Assessment of Patient Nondisclosures to Clinicians of Experiencing Imminent Threats

Levy AG, Scherer AM, Zikmund-Fisher BJ, Larkin K, Barnes GD, Fagerlin A.
JAMA Netw Open. Published online August 14, 20192(8):e199277.
doi:10.1001/jamanetworkopen.2019.9277

Question 

How common is it for patients to withhold information from clinicians about imminent threats that they face (depression, suicidality, abuse, or sexual assault), and what are common reasons for nondisclosure?

Findings 

This survey study, incorporating 2 national, nonprobability, online surveys of a total of 4,510 US adults, found that at least one-quarter of participants who experienced each imminent threat reported withholding this information from their clinician. The most commonly endorsed reasons for nondisclosure included potential embarrassment, being judged, or difficult follow-up behavior.

Meaning

These findings suggest that concerns about potential negative repercussions may lead many patients who experience imminent threats to avoid disclosing this information to their clinician.

Conclusion

This study reveals an important concern about clinician-patient communication: if patients commonly withhold information from clinicians about significant threats that they face, then clinicians are unable to identify and attempt to mitigate these threats. Thus, these results highlight the continued need to develop effective interventions that improve the trust and communication between patients and their clinicians, particularly for sensitive, potentially life-threatening topics.

Risk Management Considerations When Treating Violent Patients

Kristen Lambert
Psychiatric News
Originally posted September 4, 2018

Here is an excerpt:

When a patient has a history of expressing homicidal ideation or has been violent previously, you should document, in every subsequent session, whether the patient admits or denies homicidal ideation. When the patient expresses homicidal ideation, document what he/she expressed and the steps you did or did not take in response and why. Should an incident occur, your documentation will play an important role in defending your actions.

Despite taking precautions, your patient may still commit a violent act. The following are some strategies that may minimize your risk.

• Conduct complete timely/thorough risk assessments.

• Document, including the reasons for taking and not taking certain actions.

• Understand your state’s law on duty to warn. Be aware of the language in the law on whether you have a mandatory, permissive, or no duty to warn/protect.

• Understand your state’s laws regarding civil commitment.

• Understand your state’s laws regarding disclosure of confidential information and when you can do so.

• Understand your state’s laws regarding discussing firearms ownership and/or possession with patients.

• If you have questions, consult an attorney or risk management professional.

The info is here.

How Should Physicians Make Decisions about Mandatory Reporting When a Patient Might Become Violent?

Amy Barnhorst, Garen Wintemute, and Marian Betz
AMA Journal of Ethics. January 2018, Volume 20, Number 1: 29-35.

Abstract

Mandatory reporting of persons believed to be at imminent risk for committing violence or attempting suicide can pose an ethical dilemma for physicians, who might find themselves struggling to balance various conflicting interests. Legal statutes dictate general scenarios that require mandatory reporting to supersede confidentiality requirements, but physicians must use clinical judgment to determine whether and when a particular case meets the requirement. In situations in which it is not clear whether reporting is legally required, the situation should be analyzed for its benefit to the patient and to public safety. Access to firearms can complicate these situations, as firearms are a well-established risk factor for violence and suicide yet also a sensitive topic about which physicians and patients might have strong personal beliefs.

The commentary is here.

Doing their duty: An empirical analysis of the unintended effect of Tarasoff

By Griffin Sims Edwards
Journal of Law and Economics, Vol. 57, 2014
Emory Law and Economics Research Paper No. 10-61

Abstract

The seminal ruling of Tarasoff v. Regents enacted a duty that required mental health providers to warn potential victims of any real threat to life made by a patient. Many have theorized that this required breach of confidentiality may have adverse effects on effective psychological treatment - but the question remains unanswered empirically. Due to the presence of duty to warn laws, patients might forego mental health treatment that leads them to violence. Using a fixed effects model and exploiting the variation in the timing and style of duty to warn laws across states, I find that mandatory duty to warn laws cause an increase in homicides of 5%. These results are robust to model specifications, falsification tests, and help to clarify the true effect of state duty to warn laws.

The entire article is here.

