Sunday, March 03, 2013

What This Shrink Rapper Would Tell Congress

Recently one of our readers posted this comment:

“If any Shrink Rapper ever has the time and inclination it would be interesting to read about what you would do to fix the mental health system, particularly the issue of involuntary hospitalization, if you had unlimited funds and political resources. You've been in the trenches, it would be great to hear your thoughts.”

Simultaneously, over on Peter Earley’s blog I see that he is planning to testify next week before a U.S. house subcommittee regarding issues related to violence and severe mental illness. He is asking for people to contribute responses to six specific questions he expects to be asked. Please go over there and contribute your ideas---this is your chance to make a difference.

Meanwhile, I have my own thoughts about this which may or may not be directly relevant to the six questions, but I want to bring this to the attention of the subcommittee if Mr. Earley would be kind enough to include it. For those of you who want the "bottom line," I've underlined my main ideas.

First, a bit about why I think my experience and ideas are relevant.

As a forensic psychiatrist, I evaluate and treat severely mentally ill people who are or have been violent. I see the rare exceptions, the people who as a result of their disease commit acts that seriously injure or kill others. As a correctional psychiatrist I have also evaluated and treated thousands of prisoners, many of whom also have serious psychiatric disorders.

I will emphasize, as you've already heard from others, that violent offenses due to psychosis are the exception to the rule. Almost all crimes of violence are not committed by people with schizophrenia or other psychotic disorders. Drug and alcohol abuse is the culprit in most violent crimes and we must vigorously address this and do more to provide treatment to people with substance abuse problems at the time that they are willing to accept treatment.

From evaluating insanity acquittees, people who are found not criminally responsible for  their crimes due to mental illness, I’ve learned that one significant systemic problem is the lack of public awareness about psychosis and how to recognize prodromal symptoms. Often the early symptoms get written off as attributable to some other life stressor: the breakup of a relationship, the stress of a young adult's transition to college or some other understandable life event. Sadness, withdrawal from family, loss of interest in hobbies or friendships can be explained in this context. However, as the illness gets worse and the patient's personality changes, there is more recognition that something serious is going on. Friends, neighbors and teachers recognize psychosis only when there is increasing disorganization, inability to complete tasks, or eventual bizarre behavior and unusual statements.

Therefore, my first suggestion to address violence due to mental illness would be to provide better public education to recognize emerging psychosis.

Once the psychotic episode is recognized for what it is, the challenge for families then becomes figuring out what to do. Finding a psychiatrist and getting prompt evaluation and treatment is a tremendous challenge particularly in rural or underserved areas. In southwestern Minnesota where I was raised, there is only one fulltime psychiatrist serving a seven county area of 70,000 people. Our local Baltimore City Detention Center has a higher per capita number of psychiatrists than my hometown. That has to change.

My second recommendation is this: the government needs to provide increased funding for medical education, particularly the training of psychiatrists. There should be additional incentives, beyond Federal public health service commitments, to work in underserved regions or state facilities.

All of my patients are institutionalized but most will return to the community eventually. Insanity acquittees typically are hospitalized for substantially longer than they would have been incarcerated if convicted. The majority of my mentally ill offenders are convicted of misdemeanor property offenses that are drug or alcohol-related, and return to the community within months to a few years. Regardless of the length of confinement, we need better programs to transition patients from a public institution to the community. Insanity acquittees and mentally ill offenders need housing, transportation, educational and vocational programs in addition to addressing their medical and mental health needs. Lack of adequate community services and transition plans are a key factor in unnecessarily prolonged hospitalizations.

Many recent high profile crimes have lead the public to demand looser civil commitment standards and easing of laws for involuntary treatment. In my opinion, this creates an adversarial atmosphere and unnecessarily sets families in opposition to their mentally ill loved ones. People with psychiatric illnesses have legitimate reasons to oppose confinement, and we should examine these reasons thoroughly and address them.

Some public psychiatric hospitals, of the few that remain, are antiquated and dilapidated. We need to improve environmental conditions of these facilities and address the poor ventilation, bad plumbing and faulty infrastructure. The inpatient unit should emphasize treatment plans that respect a patient's educational level, skills and interests rather than focussing solely on disability. Inpatient safety and security are increasing concerns, leading some patients to be strip-searched arbitrarily. We must improve hospital security to protect both patients and staff from physical assault. As a recent story in our local newspaper indicates, concern about violence is not limited to free society and must be addressed within facilities as well.

