Colorado Shooting-psychiatrist testifying

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http://www.cnn.com/2015/06/16/us/james-holmes-theater-shooting-fenton/index.html

The Colorado shooter's student health psychiatrist has been testifying. Having to figure out how to manage a patient like this (before he murdered people) independently is probably one of my worst nightmares.

Any thoughts both from a patient care standpoint as well as personal liability standpoint? We don't need to discuss any specific patient, just patients in general making these sorts of statements.

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From a treatment standpoint, getting to the root of what's driving the patients anger seems the most important. If the person is psychotic of course treating the psychosis is paramount.

From a liability standpoint, these always seem like difficult situations. It ultimately comes down to the duty to warn statute and the specific language used guiding when you may or must break confidentiality. I have a copy of my state's law on my computer for quick reference when this issue comes up.
 
From the narrative in the CNN report, it seems that the psychiatrist did a pretty good job of addressing the key treatment, ethical, and legal concerns of this difficult case. That is not usually what we tend to see in these cases, unfortunately. It does points to the fact that even when the patient is engaged in treatment, we can't prevent these types of violent acts.

I have worked with several patients similar to this although none who were as focused on murder, thankfully. They don't fit into diagnostic categories very well and appear very resistant to treatment, though. Odd thinking processes, maybe a few odd beliefs, lay people can usually identify them as "weird" or "something not quite right", but they don't really have schizophrenia and they also seem extremely angry although they tend to keep it tightly capped to the point where they are not even aware of it. It seems that schizotypal personality disorder would be the most appropriate dx, but that catches a lot of patients that are not like this at all such as the happy eccentrics or run of the mill neurotic relatives of schizophrenics that have a few of the oddities, as well. i have seen some research that shows antipsychotics to be helpful with schizotypal patients, but I seem to recall that it was for first-degree relatives of people with schizophrenia. In the past I have recommended long-term residential treatment for patients like this but not sure if there are really programs to help. Ultimately, I tend to feel more like I am in a risk management mode more than treatment mode with these types of patients so I make sure to cross the t's and dot the i's.
 
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I think Dr. Fenton did a pretty good job. Holmes was a patient who went out of his way to deceive two psychiatrists, and avoid therapeutic rapport per his journal. The only thought I had was that next time I see such a patient (which I have, minus the shooting part before), I will be very quick to hospitalize the patient involuntarily. The campus police asked Dr. Fenton if she wanted Holmes picked up and hospitalized after he threatened her, and she said no because Holmes played it off as not serious, from what I've read(the incident when he emailed her a Q, and told her it was him punching her in the eye). She probably should have said yes, pick him up! But this is all Monday morning quarterbacking. In her place I may have done the same. This young man worked hard to confuse and deceive his doctor.
 
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I think Dr. Fenton did a pretty good job. Holmes was a patient who went out of his way to deceive two psychiatrists, and avoid therapeutic rapport per his journal. The only thought I had was that next time I see such a patient (which I have, minus the shooting part before), I will be very quick to hospitalize the patient involuntarily. The campus police asked Dr. Fenton if she wanted Holmes picked up and hospitalized after he threatened her, and she said no because Holmes played it off as not serious, from what I've read(the incident when he emailed her a Q, and told her it was him punching her in the eye). She probably should have said yes, pick him up! But this is all Monday morning quarterbacking. In her place I may have done the same. This young man worked hard to confuse and deceive his doctor.

I'm not too keen on this because it reinforces to society that we fix problems we don't fix. We really need to get out of the homicidal ideation business. Unless someone's delusional or psychotic, the homicidal thoughts are not in our realm, yet we continue to use hospitalization as a mitigation factor for safety and out of fear, but then society assumes we're doing something for it so the next time someone shoots a place up society believes all they needed was some involuntary commitment.
 
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I agree. We shouldn't be in the business of protecting the public from outright criminals. But, who wants to get sued like Dr. Fenton is getting sued?
I don't envy her opportunity to set society straight on what psychiatrists do and don't do. She still has to face the civil suit from the victims families when this criminal case is over.
These things can drag on for years if not quickly settled and take a heavy financial and emotional and mental toll on a psychiatrist. Now Dr. Fenton will probably have to explain to the state medical board, in writing, that she has been sued and why she has been sued every time she tries to renew her license. Malpractice insurance will probably cost her more in the future, also. I'm sure the University of Colorado that employs her is less than thrilled with the situation. I hope they are standing by her. She's another victim of Holmes, in my opinion.
Thus, I'm likely to put anybody that says such multiple homicidal statements as Holmes made on a 72 hour hold, and let the judge make the call on whether the patient goes free or not after that. Does it help the patient? Maybe, maybe not. But it sure would put a damper on a potential civil suit.
 
