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Mental Illness, Patient Confidentiality and Gun Control

The requirement to discretely disclose individuals who are mentally ill and potentially violent could reduce stigma by helping to lower violence rates.
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The New York Times and Wall Street Journal reported psychiatrists and psychologists are opposing a requirement inserted in New York State gun control legislation that requires them to tell county mental health directors when a mentally ill patient is likely to become dangerous. They fear this infringes on patient confidentiality and might dissuade someone with mental illness from coming in or telling the truth, for fear it could result in them losing the ability to own a firearm.

The reporting requirement is exceedingly important in a way that the mental health industry is avoiding mentioning: By providing directors of county mental services with the names of people with serious mental illness who may become dangerous, it allows the mental health directors to prioritize their resources. They can ensure these most seriously ill and potentially dangerous individuals -- a very small group -- go to the front of the line for services, rather than the jails, prisons, shelters, and morgues where they have been historically sent. The new reporting provisions will make it harder for county mental health program directors to look the other way and pretend they did not know of the existence of these individuals. It could help involuntarily commit the mental health system to do what it fails to do voluntarily: prioritize services for the most seriously mentally ill.

While there is a theoretical risk that disclosing mentally ill individuals who are likely to be dangerous to self or others may cause someone sometime in the future to avoid treatment for fear of having their gun taken away, the risk of not reporting someone who is mentally ill and dangerous could pose an immediate threat. The failure to report these individuals is what may have led psychiatrists to identify Jared Loughner, James Holmes, and John Hinckley as mentally ill and potentially dangerous, and then do nothing to prevent them from shooting Gabrielle Giffords, moviegoers in Aurora, Colo., and Ronald Reagan respectively. Many more cases don't make headlines, either because the person with mental illness was caught or because the victim was "only" a family member.

The psychiatrists' arguments are unfounded. The real reason people with serious mental illness do not receive proper treatment is not because they fear they will lose access to guns, it is because of (a) economics, (b) anosognosia and (c) being rejected by the mental health system. Economics prevents many from affording treatment. Anosognosia -- the inability to even recognize you are ill -- causes these individuals to reject voluntary treatment. The mental health system rejects the others until after they become danger to self or others. Even if one believed "stigma" prevents people from seeking services, the main cause of that is violence by the minority, which tars the non-violent majority. The requirement to discretely disclose individuals who are mentally ill and potentially violent could reduce stigma by helping to lower violence rates.

Presumably the same psychiatrists who object to informing authorities about mentally ill individuals who promised to kill someone else would immediately report these individuals if they themselves were the intended target. Their proposed solution: Tell the intended victim, most likely a family member, who does nothing. The family has no authority to ensure the person gets treatment. If they call the police and tell them, "my son told the psychiatrist he is going to kill himself," the police can do nothing until after the violence occurs, especially if the psychiatrist insists on hiding behind confidentiality.

We proposed that county mental health directors be required to accept reports of individuals with serious mental illness who are becoming danger to self or others, directly from family members. This would generate higher-quality reports than those that come from psychiatrists, many of whom still argue persons with mental illness are no more violent than others, and are therefore not likely to report many who are. Mental health directors could triage these calls from families and investigate ones that warrant it. But the mental health industry and mental health directors also opposed letting families report their loved ones need help.

Legislators were right to give mental health workers the responsibility to inform county mental health directors about the most seriously ill who are likely to become dangerous. They were wrong to allow directors to reject the same reports merely because they come from family members.

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