Do You Fill Out Firearm Forms?

[wolfvgang22]

I sometimes have patients who ask me to fill out forms indicating it is ok for them to possess or conceal carry a firearm in my state. Sometimes I get patients who are law enforcement officers ask me to fill out forms from their employer asking if my patient can carry a firearm and be relied upon to respond quickly and safely to dangerous high stress situations with that firearm. I forget the exact wording, but that's the gist of it. Unfortunately, I had one patient get suspended from her law enforcement job without pay by her employer because I wouldn't fill out such a form. Eventually she found a private therapist who happily did.

My personal policy is to refuse to fill out these forms for anyone, not because of any political stance regarding guns, and not because it takes time, but because I don't trust any patient to always do the right thing with a firearm, especially given that they have complex mental illness. I don't see many "worried well" patients that a primary care clinician would feel comfortable treating in my clinic. I tell patients it isn't personal, but I don't fill out such paperwork for anyone for medico-legal liability reasons.

I'm curious how other psychiatrists approach the issue. Am I being too rigid in my approach?

---

Members don't see this ad.

 

[675015]

Sometimes I get patients who are law enforcement officers ask me to fill out forms from their employer asking if my patient can carry a firearm and be relied upon to respond quickly and safely to dangerous high stress situations with that firearm. I forget the exact wording, but that's the gist of it.

Sounds like a fitness for duty eval, no? In which case it should be done by an independent evaluator and not the treating psychiatrist so you should be off the hook for those, I believe.

 

[wolfvgang22]

Sounds like a fitness for duty eval, no? In which case it should be done by an independent evaluator and not the treating psychiatrist so you should be off the hook for those, I believe.

Good point, I guess I just felt bad about my patient who had financial hardship.
What about state "conceal carry" paperwork?

 

[Bartelby]

I have never run across either scenario. What does the conceal carry paperwork ask you to sign off on?

 

[Candidate2017]

I sometimes have patients who ask me to fill out forms indicating it is ok for them to possess or conceal carry a firearm in my state. Sometimes I get patients who are law enforcement officers ask me to fill out forms from their employer asking if my patient can carry a firearm and be relied upon to respond quickly and safely to dangerous high stress situations with that firearm.

The police academy or city that trained these officers have no idea if they are properly trained or qualified to carry a gun or act as police officers? Nice. And they want you to rubber stamp them? Let me look into my crystal ball. Yeah, no.

Have you seen the multimillion dollr settlements with families of criminals legally or illegally shot by cops? Lawyers would love to add docs to the defendant list.

Guns are deadly weapons. What psychiatry magic mojo allows us to know what a cop or private gun owner will intentionally or accidentally do with their gun 1 day or 30 years from now and how they will behave?

I'll leave this here:

https://www.cnn.com/2018/06/03/us/dancing-fbi-agent-gun-discharge/index.html

 

[wolfvgang22]

I have never run across either scenario. What does the conceal carry paperwork ask you to sign off on?

I don't have one in front of me, but it basically asks if this person is mentally stable stable enough to conceal carry. I suspect it may be the result of the patient answering yes when asked on a state form if they have ever been diagnosed with a mental illness. I haven't dug into it too much because I've just been refusing to fill them out. Why would I enable the arming of a person with a mental illness? I feel like that would be stupid, but I was wondering if others see it differently.

 

[Armadillos]

I personally would never sign anything saying I think someone can carry a gun because I have exactly zero training in determining if it is safe for someone to carry a gun.

 

[hamstergang]

I had a grand rounds once from someone who has made his practice doing such evals. I'd leave it to him, not do it myself.

 

[cbrons]

Not sure that there’s any reason for “mental illness” itself to be contraindication to conceal carry; sure specific diagnoses/homicidal ideation but just broad-sweeping everyone with a mental illness into one suspect group is stupid. That being said, I think the idea of asking a physician of any kind to evaluate whether someone is mentally stable enough to carry a gun is absurd for multiple reasons, and wouldn’t fill these out myself.

 

[WisNeuro]

Well, as a country, we've decided to draw lines in certain places. In this instance we've decided that we'd like to leave this to the medicolegal arena. I'd refuse this and refer them to get an IME for this purpose. I wouldn't want the liability, even if it is small.