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Fenton wasn't alone. She had another psychiatrist meet with him as well. She had a lot more support than us private practice docs do.
 
This poor psychiatrist. Fortunately it sounds like she did a good job documenting and formulating her thoughts, and hopefully the lawsuit against her will be dismissed for that reason. About having him hospitalized, I agree that it would have done nothing for his treatment and could potentially even exacerbate things, but yeah, maybe it's the right thing to do from a CYA perspective. Show that you did all you could and get a third party involved. Of course this is all second guessing after the fact.
 
I sympathize with her as I see others here do. We are limited with what we could do.

Please bear in mind that my comments are not based on a real and thorough knowledge of what she testified and the Holmes case. I am trying to speak in generalities.

Resnick in forensic conferences emphasizes that "a building crescendo of paranoia" in and of itself is grounds to have someone held in a psych facility for further evaluation and cites several cases where people were new in their first-break psychosis, had a building crescendo of paranoia, and the clinician discharged the patient only to have that patient kill someone within the next few days.

He used the teaching case of a man whose records he evaluated from Youngstown, Ohio who had no prior mental illness, apparently was in first-break, thought people were out to get him, showed enough sx of psychosis for a confident dx but the clinician discharged him because his wife vouched for his safety and the clinician prescribed Stellazine.

Within the next day, the couple made love, he woke up and now thought the wife was part of the conspiracy against him and he killed her. He also mentioned several other cases where a clear identifiable crescendo of paranoia had built up even with someone without a history of violence and they committed a severe act of violence while psychotic.

Based on what Resnick stated I have placed people in the hospital when detecting this building crescendo of paranoia and have often times quoted him in court when these cases graduated from the hold phase to the involuntary commitment phase.

Studies show that paranoia is a high predictor for future violence. A problem here is that even good, non-antisocial, people will attack others if they believe it is under certain conditions such as self-defense and in the case of paranoia the person believes they are being threatened by someone else.

But this said, forensic training is a very specialized segment within our field. I too have had cases where there were bad outcomes and like this doctor, could not predict the future. We discharge patients all the time that made a suicidal or homicidal comment that later don't commit a dangerous act.

IMHO suspected psychosis and homicidal thinking is enough for a hold and from there it should be considered. A building crescendo of paranoia too should be in and of itself grounds for at least a hold. The risk is hurting the therapeutic alliance.

One point I would've liked to ask her and Holmes was about the obsession with killing people that she thought was OCD. I only learned this after doing forensic fellowship. Some are in a school of thought that we should be very open and fluid with dx. This type of thinking in my mind was dispelled the more I learned about detecting malingering (I am not saying Holmes was malingering).

Here's what I mean. Signs and sx in real pathology only present within a limited range. For example people don't get diabetes as a child unless it's type 1 or the child has been excessively obese for at least a few years. Someone claiming to have schizophrenia while hearing hallucinations only in one ear, they are in Spanish (the patient is not Spanish-speaking) and sees visual hallucinations in black and white is likely malingering.

The point is that obsessions in OCD present in usually limited presentations, and not in an arena of being obsessed with killing people. Excessive washing of hands? Yes, fear of germs? Yes, feeling unbalanced so if someone touches one side they touch the other? Yes, but not killing people. Could that occur? Yes but it's not an expected sign or sx.

Now all of this said, am I attacking Fenton? No. 1-As mentioned I haven't read enough of this case for real and the media rarely gives balanced presentations. 2-In her defense, if she had another psychiatrist review the case she is at a level where she is above the standard of care, so in a malpractice sense, unless someone could point out an egregious error I doubt she committed that.

and 3-There is that risk of hurting the therapeutic alliance and I'm sure all of us (maybe not you first years) discharged people where you felt there was some risk though not significant.

In a case where I was stuck and didn't know what to do I would either have another doctor evaluate the patient for a second opinion and/or perform an HCR-20. The latter is a test for evaluating the risk of future violence and using it would put someone above the standard of care.
 
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I sympathize with her as I see others here do. We are limited with what we could do.

Please bear in mind that my comments are not based on a real and thorough knowledge of what she testified and the Holmes case. I am trying to speak in generalities.

Resnick in forensic conferences emphasizes that "a building crescendo of paranoia" in and of itself is grounds to have someone held in a psych facility for further evaluation and cites several cases where people were new in their first-break psychosis, had a building crescendo of paranoia, and the clinician discharged the patient only to have that patient kill someone within the next few days.

He used the teaching case of a man whose records he evaluated from Youngstown, Ohio who had no prior mental illness, apparently was in first-break, thought people were out to get him, showed enough sx of psychosis for a confident dx but the clinician discharged him because his wife vouched for his safety and the clinician prescribed Stellazine.

