Time For A Change

Murky Thoughts posted a comment recently about an inmate wanting a sex change operation. I figured that was a natural lead-in to a short discussion about inmates' rights to treatment. Correctional folks already know this, but for those of you who are totally new to the field or who don't work in it this may be useful.

The constitutional basis for the right to treatment rests in the 8th Amendment to the Bill of Rights. This is the amendment which prohibits cruel and unusual punishment. When deciding whether or not something is "cruel and unusual" the courts look at the following factors:

• Does the punishment involve the wanton infliction of pain or suffering?
  
• Is it arbitrarily applied or excessive to the crime?
  
• Is it shocking to the conscience?
  
• Is it inconsistent with 'evolving standards of decency'?
  

Failure to provide medical care to a prisoner could lead to an excessive punishment if it leads to an inmate's death, a result clearly not intended by the sentencing judge in most cases. Untreated medical conditions can also obviously cause pain and suffering. The reference to 'evolving standards of decency' is a recognition that society changes over time; punishments that were used in Colonial times would shock people if applied today.

The landmark case which established medical treatment rights was the 1976 case Estelle v. Gamble. (Yes, the idea that inmates have any rights at all is barely 30 years old!) In this case the US Supreme Court declared that "deliberate indifference" to an inmate's serious medical need was cruel and unusual punishment. (In fact, if you sneak up behind a correctional person today and whisper 'deliberate indifference' you might get a startle response.) Later cases defined some examples of deliberate indifference: an officer who walked over the body of an unconscious inmate lying on the floor of the tier, or an inmate who was not taken for a medical evaluation in spite of obvious bone protruding from his broken leg.

The lay public tends to interpret the issue of treatment rights as a mandate to provide a customized HMO for each prisoner. Not so. The point of Gamble was to forbid institutions from denying access to care. If you lock someone up in a facility with no doctor, that inmate is barred from seeking treatment by the fact that he is in state custody. Here's a free society analogy: imagine if the governor called out the National Guard and ordered them to put up a perimeter around every hospital in the state, so that no one could enter. That would be an equivalent situation.

The right to treatment was expanded later in Bowring v. Godwin (551 F.2d 44, sorry can't find text online right now) in 1977 to include treatment for mental disorders. Case law later gave these examples of serious mental health problems: hallucinations or delusions, bizarre or disorganized behavior, and suicide attempts. Depression per se was not consistently considered a "serious" mental health problem by the courts.

Most correctional litigation since these cases have been class action suits against entire systems, filed by advocacy organizations or the Department of Justice to address infrastructure deficits. Individual inmates may file their own 8th Amendment lawsuits (also called '1983' suits, after the statute which allows institutionalized persons to sue state agents) in addition to state tort (injury) claims.

Getting back to the issue of the sex change operation, there has been established case law in various jurisdictions stating that gender dysphoria or transexualism, from a legal standpoint, is not a serious mental disorder. Thus, a sex change operation would not be constitutionally mandated. The thing to know about situations like this though is that a decision in one jurisdiction is not legally binding upon others. This case would have no precedential value for the country as a whole unless it was addressed & decided by the U.S. Supreme Court. Given the current membership of the Supremes, I wouldn't start buying any high heels just yet.

Then again, high heels would just be more cruel and unusual punishment.

(OK, so it's not a short discussion topic.)

***********************

I know we have a number of global readers of this blog. I would be interested in others' (ie non-American) experiences, if any, regarding right-to-treatment litigation on behalf of the mentally ill. I know from casual conversation with some of my foreign colleagues that America is a wierd beast regarding the amount of correctional litigation we do.

Emotional Support Duck

Well, since Roy mentioned it...

Roy: Reality Therapy Vlog: "PsychoTherapy 2.0"

I started to comment on Dinah's post, entitled That's Entertainment???, about reality TV shows exploiting folks with mental illness, and my comment turned into this new post. I have come to the following reasoned conclusion. Ahem.

I am quite certain that at some point, soon, there will be a reality therapy show... more likely an internet video log, or vlog. You know, a webcam in your office, for the world to see what happens in therapy. "Bringing The Couch into your living room."

Every Tuesday evening from 7-7:50, for example, "Melissa" can be seen talking with her therapist (live). God forbid if she's late, as the shrink would then look into the cam, telling why he thinks she's acting out because of the interpretation he offered the previous week, and her troubles confronting authority figures... maybe even with video-snippets from prior sessions, driving home the point. I'm sure if you miss a session, or "show", you can download it to your iPod from iTunes, and watch it when *your* patient no-shows, all the while wishing that you could have a successful therapy vlog, like Dr. Pheel has.

