Dinah Miller, MD

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Maryland, where we live, is one of only five states that does not have forced outpatient care for psychiatric patients. The more familiar euphemism is "assisted outpatient treatment" or AOT, but it’s a term that sugarcoats what happens, and even if it’s the right thing to legislate, we might as well call it what it is, since psychiatry has long been accused of being overly coercive. This week, the Maryland General Assembly proposed legislation to bring AOT to our state, and the swords are set to be drawn.

Recently, I had the pleasure of hearing Jeffrey Swanson, Ph.D., a medical sociologist at Duke University, speak at the Sheppard and Enoch Pratt Hospital in Baltimore on "Outpatient Commitment as Crisis-Driven Law: Evaluating Policy Options and Effectiveness Through the Lens of Gun Violence." I don’t know what that title means, but I do know it’s a good one for driving up the blood pressure of many people, my own included. If Dr. Swanson could have somehow added abortion, Obamacare, and Woody Allen to his title, the entire country could have chimed in. I’m going to summarize some of the key points of Dr. Swanson’s lecture below.

He started by discussing the controversial topic of mandated community treatment, a practice that inspires "strident disagreement." "Should we have outpatient commitment? And what does it mean to ask if it works?"

Starting with the tragic massacre in Newtown on Dec. 14, 2012, Dr. Swanson noted that in addition to the Sandy Hook victims, 85 other people died from gun fatalities that same day. But Newtown stimulated the conversation. Is it the guns? Our violent culture? The failure of the mental health system? "It’s not in our repertoire," he noted, "to limit access to guns as other nations have done, so instead, we’ve looked to limiting the right to own those guns."

A national opinion poll in 2013 shows that 60% of the U.S. public believes that people with schizophrenia are likely to be violent, and 45% believe that people with mental illness are "far more dangerous" than the general public. In fact, 1 in 70,000 people with schizophrenia kills a stranger and this, said Dr. Swanson, "is what people are really about." He went on to say that curing major mental illness would reduce serious violence by 4%. Meanwhile, 3.5 million people with serious psychiatric disorders go without treatment. "You could tell that story several different ways; it doesn’t have a lot to do with violence."

In New York, legislation to Secure Ammunition and Firearms Enforcement (the NY SAFE Act of 2013), included an expansion of that state’s outpatient forced treatment; it now lasts longer, is required for released prisoners with mental illness, and follows patients when they move to other counties. As I’ve noted in a past column, it also requires mental health professionals to report patients who are believed likely to be violent.

"It’s interesting," Dr. Swanson noted, "that they are connected as part of a gun control package."

Last month, Dr. Swanson said, the White House issued two executive actions aimed at reducing gun violence. Among the executive actions was one that seeks to strengthen gun background checks for gun permits to include people who were on AOT, in addition to people committed to hospitals involuntarily. The executive actions further remove barriers (including Health Insurance Portability and Accountability Act, or HIPAA requirements) that make it difficult to submit information about these patients.

Dr. Swanson then discussed the basic facts about outpatient commitment. It extends the state’s authority from the institution to community-based care and includes a civil court order that requires the patient to comply with recommended treatment and receive services. "It emerged from the ashes of deinstitutionalization as a way to get the treatment to people that they needed." Dr. Swanson noted that there is no requirement for forced medication in the outpatient setting.

There are three types of outpatient commitment. It can be used as a conditional release from the hospital (40 states), as an alternative to hospitalization for people meeting inpatient commitment criteria (33 states, but infrequently used), and as a preventive court-ordered treatment authorized at a lower threshold to prevent further deterioration in a patient’s condition (10 states). Of the states that have outpatient commitment statutes, there is little use of it outside New York. Dr. Swanson noted that this entails "nested prediction in the law" with regard to how likely patients are to comply with treatment and how likely they are to become dangerous.

He was careful to note that one of the major issues with AOT is that not only does it obligate the patient to obtain treatment, but it obligates the state to provide care. Those in the system in New York and North Carolina, where follow-up studies have been conducted, receive case management services, housing, and access to treatment and medications, accommodations that many patients with severe psychiatric disorders are unable to access.

Outpatient commitment’s efficacy

So does AOT work? And what does it mean to even ask that? A pilot study done at Bellevue did not show efficacy. "The treatments they were getting weren’t working very well, and overall the evidence is mixed," Dr. Swanson said. The so-called Duke study (Am. J. Psychiatry 1999;156:1968-75) and the New York AOT studies (Psychiatr. Serv. 2010;61967-9 and Am. J. Psychiatry 2013;170:1423-32), revealed that the successes of forced outpatient treatment are dependent on an investment in effective implementation, the availability of intensive community services, and the duration of treatment – with a notable decrease in hospital readmission rates for those treated for more than 180 days.

The Duke study showed that the control group had a 48% rehospitalization rate, with an average of 27.9 days hospitalized; those assigned to AOT for less than 180 days had a 50% rehospitalization rate, with an average of 37.7 days; and those assigned to AOT for more than 180 days had a 32% rehospitalization rate, with an average of 7.51 days. In fact, those assigned to AOT for less than 6 months appeared to do worse than the controls. The study did show that people receiving AOT were less likely to have violent behaviors and were less likely to be the victims of violence; however, the study included all aggressive behaviors, including shoving and acts that resulted in no injury. Obviously, these studies said nothing about the likelihood that AOT would decrease the probability that someone with a major mental illness would murder a stranger.

And what about the patients: Did they feel helped by forced treatment? This is an issue of key concern to me, because I remain perplexed at the idea that people are not grateful to be returned to a state of mental well-being, and I don’t believe that their concerns about their treatment should be dismissed with the idea that they simply lack insight. Of the patients, only 27% endorsed forced treatment after the fact, while the rest did not. On a measure of "quality of life," there were improvements for those in AOT for more than 12 months but not for those treated for 6 months.

Dr. Swanson concluded his talk by saying that the added benefits of housing and intensive services may have been instrumental in causing some of the positive change that is captured with ongoing AOT. He showed a final slide:

Outpatient commitment is neither a cure-all nor a catastrophe. It brings neither an end to violence nor an end to civil rights. It does not affect the majority of people with some form of psychiatric illness. It cannot fix a fiscal crisis of the state in which resources for mental health services continue to shrink. But it may be a reasonable and measured policy that can make effective treatment much more consistently available to those few among us who are in most need of treatment in the community, who at times may actually want it, but in the real word may not get it any other way.

My conclusion

I’ll leave Dr. Swanson out of it from here, but it’s funny that we started with Newtown, and not one of the many laws that have been passed since that tragic day have done anything to address the spiral that led to that senseless massacre. Today, the shooter’s mother would still be able to purchase guns for his use, and nothing about his story as publicized leads us to believe that he would now be entered into a public database or forced to go to a treatment program.

We’ve started with a problem, and created what we hope might be answers to a whole different set of issues. Perhaps those answers are benign or beneficial, but perhaps they will further antagonize those who most need our help. If the issue is finances and decreasing hospital stays, it’s unclear why we target the mentally ill while leaving those with diabetes and heart disease to drink soda, and those with lung disease to smoke cigarettes. What, no discussion of tobacco and sugar registries?

Until we have shown that it is the "forced" part of AOT that leads to better outcomes, we need to more vigorously address the issue of patient satisfaction, and figure why our treatments – ones that don’t always work and sometimes are toxic – are not palatable to the patients they are intended to help. Until we go there, perhaps we should tread carefully when it comes to curtailing the civil rights of those with any type of illness.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

In my last column, I invited readers to take an online survey of "Who are the mentally ill?" The term is used freely by the media, politicians, and advocates, as well as by physicians, as though this were a clearly defined group of people. Yet it has never been clear to me who, precisely, is being referenced.

The survey was designed to parse out what features respondents associate with the term "mental illness." The first four questions addressed whether it mattered who administered the care – a psychiatrist, primary care doctor, or a psychotherapist – and whether the treatment offered was therapy or medications. The survey then addressed whether specific medications or diagnoses are considered to be mental illness, and whether hospitalization – both voluntary or involuntary – has an association. What about the expression of the symptoms themselves?

Three questions were asked regarding hallucinations and delusions, serious suicide attempts, and volatile behavior that impairs the ability to maintain work or relationships. What about governmental labels – does receiving Social Security Disability Insurance (SSDI) mean one is mentally ill? And does the association with mental illness last forever?

What if someone is well but requires medications to remain so? And what about those who finished all treatments long ago and have remained well? Finally, respondents were asked whether they had ever been on medications or hospitalized themselves, and whether they consider themselves to be mentally ill, now or in the past.

First, let me tell you a little about how this survey was circulated. A link was placed on my Twitter feed with an invitation to take the survey. My Twitter followers who clicked on the link were brought to a blog post with a few paragraphs of introduction, followed by the survey. Obviously, there are several steps to get there, and a very low response rate was expected. I also assumed that respondents would be skewed to those with an interest in mental health issues.

Since I only have about 500 followers on Twitter, the reach is limited. A few people retweeted the link to their own followers, and I spent another 15 minutes sending tweets to some of the people I follow, specifically requesting a retweet. I targeted people with an interest in mental health issues or health information technology, and many retweeted it to a much larger audience. If I was tagged in the retweet, I could follow the trail, so I know the link was distributed in the United Kingdom, Ireland, and Norway.

Next, I placed the link on my personal and blog Facebook pages, and I invited members of my neighborhood listserv and of the Maryland Psychiatric Society listserv to take the survey. I also wrote blog posts on Psychology Today and the one you might have seen on Clinical Psychiatry News. The CPN staff supported this by e-mailing out a link to my article. Since I could follow how well read this was by whether or not readers were taking the survey, several hours after the article went up on CPN, I asked that the headline be changed – no one was taking the poll – and by the next day, with a new article title, the survey had another hundred respondents.

This sounds like a lot of time, but it wasn’t; it took several hours over the course of a week, mostly done on a day it snowed here in Maryland when I had a several patients cancel. The survey was left open for 12 days, during which time I periodically would tweet out a link. Given my expectation for a low response rate, I was pleased: 696 people took the survey.

Most of the results were not surprising. Seeing a psychiatrist, as compared to a therapist or primary care doctor, is associated with "mental illness," more so if the patient is prescribed medications than if the patient is seen for psychotherapy. Certain diagnoses and medications are more linked with the term, though I was surprised that more people deemed pedophilia and intermittent explosive disorder to be "mental illness" than depression. Both gender identity disorder and attention-deficit disorder were linked with the label by fewer respondents. Only half of those who took the survey considered a serious suicide attempt to be indicative of mental illness, a surprising figure given that the term is used freely with regard to gun legislation, and most gun deaths are suicides.

Less than a third of respondents associated getting SSDI payments for psychiatric reasons with mental illness, a finding I was surprised by, as it seems to me that once an individual is so ill he cannot work and requires government support, that the label might be warranted. While the strongest association with the label was for the presence of hallucinations and delusions, there were still 11% of respondents who did not feel these symptoms were indicative of mental illness. Of those taking the survey, 60% had either been hospitalized or treated with a medication, and 25% considered themselves to be mentally ill. I’ll hold off with any more statistics, and invite you to view the results and add your comments here.

I can’t emphasize enough that this survey was not validated and the data collection was not scientifically rigorous; it was my personal social media experiment. Still, I believe the responses show that when people are lumped together in the "mentally ill" category for the purposes of discussion, there should not be the assumption that everyone is speaking about the same individuals. Perhaps it is time to change some of the discussions.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

In my last column, I invited readers to take an online survey of "Who are the mentally ill?" The term is used freely by the media, politicians, and advocates, as well as by physicians, as though this were a clearly defined group of people. Yet it has never been clear to me who, precisely, is being referenced.

The survey was designed to parse out what features respondents associate with the term "mental illness." The first four questions addressed whether it mattered who administered the care – a psychiatrist, primary care doctor, or a psychotherapist – and whether the treatment offered was therapy or medications. The survey then addressed whether specific medications or diagnoses are considered to be mental illness, and whether hospitalization – both voluntary or involuntary – has an association. What about the expression of the symptoms themselves?

Three questions were asked regarding hallucinations and delusions, serious suicide attempts, and volatile behavior that impairs the ability to maintain work or relationships. What about governmental labels – does receiving Social Security Disability Insurance (SSDI) mean one is mentally ill? And does the association with mental illness last forever?

What if someone is well but requires medications to remain so? And what about those who finished all treatments long ago and have remained well? Finally, respondents were asked whether they had ever been on medications or hospitalized themselves, and whether they consider themselves to be mentally ill, now or in the past.

