Mental health care delivery in US

After I finished writing my last post, I did what I needed to do, which was to stop watching and reading the news for a while. I went out of town (already scheduled outing) and didn't even bring my laptop. Quite a feat for me. I've only started catching up on the news this morning.....

As some students go back to class at Virginia Tech this morning, many questions still remain. In catching up with the news, I was pleased to see that college campuses are now starting to analyze how they deal with mental health issues. (Seattle Times)

Awareness is especially heightened at the UW [University of Washington], given a murder-suicide earlier this month, when a campus employee was killed in her office by an ex-boyfriend who then shot himself.

The UW's president and the provost on Friday formed an advisory committee on violence prevention to take a look at safety protocols across campus.

Already, a UW counselor works part time assisting resident housing advisers with student mental-health issues. In addition to its regular clinical services, the campus counseling center also operates a consultation line five days a week to handle questions from faculty, staff or students.

When the UW identifies a student who has talked about or attempted suicide, the student must see a campus psychologist. The student is then given the option of undergoing four assessments with a mental-health provider.

If the student declines to participate in those assessments, the UW can start proceedings to remove the student from school, said Eric Godfrey, vice provost for student life at the UW.

What I really hope happens is a careful look at how all mental health care is delivered in the entire country - not just on college campuses? I know, but a doc can dream can't he?

As I've talked about on this blog before, the mental health services in my little county are sparse at best. We have about 100,000 people in the entire county and about 500 square miles to cover. The number of psychiatrists I can count on one hand (and it's even less than five).

A lot of people have barked to me that only psychiatrists should be prescribing mental illness medicines and the primary care doc should be left out of it. The reason PCPs prescribe is because there is no one else to diagnose and treat these patients. It can take months to get an appointment with a psych.

Other supportive services are overloaded as well. We do not have the number of counselors that are needed to adequately services the patients of this community. So, what happens, these patients end up in the ER.

Since there is no inpatient psychiatric hospital in the county, we have to transfer out everything. And, the ER docs out there know how difficult it is to transfer out a psych patient to a different county. This patient can sit in the ER for 8-10 hours (delaying treatment) while the doc tries to get a hospital to accept them.

Or, some patients end up in jail, dealing in the legal system, and maybe dumped back into the outpatient follow-up system which I have described above. There's no good solution here. But, maybe, just maybe, some good can come out of the VT tragedy with this look at mental health care delivery in the US.

Update 4/24/07: Here is a letter to the editor from the Chicago Tribune who states as far as her state is concerned, when it comes to grading mental health care delivery, "Illinois received an F."

Privacy laws need scrutinized

I really need to stop watching the news regarding the Virginia Tech shootings. Since I can't, I'll offer some commentary on what I watched this evening on the cable news shows and what I read in some of the online news articles with reference to privacy laws and medical records.

What is the role of the university if a student is diagnosed with a mental illness? In this article from today's New York Times, it states what we already know - That they are bound by the same federal laws that pretty much everyone else has to follow.

For the most part, universities cannot tell parents about their children’s problems without the student’s consent. They cannot release any information in a student’s medical record without consent. And they cannot put students on involuntary medical leave, just because they develop a serious mental illness.

The article goes on to say that universities have quite a problem here in trying to navigate through these privacy laws.

Universities can find themselves in a double bind. On the one hand, they may be liable if they fail to prevent a suicide or murder. After the death in 2000 of Elizabeth H. Shin, a student at the Massachusetts Institute of Technology who had written several suicide notes and used the university counseling service before setting herself on fire, the Massachusetts Superior Court allowed her parents, who had not been told of her deterioration, to sue administrators for $27.7 million. The case was settled for an undisclosed amount.

On the other hand, universities may be held liable if they do take action to remove a potentially suicidal student. In August, the City University of New York agreed to pay $65,000 to a student who sued after being barred from her dormitory room at Hunter College because she was hospitalized after a suicide attempt.

What is the role of government if a citizen is diagnosed with a mental illness and would like to purchase a firearm? There has been a lot talked about and written about how easy it was for Cho to purchase a gun in Virginia. In this article from the Associated Press, they talk with the gun store owner and his impressions of Cho during the transaction.

Roanoke Firearms owner John Markell said his shop sold the Glock to Cho in March. The serial number had been scratched off, but federal agents traced it to the store using a receipt found in Cho's backpack.

"It was a very unremarkable sale," said Markell, who did not handle the sale personally. "He was a nice, clean-cut college kid. We won't sell a gun if we have any idea at all that a purchase is suspicious."

