The Perfect Storm of Psychiatric Safety Dilemmas

A just published article caught my eye, or rather one of my targeting search bots for topics for blogging. It involves that dilemma of what to do with a ‘mental patient’ in Canada who has been ‘detained,’ i.e., involuntarily committed/hospitalized in a public [read “state hospital” in the United States] psychiatric hospital for nineteen (19) years with virtually no treatment.

He has the near perfect combination of unfortunate frightening [to the public] denominators of: 1) possible intellectual deficit and consequently, 2) lessened capacity to take in, utilize, internalize, understand and retain change from mental health treatment other than use of psychotropic medications, 4) deafness with poor knowledge, facility and use of sign language, making the enterprise of conveying concepts of treatment based healthy change and knowledge of the “wrongness” or inappropriate nature of his socially unacceptable behaviors almost impossible, and worst of all the history of and baggage of being a pedophile!

He is now is in his 50’s and has spent 19 years of his adult life in an institution under legal constraints that I assume from my own experience with just such patients as legally preventing him from “re-socialization” into the community on a long term basis to prepare for re-entry into society. Most of these patients are under near perpetual court orders keeping them under lock and key inside state hospitals as “a danger to the community.” Why, even when they go to specialty medical centers for sophisticated medical care [as they DO develop chronic medical problems just like the rest of us] they have to go in police custody. Never mind that they often have the minds of children and almost never would the capacity to escape, rob banks, kidnap persons, pull off sophisticated white collar crime scams or make an attempt on the President’s life! Unlike obviously dangerous sociopathic savvy career criminals they would not have a clue as to where and to whom to go to for purchasing an automatic rifle and even a Saturday night special cheap pistol.

So they languish in ‘interminate’ lengths of stay in hospitals ill equipped to meet their complex social, rehabilitative and psychiatric needs. And forget community speciality based supervised structured based housing for them outside the secure hospitals. Such exist only in rare enlightened communities and largely not in my bailiwick of practice. With all these ‘barriers to discharge’ as they are called in inpatient mental health jargon, they are often adjudicated “incompetent to proceed,” to trial on their charges, because they are “non-restorable” [to competency to stand trial] and no professional is going to stake their license on releasing them with the thin possibility of an adverse event of such an impaired person, say for instance, approaching a child on a school playground.

So now in Canada, comes a judicial ruling that puts a six month cap on such detaining hospitalizations altogether. As this ruling comes to be cited in the near inevitable and expectable wave of advocacy attorneys in Canada and in the US citing this as binding precedent, we could see a revolution in forced discharges for such impaired patients into the public world of communities large and small that have no place, no staff, no infrastructure, no funding, to accommodate them. Perhaps they will all end up in bankrupt empty motels and flophouse abandoned hotels as we have seen in large cities where the chronically mentally ill are housed in convenient never-ending, stopgap solutions, a contradiction in terms if I ever heard one. I sincerely doubt that our unenlightened legislatures across the country will rise to the need with the billions of dollars in funding to house and care for these very impaired, needy patients with vast multiplicity of care needs. Or will they  just dumped onto their families, abandoned military bases or sent to the other great current dumping grounds, the nation’s jails, already overflowing with disturbed mental patients.

For the report on this little noticed but potentially revolutionary, if not cataclysmic article on this ruling, please read: “Court places six-month cap on involuntary detention of mental health patients,” by Sean Fine, Justice Writer, The Globe and Mail, Published Tuesday, Dec. 24, 2014.


Children’s Vaccination Ignorance Worsens

I am old enough to have lived through as a very young child, but a fearful one, the polio scares of the 1950’s. I saw on early television that visions of children and adults living in the “iron lungs” being unable to breathe on their own. I recall that my parents were caught up, as were most parents of those times, in the misplaced but gripping fears that polio could be caught in public swimming pools and that I could not go swimming.

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The Treatment of Multiple Sclerosis as a Metaphor for Schizophrenia

Multiple sclerosis, or M.S., is a devastating, chronic, debilitating illness, that has defied until recently most treatment approaches. It hits the young adult in the prime of life typically, more young women than men. It is like ALS though much slower, and not quite as destructive neurologically as ALS but well bad enough. Only in the last two decades or so, have treatments started to be even minimally effective. I have followed M.S. patients in my decades of psychiatric practice since I started in the neurosciences, brain science as a collegian, then aspired to go into neurosurgery before I decided on psychiatry as a medical student. I have long enjoyed practicing medical centers and general hospitals on the “psychiatry consult liaison services,” almost specializing in seeing neurology patients and M.S. patients most of all.

