There is no will on the part of the politicians or public health officials to provide them appropriate care. The wish is for "out-of-sight, out-of-mind." Cut services enough and maybe they'll leave town. These people don't vote. They don't donate to political campaigns. They don't show up at meetings of the San Francisco Health Commission. They don't live in Pacific Heights or Noe Valley.

These patients are people. Each one of them is someone's son or sister or father or daughter or brother or mother. Nearly all have been lost to their loved ones and find themselves abandoned--swirling around the streets and the jail cells and the emergency rooms of the city, not taking their psych meds because they don't believe they are sick and smoking marijuana and crack cocaine or drinking alcohol to deal with their psychiatric symptoms and emotional pain. Their staunchest advocates are family members who've lost loved ones to suicide, homicide, accidental death, victimization, homelessness, or incarceration.

The number of acute care psychiatric beds are being rapidly downsized in both the public and private sector. Lengths of stay in the acute care psychiatric units are dropping.

The word has long been out in the circles of health care economics: inpatient psychiatry is a money loser. And it's not as if we're talking about taking care of babies or young mothers or old folks. We're talking about "crazy" people here. Not a warm and fuzzy bunch. Who is going to advocate for these people, who are disenfranchised, disempowered, and forgotten.

So when the public health leaders of San Francisco have an opportunity to address this imbalance by supporting the implementation of a tangible assisted outpatient treatment program for psychiatry's "sickest of the sick," what do they do? They stall, they obfuscate, they run away.

Laura's Law is California's version of assisted outpatient treatment. Passed in 2001, in the wake of the murder of Laura Wilcox by a severely psychiatrically ill person in Nevada County, it was designed to provide an administrative structure and guidelines for getting the sickest of the sick into outpatient treatment and making them, yes making them, go to their appointments, and very strongly encouraging them to take their psychiatric medications.

On the agenda for the San Francisco Board of Supervisors twice this summer, the vote has been sent back to committee, the matter stalled.

The success of a similar law in New York called "Kendra's Law" in improving the physical and mental health of the "sickest of the sick" in that state has been very well-documented.

Dr. Mitch Katz, chief of San Francisco's Department of Public Health (DPH), is an HIV specialist. He knows little about psychiatry and sadly does not get advice from any clinically based psychiatrist or other mental health professional engaged on the front lines of treating psychiatry's sickest of the sick. His mental health advisors tend to be career bureaucrats.

He treats the subject from a theoretical and overly medicalized perspective. He ignores reams of research showing that mental health case management and outpatient substance and mental health treatment is effective in managing chronic mental illness. He doesn't understand that many of these patients will begin to accept treatment voluntarily after just a few days back on psychiatric medications as long as they are supported by a functional and pragmatic system of care.

His stance is akin to having me as a psychiatrist (or a radiologist or a pathologist, for that matter) dictate HIV care without consulting an HIV specialist. It is, of course, an absurd way to generate public mental health policy.

San Francisco used to be the city that "knew how" and took bold, innovative steps to address civic problems.

But if San Francisco's politicians and public health leaders are not willing to support Laura's Law, then chances are the city's downtown and tourist areas will continue to look like open-air asylums.

Which aspects of DSM-5 are most problematic for clinicians? In my opinion, diagnostic bracket creep and dimensionality top the list.

Will the "field tests" solve these problems before DSM-5 is published (we think) in 2013? In a word -- unlikely.

Three disclaimers here:

First, I might be a direct descendant of Emil Kraepelin. My mother's people escaped forced conscription under Otto von Bismarck in 19th Century Germany to become Minnesota sodbusters so there's a chance that Kraepelin may have been my third cousin, once-removed.
Second, I am a DSM-III guy all the way, having graduated from medical school and started a psychiatric residency in the 1980s. To me, Robert Spitzer and DSM-III rule, channeling Kraepelin, and it's hard to say whether much additional progress has been made from a clinician's perspective with the publication of DSM-III-R, DSM-IV, and DSM-IV-TR.
Third, I do not belong to the APA. I stopped paying dues about the year 2000 mostly because I was a tightwad. But, furthermore, I felt that the APA did not represent me well as a salaried public sector psychiatrist. It seems to be tailor-made for private outpatient psychiatrists and academic power players, but not so much for the rest of us.

