Wednesday, April 23, 2014

No Easy Answers

Today's post is brought to you by Steve Lopez of the LA Times and is located over on Pete Earley's blog.  You can click HERE to read the touching story of Nathanial Ayers, a talented musician who suffers from schizophrenia and does not want to take medication for his condition.  On his third court appearance, a judge appointed a relative as conservator for Mr. Ayers so that medications can be given.  It sounds, from the article, like Mr. Ayers had intolerable side effects to an older anti-psychotic medication and has never been willing to try the newer, atypical anti-psychotics which have more favorable side effect profiles --unless, of course, you're the person having the side effects, in which case the "profile" may not matter.  Please read the article over on Mr. Earley's blog, then come back here to read about my thoughts.

So I'm hoping that the story has a good outcome, and here are a number of things that may happen here.  I go from best possible outcome to worse possible outcome, and feel free to shuffle the order on the shades of gray:

  • Best:  Mr. Ayers takes the medication, it works, his symptoms resolve, he feels better emotionally, and he is able to function better, and he has no side effects and decides he wants to continue it.  This would be the happy ending we all want to hear.
  • Mr. Ayers takes the medication with resolution of his symptoms, improved functioning, and no side effects, and no appearance of metabolic syndrome, but he does not recognize that he is doing better without the medications and wants to go off but the court insists he continue.
  • Not bad: Mr. Ayers takes the medication and it works with resolution of his symptoms and improved functioning, but he has side effects.  He decides the improvement is worth the side effects and chooses to continue taking the medication.
  • Mr. Ayers takes the medications and it works, but he has intolerable side effects and needs to go off it.
  • Mr. Ayers takes the medication and it works, but he has  side effects and the courts make him continue with a medication that makes him feel bad 
  • Mr. Ayers takes the medications and it doesn't work, so he stops taking it.
  • Mr. Ayers takes the medications and it doesn't work, but the court insists he continue taking it.
  • Mr. Ayers takes the medications and it doesn't work, and he has  side effects, and the court insists he continue taking it.
  • Mr. Ayers takes the medications and it doesn't work, and he has intolerable side effects, and the court insists he continue taking them and then has a stoke or heart attack or diabetes which may have been brought on by the metabolic effects of the ineffective, intolerable medication that the court made him take.  
  • The medication works and the patient stops it and has a tragic outcome, either for himself or for others.  
Unfortunately, what makes the scenario even harder, is that the medication may partially work or be  somewhat effective -- so perhaps a given patient is less irritable or combative, which makes it easier to manage him or her -- but still hears distressing voices or experiences intolerable emotions.  We don't know exactly how long to wait, how high a dose to give, or how many medications, alone or in combination, we need to try before we're sure there  is no adequate treatment.  Also, the tolerability of side effects and the acceptibility of risk are things that may be difficult for one person to make for another.  

This is a long way of saying that unless the patient has a positive response that he appreciates, the issue is not a simple one; it can be complex and nuanced in a way that many of the parties may not appreciate.  If our medications worked more reliably, and did not have side effects and pose the risks (risk, not certainty) of decreasing both the quality and quantity of life, then forced medication would not be such a difficult option.  But the issues of limited efficacy and tolerability exist before you even begin to address the civil rights of a person to decide their own care.

I hope we'll hear about the outcome from Mr. Lopez, and I do hope Mr. Ayers has a good response and decides, on his own, that he'd like to continue the medication.  And if it doesn't work, I certainly hope the court does not force him to take an ineffective agent that he does not want.  In our "meds are good" society, it's not that unusual for people to be on medications long after we've lost track of what it was we trying to target with them.

On a different note, I spent my day with a police officer today who does crisis intervention.  As we stated the day, he received an email from a patient he had petitioned to the hospital 2 years ago, thanking him for forcing her to get care and for saving her life.  It was my feel-good story for the day.

Sunday, April 20, 2014

Interesting reading around the web

Happy Easter!  ClinkShrink has become obsessed with photographing birds, and I've suggested that for today, she give us a rabbit or two.