Finally, we need to reinvigorate collaborative treatment planning through the use of psychiatric advance directives. Make them meaningful and useful. Currently patients don't trust them because they know doctors can override them. Ironically, doctors don't trust advance directives for exactly the same reason---because they can be revoked by patients. We need to update psychiatric advance directive laws to make them binding, effective and safe, then make sure treatment providers are educated about their use.

Thank you for reading this far. We can’t make the system perfect, but I’m sure we can make it better.


Anonymous said...

Clink Shrink--thank you for taking the time to answer my question. You have some excellent thoughts, but there's one area that I think requires a much longer discussion. That is the area of emerging psychosis.

I know that people experience what are called, for lack of a better term, psychotic states, and I'm sure there are signs and symptoms of this that are recognizable. The most important question concerning such states, to me, is what do you do with them when you recognize them? How do you treat them, or even decide whether they need treatment? Many people, including some I've known, have one such episode and then continue on with their lives as if nothing happened. Some people find ways to reconcile their psychosis with day to day functionality.

My fear is that idea of recognizing so called prodromal states will inevitably lead to increased marginalization of people who experience these states, along with increased use of drugs to dampen these states, that will lead to a lifetime's downward spiral. There need to be much better, and more humane ways of helping people who are distressed by such states.

Note, that I say we should help people who are distressed by psychotic states. That word choice is deliberate. If somebody has perceptions that others don't share, I'm not sure we need to treat the person unless they are harmful to others, or unless that person is distressed by their state. We need to find a way to relieve people's distress, not just ways to salve our own discomfort with those that we perceive as "other."

About 35 years ago I picked God up hitch hiking. I knew I shouldn't pick up hitch hikers, especially since I'm a woman, but the road between Espanola and Durango is a long one, and I wanted some company. So imagine my surprise, when the hitch hiker told me he was God. We spent the next three hours or so discussing scripture and theology. He actually knew his these topics as well as I did, which is saying something. I never felt threatened by him. When we got to Durango, he asked me if I could spare any money and I gave him ten of my last twenty dollars and continued up the road to Salt Lake City.

Was he God, or did he need medication? Or does the answer lie somewhere in between?

Anonymous said...


You might be interested in this article about a psychiatrist who is using the "Open Dialogue" program that has been very successful in Finland.

All your points are right on target.


Anonymous said...

Hold on, does anyone have any actual data regarding the efficacy of current maintenance treatment methods over the longterm? I recall a study that appeared to show that schizophrenics in the third world fared better than schizophrenics in the first world. Of course, antipsychotics were massively used in the first world but I think not in the third world, at least for maintenance. I don't remember the reference, but googling produces indications of old as well as somewhat recent data showing that third world schizophrenics fared significantly better, when you'd think they would've fared far worse (if you thought drugs are effective). Tighter community and less stigma in the third world were offered as explanations. Interesting, isn't it? I should look at this more carefully myself.

Here's very recent data about the benefits of forced treatment in the West:

Conclusion of that analysis: the evidence shows that forced treatment, which as a rule involves forced medication, isn't useful in preventing harm to others or increasing quality of life, although it appears to be occasionally useful for preventing harm to the patient himself. In the vast majority of cases though, there appears to be no benefit at all. So it might be useful to try to discriminate and find the high risk patients among the larger pool of patients, rather than use force in all cases, if you must use it at all. I know, not very politically correct, and I'm not personally advocating any such compromise, I just think it's the lesser of two evils for those who don't want to accept they're not supposed to play gods in the first place.

In addition to no clear benefit found in most cases, harm resulting from forced treatment, such as loss of dignity and bad side effects, is significant as is well known, thanks to bitter revelations and exposes arrived at not at all inevitably through the activism of a few dissenters, as is typical. There are drug effects such as brain damage that can't presently be avoided even when the risk is known, and such effects can occur in most cases (brain damage) or in some cases (tardive dyskinesia). That's actually a big deal. And it's something the psychiatrists seem to think isn't information relevant to their patients or, apparently, even the legislature. Or they're not themselves willing to face the very uncomfortable realisation that they may be doing more harm than good in many cases.

Dinah said...

