Monday, October 31, 2016

Reviews of Committed: The Battle Over Involuntary Psychiatric Care

Happy Halloween everyone!  Please don't dress up as a psychiatric patient, it's not funny, and depicting people with illnesses in harsh ways is...harsh and insensitive, promoting stigma and fear.

In addition to Halloween --and yes there will be candy at my house tonight --- tomorrow, November 1st, is the official publication date of our new book, Committed : The Battle Over Involuntary Psychiatric Care.  The printer got a little excited and released the books to Amazon (and maybe some libraries) a bit early, but our hard-working publicist, Gene Taft, at the Johns Hopkins University Press has been trying to keep things under wrap and he's done a fine job.

As the publication date has approached, there have been some reviews, and I'd like to list them in one place.

Dr. Damon Tweedy wrote a wonderful review in last Sunday's Washington Post: The Heated Battle Over When to Commit a Patient Involuntarily to Psychiatric Care

Dr. Rebeccah Twersky-Kengmana wrote another terrific review in Clinical Psychiatry News called "Committed Takes a Non--Patronizing Approach to Involuntary Care."

Blogger Kazen in Japan writes for Always Doing --Because Thinking About Reading isn't Enough. I do hope you'll read the Always Doing review because it really captured what I wanted the reader to get from the book.  (Feel free to also purchase the book).

And one of our colleagues, whom I believe wishes to remain nameless, wrote the nicest review on a Facebook page, so I'm stealing it hear, namelessly: 

I just finished this book, written by two people I am proud to call friends and colleagues, and one which highlights and tells the story of many of my other friends and colleagues, on all sides of the issue that the book covers. It is a marvel of balance and completeness, and of shared ideas and vigorous debate regarding differences in opinion. In a world that seems to be becoming increasingly polarized, this book is an object lesson in how to discuss contentious issues while still getting along.
None of us has a monopoly on "the truth" because in the area of involuntary treatment, there is no single, unitary "truth." I recall struggling as a psychiatry resident with issues of autonomy versus my rudimentary ideas about what would be "best" for a patient. I recall losing sleep - for patients I let go, and also, differently, and over a much, much longer term, for patients I may have wrongly retained.
This book forces the reader to confront issues related to self-direction, to the adverse impact of mental illness on decision-making, to the battles being fought over where the line is that should legally permit the involuntary treatment of a person who does not want it.
Buy it, and read it. You will learn much, and perhaps, just perhaps, get a sense of where the "other side" is coming from.

Updating on 11/1/16: a Wonderful review on Pete Earley's blog:"While books of this nature often are text book boring, COMMITTED is not. One reviewer credited the “care and consideration” that went into the book for its readability."
I'll add more as reviews come in, and on Thursday I'm going to write a bit about the process that went into writing this book in a post for the Johns Hopkins University Press blog, which I'll post over here as well.  Before I even do that, I do need to thank so many of our readers, both here and at Clinical Psychiatry News, who first made us aware of what a troublesome and complicated issue forced care is, and who opened themselves us to telling us their stories and sharing such painful parts of their lives with us.  You know who you are, and thank you so much.  If you were an integral part to the book, a copy was sent to you with the pre-release batch weeks ago.

 So if you're interested, Amazon is happy to sell a good quality, hard copy of of our book, representing many years of work by two psychiatrists for the low price of $15, or $12.99 on kindle.  

More soon, I'm just sharing my excitement. More fun than thinking about Anthony Weiner's laptop and the upcoming election.

Saturday, October 22, 2016

The Heated Battle Over Involuntary Committment

So often I write blog posts about topics I read about in the paper.  I take a few quotes and expand upon them.  Today I want to look at book review by Dr. Damon Tweedy, a psychiatrist at Duke University and author of Black Man in a White Coat: A Doctor's Reflection on Race and Medicine.  Only this is a little different. Dr. Tweedy is reviewing a book that We wrote!  And a fine job he did, if I do say so myself.

