Shrink Rap: Grand Rounds is up at Emergiblog

Check out this week's Grand Rounds on Emergiblog.

Notables:

• Doctor Anonymous' BlogTalkRadio interview of NeoNurseChic about her chronic headache pain.
• Dr Deb Serani blogs about the Mental Health Parity law.
• InsureBlog discusses the Personal Genome Project.
• Colorado Health Insurance Insider writes about autism and insurance.
• The Anesthesioboist takes on Descarte's mind-body dualism.

Where'd Ya Go?

I'm going to tell you that I haven't found that treatment termination goes quite the way they say it should go in the textbooks. By and large, my patients haven't had a pre-defined end date where we process the meaning for months beforehand then stop, never to see each other again. Psychotherapy, I've found, ends in a more fluid and phased-out way without a whole lot of talk about the meaning of ending.

So people come in pain and distress. I usually suggest they come weekly, at least until they feel better, and we continue with that until they say they'd like to come less often, then we go to every other week, then monthly, then "call me when you want to come in." It's hard for me to figure out my schedule more than a month ahead, so there are people who call when they do and everything isn't planned out, and there are people who finish with regular therapy session who still need medications and they come in for a session every few months.

Sometimes, I realize that I just haven't heard from someone in a long time--I think more about the people I'm seeing and not so much about the people I'm not seeing, so sometimes I realize after quite a long time that I haven't seen someone (sometimes the pharmacy calls for a refill and this jogs my memory). If I realize someone's fallen off my radar, and it hasn't been so long that I'm embarrassed to call, I call. Often this prompts someone to ask for an appointment. Sometimes I hear that all is well and they're fine. Once in a while, I don't reach a real person and I never get a call back. If it's someone I only saw briefly, I don't worry about it-- people know how to find me. Patients sometimes reappear years later, some only come when they're in active distress and the rest of the time they don't want to talk. Whatever.

So every now and again, someone I've been meeting with regularly and for a long time simply disappears. They don't return calls and I have to let it go-- no one wants to be hounded or stalked by their old shrink. A couple of times, I've had the sense that the disappearance is more meaningful than "I'm done"...either they've canceled a regular weekly therapy session to fade into the sunset, or they've disappeared more benignly, but after years of treatment and no response to my "I've been thinking about you" phone calls. It's unsettling to me; I wonder how they are and I'm usually left with the nagging sense that something must have been said in the last session that was upsetting, but now can never be addressed. Oh, and I guess I can also wonder if they disappeared because of something on the blog.....

What I Learned Part 3

ClinkShrink is blogging from AAPL meeting she is attending.
Click HERE for Part 1 (she'll even tell you what AAPL stands for).
Click Here for Part 2.

So, the clinical vampirism presentation taught me one main lesson: I'll never understanding how the program committee chooses which presentations to accept. The speaker presented an overview of the historical role of blood in ancient cultures and religions (remember our blog posts about Moche indian culture?), then he presented his own proposed typology of blood-seeking behaviors, then he presented two cases to illustrate that typology. The first case was your basic Goth who drank his girlfriend's blood (consensually) then beat her to death. The second case was a sad one about a psychotic killer who decapitated his mother, her bird and the family dog. (Note to future speakers: please warn your audience if you're going show autopsy photos during the time slot right before lunch.) I really don't think we need a new classification system to understand these behaviors, but there you are.

One of the next presentations was a nicely done study of violent female offenders in one Connecticut prison. These women essentially all had very early onset of conduct disordered and antisocial behavior with high levels of substance abuse and childhood trauma. I'm not sure it says as much about the women themselves as it does about the criminal justice system: in order for a woman to get sent to prison they have to be really really pathological, at least compared to men.

Next up was an update about human subject research in correctional psychiatry. The Institute of Medicine is in the process of reviewing the Code of Federal Regulations as it applies to prisoner research. As it stands now the regulations are restrictive to the point that inmates are being denied necessary research into the best practices for correctional health care. New IRB regulations will help ensure that projects are designed to give a clear risk-benefit analysis to proposals (as opposed to doing generic research on 'systems' issues or institutional issues).