First, let me tell you a little about how this survey was circulated. A link was placed on my Twitter feed with an invitation to take the survey. My Twitter followers who clicked on the link were brought to a blog post with a few paragraphs of introduction, followed by the survey. Obviously, there are several steps to get there, and a very low response rate was expected. I also assumed that respondents would be skewed to those with an interest in mental health issues.

Since I only have about 500 followers on Twitter, the reach is limited. A few people retweeted the link to their own followers, and I spent another 15 minutes sending tweets to some of the people I follow, specifically requesting a retweet. I targeted people with an interest in mental health issues or health information technology, and many retweeted it to a much larger audience. If I was tagged in the retweet, I could follow the trail, so I know the link was distributed in the United Kingdom, Ireland, and Norway.

Next, I placed the link on my personal and blog Facebook pages, and I invited members of my neighborhood listserv and of the Maryland Psychiatric Society listserv to take the survey. I also wrote blog posts on Psychology Today and the one you might have seen on Clinical Psychiatry News. The CPN staff supported this by e-mailing out a link to my article. Since I could follow how well read this was by whether or not readers were taking the survey, several hours after the article went up on CPN, I asked that the headline be changed – no one was taking the poll – and by the next day, with a new article title, the survey had another hundred respondents.

This sounds like a lot of time, but it wasn’t; it took several hours over the course of a week, mostly done on a day it snowed here in Maryland when I had a several patients cancel. The survey was left open for 12 days, during which time I periodically would tweet out a link. Given my expectation for a low response rate, I was pleased: 696 people took the survey.

Most of the results were not surprising. Seeing a psychiatrist, as compared to a therapist or primary care doctor, is associated with "mental illness," more so if the patient is prescribed medications than if the patient is seen for psychotherapy. Certain diagnoses and medications are more linked with the term, though I was surprised that more people deemed pedophilia and intermittent explosive disorder to be "mental illness" than depression. Both gender identity disorder and attention-deficit disorder were linked with the label by fewer respondents. Only half of those who took the survey considered a serious suicide attempt to be indicative of mental illness, a surprising figure given that the term is used freely with regard to gun legislation, and most gun deaths are suicides.

Less than a third of respondents associated getting SSDI payments for psychiatric reasons with mental illness, a finding I was surprised by, as it seems to me that once an individual is so ill he cannot work and requires government support, that the label might be warranted. While the strongest association with the label was for the presence of hallucinations and delusions, there were still 11% of respondents who did not feel these symptoms were indicative of mental illness. Of those taking the survey, 60% had either been hospitalized or treated with a medication, and 25% considered themselves to be mentally ill. I’ll hold off with any more statistics, and invite you to view the results and add your comments here.

I can’t emphasize enough that this survey was not validated and the data collection was not scientifically rigorous; it was my personal social media experiment. Still, I believe the responses show that when people are lumped together in the "mentally ill" category for the purposes of discussion, there should not be the assumption that everyone is speaking about the same individuals. Perhaps it is time to change some of the discussions.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

In my last column, I invited readers to take an online survey of "Who are the mentally ill?" The term is used freely by the media, politicians, and advocates, as well as by physicians, as though this were a clearly defined group of people. Yet it has never been clear to me who, precisely, is being referenced.

The survey was designed to parse out what features respondents associate with the term "mental illness." The first four questions addressed whether it mattered who administered the care – a psychiatrist, primary care doctor, or a psychotherapist – and whether the treatment offered was therapy or medications. The survey then addressed whether specific medications or diagnoses are considered to be mental illness, and whether hospitalization – both voluntary or involuntary – has an association. What about the expression of the symptoms themselves?

Three questions were asked regarding hallucinations and delusions, serious suicide attempts, and volatile behavior that impairs the ability to maintain work or relationships. What about governmental labels – does receiving Social Security Disability Insurance (SSDI) mean one is mentally ill? And does the association with mental illness last forever?

What if someone is well but requires medications to remain so? And what about those who finished all treatments long ago and have remained well? Finally, respondents were asked whether they had ever been on medications or hospitalized themselves, and whether they consider themselves to be mentally ill, now or in the past.

First, let me tell you a little about how this survey was circulated. A link was placed on my Twitter feed with an invitation to take the survey. My Twitter followers who clicked on the link were brought to a blog post with a few paragraphs of introduction, followed by the survey. Obviously, there are several steps to get there, and a very low response rate was expected. I also assumed that respondents would be skewed to those with an interest in mental health issues.

Since I only have about 500 followers on Twitter, the reach is limited. A few people retweeted the link to their own followers, and I spent another 15 minutes sending tweets to some of the people I follow, specifically requesting a retweet. I targeted people with an interest in mental health issues or health information technology, and many retweeted it to a much larger audience. If I was tagged in the retweet, I could follow the trail, so I know the link was distributed in the United Kingdom, Ireland, and Norway.

Next, I placed the link on my personal and blog Facebook pages, and I invited members of my neighborhood listserv and of the Maryland Psychiatric Society listserv to take the survey. I also wrote blog posts on Psychology Today and the one you might have seen on Clinical Psychiatry News. The CPN staff supported this by e-mailing out a link to my article. Since I could follow how well read this was by whether or not readers were taking the survey, several hours after the article went up on CPN, I asked that the headline be changed – no one was taking the poll – and by the next day, with a new article title, the survey had another hundred respondents.

This sounds like a lot of time, but it wasn’t; it took several hours over the course of a week, mostly done on a day it snowed here in Maryland when I had a several patients cancel. The survey was left open for 12 days, during which time I periodically would tweet out a link. Given my expectation for a low response rate, I was pleased: 696 people took the survey.

Most of the results were not surprising. Seeing a psychiatrist, as compared to a therapist or primary care doctor, is associated with "mental illness," more so if the patient is prescribed medications than if the patient is seen for psychotherapy. Certain diagnoses and medications are more linked with the term, though I was surprised that more people deemed pedophilia and intermittent explosive disorder to be "mental illness" than depression. Both gender identity disorder and attention-deficit disorder were linked with the label by fewer respondents. Only half of those who took the survey considered a serious suicide attempt to be indicative of mental illness, a surprising figure given that the term is used freely with regard to gun legislation, and most gun deaths are suicides.

Less than a third of respondents associated getting SSDI payments for psychiatric reasons with mental illness, a finding I was surprised by, as it seems to me that once an individual is so ill he cannot work and requires government support, that the label might be warranted. While the strongest association with the label was for the presence of hallucinations and delusions, there were still 11% of respondents who did not feel these symptoms were indicative of mental illness. Of those taking the survey, 60% had either been hospitalized or treated with a medication, and 25% considered themselves to be mentally ill. I’ll hold off with any more statistics, and invite you to view the results and add your comments here.

I can’t emphasize enough that this survey was not validated and the data collection was not scientifically rigorous; it was my personal social media experiment. Still, I believe the responses show that when people are lumped together in the "mentally ill" category for the purposes of discussion, there should not be the assumption that everyone is speaking about the same individuals. Perhaps it is time to change some of the discussions.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

I’ve been a psychiatrist for more than 2 decades, and as such, I treat patients who suffer from mental illnesses. I will be the first to admit that when I heard President Obama say we need to keep guns out of the hands of the mentally ill, I had no idea who he was talking about. I believe we should take guns out of the hands of almost everyone.

The term "mental illness" gets bandied about quite freely, and the designation of mental illness buys both stigma and entitlements. The mentally ill can take their service dogs on planes for free. This is not true for those without a diagnosis; the same dog is just a pet on a plane, and he goes in cargo for a fee. Psychiatric diagnoses sometimes allow access to good things, including extra time to take exams, smaller classes with one-on-one aides for emotionally disturbed children, monthly disability payments and Medicare benefits from the government, as well as admission to day programs and vocational rehabilitation, and sometimes even housing. Those who meet criteria for specific disorders may be able to use their health insurance benefits to pay for psychotherapy. But are all those people the mentally ill?

Mental illness is more frequently a term that is associated with stigma and the assumption of limitations. The designation might restrict a person from owning a gun, driving a car, holding certain jobs, or even – as Andrew Solomon pointed out in a New York Times editorial – passing through the country on the way to a vacation cruise ship. The National Alliance on Mental Illness posts on its website that one in four Americans are affected by these issues and lists the specific disorders that qualify. Do we all agree that everyone with these specific diagnoses are the mentally ill?

I thought I’d ask the question, but I’m not an academic psychiatrist. I hear it takes time and money to conduct surveys through the usual channels; there are grants to be written and submitted, institutional review boards to approach, instruments to validate, a population to identify, and statistics to be analyzed. That process could take months, if not years, and I actually wanted to know this right away, so I decided to ask my questions as a social media experiment. It’s not science, but it’s fast and it’s free.

I designed some questions to look at different aspects of what might constitute the public opinion of mental illness. Is it defined by who delivers the treatment? By the medications a patient takes? By the patient’s diagnosis? By behaviors? By time spent in a hospital? I put the questions together on a free Google form, and posted the survey to my free Shrink Rap blogger site, and began to circulate the survey on Twitter, Facebook, and listservs, and then I asked others to retweet it, which many kindly did. With my budget of $0, the only cost was my uncompensated time, and the weather was kind enough to oblige me; it snowed here in Maryland recently. Many of my patients cancelled and my time was uncompensated, anyway. The question remained, Would someone see a tweet, click through to read a blog post, and then take a survey?

The form went up, and Dr. Steve Daviss, my colleague in our Accessible Psychiatry Project, immediately texted me. The survey is offensive and should come down. It gives credence to those who want to paint the mentally ill with a single brush stroke, and at a minimum, I should ask about "people with mental illness."

I hoped respondents would understand that I was not in favor of such terminology and decided to leave it up for a little while, with the idea that I would take the survey down if commenters complained. Hundreds of people have now taken the survey. No one has yet complained about my use of the term, but several people – among them some psychiatrists – have told me the questions made them uncomfortable. Let’s face it, labeling people as mentally ill is uncomfortable.

With that as a prelude, I invite you to be part of this social media experiment and to add your voice to the question, "Who are the mentally ill?" The survey takes roughly 3 minutes. Click here to take the survey. I’ll also invite you to share the link with your family, followers, friends, circles, and listservs, but I will ask that each person take the survey only once. Thank you for participating, and I welcome your feedback.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

I’ve been a psychiatrist for more than 2 decades, and as such, I treat patients who suffer from mental illnesses. I will be the first to admit that when I heard President Obama say we need to keep guns out of the hands of the mentally ill, I had no idea who he was talking about. I believe we should take guns out of the hands of almost everyone.

The term "mental illness" gets bandied about quite freely, and the designation of mental illness buys both stigma and entitlements. The mentally ill can take their service dogs on planes for free. This is not true for those without a diagnosis; the same dog is just a pet on a plane, and he goes in cargo for a fee. Psychiatric diagnoses sometimes allow access to good things, including extra time to take exams, smaller classes with one-on-one aides for emotionally disturbed children, monthly disability payments and Medicare benefits from the government, as well as admission to day programs and vocational rehabilitation, and sometimes even housing. Those who meet criteria for specific disorders may be able to use their health insurance benefits to pay for psychotherapy. But are all those people the mentally ill?

Mental illness is more frequently a term that is associated with stigma and the assumption of limitations. The designation might restrict a person from owning a gun, driving a car, holding certain jobs, or even – as Andrew Solomon pointed out in a New York Times editorial – passing through the country on the way to a vacation cruise ship. The National Alliance on Mental Illness posts on its website that one in four Americans are affected by these issues and lists the specific disorders that qualify. Do we all agree that everyone with these specific diagnoses are the mentally ill?

I thought I’d ask the question, but I’m not an academic psychiatrist. I hear it takes time and money to conduct surveys through the usual channels; there are grants to be written and submitted, institutional review boards to approach, instruments to validate, a population to identify, and statistics to be analyzed. That process could take months, if not years, and I actually wanted to know this right away, so I decided to ask my questions as a social media experiment. It’s not science, but it’s fast and it’s free.

I designed some questions to look at different aspects of what might constitute the public opinion of mental illness. Is it defined by who delivers the treatment? By the medications a patient takes? By the patient’s diagnosis? By behaviors? By time spent in a hospital? I put the questions together on a free Google form, and posted the survey to my free Shrink Rap blogger site, and began to circulate the survey on Twitter, Facebook, and listservs, and then I asked others to retweet it, which many kindly did. With my budget of $0, the only cost was my uncompensated time, and the weather was kind enough to oblige me; it snowed here in Maryland recently. Many of my patients cancelled and my time was uncompensated, anyway. The question remained, Would someone see a tweet, click through to read a blog post, and then take a survey?

The form went up, and Dr. Steve Daviss, my colleague in our Accessible Psychiatry Project, immediately texted me. The survey is offensive and should come down. It gives credence to those who want to paint the mentally ill with a single brush stroke, and at a minimum, I should ask about "people with mental illness."