Within the next day, the couple made love, he woke up and now thought the wife was part of the conspiracy against him and he killed her. He also mentioned several other cases where a clear identifiable crescendo of paranoia had built up even with someone without a history of violence and they committed a severe act of violence while psychotic.

Based on what Resnick stated I have placed people in the hospital when detecting this building crescendo of paranoia and have often times quoted him in court when these cases graduated from the hold phase to the involuntary commitment phase.

Studies show that paranoia is a high predictor for future violence. A problem here is that even good, non-antisocial, people will attack others if they believe it is under certain conditions such as self-defense and in the case of paranoia the person believes they are being threatened by someone else.

But this said, forensic training is a very specialized segment within our field. I too have had cases where there were bad outcomes and like this doctor, could not predict the future. We discharge patients all the time that made a suicidal or homicidal comment that later don't commit a dangerous act.

IMHO suspected psychosis and homicidal thinking is enough for a hold and from there it should be considered. A building crescendo of paranoia too should be in and of itself grounds for at least a hold. The risk is hurting the therapeutic alliance.

Now all of this said, am I attacking Fenton? No. 1-As mentioned I haven't read enough of this case for real and the media rarely gives balanced presentations. 2-In her defense, if she had another psychiatrist review the case she is at a level where she is above the standard of care, so in a malpractice sense, unless someone could point out an egregious error I doubt she committed that.

and 3-There is that risk of hurting the therapeutic alliance and I'm sure all of us (maybe not you first years) discharged people where you felt there was some risk though not significant.

In a case where I was stuck and didn't know what to do I would either have another doctor evaluate the patient for a second opinion and/or perform an HCR-20. The latter is a test for evaluating the risk of future violence and using it would put someone above the standard of care.

Interesting. Any articles/links for this?

Also, just randomly curious -- what is the hold criteria/process like in your state? The state I live in really values individual rights (we're the west and all), so it's pretty hard to have a hold stick. As far as I know, though, there's no real harm in placing a hold that gets dropped aside from the inherent harm in placing holds (therapeutic alliance, etc.). The general standard here as I've seen applied by judges and court investigators is imminent risk of harm to yourself or someone else, and imminent is generally understood to be ~within 24 hours. I suspect in this case that one might place a hold that then gets dropped by a county investigator on the next business day.
 
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Thanks for the thoughts whopper, was really hoping you would post.

Any links to non-state specific articles you could share?
 
http://www.aapl.org/docs/newsletter/January 2013.pdf
Page 10.

Correction: he was prescribed Mellaril. Forgive me. When I posted what I did this was based on a memory about 4 years old. I only googled the article when asked above.

Also, just randomly curious -- what is the hold criteria/process like in your state?

This too is a very important question. Dr. Fenton might not have been able to hold Mr. Holmes based on the state's hold criteria. I can say this. In NJ, Ohio and Missouri he could have been held. I don't know Colorado's hold and commitment laws.

During forensic fellowship and as an attending in a forensic facility for a few years, I was on a committee that evaluated extremely dangerous cases and to see if they were fit for discharge. E.g. someone who cut someone else's head off while psychotic. The emphasis on fear and paranoia as a major red-flag sticks out while I read Holme's case.

During that time I thoroughly studied the science of predicting future violence. On top of that, the fellowship and the institution were very on top of this science and had good relations with cutting edge people in that area such as Doug Mossman (the program director) and Kevin Douglas (head author of the HCR-20).

The problem here is this level of training is not emphasized for most psychiatrists. Again, it is unfair to judge Mr. Holmes or Dr. Fenton based on media reports alone but I am seeing snippets of data that the science of predicting future violence show as potential red-flags.

Not a bad idea to have colleagues in various specialties as people you can call upon for second opinions.
 
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http://www.aapl.org/docs/newsletter/January 2013.pdf
Page 10.

Correction: he was prescribed Mellaril. Forgive me. When I posted what I did this was based on a memory about 4 years old. I only googled the article when asked above.

Interesting stuff. That does create a bit of a bind, though, in that alliance is crucial and involuntary holds are generally toxic to alliances. I'd be curious, too, about other things like bed availability and yeah, regional differences, in the people who responded to his survey. Of course standard of care is a regional standard as well.

Not to say we shouldn't be influenced by bed availability, but if there's no bed, and by keeping someone you're forcing people to be boarded in the ED for several days, that plays a role in your decision. I get that first break psychosis should ideally be treated in the hospital, but I'm not sure that's the norm in my community where again we have a libertarian bent with our commitment and involuntary hold laws and way too few beds.
 