Some patients will even develop their own following, like groupies, cheering their successes on, or jeering at the more narcissistic or annoying "clients". I suppose if there are advertising sponsors, then the therapy would be free for the patient, and the therapist would reap some financial benefit. Perhaps Google ads popping up on either side of the screen, at the mere mention of a product or service by the doctor or patient:

Sponsored Links Toxic Waste Weight Cleanse the waste "weight" and lose more pounds and inches. www.puristat.com

"Doc, ever since I started taking the Paxil, I've gained so much weight. And I've been constipated. It's really depressing."

Sponsored Links Constipation Gone Forever Read about the #1 natural remedy for constipation. It works! www.DrNatura.com

Netizens would flock to the patients' blogs to see what they are *really* thinking between sessions, leaving comments about how insensitive the shrink is; or how she should let go of the idea that her bitch of a mother will ever care about anyone but herself; or about how she is such a misandrist (or, he, a negative animus); or that her iatrist is using the wrong otropic drug; or that she could become a "clear" if she just joined the org; or maybe even that, for the low price of just $9.99, in four easy installments, that she, too, could have her very own Emotional Support Duck, thus, forever doing away with the perverse dependency on her work-a-day psychiatrist.

It would get people interested in therapy again, like in the 60's, but only more tricked-out and jazzed-up for the plugged-in generation. Who needs insurance? If your problems are interesting enough, or bizarre enough, all you need is a therapy sponsor. If you are willing to try out the latest pharmaceutical, the drug company may even sponsor your reality therapy vlog, though probably with a side contract stating that for a given sum of money you will not divulge any unpleasant reactions you might experience, such as a blue tint to your vision, spontaneous flatulence, or painful erections lasting longer than 4 hours or 10 inches.

Some day soon, this year or next, web-enabled therapeutic voyeurism -- dubbed PsychoTherapy 2.0 -- will become the biggest thing to hit Psychotherapy since Managed Care. Or Prozac.

Or even Freud.

That's Entertainment???

[posted by dinah]



It took me a while to figure this out, from the headline, Mental health chiefs blast 'dangerous' Big Brother, I somehow thought "Big Brother" referred to one of those altruistic organizations where men adopt fatherless boys to nurture and mentor. Finally, in my Pop-Culture Deprivation state, I figured out that Big Brother is a reality show where they throw a bunch of people into a house together and stick 'em on TV so people can watch them bitch at each other about who left the dishes in the sink. Or so I imagined.

Not this show.

"Sam Brodie, a pre-operative transsexual, is thought to have mental health issues," notes The Daily Mail. "Sam, 18, has already told housemates: "'I'm the most paranoid person ever.' " The article goes on to report, "Sam is among a host of vulnerable contestants put into the house.
Shahbaz threatened to kill himself live on television before quitting the show, Lea has tried to commit suicide and has undergone extensive plastic surgery because she was unhappy with her appearance, Nikki has suffered anorexia and Pete has Tourette's Syndrome. "

Since I get paid to listen to such stories, I just can't fathom how anyone else might enjoy watching this for entertainment. Here in America, we'd never stand for such things.

Okay, I'm off to clear the sink before the cameras arrive...

========Links:
[dare-to-dream

Trees In A Forest

Credit for the idea behind this post goes to foofoo5, who asked in a comment about the prevalence of antisocial personality disorder in correctional facilities. This table presents the results of various epidemiologic studies done in prisons. All studies were done using the Diagnostic Interview Schedule (DIS) on a randomly chosen sample of general population prisoners. For those who don't work in corrections, this means that all the subjects were convicted and sentenced offenders rather than pretrial detainees (jail inmates).

In the Cote study, 495 Canadian penitentiary inmates were interviewed using the DIS. They found that schizophrenia occurred at rates seven times higher than lifetime prevalence in the general population of Canada. Bipolar disorder had a six-fold higher prevalence and major depression had a two-fold higher lifetime prevalence. Inmates suffering from the severe disorders almost all met the criteria for at least one other severe disorder or ASPD or substance abuse/dependence. There was also strong clustering of ASPD with substance abuse or dependence relative to the major mental disorders.

In the Daniel study the subjects were 100 consecutive American female offenders admitted to prison. Ninety percent of these women received at least one diagnosis. Sixty-seven percent received more than one diagnosis. These rates were compared with the general population of women in St. Louis (ECA study). The lifetime prevalence of schizophrenia was seven times higher than the general population of St. Louis. Bipolar disorder and major depression were both twice as high as general population.

The final study was done on 109 volunteer inmates in the Washington State Reception Center. They found that 88% of these inmates had at least one psychiatric diagnosis.

There have been other studies since then, but this is just what I had on hand. Foo's comment (pardon the first-syllable familiarity) was specifically about antisocial personality. The low rate in the Daniels study is likely attributable to the subject gender---women tend to get diagnosed with borderline personality personality disorder while men tend to get diagnosed with antisocial personality disorder.

