To The Editor:

I’ve been following with considerable interest the discussion about enforcing/instituting laws forbidding gun sales to felons and “people with mental illness.” The former makes eminent sense, and is already covered by current laws. The latter, while it sounds logical and necessary, is a rats nest of problems.

Who defines mental illness, much less mental illness which may lead to homicide? Will it be legislators who, in my experience, have little understanding of what “mental illness” is? Will it be psychiatrists, who are becoming fewer and farther between? (Never mind that there are some psychiatrists out there who are abysmally poor at their work.) Will it be other, less-qualified mental health workers? Will it be the police?

Patients with severe psychiatric illness such as bipolar disorder or schizophrenia or addictive disorders may well be psychotic when they are untreated, either before diagnosis and the start of treatment or when they are noncompliant, refusing to continue taking medications. Suicidal ideation is often a part of this psychotic state; much less common in these patients is homicidal ideation.

Through my career, I’ve seen many people who have expressed suicidal and/or homicidal ideation, and I’ve had several who, despite everything I and their families could do, have committed suicide. I have never had a patient (except for a few with severe antisocial personality disorder — so-called “psychopaths”) who has acted on homicidal ideation, though some have certainly voiced it. A major part of determining suicidal or homicidal thoughts is establishing a trusting relationship between patient and doctor, and this takes time which, because of the many patients we need to see, isn’t always easy to find. But we must. Simply put, we need more good psychiatrists, other mental health workers, and places to treat severely ill patients.

Currently, there is a government regulation known as HIPAA which has to do with health insurance “portability,” following patients when they change jobs. For reasons I’ve never understood, part of this regulation specifies severe penalties for any medical information being released without a patient’s permission. How severe? If I release any information to anyone without a signed permission, I am subject to a $50,000 fine.

Now, think about it, say I’m seeing a patient to assess his suicidal/homicidal thinking. Currently, I do several things: establish a trusting relationship; try to get the family involved in helping me deal with the situation; and make strong recommendations to remove any weapons from the patient and the home. Patients are not always willing to have family members involved and, incredibly, even when they are, they may deny any danger that should be dealt with and ignore my recommendations.

As it stands now, what am I to do beyond the best I can in treating the patients who do come to see me? For everyone I see, there are probably 99 who haven’t presented for diagnosis and treatment. Do we need a federal law that mandates psychiatric evaluation for the entire population of the United States? That makes about as much sense as trying to ban all firearms in the country.

I am quite concerned that, in an effort to address the issue of “mental patients with guns,” some irresponsible and dangerous legislation may be passed on the state and/or federal level. This would almost certainly be some of that “feel-good” legislation we read about.

One thing that would be helpful is to provide adequate funding for psychiatric care, beginning — most importantly — with children and their families. Our country should be ashamed about how little psychiatric care is available to our population. Over the years, I’ve seen a gradual decline in available inpatient psychiatric facilities, public or private. One result of this is that jails and prisons are now the de facto places to put people with severe mental illness who have committed crimes. Not every problem can be solved by throwing money at it, but I wonder: How much better off would we all be if we had spent just a fraction of the trillions of dollars thrown away on two useless Middle Eastern wars on our own country, our own people?

One final thought, with tongue only partly in cheek: When the Second Amendment was written, the state-of-the-art gun was a muzzleloader, with which an experienced man could shoot twice in one minute. What would happen if, instead of passing a law banning all firearms, we strictly interpreted the Constitution and armed all of us with muzzleloaders in trade for the nightmarish weapons the Framers had no idea were to come? Think about it.