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I'm in a western state that is pretty strict on holds also, but I've never been unable to place a hold on someone that I do believe is a danger to self or others. If the county wants to let the patient go the next day, and that patient kills somebody, then its on the county official, not me.
 
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I'm in a western state that is pretty strict on holds also, but I've never been unable to place a hold on someone that I do believe is a danger to self or others. If the county wants to let the patient go the next day, and that patient kills somebody, then its on the county official, not me.

True, and I've got to admit that I've placed holds that I've assumed would probably be dropped because it seemed like the clinically right thing to do. To date, I've never heard of anyone experiencing consequences for placing a hold that they felt was pretty weak, but I think it must impact our judgment in some ways in that we respond to the culture of where we are. In my part of the world, I think placing a hold on this guy would be a grey area. In retrospect, it seems like the right thing to do, but this is a horrible outcome that really, really unlikely to happen. Placing too many holds might be our clinical version of doing too many CTs.
 
I don't know the setting Dr. Fenton was in. Yes I know what the newspaper says but I don't know the nature and quality of the setting.

Here's what I mean. In a community mental health setting with a case worker I err on the side of safety more so than therapeutic alliance cause the case worker can intervene more, they could call the police and the patient usually has a more extensive history of violence or non-compliance.

In a private-practice-like (emphasis on like) setting I'd err on the side of therapeutic alliance more so vs what I would do in a community mental health setting. Reason being is I would most definitely not have a case worker. I only came to this opinion after doing both settings. There's a learning curve to each setting. What I mean by a PP-like setting could also include a university/college student health clinic.

I became more and more loathe to treat schizophrenics in private practice-like settings for this reason. The science shows non-compliance is through the roof in schizophrenia. Private practice is really ideally for people that aren't that bad but need some mental health help with a GAF of about 50+. Every schizophrenic I saw in private practice I told the patient to invite their family (so I could enlist them as defacto case-workers) and told them upfront if they were non-compliant I would terminate them and refer them to a community mental health agency.

Getting a patient in PP with a GAF of say 40 is very problematic because they are in that zone where they could turn dangerous but are difficult to consider for an involuntary hold. And like I said, in PP (or similar settings) your ability to monitor the patient is very limited. Such patients IMHO are better off with case managers or more intensive treatment vs standard office visits such as partial-hospitalization or day programs.

I've also noticed psychiatrists, if only doing one type of setting, get locked into the mind of that setting. E.g. I've seen outpatient doctors never dx someone as psychosis or dig to find some BS dx to keep the patient coming so they can bill. I've also seen inpatient psychiatrists dx a severe mental illness such as schizophrenia or bipolar disorder (edit-when they knew for a fact that it was really a more minor disorder such as a personality disorder).
 
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What are your thoughts on the treating psychiatrist testifying in court as a fact witness? I haven't read the specific testimony from Dr. Fenton, but apparently she testified along with the psychiatrist from whom she requested the second opinion, and they were getting into issues of professional opinion like diagnosis and risk assessment. It seems they should be considered experts. Interestingly, I read that the defense attorney actually objected that the "second opinion" psychiatrist was providing expert testimony without being qualified as an expert, and the judge overruled that objection.
 
I really can't imagine treating someone with schizophrenia in a private practice unless they're super stable. Very few people in private practice in my community would accept patients with schizophrenia, which can leave patients with private insurance in a bind as all our community MH programs are mainly geared to bill Medicaid. I honestly don't think I'd accept a patient with bipolar disorder either unless again they had years of stability. Psychiatrists can be choosers in the current market in my town.

She was treating him in a college mental health setting which in some ways bridges elements of community and private practice. You also have to deal with university policy and cultural issues. I did a rotation in a college MH clinic and someone else there described it to me as a bit like being at the VA, which actually was surprisingly true. Lots of dependence and institutional transference issues, and wow, a wide variety of patients in terms of functioning and stability. The clinics are geared for higher functioning people, though, so there aren't case workers and whatnot.
 
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I really can't imagine treating someone with schizophrenia in a private practice unless they're super stable. Very few people in private practice in my community would accept patients with schizophrenia, which can leave patients with private insurance in a bind as all our community MH programs are mainly geared to bill Medicaid. I honestly don't think I'd accept a patient with bipolar disorder either unless again they had years of stability. Psychiatrists can be choosers in the current market in my town.

I guess I had not really thought about this sort of issue in PP. I mean, here I am, starting 2nd year of residency, contemplating what I will do in 3 years - and thinking I want to do PP - but it never occurred to me that it would be crazy to deal with schizophrenia and bipolar patients...thanks for posting this, gives me something to think about, like what exactly is smart / appropriate in the PP setting.
 