I hoped respondents would understand that I was not in favor of such terminology and decided to leave it up for a little while, with the idea that I would take the survey down if commenters complained. Hundreds of people have now taken the survey. No one has yet complained about my use of the term, but several people – among them some psychiatrists – have told me the questions made them uncomfortable. Let’s face it, labeling people as mentally ill is uncomfortable.

With that as a prelude, I invite you to be part of this social media experiment and to add your voice to the question, "Who are the mentally ill?" The survey takes roughly 3 minutes. Click here to take the survey. I’ll also invite you to share the link with your family, followers, friends, circles, and listservs, but I will ask that each person take the survey only once. Thank you for participating, and I welcome your feedback.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

I’ve been a psychiatrist for more than 2 decades, and as such, I treat patients who suffer from mental illnesses. I will be the first to admit that when I heard President Obama say we need to keep guns out of the hands of the mentally ill, I had no idea who he was talking about. I believe we should take guns out of the hands of almost everyone.

The term "mental illness" gets bandied about quite freely, and the designation of mental illness buys both stigma and entitlements. The mentally ill can take their service dogs on planes for free. This is not true for those without a diagnosis; the same dog is just a pet on a plane, and he goes in cargo for a fee. Psychiatric diagnoses sometimes allow access to good things, including extra time to take exams, smaller classes with one-on-one aides for emotionally disturbed children, monthly disability payments and Medicare benefits from the government, as well as admission to day programs and vocational rehabilitation, and sometimes even housing. Those who meet criteria for specific disorders may be able to use their health insurance benefits to pay for psychotherapy. But are all those people the mentally ill?

Mental illness is more frequently a term that is associated with stigma and the assumption of limitations. The designation might restrict a person from owning a gun, driving a car, holding certain jobs, or even – as Andrew Solomon pointed out in a New York Times editorial – passing through the country on the way to a vacation cruise ship. The National Alliance on Mental Illness posts on its website that one in four Americans are affected by these issues and lists the specific disorders that qualify. Do we all agree that everyone with these specific diagnoses are the mentally ill?

I thought I’d ask the question, but I’m not an academic psychiatrist. I hear it takes time and money to conduct surveys through the usual channels; there are grants to be written and submitted, institutional review boards to approach, instruments to validate, a population to identify, and statistics to be analyzed. That process could take months, if not years, and I actually wanted to know this right away, so I decided to ask my questions as a social media experiment. It’s not science, but it’s fast and it’s free.

I designed some questions to look at different aspects of what might constitute the public opinion of mental illness. Is it defined by who delivers the treatment? By the medications a patient takes? By the patient’s diagnosis? By behaviors? By time spent in a hospital? I put the questions together on a free Google form, and posted the survey to my free Shrink Rap blogger site, and began to circulate the survey on Twitter, Facebook, and listservs, and then I asked others to retweet it, which many kindly did. With my budget of $0, the only cost was my uncompensated time, and the weather was kind enough to oblige me; it snowed here in Maryland recently. Many of my patients cancelled and my time was uncompensated, anyway. The question remained, Would someone see a tweet, click through to read a blog post, and then take a survey?

The form went up, and Dr. Steve Daviss, my colleague in our Accessible Psychiatry Project, immediately texted me. The survey is offensive and should come down. It gives credence to those who want to paint the mentally ill with a single brush stroke, and at a minimum, I should ask about "people with mental illness."

I hoped respondents would understand that I was not in favor of such terminology and decided to leave it up for a little while, with the idea that I would take the survey down if commenters complained. Hundreds of people have now taken the survey. No one has yet complained about my use of the term, but several people – among them some psychiatrists – have told me the questions made them uncomfortable. Let’s face it, labeling people as mentally ill is uncomfortable.

With that as a prelude, I invite you to be part of this social media experiment and to add your voice to the question, "Who are the mentally ill?" The survey takes roughly 3 minutes. Click here to take the survey. I’ll also invite you to share the link with your family, followers, friends, circles, and listservs, but I will ask that each person take the survey only once. Thank you for participating, and I welcome your feedback.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: the Johns Hopkins University Press, 2011).

Readers who follow our original Shrink Rap blog may be aware that we use the image of a yellow rubber duck for our blog logo and mascot. While the intent was never to suggest that we’re quacks (we’re not), the logo came about after a 2006 article, "Wagging the dog, and a finger," in the New York Times discussed the increasing presence of animals on airplanes. The dogs fly free to provide emotional support to their troubled owners. The article also mentioned that cats, monkeys, miniature ponies, and a duck dressed in clothing have all served as emotional support service animals. The image of a dressed duck quacking about on an airplane captivated our collective sense of humor, and the years have gone by, but the duck has remained with us.

More recently, the Times ran another article, "Emotional support, with fur, draws complaints on planes," about the burden such support animals place on other passengers. For those with trained service dogs, the support animals can be distracting. For those with allergies, animal fur in an enclosed flight cabin can pose health risks. I’ll avoid the question of whose rights are more important, those of the anxious flyer or those of the allergic patient, and move straight to the question of the psychiatrist’s role in authorizing the use of a support animal.

Initially, I assumed that those who required the use of a support animal must have a phobia of flying with severe panic attacks, and that the animal was an absolute necessity, without which a patient wouldn’t be able to board a flight. Then a patient asked me to write such a letter. She’d flown many times without a creature, and I tried to understand why now she needed her new dog to accompany her. She insisted the pet was calm and well trained, and this would allow her to transport the dog back and forth at no cost, which would be quite helpful to her. And she did love the dog and find her company to be comforting, as any pet owner might.

As much as I was uncomfortable with this (my patient didn’t "need" the dog in order to fly), I looked at the criteria and felt she met it. I wrote a single-sentence note saying she was in treatment for a psychiatric disorder and it would be helpful to her to have her dog at her destination. I defined neither the disorder nor what about the dog was helpful, and I never met the pet. Fortunately, the psychiatrist is not required to comment on the mental health or behavior of the support animal, just the owner.

From the Southwest Airlines website, here is a list of requirements:

Emotional Support Animals

Animals used for a Customer’s emotional support are accepted in the cabin. In order for a Customer to travel with an emotional support animal, the Customer must provide to a Southwest Airlines Employee current documentation (not more than one year old) on letterhead from a mental health professional or medical doctor who is treating the Customer’s mental health-related disability stating:

1. The Passenger has a mental or emotional disability recognized in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV).

2. The Passenger needs the emotional support or psychiatric service animal as an accommodation for air travel and/or for activity at the passenger’s destination.

3. The individual providing the assessment is a licensed mental health professional, and the Passenger is under his or her professional care, AND

4. The date and type of mental health professional\'s or medical doctor’s license and the state or other jurisdiction in which it was issued.

Assistance and emotional support animals must be trained to behave in a public setting.

It’s an interesting set of criteria, because there is nothing specific about what "trained to behave in a public setting" might entail, and there are no specific criteria to define a patient’s "need" for a psychiatric support animal either during travel or at the destination.

When you think about it, this gets very complicated. It puts us in the position of being gatekeepers in an area for which we have no training and for which there are no set standards. It’s almost psychiatric stigma and discrimination in reverse – the presence of the dog announces that the owner is a psychiatric patient, yet dogs are no longer rare sightings on airplanes.

While it might be easier to say that as psychiatrists we don’t do that, it risks putting us at odds with patients over an issue which the airlines seem to sanction. Really, who does need their dog or their monkey or their cat to fly? Why should psychiatric patients be exempt from paying for their animals to travel, and have the comfort of knowing the pet is with them in a temperature-controlled cabin rather than crated and unattended in the cargo area, while everyone else must pay a fee?

To date, I have never seen an unruly dog on an airplane, and sadly, I’ve never seen a duck dressed in clothes. I love dogs, but certainly would never submit anyone (myself included) to flying with my own unruly little creature. Like most things, defining the lines of what it is to "need" an animal on a flight and what training should be required for "support" pets won’t be a problem until someone is bitten or distressed, or until a passenger announces they must bring their emotional support snake aboard a flight where someone has a phobia. In the meantime, I’ll contend that I like seeing an occasional cute dog on planes, but this isn’t a psychiatric issue.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

[email protected]

Readers who follow our original Shrink Rap blog may be aware that we use the image of a yellow rubber duck for our blog logo and mascot. While the intent was never to suggest that we’re quacks (we’re not), the logo came about after a 2006 article, "Wagging the dog, and a finger," in the New York Times discussed the increasing presence of animals on airplanes. The dogs fly free to provide emotional support to their troubled owners. The article also mentioned that cats, monkeys, miniature ponies, and a duck dressed in clothing have all served as emotional support service animals. The image of a dressed duck quacking about on an airplane captivated our collective sense of humor, and the years have gone by, but the duck has remained with us.

More recently, the Times ran another article, "Emotional support, with fur, draws complaints on planes," about the burden such support animals place on other passengers. For those with trained service dogs, the support animals can be distracting. For those with allergies, animal fur in an enclosed flight cabin can pose health risks. I’ll avoid the question of whose rights are more important, those of the anxious flyer or those of the allergic patient, and move straight to the question of the psychiatrist’s role in authorizing the use of a support animal.

Initially, I assumed that those who required the use of a support animal must have a phobia of flying with severe panic attacks, and that the animal was an absolute necessity, without which a patient wouldn’t be able to board a flight. Then a patient asked me to write such a letter. She’d flown many times without a creature, and I tried to understand why now she needed her new dog to accompany her. She insisted the pet was calm and well trained, and this would allow her to transport the dog back and forth at no cost, which would be quite helpful to her. And she did love the dog and find her company to be comforting, as any pet owner might.

As much as I was uncomfortable with this (my patient didn’t "need" the dog in order to fly), I looked at the criteria and felt she met it. I wrote a single-sentence note saying she was in treatment for a psychiatric disorder and it would be helpful to her to have her dog at her destination. I defined neither the disorder nor what about the dog was helpful, and I never met the pet. Fortunately, the psychiatrist is not required to comment on the mental health or behavior of the support animal, just the owner.

From the Southwest Airlines website, here is a list of requirements:

Emotional Support Animals

Animals used for a Customer’s emotional support are accepted in the cabin. In order for a Customer to travel with an emotional support animal, the Customer must provide to a Southwest Airlines Employee current documentation (not more than one year old) on letterhead from a mental health professional or medical doctor who is treating the Customer’s mental health-related disability stating:

1. The Passenger has a mental or emotional disability recognized in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV).

2. The Passenger needs the emotional support or psychiatric service animal as an accommodation for air travel and/or for activity at the passenger’s destination.

3. The individual providing the assessment is a licensed mental health professional, and the Passenger is under his or her professional care, AND

4. The date and type of mental health professional\'s or medical doctor’s license and the state or other jurisdiction in which it was issued.

Assistance and emotional support animals must be trained to behave in a public setting.

It’s an interesting set of criteria, because there is nothing specific about what "trained to behave in a public setting" might entail, and there are no specific criteria to define a patient’s "need" for a psychiatric support animal either during travel or at the destination.

When you think about it, this gets very complicated. It puts us in the position of being gatekeepers in an area for which we have no training and for which there are no set standards. It’s almost psychiatric stigma and discrimination in reverse – the presence of the dog announces that the owner is a psychiatric patient, yet dogs are no longer rare sightings on airplanes.

While it might be easier to say that as psychiatrists we don’t do that, it risks putting us at odds with patients over an issue which the airlines seem to sanction. Really, who does need their dog or their monkey or their cat to fly? Why should psychiatric patients be exempt from paying for their animals to travel, and have the comfort of knowing the pet is with them in a temperature-controlled cabin rather than crated and unattended in the cargo area, while everyone else must pay a fee?

To date, I have never seen an unruly dog on an airplane, and sadly, I’ve never seen a duck dressed in clothes. I love dogs, but certainly would never submit anyone (myself included) to flying with my own unruly little creature. Like most things, defining the lines of what it is to "need" an animal on a flight and what training should be required for "support" pets won’t be a problem until someone is bitten or distressed, or until a passenger announces they must bring their emotional support snake aboard a flight where someone has a phobia. In the meantime, I’ll contend that I like seeing an occasional cute dog on planes, but this isn’t a psychiatric issue.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

[email protected]

Readers who follow our original Shrink Rap blog may be aware that we use the image of a yellow rubber duck for our blog logo and mascot. While the intent was never to suggest that we’re quacks (we’re not), the logo came about after a 2006 article, "Wagging the dog, and a finger," in the New York Times discussed the increasing presence of animals on airplanes. The dogs fly free to provide emotional support to their troubled owners. The article also mentioned that cats, monkeys, miniature ponies, and a duck dressed in clothing have all served as emotional support service animals. The image of a dressed duck quacking about on an airplane captivated our collective sense of humor, and the years have gone by, but the duck has remained with us.

