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Farewell, Sad Clown

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Aug 262014
 

by Robert B. Young, MD

Robin Williams’ gift to the public was being the world’s wittiest improvisational comic and a heartfelt actor.  He could ad-lib jokes in a spontaneous stream that kept us in stitches and in awe, and move us emotionally with gentle humor on screen. He had been reported to have bipolar disorder.  He had referred to his own inner demons, depression and drug abuse. His struggles and death are illuminating in several ways.

Bipolar disorder is characterized by spontaneous, major mood shifts from too high (mania) to too low (depression).  When manic one enjoys it, speaks and lives fast, sleeps less, but may use poor judgment and take more risks.  When depressed, one is in despair and may be immobilized with no capacity to experience emotions other than hopelessness.  There is a greater liability to drug abuse and dependence, particularly of alcohol, and among drug addicts there are more of these mood disorders than in general.  Mr. Williams evidently experienced all that.

One of his self-descriptions became the “sad clown” (for those of a certain age, think Emmett Kelly).  That is very apt, depicting a performer who brings joy and release to others yet can’t escape his own misery.  Those two states can coexist in a sufferer sometimes, as a bipolar “mixed state”.  This usually means the person shows manic behaviors while experiencing depression within.  One wonders how often this was Mr. Williams’ experience.

There were likely personal stresses triggering his end, perhaps overreacting to early Parkinson’s disease.  However, people with serious mood disorders like bipolar, especially with drug dependence, alcohol abuse or both, are all at increased risk during their lifetimes for suicide.  Nearly all who kill themselves do so in the grip of acute psychiatric states that would have been treatable.

From his death, there are other lessons to be learned.  Talent and success, fame and fortune are no defense against psychiatric illness or tragic responses to it.  They can even impede good treatment, because of the image celebrities uphold of leading idealized lives.  Public expectations don’t accommodate private anguish.  Mr. Williams reportedly was dealing with severe depression recently, as at other times through his life.  Evidently self-inflicted cuts express how severe his emotional pain must have been.  He then hanged himself with a belt in his own closet.  It happened at night, after a normal goodbye to his wife, when no one would be expected for hours.  There was serious intent to die, even if it was unexpected.

It’s good if guns were not accessible to Mr. Williams as he was “battling severe depression”.  But though guns are lethal tools for suicide, there are many other ways to accomplish it.  Any of us, wherever we are and whatever we are doing, could easily kill ourselves in a variety of ways.  Well people don’t because it just doesn’t occur to us.  When someone truly intends to die, they can and simply do.

I daresay that mainstream media would have blamed the gun too if Mr. Williams had used one, with less attention to the more significant, complex realities of depression, suicide, and his life and struggles.  But his belt and the closet are being ignored!  Let’s not blame the method, so let’s not ban belts, closets, razors – or guns.  Let’s intervene to keep people safe when there is cause for concern, to give them the one more chance that could be their turning point.

– Robert B. Young, MD is a psychiatrist in private practice in Pittsford, NY, and a clinical associate professor at the University of Rochester School of Medicine. 

 Posted by at 10:04 pm
Aug 262014
 

By Robert B. Young, MD

A three judge panel of the 11th U.S. Circuit Court of Appeals ruled 2-1 on July 25 that the Florida state law popularly called “Docs vs. Glocks” is indeed constitutional…read more at the Herald-Tribune’s blog, The Gun Writer

 Posted by at 10:03 pm
Aug 082014
 

When a Psychiatrist Shoots to Kill

A doctor defended himself and others from a violent patient, but he had to break a no-gun policy to do so.

‘More might have died if doctor had not shot gunman” — so read the headline in the Philadelphia Inquirer on July 27. On the previous Thursday, a patient, Richard Plotts, entered the office of his psychiatrist, Lee Silverman, M.D., with his caseworker, Theresa Hunt. Plotts then became very upset and killed Hunt with two shots to her head. While this was happening, Dr. Silverman tried to take cover, drew his handgun, and shot the attacker three times. The doctor suffered slight wounds from bullets that grazed his head and hit his thumb. Staffers then succeeded in subduing the wounded Plotts. He was hospitalized in critical condition and now faces murder charges.

District attorney Jack Whelan said: “If Dr. Silverman did not have the firearm and did not utilize the firearm, he’d be dead today. And other people would be dead.” In fact, the doctor had breached the facility’s “no firearms” policy by carrying a weapon with him to work. The facility released a statement saying that it looked forward to his “return to serving patients at our hospital.”

