, and the APA are fighting with the payers to correct this improper, even illegal, corporate behavior.

Psychiatrists across the country have been confused and angered by this behavior, some even blaming the APA for supporting the changes. However, most are now realizing that it is the insurance companies that are playing games. Well, the games are over, the gloves are off, and the complaints and lawsuits are beginning to fly.

In January, the Centers for Medicare and Medicaid issued a strongly worded statement to state health officers that their Medicaid plans need to be compliant with Parity.

On March 11, the New York State Psychiatric Association filed a federal lawsuit against UnitedHealth contending that it systematically discriminates against people with mental illness by limiting, delaying, and denying care, including discriminatory payment practices.

On March 14, the APA, Connecticut Psychiatric Society, and Connecticut State Medical Society sent a letter to Anthem Blue Cross, which they believe is “violating state and federal laws and regulations, including the Mental Health Parity and Addiction Equity Act (MHPAEA), the Connecticut Parity Law, HIPAA, and the Unfair Insurance and Unfair Trade Practices laws as they pertain to the treatment of patients with a mental or substance use disorder.”

Sam Muszynski, director of APA’s Office of Healthcare Systems and Financing, enumerated the problems being seen across the country:

“Unfortunately, the apparent inability of many payers to at least maintain the reimbursement levels psychiatrists were receiving in 2012 has created a number of problems for APA members and their patients. The problems seem to differ from plan to plan and even from psychiatrist to psychiatrist within a plan’s network. Some of the issues the Office of Healthcare Systems has heard about with some regularity are:

• Plans’ inability to process the two codes now needed to represent psychotherapy with medical evaluation and management (E/M), previously coding using one code with minimal value given to the E/M, which is often a major part of psychiatric care. There are variations on this with some plans paying only for the E/M code, while others pay only for the psychotherapy code.

• Plans paying for the two codes, but at such reduced fees that psychiatrists are receiving less than they did for providing the same services in 2012 when they had no means of accurately representing the E/M work they performed.

• Plans charging patients two co-pays for a visit with a psychiatrist because two codes are used to record the visit – something that never occurs with visits to primary care physicians who often use several codes for apatient encounter.

• Plans requiring prior authorization for the use of E/M codes 99214 and 99215.

• Plans not paying anything at all because of computer problems with processing the claims.

• Plans refusing to recognize and/or pay for the psychotherapy add-on codes (90833, 90836, and 90838).

“We have an ongoing program of liaison with payers regarding these issues and are launching a new focused effort aimed at amelioration,” Muszynski said. “Where resolution is not forthcoming, the APA will commence an even more focused action with the problem payers and will consider all appropriate options as necessary.”

We need to get lawsuits against this illegal behavior blossoming in every state. The best thing we can do is to complain to the payers, our state psychiatric societies, our state insurance administrations, and our elected officials. Add your voice to the strength of the APA by sending it your evidence of improper or illegal insurance discrimination. See the box for more information.

—Steven Roy Daviss, M.D., DFAPA

Dr. Daviss is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, co-chair of the CCHIT Behavioral Health Work Group, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on at drdavisATgmail.com, and  and on the Shrink Rap blog.

On Friday, March 1, 2013, I joined 1,300 other people in giving public testimony to the Maryland General Assembly on a variety of proposed bills related to firearms legislation. As you might guess by the numbers, it was quite the dog-and-pony show, and I’ve written a detailed account of my 11 hours there over on our Shrink Rap blog in a post called “My Day With Our State Legislature.”  If you read that post, you'll know that it didn’t all go so smoothly. I did it as a story, rather than as bullet points or a plea, and that was its own risk. Because of the number of people, we were each given 1 minute, though my talk was prepared a couple of days before when I thought I had 3 minutes. Here is the text of my intended (and mostly given!) testimony:

My name is Dinah Miller, I am a psychiatrist in Baltimore and I consult to the Johns Hopkins Community Psychiatry Program and I’m a past president of the Maryland Psychiatric Society. I’ve discussed some of my concerns about this legislation in an op-piece that appeared in the Baltimore Sun on February 11th. I hope you’ll have a chance to look at it.

Please bear with me while I take you on a brief journey.

Can you imagine that one morning you might wake up only to dread the coming day, that you’ll want to stay in bed and not listen to a single whining constituent? Perhaps you are feeling down because you have overwhelming problems, or perhaps, through no fault of your own, you’ve been struck with a soul-crushing episode of depression.  Either way,  in some of those very dark moments you may start to see suicide as a possible way to end the pain.  So my question to you today is quite simple, and very personal.  Will you go for help knowing that when you tell a therapist your darkest thoughts, you may be reported to an FBI database? Why do I think you might say no?  Even if you never want to own a gun, will you hesitate to get treatment, knowing your state has a law that requires mental health professionals to report  people who are “likely to be dangerous”?   

