Questioning the Rules

Good morning.  I'm sending you to look at two articles today, both by or about people who have been on our blog before.

Over in the New York Times, Robin Weiss has a fabulous article about her work with a patient who wanted to know details of her personal life, "The 'rules' of psychotherapy."  Dr. Weiss talks about how revealing such information goes against the 'rules' of psychotherapy, and she discusses reasons why she decided that in this case, it made sense to break the rules.  She writes:

As therapy continued with her, I heard how flat and tinny I sounded whenever I attempted to analyze what was going on between us. When I lapsed into too clinical a mode, our connection would wobble, and her alienation became palpable.

In contrast, as I began, in the face of her challenges, to let down my guard, our alliance grew stronger, and she became open to treatment. We would laugh together about her bringing me just the right greeting card or a flower from her garden — exhibiting her need to challenge “the rules” and exposing my need to interpret her actions. These interactions helped develop her capacity to observe herself in action, as she courted me in her Sherpa style.

I may have been a slow student, but eventually I understood: I was the one who had to change. From then on, when she saw that look in my eyes, I said yes, I did have a migraine. We followed episodes of the TV show “ER” together, and I told her where I was going when I left for vacation.

I like the flexibility this articles conveys.  All patients aren't alike, they (and their psyches) don't all follow, or even know, the rules. It's good to question things when the treatment doesn't seem to be working.

And in the New Yorker, Jeff Swanson, a medical sociologist at Duke, is interviewed for an article by Maria Konnikova for "Is there a link between mental health and Gun Violence?"  Dr. Swanson has a wonderful idea: instead of preventing people from owning guns because they have a psychiatric diagnosis, we should prevent people from owning guns because they are violent.  Konnikova writes:

In all of his work, Swanson has found one recurring factor: past violence remains the single biggest predictor of future violence. “Any history of violent behavior is a much stronger predictor of future violence than mental-health diagnosis,” he told me. If Swanson had his way, gun prohibitions wouldn’t be based on mental health, but on records of violent behavior—not just felonies, but also including minor disputes. “There are lots of people out there carrying guns around who have high levels of trait anger—the type who smash and break things,” he said. “I believe they shouldn’t have guns. That’s what’s behind the idea of restricting firearms with people with misdemeanor violent-crime convictions or temporary domestic-violence restraining orders, or even multiple D.U.I.s.”

DJ Jaffe: The 4.2% (or the Us / Them Dichotomy)

Over on Pete Earley's blog, he gives the text of a speech by DJ Jaffe, a mental illness advocate.  Mr. Jaffe contends that those with serious mental illnesses constitute 4.2.% of the population and those people can be differentiated from the rest of the population, including the 20% of the population in any given year who have DSM diagnoses which are "mainly minor illnesses like anxiety." Jaffe would like to see those with real mental illnesses, who aren't the worried well, moved to the front of the line for services.  

I've ranted before about how I still don't know who those mentally ill people are -- I did a poll on this on Shrink Rap and got results from 696 people and wrote about the results Here and Here.  I've been in private practice for over 20 years, and have worked at 4 different community mental health centers, including a stint volunteering at HealthCare for the Homeless.  Many of the people I see spend most of their lives doing very well, and for Catlover who commented on the post on The Violent Mentally Ill, I'll add that when they are well, they are indistinguishable from everyone else: they go to work, they care for their children and parents, they are doctors, lawyers, teachers, the heads of companies, and they do amazing volunteer work and give generously to charities.  And when they are sick, they suffer, can't get out of bed, miss work, stop eating, and feel suicidal.  Some of these very well people hear voices, have delusions, and shut down.  Some of the mentally healthiest people I know are also some of the sickest people I know -- it simply depends on what slice in time you catch them, and the sick part can be a very brief, but life changing, slice.  Many people I see have been hospitalized at some point, have attempted suicide, or have needed 4 or 5 medications at a time in order to be well.  

But Mr. Jaffe is right: there are some people who are chronically ill, who never get well, and who aren't going to work and contributing to society.  They cycle from the jail to the hospital to the street, and very frequently (as in almost always) this population includes people with substance abuse disorders.  Does it matter?  If someone cycles from the jail to the street and back again and they have a substance abuse problem which contributes, do they deserve less help than the person who also has a mental illness?  What if they have a personality disorder that destroys their ability to function, have relationships, hold a job, maintain housing, and live in a meaningful way in society?  And if you're in the midst of a terrifying panic attack, who decides if your problem is "mild?"  I don't like the Us/Them split with the idea that there is a clear divide.  We're all people, we all hurt sometimes, and some of us need more help than others : diagnosis is not the thing that determines that.    Nearly 40,000 people a year die from suicide; they aren't all obviously ill and sometimes we are left to be totally shocked.  400 physicians a year (the equivalent of an entire medical school) commit suicide and they probably weren't falling in Jaffe's listing of the severely mentally ill who cycle through jails and hospitals.  When people commit suicide, or school shootings for that matter, there were often subtle signs, but most of these people weren't in that 4.2% and weren't the obvious severely mentally ill. 

If you're suffering, you're suffering, and we need better services, available more readily, for everyone. The teenager who kills himself because he is distraught over a break up is just as dead as the man with chronic schizophrenia who dies on the street.  We need more and better treatments for substance abuse, and we need more and better treatments for those mental illnesses that are resistant to the medications that are available now.  We need more ACT teams, more housing (because it's hard to get your medicines if you have no address to get your check and no shelf to put them on), more peer support, more transportation.  Offering help to those who suffer but don't have severe, chronic, and persistent mental illness should not be equated with stealing services from those most in need.   

