Is James Holmes Mentally Ill? Does It Matter?

July 25, 2012

Last Saturday’s early-morning massacre at a crowded movie theater in Aurora, Colorado, stands as one of the most horrific rampages in American history.  But before anyone had any clue as to James Holmes’ motive for such a heinous act—even before the bodies had been removed from the site of the carnage—websites and social media were abuzz with suspicions that the gunman was either mentally ill, or was under the effect of psychotropic medications—one (or both) of which may have contributed to his crime.

As of this writing, any statement about Holmes’ psychiatric history is pure conjecture (although as I post this, I see a Fox News report claiming that Holmes mailed a notebook to “a psychiatrist” detailing his plan—more will surely be revealed).  Acquaintances quoted in the media have described him as a shy person, but have reported no erratic or unusual behaviors to arouse suspicion of an underlying mental illness.  Until recently, he was even enrolled in a graduate neuroscience program.  Some reports suggest that Holmes had spent weeks engineering an elaborate and complex scheme, hinting at some highly organized—albeit deadly—motive.  Nevertheless, the fact remains that we simply don’t know about any diagnosis, medication, or other psychiatric condition or treatment, which might shed light on Holmes’ frame of mind.

Those who focus on Holmes’ mental state at the time of the murders seem to fall in one of two camps.  Some argue that medications (if he were under the influence of any) may have enabled or facilitated this horrific act.  Others say that if Holmes had been diagnosed with a psychiatric illness, then this catastrophe serves as proof that we need more aggressive treatment—including medications—and services for the mentally ill.

It will be some time before we get answers in Holmes’ case.  And to me, that’s just as well.  Determining whether he has a mental illness, or was under the influence of psychotropic drugs last weekend, unfortunately reframes the question in such a way that further propagates the rift between these two factions, and fails to address how we should handle future cases like Holmes’ more humanely.  If, for example, Holmes is found to suffer from untreated schizophrenia, our society’s (and profession’s) reaction will be to lobby for more aggressive treatment, greater access to medication, more widespread screening programs, and, perhaps, a lower threshold by which to hospitalize psychotic individuals we deem as potentially “dangerous to others.”  If, on the other hand, a toxicology report reveals that Holmes had an antidepressant or antipsychotic in his bloodstream at the time of the murders, our inclination will be to restrict our use of these drugs, remove them from our formularies, and the outcries against psychopharmacology will grow ever louder.

Whether Holmes has a mental illness or not is irrelevant.  He was in crisis—probably for quite some time before last weekend—and that‘s what matters.  There was no one—and no way—to reach out to him and meet his needs in such a way to prevent this tragedy, and that, in my opinion, transcends whether he is “mentally ill” or not.

How can we fix this?  In his column in Monday’s New York Times, David Brooks almost provides a solution.  He writes, correctly, that prevention of such catastrophic events occurs through “relationships”—relatives or neighbors, for instance, who might recognize a change in someone’s behavior and encourage him to get help.  Admittedly, establishing a caring relationship with someone who suffers a history of trauma, grief over a recent loss, poor self-esteem, pathological narcissism, or acute psychosis may be difficult.  But relatives and neighbors are indeed often the first to notice questionable behavior and are well positioned to help those in need.  Perhaps in Holmes’ case, too, we’ll soon learn of some classmates or coworkers who felt something was amiss.

Brooks goes on to argue that it’s the responsibility of that neighbor or relative to “[get] that person treatment before the barbarism takes control.”  He doesn’t define what sort of “treatment” he has in mind.  But he does say that killers are “the product of psychological derangements, not sociological ones,” so the aggressive treatment options he endorses presumably include more aggressive psychological (or psychiatric) treatment.  But to expect a neighbor or relative to help an individual access treatment is precisely a sociological phenomenon.  It puts the onus on our culture at large to pay attention to how our neighbors think and act, and to offer a helping hand or a safe environment (or a locked psychiatric unit, if it has progressed that far) to those of us who think and behave differently or who are suffering a crisis.

