Sunday, June 07, 2015

Is Psychiatry Monolithic? Can You Rule Out Mental Illness By Reading Someone's Journal/Sketchbook? And, The Murphy Bill Returns

A few things from around the web:

In The Myth of Monolithic Psychiatry, Dr. George Dawson takes on the question of "Is Psychiatry Monolithic?"  I didn't know what that even meant, but now I do, and this is a terrific piece and well worth the read.

Over on the Marshall Report,  former APA president Jeffrey Lieberman gives his opinion on the notebook the Aurora shooter mailed to his student counseling center psychiatrist before he killed innocent people in a movie theater.   Based on his review of the notebook, Lieberman was able to conclude:
His chief complaint and reason for seeking help at the university health center was related to interpersonal issues and anxiety. He does not reveal what would be considered psychotic symptoms. The major issues are his alienation, disaffection, isolation, fear and anger. No mental disorder is clearly apparent. 

Wait, do psychiatrists do that -- rule out the presence of a mental illness -- without so much as meeting the patient?  I guess I missed that part of training.   I'd also like to add as an aside that while I have no idea if the shooter had a psychotic illness or was responsible for his actions (alas, I've never met him), I do think that intense psychic pain should fall under the rubric of what psychiatrists treat even if the symptoms don't add up to meet the DSM Chinese menu criteria for a specific mental disorder. 

And the text for the 2015 version of the Helping Families in Mental Health Crisis came out on Thursday.  The text of the new congressional act is 173 pages long, nearly 40 pages longer than the last version.  Pete Early did a stand up job of getting right on it and comparing the new bill to the 2013 text in  Murphy Introduces Revamped Bill.  Outpatient Commitment is apparently no longer required, but states who adopt it will get extra funds, which I guess I find less objectionable, sort of.  And there are some limitations on ending privacy rights for psychiatric patients which I think might do a better job of serving the intent of loosening these requirements.  I'm still not a fan of singling out psychiatric patients as the only people who can't instruct a doctor not to release information about their care.  And finally,  I'm not sure how Murphy is planning to make more psychiatrists -- our field is already in a shortage situation, and psychiatrists are aging out of the field, with the majority of psychiatrists who are currently in practice now being over age 55.  Personally, I think the only way to get more people into the field is to subsidize medical school for those who go into the field.  As it stands now,  many medical students just can't take on the astronomical educational debt and still manage on a psychiatrist's pay.  

I'm still not sure I support the new version (Oh, I haven't read it and don't know if I will) but this does seem better.  Do check out Pete's post.

And to those who've commented on our decreased rate of blogging, rest assured that we're making good progress with our upcoming book on involuntary psychiatric treatment.



moviedoc said...

Jeff's statement does not say that Holmes does not suffer from a mental disorder, only that such a disorder is not "clearly apparent." The notion that "everyone needs therapy" comes from what Jeff called the "brilliant fiction" of psychoanalytic theory, what I call shrinkthink. Everyone who has "issues" is not mentally ill.

Dinah said...

I will contend that if your "issues" are such that you have psychic torment, can't finish graduate school, have difficulties in making relationships, and are drawn to the idea of killing strangers, then it's perfectly reasonable to offer psychiatric care. There are "issues" and there are "issues." I don't think we should hold up the DSM and say, 'Look, only 4out 5 symptoms, you're not mentally ill and you're not our problem.'
It's as though psychiatry would say that if we don't have a drug for it, then you don't have a problem.

Dinah said...

Also, I agree that everyone does not need therapy. Some people want it for their issues which may range from momentary distress to a pervasive inability to work and to love, to simply the concept that therapy helps them process difficult issues in their life and makes life work more easily. Reading Oliver Sacks' autobiography right now, he's been seeing the same psychiatrist, now twice a week, for 50 years. Do you begrudge him that? If you're not mentally ill, but you're thinking of killing yourself because of financial or romantic fiasco, is it 'shrinkthink' to see a therapist until the issues feel resolved?
I'm not so much arguing as saying that the lines here are blurry and the idea of dividing people into those with or without mental illnesses feels artificial. We are all people and sometimes we have problems. Some of those problems get better with medications and some do not.

bluejonah said...

Limiting a psych patients right to privacy? And people wonder why mental health has so much stigma. I know it is meant to be for "parents and caregivers" (whatever that means) but the thought of it makes me cringe. I never told anyone about my suicide attempts (I'm 33 and this was 7 years ago) and voluntary commitment. The reason I never told them is because I'm an adult. You don't get a say in my treatment unless I ask you. My father's a control freak. It terrifies me to think that my parents could have any input or say about my mental health. One of the reasons I don't see a psychiatrist in my area (and manage my depressive disorder myself) is that I live in a small town. And boy do the healthcare workers love to gossip about "the crazies". So, when I see something like "limiting psych patients right to privacy", I immediately think "See! This is why people don't ask for help". If anything, there needs to be more repercussions to those who violate a patients right to privacy. When do we ever hear about that?