First, I'll send you to Clinical Psychiatry News where Clink discusses the latest report from the Treatment Advocacy Center on how there are 10 times more people with mental illness in jails than in psychiatric hospitals.  See Report suggests reform for mentally ill in prison.

Next, I'll send you to the New York Times for a very thoughtful article on the use of antidepressants.  See Doris Irovici's article on The Antidepressant Generation.

Then I'm going to send you to Pete Earley's blog where he talks about the split in support on the Murphy Bill in Congress, HR 3717 which both increases resources for community mental health centers and increases reliance on involuntary treatments. 

Finally, I'm going to lead you to a post from one of my Twitter followers, "Sectioned @ mental health" who writes a touching post on things learned about the civil commitment process in the UK, the hard way.  See Unexpected Knowledge-- things I've learned since being sectioned. 

Thanks for reading!

Tuesday, April 15, 2014

Does bad parenting cause mental illness?

Over on our Facebook page, a reader posted: 

Supporters of families should protest SAMHSA's distribution of its new "Family Therapy Can Help" booklet. It's full of statements that imply that faulty family dynamics are the underlying problem in the development and persistence of mental illnesses. At the same time, SAMHSA does nothing to educate the public or clinicians or people with severe illnesses on what is known about psychotic disorders from a science based perspective. Here's a link to this free document:

Around the same time, a Shrink Rap reader wrote in to us saying:

    I get tired of the stories about the noble families caring for their wayward child. It's that way sometimes, but a lot of times, it's NOT that way!
   What I don't understand is this: I have NEVER EVER read an article anywhere that talked about families and an adult child with serious mental illness that did anything but praise the family of origin and their noble quests to save their unfortunate children. (Well, on Dr. Allen's site, which is like the only exception).
   I have bipolar and came from an incest family. Just about every psychiatrist I have ever seen, and every single community mental health worker (social services) has said that so many of their patients come from abusive families. In fact, the community workers who only see people with serious and persistent mental illness say that nearly ALL their clients have extremely abusive families.
   So what is going on here that there is NEVER EVER a mention that perhaps some of these sacrificing, noble family members may have been the catalyst for the mental illness and are continuing to abuse the person by committing them and placing all the blame of the messed up family at the feet of the one who has a label? And bipolar or schizophrenia labels are handy for parents or other abusers to escape culpability.
   I understand that NAMI is all about moms not wanting to be blamed for their kids' mental illnesses, which probably did happen unfairly quite a bit. But come on! Often parents are the major cause, by abusing or failing to protect their kids (in my sexual abuse support group, all the ladies were blamed and ostracized by their moms and others when they told about what happened. What I learned from that is that kids who are abused and their mom has their back don't end up so messed up that they need to be in a support group)
   So it always ticks me off when I read blogs written by mental health providers, or newspaper articles, or see something on TV showing these wonderful, loving parents, and come on, statistically, some of those families are probably very abusive and the motives for promoting involuntary commitment are very dark indeed, a legal way to continue abusing an adult who has tried to escape.
  And keep in mind that many people who have been in a mental hospital found it to be further abuse.
  Or did all those mental health workers lie to me about mental patients and their toxic families?
Clinically, I've seen all combinations.  I've seen people with really dysfunctional families and very sad histories that have included horrible losses and abuse, who have turned into very functional, loving, and productive adults.  I've seen people who have been raised by wonderful parents have serious mental illnesses, and I've seen people with awful family lives who have been come seriously mentally ill.  It's often hard to sort out the role of genes versus environment, because often the dysfunctional and abusive parents also suffered from mental illness.   People differ with their individual sensitivities to what has been sad and done to them -- some feel injured by parents who seem to have good intentions but sometimes say the wrong things, and others have no problem dismissing what sounds to be flagrant abuse.  Certainly, objectively traumatic events color who people become and how they react to the world.  But does childhood trauma cause psychotic disorders?

What do our readers think? 

Saturday, April 12, 2014

Medicare Payments to Docs Gone Public

Today's post is over on Clinical Psychiatry News where I wrote about 
"Privacy or Transparency: Maryland psychiatrists speculate on Medicare payments and their accessibility to the public."

