birchswing

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If you hadn't heard, the former democratic gubernatorial candidate for Virginia, Creigh Deeds, was apparently attacked by his son with a knife, and his son apparently then committed suicide with a gun.

Some quotes from the Washington Post:

"The day before he apparently stabbed his father at the family’s home in rural Bath County, the son of Virginia state Sen. R. Creigh Deeds (D) underwent a psychiatric evaluation but was not admitted to a hospital, because no bed was available."

"In Virginia, mental-health authorities can hold people for four to six hours after a magistrate judge issues an emergency custody order. After that, a magistrate must issue a temporary detention order, or TDO, to allow an individual to be held for 48 to 72 hours for further evaluation and treatment. But the order cannot be issued without an available bed.

In 2012, the Virginia Office of the State Inspector General probed how often clinically necessary TDOs are not issued because no facility is available to accept the patient. Over a 90-day period, the office found that 72 people were turned away despite the fact that they met the criteria to be involuntarily held for treatment."

This seems inexcusable in a nation as wealthy as ours. Even if people don't care about healthcare and want to send someone home to die, they're sending home people who can potentially hurt others.

It doesn't seem like people who need other life saving treatment are turned away for non-mental-health issues. The community-based resources are a band-aid. I have some personal experience with the system in Virginia and know people who work at the community centers, and sometimes all they can do is take a client into the emergency room, and after they get a shot of Zyprexa they're turned away back to the community board or their family. It's very often families that are doing the major lifting in trying to take care of people with severe mental illness. And the waiting lists to get into long-term care facilities are years long. For lack of a better word, we need more "asylums."
 
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shan564

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Yeah, and with the state hospitals shutting down, our regular hospitals are starting to get more and more crowded with people with chronic disease that's resistant to treatment, so now they're essentially living in the hospital. Those patients aren't benefiting from our care - all we're doing is unnecessarily confining them to an environment that's designed for acute care and stabilization, and simultaneously making that bed unavailable to somebody who we might be able to help. And it's not even cost-effective - the patient who is stuck in the acute inpatient unit is probably costing the taxpayer way more money than it would cost to keep him/her in a place that's designed for longer-term care. So we're paying extra money to deliver inappropriate care while depriving others of appropriate care.
 
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birchswing

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Yeah. It's probably important to have a discussion on how well the community-based mental health resources are working in these types of cases. From what I've heard it's extremely difficult to get into any type of long-term care situation (meaning state hospitals). Even if you only care about the money side of it, as you said it's not cost-effective for people to stay long-term in regular hospitals nor is it more cost effective to keep people in prisons.
 

SuperSoccer19

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As someone who practiced in VA, its a crappy system...not to mention the times the Community Service Board would disagree with my recommendation for admission and then send the patient out. Thankfully these were the patients who usually couldn't decide if they were suicidal or homicidal in most cases and if they were a bounce back used low lethality means after discharge.
 

Shikima

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As someone who practiced in VA, its a crappy system...not to mention the times the Community Service Board would disagree with my recommendation for admission and then send the patient out. Thankfully these were the patients who usually couldn't decide if they were suicidal or homicidal in most cases and if they were a bounce back used low lethality means after discharge.
This.
 

vistaril

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The reality is that we spend a lot of money as a country(and at a state level) on mental health services. People in every area of public spending want more money from the state or feds. We need to look at ways to do more with less in the future, because I don't sense the money will ever be flowing like people here would like it to.

Another reality is that our version of how we wantpublic mh money spent(ie to usually benefit us in some way) doesn't always fit the way it should be spent for the most efficient/economical results.
 

digitlnoize

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Weird. Where'd all the posts go. We lost, like, 10 posts or so, I think. Oh well. :/
 
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Someone posted this:
"We do not have a shortage of private practice cash only docs. These are not in short supply, thanks."
Psychiatrists are in short supply throughout the country and are needed everywhere they are.
When a patient is discharged from a hospital, they come to a PP doc.
When I have a very ill patient in my PP, I send them to the hospital.
We all are needed and in short supply.
 
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And to address OP, have their been any updates in this case regarding if there were beds available? In which case, it may not be that Virginia has such a horrible mental health system. It may be that the resources available were not utilized appropriately or searched for thoroughly enough.
 

digitlnoize

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And to address OP, have their been any updates in this case regarding if there were beds available? In which case, it may not be that Virginia has such a horrible mental health system. It may be that the resources available were not utilized appropriately or searched for thoroughly enough.
From what little I've read, it seems that there were no beds anywhere close to them, but there may have been beds at the state hospital level a few hours away. I think what likely happened is that between police transport time and evaluation time, there was little time left for the bed search. The ECO likely expired before the full search could be completed. Usually state hospitals are not contacted for these admissions, as it's not really an appropriate use of resources. They are tertiary care centers for the sickest of the sick, and typically patients are only sent over to them after they've failed hospitalization at the normal facilities. State beds are fairly limited.