My main complaint with DSM-5 is the problem of diagnostic bracket creep -- that is making patients of people who until the publication of DSM-5 would have been considered normal. A prime example of this is the "Psychosis Risk Syndrome."

The researchers involved are not bad people, but they can certainly be found guilty of having good intentions -- and you know where those lead. They would like to identify adolescents and young adults at risk of developing schizophrenia and to intervene early. This sounds like a reasonable idea and one quite worthy of ongoing research.

The problem is that such an exploration belongs in the DSM's appendix, an area created by prior authors of DSM-III, represented by Dr. Robert Spitzer, and DSM-IV, headed by Dr. Allen Frances, to identify diagnostic areas in further need of research. It would be premature to place this category in the official taxonomy.

Among other things, dimensionality is operationalizing things that ought to be in the purview and education of clinical psychiatrists -- and that is constructing a thorough history of present illness and review of symptoms during the clinical interview and write-up. I'm an old-fashioned narrative kind of guy and I feel as if things like anxiety, sleep patterns, energy, appetite, presence or absence of psychotic symptoms, presence or absence of substance use, and current psychosocial stressors should be routinely found in a "write-up." A comprehensive story needs to be told and these variables need to be covered.

For example, take the group headed by Professor Jan Fawcett in assessing suicide risk. This group has performed a very important public service by poring over studies to identify the most important risk factors of suicide. As an ER psychiatrist, I can tell you that suicide risk assessment is one of the most important parameters of a clinical evaluation.

But I'm here to tell you -- this information does not belong in a "diagnostic" manual. Suicidal ideation or suicide plans or intention or a suicide attempt are NOT diagnoses. Suicide risk runs through disorders of mood, thought, substance, personality, anxiety, etc.

Suicide risk IS an important clinical phenomenon and it needs to be covered thoroughly in things like textbooks and clinical practice guidelines. A suicide risk factor scale belongs in the appendix of a DSM, but not in the body of the DSM itself.

And this brings us to another criticism of the DSM, which I think has some merit. It's NOT supposed to be a textbook even though it often reads like one (and this does go all the way back to the 1980 publication of DSM-III.)

So, save the appendix! But continue to keep it separate from the diagnostic categories.

Okay, maybe I'm just being a curmudgeon. But I think DSM-5 should be user-friendly to front-line clinicians, whether or not we choose to belong to the APA. I find DSM-III et al to be reasonably user-friendly and frankly not too bad of a textbook on psychiatric taxonomy (but not so much on performing a psychiatric evaluation or guiding psychiatric treatment.)

While many observers have accused the APA (American Psychiatric Association) as being motivated by greed in its crafting of a new DSM, I prefer to look to another one of the Seven Deadly Sins, hubris, as the prime motivation for many of its architects.

And the transportation of choice for the prideful jockey?

The hobby horse, of course.

copyright Paul R. Linde, M.D.

"Is she demanding to leave?"

"Not yet."

"How agitated is she?" I ask.

"Not very," says Dr. Jones. "It's a tough case as it isn't clear she's out-and-out paranoid or delirious or demented. She's just a bit crotchety, hard to talk sense to."

"I take it the loss of her life or her leg is not imminent?"

"No, not yet, at least, but it's hard to say how things will play out over the next 24 to 48 hours."

"Okay, I'll be over in five to ten." (Minutes, that is.)

Dr. Jones is an experienced and savvy attending physician in the ED. If she'd been inexperienced, she might have asked, "Can you come over here and put this lady on a hold so we can draw her blood and start IV antibiotics?"

"Not so fast," I'd have to answer.

ER psychiatrists do assess whether patients meet involuntary hold criteria on psychiatric grounds, which in most jurisdictions include suicide risk, violence risk, and inability to care for self due to psychiatric symptoms, and they can detain patients against their will (for up to 72 hours in California). But the placing of a psychiatric hold can only physically keep a patient in the hospital. It does not have any bearing on whether a patient is competent to make decisions about his or her medical treatment.

In the worlds of emergency and consultation-liaison psychiatry, a medical physician's request for a psychiatrist to assess a patient's decision-making capacity is relatively common.