Also, LOVE the blog and visit it daily. I miss clinkshrink. Her specialty is so fascinating.

Dinah said...

I, too, worry that denying patients privacy is stigmatizing and might dissuade others from getting care. The intent is to include family members when people are very sick -- so sick that they need help with transportation and procuring medications. I think that it's still problematic, but somewhat helpful to limit the information to diagnosis, appointments and medications, so that parents can't call and demand information saying "You have to give me information, my son has no HIPAA rights." The intent is to help get followup and care for a very compromised group of people, not for someone who is not psychotic and says 'I don't want my parents to be included because my father is an intrusive control freak.' I can see no logic to giving this information to anyone who does not live with the patient.
But I could be wrong -- perhaps it will become standard to give this information to the housemate/caretakers of all patients upon their psych hospital discharge, even if they object and even if there is nothing to indicate that they can manage their own care, but I hope not. The truth is that few people would object -- most people are more than happy to have family included in their care and inpatient psychiatry has gotten so rushed that people are routinely told information can't be released because of HIPAA before anyone even asks a patient for permission (which they well might give). I've even heard stories of family members who couldn't get information when the patient had a signed release in their charts.

Who knows -- the Murphy Act still needs to pass and this version seems to include funding, so we'll see.

Jen said...

It's all relative. There's a shortage of teachers, particularly special ed teachers, right now. No, our loans aren't as large as med school loans, but given our low ultimate salaries, they are exactly comparable. In fact, if you look at the math, teachers generally come out with "astronomical" debt and no way to ever pay it back based on our low salaries, relative to physicians, including psychiatrists, whose relative loans-to-salary are far less "astronomical" and actually have a far more realistic shot at paying it back.

Your analysis was elitist, upper-class and self-centered. There won't be any more psychiatrists, or physicians, period, if teachers were to taker on your attitude.

And as far as limiting privacy!? I can't believe you're even trying to justify it. Does a cancer-ridden patient who is "so sick that they need help with transportation and procuring medications" give away his/her right to privacy and his/her family is automatically brought in and given information about his/her " diagnosis, appointments and medications!?" Of course not. Where's the question?! People with mental illness are people, with the same rights as anyone else, so long as they are not a danger to others.

Dinah said...

Jen it is relative and I imagine there are many people in other crucial professions who take on unreasonable, exorbitant debt which they can't afford, but this is a psychiatry blog and I'm only addressing psychiatry. Part of the shortage of psychiatrists is that people go to medical school and take on debt to do so --not uncommonly $300,000. They get to the point of deciding on a specialty and they can go into psychiatry (a wonderful and rewarding specialty) or a high paying specialty where they may make 5 or 6 times the salary, so perhaps they choose a much higher paying specialty. When I applied to some med schools, they sent a brochure out telling you how much you would be paying per month if you took out the maximum med school HEAL loans -- I needed more than that and I had college debts so this didn't begin to approach it -- the monthly payback was more than a resident's salary, so I did not apply to those very expensive medical colleges. I'm suggesting that loan forgiveness for going into a shortage field might increase the number of psychiatrists, and this is commonly done to get people to work in under-served geographic areas. It doesn't have anything to do with the fairness of the salary-debt ratio of any other field.

I do believe that if you're in a hospital with cancer or dementia or a disabling condition that it's not at all uncommon for either a doctor or nurse or social worker to meet briefly with you or your family to discuss follow-up, transportation, or medication instructions and that is what this is about. I imagine that for the family to be brought in, the patient would have to tell someone who his family is and how to reach them, there is nothing that says that a health care provider could (or would particularly want to ) instigate a manhunt. Personally, I think psychiatrists have brought a lot of this on by holding families at bay. The law specifically says family members can give a doctor information about the patient, and that right has always been protected by the first amendment. Personally, I really have not found this to be an issue -- if I feel really strongly that I need to have a family member involved, then my patients have allowed it. Often they want to bring family members, some bring one to every session. More often the issue is that the spouse refuses to be involved when the patient wishes they would be.

ClinkShrink said...

Thank you bluejonah, you're very kind. It's nice to be appreciated.

Jen said...

A field where psychiatrists routinely charge $400 for 45 minutes should not fall into a field which qualifies for loan forgiveness. Period. Loan forgiveness generally applies across fields ONLY for those who work in public service. Work in a private school? Doesn't qualify for loan forgiveness. Even 10 years of public service in a public school will only qualify for a percentage of your loans --- in part because they are so much less then med school loans. Private practice therapy or private practice medication management is about as far as possible to get from public service. Let's not conflate the issues. Of course the fairness of the salary is relevant. Loan forgiveness for private practice psychiatry is absurd -- it totally defeats the point.