Markell said it's not unusual for college students to make purchases at his shop as long as they are old enough. Cho held a green card, meaning he was a legal, permanent resident, according to federal officials. That meant he was eligible to buy a handgun unless he had been convicted of a felony.

It has been suggested in the media that if Cho's medical records, specifically his mental illness diagnosis, was somehow made available as part of the "background check," then, possibly, he would not have been able to purchase a gun at this place. I do realize that possibly no law could have prevented this kid from getting his gun.

However, this brings up an interesting point about privacy laws. Should certain medical diagnoses be made available in a law enforcement database? If so, which diagnoses? Just mental illness diagnoses? Who decides which medical information is placed into a database like this? Would that mean that if I am pulled over for speeding that my medical record would be accessed on a police cruiser computer?

These two articles bring in some new angles to the personal privacy verses public safety debate. Where is the line drawn between the two? Who decides where the line is drawn? What are the consequences if it goes too far one way or the other. I apologize for bringing up more questions, but I think the privacy laws in this country need to be placed under a microscope and analyzed. It is long overdue....

Update: Uh oh, this post got picked up this morning by RealClearPolitics.Com and by the FoxNews.Com Buzztracker - because of my quotes from the NYT story. Yeesh! Look out! I'm not a political commentator, just a doc! Oh well....

Update 4/24/07: There's now information that he should NOT have been sold a gun because he was seen as a danger to himself and others. But, the information was never entered into the National Instant Criminal Background Check System. Read more in this cnn.com story.

Depression = Murderer?

The term psychological autopsy is now being thrown around by the talking heads on cable news shows in the analysis of Cho Seung-Hui, the Virginia Tech gunman. The first words from the TV medical experts are that this kid was not only depressed but also being treated with medications. I also found it interesting that an article from the Associated Press has this as the second paragraph...

News reports said that he may have been taking medication for depression and that he was becoming increasingly violent and erratic.

The article goes on to outline some of his other characteristics as they try to profile this individual: a loner; a writer of disturbing plays; a writer of the suicide note against "rich kids," "debauchery," and "deceitful charlatans."

I could be wrong, but I'm starting to see people in the press making the association between depression and murder. Of course, this kid had mental illness and of course he was undergoing treatment for it. But, the implication that everyone with mental illness has the potential "to snap" and kill people - as being suggested in the media - This bothers me.

With the Virginia Tech story as a backdrop, I was scanning the health headlines and ran into a different Associated Press article today with this title: Antidepressants' benefits trump risks for kids

If you remember, three years ago, the Food and Drug Administration made a statement warning the public about use of antidepressants in children and teens. At the time, they stated that there was an increased risk of suidical thoughts and behaviors. There was a huge uproar then. All my patients were talking about it - particularly parents. Now, the research is stating that those concerns are not as serious as once thought.

Researchers analyzed data on 5,310 children and teenagers from 27 studies. They found that for every 100 kids treated with antidepressants, about one additional child experienced worsening suicidal feelings above what would have happened without drug treatment. In contrast, the FDA analysis found an added risk affecting about two in 100 patients.

There were no suicides in any of the studies. The antidepressants included Prozac, Paxil, Zoloft, Celexa, Lexapro, Effexor, Serzone and Remeron.

"The medications are safe and effective and should be considered as an important part of treatment," said study co-author Dr. David Brent of the University of Pittsburgh School of Medicine. "The benefits seem favorable compared to the small risk of suicidal thoughts and behavior."

Now, this is by no means the final word on this issue. Some may even say this study complicates the discussion. So, what is a doctor to do? What is a parent to do?

I think this study emphasizes the close communication that is needed between docs, patients, and their parents - especially when it comes to mental illness diagnosis and treatment. I realize that's easier said than done.

But, as more of this Virginia Tech case is uncovered, it seems as if improved communication could (and I emphasize could) have changed the outcome of this tragedy. Of note, N=1's comment in my previous post makes an excellent point.

Can the cycle be broken

This is the picture on the front page of FoxNews.Com from this morning. This is Cho Seung-Hui, a student from South Korea, apparently an English major. What was the motive? I guess authorities are still trying to figure it out.

It may be too soon for a post like this, but it's what I'm thinking right now, and I just have to get it out there. Unfortunately, this is not the first shooting to occur on a school campus. Back in November, Dr. Deb wrote about a Map of School Violence between 1995 and 2005. At the end of her post, she posed this question - "What can be done to minimize such violence?" Here was my comment:

Dr. A said...