What would a reasonable person decide? That is the essence of both ethical and legal issues. Competency to make decisions regarding medical treatment in non-emergent situations is determined by a judge or hearing officer in a court of law. The psychiatrist's assessment of capacity is just one of many variables considered by the court in such matters.

This overarching question is complicated by several other ones: How dangerous is the condition? How treatable is the condition? How invasive or harmful are the proposed treatments? How well have the risks and benefits of both not treating versus treating the condition been explained to the patient? What sorts of psychiatric or cognitive problems might be clouding the patient's judgment?

As I examine the chart of Ms. Smith I begin to think of what I would do if I were in her shoes, so to speak, as I consider myself a reasonably reasonable person. And, in this case, I would not hesitate to start on IV antibiotics post-haste. But if they wanted to slice open my ankle to let out the steam, I may have to think twice about that. The chart tells me a few important things: no known psychiatric history, fairly standard medical problems of high blood pressure, high cholesterol, history of gallstones, non-smoker, not a drinker.

I approach Ms. Smith, wearing a hospital gown, lying quietly on a hospital bed, walled off from the rest of the ER by curtains only. She looks about her age, thin but reasonably groomed. Her face displays a mask of fretfulness.

"Good morning, Ms. Smith, my name is Dr. Linde. I am a psychiatrist who works in the ER. Your doctor asked me to check in with you."

"Good morning, doctor," she says, managing a weak smile.

"How does your leg feel."

"My leg? What do you mean?"

"Well, Dr. Jones tells me you have a pretty serious infection in both of your legs."

"No, I doubt that. I'm fine."

I lift up the blanket to examine her legs. It looks just as bad as Dr. Jones had described it. I resist the temptation, common to all physicians, to press on her shin to assess the amount of swelling and tenderness, even though it might help break through Ms. Smith's seeming denial of illness.

"What did Dr. Jones explain to you about your leg?"

"I don't know."

"What did she say about the tests she'd like to run and what might happen if we don't treat the infection in your leg."

"I'm not sure."

I was pretty sure Dr. Jones had indeed explained these things to Ms. Smith, but for good measure I told the patient again.

"My understanding is that your legs are badly infected and you're at risk of developing blood poisoning or maybe even losing your foot if the infection isn't treated very soon. The infection could actually kill you. She wanted to draw some blood from you, start an intravenous line, and begin to give you antibiotics. The risks of doing those things is small. We, of course, would want to avoid an allergic reaction to the antibiotic. Dr. Jones also wanted a surgeon to examine your leg, not to do surgery yet but just to be ready in case the infection gets worse."

Ms. Smith truly seems to follow the conversation, quietly listening and mostly looking me in the eye as I speak. Her hands begin to tremble, however.

So I think, given her age, maybe she has dementia or perhaps an acute confusional state, though the history and her behavior do not point to acute confusion or even dementia for that matter. I perform a bedside cognitive screening exam, on which she does remarkably well, scoring 28/30 points. I proceed to screen for paranoia, hallucinations, mania, and depression. As we talk, I soon discover that she is afraid of having her foot amputated.

"My mother was a diabetic and when she was my age, they cut off her foot. I was her main support then. Since I had never married or had children I could take care of her. She died soon after."

Ah-ha, I thought, a symptom model. My psych C-L mentor had taught me about this phenomenon and showed me its importance in the assessment of illness behavior. So, not finding much else psychiatrically, I follow up on her statement.

"That must have been very difficult for you."

"Oh, doctor, you just can't imagine. Her amputation stump kept getting infected, in and out of the hospital. The prosthesis never fit right. She was always in pain. When she died of an insulin reaction, it was almost a blessing in disguise. I never want to suffer like that."

Her statement represents a fountain of clarity. "I definitely understand what you're saying," I say. "It sounds like watching your mother suffer so much really affected you."

"Yes, doctor."

"I'm certain that Dr. Jones would like to prevent any complications and feels that the sooner treatment gets started the better you're going to do. Delaying treatment actually increases the risk of a bad outcome in this situation, Ms. Smith."

"I see," she says, pausing, as I remain silent. "Let me think about it."

