Monday, September 02, 2013

Deeds, not Diagnosis.



Here on Shrink Rap, we've talked at length about the implications of having a psychiatric diagnosis on one's future occupational endeavors.  For example:

We've talked about whether you can have bipolar disorder and be a doctor.
We've talked about the fact that a psychiatric diagnosis prevents you from being a pilot.
We've talk about psychiatric disorders and being in a powerful political office.
We've noted that the New York Times recently ran an article on psychiatric diagnoses and how it affects one's ability to be admitted to the Bar Association.
We've discussed mental illness and gun legislation

 What the DSM does for us is it gives us a list of symptoms that go with every diagnostic category.  It means that if a patient presents at a given time with a specific set of symptoms, and they are examined and a history is taken, that different psychiatrists at that point in time, with the same data, will come up with the same diagnosis.  It's actually good for that, and we call this inter-rater reliability.  

What the DSM doesn't do is tell us which patients with a given disorder will get better with medicines, will get better without medicines, will respond well to therapy, will do better without medicines, or will be hopelessly sick and disabled no matter what is done.  Schizophrenia is often a poor prognosis illness to have, and nothing about diagnostic criteria tells us who with schizophrenia will become a law professor, like Elyn Saks, and who will end up living in a cardboard box under a bridge.  

Given this fact, we need to stop using psychiatric diagnoses for anything to do with occupations or gun ownership or drivers' licenses, or much of anything else aside from the treatment of psychiatric disorders.  It's silly anyway: Why should you be prevented from being an attorney because you have a history of a mood disorder, but it's fine for you to be a school bus driver with dozens of children depending on your mental stability?  

We need to judge people's competence based on their deeds.  If you run naked through the hospital, you can't be a surgeon there (not this week, anyway).  If you're so depressed you can't get out of bed and you're always late to work, perhaps you shouldn't be President of the United States, because I hear it entails being at a lot of meetings and press conferences.  If you're behavior when ill leads you to do illegal or dangerous things, then you should be barred from doing things that one needs to be a safe and law abiding citizen to do.  But it's the behavior, or the expressed potential behavior that counts.   So if you've quietly been depressed, gone to tell this to a psychiatrist who prescribed you a medication that took that depression away, and a pill and some therapy keep you well, then why shouldn't you be running the country or driving those kids to school?  Oh, there's risk, you could get depressed again.  But you could also have a heart attack or get cancer or epilepsy or Alzheimer's Disease.

When I'm on a plane, I want a pilot who does a great job of flying a plane.  Perhaps there are some objective measures of what we want to see in a pilot -- things like reaction speed which could be impaired by depression or by medications.  Instead of stopping someone from flying because his depressive symptoms are adequately addressed with an antidepressant, perhaps we should be checking his reaction times on a simulator.  If a pilot does a great job of flying, then I don't care that he's on an antidepressant, and I don't care if he's thinking about his grocery list, or anything else that I have no control over.  But  I do care that he flies well, that he's not impaired, and since history may repeat itself, then I care about his past behaviors: if he's had close calls when flying for any reason, or a history of a suicide attempt, then I'd like another pilot, please.

And I personally don't think anyone should own guns, but since no one cares that I think that (yes, yes, 2nd amendment...), well then what say we prohibit the following people from owning guns, at least for a period of time: anyone with a history of assaultive behavior, and anyone who has had a suicide attempt serious enough to require medical attention.  Both imply that the person has a level of impulsivity where a gun could be a problem.  And, yes, I think that someone who gets in a bar fight and throws some punches shouldn't have a gun, at least for a given period of time -- say long enough to age into some brain maturity or get some treatment for their alcohol problem. 

 I don't care what the diagnosis is: no diagnosis precludes any type of employment, and no lack of diagnosis is any guarantee of safety.  What matters is behavior, and that's what people should be judged on.  Oh, you're going to say I think this means it's okay if the pilot tells his co-pilot he's thinking of crashing the plane: and I'm going to say No!  The act of telling another that you have violent criminal intentions is a behavior, that pilot should not be permitted to fly.  Silent thoughts which one never intends to act on are one thing (we all have weird thoughts from time to time), expressing such thoughts can be a cry for help, or it can indicate poor judgement, or it can be an expression of a symptom of serious mental illness, but once expressed, it's a different animal than a quiet fantasy.  

We need to change the questions.  'Do you have a diagnosis of X,Y, or Z' is not relevant.  Have you ever been convicted of a crime beside a minor traffic violation?  Have you ever filed for bankruptcy (I don't want you running my accounting department, thank you, anyway)?  Have you ever been treated in a psychiatric facility for violent behavior or a suicide attempt?  Have you ever been committed to a psychiatric facility involuntarily for dangerous to self or others  ("committed" implies that you were not just observed for 72 hours, but that a hearing was held where you were determined to be dangerous by a judge).   And for many of these things, there should be a period after which it's no longer an issue.  A single suicide attempt at age 15 following a break up with a boyfriend, followed by years of mental stability as an adult should not haunt one forever.  Maybe 7 to 10 years without troublesome behavior is enough.    But a diagnosis of Bipolar disorder?  Now what does that mean?

Okay, rant.  And please tell Clink that "twerk your giblets" is not something that normal people say.