As far as patient privacy laws, you're twisting the issue. The point is the right to privacy, and psychiatric patients have every much of a right to privacy as patients in any other specialty. You do not know and cannot say that "most" people want their
family involved. At best, you can say "most" [of your patients] may have wanted that. You certainly do not work with the majority of psychiatric patients throughout the country. As you have pointed out so many times, your patients are self-selected for the most part and from a specific demographic.

As only one example, and from a somewhat self-selected sample myself, when I was hospitalized (for depression/suicidality, no history of violence, no psychosis, no personality disorder, 100% able to manage full time work and full time school at an ivy league grad school) they wanted my family to be involved. I objected, strenuously. I was told multiple times by multiple people in charge that I would not be discharged until I agreed. I was younger and more stubborn then and stuck it out and would not permit my family to be contacted. I had my own, valid, reasons. Eventually, they couldn't keep me any longer -- I was a voluntary patient, had protective factors, and was no longer a danger to myself. My state has no law like that in effect and I did not appreciate the coercive tactics used - most that were couched in very similar language to yours. I cannot begin to imagine how I would have felt - or how violated I would have felt - had there been a law in place forcing me as an intelligent, capable, independent, functioning adult to yield my personal, stigmatizing health information to someone else.

Anonymous said...

I don't want my family involved with treatment decisions. Had this been law when I was in college I would not have talked to a psychiatrist, because I would have worried about them talking to my parents behind my back. What will likely happen is that it will piss many patients off, and then they will move even further away from their family. I've mentioned before what happened when NAMI told my parents to question me repeatedly about whether I was taking my medications. All that ended up doing was creating conflict between my parents and myself. Luckily they got a clue and stopped doing that. I am an adult, and I expect to be treated like one. I did not provide any contact information for my parents when I first began seeing my current psychiatrist, so luckily if this mess passes he wouldn't be able to contact anyone in an emergency even if he wanted to.

Another problem with the bill, among many, is the financial incentives provided to psychiatrists who use EMR's. EMR's are not secure, and they never will be. Major security breaches happen all the time. The government even has a database full of these examples. If and when my psychiatrist chooses to put my private medical data at risk like this is the day I stop going.


Steven Reidbord MD said...

"psychiatrists routinely charge $400 for 45 minutes..."

Wow. I need to double my fee.

Dinah said...

Your response to Steve Reidbord was insulting, so I'm not publishing it. I've decided that open hostility squelches discussions.

You've made your point that psychiatrists make significantly money than teachers and you feel it's not reasonable for people making a large hourly income to suggest that loan forgiveness might be one way to entice people to go into a shortage field.

Let's move on.

RB said...

Yes, it is all relative. In my state the auto repair shops hourly rates are now approaching what Dr. Reidbord alludes to as his fee. I know it does not all go to the mechanics but most of them do not take out college loans for their education either. And, regardless, it is still coming out of my pocket.

On a lighter note, I ran across this quote today. I found it quite funny even though I don't partake of psychotherapy.

“I quit therapy because my analyst was trying to help me behind my back.” Richard Lewis

catlover said...

From my position of not knowing all the details, but helping relatives who have serious mental or physcial problems, I think a major problem is those HIPPA releases - those could be streamlined! Maybe a release that will work at multiple providers or for a few years, instead of families having to keep track of this health system, that one, the hospital, and oh there is that clinic over there, need a release in place for each and every place you go, and gotta do them all once a year. .. and even if there is a release, the medical records people will hassle the heck out of you and want their own release etc. It's a pain for anybody who is really sick and needs family help and the clinic workers don't remind family members Oh, it's another year, gotta fill out paperwork again. . . family just finds out surprise! The release is out of date now and here it's a crisis and they can't even find out when the next appointment is so they can take their relative who doesn't drive and can't manage their own calendar to that appointment. This is a problem for ANY patient who is lacking some competency (physical or mental abilities) whether it's mental illness, just getting really old, or are really sick and run down.

I would not have gone for mental health care if my family had access. It's just plain wrong. Usually I had the opposite experience in the hospital than another commenter - I wanted family involved, and the hospital staff did not want to deal with it. Not that they thought it was wrong, just didn't want to take time to call my husband.

Anonymous said...

I agree with bluejonah that this legislation stigmatizes people with mental illness. If you notice the patient is not even in the title of the legislation. The priority is what the family members want, and that's the wrong focus. Family can already be involved against the patient's wishes if the patient is incompetent, so why would we take rights away from those who are not incompetent to make treatment decisions? Under this law I could refuse medication while inpatient, but I couldn't refuse my family being informed about the treatment I refused? How does that make any sense?