"Fair enough," I say. "Dr. Jones will come back to talk to you very soon."

I walk away, thinking that anxiety and unresolved grief are clouding Ms. Smith's ability to make a reasoned judgment regarding her medical treatment. But is it enough to tie her down, draw her blood, start an IV, and give her antibiotics against her will?

I find Dr. Jones in the ER's hubbub.

"How'd it go?" she asks.

"Pretty well. Her thinking is pretty clear. She's just afraid. Her mother was a diabetic who underwent a BKA and died soon after and the memory has her anxious. I tried to explain to her that we are trying hard to prevent anything like that from happening."

"Right, Paul, true enough."

"I have a suspicion that she'll actually let you guys draw blood and start IV antibiotics though officially she told me that she'll 'think about it.'"

"Thanks, Paul."

"Call me back if you have to."

Turned out that Ms. Smith did allow her blood to be drawn. Her white blood cell count was elevated. Blood cultures revealed no systemic infection of her blood. She was admitted to the hospital, responded robustly to the first rounds of IV antibiotics and was able to go home, ambulating with minimal assistance, with home health care, in five days.

Thankfully, these situations often do resolve themselves, but not usually without letting "the process" play out and the performance of "due diligence" on the parts of multiple players, including the consultation-liaison psychiatrist.

Or nearly all would agree that if an injury has caused a person's femoral or brachial artery to begin spurting with a rapidly dropping blood pressure, it would be hard to argue ethically against the placement of a tourniquet, hemodynamic stabilization, and rapid assessment/intervention by a trauma/vascular surgeon.

In considering the motivations and conduct of an ER doctor, should paternalism be such a dirty word?

Consider the following example, in which the principles of a physician's duty for beneficence and a patient's right to autonomy come into conflict. Shades of grey predominate here.

An 80-year-old woman with a history of multiple medical problems, eccentricity, and perhaps early signs of dementia who lives alone is brought in by paramedics after neighbors call the police to perform a well-being check since they hadn't seen or heard from the woman in five days. They usually see or hear from her at least every other day. She wasn't answering her door, the mail and papers were piling up, and she wasn't answering her telephone.

The ER doctor examines her: The patient is somewhat irascible but oriented and seeming to follow the conversation. Both of her legs are swollen to just above the knee, red, and warm to the touch, but the left leg is much, much worse than the right. It is taut and sensitive to touch. Red streaks can be seen extending up to her groin from around the knee. The small toe on her left foot is turning black. She has a low-grade fever. She does not allow the doctor to examine the lymph nodes in her groin.

To the ER doctor, it is clear what must be done medically for this patient with a severe case of cellulitis. Though the patient doesn't have gangrene at this point, her risk to develop it is moderately high. And gangrene, of course would make the loss of limb, and possibly the loss of life, imminent so that the patient could then be taken to the operating room on the basis of the situation becoming a medical emergency.

The ER doctor, however, thought she could forestall the possible complication of gangrene if the patient would agree to have her blood drawn, blood cultures sent, x-rays of both feet and lower legs done to investigate for possible bone infection, IV antibiotics started, and consultation from a surgeon, who would see if an incision and drainage of the infection would be of benefit. The ER doctor saw the case as a severe but absolutely treatable infection.

The following questions could be posed to the ER doctor:

Was the patient at risk of losing her left leg imminently? "Not really. She'll probably be okay for a day or two, but then . . ."

Was the patient at risk of dying imminently? "No. Mentation and vital signs are actually okay. Sepsis would be the most dangerous thing and she's not there right now."

So what's going to happen if her leg infection goes untreated? What are the chances she is at risk to lose her leg or her life? "I'd say the chances of her eventually requiring a life-saving amputation are high. Should we wait for that? Should we wait for her to get sepsis, to become delirious with a high fever, when her blood pressure would be bottoming out and she would be a much more dangerous candidate for surgery if that was necessary?"

So how does the ER doctor communicate her concern to the patient?

"How are you doing, Ms. Smith," asks Dr. Jones when returning to the exam room to discuss the situation.

"I really want to get out of here," says Ms. Smith. "There's no reason for me to be here."

"Actually, you are very sick. How much does your leg hurt?"

