Thought Broadcast

Last Saturday’s tragic events in Tucson have called attention to the behavior of Jared Loughner, the perpetrator, as well as the political climate in which this horrific event occurred.  While it is likely too early to determine to what degree, if any, Loughner’s political views may have motivated this unspeakable act, information has come to light regarding his unusual behavior and unorthodox opinions, raising questions regarding his mental state.

Without direct observation of Loughner and his behavior, it would be risky to posit a diagnosis at this time.  Even though details are emerging, I do not yet know whether Loughner had been diagnosed with an illness, or whether he was taking medications.  But if it is determined by forensic experts that Loughner did indeed suffer from a psychiatric illness, one question that is certain to arise is:  Can a person with an illness that gives rise to unconventional views and a potential for violence be forcibly treated, so that events like this can be prevented?

[Before answering this question, two things should be emphasized:  First, mental illness very rarely causes violent behavior; and as a consequence, the function of psychiatric medication is not to prevent violence (indeed, see my earlier post).  Antipsychotic drugs can, however, minimize delusional and paranoid thoughts, and improve a person’s ability to negotiate the difference between reality and fantasy, and some mood stabilizers and antidepressants may lessen impulsivity and aggression, but we cannot assume that medications could have prevented Loughner’s act.]

Several landmark cases addressing this very issue have said no; patients retain the right to refuse treatment.  Patients can, however, be involuntarily committed to a hospital, but only when immediate intervention is required to prevent death or serious harm to themselves or to another person, or to prevent deterioration of the patient’s clinical state.  In California, the relevant section of the law is section 5150 of the Welfare and Institutions Code.  This allows a law enforcement officer or a clinician to involuntarily confine a person to treatment for a 72-hour period.  The criteria for a 5150 hold require the presence of “symptoms of a mental disorder” prior to the hold.  (Thus, self-injurious behavior as a result of alcohol intoxication does not qualify a person for a legal hold.)  All states provide some comparable form of brief involuntary commitment for those suspected of danger to self or others, or grave disability, as a result of a mental illness.

Even after hospital admission, though, patients have the right to refuse medications.  Medications can only be given involuntarily if a court determines, based on evidence presented by doctors, that a patient lacks the capacity to give informed consent (in California, this process is called a Riese hearing).

But what about cases that are less acute?  If Loughner’s behavior arose from a psychotic disorder such as paranoid schizophrenia (and his behavior does indeed have hallmarks of such a diagnosis) but not significant enough to require hospitalization, one might argue that adherence to an antipsychotic regimen may have prevented the extreme behavior we saw on Saturday.

He still could have refused.  A number of court decisions (discussed here) have established and affirmed this right.  Recent exceptions include Kendra’s Law in New York and Laura’s Law in California.  Kendra’s Law, enacted in 1999, allows courts to order seriously mentally ill individuals to accept treatment as a condition for living in the community.  It was originally designed to target those with a history of repeat hospitalizations that resulted from nonadherence to medications.  Patients can be ordered into assisted outpatient treatment if they are “unlikely to survive safely in the community without supervision” and have demonstrated either (a) acts of serious violent behavior toward self or others, or (b) at least two hospitalizations within the last 3 years, resulting from nonadherence to a treatment regimen.  Laura’s Law was signed into law in 2002 in California, although as of 2010 only two California counties have implemented it.  Studies reviewing the effects of these laws have found that patients in assisted outpatient treatment had fewer hospitalizations, fewer arrests and incarcerations, and had were less likely to be homeless or to abuse alcohol or drugs.

If Loughner had made threats of violence while engaged in treatment, another related decision, the Tarasoff duty, could have been invoked.  In the 1976 case of Tarasoff vs Regents of University of California (and a second ruling in 1982), it was determined that a physician or therapist who has reason to believe that a patient may injure or kill someone must warn the potential victim (the 1982 ruling broadened the decision to include the duty to protect, as well).  Thus, if a patient makes a threat against another person—and the clinician perceives it to be credible—he or she must warn the targeted individual, law enforcement, or take any other steps that are “reasonably necessary.”  

Clearly, there is a great deal of uncertainty and latitude in the above cases.  While the Tarasoff duty is clearly designed to prevent danger to others, it may potentially destroy the trust between doctor and patient and therefore hinder treatment; similarly, it is often difficult to determine whether a patient’s threats are credible.  In the case of a patient like Loughner, would antigovernment rhetoric prompt a warning?  What about threats to “politicians” in general?  The clinician’s responsibility is not always clear.

With regard to Kendra’s and Laura’s Laws, the meaning of “survival in the community” can be debated, and it is often arguable whether compliance with medications would prevent hospitalization.  Opponents argue that the best solution is more widespread (and more effective) voluntary outpatient treatment, rather than forced treatment.

As more information on this case comes to light, these issues are certain to be discussed and debated.  We must not rush to judgment, however, regarding motives and explanations for Loughner’s behavior and the
steps we could take (or could have taken) to prevent it.

Is marijuana really medicine?  I’m not arguing against the potential for marijuana to treat illness, nor do I mean to imply that marijuana is simply a recreational drug that has no place in medicine.  Instead, I simply wish to point out how the “medical” label, I feel, has been misused and co-opted in a way that reveals what “medicine” really is (and is not).

Let me state, for the record, that I have no position on medical marijuana.  I practice in California, a state in which it is legal to use marijuana for medicinal purposes.  Even though I do not prescribe it, I do not judge those who do, nor those who use it.  I agree that it can be helpful in a wide range of illnesses– sometimes even in the place of established medicines.  It is unfortunate that controlled studies on THC and other cannabinoid compounds– studies that could lead to new therapies– have not been performed.

