Deadly Consequences of Negligence

A Double Tragedy Unfolds in Florida
On the evening of July 21, chronic psychiatric patient Mark Rohlman was brought in twice to Fort Walton Beach Medical Center for emergency psychiatric evaluations. Both times, he escaped. How, exactly, no one’s telling just yet, but the story ended tragically for Mark and Sheriff’s Deputy Anthony Forgione.

After his escape from Fort Walton Beach Medical Center, Mark found his way to his deceased father's home where he barricaded himself with a gun. When sheriff's deputies arrived to take Mark back to the hospital, he fired on them. His bullets killed Okaloosa County Deputy Anthony Forgione, a 33-year-old deputy from Niceville. Mark then turned the gun on himself and pulled the trigger.

In these last few days after the tragic series of incidents, politicians and pundits alike have been hammering at Florida’s Baker Act. But do they have the right culprit in their crosshairs?

What is the Baker Act?
Like many other involuntary detention laws across the nation for psychiatric patients, the Baker Act allows that individuals unable to care for themselves or presenting imminent danger can be detained for psychiatric assessment. They are taken to a designated facility where, within 72 hours, they are evaluated. Afterwards, the individual can be released into the community, involuntarily committed to an inpatient psychiatric hospital, or mandated to accept outpatient treatment. Inpatient hospitalization under this law extends up to six months.

The law has multiple patient's rights safeguards built into it, but many are arguing these protections are simply creating a loophole through which potentially dangerous patients can escape.

The Community Outraged
Reporter Tom McLaughlin of the Northwest Florida Daily News wrote a blog post headlined, "In FWB, little is done to secure mental patients. " McLaughlin is one of a growing chorus of understandably outraged citizens suggesting that maybe restraints or seclusion are the best antidote to dangerous psych patients.

On the other extreme, probably laying the groundwork for her hospital's defense, is Fort Walton Beach Medical Center's risk management officer Evelyn Ross. She is quoted in McLaughlin's blog stating, “The Baker Act does give us the opportunity to evaluate the patient even if they don't want to be here, but it does not give us the opportunity to secure them here. You don't restrain people just because they've been Baker Acted." True, but you don't just let them walk off, either. And twice in one day, no less.

Adding his voice to the cacophony was Okaloosa County Sheriff Charlie Morris who said the tragedy "absolutely a wake-up call" to change the Baker Act.

For their part, officials at Fort Walton Beach Medical Center have been mum on the particulars of how Mr. Rohlman escaped. Probably a good idea.

Who's really at fault here?
Vilifying a mentally deranged man who killed one of our finest might make sense of an otherwise senseless crime. Calling for legislative reforms makes better politics and press than examining the mundane details of this incident.

The fact is Fort Walton Beach Medical Center has been notorious for insufficient management of psychiatric patients, put mildly. Really, it’s downright incompetence. As McLaughlin has pointed out, the hospital has placed 45 calls to the Sheriff's Department reporting elopements of Baker act patients since January 1, 2007. They have made 21 such calls this year alone. These are simply staggering statistics for any one hospital.

Any hospital is responsible for their patients and that often means guarding them with one-to-one attention. Could it be that these deaths were needless not because the law is weak but because the hospital bungled the case? That one staff member taking care of the patient could have saved two lives? Right now, it’s too disconcerting to think that way.

But, experience tells me that the real story here is what’s going on at Fort Walton Beach Medical Center, not in Tallahassee.
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Suzy's Law: Parents Turn Grief Into Action

You've read in this blog last week about Kendra's Law and Laura's Law. Today, I'm writing to raise awareness of a like-titled piece of legislation, Suzy's Law.

Photo by Georgios Wollbrecht
HR 940, as it's officially known, proscribes using interstate commerce to publish suicide promotionals, such as how to kill yourself quickly and effectively, how to write a powerful suicide note, how to get the material means for suicide and how to delay others finding out you're dead.