"No, it doesn't hurt in the least."

"I'm surprised because from my exam, it looks like you have a very serious infection of the legs called cellulitis, your left worse than your right."

"There's nothing wrong with my legs."

"But you were found down on the floor of your apartment. When the paramedics came, you weren't able to get up. They had to lift you on to the gurney."

(Silence from Ms. Smith.)

"There are a few things I recommend we do," says Dr. Jones.

(Still silence.)

"First of all, since you can't walk on your own and you're sick, I want to admit you to the hospital."

"You have no right. I didn't do anything to you. Why are you taking away my rights? I live a simple life. I like my independence, living by myself."

Ignoring the patient's protestations for the moment, Dr. Jones continues, "Plus, Ms. Smith, I'd like to draw your blood, start an intravenous line for antibiotics. You might even need surgery to relieve the pressure on your legs. This infection is very severe, but I think we can overcome it if we get started now. You made it to the hospital just in time. Another day or two and you'd be at risk to die. If we don't treat it aggressively now, then there is a very high risk this infection can spread to the rest of your body and kill you."

"NO!" screams Ms. Smith. "I'll have none of it! I'm going home. Call my neighbor Phoebe, she'll come and get me, take me home."

Frustrated but diplomatic, Dr. Jones says calmly, "I hear what you're saying, Ms. Smith. You'd like to go home. You don't want us to do anything medically for you at this time. I'll come back in a little bit to talk more. This is a very serious infection and the treatment is straightforward and likely to work. I'd like you to think about it some more."

"Okay, doctor," says Ms. Smith, seemingly tired, the interaction stealing some of her energy.

But Dr. Jones knows how these things usually go. Ms. Smith will likely continue to refuse these potentially limb- and life-saving interventions.

And if that's the case, then Dr. Jones will have to obtain consultation from a psychiatrist to assess Ms. Smith's capacity, a clinical parameter, to make decisions regarding her medical care. And then she could apply to the court for a medical probate hearing to determine whether the patient has competency, a legal term, to make decisions regarding her medical care.

Unless, of course, what is now a medically urgent situation becomes a true emergency and then the doctor can proceed without the consent of the patient.

(To be continued)

The most "in-your-face" are the speeders, of course. These aren't your run-of-the-mill giggly runny-nose tweakers, but the slammers, those who jam a needle packed with solubilized crystal methamphetamine into their veins. Lots of these folks go over the brink, becoming manic and psychotic. Meth is a brain destroyer.

PCP is called "angel dust." Nuff said, I hope.

Crack cocaine still makes people paranoid, twitchy, and restless and is a favorite of folks who take methadone-a little something to cut through the cerebral fog. While crack is particularly hard on your heart, it's not so great for your brain, either.

Alcohol. What can you say? Cheap, legal, eminently available. High-octane malt liquors. Fortified wines. Rotgut vodka. Gnarly depressants, one and all. A little crying in your beer (or cheap vodka) can turn into suicidal thoughts pretty quickly.

LSD, ‘shrooms, mescaline, peyote, and a veritable alphabet soup of designer drugs, these substances might transiently enlighten you, but ultimately they also rearrange your brain chemistry if you do them hard enough and long enough.

Ecstasy, in its effects, makes for a combination of speed and hallucinogen. Not surprisingly, it's also bad for your noodle. The only reason it's this low on the list is that most ravers can handle their drugs.

It's kickin' heroin that makes a person super-cranky and sick. The drug itself plows most people under and makes them snooze.

Cigarettes? Yeah, cigarettes can exacerbate psychiatric emergencies when someone who is bipolar and/or schizophrenic and/or high on one or more of the above substances is in the midst of a "niccie" fit and tries to AWOL out of the non-smoking zone.

Weed mostly chills people out. When it's dusted with something else that's problematic. But don't blame the cannabis.

So, in other words, if one removed drugs and alcohol from society, the incidence of behavioral emergencies would plummet.

Out of a job, really? Probably not since I've been working in psych emergency for nearly 20 years and seniority does count for something. At least for now.

For more information about club drugs and methamphetamine use in the gay community, respectively, check out www.dancesafe.org and www.tweaker.org.