This is a very emotional issue, and the really sad part is that no one wants to take ownership of the problem. Everyone blames everyone else for the problem whether is blaming school officials to "not keeping school safe" to blaming parents for "not bring up kids right" to the media to exposing kids to too much violence.

Until someone steps up and accepts even a little responsibility for the problem, the blame game will continue and more children will be harmed - or even killed.

November 03, 2006 1:09 PM

History is repeating itself again with the blame game. There are already early articles being written asking whether there were Too Few Warnings at Virginia Tech? The outrage is beginning to build against the university and university officials.

Student Maurice Hiller said he went to a 9 a.m. class two buildings away from the engineering building, and no warnings were coming over the outdoor public address system on campus at the time.

Everett Good, junior, said of the lack of warning: "I'm trying to figure that out. Someone's head is definitely going to roll over that."

"We were kept in the dark a lot about exactly what was going on," said Andrew Capers Thompson, a 22-year-old graduate student from Walhalla, S.C.

Of course, people are outraged by this situation. I'm outraged by what happened. But, I've seen this too many times. We are shocked by what happened, we mourn the victims, we blame whomever we need to blame for what happened, then we go back to our apathy until the next tragedy happens.

Well, I'm sick and tired of this useless cycle. Instead of outrage turning into apathy, let's turn outrage into action. And, I'm not talking about knee-jerk reactions like firing some university official somewhere or a more strict student visa process or permanent resident visa process - like what's being talked about now.

Um, uh, wait a minute. As I think about things now (a couple of hours after starting to write this post), I'm thinking about what realistically can happen? Would it mean a radical change in American culture? A culture that celebrates violence? A culture that makes celebrities out of people like Eric Harris, Dylan Klebold, and Cho Seung-Hui. Here's the latest press on this killer from the Chicago Tribune:

The suspected gunman in the Virginia Tech shooting rampage, Cho Seung-Hui, was a troubled 23-year-old senior from South Korea who investigators believe left an invective-filled note in his dorm room, sources say.

The note included a rambling list of grievances, according to sources. They said Cho also died with the words "Ismail Ax" in red ink on one of his arms.

Cho had shown recent signs of violent, aberrant behavior, according to an investigative source, including setting a fire in a dorm room and allegedly stalking some women.

A note believed to have been written by Cho was found in his dorm room that railed against "rich kids," "debauchery" and "deceitful charlatans" on campus.

Unfortunately, this is a culture that shirks at the idea of accountability. A culture that believes that it's someone else's job to fix the problem. A country and culture that feels no personal investment to fix its own problems. Am I wrong here? Please tell me I'm wrong. Is there a realistic way to curb the violence on school/college campuses?

Grand Rounds

Grand Rounds 3.30 is now up and running at FD's place. There are 39 entries for your review and enjoyement. I admit I forgot to submit a post this week. That time off from blogging last week really made me forget about a lot of things.

If you don't know what Grand Rounds is, it is a weekly compilation of the best posts from the medical blogosphere that moves to different sites each week. And, who doesn't like reading about medicine and science? Next week, GR moves to Med Valley High.

Sicko

The film called Sicko has been two years in the making, and those in the medical industry have been closely watching Michael Moore and what kind of antics that he was going to try to pull.

There have been rumors that his film crew have been going to medical conventions and filming the pharmaceutical displays and trying to get docs on film talking about their free pens.

In Sunday's New York Post, there is a new twist. According to the report, he took ailing Ground Zero responders to Cuba to film how (in his opinion) Castro's socialized medicine is superior to the medical care in the United States.

Responders were told Cuban doctors had developed new techniques for treating lung cancer and other respiratory illness, and that health care in the communist country was free, according to those offered the two-week February trip.

Cuba has made recent advancements in biotechnology and exports its cancer treatments to 40 countries around the world, raking in an estimated $100 million a year, according to The Associated Press.

In 2004 the U.S. government granted an exception to its economic embargo against Cuba and allowed a California drug company to test three cancer vaccines developed in Havana, according to the AP.

Naturally, some people are upset by this and see this as exploitation....

"He's using people that are in a bad situation and that's wrong, that's morally wrong," railed Jeff Endean, a former SWAT commander from Morris County, N.J., who spent a month at Ground Zero and suffers from respiratory problems.

The article goes on to mention one 9/11 worker who didn't want to go on the Cuba trip and another worker who states me was left behind by the filmmaker. I love the closing paragraphs of this article.