Plotts had a previous record of violence, including suicide attempts, and he has been involuntarily committed twice to psychiatric care, most recently last year. He was a convicted felon, with two gun-related convictions, and he had served time in prison for bank robbery. His violent behavior had led a local homeless shelter to ban him, and he had caused previous trouble at the hospital. In another article, Plotts’s ex-wife described him as abusive and violent, and she also has said that she remains afraid of him 15 years after their divorce. What was he doing with a firearm? Oh, of course: It was illegal. Convicted felons are prohibited by law from owning a weapon.Theresa Hunt, by all accounts, was a dedicated, caring woman who made it her life’s mission to help those in need of mental-health care and social services. She recognized the risk she faced from unstable patients. She probably died instantly.

In deciding to carry a loaded handgun at his workplace, Dr. Silverman judged that he would be wise to ignore the hospital’s no-guns policy. No one should fault him for this. Perhaps he recognized that it was more important to protect lives than to trust in the false promises of safety offered by “gun-free zones.” Every year mental-health professionals are assaulted by clients, and some are killed. Psychiatrists are the physicians most likely to encounter unpredictably dangerous patients. With the exception of threats and one knock-down, I have been spared so far. But I do know a colleague whose patient shot himself dead in the psychiatrist’s office, and a patient of mine slashed her throat in the waiting room of my clinic. Contrast Dr. Silverman’s experience with that of Kathryn Faughey and Kent Shinbach, two doctors who were unarmed when attacked by a delusional schizophrenic patient in 2008. In that assault, Dr. Faughey was killed and Dr. Shinbech was injured.

The hospital’s announcement that it will welcome Dr. Silverman back once he recovers is amazing compared with the usual treatment of employees who choose self-defense over death and end up being fired for breaching no-gun rules. Dr. Silverman and the staffers exercised a good dose of ordinary, self-preserving common sense — and in doing so they became extraordinary heroes.

Another element of this tragedy, one to which all physicians can relate, is that doctors are taught, first and foremost, the golden rule of medicine: “Do no harm.” It would be a particular grief for a physician to have to harm or kill a patient intentionally. We hope never to have to respond to any patient with anything but care and compassion. But that may not be possible, or right, when a patient is the cause of harm.

Responsible people do right by themselves and, especially, others. Is it possible that we are finally coming to understand that doing right can include using guns, too?

— Robert B. Young, M.D., is a private psychiatrist in Pittsford, N.Y., and a clinical associate professor at the University of Rochester School of Medicine. 

 Posted by at 8:25 pm
Jul 222014
 

Gun Violence Restraining Orders

July 16, 2014

By Robert B. Young, MD

Killers, especially mass murderers, often appear to have some mental illness.  They may not have been treated, or were not successfully treated, or their need for treatment wasn’t recognized.  Overall, people with mental illnesses are no more likely to commit violence than the general population and are far more likely to become victims. 1  However, there are a few major psychiatric problems (for example, paranoid delusions, hallucinations commanding aggression, and major depression with suicidality) that, when acutely symptomatic, do increase the risk of violent behavior.  That risk is heightened when there is previous history of violence or concomitant drug or alcohol abuse.  So it’s very important to try to identify potentially dangerous folks, mentally ill and otherwise, in order to intervene in time to prevent violence.

The best intervention for the mentally ill is good treatment, sometimes by commitment to inpatient care to resolve symptoms of risk or to outpatient care to prevent recurrence.  There are also proposals to remove firearms from individuals at risk.  The inability to accomplish either of these was deadly in the case of James Holmes, the Colorado movie theater killer, whose psychiatrist reported his apparent dangerousness to police but no meaningful action was taken. 2

In most jurisdictions, psychiatrists, other physicians or other mental health authorities can commit people for psychiatric evaluation.  Police will remove firearms from suspects, or from potentially dangerous patients on the request of the treating clinician.   In some states (Connecticut and Indiana) judicial intervention is well established, and other states (California and New Jersey) are considering expanding that. 3  There’s no simple route in most places for the return of those firearms.  Sometimes this can be done on the recommendation of a psychiatrist, but many are reluctant to make these decisions.

In a recent Los Angeles Times op-ed, Renée Binder, MD argues that “California Needs a Gun Violence Restraining Order” (and other states, too). 4  Dr. Binder is Director of the Psychiatry and the Law program at the University of California at San Francisco and is president-elect of the American Psychiatric Association.  The APA strongly advocates dealing with mentally ill people compassionately and respectfully, supports their full exercise of civil rights, and stresses the irrelevance of mental illness to the vast majority of violent acts.  The mental health community also recognizes that certain mental illnesses can be a factor in some cases of violence.  Unfortunately, proponents of seizing firearms aren’t often concerned about the rights of gun owners or the mentally ill, which may conflict with their goals.

