Risk of Violence
Managing Risk of Violence in Primary Care Practice
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Ironically, it has been exactly one year since I last wrote about a tragedy in our northern Virginia community, “Suicide Prevention in Primary Care Practice”.  Although this story is still unfolding under the lights of the national news media and Congressional investigation, flags are at half-staff this week because a dozen of our neighbors went to work at the Washington Navy Yard Monday morning and died there. Most of them, like 34-year-old Aaron Alexis, who shot all of them to death before being shot by police, were civilian employees and many were military veterans. Alexis had reportedly been seen twice within the past month at emergency departments of Veterans Administration hospitals in Providence, RI and Washington, DC for complaint of insomnia. He is reported to have answered “no” to questions screening for anxiety, depression, and danger to self or others. He was given a prescription for trazodone and a recommendation to follow up with a primary care provider.  As primary care providers, what are our obligations to protect patient privacy and public safety (including our own and the safety of our colleagues) when we discover a risk of violence and how do we handle the conflicting obligations?
If the individual accepts a recommendation for referral, there are crisis resources in nearly every community. An excellent resource is MentalHealth.gov which has a treatment locator resource based on zip code.  The website has resources for emergency referrals as well.  It is sponsored by the US Department of Health and Human Services and emphasizes publicly available facilities. If the individual has health insurance, contact the insurer to see if there are preferred providers. The Federal Mental Health Parity and Addictions Equity Act (MHPAEA) now requires coverage for “mental illness” if an individual is insured for medical illness; this coverage is expected to expand substantially under the Affordable Care Act beginning January 1, 2014. A resource on these upcoming changes is found at the Substance Abuse & Mental Health Services Administration (SAMHSA).  If the individual is not willing to accept a recommendation for referral and we believe their statements or behavior constitutes a risk to his or her own health or to the health of others, almost every state has a procedure for enforcing referral for mental health specialist evaluation and involuntary treatment if it is recommended by the specialists involved. These “involuntary commitment” procedures differ by jurisdiction.
Mentalillnesspolicy.org has compiled a table outlining the basic procedure for requiring outpatient and inpatient treatment in each state, but cautions the user to check with law enforcement in each local jurisdiction to determine the appropriate policy and procedure.  Law enforcement training on handling threats of violence by individuals with behavior disturbance is becoming more widespread. National Alliance on Mental Illness (NAMI) has been promoting the concept of crisis intervention team (CIT) training for the past quarter century.  CIT programs are local initiatives designed to improve the way law enforcement and the community respond to people experiencing mental health crises. They are built on strong partnerships between law enforcement, mental health provider agencies and individuals and families affected by mental illness.
Unless we notify law enforcement authorities, we may incur liability to warn anyone threatened by the individual. A legal case which was decided by the California Supreme Court in the 1970s involved a psychologist employed by the University of California Berkeley counseling a male graduate student who threatened to kill a female graduate student. The psychologist reported this threat to campus police who interviewed the male graduate student; the male student agreed to a restraining order. The male student refused further counseling and several months later killed the female student. The female student was never informed of the threat by either the university counseling service or the campus police and her parents successfully sued the State of California for failing to warn their daughter. This case has sparked much discussion and legislation across the nation on the handling of this fairly common circumstance of an individual whose communication or behavior suggests a significant risk of violence to either self or others which is revealed in a healthcare setting and is thus protected by the ethics of confidentiality and the laws of privacy. 
The US Department of Health and Human Services which administers the Health Information Portability and Accountability Act (HIPAA) has the following guidance: “The Privacy Rule is balanced to protect an individual’s privacy while allowing important law enforcement functions to continue.” The Rule permits covered entities to disclose protected health information (PHI) to law enforcement officials, without the individual’s written authorization, under specific circumstances summarized below. For a complete understanding of the conditions and requirements for these disclosures, please review the exact regulatory text at the citations provided. Disclosures for law enforcement purposes are permitted … “when consistent with applicable law and ethical standards to a law enforcement official reasonably able to prevent or lessen a serious and imminent threat to the health or safety of a person or the public (45 CFR 164.512(j)(1)(i)).”  I have added the bolding here to emphasize that, unless there is state or local law clearly permitting or requiring reporting, we are potentially at risk of violating HIPAA by disclosing risk of violence to self or others even to law enforcement agencies. 