Who Was Suzy Gonzales?
A resident of Red Bluff, California, a quaint town in the far reaches of Northern California, Suzanne Gonzales was a bright and fun-loving 19-year-old girl with a stellar future ahead of her. She was a national Hispanic scholar finalist and had a full scholarship to Florida State University. To quote the Suzy's Law web site,

"She loved to set her own style and was not afraid to march to her own beat. She was known as the girl wearing glasses with no lenses and hand-painted colorful shoes, and riding a red scooter carrying the stuffed two-headed cat she made herself. She loved polka-dot dresses and ska music, and she was a joy and bright light to be around."

That bright light was about to be tragically extinguished. Suzy became depressed while attending Florida State. She tried to talk to her boyfriend about the increasing thoughts of suicide she experienced, but he told her she needed help.

So Suzy turned to the Internet and found multiple resources encouraging her to kill herself and providing her with the know-how to get the job done. They taught her how to pose as a jeweler to buy potassium cyanide. They gave her instructions on how to send time-delayed emails that would go out after her death. They taught her how to lie to her psychiatrist so she wouldn't get hospitalized. On and on it went.

Finally, on March 23, 2003, Suzy checked into a Florida motel and ingested a lethal dose of potassium cyanide.

Parents Turn Grief Into Action
Mike and Mary Gonzales were devastated by their daughter's suicide, but decided to take action. Suzy's Law was initially introduced in February 2007 by Rep. Wally Herger.

Under the Suzanne Gonzales Suicide Prevention Act of 2007, an individual who uses the Internet or other interstate commerce to teach a suicidal person how to commit suicide or provides them the resources to do it would be guilty of a crime punishable by fines and up to five years in prison. If the recipient actuall suicides, the penalty goes from five years to life in prison.

The bill was referred to the Judiciary Committee's subcommittee on Crime, Terrorism and Homeland Security. It has been in limbo ever since.

So Mike and Mary are going to Washington, DC, this week to bring Suzy's Law out into the daylight for support and, hopefully, action. If you want to get involved, you can read the full text of the law, urge your Congressperson to co-sponsor the bill, and tell your friends.

Here's wishing you the best, Mike and Mary!
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An Ovation for Medivation

More good news on the Alzheimer's treatment front today. New research released today and being published in The Lancet demonstrates a significant improvement in people with Alzheimer's taking the drug Dimebon. Patients showed a substantial reduction in Alzheimer's symptoms after 6 months on Dimebon, and even more improvements at 12 months. Dimebon maker Medivation said they hope to have the drug to market in the US in 2010. The drug is also being investigated as a treatment for Huntington's Disease. If you or a loved are affected by Alzheimer's and are interested in enrolling in clinical drug trials, please visit The Connection Study today.Sphere: Related Content
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Managed Care: Who Pays?

One of the questions I am most frequently asked in my private practice is whether I accept insurance reimbursement. I have always been happy to provide clients with statements so they may seek reimbursement from their health insurance provider.

However I am part of a rapidly growing cadre of mental health professionals who do not accept health insurance. Following are issues I would urge you to carefully consider prior to seeking managed care coverage for your mental health services.

Is My Personal Information Private? If your managed care provider is paying for your treatment, they will review the details of your therapy sessions. In order for them to authorize a handful of sessions, I must provide them with an extensive list of information. If I don’t have it, I am expected to get it.

The information required is extensive: Has the client ever been in therapy before? If so, what was the precipitating event? Why did they terminate the previous therapy? What is the precipitating event now? Do they use alcohol or drugs, illicit or otherwise? Have they ever been medically treated for their psychological issues? What is their marital status? What is their family dynamic? In short, every conceivable detail of your private life is up for discussion between their case manager and me. This information then becomes part of the documentation which follows you throughout life. Should you apply for health insurance elsewhere, you will have the “mentally ill” stigma following you.

Who’s in Charge? As the old saying goes, “He who pays the piper picks the tune.” If a managed care company is footing the bill for your therapy, neither you nor I are really in control. Rather, a case manager, who is given financial incentive (bonuses, raises, promotions) to deny care, has the power to determine when you are ready to cease therapy. This is, of course, why they call it managed care in the first place.