I really can't imagine treating someone with schizophrenia in a private practice unless they're super stable. Very few people in private practice in my community would accept patients with schizophrenia, which can leave patients with private insurance in a bind as all our community MH programs are mainly geared to bill Medicaid. I honestly don't think I'd accept a patient with bipolar disorder either unless again they had years of stability. Psychiatrists can be choosers in the current market in my town.

She was treating him in a college mental health setting which in some ways bridges elements of community and private practice. You also have to deal with university policy and cultural issues. I did a rotation in a college MH clinic and someone else there described it to me as a bit like being at the VA, which actually was surprisingly true. Lots of dependence and institutional transference issues, and wow, a wide variety of patients in terms of functioning and stability. The clinics are geared for higher functioning people, though, so there aren't case workers and whatnot.

Insightful post.

Any other conditions come to mind that you wouldn't be comfortable treating in PP settings?
 
Insightful post.

Any other conditions come to mind that you wouldn't be comfortable treating in PP settings?
Eating disorders are pretty serious and lethal.
 
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Eating disorders are rare to the point where even experienced psychiatrists don't know how to deal with it. There are psychologists and psychiatrists that specialize in it. Leave it to them or start studying on how to treat these patients.

Schizophrenic patients can be treated in PP but they need to be very compliant patients that aren't that bad to begin with while on meds. Same with bipolar disordered patients.

A trap in PP is when you get a new patient you don't know what they have until you evaluate them. Then once you have you're locked into being their doctor. It is unethical to simply dismiss someone in need of treatment such as a schizophrenic and when I did PP I didn't just blow these patients off. I did make a sincere attempt but if they were non-compliant or caused problems a PP couldn't handle I referred them to community practice. If you do PP have a list of other providers handy and don't just dump a patient that will make you work for real off. Only do so if you're not equipped and the other place they are referred to is better for them.

Another piece of advice. Do not be so quick to take new patients that are immediately discharged from a psych unit unless you have a good relationship with that unit and trust them. Some psych units discharge right when the insurance or Medicare/Medicaid decide to stop paying even if the patient is still dangerous. If you accept the patient the unit can now claim they got after-care and you are now the last idiot holding the bag on a patient really too dangerous for your practice.

The above happened to me and I had an idiot running the office who kept taking patients in from a local hospital with an attending with a known local rep for being a quack despite me telling the officer manger to stop taking patients from that hospital.
 
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Jeez, it seems crazy to me even consider taking a patient who has recently been hospitalized into your private practice. The thing with a true solo private practice is that you've got no coverage but you -- can you handle someone who is likely to be in a crisis? Also, my understanding is that you really can dismiss patients if you feel you can't meet their needs, which really could be the case if they're pretty sick and you're a solo private practice person. This at least is what has been taught to me by supervisors who are in private practice. I would like more clarification around that issue, though.

This patient in the Colorado case sounds like someone who could truly screw you over in private practice. Graduate student seeking a referral for anxiety with an initial diagnosis of social anxiety. Sounds totally OK for private practice and then it turns into a huge mess.

Of course maybe goals for private practice depend on what you want out of it and what you can tolerate. I'm planning on starting a small private practice for some autonomy and to give me the chance to do some therapy which I like doing and no one else will pay me to do it. So yeah, no psychosis, recent hospitalizations, etc. And certainly no Medicaid or Medicare because you lose money with those patients anyway. If you want to have a high volume, super high income type of private practice doing medication management, maybe you'd have a bit more flexibility to accept sicker patients because you might have other additional support.

And yeah, for serious -- no eating disorders, at least not serious ones.

About figuring out what works and what doesn't work, I'm certainly not there and anticipate getting burned, but you do pick up red flags when you get your own outpatient clinic as a resident.
 
From what I'm reading I get the feeling what happened to Fenton was she was in a setting dealing with a patient out of her league. Again this is just speculation and it's not right to judge her, and when I say "out of her league" I don't mean that as a criticism. I mean maybe this patient was really being treated in the wrong setting, and she didn't have the tools such as a case manager to figure out what was really going on with him to treat him effectively.
 
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If you have a solo pp you need to be sure that you can meet the needs of the patient and refer appropriately. Not all outpatient settings provide the same level of care. If it's just you in closet sized office with your cell phone you cannot effectively treat a complex case of Schizophrenia. Always do what is best for the patient, even if it means turning down the referral and sending them elsewhere. Your safety and the safety of the patient takes priority.
 
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If you have a solo pp you need to be sure that you can meet the needs of the patient and refer appropriately. Not all outpatient settings provide the same level of care. If it's just you in closet sized office with your cell phone you cannot effectively treat a complex case of Schizophrenia. Always do what is best for the patient, even if it means turning down the referral and sending them elsewhere. Your safety and the safety of the patient takes priority.