There are a variety of approaches to firearm seizure.  When police confiscate a suspect’s firearms in Connecticut, a court hearing takes place in 2 weeks to determine whether they should continue to be held for up to one year.  Then a second hearing could be sought by the subject, to show why the confiscation order should end.  If this isn’t sought, the property could continue being held. 3  California prohibits gun possession for 5 years following involuntary psychiatric hospitalization (even if released from no more than 72 hours observation), while a domestic violence restraining order is in effect, and for up to 10 years following conviction of a violent misdemeanor. 4,5  

These issues raise serious concerns:

  • What standards of evidence justify a seizure?  Commitment for psychiatric treatment doesn’t necessarily imply danger with a firearm, let alone for 5 years.  Most of those patients readily recover and many never again require that level of intervention.  In domestic conflicts, there are sometimes false or exaggerated allegations.  Convictions (not just charges) for violent misdemeanors may merit prohibition of gun possession for some time, but 10 years without recourse is longer than necessary or fair in many circumstances.
  • What sort of evidence is required to reverse the seizure?   There’s no way to guarantee that someone will behave safely.  It’s not possible even for psychiatrists to predict the likelihood of violent behavior beyond a day or two.
  • How does the initial seizure of property incorporate any due process, particularly since this contravenes a federal constitutional right?   Yet emergencies do happen, and deaths might be prevented if weapons could be confiscated in time and with good judgment.
  • Police officers deserve great respect but there are always a few who abuse their powers.  How can this be safeguarded?
  • What is reasonable about not permitting the subject to contest these decisions for a year or more?

So here are some thoughts:

  • Clearly criteria must be defined that justify the seizure of individuals’ legally owned firearms, not just any diagnosis of mental illness.  Actual violent threats or acts, preoccupation with violent acts of others or indications of planning such acts, and a history of violent behavior would be more meaningful than someone’s suspicion alone.  Certain psychiatric and substance use problems are suggestive of poor control over dangerous impulses.
  • The presumption of innocence is central to due process in our legal system.  If firearms are seized, the burden of proof should be on the state to justify continuing to deprive owners, not on owners to show that they are no danger.  When commitments of psychiatric patients in New York need to be extended due to similar risks, staff must show why at intervals of from 14 to 60 days.  So such proceedings need to take place early and often, not a year later and only if the subject can initiate and pay for an appeal.  Unless the subject is incarcerated or under psychiatric commitment , how about requiring the state to justify retaining the property every 60 days?
  • When it is decided to return firearms to someone, this must happen promptly within a legally prescribed time period.  It can take far too long to restore property held by law enforcement agencies.  It took 3 years and a lawsuit to get New Orleans to begin returning guns confiscated during Hurricane Katrina, and then many were damaged, unidentifiable or lost. 6   Confiscated property has to be returned in the same condition in which it was taken.  Those responsible for failing to properly care for these valuables, and to return them in a timely fashion, should be penalized.  Owners should be indemnified in cases of lost or damaged property.

There are good reasons to be concerned about leaving weapons with agitated, threatening, intoxicated and/or certain mentally ill people.  As always, the devil is in the details. Core issues about gun seizures are whether the civil rights of potentially risky (and possibly mentally ill) people will be respected and whether needed treatment can be ensured.   Also, it’s past time for all states to contribute complete data about currently prohibited persons to the NICS system.   Had it been up-to-date, Seung-Hui ho’s rampage at Virginia Tech might have been forestalled. 5

Of course, we’ve been discussing firearm risks only, while many more people are killed and injured by accidental poisoning, falls and motor vehicle accidents. 7  What shall we confiscate to prevent those?

 

—  Robert B. Young, MD is a private psychiatrist in Pittsford, NY                                                                  and a Distinguished Fellow of the American Psychiatric Association.

 

 

Footnotes:

1   SAMHSA – “Violence & Mental Illness: The Facts”

2  CNN Justice – 4/5/2013

3  ABC News – 7/6/2014

4  LA Times Op-Ed 5/26/2014  and Hopkins Center for Gun Policy & Research

(and ref. there “Evidence Based Approach for Federal Policy” and “… for State Policy”)

5  NPR – “States Aren’t Submitting Records” 8/16/2012

6  RightofANation.com 1/5/2010 re: NRA “First Freedom” January 2010

7  CDC – “10 Leading Causes of Death & Injury” 2011

 Posted by at 5:13 pm