More recently, the Times ran another article, "Emotional support, with fur, draws complaints on planes," about the burden such support animals place on other passengers. For those with trained service dogs, the support animals can be distracting. For those with allergies, animal fur in an enclosed flight cabin can pose health risks. I’ll avoid the question of whose rights are more important, those of the anxious flyer or those of the allergic patient, and move straight to the question of the psychiatrist’s role in authorizing the use of a support animal.

Initially, I assumed that those who required the use of a support animal must have a phobia of flying with severe panic attacks, and that the animal was an absolute necessity, without which a patient wouldn’t be able to board a flight. Then a patient asked me to write such a letter. She’d flown many times without a creature, and I tried to understand why now she needed her new dog to accompany her. She insisted the pet was calm and well trained, and this would allow her to transport the dog back and forth at no cost, which would be quite helpful to her. And she did love the dog and find her company to be comforting, as any pet owner might.

As much as I was uncomfortable with this (my patient didn’t "need" the dog in order to fly), I looked at the criteria and felt she met it. I wrote a single-sentence note saying she was in treatment for a psychiatric disorder and it would be helpful to her to have her dog at her destination. I defined neither the disorder nor what about the dog was helpful, and I never met the pet. Fortunately, the psychiatrist is not required to comment on the mental health or behavior of the support animal, just the owner.

From the Southwest Airlines website, here is a list of requirements:

Emotional Support Animals

Animals used for a Customer’s emotional support are accepted in the cabin. In order for a Customer to travel with an emotional support animal, the Customer must provide to a Southwest Airlines Employee current documentation (not more than one year old) on letterhead from a mental health professional or medical doctor who is treating the Customer’s mental health-related disability stating:

1. The Passenger has a mental or emotional disability recognized in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV).

2. The Passenger needs the emotional support or psychiatric service animal as an accommodation for air travel and/or for activity at the passenger’s destination.

3. The individual providing the assessment is a licensed mental health professional, and the Passenger is under his or her professional care, AND

4. The date and type of mental health professional\'s or medical doctor’s license and the state or other jurisdiction in which it was issued.

Assistance and emotional support animals must be trained to behave in a public setting.

It’s an interesting set of criteria, because there is nothing specific about what "trained to behave in a public setting" might entail, and there are no specific criteria to define a patient’s "need" for a psychiatric support animal either during travel or at the destination.

When you think about it, this gets very complicated. It puts us in the position of being gatekeepers in an area for which we have no training and for which there are no set standards. It’s almost psychiatric stigma and discrimination in reverse – the presence of the dog announces that the owner is a psychiatric patient, yet dogs are no longer rare sightings on airplanes.

While it might be easier to say that as psychiatrists we don’t do that, it risks putting us at odds with patients over an issue which the airlines seem to sanction. Really, who does need their dog or their monkey or their cat to fly? Why should psychiatric patients be exempt from paying for their animals to travel, and have the comfort of knowing the pet is with them in a temperature-controlled cabin rather than crated and unattended in the cargo area, while everyone else must pay a fee?

To date, I have never seen an unruly dog on an airplane, and sadly, I’ve never seen a duck dressed in clothes. I love dogs, but certainly would never submit anyone (myself included) to flying with my own unruly little creature. Like most things, defining the lines of what it is to "need" an animal on a flight and what training should be required for "support" pets won’t be a problem until someone is bitten or distressed, or until a passenger announces they must bring their emotional support snake aboard a flight where someone has a phobia. In the meantime, I’ll contend that I like seeing an occasional cute dog on planes, but this isn’t a psychiatric issue.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

[email protected]

Almost 1 year ago, New York lawmakers passed some of the most stringent gun control measures in the country. One of the provisions of the New York Secure Ammunition and Firearms Enforcement, or SAFE Act, requires mental health professionals to report individuals they believe are likely to be dangerous to their director of community services, who then decides if patients are to be reported to the criminal justice system. The initial report, called a "9.46," goes through a website set up by the state. These patients may be investigated to determine if they have a firearms permit and whether that permit should be revoked.

The law is controversial. The federal Veterans Affairs Department said it would not comply because the law violates federal HIPAA requirements, and the New York State Psychiatric Association also registered objections, as did I – soon after it was passed. Of note, nothing in the law allows for a mental health professional to directly notify law enforcement officials to confiscate weapons from dangerous patients.

Now that it’s been a while since implementation, it’s time to start asking how it’s going. How many patients have been reported to the directors of community services through the website? How many of those have been investigated? How many guns have been confiscated or surrendered? And how much safer are New Yorkers? Are suicide and violent crime rates dropping? Are the agencies involved pleased with the results to date?

In June, The New York World posted a piece headlined "SAFE Act registry of mentally ill nets few gun permit holders" that read, in part:

"Of the 6,000 reports that have been filed, 11 have been acted upon, testified Jed Wolkenbreit, counsel to the New York State Conference of Local Mental Hygiene Directors, citing figures from the state Office of Mental Health.

His organization’s members are county directors of community services, who under the law must approve or dispute assessments made by mental health providers of the potential of their patients to cause harm.

The flood of SAFE Act reports, Mr. Wolkenbreit asserted, is taking time away from commissioners’ other responsibilities in running their counties’ mental health systems: 'The biggest problem is the amount of time and resources that the SAFE Act is diverting from all of the other duties of the DCS [directors of community services] for what we believe to be a minimal return.'

The law says that reports must be made by the mental health professional. Yet some reports, testified Mr. Wolkenbreit, are being filed by someone other than the mental health provider seeing the patient, and many appear to be computer generated, based on existing patient files. In many cases, mental health providers listed on the documents, when contacted by community services directors for review, either said that they had not filed the reports or that the patients they had seen did not meet the SAFE Act reporting criteria, according to Mr. Wolkenbreit."

That was back in June. In late October, I spoke with Mr. Wolkenbreit, who did not have up-to-date statistics. He noted that the original reports that patients were being reported erroneously was inaccurate, and the issue instead was that there had been confusion with people who had the same name and birth dates as those being reported.

Wait, so first it was stated that patients were reported in error but, in fact, that was a mistake?

"At the very beginning, there were problems with identification, and now we’re getting more information," Mr. Wolkenbreit said.

In April, WGRZ-TV in Buffalo reported on David Lewis, a college librarian in treatment for anxiety, who lost his pistol permit. Once the situation was clarified, his firearms were returned. Mr. Lewis, however, was not happy with the situation and made his story public.

WGRZ went on to discuss difficulties enacting the legislation and how the agencies involved were unclear about who was verifying information – the state police or the counties. In Rochester, the station reported, a county clerk was told to call the patient to verify that he was the subject of a report.

Mr. Wolkenbreit now estimates that 15,000 people statewide have been reported to the justice system.

"A high percentage of those are people who have been hospitalized, the next greatest number come from clinics, and a smaller number come from private practitioners. Most of the reports come from New York City."

He noted that those reporting must supply identifying information to confirm that the reporter is a legitimate mental health professional, and there needs to be a clinical reason; simply stating that a patient has suicidal ideation is not enough to trigger a report to the justice system.

"The law was a reaction to the shootings in Connecticut and was not well thought out," Mr. Wolkenbreit said.

It is estimated that most of the reports filed with the directors of community services go on to be filed with the justice system. In only a small number of cases have the reports resulted in the removal of guns from owners – Mr. Wolkenbreit was quick to say that he did not have access to these statistics. He was able to say that mental health professionals have not been happy with the reporting requirements. He did not know whether SAFE Act legislation has made a difference in firearms violence.

I spoke with Benjamin Rosen, director of public information for the New York State Office of Mental Health. Mr. Rosen directed me to some informational websites and spoke with me twice, kindly calling me back to follow up. Unfortunately, he did not have any statistics and said those numbers would have to be collected from each of the 57 counties and New York City. He noted that such information is not generally released, and if he does provide more details down the line, there will be another follow-up column here on Shrink Rap News.

As much as the idea of mandatory reporting of patients "likely to be dangerous" is distasteful to mental health professionals, New York state has passed this law, and the experiment has begun. The fear is that it will deter people from seeking care, a concern that some are quick to dismiss. Since we don’t have the answers as to how difficult such laws are to implement and what impact they have, this is extremely important work that New York is doing. It is crucial that other states have access to their experience and results to guide policy.

In Maryland, a similar reporting law was proposed last year, and it was not passed. If patient reporting and keeping guns from the dangerous mentally ill, however, result in changes in suicide and/or gun violence rates, in either direction, this needs to be made public. Either way, it’s important for New York to be the leader on this issue and help to guide policy across the country.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Almost 1 year ago, New York lawmakers passed some of the most stringent gun control measures in the country. One of the provisions of the New York Secure Ammunition and Firearms Enforcement, or SAFE Act, requires mental health professionals to report individuals they believe are likely to be dangerous to their director of community services, who then decides if patients are to be reported to the criminal justice system. The initial report, called a "9.46," goes through a website set up by the state. These patients may be investigated to determine if they have a firearms permit and whether that permit should be revoked.

The law is controversial. The federal Veterans Affairs Department said it would not comply because the law violates federal HIPAA requirements, and the New York State Psychiatric Association also registered objections, as did I – soon after it was passed. Of note, nothing in the law allows for a mental health professional to directly notify law enforcement officials to confiscate weapons from dangerous patients.

Now that it’s been a while since implementation, it’s time to start asking how it’s going. How many patients have been reported to the directors of community services through the website? How many of those have been investigated? How many guns have been confiscated or surrendered? And how much safer are New Yorkers? Are suicide and violent crime rates dropping? Are the agencies involved pleased with the results to date?

In June, The New York World posted a piece headlined "SAFE Act registry of mentally ill nets few gun permit holders" that read, in part:

"Of the 6,000 reports that have been filed, 11 have been acted upon, testified Jed Wolkenbreit, counsel to the New York State Conference of Local Mental Hygiene Directors, citing figures from the state Office of Mental Health.

His organization’s members are county directors of community services, who under the law must approve or dispute assessments made by mental health providers of the potential of their patients to cause harm.

The flood of SAFE Act reports, Mr. Wolkenbreit asserted, is taking time away from commissioners’ other responsibilities in running their counties’ mental health systems: 'The biggest problem is the amount of time and resources that the SAFE Act is diverting from all of the other duties of the DCS [directors of community services] for what we believe to be a minimal return.'

The law says that reports must be made by the mental health professional. Yet some reports, testified Mr. Wolkenbreit, are being filed by someone other than the mental health provider seeing the patient, and many appear to be computer generated, based on existing patient files. In many cases, mental health providers listed on the documents, when contacted by community services directors for review, either said that they had not filed the reports or that the patients they had seen did not meet the SAFE Act reporting criteria, according to Mr. Wolkenbreit."

That was back in June. In late October, I spoke with Mr. Wolkenbreit, who did not have up-to-date statistics. He noted that the original reports that patients were being reported erroneously was inaccurate, and the issue instead was that there had been confusion with people who had the same name and birth dates as those being reported.

Wait, so first it was stated that patients were reported in error but, in fact, that was a mistake?

"At the very beginning, there were problems with identification, and now we’re getting more information," Mr. Wolkenbreit said.

In April, WGRZ-TV in Buffalo reported on David Lewis, a college librarian in treatment for anxiety, who lost his pistol permit. Once the situation was clarified, his firearms were returned. Mr. Lewis, however, was not happy with the situation and made his story public.

WGRZ went on to discuss difficulties enacting the legislation and how the agencies involved were unclear about who was verifying information – the state police or the counties. In Rochester, the station reported, a county clerk was told to call the patient to verify that he was the subject of a report.

Mr. Wolkenbreit now estimates that 15,000 people statewide have been reported to the justice system.

"A high percentage of those are people who have been hospitalized, the next greatest number come from clinics, and a smaller number come from private practitioners. Most of the reports come from New York City."

He noted that those reporting must supply identifying information to confirm that the reporter is a legitimate mental health professional, and there needs to be a clinical reason; simply stating that a patient has suicidal ideation is not enough to trigger a report to the justice system.

"The law was a reaction to the shootings in Connecticut and was not well thought out," Mr. Wolkenbreit said.

It is estimated that most of the reports filed with the directors of community services go on to be filed with the justice system. In only a small number of cases have the reports resulted in the removal of guns from owners – Mr. Wolkenbreit was quick to say that he did not have access to these statistics. He was able to say that mental health professionals have not been happy with the reporting requirements. He did not know whether SAFE Act legislation has made a difference in firearms violence.