M.S. is like many other chronic illnesses. For decades we had only paltry symptomatic treatments. That is to say, our treatment only treated symptoms, or brought episodes to a close and did not treat the etiological, causative basis of M.S. When one had a flare of M.S. with “shorting out,” loss of a sense, use of a limb, sight, balance, etc., then one was given intravenous treatments with whatever immunosuppressant was in vogue at the time. These over the last 40 years or more have included ACTH, prednisone, methotrexate, bee venom (which like many other briefly popular treatments, did NOT work) and other agents de jure.

Then the advent of more scientifically based, more specific anti-immune system based medications came out in the 1990’s, the family of the interferons. These were much better for many M.S. patients at stopping an episode in its tracks than the previous agents. But they had like so many modern medicines in all branches of medical practice, enormous side and adverse effects. Betaseron based medicines tended to be given by injection shallowly into the subcutaneous tissues every other day and would cause in the vast majority of persons, a day of in-the-bed-flu like syndrome. “Flu without the flu” as many called it. And on an every other day schedule, you got the shot, had the flu and then the next day when the flu like aches and low grade fever and fatigue passed, you got your next shot and braced yourself for starting to feel bad physically that evening…it was awful and many many patients tolerated this for years and then en masse stopped the interferon based therapies. A newer, slightly different family of agents came out nearly a decade ago but were no better.

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DMS-5 Part II

In my previous post on American psychiatry’s new and fifth edition of its “diagnostic manual” for mental conditions, I covered the history of the previous four editions of the “DSM” which stands for Diagnostic and Statistical Manual.

I will talk of two topics in this post; first as understandable explanation of the ‘sorting science’ that lies behind how psychiatric diagnostic categories are arrived at, and, second some of the misses and one correct addition in DSM-5.

The statistical science behind the DSM from its 3rd edition onward, is called “factor symptoms cluster analysis.” Quite a mouthful but simple concept once it is parsed and enumerated, element by element.

1. symptoms: these are the cardinal signs of an illness e.g., rash bumps and fever of chicken pox for instance. For sake of explanation I will grossly simplify all this and not get into such controversies as only a few symptoms in the world of medicine are truly unique and totally specific to an illness, which is called “pathogonomonic.”

2. all the symptoms that are clinically observed to appear in someone with the illness being considered are grouped together (clustered);

3. many cases and aggregated together, the more the better as in statistical sampling, it is a basic precept that the larger the sample size, i.e., the more people that are surveyed in a public opinion poll, the more accurate the groupings will be;

4. many clinicians, psychiatrists, are involved in pooling all these cases together as no one psychiatrist could have thousands of cases active of the same kind of symptom bearing patient illness;

5. a sorting process takes place in which it is determined, often in the early days before true computerized high speed sorting, counting and grouping could be performed, by manually grouping together cases that shared the same symptoms sets;

6. a name was discussed and commonly agreed to; its more specific subtypes were worked out with the addition of ‘qualifier’ description terms such as acute, subacute or chronic to give a simplest example (but one no longer used nowadays…);

7. confirmatory field trials were the performed utlizing the resulting description diagnostic criteria sets so generated and the members of the large working DSM edition task force would meet periodically, present cases they had found within their own worlds of practice and case by case debates would ensue whether the offered case “fit.”

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How Much Does It Cost To Take Psych Meds?

For years as a psychiatrist I have observed the pharmaceutical companies charge huge amounts for every new psychiatric medication. This started in my view with the emergence of Prozac ( generic: fluoxetine) in the late 1980’s. Suddenly this drug cost several times what previous antidepressants had cost before Prozac. I felt later that part of what happened was the Big Pharma watched intently as the Reagan administration deregulated industries and let the “market forces” take over. They saw no enforcement or regulation of higher prices. They priced Prozac accordingly higher, much higher. But since Prozac was supposedly the best thing since toasters, and a ‘new’ class of antidepressant, many people were willing to pay the higher costs and the insurance companies largely followed suit and covered it.  All other classes of medications, antibiotics, blood pressure medications, etc., also took the initiative and priced their emerging drugs to market from then on and we had a spike in health costs as medications nationally became a higher cost for everyone including corporate entities since companies are now to be considered “citizens” due to the Supreme Court’s Citizen v. United States decision.

Perhaps a review of the drug pricing cycle is in order for the non medical professional reader. Drug companies have by law for decades, a 20 year exclusive right to a medication from discovery and patent filing, through research and development, drug trials and approval. This usually takes on average approximately 10 years. Then when a drug comes on the market, it is a “brand name” drug and its pharamceutical company can price it at whatever level they wish until that 20 year total is met. Then the medication goes “generic” and can be manufactured and sold by any other company after FDA approval in the generic pipeline which is much much shorter.

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