In my experience, about a quarter of our inmates get diagnosed with any personality disorder. I'm always surprised by this because it's quite a bit lower than what you see in the literature. What this tells me is that correctional clinicians don't bother diagnosing trees in a forest. In order to get a personality disorder diagnosis the disorder has to be pretty severe.

*************************
(1) Cote G, Hodgins S, "Co-Occurring Mental Disorders Among Criminal Offenders", Bull Am Acad Psych Law 18(3):271-281, 1990

(2) Daniel, et. al., "Lifetime and Six-Month Prevalence of Psychiatric Disorders among Sentenced Female Offenders", Bull Am Acad Psych Law 16(4):333-342, 1988

(3) Chiles, et. al., "Substance Abuse and Psychiatric Disorders in Prison Inmates", Hosp Comm Psych 41(10): 1132-1134, 1990

Roy Unleashed!

[posted by dinah]



I checked the blog yesterday was surprised to find three, count 'em, three new posts by Roy! Is he manic, I wondered? Oh, probably not...just unleashing his pent-up blogs which have been festering... I can only speculate. But this brings me to an interesting study I found, one that pertains to Roy's comments on most frequent diagnoses among psychiatric patients. A landmark 1998 study by Sille, et. al. revealed that the most common psychiatric diagnosis among bloggers is, in fact, Bipolar Disorder, accounting for 61.8% of all psychiatric diagnoses (most recent episode being a Mixed State), followed by Obsessive Compulsive Disorder, with compulsive writing being the most common symptom, followed by compulsive email checking. In a follow-up study done by Monke in 2001, it was found in a randomized, placebo-controlled, double blind study that manic bloggers were more likely to report remission of symptoms, a return to euthymia, and a decrease in compulsive blogging, when treated with a combination of Depakote, chocolate and caffeine. Interestingly enough, none of the bloggers studied responded to either Lithium or any of the novel anti-psychotic agents.

Okay, so I made it all up, but I had fun doing it!

Clin Psyc News notes: May 2006

• Ritalin patch: I expect to see this a lot in nursing homes. I've seen methylphenidate make a huge positive impact on older depressed folks, and a patch form of administration makes it easier. But, it's another one of those dang off-label issues that's flaring up lately.
  
  
• 4.6% Medicare cuts next year: Will this ever get fixed? Locally, I hear of folks having a hard time finding psychiatrists who will even take Medicare. It used to be one of the easiest to participate with... no multipage treatment plans, etc. But practice costs increase every year, and we cannot make up the difference by seeing more pts (although I hear there have been some "creative" docs who have learned how to squeeze 50 90807s in a 24-hour day... no, thanks).
  
  
• Top 10 Psychiatrist Diagnoses: Something is wrong with this picture. The #1 dx is 296.2 (single episode major depr). I would expect recurrent episode major dep to be #1. And all of "Anxiety states" is only #3? I don't think so. The data come from Verispan's survey of 162 psychiatrists. GIGO.
  
  
• Don't flush your fluoxetine: Says to advise your pts on how to dispose of old pills, but does not say what to tell them. I used to tell them to flush them, but now I say to either return to pharmacy. It seems that flushing has led to high drug levels in the water supply.
  
  
• Prazosin reduces PTSD nightmares: This is new to me. Alpha-1 antagonists apparently reduce sleep problems and nightmares in PTSD. [PubMed]
  
  
• Vivitrol: I saw an ad for this recently approved i.m. form of naltrexone (it was going to be named Vivitrex, but I guess this was too close to some other name). Even if there is some efficacy data, this drug will go nowhere. Why? $695 per injection! Are folks gonna pay $22/day to be sober? It's cheaper to stay drunk! Cephalon blew it. I can only imagine that the market they are going after is the court-ordered treatment market. If they hit that one, they will have a blockbuster on their hands, because it is worth $22/day to stay out of jail. (The number of ad-blogs for this drug are incredible.)
  

Roy: Can't tell if this is a joke or not

Nevada therapist's site (SnapOutOfIt.com!).

But here's what I can't figure out. She posted this 10 days ago, and already has 66 comments. But read the comments.

I can so not relate.

Roy: Rolling Stone's deconstruction of Scientology

This is an interesting read.

In June of last year, I set out to discover Scientology, an undertaking that would take nearly nine months. A closed faith that has often been hostile to journalistic inquiry, the church initially offered no help on this story; most of my research was done without its assistance and involved dozens of interviews with both current and former Scientologists, as well as academic researchers who have studied the group. Ultimately, however, the church decided to cooperate and gave me unprecedented access to its officials, social programs and key religious headquarters. What I found was a faith that is at once mainstream and marginal ... It is an insular society -- one that exists, to a large degree, as something of a parallel universe to the secular world, with its own nomenclature and ethical code, and, most daunting to those who break its rules, its own rigorously enforced justice system.