I spoke with Benjamin Rosen, director of public information for the New York State Office of Mental Health. Mr. Rosen directed me to some informational websites and spoke with me twice, kindly calling me back to follow up. Unfortunately, he did not have any statistics and said those numbers would have to be collected from each of the 57 counties and New York City. He noted that such information is not generally released, and if he does provide more details down the line, there will be another follow-up column here on Shrink Rap News.

As much as the idea of mandatory reporting of patients "likely to be dangerous" is distasteful to mental health professionals, New York state has passed this law, and the experiment has begun. The fear is that it will deter people from seeking care, a concern that some are quick to dismiss. Since we don’t have the answers as to how difficult such laws are to implement and what impact they have, this is extremely important work that New York is doing. It is crucial that other states have access to their experience and results to guide policy.

In Maryland, a similar reporting law was proposed last year, and it was not passed. If patient reporting and keeping guns from the dangerous mentally ill, however, result in changes in suicide and/or gun violence rates, in either direction, this needs to be made public. Either way, it’s important for New York to be the leader on this issue and help to guide policy across the country.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

Almost 1 year ago, New York lawmakers passed some of the most stringent gun control measures in the country. One of the provisions of the New York Secure Ammunition and Firearms Enforcement, or SAFE Act, requires mental health professionals to report individuals they believe are likely to be dangerous to their director of community services, who then decides if patients are to be reported to the criminal justice system. The initial report, called a "9.46," goes through a website set up by the state. These patients may be investigated to determine if they have a firearms permit and whether that permit should be revoked.

The law is controversial. The federal Veterans Affairs Department said it would not comply because the law violates federal HIPAA requirements, and the New York State Psychiatric Association also registered objections, as did I – soon after it was passed. Of note, nothing in the law allows for a mental health professional to directly notify law enforcement officials to confiscate weapons from dangerous patients.

Now that it’s been a while since implementation, it’s time to start asking how it’s going. How many patients have been reported to the directors of community services through the website? How many of those have been investigated? How many guns have been confiscated or surrendered? And how much safer are New Yorkers? Are suicide and violent crime rates dropping? Are the agencies involved pleased with the results to date?

In June, The New York World posted a piece headlined "SAFE Act registry of mentally ill nets few gun permit holders" that read, in part:

"Of the 6,000 reports that have been filed, 11 have been acted upon, testified Jed Wolkenbreit, counsel to the New York State Conference of Local Mental Hygiene Directors, citing figures from the state Office of Mental Health.

His organization’s members are county directors of community services, who under the law must approve or dispute assessments made by mental health providers of the potential of their patients to cause harm.

The flood of SAFE Act reports, Mr. Wolkenbreit asserted, is taking time away from commissioners’ other responsibilities in running their counties’ mental health systems: 'The biggest problem is the amount of time and resources that the SAFE Act is diverting from all of the other duties of the DCS [directors of community services] for what we believe to be a minimal return.'

The law says that reports must be made by the mental health professional. Yet some reports, testified Mr. Wolkenbreit, are being filed by someone other than the mental health provider seeing the patient, and many appear to be computer generated, based on existing patient files. In many cases, mental health providers listed on the documents, when contacted by community services directors for review, either said that they had not filed the reports or that the patients they had seen did not meet the SAFE Act reporting criteria, according to Mr. Wolkenbreit."

That was back in June. In late October, I spoke with Mr. Wolkenbreit, who did not have up-to-date statistics. He noted that the original reports that patients were being reported erroneously was inaccurate, and the issue instead was that there had been confusion with people who had the same name and birth dates as those being reported.

Wait, so first it was stated that patients were reported in error but, in fact, that was a mistake?

"At the very beginning, there were problems with identification, and now we’re getting more information," Mr. Wolkenbreit said.

In April, WGRZ-TV in Buffalo reported on David Lewis, a college librarian in treatment for anxiety, who lost his pistol permit. Once the situation was clarified, his firearms were returned. Mr. Lewis, however, was not happy with the situation and made his story public.

WGRZ went on to discuss difficulties enacting the legislation and how the agencies involved were unclear about who was verifying information – the state police or the counties. In Rochester, the station reported, a county clerk was told to call the patient to verify that he was the subject of a report.

Mr. Wolkenbreit now estimates that 15,000 people statewide have been reported to the justice system.

"A high percentage of those are people who have been hospitalized, the next greatest number come from clinics, and a smaller number come from private practitioners. Most of the reports come from New York City."

He noted that those reporting must supply identifying information to confirm that the reporter is a legitimate mental health professional, and there needs to be a clinical reason; simply stating that a patient has suicidal ideation is not enough to trigger a report to the justice system.

"The law was a reaction to the shootings in Connecticut and was not well thought out," Mr. Wolkenbreit said.

It is estimated that most of the reports filed with the directors of community services go on to be filed with the justice system. In only a small number of cases have the reports resulted in the removal of guns from owners – Mr. Wolkenbreit was quick to say that he did not have access to these statistics. He was able to say that mental health professionals have not been happy with the reporting requirements. He did not know whether SAFE Act legislation has made a difference in firearms violence.

I spoke with Benjamin Rosen, director of public information for the New York State Office of Mental Health. Mr. Rosen directed me to some informational websites and spoke with me twice, kindly calling me back to follow up. Unfortunately, he did not have any statistics and said those numbers would have to be collected from each of the 57 counties and New York City. He noted that such information is not generally released, and if he does provide more details down the line, there will be another follow-up column here on Shrink Rap News.

As much as the idea of mandatory reporting of patients "likely to be dangerous" is distasteful to mental health professionals, New York state has passed this law, and the experiment has begun. The fear is that it will deter people from seeking care, a concern that some are quick to dismiss. Since we don’t have the answers as to how difficult such laws are to implement and what impact they have, this is extremely important work that New York is doing. It is crucial that other states have access to their experience and results to guide policy.

In Maryland, a similar reporting law was proposed last year, and it was not passed. If patient reporting and keeping guns from the dangerous mentally ill, however, result in changes in suicide and/or gun violence rates, in either direction, this needs to be made public. Either way, it’s important for New York to be the leader on this issue and help to guide policy across the country.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I highlighted the blog post of National Institute on Mental Health Director Dr. Thomas Insel, in which he discussed how some patients with schizophrenia do better on lower doses of antipsychotic medications (or even off medications), over the long-run.

Soon afterward, the American Psychiatric Association announced that psychiatrists should use care when prescribing antipsychotics, and specific recommendations were made, along with information that was posted to the Choosing Wisely website. Choosing Wisely is an initiative of the ABIM Foundation aimed at promoting discussions between physicians and patients about the overuse of medical tests and procedures. The APA "identified five targeted evidence-based recommendations" that can be used to prompt conversations with patients:

• Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

• Don’t routinely prescribe two or more antipsychotic medications concurrently.

• Don’t prescribe antipsychotics as a first-line intervention to treat behavioral and psychological symptoms of dementia.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

"As clinicians, we know we can improve the care we deliver by engaging our patients in conversations about their care. The recommendations from APA released today provide valuable information to help patients and physicians start important conversations about treatment options and make informed choices about their health care," Dr. Jeffrey Lieberman, APA president, said in the announcement. "This is not to preclude the use of antipsychotic medications for these indications and populations, but to suggest that other treatment options should be considered first, and patients should be engaged in discussion of the rationale for use and the potential benefits and risks."

We can add to this call for caution the growing information we have that psychiatric medications are a mixed blessing for some patients. In a June 1, American Journal of Psychiatry article, "Relapse Duration, Treatment Intensity, and Brain Tissue Loss in Schizophrenia: A Prospective Longitudinal MRI Study," Dr. Nancy C. Andreasen and her colleagues reported data that left us with the perplexing conundrum that decreasing brain volume is associated both with longer duration of psychosis (but not with increased number of episodes) and with increased exposure to antipsychotic medications.

The authors noted, "Relapse prevention is important, but it should be sustained using the lowest possible medication dosages that will control symptoms." However, the only way to ascertain the lowest possible dose is to decrease the dosage until the patient becomes symptomatic, thereby risking another episode of psychosis (Am. J. Psychiatry 2013;170:609-15).

Whenever news circulates about the downside of commonly used psychotropic medications, the media is quick to circulate the news. As if on cue, USA Today printed an article 3 days after the APA released its list, headlined "Doctors: Antipsychotic meds overused for dementia, kids."

The study by Dr. Andreasen recirculated on Twitter recently but has been quoted by antipsychiatry sources on and off over the past 5 years. To most psychiatrists, it is not quite news that these medications might be overprescribed or that they can have adverse effects.

We’re in a really tough place. The longer antipsychotic medications are available, the more we become aware of the health problems associated with them, hence the justified call for caution. On the other hand, the morbidity and mortality from the conditions these medications address are considerable, and we often don’t have safe, effective alternatives with side effect profiles that are acceptable to patients.

And to state the obvious, the general public seeking psychiatric care has come to agree that symptoms are caused by "chemical imbalances," and both patients and their caretakers now request medications to fix their problems. This isn’t all bad; there’s more awareness of psychiatric symptoms and more willingness to seek treatment, and for many patients, their suffering (or the suffering of their caretakers) is eased. For the psychiatrist, however, the options are often limited, and it seems possible that we’re damned if we do prescribe and damned if we don’t.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I highlighted the blog post of National Institute on Mental Health Director Dr. Thomas Insel, in which he discussed how some patients with schizophrenia do better on lower doses of antipsychotic medications (or even off medications), over the long-run.

Soon afterward, the American Psychiatric Association announced that psychiatrists should use care when prescribing antipsychotics, and specific recommendations were made, along with information that was posted to the Choosing Wisely website. Choosing Wisely is an initiative of the ABIM Foundation aimed at promoting discussions between physicians and patients about the overuse of medical tests and procedures. The APA "identified five targeted evidence-based recommendations" that can be used to prompt conversations with patients:

• Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

• Don’t routinely prescribe two or more antipsychotic medications concurrently.

• Don’t prescribe antipsychotics as a first-line intervention to treat behavioral and psychological symptoms of dementia.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

"As clinicians, we know we can improve the care we deliver by engaging our patients in conversations about their care. The recommendations from APA released today provide valuable information to help patients and physicians start important conversations about treatment options and make informed choices about their health care," Dr. Jeffrey Lieberman, APA president, said in the announcement. "This is not to preclude the use of antipsychotic medications for these indications and populations, but to suggest that other treatment options should be considered first, and patients should be engaged in discussion of the rationale for use and the potential benefits and risks."

We can add to this call for caution the growing information we have that psychiatric medications are a mixed blessing for some patients. In a June 1, American Journal of Psychiatry article, "Relapse Duration, Treatment Intensity, and Brain Tissue Loss in Schizophrenia: A Prospective Longitudinal MRI Study," Dr. Nancy C. Andreasen and her colleagues reported data that left us with the perplexing conundrum that decreasing brain volume is associated both with longer duration of psychosis (but not with increased number of episodes) and with increased exposure to antipsychotic medications.

The authors noted, "Relapse prevention is important, but it should be sustained using the lowest possible medication dosages that will control symptoms." However, the only way to ascertain the lowest possible dose is to decrease the dosage until the patient becomes symptomatic, thereby risking another episode of psychosis (Am. J. Psychiatry 2013;170:609-15).

Whenever news circulates about the downside of commonly used psychotropic medications, the media is quick to circulate the news. As if on cue, USA Today printed an article 3 days after the APA released its list, headlined "Doctors: Antipsychotic meds overused for dementia, kids."

The study by Dr. Andreasen recirculated on Twitter recently but has been quoted by antipsychiatry sources on and off over the past 5 years. To most psychiatrists, it is not quite news that these medications might be overprescribed or that they can have adverse effects.

We’re in a really tough place. The longer antipsychotic medications are available, the more we become aware of the health problems associated with them, hence the justified call for caution. On the other hand, the morbidity and mortality from the conditions these medications address are considerable, and we often don’t have safe, effective alternatives with side effect profiles that are acceptable to patients.

And to state the obvious, the general public seeking psychiatric care has come to agree that symptoms are caused by "chemical imbalances," and both patients and their caretakers now request medications to fix their problems. This isn’t all bad; there’s more awareness of psychiatric symptoms and more willingness to seek treatment, and for many patients, their suffering (or the suffering of their caretakers) is eased. For the psychiatrist, however, the options are often limited, and it seems possible that we’re damned if we do prescribe and damned if we don’t.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I highlighted the blog post of National Institute on Mental Health Director Dr. Thomas Insel, in which he discussed how some patients with schizophrenia do better on lower doses of antipsychotic medications (or even off medications), over the long-run.