The truth is that a psychiatrist can’t be your agent and also be the agent of the state; it just doesn’t work.

Maybe you can’t come on this journey with me.  Perhaps you’ve already lived through terrible times without ever entertaining the thought of harming yourself, much less anyone else. So let me take you instead on a similar journey, only this time, it’s with your teenage child. Your wonderful son has been feeling down since his girlfriend dumped him for his best friend. He was in love, and he just can’t shake it, no matter how many times he hears about those other fish in the ocean. As teenage boys do, he grunts and keeps to himself and you suspect he smokes some of that medical marijuana stuff, and oh my, he’s playing Call of Duty on his Xbox. Finally, he makes a comment about not wanting to live without her, and he’d like to kill her new boyfriend. Obviously, figures of speech, right?  But teenagers do kill themselves over emotions that will pass.  So let me ask again: Will you pause before you get him help, knowing your son’s name might be placed in an FBI database? Will it matter that he loves to hunt with his dad, and he may never again be legally allowed to hunt?  Or will it be a shock – 25 years from now and long after he’s gotten over his teenage heartbreak – when the Wal-Mart clerk says he can’t buy a gun because he’s in a database for felons and the mentally ill?

In Maryland, the Tarasoff requirements already spell out what actions we must take in the case of an imminent threat.  But this law is about populating a database; there is nothing in it that compels law enforcement officials to  seize weapons from a dangerous person in a timely manner.  And nothing in it that would prevent a school shooting.

It’s likely some therapists will ignore these mandates; they do, after all, legislate what we believe, and what goes on inside our heads is probably not subject to legislation.  I would contend that the details don’t matter, that the fear of being reported will be enough to stop people who are dangerous, especially gun owners, from seeking care. And some of those people, feeling there is no help to be gotten and no where to turn, will their end their lives and perhaps the lives of others. That said,  I hope you never find yourself in that miserable, dark place.

—Dinah Miller, M.D.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, released by Johns Hopkins University Press.

On Friday, March 1, 2013, I joined 1,300 other people in giving public testimony to the Maryland General Assembly on a variety of proposed bills related to firearms legislation. As you might guess by the numbers, it was quite the dog-and-pony show, and I’ve written a detailed account of my 11 hours there over on our Shrink Rap blog in a post called “My Day With Our State Legislature.”  If you read that post, you'll know that it didn’t all go so smoothly. I did it as a story, rather than as bullet points or a plea, and that was its own risk. Because of the number of people, we were each given 1 minute, though my talk was prepared a couple of days before when I thought I had 3 minutes. Here is the text of my intended (and mostly given!) testimony:

My name is Dinah Miller, I am a psychiatrist in Baltimore and I consult to the Johns Hopkins Community Psychiatry Program and I’m a past president of the Maryland Psychiatric Society. I’ve discussed some of my concerns about this legislation in an op-piece that appeared in the Baltimore Sun on February 11th. I hope you’ll have a chance to look at it.

Please bear with me while I take you on a brief journey.

Can you imagine that one morning you might wake up only to dread the coming day, that you’ll want to stay in bed and not listen to a single whining constituent? Perhaps you are feeling down because you have overwhelming problems, or perhaps, through no fault of your own, you’ve been struck with a soul-crushing episode of depression.  Either way,  in some of those very dark moments you may start to see suicide as a possible way to end the pain.  So my question to you today is quite simple, and very personal.  Will you go for help knowing that when you tell a therapist your darkest thoughts, you may be reported to an FBI database? Why do I think you might say no?  Even if you never want to own a gun, will you hesitate to get treatment, knowing your state has a law that requires mental health professionals to report  people who are “likely to be dangerous”?   

The truth is that a psychiatrist can’t be your agent and also be the agent of the state; it just doesn’t work.