Then I went to the Computers in Forensic Psychiatry presentation, an annual tradition that I as a geek always enjoy. Once again, computers don't always behave in public the way the geeks plan. After some fiddling and tweaking I saw some fun new gadgets, including a pen that electronically records everything you write and uploads it to organizing software through a USB port. Pretty wild. It can also record up to 100 hours of audio.

Last but not least, I went to an update on the US v Hamdan case. Hamdan was Osama Bin Laden's chaffeur, and was the subject of the landmark US Supreme Court case in which Sandra Day O'Connor declared that a "state of war is not a blank check for the President." In other words, that the President could not unilaterally create his own separate legal system. Hamdan has been a Guantanimo Bay detainee since shortly after start of the Afghanistan war (except for one month spent in a suspected secret CIA facility in northern Afghanistan). Anyway, two of Hamdan's lawyers spoke as well as the forensic psychiatrist who spent 120 hours evaluating him. While the legal issues were pretty egregious, in the back of my mind I kept wondering how I could testify, if placed in a similar position, that this person would not participate in future terrorism. I mean, what in psychiatric training would really qualify one to testify to that? If there was clear evidence that he was not a central conspirator, as they suggest, then why would they really need a mental health expert to testify to that fact? It seemed to be a situation where political ideology dragged mental health into a realm that it was never designed for. If AAPL feels strongly that mental health professionals should not assist or participate in interrogations (a position I agree with) then perhaps they should also encourage members not to express opinions about the future dangerousness of suspected terrorists---an area for which data is lacking, to say the least.

So that was my third day.

What I Learned Part 2

Click here for Part 1


So today I started out with a presentation on ethics training in forensic psychiatry. The most useful portion of that was an overview of teaching techniques used to bring out ethics discussion among students. The presenter gave demonstrations of mock trial testimony, videotaped assessments and vignettes involving ethical issues. I thought that was a nice way to keep people engaged and to challenge them a little bit.

Next was a presentation on neonaticide. It started with a presentation of a neonaticide case, then went on to a discussion of national 'safe haven' laws and judicial waiver laws for teenage abortion. A survey of courts in one state revealed that nearly two-thirds of the courts responsible for providing judicial waivers were not educated themselves in the waiver laws. (This reminded me of one of the presentations from yesterday---only 5% of surveyed judges knew what a 'standard error' was in relation to scientific tests, although all judges were responsible for being able to interpret scientific evidence.) The neonaticide talk ended with a videotaped interview of a woman who had committed neonaticide over 20 years before. I've interviewed neonaticide perpetrators so that itself wasn't new to me, but I did enjoy seeing a video of a young Phil Resnick doing the interview. I learned that if neonaticide perpetrators go on to have additional children they generally don't have parenting issues and don't reoffend. (I don't know what base rate data they have on that though.)

The poster sessions were better today. I liked the summary statistics of one state's competency referrals; only about 5% of all defendants were referred for evaluation of competency to stand trial, and on the average it took two months of treatment to restore the defendants who were found incompetent. One rather clever poster presented the results of a study done in Arkansas, where they looked at PRITE scores for psych residents before and after the founding of a forensic psychiatry fellowship. They found that the forensic psychiatry subscale of the PRITE improved significantly when comparing two year pre- and post-fellowship data.

In the afternoon I attended the peer review session that examined and critiqued videotaped testimony. I give extra brownie points to the AAPL members who volunteer their work product for review---the audience is NOT an easy crowd. But it's a good educational experience.

Finally, I attended the session on evaluation of chronic pain and disability. This is not something I commonly do, which was why I thought it would be good to attend. I received an excellent review of the neuroanatomy of pain as well as an overview of how to do a thorough impairment/disability evaluation. One of the speakers presented a meta-analysis of studies looking at litigation and compensation in relation to chronic pain. Not too surprisingly, there was a correlation between levels of reported pain, impairment, and the amount of compensation.

So that was Friday. Tomorrow: forensic aspects of clinical vampirism (I can't wait), false confessions, new landmark cases and computers. Stay tuned.