Soon afterward, the American Psychiatric Association announced that psychiatrists should use care when prescribing antipsychotics, and specific recommendations were made, along with information that was posted to the Choosing Wisely website. Choosing Wisely is an initiative of the ABIM Foundation aimed at promoting discussions between physicians and patients about the overuse of medical tests and procedures. The APA "identified five targeted evidence-based recommendations" that can be used to prompt conversations with patients:

• Don’t prescribe antipsychotic medications to patients for any indication without appropriate initial evaluation and appropriate ongoing monitoring.

• Don’t routinely prescribe two or more antipsychotic medications concurrently.

• Don’t prescribe antipsychotics as a first-line intervention to treat behavioral and psychological symptoms of dementia.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

• Don’t routinely prescribe antipsychotic medications as a first-line intervention for children and adolescents for any diagnosis other than psychotic disorders.

"As clinicians, we know we can improve the care we deliver by engaging our patients in conversations about their care. The recommendations from APA released today provide valuable information to help patients and physicians start important conversations about treatment options and make informed choices about their health care," Dr. Jeffrey Lieberman, APA president, said in the announcement. "This is not to preclude the use of antipsychotic medications for these indications and populations, but to suggest that other treatment options should be considered first, and patients should be engaged in discussion of the rationale for use and the potential benefits and risks."

We can add to this call for caution the growing information we have that psychiatric medications are a mixed blessing for some patients. In a June 1, American Journal of Psychiatry article, "Relapse Duration, Treatment Intensity, and Brain Tissue Loss in Schizophrenia: A Prospective Longitudinal MRI Study," Dr. Nancy C. Andreasen and her colleagues reported data that left us with the perplexing conundrum that decreasing brain volume is associated both with longer duration of psychosis (but not with increased number of episodes) and with increased exposure to antipsychotic medications.

The authors noted, "Relapse prevention is important, but it should be sustained using the lowest possible medication dosages that will control symptoms." However, the only way to ascertain the lowest possible dose is to decrease the dosage until the patient becomes symptomatic, thereby risking another episode of psychosis (Am. J. Psychiatry 2013;170:609-15).

Whenever news circulates about the downside of commonly used psychotropic medications, the media is quick to circulate the news. As if on cue, USA Today printed an article 3 days after the APA released its list, headlined "Doctors: Antipsychotic meds overused for dementia, kids."

The study by Dr. Andreasen recirculated on Twitter recently but has been quoted by antipsychiatry sources on and off over the past 5 years. To most psychiatrists, it is not quite news that these medications might be overprescribed or that they can have adverse effects.

We’re in a really tough place. The longer antipsychotic medications are available, the more we become aware of the health problems associated with them, hence the justified call for caution. On the other hand, the morbidity and mortality from the conditions these medications address are considerable, and we often don’t have safe, effective alternatives with side effect profiles that are acceptable to patients.

And to state the obvious, the general public seeking psychiatric care has come to agree that symptoms are caused by "chemical imbalances," and both patients and their caretakers now request medications to fix their problems. This isn’t all bad; there’s more awareness of psychiatric symptoms and more willingness to seek treatment, and for many patients, their suffering (or the suffering of their caretakers) is eased. For the psychiatrist, however, the options are often limited, and it seems possible that we’re damned if we do prescribe and damned if we don’t.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I was talking to a psychiatrist about one of his former patients whom I was interviewing for a book. The patient was hospitalized years ago for a single episode of mania. She spent a few weeks on an inpatient unit where she raised all hell and was in and out of seclusion, only to be heavily medicated, and still have it in her to raise Cain. She then spent a few weeks in a day hospital. She ended her single psychiatric episode by being discharged on three antipsychotic medications, one benzodiazepine, and Cogentin, all in sizeable doses.

The inpatient psychiatrist did not remember this patient; why would he? Aside from her unusual age (54) at the time of her presentation, the chart documented just another manic patient who was certified, committed for being gravely disabled, and authorized for medication administration against her will, and she recovered. The patient left the hospital settings and began to slowly taper her medications because the side effects were intolerable (perhaps because she was on enough medicine to drop a Clydesdale). She found a psychiatrist she could work with, one with a reputation for using medication only as a last resort, and she has been off medication, without a relapse, for 7 years now. I mentioned this to the psychiatrist who had seen her in the hospital and his response – without remembering the patient and without reviewing her chart – was swift: "She’ll get sick again." And she may; bipolar disorder is a recurrent illness, but since she presented following unusual circumstances, at an atypical age, and has done quite well in the intervening years, I am hoping his dismal prognosis will prove to be wrong. Perhaps a single episode of mania was just a single episode of mania – a few bad weeks in someone’s life precipitated by extreme stress. The patient believes her course was worsened by the medication she was given and the unkind treatment she received.

We were taught that if patients are diagnosed with certain psychiatric disorders, the recommendation is for them to remain on medication for life.

In clinical practice, we’ve also learned that as much as we may recommend that patients take their medicine, most patients try the experiment of going off, with or without our agreement, concession, or even our encouragement. And we certainly know that some of those people try this experiment over and over, only to land in the same bad place (often the psychiatric unit or jail) again and again. What we see less is that some of those people do just fine without the medications one might have predicted they’d need for the rest of their life. In private practice, a few will stop their medications – or refuse to take them in the first place – and do quite well. They may continue to come for supportive or insight-oriented psychotherapy. But the truth is that most patients who stop their medications and do fine just drift off, lost to the attrition of being well. They may never return or may come later when they have a recurrence, but we are left to wonder if the risks of prophylactic medication are worth the benefit given the following: These recurrences can be years or even decades apart, not all recurrences are catastrophic or difficult to treat, and the medications are often not benign. For patients who have repeatedly become psychotic, suicidal, and unable to function within weeks of stopping their medication, there is little choice; they need chronic treatment.

For the patient who gets delusional every 10 years, it may not be worth the tradeoff of chronic antipsychotics if that patient is one of the many who develop a metabolic syndrome. These are things we’ve known in clinical practice for a long time; not every teenager labeled "bipolar" needs lifelong lithium.

But what’s new, and what should shake us up, is the blog National Institute of Mental Health Director Thomas Insel posted on Aug. 28. Dr. Insel discussed the research that has shown that a subset of psychotic patients do significantly better if they lower or even completely stop their antipsychotic medication following the acute phase of treatment of schizophrenia. If you haven’t read Dr. Insel’s post, "Antipsychotics: Taking the Long View," it’s well worth the read.

He wrote: "Wunderink and colleagues from the Netherlands report on a 7-year follow-up of 103 people with schizophrenia and related disorders who had experienced a first episode of psychosis between 2001 and 2002. After 6 months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by 7 years, the discontinuation group had achieved twice the functional recovery rate: 40.4% vs. only 17.6% among the medication maintenance group. To be clear, this study started with patients in remission, and only 17 of the 103 patients – 21% of the discontinuation group and 11% of the maintenance group – were off medication entirely during the last 2 years of follow-up. An equal number were taking very low doses of medication – meaning that roughly one-third of all study patients were eventually taking little or no medication."

Our antipsychiatry foes will read this as saying that people do better without antipsychotics, and that’s not what this says at all. But what it does say is that a subset of people, whom we can’t identify beforehand, will do better over the long term with lower doses, or no, medication. Although we can’t identify who will do better beforehand, this does totally change the risk-benefit discussion we have with our patients, especially the more compliant of those patients, and it completely disrupts the idea that prophylaxis for all patients with schizophrenia is the right and only thing to do.

Psychiatry seems to have its own leagues of critics. Certainly, assumptions are made in all areas of medicine, but there isn’t an outspoken group of antioncology patients who take to the streets with signs and megaphones. And being a cancer survivor is a good thing, while being a "psychiatry survivor" is not.

But psychiatry is not alone in being faced with challenges to assumptions we’ve taken as gospel. The food pyramid is one example of a frequently changing ideal about what we should be consuming. Is coronary artery stenting good, bad, or just oversold? The Institute of Medicine released a 169-page report this year discussing how the evidence that a sodium-restricted diet, which does lower blood pressure, is short on proof that it also lowers the risk of stroke and cardiac events. Knee jerk hormone replacement therapy for postmenopausal women proved to be a big mistake. But we have been prescribing long-term antipsychotics without question for more than 50 years, and I applaud Dr. Insel for asking us to at least reconsider the status quo, whether it’s how we establish our diagnostic criteria or the assumptions we make about what treatments best help all patients.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I was talking to a psychiatrist about one of his former patients whom I was interviewing for a book. The patient was hospitalized years ago for a single episode of mania. She spent a few weeks on an inpatient unit where she raised all hell and was in and out of seclusion, only to be heavily medicated, and still have it in her to raise Cain. She then spent a few weeks in a day hospital. She ended her single psychiatric episode by being discharged on three antipsychotic medications, one benzodiazepine, and Cogentin, all in sizeable doses.

The inpatient psychiatrist did not remember this patient; why would he? Aside from her unusual age (54) at the time of her presentation, the chart documented just another manic patient who was certified, committed for being gravely disabled, and authorized for medication administration against her will, and she recovered. The patient left the hospital settings and began to slowly taper her medications because the side effects were intolerable (perhaps because she was on enough medicine to drop a Clydesdale). She found a psychiatrist she could work with, one with a reputation for using medication only as a last resort, and she has been off medication, without a relapse, for 7 years now. I mentioned this to the psychiatrist who had seen her in the hospital and his response – without remembering the patient and without reviewing her chart – was swift: "She’ll get sick again." And she may; bipolar disorder is a recurrent illness, but since she presented following unusual circumstances, at an atypical age, and has done quite well in the intervening years, I am hoping his dismal prognosis will prove to be wrong. Perhaps a single episode of mania was just a single episode of mania – a few bad weeks in someone’s life precipitated by extreme stress. The patient believes her course was worsened by the medication she was given and the unkind treatment she received.

We were taught that if patients are diagnosed with certain psychiatric disorders, the recommendation is for them to remain on medication for life.

In clinical practice, we’ve also learned that as much as we may recommend that patients take their medicine, most patients try the experiment of going off, with or without our agreement, concession, or even our encouragement. And we certainly know that some of those people try this experiment over and over, only to land in the same bad place (often the psychiatric unit or jail) again and again. What we see less is that some of those people do just fine without the medications one might have predicted they’d need for the rest of their life. In private practice, a few will stop their medications – or refuse to take them in the first place – and do quite well. They may continue to come for supportive or insight-oriented psychotherapy. But the truth is that most patients who stop their medications and do fine just drift off, lost to the attrition of being well. They may never return or may come later when they have a recurrence, but we are left to wonder if the risks of prophylactic medication are worth the benefit given the following: These recurrences can be years or even decades apart, not all recurrences are catastrophic or difficult to treat, and the medications are often not benign. For patients who have repeatedly become psychotic, suicidal, and unable to function within weeks of stopping their medication, there is little choice; they need chronic treatment.

For the patient who gets delusional every 10 years, it may not be worth the tradeoff of chronic antipsychotics if that patient is one of the many who develop a metabolic syndrome. These are things we’ve known in clinical practice for a long time; not every teenager labeled "bipolar" needs lifelong lithium.

But what’s new, and what should shake us up, is the blog National Institute of Mental Health Director Thomas Insel posted on Aug. 28. Dr. Insel discussed the research that has shown that a subset of psychotic patients do significantly better if they lower or even completely stop their antipsychotic medication following the acute phase of treatment of schizophrenia. If you haven’t read Dr. Insel’s post, "Antipsychotics: Taking the Long View," it’s well worth the read.

He wrote: "Wunderink and colleagues from the Netherlands report on a 7-year follow-up of 103 people with schizophrenia and related disorders who had experienced a first episode of psychosis between 2001 and 2002. After 6 months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by 7 years, the discontinuation group had achieved twice the functional recovery rate: 40.4% vs. only 17.6% among the medication maintenance group. To be clear, this study started with patients in remission, and only 17 of the 103 patients – 21% of the discontinuation group and 11% of the maintenance group – were off medication entirely during the last 2 years of follow-up. An equal number were taking very low doses of medication – meaning that roughly one-third of all study patients were eventually taking little or no medication."

Our antipsychiatry foes will read this as saying that people do better without antipsychotics, and that’s not what this says at all. But what it does say is that a subset of people, whom we can’t identify beforehand, will do better over the long term with lower doses, or no, medication. Although we can’t identify who will do better beforehand, this does totally change the risk-benefit discussion we have with our patients, especially the more compliant of those patients, and it completely disrupts the idea that prophylaxis for all patients with schizophrenia is the right and only thing to do.

Psychiatry seems to have its own leagues of critics. Certainly, assumptions are made in all areas of medicine, but there isn’t an outspoken group of antioncology patients who take to the streets with signs and megaphones. And being a cancer survivor is a good thing, while being a "psychiatry survivor" is not.