When Doctors ‘Google’ Their Patients

By Haider Javed Warraich
The New York Times - Well Blog
Originally published January 6, 2013

Here is an excerpt:

I am tempted to prescribe that physicians should never look online for information about their patients, though I think the practice will become only more common, given doctors’ — and all of our — growing dependence on technology. The more important question health care providers need to ask themselves is why we would like to.

To me, the only legitimate reason to search for a patient’s online footprint is if there is a safety issue. If, for example, a patient appears to be manic or psychotic, it might be useful to investigate whether certain claims the patient makes are true. Or, if a doctor suspects a pediatric patient is being abused, it might make sense to look for evidence online. Physicians have also investigated patients on the web if they were concerned about suicide risk, or needed to contact the family of an unresponsive patient.

The entire article is here.

Advocates Seek Mental Health Changes, Including Power to Detain

By BRANDI GRISSOM
The Texas Tribune/The New York Times
Published: February 23, 2013

Here are some excerpts:

Mr. Thomas, who confessed to the murders of his wife, their son and her daughter by another man, was convicted in 2005 and sentenced to death at age 21. While awaiting trial in 2004, he gouged out one of his eyes, and in 2008 on death row, he removed the other and ate it.

At least twice in the three weeks before the crime, Mr. Thomas had sought mental health treatment, babbling illogically and threatening to commit suicide. On two occasions, staff members at the medical facilities were so worried that his psychosis made him a threat to himself or others that they sought emergency detention warrants for him.

Despite talk of suicide and bizarre biblical delusions, he was not detained for treatment. Mr. Thomas later told the police that he was convinced that Ms. Boren was the wicked Jezebel from the Bible, that his own son was the Antichrist and that Leyha was involved in an evil conspiracy with them.

He was on a mission from God, he said, to free their hearts of demons.

Hospitals do not have legal authority to detain people who voluntarily enter their facilities in search of mental health care but then decide to leave. It is one of many holes in the state’s nearly 30-year-old mental health code that advocates, police officers and judges say lawmakers need to fix. In a report last year, Texas Appleseed, a nonprofit advocacy organization, called on lawmakers to replace the existing code with one that reflects contemporary mental health needs.

(cut)

Hospital officials say they face a Catch-22 under current law: if they detain a mentally ill person against his or her will, they face liability because they have no legal authority to do so. If they allow the person to leave and something tragic happens, they risk a lawsuit like the one the Boren family filed.

The entire story is here.

Clinical Psychologists’ Firearm Risk Management Perceptions and Practices

Andrea Traylor, James H. Price, Susan K. Telljohann, Keith King, and Amy Thompson

J Community Health. 2010 February; 35(1): 60–67.
Published online 2010 January 22.
doi:  10.1007/s10900-009-9200-6

Abstract

The purpose of this study was to investigate the current perceptions and practices of discussing firearm risk management with patients diagnosed with selected mental health problems. A three-wave survey was mailed to a national random sample of clinical psychologists and 339 responded (62%). The majority (78.5%) believed firearm safety issues were greater among those with mental health problems. However, the majority of clinical psychologists did not have a routine system for identifying patients with access to firearms (78.2%). Additionally, the majority (78.8%) reported they did not routinely chart or keep a record of whether patients owned or had access to firearms. About one-half (51.6%) of the clinical psychologists reported they would initiate firearm safety counseling if the patients were assessed as at risk for self-harm or harm to others. Almost half (46%) of clinical psychologists reported not receiving any information on firearm safety issues. Thus, the findings of this study suggest that a more formal role regarding anticipatory guidance on firearms is needed in the professional training of clinical psychologists.

The entire article is here.

Thanks to Dan Warner for this article.

Colo. man plotted to kill children, president

By 9News
Originally published November 14, 2012


9Wants to Know has learned a Colorado man is in federal custody after plotting to kill President Barack Obama and kill children on Halloween night in Westminster.

Sources tell 9Wants to Know Mitchell Kusick's plan involved stealing a family member's shotgun and using it to shoot children on Halloween and assassinate the president in Colorado.

Officials do not know when he wanted to kill the president.

The restraining order filed in Jefferson county court says Kusick "stole a shotgun from his aunt's house, hid the weapon, attempted to purchase ammunition for the gun" and then told his therapist about his plan.




The entire story is here.