Click HERE to see what ClinkShrink learns in Part 3.

Parity as Bogus Bail-out Bonus?

[credit: flickr user The_Leader]

Nice to see Clink sharing her AAPL learnings with us, as the forensic experts try to understand the behavior of forensic bogeymen (or the gender-neutral bogeypeople) like Freddie and Jason.   Just in time for Halloween. 

I was struck by the total lack of understanding by two nay-sayers in yesterday's Opinion column in the Baltimore Sun.  Richard Vatz and Jeffrey Schaler often write about the so-called "myth of mental illness", taking a page from the 1960 Szasz book of the same name.

In the newspaper article, they lambast our legislators for using "political legerdemain" to sneak the long-negotiated Mental Health Parity Bill into the $700B bank bail-out bill.  Their opinion is that the category of "mental illness" is too broad and too costly, and provides an impression that most people with a label of mental illness are actually just whiny babies who can't accept the responsibility of dealing with "problems in living", like death, rape, or loss of job/house/401k/spouse.  They write:

"• Supporters of parity celebrate the new law as signaling the end of "stigma," but they fail to consider that stigmatization is a marvelous negative reinforcer for undesired behavior, some of which is called "mental illness." 



• Substance disorders are arguably a function of behavioral choices and in no way constitute diseases to which insurance should apply. Such self-destructive behavior is best explained by mindset, personal values and how a person copes with his or her environment. Incidence varies by cultural context, and people can clearly stop or control their addictions through an exercise of free will. Not so when it comes to bodily illness; one can no more will away cancer, heart disease or diabetes than he or she can will their onset."

Lack of understanding.

They appear to also have a lack of understanding about how our health care system works for other (non-mental) illnesses.  One of the reasons they are against parity is that "there is no way to accurately confirm or disconfirm 'mental illness' ."  The same could be said for many somatic problems, such as headaches, back pain, nausea, and fatigue.  However, our health care system will pay for treatment of all these conditions, no matter how minor or subjective.  There is not a severity-based system where only physical conditions deemed worthy or severe enough get covered.  If you go to the doctor for a stubbed toe, the insurance company will pay for the visit and the Xray.  So, unless they advocate just as strongly for similar changes to the rest of health care, this argument does not hold water. 

By the way, I also did not like the fact that the Parity bill was tacked on to the Bail-out bill, but only because I think such a bill should pass on its own merits.  

And with Halloween right around the corner, what is truly frightening about their article is that one of the authors is an associate editor for the Psychology section of USA Today magazine, and is thus in an influential position to control what the nation's population of hotel customers and other readers get to read about these topics.  [Correction: I think this is USA Today Magazine, which appears to be a very different animal than the newspaper that gets placed in front of every hotel room door every morning... still...]

Boo!

What I Learned Part 1

For new readers, it's a ClinkShrink tradition to report on the annual American Academy of Psychiatry and Law conference, which is being hosted in Seattle this year.

Today was the first day of the conference. It began with an excellent keynote address by AAPL president Dr. Jeffrey Janofsky, who talked about reducing inpatient suicides. He presented the result of an interesting quality assurance study done at Johns Hopkins Hospital which applied the principles of "failure mode and effects analysis" (FMEA) to the problem of inpatient suicide. He found that there were over 40 potential failure points with 90 possible causes, all of which could lead to a completed suicide. FMEA is a process developed for use in manufacturing but which is more recently being applied to hospital-based medical errors.

From there I went to a debate over the treatment of Dangerous Seriously Personality Disordered offenders (DSPD), people committed indefinitely for treatment under Britain's DPSD act. There was some debate over whether or not the costs of confinement outweighed any potential benefit, but almost no practical discussion of whether or not the treatment actually benefitted the offenders which I think is a more relevant issue. The more interesting point that came out was a discussion of Hollands TBS sentencing system. This allows judge, at the time of sentencing, to determine a proportional amount of criminal responsibility for an offense and to assign the offender to either a hospital or a prison for the amount of time proportional to that responsibility. In other words, if you're found 60% responsible and 40% impaired you'd spend about half your time in a treatment facility until you 'earn' your way out to a prison. It's an interesting idea. It has reduced recidivism from almost 50% to around 17%.