 

[Bartelby]

It seems like this determination comes down to risk assessment. If I were treating someone who seemed to be very low risk (a mild nonpsychotic mental disorder, no history of violence, stable, no substance abuse, etc.) I might be comfortable stating that there is no evident psychiatric contraindication to his having a concealed carry permit. If I felt at all on the fence, wanted more information, etc. then I would recommend they get an IME from someone who specializes in those assessments. The latter would probably be what I would do most of the time.

 

[FlowRate]

I don't have one in front of me, but it basically asks if this person is mentally stable stable enough to conceal carry. I suspect it may be the result of the patient answering yes when asked on a state form if they have ever been diagnosed with a mental illness. I haven't dug into it too much because I've just been refusing to fill them out. Why would I enable the arming of a person with a mental illness? I feel like that would be stupid, but I was wondering if others see it differently.

Not sure that there’s any reason for “mental illness” itself to be contraindication to conceal carry; sure specific diagnoses/homicidal ideation but just broad-sweeping everyone with a mental illness into one suspect group is stupid. That being said, I think the idea of asking a physician of any kind to evaluate whether someone is mentally stable enough to carry a gun is absurd for multiple reasons, and wouldn’t fill these out myself.

Exactly, making "mental illness," whatever that even means, a category that earns automatic loss of rights just worsens stigma and makes people less likely to seek care.

 

[nexus73]

From a purely pragmatic standpoint you have nothing at all to gain from filling out such a form.

 

[NickNaylor]

Hell no, I wouldn't want anything to do with that. And I live in a super gun-friendly state and am a gun owner myself. But there's way too much uncertainty there and too much potential risk to sign off on someone's capacity to safely use a firearm. There are plenty of people that are psychiatrically stable who cannot safely handle a firearm. They are inherently dangerous objects with potentially lethal consequences, intended or not. We have no ability to predict whether or not an individual can reliably use one.

 

[DD214_DOC]

I have had concealed carry permits in several states over the years, and none of the applications has ever asked about general mental health diagnoses that I recall. They all have asked about any history of involuntary hospitalizations and have also asked about a history of illicit substance use or any substance use issues, which are also asked when applying to purchase a firearm. Both completely rely on the, "honor system", by the way, as there isn't any actual database where this information is kept.

What state is this? I'm curious to look at the application myself.

Also, I would never fill one out for any patient. If accurate, this seems to be the state finding a way to absolve itself of liability.

 

[clausewitz2]

I have had concealed carry permits in several states over the years, and none of the applications has ever asked about general mental health diagnoses that I recall. They all have asked about any history of involuntary hospitalizations and have also asked about a history of illicit substance use or any substance use issues, which are also asked when applying to purchase a firearm. Both completely rely on the, "honor system", by the way, as there isn't any actual database where this information is kept.

Not quite true. There is a federal database that is supposed to track various conditions and events that make people ineligible to own firearms under federal law. A succinct summary here: NICS Indices Brochure

State reporting to the NICS is entirely voluntary, however, and so there are big gaps. My current state is fairly aggressive in reporting involuntary hospitalizations and definitely have had patients who had state troopers show up at their house to get their guns during/after their involuntary hospitalizations, but it remains an unreliable system.

 

[thoffen]

Pretty much what everyone else says. Unless the law would indemnify me for rendering such an opinion, there is no circumstance that I would fill it out. If I were indemnified, I'd still refuse on the basis of not being trained to render such an opinion. As far as I understand there is little evidence to independently connect mental illness with risk of gun violence except suicide. Different scenario obviously if someone is expressing specific HI or having violent fantasy or having hx of committing interpersonal violence.

Also surprised no one has mentioned suicide. We should at least be giving education on risks of firearm ownership and suicide completion.

 

[DD214_DOC]

Not quite true. There is a federal database that is supposed to track various conditions and events that make people ineligible to own firearms under federal law. A succinct summary here: NICS Indices Brochure

State reporting to the NICS is entirely voluntary, however, and so there are big gaps. My current state is fairly aggressive in reporting involuntary hospitalizations and definitely have had patients who had state troopers show up at their house to get their guns during/after their involuntary hospitalizations, but it remains an unreliable system.

Thanks for sharing. I was not aware of this.

