Hello and welcome to the IMS Insights Podcast. I’m your host, Adam Bloomberg.

Today, we’re speaking with American Psychiatric Association member Dr. Neil Kaye about the realities of mental illness and gun ownership, breaking the stigma of mental health, ongoing trends in the psychiatric and healthcare industries, and the impact of mentors on your career.

Dr. Kaye is a clinical and forensic psychiatrist with more than 35 years of experience treating patients. He is an IMS Elite Expert, neuropsychiatrist, and pharmacologist—board-certified in general adult psychiatry, geriatric psychiatry, and forensic psychiatry.

Adam Bloomberg:

You mentioned Buffalo and unfortunately, those sorts of situations are happening monthly, weekly. It’s devastating. With elections and lawmakers at the forefront right now, a light has definitely been shined on mental illness and the second amendment. Could seeking therapy eliminate someone’s right to bear arms and in what instances?

Neil Kaye:

So the answer to that is generally no. There are a couple of exceptions. So the important rule to remember first is that if someone is involuntarily psychiatrically hospitalized, what we call involuntary commitment, there is a federal mandate that the person is reported to what’s called the National Instant Crime reporting database, the NICs database, and they will have their weapons taken from them. There is a restoration process through the courts for someone to get those weapons back, but that is in the rare cases where someone is involuntarily hospitalized.

Neil Kaye:

If somebody’s voluntarily hospitalized, nothing happens. There’s no duty to report, to take, to do anything about that. And certainly in the outpatient arena, there is no requirement either. There are two other things people might want to know about. Some states, in fact, probably most states at this point, have a duty for clinicians to take action to protect someone if a person with mental illness and as a direct result of that mental illness makes a clear threat to a specifically identified individual of harm to them and the clinician believes that they could carry that out. Then we would have a duty to either warn or protect depending on which state you’re in. That doesn’t mean that your guns are taken, although they might be. And that would be temporary in those circumstances.

Neil Kaye:

Probably the growth area in this concept is not really a psychiatric issue, but these are the states that have what are called red flag laws. Where, as a result of someone’s behavior, law enforcement may seek a court order to remove someone’s weapons. Again, it’s temporary. What’s important for people to understand and the red flag laws are good, I like them, is that they are triggered by behavior, not by mental illness.

Neil Kaye:

The reality is that most people with mental illness are not dangerous, and they’re not the problem. While people like to talk about people who are mentally ill being dangerous and shooting the place up, that’s rarely the case. Most of the mass shootings and problems are done by people who are not mentally ill. As I like to say, they’re bad, not mad. And so what I really think makes sense for legislators, governments, even the NRA to focus on is behavior, not mental illness, because it’s the behavior that’s the problem. And frequently, the behavior is coming from either anger, feelings of deprivation, substance abuse, but it’s not because they have schizophrenia or bipolar disorder. Those people are rarely violent. In fact, more often than not, they’re likely to become victims than perpetrators.

Adam Bloomberg:

Currently, there’s a large focus on mental health throughout the country. We see it in schools. We see it in corporations. With more people becoming comfortable with saying, “I’m going to speak to my therapist about this or that,” how do you think today’s acceptance and awareness of mental health and I guess the school of psychology differ from when you first began in your career to today?

Neil Kaye:

So we’re talking really about what we call stigma and we’ve made a lot of headway, but we have a lot further to go. So the stigma is definitely breaking down and the generation or two behind me are far more comfortable with being open about that. You’ve talked about social media, seeing people post on social media about getting therapy, taking medications, having a psychiatrist or psychologist is much more common and much more acceptable and that’s actually a good thing.

Neil Kaye:

Access to mental health is clearly better, but not what it needs to be. We have a shortage of mental health clinicians at every level from social worker, psychologists, psychiatrists, psychiatric nurse practitioners, peer therapists. Across the board, we need more, but we really have done a lot to break down the stigma.

Neil Kaye:

However, still at the same time, we do have stigma around things like well, if somebody shot up a store, they must be crazy. Well, actually they’re probably not crazy. The more victims, the less likely it is that they are crazy actually. And so there are areas we need to break down still around the issue of stigma, but the increased acceptance, the increased awareness is a good thing for our society on the whole.