Their focus is “symptom reduction” and once that has been achieved, there is simply no point from their perspective to continue. This is not to say that “symptom reduction” isn’t a worthwhile goal, but it isn’t the penultimate goal of therapy, either. This leads to the third issue of managed care therapy.

Whatever Happened to Happy? To reduce the power of therapy to “symptom reduction” is to undermine it all together. Psychotherapy in its various forms throughout the ages has been the key to personal liberation and fulfillment. Managed care isn’t particularly concerned with the quality of life or whether you’re happy and peaceful; they just want you to be able to have fewer “symptoms.”

These are three of the serious concerns about allowing managed care to manage your therapy. I urge you to consider them carefully.

PHOTO: STEVE WOODS, ESSEX, UK. THANKS, STEVE!Sphere: Related Content
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Without Warning: Epilepsy Drugs, Suicide and the FDA

Numbers are convenient stand-ins for flesh-and-blood humans, making cold clean symbols behind which to hide the carnage of wars, car crashes and, apparently, suicidal tendencies.

In January of this year, the FDA came forward with the news that after a review of some 199 studies, people taking any of 11 epilepsy drugs had around twice the rate of suicide as those taking placebos. The culprits included heavy-hitters like Lamictal and Lyrica. This, they said, warranted consideration of the dreaded black label warning.

Yesterday, the FDA said the suicide rate was morbid, but not enough for a death warrant on the drugs. See, slap a black label on those bottles and it's pretty much guaranteed those bottles will sit on pharmacy shelves collecting dust. Meanwhile the profits of ailing pharmaceutical companies will continue plunging southward into a sea of red ink.

I do wonder, out of a disdainful and morbid curiosity: Have any of these FDA decision-makers ever experienced a suicide in their family? Have any come home from work one day to find their teenaged son's brains splattered across their white walls after he cracked the gun safe combo in hopelessness and panic over girlfriend issues? Have any awakened to find their partner's side of the bed untouched all night, only to discover their limp and lifeless body hanging by rope from a rafter in the garage?

Had they experienced such horrors, I doubt they would find a doubled suicide rate an acceptable risk.

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NYC Health Department Gets Its Own MySpace

Here are some statistics to consider: According to the Pew Internet and American Life Project, 58% of kids between 12 and 17 years old have a profile on a social networking site, such as MySpace. Meanwhile, about 20% of teens have mental health and/or substance abuse problems with very few of them getting needed professional help. Faced with those numbers, it would seem to make sense that health outreach efforts to teens have a strong Internet presence.

It has always been a disappointment to me that our institutions move slower than molasses and miss opportunities to optimize their programs. But finally, one agency has taken a leap in the right direction.

The New York City Health Department now has its own MySpace, complete with a healthy roster of friends (albeit may fictional ones) at its debut this week. The Department anticipates their presence in the world of social networking will create a safe place for teens and tweens to seek help, take polls and play games. Visitors will also have the opportunity to send confidential messages to mental health counselors. Sounds great, but it's about 10 years too late.

Just as they're coming online, social networking has catapulted far beyond the promise of MySpace. Services like Twitter and the revolution in telepsychiatry continue to open up brave new frontiers. The point isn't technology for its own sake, of course; it's to help people and maybe save lives. Technology is endlessly revealing new and improved means to do just that.

So kudos and plaudits to the New York City Health Department; I wish others would be progressive as well. Now if we can just get bureaucracy to get in step with technology, we would realize a compunding of benefits.Sphere: Related Content
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A Hard Day's Night for the Mentally Ill: Psych Patients Waiting In Emergency Rooms

In centuries past, the mentally ill were neatly locked away from public view, along with society’s other smelly unmentionables; the homeless, the unemployed, the criminally insane, and the drunkards among them. They would be herded onto ships of fools and sent out to sea, to land at some unsuspecting port, or to simply die in the blue beyond.