In the afternoon I attended the obligatory serial killer talk. There has to be one at every meeting. In my early forensic days these were the talks you looked forward to because they were the most intriguing. Now after several years of forensic work I find them mostly very speculative and theoretical. The only data-based statement I heard was that about a quarter of all sadistic serial killers were also masochists. I heard a lot of psychoanalytic speculation. Too much speculation. The only definitive thing I came away with was the knowledge that the BTK killer looked lousy in women's lingerie.

The best presentation was given by members of the American Academy of Forensic Sciences. I try to make their presentations every year because they've uniformly been fascinating. This year's presentation was about arson investigation and how electrical causes of fires leave certain predictable traces. It was great. Then the president of the AAFS, an attorney, gave a presentation about how lawyers use the Internet to investigate expert witnesses. That was great too. She gave a run-down of common Internet diploma mills and talked about the infamous case of the famous hypnotherapy expert witness, Dr. Zoe Katze. If you haven't read this, it's worth a trip to follow the link. And here I spent all that money getting re-credentialled in forensic psychiatry.

So that's how I spent my day. There were loads of poster presentations I'm not going to review here, because frankly a lot of them weren't that great. I'm getting picky in my old age when it comes to conference material.

More to follow. I'm off to dinner now.

Oh yeah, I'm on the 46th floor of a 47 floor hotel. The view is terrific, but not quite as good as the view from the top of Seneca Rocks:


Click here to see what ClinkShrink learns in Part 2.

Another Way to Waste Time

My children do it, for hours on end.
My patients talk about it, a lot.
I tried, there was nothing to do. I sat there alone. My children called me Creepy.
I thought I had it figured out that it's the domain of a very distinct demographic group, one to which I don't belong: the 14 - 30 year olds.
Then, suddenly, I realized that the old folks were doing it, too. I found Fat Doctor, there she was, with lots of friends. I found a bunch of my friends, I said Hi.
Time: it evaporates, but nothing happens. No calories get burned, nothing gets produced, consumed, washed, folded and nothing gets done. Even the connection is kind of vapid, meaningless, and somehow I can better rationalize the other silly things I do-- the hours of email, the blog, the unpublished novels. This, I don't quite get it or why I'm spending my time this way.
Facebook, of course.

Okay, I have to make this about psychiatry, so I'll ask this: is it a boundary violation to Friend your patients on Facebook? To accept when they Friend you? And how hurtful is it to refuse a patient's Friend request? Is it creepy to look at a patient's profile?

No, this hasn't come up, but one of the residents mentioned to me that they feel weird when the psychiatry faculty members want to Friend them on Facebook and it got me thinking about all the unwritten rules. My kid tells me her teachers won't be their Facebook friends until after graduation. I'm told a romance is really only valid if it's on your profile, and Facebook only allows you to post that you're in a relationship with someone if that someone also agrees to the status. And how do we even begin to deal with "unfriending?"
Is it my imagination, or was life just a little simpler way back when?
And, oh, if I haven't met you in real life, I don't want to be your Facebook friend. Please don't be insulted.

Mindsite: Free "Full-text" DSM4, Diagnostic Tools for Depression, Bipolar, ADHD, etc

I don't know where most people go when they want to look up DSM4 diagnostic criteria on mental illnesses, but Mindsite.com looks like THE place to be.

I Googled dsm4|"dsm 4"|dsmiv|"dsm iv" (to get all iterations of possible searches -- no, I didn't expand it to the other 8 options of adding "TR" with or without a space), and here are the top 5 hits:

1. PsyWeb: has some illness criteria, though 3 of their 6 nav links are to Xanax, Valium, and Ativan, pages which contain Buy Xanax Here ads (first link lists "DSM Disoders" ... smells fishy to me).
2. Wikipedia: nice history of the DSM.
3. AllPsych: lists many more of the DSM4 diagnoses, and includes Symptoms, Etiology, Treatment, and Prognosis.
4. DSM-IV-TR: this is the official APA site, though it does not have any DSM4 content on it, nor does is list in its FAQs where to buy it (huh?).  It does list the contact email for copyright permission requests.
5. PsychNet-UK: which lists a portion of the diagnoses including Criteria, Cause, Treatment, and Pharmacotherapy.