But psychiatry is not alone in being faced with challenges to assumptions we’ve taken as gospel. The food pyramid is one example of a frequently changing ideal about what we should be consuming. Is coronary artery stenting good, bad, or just oversold? The Institute of Medicine released a 169-page report this year discussing how the evidence that a sodium-restricted diet, which does lower blood pressure, is short on proof that it also lowers the risk of stroke and cardiac events. Knee jerk hormone replacement therapy for postmenopausal women proved to be a big mistake. But we have been prescribing long-term antipsychotics without question for more than 50 years, and I applaud Dr. Insel for asking us to at least reconsider the status quo, whether it’s how we establish our diagnostic criteria or the assumptions we make about what treatments best help all patients.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

A few weeks ago, I was talking to a psychiatrist about one of his former patients whom I was interviewing for a book. The patient was hospitalized years ago for a single episode of mania. She spent a few weeks on an inpatient unit where she raised all hell and was in and out of seclusion, only to be heavily medicated, and still have it in her to raise Cain. She then spent a few weeks in a day hospital. She ended her single psychiatric episode by being discharged on three antipsychotic medications, one benzodiazepine, and Cogentin, all in sizeable doses.

The inpatient psychiatrist did not remember this patient; why would he? Aside from her unusual age (54) at the time of her presentation, the chart documented just another manic patient who was certified, committed for being gravely disabled, and authorized for medication administration against her will, and she recovered. The patient left the hospital settings and began to slowly taper her medications because the side effects were intolerable (perhaps because she was on enough medicine to drop a Clydesdale). She found a psychiatrist she could work with, one with a reputation for using medication only as a last resort, and she has been off medication, without a relapse, for 7 years now. I mentioned this to the psychiatrist who had seen her in the hospital and his response – without remembering the patient and without reviewing her chart – was swift: "She’ll get sick again." And she may; bipolar disorder is a recurrent illness, but since she presented following unusual circumstances, at an atypical age, and has done quite well in the intervening years, I am hoping his dismal prognosis will prove to be wrong. Perhaps a single episode of mania was just a single episode of mania – a few bad weeks in someone’s life precipitated by extreme stress. The patient believes her course was worsened by the medication she was given and the unkind treatment she received.

We were taught that if patients are diagnosed with certain psychiatric disorders, the recommendation is for them to remain on medication for life.

In clinical practice, we’ve also learned that as much as we may recommend that patients take their medicine, most patients try the experiment of going off, with or without our agreement, concession, or even our encouragement. And we certainly know that some of those people try this experiment over and over, only to land in the same bad place (often the psychiatric unit or jail) again and again. What we see less is that some of those people do just fine without the medications one might have predicted they’d need for the rest of their life. In private practice, a few will stop their medications – or refuse to take them in the first place – and do quite well. They may continue to come for supportive or insight-oriented psychotherapy. But the truth is that most patients who stop their medications and do fine just drift off, lost to the attrition of being well. They may never return or may come later when they have a recurrence, but we are left to wonder if the risks of prophylactic medication are worth the benefit given the following: These recurrences can be years or even decades apart, not all recurrences are catastrophic or difficult to treat, and the medications are often not benign. For patients who have repeatedly become psychotic, suicidal, and unable to function within weeks of stopping their medication, there is little choice; they need chronic treatment.

For the patient who gets delusional every 10 years, it may not be worth the tradeoff of chronic antipsychotics if that patient is one of the many who develop a metabolic syndrome. These are things we’ve known in clinical practice for a long time; not every teenager labeled "bipolar" needs lifelong lithium.

But what’s new, and what should shake us up, is the blog National Institute of Mental Health Director Thomas Insel posted on Aug. 28. Dr. Insel discussed the research that has shown that a subset of psychotic patients do significantly better if they lower or even completely stop their antipsychotic medication following the acute phase of treatment of schizophrenia. If you haven’t read Dr. Insel’s post, "Antipsychotics: Taking the Long View," it’s well worth the read.

He wrote: "Wunderink and colleagues from the Netherlands report on a 7-year follow-up of 103 people with schizophrenia and related disorders who had experienced a first episode of psychosis between 2001 and 2002. After 6 months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by 7 years, the discontinuation group had achieved twice the functional recovery rate: 40.4% vs. only 17.6% among the medication maintenance group. To be clear, this study started with patients in remission, and only 17 of the 103 patients – 21% of the discontinuation group and 11% of the maintenance group – were off medication entirely during the last 2 years of follow-up. An equal number were taking very low doses of medication – meaning that roughly one-third of all study patients were eventually taking little or no medication."

Our antipsychiatry foes will read this as saying that people do better without antipsychotics, and that’s not what this says at all. But what it does say is that a subset of people, whom we can’t identify beforehand, will do better over the long term with lower doses, or no, medication. Although we can’t identify who will do better beforehand, this does totally change the risk-benefit discussion we have with our patients, especially the more compliant of those patients, and it completely disrupts the idea that prophylaxis for all patients with schizophrenia is the right and only thing to do.

Psychiatry seems to have its own leagues of critics. Certainly, assumptions are made in all areas of medicine, but there isn’t an outspoken group of antioncology patients who take to the streets with signs and megaphones. And being a cancer survivor is a good thing, while being a "psychiatry survivor" is not.

But psychiatry is not alone in being faced with challenges to assumptions we’ve taken as gospel. The food pyramid is one example of a frequently changing ideal about what we should be consuming. Is coronary artery stenting good, bad, or just oversold? The Institute of Medicine released a 169-page report this year discussing how the evidence that a sodium-restricted diet, which does lower blood pressure, is short on proof that it also lowers the risk of stroke and cardiac events. Knee jerk hormone replacement therapy for postmenopausal women proved to be a big mistake. But we have been prescribing long-term antipsychotics without question for more than 50 years, and I applaud Dr. Insel for asking us to at least reconsider the status quo, whether it’s how we establish our diagnostic criteria or the assumptions we make about what treatments best help all patients.

Dr. Miller is a coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: The Johns Hopkins University Press, 2011).

It wouldn’t be the American Psychiatric Association’s annual meeting without them: the protestors. Every year for as long as I can remember, they line up with their signs and chant. In more recent years, there have been megaphones, speaker systems, and a Jumbotron.

It takes dedication.

It’s easy to ignore those who have beefs with psychiatry. We’re in demand, and I believe that because our practices remain busy with long waits to access psychiatrists in the public mental health system, it’s been to easy to ignore a small, but growing, group of individuals we may have once written off as being zealots or “kooks.” With time, their numbers and voice have gotten stronger, and their constituents more mainstream.

In the last few weeks, the New York Times published an article about the financial benefits of mandated (also called “assisted” or “forced”) outpatient programs. A letter in response was written by three professors of social work and social welfare who have authored a book called “Mad Science” (Livingston, N.J.: Transaction Publishers, 2013). It joins a number of books by Robert Whitaker that denounce our profession. This year, the National Alliance on Mental Illness invited Mr. Whitaker to speak at its annual convention – a controversial choice by any standard.

How should we, as a profession, deal with those who denounce the benefits of psychiatric care? It’s a difficult question, because they are often intent on using sensational examples, and their tone is offensive and not open to conflicting ideas. “Mad Science” uses for its first clinical example of psychiatric mistreatment a vignette about a young man with symptoms of depression who is brought to the hospital by his parents. There, with no evaluation, he is strapped to a gurney and taken immediately for brain surgery, and he is left with permanent brain damage. We have to read for several pages before the authors mention that this happened in China, even though their book is about American psychiatry. 

For starters, I believe we need to acknowledge that some of the points the protesters make are valid. Our diagnostic criteria are arrived at by consensus and not by biological markers. This is a major point that those against pharmacologic treatments want to make. They seem unaware that the values for defining diabetes and hypertension were also arrived at by consensus, and in June, the American Medical Association decided that obesity was a disease. We have loosened the criteria for diagnosis of bipolar disorder and attention-deficit disorder to the point that we should use caution before recommending lifetime treatment, and should probably not do so at the initial interview with outpatients, especially if the patients are teenagers. Few psychiatrists do this anymore, but those examples circulate. 

The hopes we’ve had for finding the biological basis to psychiatric disorders have, so far, been disappointing. The pharmaceutical companies have skewed the publication of data to show only the positive results, and there are individual research psychiatrists who have been corrupt in manipulating data for their own financial gain (for this, our own profession should join the opposition in being angry). And our treatments don’t help everyone, which is not news to any psychiatrist.

Other antipsychiatry voices go on to talk about how treatments are not only not helpful, but also harmful. They present cases such that perfectly well individuals were given medications that caused them to become psychiatrically ill, physically ill, occupationally disabled, suicidal, and even homicidal. We might point out that perfectly well people don’t generally seek psychiatric care, and be more open about the fact that people have a variety of responses to our medications, such that the bad sometimes outweighs the good. We need to respond to studies showing fault with psychiatry that have been overly touted by the media and are simply wrong. For example, a widely publicized and often quoted study showed that an initial trial of antidepressants is comparable in efficacy to placebo. But this is not reflective of psychiatric practice, where we often need trials of several medications, sometimes with augmenting agents, to yield much higher improvement rates. That fact is left out, and the message the public sees is that antidepressants don’t work. Only with my patients, they do work. 

I often wonder why there isn’t a loud and growing anti-oncology movement. Oncologists offer toxic treatments with horrible side effects to dying patients. Our protesters would point out that treatments for cancer are never forced, and perhaps we should look more carefully at the impact of civil commitment and forced medications on patient satisfaction and outcomes.

As a profession, I don’t know what we should say to the antipsychiatry advocates, and I don’t know that they want to hear from us, anyway. I do think we should listen to them long enough to process their points, respond when appropriate, and question our own clinical practices. 

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011).

It wouldn’t be the American Psychiatric Association’s annual meeting without them: the protestors. Every year for as long as I can remember, they line up with their signs and chant. In more recent years, there have been megaphones, speaker systems, and a Jumbotron.

It takes dedication.

It’s easy to ignore those who have beefs with psychiatry. We’re in demand, and I believe that because our practices remain busy with long waits to access psychiatrists in the public mental health system, it’s been to easy to ignore a small, but growing, group of individuals we may have once written off as being zealots or “kooks.” With time, their numbers and voice have gotten stronger, and their constituents more mainstream.

In the last few weeks, the New York Times published an article about the financial benefits of mandated (also called “assisted” or “forced”) outpatient programs. A letter in response was written by three professors of social work and social welfare who have authored a book called “Mad Science” (Livingston, N.J.: Transaction Publishers, 2013). It joins a number of books by Robert Whitaker that denounce our profession. This year, the National Alliance on Mental Illness invited Mr. Whitaker to speak at its annual convention – a controversial choice by any standard.

How should we, as a profession, deal with those who denounce the benefits of psychiatric care? It’s a difficult question, because they are often intent on using sensational examples, and their tone is offensive and not open to conflicting ideas. “Mad Science” uses for its first clinical example of psychiatric mistreatment a vignette about a young man with symptoms of depression who is brought to the hospital by his parents. There, with no evaluation, he is strapped to a gurney and taken immediately for brain surgery, and he is left with permanent brain damage. We have to read for several pages before the authors mention that this happened in China, even though their book is about American psychiatry. 

For starters, I believe we need to acknowledge that some of the points the protesters make are valid. Our diagnostic criteria are arrived at by consensus and not by biological markers. This is a major point that those against pharmacologic treatments want to make. They seem unaware that the values for defining diabetes and hypertension were also arrived at by consensus, and in June, the American Medical Association decided that obesity was a disease. We have loosened the criteria for diagnosis of bipolar disorder and attention-deficit disorder to the point that we should use caution before recommending lifetime treatment, and should probably not do so at the initial interview with outpatients, especially if the patients are teenagers. Few psychiatrists do this anymore, but those examples circulate. 

The hopes we’ve had for finding the biological basis to psychiatric disorders have, so far, been disappointing. The pharmaceutical companies have skewed the publication of data to show only the positive results, and there are individual research psychiatrists who have been corrupt in manipulating data for their own financial gain (for this, our own profession should join the opposition in being angry). And our treatments don’t help everyone, which is not news to any psychiatrist.

Other antipsychiatry voices go on to talk about how treatments are not only not helpful, but also harmful. They present cases such that perfectly well individuals were given medications that caused them to become psychiatrically ill, physically ill, occupationally disabled, suicidal, and even homicidal. We might point out that perfectly well people don’t generally seek psychiatric care, and be more open about the fact that people have a variety of responses to our medications, such that the bad sometimes outweighs the good. We need to respond to studies showing fault with psychiatry that have been overly touted by the media and are simply wrong. For example, a widely publicized and often quoted study showed that an initial trial of antidepressants is comparable in efficacy to placebo. But this is not reflective of psychiatric practice, where we often need trials of several medications, sometimes with augmenting agents, to yield much higher improvement rates. That fact is left out, and the message the public sees is that antidepressants don’t work. Only with my patients, they do work. 