Many years later they were hidden behind tightly locked doors of forbidding sanitariums. In any case, society was more than happy to “treat” these unfortunates because that meant shrouding their cockeyed faces, shrill screams and endless gibberish from plain view. We as a society have a well-honed ability to simply tune them out, at least until they’re in our face.

Now they’re in our emergency rooms, as they have been since Ronnie Raygun put it to the mental health system. Every now and again a news organization will run a story about all these psych patients clogging up the ERs. Today’s AP story offered a new twist: Patients are clogging psychiatric ERs because there simply aren’t enough services. This notable, albeit subtle, shift has been a long time coming. No longer are we only concerned that mentally ill patients are occupying beds that should be reserved for the “truly sick” people. In a moment of clarity, someone in the press is finally declaring the mental health system itself is sick. And it is-- severely, chronically so-- and cannot be treated with a standard regimen.

I have spent the better part of the last ten years holed up in California emergency rooms assessing, detaining, admitting and discharging psychiatric patients. Some are schizophrenics, pleasantly insane and otherwise. Some are malevolent sociopaths who wouldn’t, or didn’t, hesitate to butcher their own mother. Others are depressed and bipolar who see no recourse other than to kill themselves. And there are the kids who tried meth or some designer drug and triggered a chemical reaction unleashing heretofore dormant psychoses. There are the older drug addicts whose trips, like their dependence, won’t stop. Then, as always, you have the handful of players who come in looking for three hots and a cot and will feign absolutely any symptom for their price of admission.

During this tenure, advocating for, not just serving, the mentally ill in our society has become something of a personal mission for me. The solution is not to throw some more money at the problem, put some more services out there and hope everyone will shut up. Instead, a fundamental paradigm shift is what we need.

As with the individual, our society’s collective thought creates reality. The underfunded, broken mental health system is only an expression of our mutual fear and loathing of mental illness and, consequently, those who it affects. Change the belief and we’ll change the reality.

It wasn’t that long ago that a mysterious illness swept like a wildfire through a freewheeling slice of the gay community and a hodgepodge of IV drug abusers, two of the most marginalized populations in society. No one really cared about the carnage of AIDS until it struck middle America’s nerve when Rock Hudson sickened and died. Then Liberace. Then Freddie Mercury. The face of AIDS changed and services and funding grew accordingly. The same must be and can be done for mental illness.

Efforts like Joe Pantoliano’s Efforts like Joe Pantoliano’s No Kidding, Me Too! which seeks to remove the stigma of mental illness using star power, are on the right track. We just need more of them.

Raising awareness can raise funding. But improved policing of where the money is spent would be well worth the effort. The group I mentioned earlier, the impostors who feign mental illness for a free place to stay need to be redirected elsewhere, such as homeless shelters and case management services. This cannot be accomplished, though, until there is adequate liability protection for physicians and other professionals who dare to just say no to a malingerer, only to have the person walk out and knife themselves, just to prove a point, but unexpectedly die. It may smell of sweet justice, but it reeks in the courtroom when family members suddenly emerge from the woodwork to sue the unlucky physician.

Then there are the politicians and other stakeholders. One look at the internecine dealings behind distribution of California’s “millionaire tax” for mental health services is an embarrassing look at bureaucrats and technocrats gone wild. How long before grabby government hands are dipping into this till to fund everything but mental health in this cash-strapped state? Accountability cuts all ways.

The political will for treatment is another key issue. States like California have created legislation such as Laura’s Law, which provides for mandated outpatient treatment, but without any funding source. We can all do that kind of math: Good law+ no money=hot air. Meanwhile, many patients continue to wind through the system’s Great Revolving Door on a monthly basis, noncompliant with treatment, penniless after spending their SSI checks on drugs, and carrying “insurance” like Medicaid, which doesn’t even pay the direct costs of their care. A dollar reimbursement for $5 worth of care is a great way to devolve to no services.

Until we as a society decide if the mentally ill are really worth treating, we will continue to see ERs, general and psychiatric alike, overflowing with insanity.

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