So, Mindsite lists 9 different chapters of the DSM (Mood Disorders, Sleep Disorders, Personality Disorders, etc) and lists the FULL TEXT from the following DSM sections:

• Diagnostic Criteria
• Diagnostic Features
  
• Associated Features & Disorders, including Lab Findings and Physical Exam Findings
• Course
• Specific Culture, Age, & Gender Features
• Prevalence
• Familial Pattern
• Differential Diagnosis
• Specifiers
• Recording Procedures

Take a look at their Major Depression page to get a feel for how complete this is.  It feels like I have the actual DSM book right in front of me.  This is the most complete version of the DSM on the web that I am aware of.  (No, this is not a paid endorsement... I am genuinely impressed with the content here.)  They also have illness "portals", containing links to diagnostic tests and community discussion sections.  There's probably more here... let us know what else you find in the Comments.

I interviewed David Eraker, Mindsite's founder and CEO, by email over the past month or two and learned some other bits about his site:

• they pay big bucks to the APA to license the DSM-IV-TR content, so it is legit.
• at this point, the revenue model is advertising, but I haven't seen any of that yet.
• contains about half of the DSM4.
• at least 28 diagnostic tests, most from the WHO's CIDI, which was developed at Harvard.
• he prefers Redfin to Zillow.

I hope to get him on a podcast soon (if we can ever get back to doing them... we will!) to tell us more about their plans.

An Adventure A Day Has Kept ClinkShrink Away

Oh dear. I really have been negligent. Dinah has been working hard to carry on Shrink Rap single-handedly---and done a smart job of it too---while I've been frittering my time away hanging from rocks. But more about that later.

So here is my post. Late, short, but better than nothing.

So I've been hearing a lot lately that I may be rather crazy, or at least lacking in good judgment, for my newest hobby. Dinah has suggested that I could use it as the starting point for a blog post, and I think that's a good idea.

For the past couple months I've been off rock climbing. It's something I've always wanted to try but couldn't convince my friends to try with me. Unfortunately, for the kind of climbing I do you actually do need a friend to go with you to hold the end of the rope. And the friend has to be someone you trust completely. Given that Dinah refused, repeatedly, to hold the end of my rope it took me a while to try this hobby. Now that I've done it, I'm hooked.

So how does this relate to psychiatry? Wow, there are a lot of take-off points here. I could talk about the difference between intelligence and judgment. I could talk about issues related to trust and how you choose the people you trust. Or---and this is my preference---you could talk about risk-taking behaviors in general.

My prison patients are risk-takers. They grab opportunities to make a quick buck, get revenge, blow off steam or just blow up. The problem with my patients' risk-taking behavior is that it gets them into trouble with the law.

I rarely see pro-social risk-takers because they channel their proclivities in ways that are either beneficial for them or at least don't injure others. Pro-social risk takers are people who start businesses, explore new countries, try to set new world records or who 'boldly go where no man has gone before'. They are the adventurers and visionaries.

Why do these folks fall into one category versus the other? And what makes people risk-takers?

I think there are three things that interact here: inheritance or biology, environment (including things like socioeconomic status and resources) and individual life events or experience.

Risk-taking is a character or personality trait that exists in everyone across a continuum, like extroversion or neuroticism. People are more or less risk-taking and open to new experience. There's a biological basis for many personality traits, and risk taking does seem to be heritable. Risk-taking or sensation-seeking tendencies may co-exist with impulsivity, but not always. Non-impulsive risk-takers take the time to plan their risks---to take reasonable precautions or safety measures and to weigh out the odds (or in the case of rock-climbing, make sure the rope is anchored soundly) to maximize the chance of success. If you've grown up in a disadvantaged neighborhood where the school drinking fountains are laced with lead, you're more likely to be an impulsive risk-taker (or one of my patients). Thus, environmental factors can influence the way an inherited trait is expressed.