Maybe you can’t come on this journey with me.  Perhaps you’ve already lived through terrible times without ever entertaining the thought of harming yourself, much less anyone else. So let me take you instead on a similar journey, only this time, it’s with your teenage child. Your wonderful son has been feeling down since his girlfriend dumped him for his best friend. He was in love, and he just can’t shake it, no matter how many times he hears about those other fish in the ocean. As teenage boys do, he grunts and keeps to himself and you suspect he smokes some of that medical marijuana stuff, and oh my, he’s playing Call of Duty on his Xbox. Finally, he makes a comment about not wanting to live without her, and he’d like to kill her new boyfriend. Obviously, figures of speech, right?  But teenagers do kill themselves over emotions that will pass.  So let me ask again: Will you pause before you get him help, knowing your son’s name might be placed in an FBI database? Will it matter that he loves to hunt with his dad, and he may never again be legally allowed to hunt?  Or will it be a shock – 25 years from now and long after he’s gotten over his teenage heartbreak – when the Wal-Mart clerk says he can’t buy a gun because he’s in a database for felons and the mentally ill?

In Maryland, the Tarasoff requirements already spell out what actions we must take in the case of an imminent threat.  But this law is about populating a database; there is nothing in it that compels law enforcement officials to  seize weapons from a dangerous person in a timely manner.  And nothing in it that would prevent a school shooting.

It’s likely some therapists will ignore these mandates; they do, after all, legislate what we believe, and what goes on inside our heads is probably not subject to legislation.  I would contend that the details don’t matter, that the fear of being reported will be enough to stop people who are dangerous, especially gun owners, from seeking care. And some of those people, feeling there is no help to be gotten and no where to turn, will their end their lives and perhaps the lives of others. That said,  I hope you never find yourself in that miserable, dark place.

—Dinah Miller, M.D.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, released by Johns Hopkins University Press.

On Friday, March 1, 2013, I joined 1,300 other people in giving public testimony to the Maryland General Assembly on a variety of proposed bills related to firearms legislation. As you might guess by the numbers, it was quite the dog-and-pony show, and I’ve written a detailed account of my 11 hours there over on our Shrink Rap blog in a post called “My Day With Our State Legislature.”  If you read that post, you'll know that it didn’t all go so smoothly. I did it as a story, rather than as bullet points or a plea, and that was its own risk. Because of the number of people, we were each given 1 minute, though my talk was prepared a couple of days before when I thought I had 3 minutes. Here is the text of my intended (and mostly given!) testimony:

My name is Dinah Miller, I am a psychiatrist in Baltimore and I consult to the Johns Hopkins Community Psychiatry Program and I’m a past president of the Maryland Psychiatric Society. I’ve discussed some of my concerns about this legislation in an op-piece that appeared in the Baltimore Sun on February 11th. I hope you’ll have a chance to look at it.

Please bear with me while I take you on a brief journey.

Can you imagine that one morning you might wake up only to dread the coming day, that you’ll want to stay in bed and not listen to a single whining constituent? Perhaps you are feeling down because you have overwhelming problems, or perhaps, through no fault of your own, you’ve been struck with a soul-crushing episode of depression.  Either way,  in some of those very dark moments you may start to see suicide as a possible way to end the pain.  So my question to you today is quite simple, and very personal.  Will you go for help knowing that when you tell a therapist your darkest thoughts, you may be reported to an FBI database? Why do I think you might say no?  Even if you never want to own a gun, will you hesitate to get treatment, knowing your state has a law that requires mental health professionals to report  people who are “likely to be dangerous”?   

The truth is that a psychiatrist can’t be your agent and also be the agent of the state; it just doesn’t work.

Maybe you can’t come on this journey with me.  Perhaps you’ve already lived through terrible times without ever entertaining the thought of harming yourself, much less anyone else. So let me take you instead on a similar journey, only this time, it’s with your teenage child. Your wonderful son has been feeling down since his girlfriend dumped him for his best friend. He was in love, and he just can’t shake it, no matter how many times he hears about those other fish in the ocean. As teenage boys do, he grunts and keeps to himself and you suspect he smokes some of that medical marijuana stuff, and oh my, he’s playing Call of Duty on his Xbox. Finally, he makes a comment about not wanting to live without her, and he’d like to kill her new boyfriend. Obviously, figures of speech, right?  But teenagers do kill themselves over emotions that will pass.  So let me ask again: Will you pause before you get him help, knowing your son’s name might be placed in an FBI database? Will it matter that he loves to hunt with his dad, and he may never again be legally allowed to hunt?  Or will it be a shock – 25 years from now and long after he’s gotten over his teenage heartbreak – when the Wal-Mart clerk says he can’t buy a gun because he’s in a database for felons and the mentally ill?

In Maryland, the Tarasoff requirements already spell out what actions we must take in the case of an imminent threat.  But this law is about populating a database; there is nothing in it that compels law enforcement officials to  seize weapons from a dangerous person in a timely manner.  And nothing in it that would prevent a school shooting.