Anyways, the governor is looking at extending ECO time, which is a must, IMO. 4-6 hours is not enough given the transport times, eval times, and bed shortages involved. I also think we need to seriously look at the inability to transfer TDO's (48 hr hold) between facilities if needed. Also, If you look in the new JAMA, Virginia is one of the worst states for acceptance of in-state students in its med schools. We are shipping our wanna be docs of to other states whole sale. Virginia public schools take about 50% instate. Compare this to TX which keeps between 70-95% of their doctors. Residency is just as bad. Almost all of my co residents are from outside Va and have little interest in staying here. So of the 10 psychiatrists Virginia just helped pay to train are going to leave and go elsewhere. Partly because the pay is better, but largely because they're not natives and want to go home.

I beg any PD's reading this to seriously consider accepting reasonable candidates from your state who want to be back home and are committed to staying there to practice post residency before you start looking at stellar candidates from other states.
 
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Shikima

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Recently I read that California was paying medical school to those applicants who are from California and wish to remain in California once schooling is complete.
 
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CNN later learned that at least three Virginia hospitals had psychiatric beds available the day before the stabbing and suicide.

Officials at Western State, Rockingham Memorial and UVA Charlottesville hospitals said beds were available, but they had not been contacted by medical personnel who evaluated the younger Deeds.

The hospitals are within an hour or two from Bath County, where the incident occurred, but it was unclear whether those who had the initial contact with Gus Deeds reached out only to hospitals closer to Bath County.

http://www.cnn.com/2013/11/25/politics/creigh-deeds-attack/
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I do agree with digitnoize that time was a major factor as well. There is a tenuous balance between safety and then patient advocates and rights as well.
 

notdeadyet

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Someone posted this:
"We do not have a shortage of private practice cash only docs. These are not in short supply, thanks."
Psychiatrists are in short supply throughout the country and are needed everywhere they are.
When a patient is discharged from a hospital, they come to a PP doc.
Source? Maybe I'm just in a particularly saturated area, but I don't much from patients complaining about wait times for appointments when they're willing to pay cash out-of-pocket. The bigger shortage is for psychiatrists who treat the 99% of patients who can't afford it.

There is definitely a psychiatrist shortage, but the ones taking cash-only are not scratching that itch.
 
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I guess we do practice in different areas then. Do you think those patients don't need to be seen too? They don't benefit from psychiatric care? I have worked in many places and I think all these people were in need of psychiatric care. Pertaining to OP, do you think a dearth of psychiatrists inpatient caused any of the issues that resulted in the VA death?
 

notdeadyet

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Do you think those patients don't need to be seen too? They don't benefit from psychiatric care? I have worked in many places and I think all these people were in need of psychiatric care.
We're in agreement on the fact that the well-off are in need of psychiatric services and have the right to them.

My only point is that the shortage of psychiatric care available is much more prominent among those who can not afford $300/hour cash service than those that can. If you look at the estimated wait times for someone willing to pay cash and someone trying to pay Medicaid it's pretty illustrative and in no way comparable. The country needs more psychiatrists, but it would be an uphill battle arguing the country's needs for cash-only docs of any stripe are even a fraction of the need for those seeing the population-at-large.
Pertaining to OP, do you think a dearth of psychiatrists inpatient caused any of the issues that resulted in the VA death?
My take on the case in Virginia is that the community mental health situation is at crisis point. I'm not sure that an influx of cash-only docs would alleviate much of that problem.
 

notdeadyet

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I realize that this is a touchy subject because SDN has a fair number of cash-only private psychiatists. And there's nothing ethically wrong (in my book) with setting up a practice that way. I just can't imagine a good argument that 1,000 more practices like this will be more beneficial to the community at large than 1,000 more psychiatrists taking all comers.
 
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notdeadyet

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Fair enough. Then the government has to make it less onerous for a PP doc to be able to work with Medicare and Medicaid.
Amen to that. Between the amount of reimbursement and the hoops to jump through to get reimbursed, it's approaching nightmarish.
 

digitlnoize

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CNN later learned that at least three Virginia hospitals had psychiatric beds available the day before the stabbing and suicide.

Officials at Western State, Rockingham Memorial and UVA Charlottesville hospitals said beds were available, but they had not been contacted by medical personnel who evaluated the younger Deeds.

The hospitals are within an hour or two from Bath County, where the incident occurred, but it was unclear whether those who had the initial contact with Gus Deeds reached out only to hospitals closer to Bath County.

http://www.cnn.com/2013/11/25/politics/creigh-deeds-attack/
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I do agree with digitnoize that time was a major factor as well. There is a tenuous balance between safety and then patient advocates and rights as well.

Western State is considered off-limits for ER patients for the most part. State hospital beds are so protected that the hospitals have committees which have to meet bi-weekly to approve patients for admission. They are now working on changing this, but its' not really an appropriate use of resources to use state hospitals for relatively less severe patients.