So what is left to treat in a safety/liability conscious solo PP? Treating the worried well?

Remember, I am just finishing the intern year. I have only seen the worst cases so far, certainly no outpatient psych. Maybe I don't understand what is "out there" in terms of degrees of pathology, etc.

Does this explain why some of you have smaller, part time PPs, and also still have one foot in the suboxone clinic/community health/hospital settings? Is your PP only part time because you can't fill it, or is it because you want to stay in the game of treating the bonafide crazies, in settings with proper safeguards and support?
 
So what is left to treat in a safety/liability conscious solo PP? Treating the worried well?

Remember, I am just finishing the intern year. I have only seen the worst cases so far, certainly no outpatient psych. Maybe I don't understand what is "out there" in terms of degrees of pathology, etc.

Does this explain why some of you have smaller, part time PPs, and also still have one foot in the suboxone clinic/community health/hospital settings? Is your PP only part time because you can't fill it, or is it because you want to stay in the game of treating the bonafide crazies, in settings with proper safeguards and support?

You can still these patients in pp. I would recommend you have a secretary, a case manager, a nurse, and a back up MD. If you want to be all those staff members and more, you can... But you won't have time to treat as many people as you would like.
 
There are psychiatrists in forensic systems, state hospital settings, and acute public settings that feel like any patients without schizophrenia are wasting their time and don’t deserve to avail themselves of their efforts. Discussions like these earn the enmity towards private practice that these psychiatrist hold so dear. Just a reminder of the other end of the spectrum.
 
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Just to give you an idea the case managers at my CMHC are working 40 hours a week behind the scenes even when the patients don't come in. The ratio is one case manager for 30 patients and that is a full time job
 
There are psychiatrists in forensic systems, state hospital settings, and acute public settings that feel like any patients without schizophrenia are wasting their time and don’t deserve to avail themselves of their efforts. Discussions like these earn the enmity towards private practice that these psychiatrist hold so dear. Just a reminder of the other end of the spectrum.

The idea of a part time, small, one man band PP, and part time acute public setting appeals to me. I gather this is what Fonzie does?

I have 3 years to figure it out, I guess. I kind of enjoy the hardcore pathology cases, but I don't want to be full time inpatient.
 
Part of being a good psychiatrist is understanding how the entire spectrum works and doing your part in that spectrum. E.g., and I used to work ina forensic unit that would've been what the old-time asylums were back in the day.

This unit was supposed to get the worst of the worst. When they got better we graduated them to units where they required lesser maintenance. Eventually they hopefully could be discharged.

And likewise this also means that outpatient providers have to do their part to prevent someone with a personality disorder or minor Axis I disorder from going to the hospital.

If you ever work with me as a student or resident on both ends of the spectrum you see me usually trying to kick out most people from inpatient (e.g. remember my vegetarian diet thread?) but in outpatient really try to be more empathizing. Why? Cause homeless people wanting to go to the hospital for a respite do have crappy lives and need help but not help in the inpatient unit. Depending where you are, the circumstances of the right type of treatment changes.

In PP, you don't have to be limited to worried-wells. You will treat people with real bona-fide Axis I disorders, but these people need to have enough insight and cognition to make meetings, (including being able to drive or get a ride), pay for visits, and be able to self-monitor and report what is going on.

It's a fool's errand to always believe your patient especially in forensic psychiatry. You need patients that will be honest about their problems in outpatient without case management if the bad outcome could be very bad-this means schizophrenic patients. Someone not telling me the truth concerning a minor anxiety disorder? I'm not going to lose any sleep over it.

Here's a rough draft of what I mean in terms of GAF.

70+ Treatment should be focused on prevention of mental illness or augmentation of current status. E.g. Psychotherapy to get rid of long-time issues. Private Practice is suitable for this.
51+ Outpatient (without case management) suitable but the worse the GAF the better the PP services needed. More frequent visits, family on-board, etc.
31-50: Difficult zone where inpatient is too much but PP might not be enough. Consider day programs or partial hospitalization for patients with poor insight. If doing outpatient only consider getting family members on board, having 24-hour availability for an emergency, a case manager. A patient with a GAF of this level may only be suitable for outpatient without case management if they have extremely good insight and are reliable enough to contact emergency services if need be.
O-30: inpatient

Some of you might not want to limit yourself to PP only because of the limited spectrum you treat. I'm one of those types, and that's a reason why I'm in academia despite it making much less money. I like to see it across the whole spectrum and teach while being with the best of the best and learning from them.