The third and final way is through life experience. You can imagine all the life-changing events that could influence risk-taking behavior---watching the market crash, for example, is probably putting a damper on some economic risk-taking right now. Similarly, someone who is given a diagnosis of a terminal illness might decide to uncharacteristically go on a round-the-world trip. You get the drift.

As far as my risk-taking is concerned, it's basically just for the fun of it. Thanks for bearing with me, my fellow Shrink Rappers.

And thanks for the pic.

Washington State Task Force Recommends Changes to Laws

An article by Carol Smith in the Seattle Post-Intelligence discusses a task force's recommendation to the state's involuntary commitment laws after a man with a psychotic illness murdered Sierra Club worker Shannon Harps last year.

James Williams, a repeat violent offender with severe schizophrenia, has been charged with first-degree murder in Harps' death. Williams, who was under community supervision at the time of the murder, wasn't complying with court-ordered treatment and had been off the medications that helped control his violent hallucinations when he allegedly stabbed Harps to death.

Community corrections officers supervising Williams used every tool the system provided to try to keep Williams in treatment and out of trouble, said King County Prosecutor Dan Satterberg, who convened the task force to examine the case.

"The bottom line -- they ran out of tools, Mr. Williams was let out and 10 days later he was charged in Harps' death," Satterberg said.

Their recommendations noted in the story:

1. Change the state's involuntary commitment laws to mandate treatment for those with a significant history of violence.
2. Provide more tools for enforcing outpatient treatment in the community.
3. Reduce privacy barriers so police can know the mental health histories of people they deal with in "real time."
4. Allow those who make involuntary treatment decisions more leeway to consider past history of violence.

This issue of compulsory treatment is gaining more and more supporters, usually after this or a Virginia Tech-like story.  It is something our society continues to struggle with -- the balance between civil liberties and the right to control one's own body on one side, and public safety and the responsibility that society has to "help" vulnerable people.

I see the pros and cons on either side.  Personally, I think that when one's illness interferes with others, particularly other's safety (think epilepsy and driving, TB and isolation, STD and contact reporting), that is when society has a responsibility to intervene.

Resources:

1997 King County Mentally Ill Offender Task Force Recommendations

2008 King County Mental Illness and Drug Dependency (MIDD) Oversight, Implementation and Evaluation Plans

Details on the Implementation Plan (1.3MB Word doc)

PS: My apologies to the readers for my extended absence.  If you knew what was going on in my life, you'd understand (all is well, though).  A big Thank You to Dinah for keeping the flame alive!!

Shrink Rapper Goes Politico!

I'm so tired of it: the debates, the fuss, the arguments, the question of what species Vice Presidents like to shoot. I'm counting down the days.

Fortunately, there's now a new option:

Subject:
New Presidential Candidate... It's someone we know!

There's an effort to elect an unknown random person as President... and it's a Shrink Rapper! Watch this online video about the surprising new nominee:

Click Here to Watch!

Jot back a comment to let us know what you think!

We're in Psychiatric News!

I wish my co-bloggers would come back, I'm suddenly tired of holding up the blog on my own. Sigh...it's okay if I whine?

So we're in a story in Psychiatric News on Psychiatrists in the Blogosphere. The interviewed Roy, but please do note that the man pictured is not our Roy.

Fat Acceptance

I don't know too many women who are happy with their weight. It's a topic that comes up often in psychotherapy, and the degree of someone's distress seems to have little to do with the patient's actual weight: slim, fit women are often obsessed with wanting to be a few pounds lighter, and while heavier women also wish to be thinner, their distress isn't proportionally more-- so someone who is 50 pounds heavier than they'd like to be is not necessarily 10 times more distressed than someone who is 5 pounds heavier than they'd like to be. And outside of therapy, in the course of conversation with friends, oh, it seems if you stick people in a room for long enough, the subject of weight and diet becomes inevitable.