Medical care usually follows a well-established outline: a patient with a complaint undergoes an examination by a provider; a diagnosis is determined; potential courses of treatment are evaluated; and the optimal treatment is prescribed.  Afterward, the patient follows up with the provider to determine the efficacy of treatment, any potential side effects, and interactions with other medications or therapies.  The frequency of follow-up is determined by the severity of the illness, and therapy is discontinued after it is no longer necessary, or becomes detrimental to the patient.

Unfortunately, none of this describes how medical marijuana is practiced.  Any patient can undergo an examination; the vast majority of such patients have already been using marijuana and explain that they find it helpful, and the provider issues a card stating that they “advise” the use of medical marijuana.  Not a prescription, but a card– which permits him or her to buy virtually any amount, of any type of cannabis desired.  Follow-up visits are typically yearly, not to evalaute response to treatment, but to issue a new card.

As a psychiatrist, I frequently see patients who tell me they have been prescribed marijuana for “anxiety” or “depression.”  Often, my evaluation confirms that they do indeed suffer from, say, a clinically relevant anxiety disorder or major depression.  However, when I know they are using another chemical to treat their symptoms (whether cannabis, alcohol, or a medication prescribed by another physician) it becomes my responsibility to determine whether it will interfere with treatment.  In most cases, it also makes sense to collaborate with the other provider to develop a treatment plan, much as a cardiologist might collaborate with a family physician to manage a patient’s coronary artery disease.  [Sometimes the treatment plan might be to continue marijuana because I believe psychiatric meds simply won’t have any effect.]

But efforts to communicate with marijuana prescribers often fail (and when I have been successful in communicating with such a prescriber, they’re usually surprised that I made the effort!).  Similarly, if I suggest to a patient that he or she consult with the marijuana prescriber to find a strain, or a delivery method, or a dosing interval, that would provide the best symptom relief, or the least interaction with conventional medications– they often react with shock.  “But I only see him once a year,” is the answer I receive.

Often I say to myself something like, “well, marijuana helps him, so I’ll let him continue using it; I’ll just ‘work around it’ unless it becomes a problem.”  The patient usually tells me that he wants to continue using marijuana “as needed,” but he also wishes to continue in treatment with me, taking the medications I prescribe and following through with any treatment I suggest.

It leads to an uncomfortable compartmentalization of care, in which I feel that I’m practicing “real” medicine, while simultaneously condoning his use of another substance, even though neither of us knows the true chemical content of this substance, doses might vary from day to day, and some might be shared with friends.  To top it all off, patients frequently report a greater response to marijuana than what I prescribe, and yet I ignore it?  This is not the way I was trained to practice medicine, and yet I do it almost every day.

The approval of “medical marijuana” has been, I believe, a successful campaign by proponents of marijuana legalization to take advantage of the fragmented and confused health care system to create a de facto social sanction of marijuana use, rather than (a) introducing it as a true “medicine” through the proper and accepted channels (clinical trials, FDA approval, etc) or (b) decriminalizing it into a legal drug, much like alcohol.  I can see the arguments in favor of either approach, but the “medical” label unfortunately undermines what we actually try to do in medicine.

On the other hand, if it works, maybe we ought to take a closer look at what we actually are trying to do in medicine.  If medicine worked all the time, there would be no need for medical marijuana, would there?

Are people with mental illness more violent or aggressive, or more likely to commit crimes than those without mental illness?  Two recent papers investigate different aspects of this question.

In the January 2011 issue of Psychiatric Services, Fisher and colleagues investigate data from the Massachusetts Department of Mental Health, and found that people who had been diagnosed with a “severe and persistent psychiatric disorder” were two-thirds more likely than the general population to be arrested within a one-year period.  Arrest rates were significantly higher for all crimes, but particularly high for assault and battery on a police officer, a felony (odds ratio 5.96, or about 6 times more likely), and “crimes against public decency” (odds ratio 4.72).  While the data only reflect arrests (and not convictions, which would be fewer, since some charges were undoubtedly dropped), and say nothing about whether a person was actively involved in treatment at the time of his or her arrest, it does portray the severely mentally ill as more likely to engage with the criminal justice system.

A separate study, published last month in PLOS One, examined reports of medication-related adverse events to the FDA.  The authors looked at 484 drugs and the rates with which they had been associated with “violence-related symptoms.”  All medications had some such symptoms reported, but certain classes of drugs were associated with more frequent violent events than would occur by chance alone.  In particular, varenicline (Chantix) was most frequently associated with reports of violence, with a PRR (proportional reporting ratio) of 18.0.  (This means that the proportion of violent events by patients on Chantix was 18 times greater than the proportion of violent events reported for all other drugs).  Other medications shown to be associated with violent behaivor included antidepressants (average PRR = 8.4) and psychostimulants (average PRR = 6.9).  

It should be pointed out that the authors of the PLOS study have served as expert witnesses in criminal cases involving psychiatric drugs, and work for the Institute for Safe Medication Practices, a nonprofit group dedicated to exposing medication risks.  Furthermore, the reports of adverse events to the FDA may suffer from “attribution error”: when an adverse event like a violent act occurs, we search for possible causes, and medications– particulalry psychiatric meds– are frequent culprits, when in fact there may be no causal relationship.  Nevertheless, the large numbers of events, and the relative consistency within drug classes, should give us reason for concern.

But even with these limitations, these studies unfortunately show that criminal activity may indeed be more common among the mentally ill, and we need to exercise caution when using medications when the risk of aggression is high, to avoid making matters worse.