(But yes I sometimes to kick myself for not making more money).
 
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There are psychiatrists in forensic systems, state hospital settings, and acute public settings that feel like any patients without schizophrenia are wasting their time and don’t deserve to avail themselves of their efforts. Discussions like these earn the enmity towards private practice that these psychiatrist hold so dear. Just a reminder of the other end of the spectrum.

Warning -- rant (in agreement with MDT)! Not treating the *gasp* "worried well." Just because you have a decent income or education level doesn't mean you don't suffer. It also doesn't mean your condition is necessarily easy to treat even if you don't have schizophrenia or bipolar disorder. Suicidality, homicidality and psychosis aren't the only examples of significant mental health consequences worth treating.

As for getting patients, supposedly that's not an issue in my community. Limiting your practice doesn't mean you won't fill all the same. People do multiple things for a lot of reasons.
 
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I have worked with several patients similar to this although none who were as focused on murder, thankfully. They don't fit into diagnostic categories very well and appear very resistant to treatment, though. Odd thinking processes, maybe a few odd beliefs, lay people can usually identify them as "weird" or "something not quite right", but they don't really have schizophrenia and they also seem extremely angry although they tend to keep it tightly capped to the point where they are not even aware of it.

God, you just described a kid I worked with who I closed about a year ago (whose mother tried to contact me about some vague letter she wanted me to write the day after I completed residency). To this day I have no idea WTF was going on with him. Started out as a SSRI+CBT referral for "anxiety" then just got weirder and weirder. Eventually changed insurances and had to find a new psychiatrist who immediately put him on abilify.
 
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No mention of the whether defendant met the statutory requirement of insanity from the defense expert. Maybe it just wasn't reported on but that's the most important thing. Not this nonsense about how "irrational" he was. From the articles I've read the defense seems to have found an expert to say how mentally ill Holmes was but makes no mention of whether he was legally insane.
 
So lets see the guy interviewed the defendant for "one hour," (not good considering the severity of the case), didn't return a phone call (usually when other docs call you it's important), and didn't talk to the defendant about the crime, something that is considered standard in an NGRI?

Not good at all. Ouch. I ought to keep my mouth shut unless I actually see the cross examination.
 
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It strikes me as almost purposely bad work in order to avoid addressing the statutory criteria of distinguishing right from wrong or being prevented from forming the culpable mental state . I suspect the available evidence clearly shows Holmes was legally sane and the defense is grasping at straws. If the overwhelming evidence indicates Holmes was legally sane, the defense's only option is to try and play up the severity of his mental illness and minimize any comment about whether the insanity defense criteria are actually met. Then they hope a jury of laypeople don't understand the insanity defense statute and find him NGRI because he was acting so "crazy" or "irrational."

I remember seeing hired gun defense expert reports in fellowship coming to opinions like "The patient's mental illness was certainly a significant factor in the instant offense and his mental state was unquestionably impaired." They wouldn't address the statute language/criteria at all, which I think was done purposefully because if they tried they wouldn't be able to logically claim the defendant was NGRI, so they play this BS game saying the defendant was really mentally ill at the time based on such and such symptoms and so he has to be NGRI because of that. I'd put $100 on Holmes being found guilty in this case based on the lack of focus on him knowing the wrongness of his actions which is the really the only thing at issue here.
 
Another thing could be that this guy did regular ho-hum (for him) interview that many docs do when they are paid by the state. It's kind of like a state-provided defense attorney. Many of them do bottom of the barrel work because they're overworked and underpaid.

(I had a few cases where I spent hours on the case, and talked to the state-provided attorney who literally didn't even known anything about the case except what time to show up, saw the client for the first time at the hearing, and expected me to report everything to him as if I was his stooge).

The psychiatrist on the prosecution side could've been paid big bucks (I don't know what he was paid or what the defense was paid), and sometimes in those cases, doctors really go out of the way, I'm talking very very very much so cause each hour could be over $500. In one case a colleague of mine was getting thousands an hour (and he got to keep none of it cause he is in a teaching institution and they pocketed ALL OF IT!) Could be that the prosecution psychiatrist knew this is perhaps the highest profile case of the year if not more and intentionally did the best over-the-top job despite what he was being paid.
 
Another thing could be that this guy did regular ho-hum (for him) interview that many docs do when they are paid by the state. It's kind of like a state-provided defense attorney. Many of them do bottom of the barrel work because they're overworked and underpaid.

(I had a few cases where I spent hours on the case, and talked to the state-provided attorney who literally didn't even known anything about the case except what time to show up, saw the client for the first time at the hearing, and expected me to report everything to him as if I was his stooge).