So from the Washington Post, to appear in print tomorrow, Tweedy writes about
 Committed: The Battle Over Involuntary Psychiatric Care 

Here, they explore forced psychiatric care, perhaps the most polarizing aspect of a controversial profession. The result is a highly informative and surprisingly balanced book that should be read by anyone with a personal or professional stake in how the mental health system provides care to those with chronic severe illnesses and those in acute crisis.

Miller and Hanson take us on a journey across America, where we witness significant variability in how states approach the issue of forced care. In some states, patients must be deemed imminently dangerous to themselves or others (i.e. high risk for suicide or homicide) for forced treatment, while in other states an inability to provide for basic needs due to mental illness is sufficient. The process of commitment also differs. California, for instance, does not require a formal psychiatric evaluation before patients can be involuntarily admitted to a psychiatric hospital, while in Maryland an evaluation must be done before admission and requires the input of two physicians or psychologists. Until recently, doctors in Virginia could not use the input of family members in assessing a person’s potential dangerousness.  

And finally:

Although “Committed” explores a complex subject, Miller and Hanson make a great effort to humanize this discussion. In each section, they introduce us to individuals — patients, family members, advocates, lawmakers, emergency-room doctors, psychiatrists, police officers and judges — involved in some aspect of forced treatment.

Thank you, Dr. Tweedy!

Thursday, October 20, 2016

Attend a Penn Conference on Ethics and Correctional Mental Health for Free

Ah, technology.  The Scattergood Foundation is having an all day conference on Ethics and Correctional Mental Health today in Philadelphia.  No the conference is not free, but I imagine there will be time to get a cheesesteak (whiz, please) and if you've lived in Philly, you'll understand the reference to Cheese Whiz.  

The Conference is being lived streamed, so you want to learn about ethics and mental health care in our jails and prisons, do consider attending, in your pajamas if you'd like.  

Here is the information:

Ethics and correctional Mental Health Conference live stream from 8:45 AM 
Watch the live stream of speakers:

 Follow tweets:

Sunday, October 09, 2016

Is Everyone's Experience of Mental illness the Same?

When I was in high school, one of my friends got mono -- infectious mononeucleosis or kissing disease.  He had a minor sore throat and, because his girlfriend was quite sick with mono, he went to the doctor and was tested.  He tested positive, but unlike his girlfriend, he never got sick and said, "Well, I haven't tried to run a mile, but I'm pretty sure I could."  Still, there is no doubt that both young people had been infected with the virus and one got sick while one did not.

One of the things I learned from the extensive research we did for our forthcoming book,  Committed: The Battle Over Involuntary Psychiatric Care  is that not every has the same experience of the same illness or the same treatments.  Okay, I didn't have to write a book to tell you that, I see it in my office every single day with every single patient.  Why does one person get a severe tremor to Wellbutrin while another with similar symptoms just gets better with no side effects? Why do some people need psychotherapy while others get better from a pill?  Clearly psychotropic medications don't agree with some people, and clearly they don't make everyone with psychiatric illness all better, but there is a contingency of people who feel that since medications were for bad for them, they are bad for everyone.  They are wrong. 

I wrote a blog post about a NY Times op-ed piece last week called "Medicating a Prophet" by Penn psychiatrist Irene Hurford.  She works with young people with psychosis, and I'm going to guess that she seen patients with a range of experiences.  In her op-ed piece, Dr. Hurford makes the point that there are people who like their psychotic symptoms, who gain some comfort from them, and who suffer when they lose their delusions and get smacked with the awful reality of their illness.  She doesn't say that there are not patients who are tormented by their psychosis and I'm going to make the assumption that she has met many paranoid, uncomfortable, and suffering patients -- psychosis is not fun for most people.  Dr. Hurford further makes the point that forced care can be traumatic-- and, as we write in Committed,  it can be for some people, even if it is appreciated by others.  I read from her article not that psychosis never leads to violence, but that rare, extreme acts of violence are rate and extreme and shouldn't be what sets public policy.  She is not the only psychiatrist I know of who is not gung-ho on making forced care easy policy, and I know several forensic psychiatrists who work with the most violent of patients on a daily basis, and still don't see involuntary treatment as the way to prevent these acts.