"From what I heard through the grapevine, those people that went are utterly happy," said John Feal, who runs the Fealgood Foundation to help raise money for responders and was approached by Moore to find responders willing to take the trip.

"They got the Elvis treatment."

Although he has been a critic of Cuba, Moore grew popular there after a pirated version of his movie, "Fahrenheit 9/11," was played on state-owned TV.

I usually don't dignify garbage like this with a post, but it's going to be a news story eventually - especially with the slated premiere at the Cannes Film Festival in about four weeks. It's definitely going to be hit piece on the pharmaceutical industry with docs being another target.

The press love to spin things up into a frenzy - the recent Imus story is a prime example. I'll have more to say over the next four weeks as the hype increases. I just wanted to get you ready, because the medical industry is going to take more of a beating in the press than usual (and probably from the US presidential candidates as well)....

House of God

I've been catching up on my Bloglines this past weekend, and I was taken by a quote from Dr. Wes' post called, "Welcome to My World."

Remember the first rule of ER medicine: Take your own pulse first.

Of course, the quote is self-evident to most people reading this blog. But, to me, I've been racking my brain to figure out where I heard/read this quote before. Then, it came to me, House of God by Samuel Shem.

This is a great book and highly recommended to Doctor Anonymous blog readers and anyone else who likes reading medical blogs and medicine in general. The book speaks of the Laws of the House of God. And, for those of you who haven't read the book for the while, they are listed below. Enjoy!

1. Gomers don't die.
2. Gomers go to ground.
3. At a cardiac arrest, the first procedure is to take your own pulse.
4. The patient is the one with the disease.
5. Placement comes first.
6. There is no body cavity that cannot be reached with a #14 needle and a good strong arm.
7. Age + BUN = lasix dose.
8. They can always hurt you more.
9. The only good admission is a dead admission.
10. If you don't take a temperature, you can't find a fever.
11. Show me a medical student who only triples my work and I will kiss his feet.
12. If the radiology resident and the medical student both see a lesion on the chest x-ray, there can be no lesion there.
13. The delivery of good medical care is to do as much nothing as possible.

Thanks Trisha from BlogHer!

Since I've been away from my blog for a little while, I haven't had the chance to write this gratitude post, so here goes....

Thanks so much to Trisha from BlogHer for linking not one but two of my posts over the past few weeks. She writes for their Health and Science News of the Week, and I was linked on their March 30, 2007 post and their April 6, 2007 post.

I very much appreciate being mentioned and appreciate the traffic that came my way from those postings. I tried e-mailing Trisha but somehow my messages were not getting through (I kept getting error messages).

I hope to keep writing interesting stuff for Trisha's readers so that I may have another opportunity to be included in their health and science news of the week. Thanks again!

The No Tag Zone

I know I'm going to offend some people out there in happy blog land, but I just have to be honest about something (and I know I can be honest with all of you being my blog friends and all).

But, this meme thing, and this "getting tagged" thing, it's really not as fun as it used to be (at least for me). I know that this may sound hypocritical, because I participated a lot in memes in the past. Heck, I even started a meme last December.

In the past few months, I responded but I have been tagging less and less people, and giving that generic "you're all tagged" message. But, now, I'm going to be honest and telling everyone that I'm taking a break from memes.

My apologies especially to the Queen of Memes and to everyone else who think I may just be having a temper tantrum here. Rather than just ignore future tags and memes, I just wanted to be up front and honest about where I stand with memes at this point.

I know other people out there agree with me on this one, even if you don't blog about it. Maybe some day in the future I'll come back to memes, being tagged, and tagging others to continue the fun. But, not right now....

Worst blog of all time

Vote for me today! I was nominated in the Blogger's Choice Awards for the Worst Blog of All Time. What an honor! I can't believe that someone would go through all the time and trouble for nominating me. Thanks to all of you who nominated me. I'll try to do you proud!

Actually, not really. Just kidding. But, there has been a little bit of a buzz out there in the blogosphere about these blogger choice awards. In looking at the best health blog category, the top vote-getter only has about 50 votes.

I learned the first time about blog awards. I just let myself get caught up in the hoopla. There's a lot of other better and more popular blogs out there. I'm content to sit on the sidelines and let others fight it out on this one.

By the way, I did enjoy my little blog holiday. I hope I didn't worry anyone. Sometimes you just need to take a break away from things to clear your mind before re-starting again. More posts soon....