Most likely, the ECO simply expired before they had a chance to call RMH and UVA. They were probably waiting to hear back from Carilion and/or Lynchburg (I would imagine these were their first tries) when it expired and he had to be released. They did contact Augusta medical center, which was full. My hunch is that the CSB has their "first tier" places and tried those first, and didn't make it to their backups before time ran out.

Again, this is all speculative, but between police transport time, ED wait time, CSB person drive time, and evaluation time, it is not uncommon for the ECO to expire before the bed search is complete. It's just that usually by that point the patients agree to stay even though they have the right to walk out. In this case, apparently, that wasn't good enough.

It could also be that they did contact those hospitals (RMH/UVA/Etc) at night and the patient was turned down for some reason (possibly for violence reasons?) and the night shift just didn't document it well. It is VERY common for hospitals in Va to refuse patients at night on even the most minor grounds (no CXR, no lab test X, too violent, not enough nurses on staff to do another 1:1 patient, etc). Perhaps he was refused and these places just weren't aware...wouldn't put it past them.

Regardless, the time frames are absurdly short given the vast distances patients are sometimes transported, and the time needed to do a proper psych eval and bed search. The good news is that politicians are now paying attention.
 

whopper

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In regards to severe violence and severe mental illness, as a society we've hit to extremely rare phenomenon intersecting.

It's rare for someone that is mentally ill to become violent though it does happen. It's also rare for gun-owners to use firearms illegally.

Two shifts have happened more and more in the last few decades. 1) More and more mentally ill have been shifted out into the community. 2) With guns becoming more efficient thanks to technology, their use and availability to be bought and used in a legal sense has been questioned. Thirdly, and I put this in a separate odd category: IMHO due to the end of the cold war (read up Stephen Jay Gould if you don't know what I'm talking about) the end of the geographic/national war mentality that ended with the cold war has taken away from us a shared enemy. When there's a lack of a shared enemy (such as the Nazis or Communists), people in a society see themselves less as team players and more as being out for themselves. IMHO this has increased violence against each other in society (Don't believe me? You need to study this phenomenon more. It's not taught in psychiatry. It is taught in psychology).

Add another layer of complexity: it's difficult to predict future violence, existing laws and standards only allow for holding someone against their will if the evidence reaches reasonable medical certainty and that the threat is within some immediate time frame such as the next few days or weeks at most.

Making a law against gun ownership would take guns out of the hands of vast majority that use them appropriately. In some cases, even putting those lawful gun owners in more danger because they may be possibly used for protection in an appropriate manner and would be unconstititional. Making a law to make it easier to hold the mentally ill against their will increases the risk of holding someone against their will in a manner that goes against the Constitution

And we, as psychiatrists, psychologists, lawmakers, what have you, don't have an easy equation to surgically strike the problem. Take away guns only away from the mentally ill? How the heck are you going to make a law out of that? What defines mental illness under such a law-because if you ask me everyone has some type of mental issue that could arguably be an illness whether it ranges from at least a few traits of a personality disorder to at least a case of adjustment disorder now and then.
 

whopper

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The Goldwater Rule in psychiatry (and although was set out by the APsychiatricA, should also be practiced by our colleagues in psychology) is a much needed one, and one readily and often violated by the likes of Drs. Drew and Phil. By the way, Dr. Phil lost his license to practice, but that didn't prevent him from becoming a TV celebrity. IMHO he's never been appropriately vetted to be in the position he's in. If the public knew his real history...but I digress.

A problem, however, with the Goldwater Rule is when incidents of violence and mental illness hit the headlines, people want answers, and it binds our hands. Based on the many recent occurrences of gun violence with mental illness, and a failure by our community to give the community answers that can at least give them some type of understanding, I sometimes think the Goldwater Rule needs to be fine-tuned. Maybe we should be talking about specific incidents on some level.

The state's attorney reports for the Newtown/Sandy Hook shooting only became available weeks ago. During the interim, no one could really explain why this happened. We still can't, but at least we can see the results of an exhaustive study.

http://www.scribd.com/doc/187053097/Sandy-Hook-State-s-Attorney-Report

Maybe at the least the profession should be making public statements on how the process works in investigating issues like this because when people are at least told that it can calm them down knowing something is being done. It seems it's the new normal for a bunch of people to get shot up for no good reason.
 
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digitlnoize

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A problem, however, with the Goldwater Rule is when incidents of violence and mental illness hit the headlines, people want answers, and it binds our hands. Based on the many recent occurrences of gun violence with mental illness, and a failure by our community to give the community answers that can at least give them some type of understanding, I sometimes think the Goldwater Rule needs to be fine-tuned. Maybe we should be talking about specific incidents on some level.
You can talk about general problems without violating Goldwater. For example, with everything I've brought up about Virginia, I've said that I "don't have knowledge of that specific case, but from what I've seen..." I think it's irresponsible of us to NOT point out problems in the system. We don't have to comment on whether Miley Cyrus is mentally ill in order to do that.
 

whopper

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True. I question though is there at least some level where we can discuss the case that comes into question when it hits the news on at least some level that could at least give the public some type of understanding more so than the current standards suggest. I don't have an answer to that.