Arizona rampage highlights barriers to intervention with volatile patients

During a routine day, physicians rarely are confronted with patients showing dangerous psychotic behavior. But precarious situations with volatile patients do happen.

Milton, Fla., family physician Dennis Mayeaux, MD, knows what it's like to face an unstable patient teetering on the edge of tragedy. "I've actually gone to a patient's home and taken the gun out of their hands."

In serious cases, he tries to persuade the patient to go a mental health facility as an inpatient. If the person refuses, he calls law enforcement. "The difficulty is always in ascertaining whether the [person] is a danger to himself or others. In a clinical setting, if someone has verbalized [irrational] thoughts, you fear they may carry out those thoughts."

Mental illness intervention has gained renewed attention since the Jan. 8 shooting in Tucson, Ariz., that left six people dead and more than a dozen seriously wounded, including Rep. Gabrielle Giffords (D, Ariz).

Former friends and teachers of alleged shooter Jared Lee Loughner, 22, say he showed bizarre and frightening behavior. The community college Loughner attended prohibited him from returning unless he underwent a mental evaluation and produced a doctor's note. He never returned.

Similar reports were made about Virginia Tech shooter Seung-Hui Cho, who killed 32 people in 2007 before taking his own life. Cho had been court-ordered into outpatient psychiatric care but refused to go.

Mental health experts say the cases highlight a lack of coordinated effort within the mental health system to intervene early. "The system is very reactive," said Michael Fitzpatrick, executive director of the National Alliance on Mental Illness. "The challenge is identifying someone at risk and getting them an evaluation."

For physicians, there is no definitive approach to handling mentally ill patients who could pose a threat, experts say. Intervention depends on the patient, the community and the resources available. However, legal and ethical guidelines can help doctors navigate the gray areas.

All states allow emergency commitment of a person who appears to have a mental illness and whose conduct reflects an immediate threat to himself or others, said attorney John Petrila, a professor of mental health law and policy at the University of South Florida. The difficulty is defining what behavior reaches the threshold of "threatening."

Looking for symptoms

Warning signs that might indicate potential violence include a patient acting withdrawn or aggressive or having inappropriate social interactions, said Frederic Bemak, a professor in the counseling and development program at George Mason University in Virginia.

But even with suspicious symptoms, legal obstacles often prevent intervention until it's too late. "It's very difficult for us to catch someone in advance," Bemak said. "And this was the No. 1 problem in Arizona. Unless someone does something [violent], it's very difficult to intervene."

When a patient is committed to a mental health facility or has medication prescribed, Petrila said help can stop there. Emergency detainment is from two to five days, depending on the state, after which a judge decides if longer commitment is necessary.

In many cases, unless longer detainment is paid for privately or the person was committed by a criminal court, the patient won't receive long-term inpatient care, Petrila said.

Responding to the Arizona shooting, American Psychiatric Assn. President Carol A. Bernstein, MD, and others said it's important to note that having a mental illness, in general, does not increase one's likelihood of committing violence against others. "The vast majority of individuals living with mental illness are not a threat to others," she said.

When there are concerns, alerting others can pose a dilemma.

Making such disclosures may have serious ramifications, especially if police are involved, said Howard Zonana, MD, a professor of psychiatry at Yale University School of Medicine in Connecticut and medical director of the American Academy of Psychiatry and the Law.

For instance, if a patient makes threats against an employer or a landlord, relating that information to authorities could get the patient fired or evicted, Dr. Zonana said. The patient-physician relationship also could be irrevocably damaged.

"How do you know if someone is turning violent?" Dr. Zonana asked. "It's not foolproof. There's no lie detector or blood test that is going to answer these questions."

Close relationships between primary care physicians and mental health professionals are key in discussing complex cases and gauging a patient's mental state, experts say. Most confidentiality statutes have exceptions that allow doctors to talk with colleagues about patients they are treating, Dr. Zonana said.

"It's good to have a close relationship to talk over these cases just as I would talk to a primary care physician about a patient who had pneumonia," he said.

The American Medical Association has ethical guidance on when it is appropriate for doctors to break patient confidentiality. It says, "When a patient threatens to inflict serious physical harm to another person or to him or herself and there is a reasonable probability that the patient may carry out the threat, the physician should take reasonable precautions for the protection of the intended victim, which may include notification of law enforcement authorities."

Trouble finding services

Finding mental health resources for patients is not easy, doctors say.

Tucson, Ariz., family physician Michael Hamant, MD, remembers a troubled patient he once treated who resisted medical care, refusing even routine scans and lab tests.

The 60-year-old man had severe personality disorders, was reclusive and showed signs of obsessive-compulsive disorder. Dr. Hamant eventually contacted a local agency that assists the elderly, and the agency sent someone to the man's home for an evaluation. Still, it took nine months and a court-appointed guardian before the patient received the mental health treatment he needed.

In a survey published in the May 2009 Health Affairs, of 6,600 physicians listed outpatient mental health services as the most difficult service to obtain for patients. Roadblocks included inadequate insurance coverage or a lack thereof, health plan barriers, and shortages of mental health professionals, the study said.

Study author Peter J. Cunningham, PhD, said not much has changed since the survey. Physician site visits done in 2010 found similar problems.

"The public system of mental health has been eroding for a long time," said Cunningham, a senior fellow at the Center for Studying Health System Change, a nonpartisan policy research group in Washington, D.C.

The Mental Health Parity and Addiction Equity Act of 2008 has helped somewhat, he said. The law requires that mental health coverage be equal with other medical benefits.

But Cunningham said shortages of psychiatrists and cuts in mental health services have widened the gap to access.

Dr. Hamant would like a mental health system in which doctors could better connect patients to resources and help prevent a volatile patient from doing harm. "It's very frustrating. The system is not designed to make those cases easy."