State laws vary greatly as to the duty of healthcare providers to disclose risk of harm from violence. The National Council of State Legislatures has a very helpful online table of state regulations of the duty of “mental health professionals” to warn of potential violent behavior.  It is prudent to examine any existing legislation in your state to see how it applies to you and to make sure your practice is consistent with those requirements.
It is also important to include the management of violence in our office emergency preparedness plans. Robert Simon of Georgetown University School of Medicine has an excellent article on patient violence against health professionals that is available online at the Psychiatric Times website.  Jan Volavka of the NYU School of Medicine recently reviewed medical management of violent ideation in patients with schizophrenia and bipolar disorder. 
Charles Sneiderman MD PhD DABFP
Family Physician and Medical Director
Culmore Clinic, Falls Church, VA
Published on December 24, 2013
Charles Sneiderman, MD PhD, retired in 2010 after a 31-year career in medical informatics at the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health. His work included research and development in telemedicine, distance learning, and medical language and image processing. Since leaving federal service, he has developed a computerized clinical decision support system to assist primary healthcare practices in the recognition and management of post-traumatic stress syndromes with support from the NLM Disaster Information Management Research Center. Dr. Sneiderman received a B.S. with high honors from the University of Maryland in 1969, and M.D. and Ph.D. degrees from Duke University in 1975 and completed residency training in family medicine at the Medical University of South Carolina in 1979. He has authored numerous scientific reports, book chapters, and medical educational media. Dr. Sneiderman was a Clinical Assistant Professor of Family Practice at the Uniformed Services University of the Health Sciences and maintains certification by the American Board of Family Medicine. He has practiced family medicine part-time in the Washington, DC area since 1980. He has assisted wounded warriors with adaptive snowsports since 2005.
- Sneiderman C. Suicide Prevention in Primary Care Practice. Primary Issues. October 30, 2012. http://www.primaryissues.org/2012/10/suicide_prevention/
- Vogel S, Horwitz S, Fahrenthold DA. Navy Yard gunman Aaron Alexis told VA doctors he was not thinking of harming others. Washington Post. September 18, 2013. http://www.washingtonpost.com/politics/2013/09/18/aee01b22-20a6-11e3-b73c-aab60bf735d0_story.html
- MentalHealth.gov. http://www.mentalhealth.gov/
- MentalHealth.gov. Get immediate help. http://www.mentalhealth.gov/get-help/immediate-help/index.html
- Substance Abuse & Mental Health Services Administration. Health Reform: Mental Health Parity and Addiction Equity. http://beta.samhsa.gov/health-reform/parity
- Mental Illness Policy.org. State-by-State Standards for Involuntary Commitment (Assisted Treatment). http://mentalillnesspolicy.org/studies/state-standards-involuntary-treatment.html
- National Alliance on Mental Illness (NAMI). Crisis intervention teams (CIT). http://www.nami.org/template.cfm?section=CIT2
- Herbert PB, Young KA. Tarasoff at twenty-five. J Am Acad Psychiatry Law. 2002;30(2):275-281.
- U.S. Government Printing Office. Code of Federal Regulations. (45 CFR 164.512(j)(1)(i). http://www.gpo.gov/fdsys/browse/collectiontab.action
- USDHHS. Office of Civil Rights, Health Information Privacy. Frequently Asked Questions. When does the privacy rule allow covered entities to disclose protected health information to law enforcement officials? http://www.hhs.gov/ocr/privacy/hipaa/faq/disclosures_for_law_enforcement_purposes/505.html
- National Conference of State Legislatures. (NCSL). Mental health professionals’ duty to protect/warn. January 2013. http://www.ncsl.org/issues-research/health/mental-health-professionals-duty-to-warn.aspx
- Simon RI. Patient violence against health care professionals. Psychiatric Times. March 3, 2011. http://www.psychiatrictimes.com/schizophrenia/patient-violence-against-health-care-professionals
- Volavka J. Violence in schizophrenia and bipolar disorder. Psychiatr Danub. 2013 Mar;25(1):24-33.