Please surf over there to read, then return here if you'd like to comment.  The CPN site is not taking comments lately. 

Sunday, April 06, 2014

Dear Congressman Murphy: Regarding HR 3717

American Enterprise Institute, AEI, a conservative think tank, held a panel on Fixing The Mental Health System, What Congress Can Do.  I posted the discussion above, the talking begins at 12 minutes.  The panel is introduced by Dr. Sally Satel, and the speakers include:

  • Congressman/Psychologist Tim Murphy who talks about legislation in Congress, HR 3717.  This bill pushes the federal government to provide more services -- a good thing -- and it also ties in requirements for Involuntary Outpatient Treatment (also known as Assisted Outpatient Treatment or AOT).  The New York Times has discussed this in Mental Health Groups Split on Bill To Overhaul Care.  
  • Dr. Jeffrey Lieberman, the President of the American Psychiatric Society
  • Dr. E. Fuller Torrey of the Treatment Advocacy Center
  • Former Congressman Patrick J. Kennedy
If you'd like to watch the event, the video is above, if you want to read about it, read Here. 

I don't want to dwell on the issue of involuntary treatments today, but instead, I'd like to make some comments on H.R. 3717 The Helping Families in Mental Health Crisis Act.  I've read about the bill, I have not read the full text, but if you'd like to, it's here. 

Dear Congressman Murphy,

I'm no fan of HIPAA, as a physician, I find it makes it more difficult to get information from other clinicians.  Your point, however, that HIPAA prevents a doctor from getting information from a family is not quite right and you were more on target when you said it was misunderstood.  Physicians can listen, and families can talk, but privacy laws mean that physicians can't release information without the patient's permission.  Actually HIPAA defines all sorts of entities that can get medical information, but there is nothing in it that says a family member can't tell a physician about their concerns or relay past history.  Sometimes, clinicians refuse to release information to families or even other physicians, citing HIPAA, when in fact, they haven't specifically asked the patient for permission.  Sometimes doctors or facilities are lazy, sometimes they are misinformed, and sometimes they are afraid of being sanctioned or sued so they err on the side of being overly careful about whom they communicate with.  For the most part, I don't believe that doctors should release psychiatric information unless a patient consents to this.  Lets hope that everyone's judgement on these issues gets a lot better. 

In talking about access to care and a shortage of psychiatrists, because psychiatrists are in such demand, many psychiatrists have chosen to opt out of participating with health insurance.  I've written about that Here.  Part of the access problem lies with the fact that insurance companies either restrict patients to seeing in-network psychiatrists, or reimburse less if patients go out of network.  At the same time, insurance companies will list psychiatrists as being in their network when they are not, creating the false impression that the network has plenty of providers: see this Wall Street Journal Article.   So what about increasing the number of available psychiatrists by requiring insurance companies to reimburse the same for both in-network and out-of-network treatment when access to care becomes difficult?  If a family is told that the next in-network appointment is 6 weeks away, but an out-of-network doctor can see them the next day, should the insurance company really be permitted to save money and reimburse less?  And should insurance companies be permitted to have "Usual and Customary" rates that are far below the community standard?  And perhaps if Medicaid and Medicare would reimburse for out-of-network services (they don't), the number of treatment options might open up. 