The psychiatrist on the prosecution side could've been paid big bucks (I don't know what he was paid or what the defense was paid), and sometimes in those cases, doctors really go out of the way, I'm talking very very very much so cause each hour could be over $500. In one case a colleague of mine was getting thousands an hour (and he got to keep none of it cause he is in a teaching institution and they pocketed ALL OF IT!) Could be that the prosecution psychiatrist knew this is perhaps the highest profile case of the year if not more and intentionally did the best over-the-top job despite what he was being paid.
Most likely, especially if he works at a state forensic evaluation center with several other doctors. His entire report was probably thoroughly reviewed by several knowledgeable people who are also regularly doing forensic work. If the public defenders did cheap out on their expert I wonder if that is grounds for legal malpractice, considering the severity of the charges and possible death penalty.
 
What states have forensic evaluation centers? For a pre-trial detainee? Enlighten me.

Generally, under the Colorado Governmental Immunity Act [CGIA] government is immune from liability for its own negligence. The public defenders appear to have sovereign immunity. See this Note from the Valparaiso Law Review: http://scholar.valpo.edu/cgi/viewcontent.cgi?article=1931&context=vulr
 
What states have forensic evaluation centers? For a pre-trial detainee? Enlighten me.

Generally, under the Colorado Governmental Immunity Act [CGIA] government is immune from liability for its own negligence. The public defenders appear to have sovereign immunity. See this Note from the Valparaiso Law Review: http://scholar.valpo.edu/cgi/viewcontent.cgi?article=1931&context=vulr

In states where I trained, the state psych hospitals served multiple roles including longer-term treatment/stabilization for the civilly committed, post-trial treatment/holding/risk assessment for insanity acquittees, and pre-trial forensic evaluation centers for both competency to stand trial and insanity defense evaluations. They were also where competency restoration was done.

The forensic evaluation services at these hospitals were made up of both psychologists and psychiatrists (state employees) regularly doing court ordered competency to stand trial and insanity defense evaluations. And they would often discuss difficult cases and edit each others reports on more difficult cases. On a case with this much media attention they would certainly be discussing the case with colleagues.
 
The state must provide a mental health professional to provide an evaluation should the defendant want an NGRI plea and cannot afford a doc to do one. That said, the court case that made this decision stated they are entitled for the state to provide only ONE competent evaluation. If the defendant didn't like the results of that evaluation-too bad.

I've done NGRI evaluations and I never just spent just one hour on one. Heck one of them was just for a simple misdemeanor and I spent a few hours on it, and I wasn't getting paid for that one.

In states where I trained, the state psych hospitals served multiple roles including longer-term treatment/stabilization for the civilly committed, post-trial treatment/holding/risk assessment for insanity acquittees, and pre-trial forensic evaluation centers for both competency to stand trial and insanity defense evaluations. They were also where competency restoration was done.

Same here, and with the state you're not guaranteed quality. I know several excellent doctors in the state system but there's also plenty of bad ones too that are not in danger of losing their jobs.
 
The defense's most recent psychiatric expert, Raquel Gur, is not board certified. Not that it necessarily matters for a clinical psychiatrist, but if you're going to testify in major cases being board certified seems like a good idea. Her voir dire is not going smoothly. It will be nice if her opinion on Holmes' insanity is well reasoned, as opposed to the prior defense witness who, from everything I read, did a horrible job addressing the actual language/requirements of the insanity statute.
 
Her voir dire is not going smoothly.

Voir dire is the questioning of prospective jurors by a judge and attorneys in court in order to empanel a jury. Remember the voir dire in Runaway Jury?

Do you mean direct or cross examination?

Has Dr. Resnick testified yet?
 
Voir dire is the questioning of prospective jurors by a judge and attorneys in court in order to empanel a jury. Remember the voir dire in Runaway Jury?

Do you mean direct or cross examination?

Has Dr. Resnick testified yet?
Voir dire is also the questioning of an expert witness to verify they are indeed an expert and acceptable as such by the court. Remember voir dire in My Cousin Vinny?
 
Resnick hasn't testified yet. I read he might and is retained by the prosecution.
 
Voir dire is also the questioning of an expert witness to verify they are indeed an expert and acceptable as such by the court. Remember voir dire in My Cousin Vinny?

You are correct. I had to get out my Black's. And then, to further muddy the lexicon, it's 3rd meaning is any hearing outside the presence of the jury held during trial.

ignorantia iuris nocet
 
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I'm surprised but also not surprised by the doctor testifying despite no board-certification. Surprise: because it's such a high-profile case over something very serious. Not surprised: the state system, like I said, is loaded with bad doctors that aren't very competitive or narcissistic (in a good way) when it comes to their credentials.
 
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