It seems we've all signed on to the idea that thinner is better and thinner is healthier. We take this as a given and somehow it's something we've bought into so strongly that we don't even question it. It's unhealthy and that's the refrain, but we also think fat people are fat because of laziness, lack of self-control, bad habits, and "how did she let herself get so fat?" In essence, it becomes okay to blame people for being heavier than we think they should be, and often they agree.

Okay so...and you knew I was going here...in today's Sunday New York Times Magazine, Robin Marantz Henig writes in "Losing the Weight Stigma" :

Scientists who study obesity at the cellular level say genetics determines people’s natural weight range, right down to the type and amount of food they crave, how much they move and where they accumulate fat. Asking how someone got to be so fat is as meaningless as asking how he got to be so tall. “The severely obese have some underlying genetic or metabolic difference we’re not smart enough to identify yet,” says Dr. Rudolph Leibel of Columbia University Medical Center. “It’s the same way that a 7-foot-tall basketball player is genetically different from me, at 5-foot-8.”

Fat has been blamed for cardiac trouble, diabetes and some forms of cancer. But fat-acceptance activists argue that the epidemiological studies that link fatness to disease often fail to adjust for non-weight-related risk factors found more often in fat populations. Poverty, minority-group status, too much fast food, a sedentary lifestyle, lack of access to health insurance or to nonjudgmental medical care, the stress of self-loathing and being part of a stigmatized group — all are more common among fat people, and all are linked to poorer health outcomes at any weight. This makes it harder to say to what extent an association between obesity and disease is due to the fatness itself or to the risk factors that tend to go along with being fat.

It remains an open question, one deserving of further scientific scrutiny, whether the health risks seen in fat populations are caused by the fat itself or by something else. Only then can we really know how to effectively wage the war on obesity — or if such a war even needs to be waged.

Henig makes the point that there are many slim people with cardiac disease, diabetes, and cancer (illnesses associated with being overweight) and that half of overweight people-- and a third of obese individuals--- have normal blood pressure, cholesterol, and blood sugars.

The issue of "health" gives credence to the belief that it's best to be slim-- but regardless of the health issues, as long as thinness is equated with attractiveness, we might all still want to be a little thinner.

Mental Health Parity and The Financial Bailout

Two days ago, I got an email from one of those psychiatric organizations I belong to. The Senate would be voting on the Wellstone Mental Health Parity bill. Huh, I thought, isn't the country in a financial crisis, isn't the Senate supposed to be addressing the issue of whether to 'bail out' the disaster on Wall Street? Some 700 billion dollar problem? Mental health parity is nice, but why on this particular day.



In the middle of the day, I got a romantic text message from hubby: The Senate is rolling mental health parity snuck into the bailout package.

The Wall Street Journal Health blog has a piece about it-- it's short, so I'll copy it here:
_______

Senate Folds Mental Health Parity Into Wall Street Bailout Bill

Posted by Jacob Goldstein

For those Health Blog readers who didn’t manage to read every line of the ballyhooed bailout bill the Senate passed last night, allow us to direct your attention to page 310 (Title V, Subtitle B), home to the “Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.”

What’s a mental health bill doing in a piece of legislation designed to grease the gears of global finance? Turns out, it’s just a bit of Congressional housekeeping.

The Senate and the House both passed the mental health bill last week. The bill requires mid-sized and large businesses that offer mental health coverage to provide benefits that are comparable to the benefits provided for physical ailments. It was a compromise years in the making, and drew broad support.

The bill passed the House as a standalone measure but was folded in with other legislation in the Senate; in order to send the bill off to the President (who supports the bill), both houses have to pass it in identical form.

Enter the bailout bill. It could be the last major piece of legislation passed by Congress this year, the AP says. And it gives Congress a chance to get the mental health parity bill on the President’s desk to be signed into law — provided the House of Representatives passes the bailout bill this time around. House leaders are cautiously optimistic that the bill will go through, but they’re not making any promises, the WSJ reports.

Sen. Ted Kennedy, who has worked on mental health parity for a decade, was the lone senator not to cast a vote on the bailout legislation. He missed it due to his continuing battle with brain cancer.

Photo by dbking via Flickr