Adam Bloomberg:

As someone who diagnoses and treats others, how important is it for you to know when to step back and evaluate your own health needs? And is this a topic freely discussed among mental health professionals?

Neil Kaye:

It’s critically important to do that. It helps you maintain your own stability and balance. It grounds you. It helps you to be more objective in your work, which is necessary. So it’s very important that we try to teach all doctors to be mindful of this and doing this from the beginning of their training.

Neil Kaye:

So now in residency training, all branches of medicine, not just psychiatry are addressing the mental health side and the stress that we are under because physicians like a lot of workers, not the only ones, but we’re certainly under a lot of pressure. And now with a pandemic going on and it’s sort of the open-ended pandemic, endemic, our stress level is not going down at all. It’s going up, and we face the politicization of medicine and what we’re doing and that’s not fun either. So yeah, it’s very important.

Neil Kaye:

Is it freely discussed? Again, we’re breaking down the stigma, but there is still a real area of stigma, I’m going to say, among many of my older colleagues who were from the boot camp side of the learning curve and time in medicine, where they just had to do it kind of thing. Now we’ve made it a part of residency training and we’re much more open about it.

Neil Kaye:

In my world, the psychiatrists I think are better than most about it, because we’re used to talking about emotions. The trick is to find a group of colleagues that you feel safe and comfortable with, who are going to maintain your privacy and confidentiality and respect that.

Neil Kaye:

I can say in the last couple of years at the big national forensic psychiatric meetings run by the academy of psychiatry and law, this has been a topic on the agenda. There has been open discussion in our meetings about this, and I think that’s a really remarkable breakthrough. Last year, one of our past presidents gave a wonderful talk about his depression and suicide attempts and was very open about it and talked about how the baggage he was carrying with him was immense.

Neil Kaye:

In the forensic world, we’re also seeing a little bit more of it, both for ourselves and also with the law enforcement people that we work with, the judges, and the jurors and the lawyers in cases because in today’s world, they are being exposed to the same overwhelming traumatic material that people like me see every day and it’s taking a toll.

Neil Kaye:

So if you sit through a mass shooting case on a juror or a case where someone’s charged with multiple sexual offenses against infants and minor children and you have to review that material, you have to see photographs of it, you have to hear testimony about it, it can cause vicarious trauma, essentially PTSD, post-traumatic stress disorder in all of us as professionals. And the recognition of that really has been great.

Neil Kaye:

And so we’re seeing in some of the bigger high profile cases, judges mandating that the courts make available mental health treatment to everybody involved in the case because they recognize that it’s traumatic. And some of them are good enough to set the example and tell everyone they are going to or are getting treatment for that themselves and that there’s no shame, no embarrassment about it. It’s a little bit like after 9/11, the New York City police commissioner did a remarkable job by going and getting treatment and making it public that he was getting treatment and setting the example for all of his officers to get treatment as well because there wasn’t going to be any stigma about it and that’s how you beat it.

Adam Bloomberg:

So let’s talk a little bit about the field and maybe some trends. What sort of trends are you seeing in mental health and the healthcare in general, speaking at it from a business level?

Neil Kaye:

Sure. So there’s two trends I think that are sort of the most prominent at the moment, and they would be the use of non-MD physician extenders. Those could be physician assistants, nurse practitioners, or other lower-level providers, as they’re called. And I think there’s an absolute place for them, but I don’t think that they replace physicians.

Neil Kaye:

Their training, knowledge, and experience is different; and there’s lots of things they can handle, but some they can’t and shouldn’t. And while legislatures and insurers find that the argument for increased access by increasing the scope of practice for non-MDs is a good business decision, a good political decision, it’s not necessarily a good care decision. So I think that’s one trend that we really need to be mindful of.

Neil Kaye:

The other would be the use of telemedicine. So telemedicine is something that, I mean, in psychiatry, we’ve worked with telemedicine probably 15, maybe even 20 years. It’s been around a long time, but it hit its stride throughout medicine with the pandemic, the beginning of COVID, and the benefit obviously is there’s much greater access.