I often wonder why there isn’t a loud and growing anti-oncology movement. Oncologists offer toxic treatments with horrible side effects to dying patients. Our protesters would point out that treatments for cancer are never forced, and perhaps we should look more carefully at the impact of civil commitment and forced medications on patient satisfaction and outcomes.

As a profession, I don’t know what we should say to the antipsychiatry advocates, and I don’t know that they want to hear from us, anyway. I do think we should listen to them long enough to process their points, respond when appropriate, and question our own clinical practices. 

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011).

It wouldn’t be the American Psychiatric Association’s annual meeting without them: the protestors. Every year for as long as I can remember, they line up with their signs and chant. In more recent years, there have been megaphones, speaker systems, and a Jumbotron.

It takes dedication.

It’s easy to ignore those who have beefs with psychiatry. We’re in demand, and I believe that because our practices remain busy with long waits to access psychiatrists in the public mental health system, it’s been to easy to ignore a small, but growing, group of individuals we may have once written off as being zealots or “kooks.” With time, their numbers and voice have gotten stronger, and their constituents more mainstream.

In the last few weeks, the New York Times published an article about the financial benefits of mandated (also called “assisted” or “forced”) outpatient programs. A letter in response was written by three professors of social work and social welfare who have authored a book called “Mad Science” (Livingston, N.J.: Transaction Publishers, 2013). It joins a number of books by Robert Whitaker that denounce our profession. This year, the National Alliance on Mental Illness invited Mr. Whitaker to speak at its annual convention – a controversial choice by any standard.

How should we, as a profession, deal with those who denounce the benefits of psychiatric care? It’s a difficult question, because they are often intent on using sensational examples, and their tone is offensive and not open to conflicting ideas. “Mad Science” uses for its first clinical example of psychiatric mistreatment a vignette about a young man with symptoms of depression who is brought to the hospital by his parents. There, with no evaluation, he is strapped to a gurney and taken immediately for brain surgery, and he is left with permanent brain damage. We have to read for several pages before the authors mention that this happened in China, even though their book is about American psychiatry. 

For starters, I believe we need to acknowledge that some of the points the protesters make are valid. Our diagnostic criteria are arrived at by consensus and not by biological markers. This is a major point that those against pharmacologic treatments want to make. They seem unaware that the values for defining diabetes and hypertension were also arrived at by consensus, and in June, the American Medical Association decided that obesity was a disease. We have loosened the criteria for diagnosis of bipolar disorder and attention-deficit disorder to the point that we should use caution before recommending lifetime treatment, and should probably not do so at the initial interview with outpatients, especially if the patients are teenagers. Few psychiatrists do this anymore, but those examples circulate. 

The hopes we’ve had for finding the biological basis to psychiatric disorders have, so far, been disappointing. The pharmaceutical companies have skewed the publication of data to show only the positive results, and there are individual research psychiatrists who have been corrupt in manipulating data for their own financial gain (for this, our own profession should join the opposition in being angry). And our treatments don’t help everyone, which is not news to any psychiatrist.

Other antipsychiatry voices go on to talk about how treatments are not only not helpful, but also harmful. They present cases such that perfectly well individuals were given medications that caused them to become psychiatrically ill, physically ill, occupationally disabled, suicidal, and even homicidal. We might point out that perfectly well people don’t generally seek psychiatric care, and be more open about the fact that people have a variety of responses to our medications, such that the bad sometimes outweighs the good. We need to respond to studies showing fault with psychiatry that have been overly touted by the media and are simply wrong. For example, a widely publicized and often quoted study showed that an initial trial of antidepressants is comparable in efficacy to placebo. But this is not reflective of psychiatric practice, where we often need trials of several medications, sometimes with augmenting agents, to yield much higher improvement rates. That fact is left out, and the message the public sees is that antidepressants don’t work. Only with my patients, they do work. 

I often wonder why there isn’t a loud and growing anti-oncology movement. Oncologists offer toxic treatments with horrible side effects to dying patients. Our protesters would point out that treatments for cancer are never forced, and perhaps we should look more carefully at the impact of civil commitment and forced medications on patient satisfaction and outcomes.

As a profession, I don’t know what we should say to the antipsychiatry advocates, and I don’t know that they want to hear from us, anyway. I do think we should listen to them long enough to process their points, respond when appropriate, and question our own clinical practices. 

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: The Johns Hopkins University Press, 2011).

When a doctor treats a patient – any patient, and perhaps psychotherapy patients in particular – there is one tenet that holds true for all visits: The visit is about the patient. Psychiatrists vary a great deal with respect to how much they reveal to patients about their personal lives. As the years have gone by, and we’ve talked more about controlled clinical trials and evidence-based medicine, we’ve talked less about boundaries and how much to disclose, or not, to patients about our personal lives.

I’m not a psychoanalyst. For them, boundaries about such things are clear, and self-disclosure about the therapist’s life is often taboo. Still, I do think it’s important to limit talking about oneself in psychotherapy for several reasons. For one thing, it takes up time that the patient could be using to do work and risks turning the session into a meeting that is about the therapist, and not the patient. And finally, having some distance keeps it clear that the relationship is a professional and therapeutic one, and not a friendship or romantic encounter, and that message hopefully is conveyed in a number of other ways as well.

I often tell people stories from my own life if I think it will convey a message or resonate for them: I may briefly talk about a movie I saw that pertains to the patient’s concerns or commiserate with them about life’s aggravations. My favorite story to tell patients who worry excessively that they might do something that will embarrass them, is that I once went to work at the clinic with my dress on inside out. Yes, it was immediately noticeable, but after my initial mortification and dash to the restroom, I was happy that I gave some kind social workers a good laugh. And life does go on, even after one embarrasses oneself. I share short stories that I hope will resonate, or give some perspective to an individual’s troubles, or simply let the patient know that we are all part of the same muck of humanity and things are not always easy.

What I don’t offer are stories that are very personal. I don’t talk about my children or husband, I don’t offer information about my health unless it’s absolutely necessary, the only relevant example being two pregnancies when I first started practicing.

But lives don’t always go smoothly. There was an unexpected death in my family a few weeks ago – the impetus for my thinking and writing about this topic now – and I felt I needed to offer an explanation to the patients I canceled on very little notice. It left those patients knowing that I’ve been struggling, though I am mostly able to put it aside while I work. Still, I feel badly that the patients have worried about me when they have their own difficulties.

The other day, the door of my suite bore a sign: One of my colleagues had a family emergency and requested that patients call to reschedule. I did learn that she had to run a sick child to the doctor, but I don’t know what she told those patients.

Although disclosing personal information can be distracting, or even disturbing, it seems reasonable to let patients know about emergencies that directly affect them. I long ago gave up on absolute answers to such questions; some patients press me for personal information and if it doesn’t feel overly intrusive, I simply respond and I don’t always ask why they want to know. When I do delve, sometimes the reasons reveal interesting information, but not always. Other patients never ask a thing. So while I have no answers but to say what has mostly worked for me, it somehow feels comfortable to revisit an old topic that doesn’t get much attention anymore.

Dr. Miller is coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). 

When a doctor treats a patient – any patient, and perhaps psychotherapy patients in particular – there is one tenet that holds true for all visits: The visit is about the patient. Psychiatrists vary a great deal with respect to how much they reveal to patients about their personal lives. As the years have gone by, and we’ve talked more about controlled clinical trials and evidence-based medicine, we’ve talked less about boundaries and how much to disclose, or not, to patients about our personal lives.

I’m not a psychoanalyst. For them, boundaries about such things are clear, and self-disclosure about the therapist’s life is often taboo. Still, I do think it’s important to limit talking about oneself in psychotherapy for several reasons. For one thing, it takes up time that the patient could be using to do work and risks turning the session into a meeting that is about the therapist, and not the patient. And finally, having some distance keeps it clear that the relationship is a professional and therapeutic one, and not a friendship or romantic encounter, and that message hopefully is conveyed in a number of other ways as well.

I often tell people stories from my own life if I think it will convey a message or resonate for them: I may briefly talk about a movie I saw that pertains to the patient’s concerns or commiserate with them about life’s aggravations. My favorite story to tell patients who worry excessively that they might do something that will embarrass them, is that I once went to work at the clinic with my dress on inside out. Yes, it was immediately noticeable, but after my initial mortification and dash to the restroom, I was happy that I gave some kind social workers a good laugh. And life does go on, even after one embarrasses oneself. I share short stories that I hope will resonate, or give some perspective to an individual’s troubles, or simply let the patient know that we are all part of the same muck of humanity and things are not always easy.

What I don’t offer are stories that are very personal. I don’t talk about my children or husband, I don’t offer information about my health unless it’s absolutely necessary, the only relevant example being two pregnancies when I first started practicing.

But lives don’t always go smoothly. There was an unexpected death in my family a few weeks ago – the impetus for my thinking and writing about this topic now – and I felt I needed to offer an explanation to the patients I canceled on very little notice. It left those patients knowing that I’ve been struggling, though I am mostly able to put it aside while I work. Still, I feel badly that the patients have worried about me when they have their own difficulties.

The other day, the door of my suite bore a sign: One of my colleagues had a family emergency and requested that patients call to reschedule. I did learn that she had to run a sick child to the doctor, but I don’t know what she told those patients.

Although disclosing personal information can be distracting, or even disturbing, it seems reasonable to let patients know about emergencies that directly affect them. I long ago gave up on absolute answers to such questions; some patients press me for personal information and if it doesn’t feel overly intrusive, I simply respond and I don’t always ask why they want to know. When I do delve, sometimes the reasons reveal interesting information, but not always. Other patients never ask a thing. So while I have no answers but to say what has mostly worked for me, it somehow feels comfortable to revisit an old topic that doesn’t get much attention anymore.

Dr. Miller is coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011). 

When a doctor treats a patient – any patient, and perhaps psychotherapy patients in particular – there is one tenet that holds true for all visits: The visit is about the patient. Psychiatrists vary a great deal with respect to how much they reveal to patients about their personal lives. As the years have gone by, and we’ve talked more about controlled clinical trials and evidence-based medicine, we’ve talked less about boundaries and how much to disclose, or not, to patients about our personal lives.

I’m not a psychoanalyst. For them, boundaries about such things are clear, and self-disclosure about the therapist’s life is often taboo. Still, I do think it’s important to limit talking about oneself in psychotherapy for several reasons. For one thing, it takes up time that the patient could be using to do work and risks turning the session into a meeting that is about the therapist, and not the patient. And finally, having some distance keeps it clear that the relationship is a professional and therapeutic one, and not a friendship or romantic encounter, and that message hopefully is conveyed in a number of other ways as well.

I often tell people stories from my own life if I think it will convey a message or resonate for them: I may briefly talk about a movie I saw that pertains to the patient’s concerns or commiserate with them about life’s aggravations. My favorite story to tell patients who worry excessively that they might do something that will embarrass them, is that I once went to work at the clinic with my dress on inside out. Yes, it was immediately noticeable, but after my initial mortification and dash to the restroom, I was happy that I gave some kind social workers a good laugh. And life does go on, even after one embarrasses oneself. I share short stories that I hope will resonate, or give some perspective to an individual’s troubles, or simply let the patient know that we are all part of the same muck of humanity and things are not always easy.

What I don’t offer are stories that are very personal. I don’t talk about my children or husband, I don’t offer information about my health unless it’s absolutely necessary, the only relevant example being two pregnancies when I first started practicing.

But lives don’t always go smoothly. There was an unexpected death in my family a few weeks ago – the impetus for my thinking and writing about this topic now – and I felt I needed to offer an explanation to the patients I canceled on very little notice. It left those patients knowing that I’ve been struggling, though I am mostly able to put it aside while I work. Still, I feel badly that the patients have worried about me when they have their own difficulties.

The other day, the door of my suite bore a sign: One of my colleagues had a family emergency and requested that patients call to reschedule. I did learn that she had to run a sick child to the doctor, but I don’t know what she told those patients.

Although disclosing personal information can be distracting, or even disturbing, it seems reasonable to let patients know about emergencies that directly affect them. I long ago gave up on absolute answers to such questions; some patients press me for personal information and if it doesn’t feel overly intrusive, I simply respond and I don’t always ask why they want to know. When I do delve, sometimes the reasons reveal interesting information, but not always. Other patients never ask a thing. So while I have no answers but to say what has mostly worked for me, it somehow feels comfortable to revisit an old topic that doesn’t get much attention anymore.

Dr. Miller is coauthor of "Shrink Rap: Three Psychiatrists Explain Their Work" (Baltimore: Johns Hopkins University Press, 2011).