That, unfortunately, is not what Brooks is arguing for.  (After all, the title of his essay is “More Treatment Programs.”)  If mass murderers suffer from psychological problems, which is what Brooks seems to believe, the solution “has to start with psychiatry.”  But this introduces the longstanding problem of defining that arbitrary border between “normal” and “abnormal”—a virtually impossible task.  And, of course, once we pathologize the “abnormal,” we’re then obligated to provide treatments (antipsychotic medication, involuntary hospitalization, assisted outpatient treatment, forced drugging) which, yes, might decrease the likelihood of further dangerousness, but which also compromise patients’ civil rights and do not always enable them to recover.

Brooks is right on one point.  Relationships are part of the answer.  Relationships can provide compassion and support in one’s most difficult times.  One take-home message from the Aurora tragedy should be that people like Holmes—regardless of whatever he is even “mentally ill” at all—need the security and comfort of safe, trustworthy individuals who are looking out for his (and society’s) best interests and who can intervene at a much earlier stage and in a much less aggressive way, perhaps even avoiding conventional psychiatric treatment altogether.

Getting to that point, unfortunately, requires a sea change in how we deal more compassionately with those in our society who are different from the rest of us—a change that our nation may be unwilling, or unable, to make.  If we fail to make it, we’ll be stuck with the never-ending debate over the validity of psychiatric diagnoses, the effectiveness of psychiatric drugs, the ethics of forced treatment, and the dilemma of defining when antisocial behavior becomes a “disease.”  In the meantime, troubled souls like James Holmes will continue to haunt us, left to their own devious plans until psychiatric treatment—or worse—is the only available option.

Turf Wars

July 6, 2012

The practice of medicine has changed enormously in just the last few years.  While the upcoming implementation of the Affordable Care Act promises even further—and more dramatic—change, one topic which has received little popular attention is the question of exactly who provides medical services.  Throughout medicine, physicians (i.e., those with MD or DO degrees) are being replaced by others, whenever possible, in an attempt to cut costs and improve access to care.

In psychiatry, non-physicians have long been a part of the treatment landscape.  Most commonly today, psychiatrists focus on “medication management” while psychologists, psychotherapists, and others perform “talk therapy.” But even the med management jobs—the traditional domain of psychiatrists, with their extensive medical training—are gradually being transferred to other so-called “midlevel” providers.

The term “midlevel” (not always a popular term, by the way) refers to someone whose training lies “mid-way” between that of a physician and another provider (like a nurse, psychologist, social worker, etc) but who is still licensed to diagnose and treat patients.  Midlevel providers usually work under the supervision (although often not direct) of a physician.  In psychiatry, there are a number of such midlevel professionals, with designations like PMHNP, PMHCNS, RNP, and APRN, who have become increasingly involved in “med management” roles.  This is partly because they tend to demand lower salaries and are reimbursed at a lower rate than medical professionals.  However, many physicians—and not just in psychiatry, by the way—have grown increasingly defensive (and, at times, downright angry, if some physician-only online communities are any indication) about this encroachment of “lesser-trained” practitioners onto their turf.

In my own experience, I’ve worked side-by-side with a few RNPs.  They performed their jobs quite competently.  However, their competence speaks less to the depth of their knowledge (which was impressive, incidentally) and more to the changing nature of psychiatry.  Indeed, psychiatry seems to have evolved to such a degree that the typical psychiatrist’s job—or “turf,” if you will—can be readily handled by someone with less (in some cases far less) training.  When you consider that most psychiatric visits comprise a quick interview and the prescription of a drug, it’s no surprise that someone with even just a rudimentary understanding of psychopharmacology and a friendly demeanor can do well 99% of the time.

This trend could spell (or hasten) the death of psychiatry.  More importantly, however, it could present an opportunity for psychiatry’s leaders to redefine and reinvigorate our field.

