Jessie Close’s guest blog yesterday hit a nerve and sparked an email from Dr. Dinah Miller, a Baltimore psychiatrist and founder of SHRINK RAP, one of the most helpful mental health blogs on the Internet.
I want to share Dr. Miller’s email with you. I would encourage you to read the editorial from the Baltimore Sun that follows her note. In it, Dr. Miller points out that most of the legislation being suggested is a knee jerk reaction to the Sandy Hook shootings. There is no evidence that many of the bills being rushed through will accomplish much except further stigmatizing individuals with mental disorders.
Please thank Jessie Close for writing about guns and medical records — an issue that all of us need to monitor. The Newtown massacre ignited legislators to propose many bills which will attempt to keep guns out of the hands of the mentally ill. In Maryland alone, I believe we have about 40 bills before our General Assembly. I have been writing about the intrusion that mandated reporting may have on doctor-patient confidentiality, and how that may stigmatize patients and discourage them from getting care.
In terms of Jessie’s concerns, reporting (if it even passes) will consist of adding names to a database. While the local gun dealer will know that someone can’t buy a gun, he won’t know why– though the imagination certainly doesn’t lead to nice places since the disqualifiers include criminal convictions, involuntary psychiatric hospitalizations, being a drug addict, or a “habitual drunkard.” But the gun dealer will not have access to medical records.
I have not seen or heard of any legislation that will mandate reporting of outpatients who aren’t dangerous. This simply wouldn’t make sense given the numbers of people who seek treatment. Even a patient who talks about suicidal thoughts is not likely to be put into a database. Many people think about suicide, many people have passing fantasies about harming someone who has done them wrong, and psychiatrists are used to hearing such things. Doctors don’t like reporting their patients, so I don’t think there is going to be a big rush to report outpatients unless the doctor is truly worried that the patient is going to really kill someone. Of course, there are those patients who really are quite dangerous and would be better off without access to guns. I don’t think the argument that more mentally ill people use guns to kill themselves than others is going to encourage anyone to leave the mentally ill with access to guns.
As you know, I feel strongly that it’s not the psychiatrist’s role to serve the state and populate a database, but rather to do what is in the best interest of the patient.
Here is Dr. Miller’s editorial and a link to an article that she wrote about medical records for the Clinical Psychiatric News.
Bills to keep guns out of the hands of psychiatric patients pose risks
Requiring psychiatrists to report on their patients could discourage some to get help
In December, a young man in Newtown, Conn., killed 20 small children and seven adults, including his mother, and then committed suicide. This tragic massacre has prompted legislators to reexamine firearms laws and quickly propose legislation that might prevent future mass murders. Much of it focuses on people who have sought mental health care.
The Maryland General Assembly is considering legislation that requires mental health clinicians to report patients who are potentially dangerous for the purpose of restricting their access to guns. Gov. Martin O’Malley’s proposed 2013 Firearms Safety Act (SB 281) includes a number of items that are specific to patients with mental illnesses. The act would require that all voluntary psychiatric patients who are hospitalized for 30 days or more be reported to an FBI database.
Most patients with mood and psychotic disorders are released much sooner than 30 days, and this mandate may well capture populations who are at low risk of becoming spree killers. Involuntary patients would be reported much sooner if they are determined to be potentially dangerous, presumably at the time of their commitment hearings. If any of these individuals later wants their right to own firearms returned, one step of the process includes having a psychiatrist or psychologist file a certificate that states the person is safe to own a gun. I don’t know any mental health professional who would be willing to risk the liability of making such predictions about safety; we are psychiatrists, not clairvoyants.
House Bill 810, sponsored by Del. Luiz Simmons, requires that mental health professionals report patients they believe are likely to be dangerous to, in its words, the “Director of Mental Hygiene,” who would then decide whether to report those patients to the State Police.
Although the Newtown massacre spawned this legislation, so far there has been nothing in the media to suggest the Newtown shooter would have been brought to the attention of authorities if such laws had been in place. We’ve heard he had an autism-spectrum illness; that he was anxious, intelligent and a loner — but no reports that he’d been violent, hospitalized, or ever told a mental health professional that he was planning a school shooting.
The hope might be that more funds will be funneled into following up on all those who are identified as dangerous, reclaiming their weapons, and overseeing the storage of firearms by residents of their households. Proposed legislation, however, seems to be more about populating government databases. Increased treatment of those identified as dangerous is certainly desirable, but it remains to be seen if such funding will follow these measures — especially in times when psychiatric hospitals are closing, medical reimbursements are decreasing, paperwork burdens are shifting doctor time away from patient care, and psychiatric services are difficult to access.
Let’s be thoughtful. These bills are not about public safety; they are about “doing something” — and in the process, scapegoating the mentally ill in a way that distracts from enacting substantive legislation. And shouldn’t we acknowledge that all this talk of identifying and reporting those with psychiatric problems is at direct odds with the intention to increase access to care and decrease stigma as a means of preventing tragedies?
These proposed laws set in motion a barrier to getting help for those who most need it. Who would willingly seek treatment and tell a psychiatrist their dark thoughts, knowing such thoughts will be reported to law enforcement authorities and entered into an FBI database? Certainly no gun owner, and certainly no troubled law enforcement officer.
True, other laws have sometimes overridden doctor-patient confidentiality, but those laws address problems that have already happened. While I am an avid proponent of stricter gun control regulation, as a psychiatrist, I find the requirement to report patients to the police to be quite troublesome. It makes us agents of the state, whereas to be a physician one must be an agent of the patient; the ethical conflict here is profound. These laws annihilate psychiatrist-patient confidentiality in the most egregious of ways: by inserting the government into situations where violent acts have not even occurred. They mandate government intrusions into our ruminations, and they set a precedent to end the relationship that is necessary for psychiatric treatment to occur.
Keep in mind that violent thoughts are very common, and in the absence of specific indicators, mental health professionals are not particularly good at predicting who will act on them. If we allow this, in the name of public safety and health, what else might we extend reporting requirements to include? The sexual activities of patients with HIV? Patients who drive while intoxicated? The financial behaviors of those running Ponzi schemes?
Ironically, all of these measures target mental health settings, while preserving doctor-patient confidentiality elsewhere. As a result, a person having violent thoughts who wants to retain his gun rights or to stay out of a government database may be more comfortable confiding in his internist and refusing care by a mental health specialist. Is this really what we want?
Dinah Miller, M.D., is a psychiatrist in Baltimore. Her email is [email protected]