Neil Kaye:

It can be easier. It can be less expensive. You can get specialty care into rural areas where the specialists might not otherwise be available. So there’s a lot of good, but one of the realities is again that the standard of care, which is the foundation for malpractice, is not really the same in telemedicine as it is in face-to-face in-person contact.

Neil Kaye:

Unfortunately, the law generally holds that the standard of care is the same regardless of how it’s being delivered. And that’s creating a new area in medical malpractice and that is over standard of care in telemedicine cases. And that’s an emerging area. I think it’s going to be a growth area. Personally, I’ve already done three cases in that particular area where the argument has been, had the person been seen face-to-face, a different diagnosis, a different treatment would have played out than what was diagnosed and delivered through Zoom, Facebook, Doximity, whatever. So that’s, I think, the two big areas that we’re going to see. So scope of practice through physician extenders and telemedicine.

Neil Kaye:

The one I’d love to see happen, but I don’t think is really likely, is I would love to see a national medical license system. The fact is the standard of care is national. We all have access to the same sorts of technology today and much like you can drive your car in every state, you don’t need 50 licenses. And with telemedicine, most states and the federal government suspended the need for a specific state license and allowed us to practice with telemedicine across state borders. Some states are now rescinding that as the pandemic is winding down, but the need or the benefit of having a national medical licensure system where docs can practice with the one license everywhere to the same standard seems incredibly logical and reasonable to me, but there’s great pushback from state licensing boards for their own reasons.

Adam Bloomberg:

You mentioned Larry Kolb as one of your mentors. You’ve had a very seasoned career so far. What sort of guidance did Larry and others give you along the way and maybe early on, too?

Neil Kaye:

Sure. So really, it’s time I think for a shout-out. I have been incredibly blessed and lucky. I have been in the right place at the right time, just by serendipity and have had some of the best mentors available. Larry Kolb, Paul Appelbaum, Jeff Giller, Richard Rosner, Bob Sadoff, John Bradford, Bill Reed, Phil Resnik. These are pillars of academia and excellence in my field. And as I said, I’ve been in the right place at the right time and been able to work with all of them, develop friendships with all of them. And I still refer to them and call them actually.

Neil Kaye:

Dr. Resnik and I just had a call over the last couple of days about a case I’m involved in that I wanted his thoughts about. And it’s a small group of forensic psychiatrists nationally. There’s maybe 1,500 or so members of the Academy of Psychiatry and Law. And really when you get down to it, there’s probably only a few hundred of us who are active in doing the kinds of work that I do with the scope, depth, and breadth of it. And so the family that we have that allows us to consult with one another is very special, and we take advantage of it.

Neil Kaye:

Again, if you’re feeling bad about a case and you want some help or you want advice about how to approach something or you want to check, is your opinion really mainstream or are you approaching an outlier opinion? Consulting with each other is critical. As you said, I’ve been at this for a while now, Dr. Sadoff who’s now deceased, asked me to write the Ask the Expert column with him for the Academy of Psychiatry and Law newsletter many years ago. So I was his junior partner, if you would, in that. He, at some point, turned the reins over to me and made me the senior expert when he retired. And I brought in Dr. Glancy from Canada, a remarkable forensic psychiatrist to be my associate with that. And he and I are discussing bringing in Dr. Hall, a slightly younger colleague from Florida to follow in our footsteps and to create the line of succession.

Adam Bloomberg:

Last question, if you could go back 40 years and give yourself advice, what would that be?

Neil Kaye:

Wow. Make sure that what you’re doing is fun. If you don’t enjoy it, don’t be doing it. That would certainly be one of my pieces of advice. Don’t be afraid to say no, to turn down a case or to say that you’re not really the right person or the right expert for it. There’s plenty of other business that will come your way. You will actually get respect from people for knowing what you know and knowing what you don’t know. And it’s okay to do that.

Neil Kaye:

And a piece of advice I always share that was taught to me by all of my mentors is you don’t win and lose cases. We’re there to teach. You should be impartial in reaching your opinion. Once you have formed that opinion, it’s perfectly appropriate to advocate for that opinion, which is different than advocating for a particular side in a case. Lawyers keep wins and losses. Good experts have no idea whether or not a case is won or lost, because we’re just there to teach. The wins and the losses are for the lawyers. They’re not for the experts.