[This weather calls more for a snowy owl theme, I think. --Clink]

 

The Violent Mentally Ill

There's been lots in the news lately about forensic hospitals and the management of violence by psychiatric patients. Here's a short list:

1. Beyond the Gates of Gomorrah

A new book by Dr. Stephen Seager, a tell-all about his work in a California forensic hospital.

2. Broadmoor

A very rare documentary filmed within the walls of a British forensic hospital. In two parts, all on YouTube:

Ep 1 http://youtu.be/bNifHcZV_4Y  Ep 2 http://youtu.be/QNlGxWe-z6s 

3. Clinical Psychiatry News

My recent column, a review of new California guidelines for the treatment and management of inpatient violence. 
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Note from Dinah: the birds have nothing to do with the post, but I don't like it when Clink is too lazy to add a graphic.  Aren't they cute? 

Abilify: It's Really Expensive!

Sometimes, I like to bother pharmacists.  They are the nicest people, and very patient about looking up medication costs for me.  Once, I wrote a post called The Co$t of Being Depressed, where I compared the cost of anti-depressants. Today,  I'm writing over on our Clinical Psychiatry News website about The Surprisingly High Cost of Abilify. 

Here's the short form, but do surf over there for details:
I called three pharmacies and compared prices on Abilify.
Please remember, this data is for three pharmacies only

• A single 2 mg tablet cost between $30 and $33 dollars.  More don't cost appreciably less per pill so a 90 day supply ran $2700 at a local independent pharmacy to $2724.81 at Wal-mart.  If you do the math, you'll realized that at Wal-mart there was some discount for bulk : the pill price for 90 tablets is about 30 cents/pill less than for 90 pills. 
• A single 30mg tablet runs $38-$47.  
• A 2mg tablet costs the same as a 15mg tablet --which is the same as a 5mg and 10mg tablet
• A 20mg tablet costs the same as a 30mg tablet.
• It costs a whole lot less if you split the pills.
• This stuff is expensive.

 You'll note the graphic above is an animated Abilify commercial.  I hope the pharmaceutical company appreciates the free advertising.

Out of the Hospitals & Into the Jails?

Over on Saving Normal, psychiatrist-blogger Dr. Allen Frances has put up a thought provoking article called We Should All Be Ashamed.    Frances asserts that closing the state hospitals was the wrong thing to do : those patients now live on the streets and cycle through the jails.  We haven't freed them, he says, we've abandoned them.  Frances goes on to say that Dr. E. Fuller Torrey is right: our society needs laws that allow us to force those who need help into care and Representative Tim Murphy is right: we need to pass the Helping Families in Mental Health Crisis Act -- one that mandates states to have programs for involuntary outpatient commitment.  

Frances concludes:

Is there any possible way to get this train back on track? First, implementing Tim Murphy’s Helping Families in Mental Health Crisis Act (H.R. 3717) would be a good start. Second, Congress should abolish the IMD (Institution for the Treatment of Mental Disease) exclusion. In fact, I personally believe that the federal government should get out of the mental illness treatment business altogether. They have been in this business since the passage of the CMHC legislation in 1963 and it has been all downhill. Let’s give the responsibility – and the federal money—back to the states and then hold the governors accountable for the results. They cannot do worse than we are doing now. Third, there needs to be further modification of state involuntary treatment laws and increased use of assisted outpatient treatment (AOT) and conditional release so that the small number of seriously mentally ill individuals who need these kind of services can be treated before they end up homeless or incarcerated. These three steps alone would go a long ways toward improving the treatment system."

Over the years, we've see lots of controversy about these topics on Shrink Rap and as you know, we are working on a book called Committed: The Battle Over Forced Psychiatric Care, so an article like this catches my attention.  

Surf over to Saving Normal, read the whole thing, and I'll invite you to return and comment here, if you'd like. 

What Happened to You in the ER?

I'm writing about what happens in the Emergency Room from the perspective of a psychiatry resident (the doctor who is training to be a psychiatrist).  I'd like to include  a couple of quotes from patients who have been through the experience of going to an Emergency Room with a psychiatric crisis. They would be short quotes -- though you're welcome to tell me the longer story.
~The ER visit needs to have been within the last 2-3 years
~Must be in the United States only
~I'd need the name of the state
~I might want to talk to you to verify that you are a real person
~I would not include your name or any identifying information, but you could make up a pseudonym. 
~Of interest would be how many hours were  you in the ER and who did you speak with there? Did they share with you their thought processes on disposition -- for example, "I'm afraid you're at risk so I'm admitting you,"  or "I'd like to admit you but there are no beds,"  or anything along those lines.
~Thank you for adding your voice!

On a related note, there has been a lot in the news recently about "boarding" in psychiatric ERs and you may be interested in this article about ER boarding in The Orange County Register by Bernard J. Wolfson: Psych Patients Pack Emergency Rooms
Wolfson writes:

Once they get to the ER, patients with mental health disorders are are often held without treatment for many hours, or even days, while they wait for a psych bed to open up – or for an assessment to determine they don’t need one. In an ideal world, those patients would be seen much more quickly, by qualified professionals, in a setting intended specifically for handling urgent psychiatric cases.

Brandon Marshall: Football Player with Borderline Personality Disorder

This is a short post to send you over to Clinical Psychiatry News where I wrote an article on an NFL.com television special "A Football Life" special about Brandon Marshall, the Chicago Bears wide receiver, who struggles with borderline personality disorder.  It's not often that I get to write about football and psychiatry in the same post, and I always like it when successful people are public about their psychiatric disorders -- what better to help de-stigmatize conditions that are erroneously associated with people who have been marginalized?