Another problem is inpatient psychiatrists may know little if anything about the patient-family relationship. So, this could end up creating a lot of unnecessary stress for the patient. Sometimes patients don't want family involved because it makes things worse. We cannot discount the voices of patients who do not want their families involved, particularly since these decisions are going to be made by many psychiatrists who don't know anything about the patient-family relationship. That's not fair to patients.

Many patients may want their families involved, so get them to sign a release. And, as catlover said make it easier for patients and families who do want others involved to be involved.

Hopefully the democrats will oppose this.


Anonymous said...

I had one last thought on this. Per the legislation (if I read it correctly) the psychiatrist cannot tell the family about treatment, etc if there is documentation of abuse in the family. What could end up happening with patients who feel strongly about their records not being released against their wishes is that they may make a false accusation of abuse. I would hate for patients to feel that that was the only way they could ensure their privacy was protected.


Anonymous said...

In the times I have been hospitalized the absolute WORST part of the experience is the utter lack of respect shown me by hospital staff (doctors, nurses, "psych" techs, social workers, even the freaking cafeteria staff). Every time I went in hospital I signed a "patients' rights" document giving me the right to refuse treatment and every time I told them I didn't want to take whatever scary drug they wanted to try I got grief for it (including threats of a six months long commitment where I could be forced to take them). Every time I was in hospital I told them explicitly, verbally and in writing, that I did not want my family involved and every single time they actually let my mother into the hospital to visit and forced me to either visit with her or make them remove her. The doctors and social workers discussed my care with her, hypothesized on my prognosis with her, and formulated release plans with her (without involving me). One of these release plans was that I, a 50 year old woman with a graduate degree and a full time job (which I was managing fine) and my own home (also managing fine), would have to agree to live indefinitely with my mother if I wanted to be released from the hospital. Every attempt I made at making decisions about and managing my own care, from medication decisions to determining what therapy sessions would be useful to planning for release, was considered "treatment resistance", and I was punished for it. When I complained about this absolutely unprofessional and probably illegal violation of my rights I was told, verbatim, "once you are behind those locked doors, voluntary or involuntary, you have no rights."

So. All these proposed new laws that I read, with their helpful attempts to infantilize psychiatric patients basically make one thing very clear. The next time I am in crisis and need help I will stay as far away as humanly possible from the mental health industry.

Sorry for the rant. Love you guys. I miss Clink too. :)

Joel Hassman, MD said...

I think too many here want to pontificate or argue semantics, but, it is a simple truism at the end of the day:

Politicians have no business, nor expertise, to set standards for mental health care, and for the life of me, why do so many colleagues either abdicate, or just dismiss, how disruptive politicians and non-clinician trained administrators set the bar for mental health care needs?

I'll give you my hypothesis: I think so many psychiatrists over the last 20 years are so pathetically cowardly or uninvested in being true advocates for mental health care, they just want to make sure they make their best income stream at the end of the day, they don't care what is lost and disrupted in the process.

And, if that hypothesis is true, then they violated the oath they took at graduation of medical school, and have no business calling themselves physicians. Oh, that is almost true at the end of the day. We have a bunch of psychopharmacologists out there, not psychiatrists!

Biopsychosocial model, what is that to most psychiatrists these days? I want to ask the owners of this blog to offer a true moment of candor and honesty, did the 2015 APA convention really display a reflection of the biopsychosocial model?

Or, is it either too painful to admit I might be right that is not the agenda of the APA today, or, do some or all three of you reject that model as the basis to effective mental health care today?

I honestly say this at the end, I don't care if you don't print this comment, I think the fraud that is psychiatry today as a whole is so condemnable, I don't know how people who say in public they care about the state of affairs in mental health then go out and do things that don't practice what is honest and true mental health care.

I leave those of you with this if the comment is allowed: I see more and more patients in the private practice I work in now shrink in participating in therapy because (A)Obama(nation)care is making deductibles so high and unaffordable, that people are forgoing therapy and just wanting to see a psychiatrist, or anyone to prescribe, to sell the "biochemical imbalance" model.

And there it is, we have allowed people who have no business dictating the course of care get away with doing so. And, the APA, in their infinite wisdom, is complicit and condoning. Think about that, APA members!!!

At least patients who come into my office, more often than not, either agree or at least respect my point of view. We are doomed, folks!

Thank you for the opportunity to comment.

Joel Hassman, MD

Unknown said...

I was surprised that Lieberman concluded that Holmes was not insane without interviewing him. I have not read the journal nor have I interviewed Mr. Holmes. However, the kind of paranoia that Holmes espoused would have to make anyone who know about these things think about a diagnosis of some kind of mental illness. I have been thinking about what Clinkshrink would say about this whole situation.
I miss you Clink Shrink.