 

[whopper]

The bottom line is our practice and the law doesn't have good and clear directives on what to do with people with guns and mental illness. The APA did make a statement years ago (and I don't feel like finding the source at the moment) that if one has a mental health problem but it's under control and treatment we shouldn't advocate for guns to be taken away, but that's pretty much it.

It's also clear that anyone with a mental health problem who is clearly dangerous shouldn't have a gun, but this leaves a HUGE AMOUNT OF AREA IN BETWEEN where no one is telling us what to do.

Take for example the alcohol-abusing patient with dozens of guns who relapses on the order of once every few months? Add to it that he never has yet misused them while drunk but while drunk has done some stupid things like punch a hole in the wall. Can you take his guns away? What can you do other than offer treatment and recommend he get rid of them since he doesn't have the problem under full control, but he refuses?

What about the guy who shows up in the ER every few weeks for some type of psychiatric decompensation and has a gun? Heck the guy even put it in his mouth on the last visit but was given his guns back a few days after discharge. When he shows up again, he's admitted, treated and now discharged can you take away his guns? No. But then what can you do other than give recommendations and document?

Someone tell me cause I don't know and I'm a forensic psychiatrist.

 

[whopper]

Exactly, making "mental illness," whatever that even means, a category that earns automatic loss of rights just worsens stigma an makes people less likely to seek care.

I've had several patients with mild issues come to my office think if I press a button something equivalent to a cage dropping on them and them being sent to an asylum for life will happen.

Psychiatry remains largely misunderstood. I also get patients think all psychiatrists still do the Chaise Lounge thing, some think they just walk in and demand a med and I'm supposed to give it....
My favorite are the ones that think that because I'm a psychiatrist I'm psychic. If that were the case, I tell them, I'd be a casino and not in this office.

Heck IMHO half the psychiatrists out there don't know what psychiatry is about either.

 

[WingedOx]

Heck IMHO half the psychiatrists out there don't know what psychiatry is about either.

Some threads this week have shown us that.

 

[WingedOx]

Well, as a country, we've decided to draw lines in certain places. In this instance we've decided that we'd like to leave this to the medicolegal arena. I'd refuse this and refer them to get an IME for this purpose. I wouldn't want the liability, even if it is small.

I run into VA patients wanting various forms filled out all the damn time. Do you have a go-to for referral for an IME?

 

[WisNeuro]

I run into VA patients wanting various forms filled out all the damn time. Do you have a go-to for referral for an IME?

Depends on what they need, specifically. For the firearm issue, I don't have anyone off the top of my head, but I haven't had in come up in my clinics.

Although, the VA is a different animal, that whole system is a clusterf*ck of clinical care intertwined with medicolegal issues.

 

[WingedOx]

So Illinois just changed up their laws regarding MH admissions at FOID cards. Supposedly all admissions are now mandated to be reported to the state's department of human services, where it was more or less discretionary before (?). My VA has been previously non-compliant with the old rule. Not sure what we're doing this time around, but I'm prepared to be really annoyed at the number of requests I'm about to get to write a letter stating the patient can have his guns back.

I've got one request I said no no in the last couple weeks where the kid, prior to me taking over his care, was hospitalized at another facility after (in his side of the story) he had an accidental "oops" while cleaning his gun and the girlfriend thought was a suicide attempt. His FOID is invalid until 2020 and wants me to write saying he can have his gun back. I told him that he's SOL for now, but even with a more established relationship (I've only seen him once), I doubt I'd be willing to put my name on paper for something like that. A letter like that is instant lawsuit bait if something were to ever happen. There's absolutely no benefit to me to do such a thing.

 

[WisNeuro]

So Illinois just changed up their laws regarding MH admissions at FOID cards. Supposedly all admissions are now mandated to be reported to the state's department of human services, where it was more or less discretionary before (?). My VA has been previously non-compliant with the old rule. Not sure what we're doing this time around, but I'm prepared to be really annoyed at the number of requests I'm about to get to write a letter stating the patient can have his guns back.

I've got one request I said no no in the last couple weeks where the kid, prior to me taking over his care, was hospitalized at another facility after (in his side of the story) he had an accidental "oops" while cleaning his gun and the girlfriend thought was a suicide attempt. His FOID is invalid until 2020 and wants me to write saying he can have his gun back. I told him that he's SOL for now, but even with a more established relationship (I've only seen him once), I doubt I'd be willing to put my name on paper for something like that. A letter like that is instant lawsuit bait if something were to ever happen. There's absolutely no benefit to me to do such a thing.