It’s likely some therapists will ignore these mandates; they do, after all, legislate what we believe, and what goes on inside our heads is probably not subject to legislation.  I would contend that the details don’t matter, that the fear of being reported will be enough to stop people who are dangerous, especially gun owners, from seeking care. And some of those people, feeling there is no help to be gotten and no where to turn, will their end their lives and perhaps the lives of others. That said,  I hope you never find yourself in that miserable, dark place.

—Dinah Miller, M.D.

Dr. Miller is the co-author of Shrink Rap: Three Psychiatrists Explain Their Work, released by Johns Hopkins University Press.

As a general rule, I find films about forensic psychiatrists tolerable but usually not that entertaining. They inevitably involve serial killers, criminal profilers or other tropes that have little to do with the reality of forensic life. When I saw a trailer for the new film "Side Effects," I expected much of the same. Surprisingly, I enjoyed it.

Jude Law plays Dr. Jonathan Banks, a forensic psychiatrist who somehow manages to juggle work in an emergency room, a private outpatient practice, and inpatient work in a forensic hospital with private expert testimony for both the prosecution and the defense. I was exhausted just watching him. With a child in private school, a Manhattan lifestyle and an unemployed wife, he supplements his income with pharmaceutical money as well.

Dr. Banks takes on the treatment of a suicidal young woman, Emily Taylor (Rooney Mara), who suffers intolerable side effects to most antidepressant medications and who has a bad habit of driving into walls. Psychiatrists watching the film will find the recitation of brand-name medications a bit distracting and there's enough discussion about treatment-resistant depression to get me wondering what I'd try next if I was in Dr. Banks's shoes. Even Emily's friends and co-workers have suggestions about medication, and judging from the buzz in the audience near me, this spurred some discussion among viewers as well.

The film nails the pharmaceutical industry head-on, with breezy television and magazine ads featuring happy and content young women enjoying carefree days, drug reps meeting with doctors to talk money and even the obligatory drug rep lunch. At times this verged on medical insider humor, particularly when one doctor offers another a free brand name drug pen. No worries about ethical standards here, the psychiatrists have no qualms about accepting tens of thousands of dollars in pharmaceutical money.

When Emily finally asks her doctor to prescribe the new medication, Ablixa, things get complicated. I'm not giving away any spoilers since the murder is mentioned in the movie trailer, and the fairly predictable plot featured an equally-predictable insanity defense. Nevertheless, many of the twists and turns featured more than expert testimony and questions of defendant malingering. The question becomes what role, if any, the new medication played in the murder and who knew about this strange, rare, potentially deadly side effect. Dr. Banks is flung into personal and professional complications not usually covered in the typical psychiatric thriller. I won't go into detail on that aspect since it verges into spoiler territory.

I can't help comparing "Side Effects" to other movies with a "is he crazy or is he malingering" insanity theme, most notably "Primal Fear" featuring Ed Norton. "Side Effects" is more than a murder mystery and has more depth than "Primal Fear." With side commentary on the stigma of mental illness, trial-and-error prescribing practices, corruption of the medical profession and duplicitous expert witnesses, there would be enough substance here to carry the film even without the murder.

Whenever a new movie featuring a psychiatrist comes out we wonder how this will impact the public perception of our profession or the perception of the mentally ill. This movie won't deter anyone from seeking care. It will, however, deter me from ever prescribing Ablixa.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author 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.

As a general rule, I find films about forensic psychiatrists tolerable but usually not that entertaining. They inevitably involve serial killers, criminal profilers or other tropes that have little to do with the reality of forensic life. When I saw a trailer for the new film "Side Effects," I expected much of the same. Surprisingly, I enjoyed it.

Jude Law plays Dr. Jonathan Banks, a forensic psychiatrist who somehow manages to juggle work in an emergency room, a private outpatient practice, and inpatient work in a forensic hospital with private expert testimony for both the prosecution and the defense. I was exhausted just watching him. With a child in private school, a Manhattan lifestyle and an unemployed wife, he supplements his income with pharmaceutical money as well.

Dr. Banks takes on the treatment of a suicidal young woman, Emily Taylor (Rooney Mara), who suffers intolerable side effects to most antidepressant medications and who has a bad habit of driving into walls. Psychiatrists watching the film will find the recitation of brand-name medications a bit distracting and there's enough discussion about treatment-resistant depression to get me wondering what I'd try next if I was in Dr. Banks's shoes. Even Emily's friends and co-workers have suggestions about medication, and judging from the buzz in the audience near me, this spurred some discussion among viewers as well.