It’s easy to see how this trend could bring psychiatry to its knees.  Third-party payers obviously want to keep costs low, and with the passage of the ACA the role of the third-party payer—and “treatment guidelines” that can be followed more or less blindly—will be even stronger.  Patients, moreover, increasingly see psychiatry as a medication-oriented specialty, thanks to direct-to-consumer advertising and our medication-obsessed culture.  Taken together, this means that psychiatrists might be passed over in favor of cheaper workers whose main task will be to follow guidelines or protocols.  If so, most patients (unfortunately) wouldn’t even know the difference.

On the other hand, this trend could also present an opportunity for a revolution in psychiatry.  The predictions in the previous paragraph are based on two assumptions:  first, that psychiatric care requires medication, and second, that patients see the prescription of a drug as equivalent to a cure.  Psychiatry’s current leadership and the pharmaceutical industry have successfully convinced us that these statements are true.  But they need not be.  Instead, they merely represent one treatment paradigm—a paradigm that, for ever-increasing numbers of people, leaves much to be desired.

Preservation of psychiatry requires that psychiatrists find ways to differentiate themselves from midlevel providers in a meaningful fashion.  Psychiatrists frequently claim that they are already different from other mental health practitioners, because they have gone to medical school and, therefore, are “real doctors.”  But this is a specious (and arrogant) argument.  It doesn’t take a “real doctor” to do a psychiatric interview, to compare a patient’s complaints to what’s written in the DSM (or what’s in one’s own memory banks) and to prescribe medication according to a guideline or flowchart. Yet that’s what most psychiatric care is.  Sure, there are those cases in which successful treatment requires tapping the physician’s knowledge of pathophysiology, internal medicine, or even infectious disease, but these are rare—not to mention the fact that most treatment settings don’t even allow the psychiatrist to investigate these dimensions.

Thus, the sad reality is that today’s psychiatrists practice a type of medical “science” that others can grasp without four years of medical school and four years of psychiatric residency training.  So how, then, can psychiatrists provide something different—particularly when appointment lengths continue to dwindle and costs continue to rise?  To me, one answer is to revamp specialty training.  I received my training in two institutions with very different cultures and patient populations.  But both shared a common emphasis on teaching medication management.  Did I need four years to learn how to prescribe drugs?  No.  In reality, practical psychopharmacology can be learned in a one-year (maybe even six-month) course—not to mention the fact that the most valuable knowledge comes from years of experience, something that only real life (and not a training program) can provide.

Beyond psychopharmacology, psychiatry training programs need to beef up psychotherapy training, something that experts have encouraged for years.  But it goes further than that: psychiatry trainees need hands-on experience in the recovery model, community resources and their delivery, addictive illness and recovery concepts, behavioral therapies, case management, and, yes, how to truly integrate medical care into psychiatry.  Furthermore, it wouldn’t hurt to give psychiatrists lessons in communication and critical thinking skills, cognitive psychology principles, cultural sensitivity, economics, business management, alternative medicine (much of which is “alternative” only because the mainstream says so), and, my own pet peeve, greater exposure to the wide, natural variability among human beings in their intellectual, emotional, behavioral, perceptual, and physical characteristics and aptitudes—so we stop labeling everyone who walks in the door as “abnormal.”

One might argue, that sounds great but psychiatrists don’t get paid for those things.  True, we don’t.  At least not yet.  Nevertheless, a comprehensive approach to human wellness, taken by someone who has invested many years learning how to integrate these perspectives, is, in the long run, far more efficient than the current paradigm of discontinuous care, in which one person manages meds, another person provides therapy, another person serves as a case manager—roles which can change abruptly due to systemic constraints and turnover.

If we psychiatrists want to defend our “turf,” we can start by reclaiming some of the turf we’ve given away to others.  But more importantly, we must also identify new turf and make it our own—not to provide duplicate, wasteful care, but instead to create a new treatment paradigm in which the focus is on the patient and the context in which he or she presents, and treatment involves only what is necessary (and which is likely to work for that particular individual).  Only a professional with a well-rounded background can bring this paradigm to light, and psychiatrists—those who have invested the time, effort, expense, and hard work to devote their lives to the understanding and treatment of mental illness—are uniquely positioned to bring this perspective to the table and make it happen.

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