Exactly/ This is an all-risk, zero reward issue. I would just take a firm stance that this is a medico-legal issue and you do not do these. I'd ask around and see if anyone is doing IME type risk assessments in the community and if you find one, just refer them on over.

 

[WingedOx]

Exactly/ This is an all-risk, zero reward issue. I would just take a firm stance that this is a medico-legal issue and you do not do these. I'd ask around and see if anyone is doing IME type risk assessments in the community and if you find one, just refer them on over.

Like I said too... the law changed here within the last couple weeks, so it gives me some cover, but I'm honestly not sure about what exactly is going on with the law itself. The news media here didn't cover the story super well and I haven't heard anything from the higher ups about it (though in the short term it's a bigger issue for our inpatient staff).

 

[wolfvgang22]

Well, the VA is federal, not state. Generally federal law supersedes state law, especially on VA property. What I would do is consult with your department chief, who should refer the matter to the VA's legal counsel for recommendations on how to proceed. If outside the VA, I'd consult an attorney or your organizations legal counsel.

For me, unless they make it part of your contract or, at the VA part of your terms for employment, I wouldn't write any letters that anyone can have firearms, ever. If required to do them, I would quit and go into private practice or work somewhere else.

To me, this is just a way for government to lay the blame for shootings on every scale on mental health practitioners while avoiding doing anything substantial. Every time there is a shooting in the U.S. certain people proclaim "it's a mental health problem!". It's not. It's a cultural problem.

 

[WingedOx]

Well, the VA is federal, not state. Generally federal law supersedes state law, especially on VA property. What I would do is consult with your department chief, who should refer the matter to the VA's legal counsel for recommendations on how to proceed. If outside the VA, I'd consult an attorney or your organizations legal counsel.

For me, unless they make it part of your contract or, at the VA part of your terms for employment, I wouldn't write any letters that anyone can have firearms, ever. If required to do them, I would quit and go into private practice or work somewhere else.

To me, this is just a way for government to lay the blame for shootings on every scale on mental health practitioners while avoiding doing anything substantial. Every time there is a shooting in the U.S. certain people proclaim "it's a mental health problem!". It's not. It's a cultural problem.

To the bolded, our inpatient unit has chosen not to report admissions for a while because of this, and under the assumption that if word gets around that we're gun grabbers over here, that vets won't come for care... which is probably true.

Though as for the rest of it I'm pretty confident that my department would back me up on this. The patient may have gotten himself into a Kafka-esque situation, but he got into it himself. It's not my job to bail him out of it.

The big thing beyond a lawsuit would be having my name dragged across the media like the Psychiatrist who evaluated James Holmes. I already had one of my antisocial patients get into an armed standoff a couple years back and his public defender dropped a quote in the local paper that he was trying ever so hard to get care at the VA but the horrible VA just wasn't providing it to him. The guy never showed up to his appointments, and when he did come it was as an unannounced walk-in where he'd demand benzos to abuse.

 

[sunlioness]

I’m also in Illinois where your FOID card gets yanked for ANY psychiatric hospitalization for five years. So if you realize you’re in a bad spot, secure your firearms, and sign yourself in? Tough cookies. No guns for five years. This has presented a hardship to certain patients I’ve had who worked in law enforcement, the prisons, and one woman who hunted her own land to supplement a meager food budget. I’ll advocate with the state to help them get their cards back. All of these people were voluntary admits who demonstrated good sense around their weapons even while acutely ill and had no personal histories of violence.

One guy I refused though. He was an dingus with a history of physically abusing his female partners. Which if you read the data is the one thing consistently correlated with gun violence.

 

[whopper]

There's a science of predicting future violence. It's not anywhere close to 100% accurate. I've been trained in it. No where does it specifically state if a person should or shouldn't have a gun.

There's no definition that clearly states when gun ownership is involved we psychiatrists are supposed to delve into this matter. We do not get training in gun safety. Most of us aren't gun owners. The APA has come out no official stance on guns other than that if someone has/had mental illness and it's in remission they should get access to them if they chose to do so and that's something they don't usually talk about.

There have been landmark cases where psychiatrists (and psychologists) have stated to the court to not to have us as a profession answer the legal question. This is one of those situations.