We don't have evidenced based studies that show that talking treats psychosis. I do have many patients with psychotic illnesses who find medications to be helpful and want to take them, but have no interest in talking. Forcing psychotherapy on someone who doesn't want it seems as intrusive as insisting people who don't want medications must take them.

This is not to say that on an individual basis that psychotherapy for those who want it, might not be beneficial. Medicines are not effective for everyone, some people are not willing to take them, and for those people, if they want psychotherapy, it is sometimes very helpful. Psychotherapy in combination with Medications seems to be the best we have to offer at the moment. I think it's harmful to think of it as an either/or for the overall treatment of everyone with a given condition.

There has been some evidence that treating prodromal states causes less morbidity for people who go on to have schizophrenia. This was part of the push to define such prodromal states as an illness in DSMV -- the hope of capturing and treating people early, and hoping this would enable them to live fuller, healthier lives. Unfortunately, these are studies of Populations, not individuals, so even if the overall is a positive, in terms of the individual, you capture some people who will not go on to become schizophrenic and treat them with medications that can harm them. If the medicines were cheap and harmless, it might make sense -- kind of like all those folks on aspirin and lipitor who may well never go on to have cardiovascular disease, even if you didn't treat them for a random cutoff of a certain cholesterol number which cites risk, not absolutes.

Anon is right: some people have a single psychotic episode, others have multiple episodes but spaced over decades, not weeks, and some find a way to reconcile their psychosis with daily functioning.

Most (not all) people I've seen with psychotic illnesses want medication and want it never to happen again.


Plain Anon said...

Great post Clink! It would also be good if someone would tell Congress to disallow insurance companies mandating that a patient has to get a 90 day supply of medication. I have to start paying out-of-pocket on some of my meds because they won't approve 30 day scripts anymore. Giving me a 90 day supply of meds is like putting a loaded gun in my house.

Liz said...

plain anon-- seriously? some companies are mandating ninety days! i feel your pain. back when i was on meds, my psychiatrist would only write a short script-- like two weeks or so. luckily my insurance never gave him any grief over it.

in general, here is what i want pete earley to say: PLEASE fund studies that are NOT drug related... PLEASE support treatment such as DBT that might take a long time and have a high up front cost, but WORKS IN THE LONG RUN. let's also encourage innovation in treatment-- what could be tried that isn't? what are some people doing (WORLDWIDE) that is working, and why?

Anonymous said...

I agree with a lot of the post.
I think the education part is good, but it's a slippery slope. We don't want people unnecessarily treated just because they are odd or introverted. And, then there's the added problem where if the patient rejects treatment for being odd and introverted, then someone may come along and say they have anosognosia, when they really just don't want/need treatment. That makes me a little uneasy. As long as we are talking education at that point, and not force, then I'm okay with it. THe irony is that we have Kendra's Law because a person who voluntarily sought treatment was turned away and subsequently caused the death of another person. I wonder how things might have been different if he had been able to receive the treatment he was seeking. Why don't we provide treatment to patients who want it before it's a crisis?

I think the link to the psychiatric hospital is indicative of how harmful some of these environments are for patients. Imagine not having the keys or any way to escape if another patient is threatening you. When a psychiatric hospital is so bad that it's become a place were patients who have a history of being sexually assaulted have to worry about being forcibly stripped and then in addition to that have to worry about patients there who may physically and/or sexually assault them then I think it's pretty safe to say they are better off not being admitted. If the only option is to admit a person who has a mental illness to a hell hole, then I think we're better off leaving them be. Surely we can do better than this.

catlover said...

I literally thought I was the antichrist for many years, every time I got depressed, and thank goodness the psychiatrists did not diagnose me with schizophrenia, or I'd be drugged to this day. The antipsychotics never helped my bipolar depressions one bit and made me so much worse off. But at least since it's bipolar, I have the choice to say no. I got counseling for sexual abuse, and the belief gradually went away, over a period of about a year (??? It was a long time ago). Before counseling, I spent many years trying to atone for my evilness, which was a hell of a thing. I wonder if a lot of people with psychosis have it because of trauma.

Anonymous said...

I bet that many do, not all but enough. I think my own psych issues are linked to that. After so many years on meds I can no longer know what my brain might have been like had someone early on figured out what was really making me crazy. Now I have lost track.