Finally, you talked a lot about the standard of "imminent danger" as being too high standard for hospitalization.  That's all well and good, and I agree with you that we shouldn't be waiting for metastatic disease (as your comparison mentioned) to begin care, on an inpatient unit if needed.  But it's not just about that standard of care for forcing treatment, it's about what insurance will reimburse for.  Have you ever tried to admit a patient to a hospital?  Insurance companies generally will not authorize treatment for psychosis alone.  The only level of illness that they will authorize inpatient care for is the same level that one needs for involuntary commitment: imminent dangerousness.  So you can drop the level of illness it takes to get a patient admitted -- and I presume you mean by allowing for involuntary treatment -- but does it matter if the law changes to a "need for treatment" standard if insurance companies don't agree that the patient needs treatment?  I asked a woman the other day why she didn't sign herself in voluntarily after a serious suicide attempt -- she was being transferred from an ICU and was distraught that she was being 5150'd (California lingo).  She told me the doctor said the insurance company wouldn't pay for the admission if she wasn't committed, otherwise she would have signed herself in.    One ER psychiatrist I know was asked by the insurance company if the patient's gun was loaded.  Does that matter?    If the Navy Yard shooter had been brought to the hospital by the police, as he should have been, they may well have let him go if it was believed that insurance wouldn't pay for an inpatient stay.  And while severely mentally ill people may have higher rates of violence, studies have shown that treatment deceases violence.  In fact, patients who are seen weekly after a hospitalization are half as likely to be violent as the general population -- voluntary treatment makes a big difference.  But getting that level of care for our patients in the public mental health system only happens with the few who get put with Assertive Community Treatment teams. 

One thing is clear, before we start forcing care, let's make sure there is even care to be had, and that those who want it, or can be encouraged to get it, have a means to do so. 

Friday, April 04, 2014

Book review: Viviane (a novel)

With thanks to Jed who thought I'd like this novel.

Take a deep breath before you get on this ride.  The twists and turns come fast, and the trip is short, but memorable, with moves that made me gasp.  So short, it's almost more of a novella, and that's good because a ride like this is compelling for hours; I'm not sure I'd want to be on long journey.  

Viviane is dark and mysterious, the psychologically-laden plot pulls the reader along quickly, and if that's what you're looking for, stop here before I move you to plot spoilers.  It's a first novel by Julia Deck, translated from the original French by Linda Coverdale.

Very quickly, we learn about Viviane.  She is 42 years old and she has a 12 week old daughter, a peaceful baby who seems to never want for very much.  Viviane is the public relations officer for a concrete company, and her husband Julien can no longer stand being married to her; he's having an affair and "it isn't even from love but from despair."  He wants to leave, he needs air, but instead, Viviane leaves and moves into her own apartment.  Then she goes to see her psychoanalyst and kills him.  We are now on page 8.

The circumstances that led up to the murder of the psychiatrist are described.  Viviane was struggling.  Something needs to be done, I can't take it anymore.  Doctor, you're not listening to me.  He is insensitive, he implies that her problems are her own fault.  You'll take these pills for a few months, you know, the antidepressants, plus the ones for when your nerves give way, they help stabilize the hysteria.  She stabs him and leaves, taking the knife with her.

Viviane then proceeds to stalk, meet, and talk with those suspected of murdering the psychiatrist: his pregnant lover, his widow (who lives with her own lover), a young patient with a history of violence.  She doesn't just stalk the patient, she sleeps with him.  We learn about how her husband's lover was the woman who took her job while she is on maternity leave, how jealousy strikes her, and how she can't let go of dead mother's apartment.  All the while, Viviane is searching, and the reader (or this reader, anyway) waits to understand what could have motivated her to commit murder.  She is not, it seems, delusional. But Viviane arranges to meet Julien, and she stands back and watches him, not letting him know she is there.  This is her end, her part from sanity, and she lands in a hospital, where she confesses to the murder.  She is moved to another facility, one for longer term care, and oddly, the baby goes with her.   Oh, but the end comes with a jarring twist, and all we thought we knew was not to be, the entire landscape shifts from under us. 

That is the thing with this novel, it is constantly shifting.  The language is dark and we feel a distance from Viviane who remains an unknowable person, even as we move closer to know more of her, then farther away to see she is truly a stranger.  As we move in and out,  the point of view constantly shifts: at one moment the story is being told in first person singular, and the next moment it shifts to third person, or even second person.  In French it must be more intriguing, because there is the second person pleural, or formal, tense, one that can't be bridged in the translation to English. (Reviewer's note: finally!  Those years of college French I sat through, that evaporated from my brain no sooner than I left the classroom, have finally served some purpose.)  This constant movement feels odd, quirky, and most unusual.  It parallels the ever-shifting sense of reality that the book creates, where we don't know whose story it is, what truth is to be had, or where it will all stop.  A truly unique ride.