The film nails the pharmaceutical industry head-on, with breezy television and magazine ads featuring happy and content young women enjoying carefree days, drug reps meeting with doctors to talk money and even the obligatory drug rep lunch. At times this verged on medical insider humor, particularly when one doctor offers another a free brand name drug pen. No worries about ethical standards here, the psychiatrists have no qualms about accepting tens of thousands of dollars in pharmaceutical money.

When Emily finally asks her doctor to prescribe the new medication, Ablixa, things get complicated. I'm not giving away any spoilers since the murder is mentioned in the movie trailer, and the fairly predictable plot featured an equally-predictable insanity defense. Nevertheless, many of the twists and turns featured more than expert testimony and questions of defendant malingering. The question becomes what role, if any, the new medication played in the murder and who knew about this strange, rare, potentially deadly side effect. Dr. Banks is flung into personal and professional complications not usually covered in the typical psychiatric thriller. I won't go into detail on that aspect since it verges into spoiler territory.

I can't help comparing "Side Effects" to other movies with a "is he crazy or is he malingering" insanity theme, most notably "Primal Fear" featuring Ed Norton. "Side Effects" is more than a murder mystery and has more depth than "Primal Fear." With side commentary on the stigma of mental illness, trial-and-error prescribing practices, corruption of the medical profession and duplicitous expert witnesses, there would be enough substance here to carry the film even without the murder.

Whenever a new movie featuring a psychiatrist comes out we wonder how this will impact the public perception of our profession or the perception of the mentally ill. This movie won't deter anyone from seeking care. It will, however, deter me from ever prescribing Ablixa.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author 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.

As a general rule, I find films about forensic psychiatrists tolerable but usually not that entertaining. They inevitably involve serial killers, criminal profilers or other tropes that have little to do with the reality of forensic life. When I saw a trailer for the new film "Side Effects," I expected much of the same. Surprisingly, I enjoyed it.

Jude Law plays Dr. Jonathan Banks, a forensic psychiatrist who somehow manages to juggle work in an emergency room, a private outpatient practice, and inpatient work in a forensic hospital with private expert testimony for both the prosecution and the defense. I was exhausted just watching him. With a child in private school, a Manhattan lifestyle and an unemployed wife, he supplements his income with pharmaceutical money as well.

Dr. Banks takes on the treatment of a suicidal young woman, Emily Taylor (Rooney Mara), who suffers intolerable side effects to most antidepressant medications and who has a bad habit of driving into walls. Psychiatrists watching the film will find the recitation of brand-name medications a bit distracting and there's enough discussion about treatment-resistant depression to get me wondering what I'd try next if I was in Dr. Banks's shoes. Even Emily's friends and co-workers have suggestions about medication, and judging from the buzz in the audience near me, this spurred some discussion among viewers as well.

The film nails the pharmaceutical industry head-on, with breezy television and magazine ads featuring happy and content young women enjoying carefree days, drug reps meeting with doctors to talk money and even the obligatory drug rep lunch. At times this verged on medical insider humor, particularly when one doctor offers another a free brand name drug pen. No worries about ethical standards here, the psychiatrists have no qualms about accepting tens of thousands of dollars in pharmaceutical money.

When Emily finally asks her doctor to prescribe the new medication, Ablixa, things get complicated. I'm not giving away any spoilers since the murder is mentioned in the movie trailer, and the fairly predictable plot featured an equally-predictable insanity defense. Nevertheless, many of the twists and turns featured more than expert testimony and questions of defendant malingering. The question becomes what role, if any, the new medication played in the murder and who knew about this strange, rare, potentially deadly side effect. Dr. Banks is flung into personal and professional complications not usually covered in the typical psychiatric thriller. I won't go into detail on that aspect since it verges into spoiler territory.

I can't help comparing "Side Effects" to other movies with a "is he crazy or is he malingering" insanity theme, most notably "Primal Fear" featuring Ed Norton. "Side Effects" is more than a murder mystery and has more depth than "Primal Fear." With side commentary on the stigma of mental illness, trial-and-error prescribing practices, corruption of the medical profession and duplicitous expert witnesses, there would be enough substance here to carry the film even without the murder.

Whenever a new movie featuring a psychiatrist comes out we wonder how this will impact the public perception of our profession or the perception of the mentally ill. This movie won't deter anyone from seeking care. It will, however, deter me from ever prescribing Ablixa.

—Annette Hanson, M.D.

DR. HANSON is a forensic psychiatrist and co-author 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.