DJ Jaffe has an article over on Policy Madness in response to Hurford's NYTimes article.  He writes in "Policy Madness: Serious Mental Illness is Not Enriching:"

The New York Times recently ran an op-ed declaring that being psychotic is “enriching,” and arguing against involuntary treatment of the psychotic. “The assumption that someone else’s reality is invalid can foster distrust; it sends the message that we don’t respect this person’s experience of his or her own life,” wrote Irene Hurford, an assistant professor of psychiatry at the University of Pennsylvania. This romantic, Pollyannaish, and false view of psychosis is rampant in the mental-health system, regularly parroted by the media, and dangerous to both patients and public.

Jaffe goes on to talk about people with psychosis who have killed, and how assisted outpatient treatment can be live-saving.  He talks about how nurses who treat psychiatric patients have emergency buttons, but those who treat psoriasis don't.  Well, there are several cases, at Harvard and at Johns Hopkins, where surgeons have been shot by disgruntled family members.  Maybe everyone needs emergency buttons.  

I want to borrow these articles to make the point that there is no single reality.  Some patients find their psychotic symptoms to be tormenting.  Some may find their private reality to be enriching, especially during a mania.  Some patients with psychiatric disorders are dangerous.  Some people get in cars after they've been drinking or using drugs and are dangerous.  And some people are just angry and dangerous.  Please, let's not assume that the experience or the needs of all people with mental disorders are the same.  And let's not even assume that psychiatrists are the same -- some are quicker to prescribe, and some are quicker to commit patients to hospitals.  Often studies of violence outcome look at acts like slamming doors or shoving someone.  While I have no doubt that psychiatric treatment, especially treatment done with with the doctor on the same team with the patient, saves or at least enriches lives, there is no evidence beyond the anecdotal that forced outpatient care prevents murders, mass murders, or even suicide, or that other, more collaborative methods might be more effective. 

And please, don't even consider reading this and thinking that I believe there aren't situations where the only option is to force a very sick patient to get involuntary care.  I just don't think we should assume all people with psychotic disorders have the same experience.  

Tuesday, October 04, 2016

More On Forced Psychiatric Care

For years -- over 10 to be a bit more exact-- we've had controversy here at Shrink Rap when we've talked about forced psychiatric care.  It's a controversial topic not just for patients -- some who have benefited from it and some who feel injured by it, but also for psychiatrists who vary in their own views about civil liberties and medical paternalism.  Ah, as I'm sure our regular readers know, it inspired us to write a book, Committed: The Battle Over Involuntary Psychiatric Care, and I do hope you'll read it.

 I was pleased to read "Medicating a Prophet," in this past Sunday's New York Times.  Psychiatrist Irene Hurford  adds to the idea that there is not a single truth about involuntary treatment as good or bad, and that this is a complex topic where there may be more than one reality.  Dr. Hurford writes:

Proponents of enforced treatment often point to horrific but rare events, like mass shootings, committed by people with mental illness. But psychosis alone is only a modest risk factor for violence. A 2009 study of more than 8,000 people with schizophrenia found that those who did not abuse drugs or alcohol were only slightly more likely than the general population to be violent.

There are several studies that demonstrate that assisted outpatient treatment can reduce the risk of hospitalization, arrest, crime, victimization and violence. Few, however, are based on high-quality randomized controlled trials. A 2014 meta-analysis of three randomized-controlled studies of more than 700 people found no statistically significant benefit of enforced outpatient care in reducing hospitalizations, arrests, homelessness or improving quality of life.

It can be devastating for families and doctors alike to watch psychosis seemingly claim the lives of those we love or care for. And in some situations, brief episodes of enforced inpatient or outpatient treatment may be necessary. But in my experience, weeklong inpatient stays, or yearlong outpatient treatment regimens, can do more harm than good when they engender distrust. Perhaps we must accept a new reality — to truly engage people in treatment we need to understand their own experience of psychosis and its treatment.