When asked what, if anything, posted by the apostates is true, Mike Rinder, the fifty-year-old director of the Church of Scientology International's legal and public-relations wing, known as the Office of Special Affairs, says bluntly, "It's all bullshit, pretty much."

The most important, and highly anticipated, of the eight "OT levels" is OT III, also known as the Wall of Fire. It is here that Scientologists are told the secrets of the universe, and, some believe, the creation story behind the entire religion. It is knowledge so dangerous, they are told, any Scientologist learning this material before he is ready could die.

On January 17th, 1986, Hubbard suffered a crippling stroke. A week later, he died, in a 1982 Blue Bird motor home on his property. He was seventy-four years old.

Upon Hubbard's death, his ambitious twenty-five-year-old aide, David Miscavige, who would soon succeed him as leader of the church, announced that Scientology's founder had willingly "dropped" his healthy body and moved on to another dimension. In keeping with Hubbard's wishes, his body was cremated within twenty-four hours. There was no autopsy. But the coroner's report described the father of Scientology as in a state of decrepitude: unshaven, with long, thinning whitish-red hair and unkempt fingernails and toenails. In Hubbard's system was the anti-anxiety drug hydroxyzine (Vistaril), which several of his assistants would later attest was only one of many psychiatric and pain medications Hubbard ingested over the years.

Discussion, as some academics like Kent note, isn't encouraged in Scientology, nor in Scientology-oriented schools. It is seen as running counter to the teachings of Scientology, which are absolute. Thus, debate is relegated to those in the world of "Wogs" -- what Scientologists call non-Scientologists. Or, as Hubbard described them, "common, ordinary, run-of-the-mill, garden-variety humanoid[s]."

Roy: Students' blogging may get them suspended

The Libertyville-Vernon Hills Area High School District 128 board has voted to suspend students for "maintaining or being identified on a blog site (that) depicts illegal or inappropriate behavior."

Is this for real? I don't see how this can be enforced, and it is easy to see how it can be abused. I am publishing this blog under the name "Roy". Say I called myself Roy Johnson. I could get the real Roy J. in a lot of trouble with the school.

Do you think the real Roy Johnson would sign a blog or a comment under his real name? It seems to me that most blogs are de-identified in this manner. And who defines what is "inappropriate"?

Kids have enough to worry about without having to worry about getting suspended for a blog. How about some education or counseling about online risks? This isn't easy, I know. I called the parent of my child's friend to warn him that his daughter has her cell phone number readily available on another friend's MySpace page. He treated me like I was the Volunteer Fire Department calling at dinner time on a Friday night. I even emailed him the link. The number is still there.

Maybe I should have emailed her school principal. Got her suspended. That would teach her not to blog inappropriately. Of course, what would she do at home while suspended? IM and blog with all the other homebound blogging convicts.

At least the NSA isn't going after them. Yet.

Back From APA

I don't go to APA every year by any means; I last went in NYC two years ago.

So here is my take on it:

It was too cold in Toronto, especially on Monday.

As of Tuesday, there were 17,000 people registered. In NYC, I believe there were 26,000 registered (I always ask). It seemed like there was less of everything, though maybe it's similar to how the playground slide gets smaller as one gets older. Some sessions were still extremely crowded, and I went to hear Glen Gabbard talk-- he was terrific, but it was like hearing a talk on crowded NYC subway with the body parts of assorted strangers being jammed into me. The quality of the sessions varied, but that isn't new.

It seemed there were many more non-members than usual, and what felt like huge numbers of people from other countries around the world. While this is always the case, it was more striking, and a drug rep told me that 40% of attendees were from other countries (by 'other' I mean not Canada or the US). Lots of folks from Turkey and the Netherlands.

Most notably: the toys were not good. The freebie drug company giveaways (pens, squishy brains) were all but absent; apparently the laws in Canada are stricter about such things, though I wondered if part of it was also due to all the fuss in the press here about drug companies influencing docs. The lack of toys meant the Exhibit Halls-- where I often bump into long lost people from my past lives-- were fairly empty.

Fun things: I made it to Steve Sharfstein's Presidential farewell bash and had dinner at Susur-- an event in its own right. Susur does only a tasting menu, probably the most interesting meal I've ever eaten out, definately the most expensive...the food was delicious. We flew into Buffalo and pit stopped enroute for Buffalo Wings and to see Niagra Falls.

Funniest moment: leaving the country, I handed my passport and boarding pass to the Immigration officer. He asked why I was in Canada and Was I a Psychiatrist. When I said I was, he moaned and said, "At least your not as disorganized as the rest of them."

In Memoriam

[Posted by ClinkShrink]

I lost a great officer last week and I'm sad.

Correctional Officer X** was assigned to work in the psychiatric infirmary. He had been there for years and he was good at it. CO ("Correctional Officer") X was build like a sumo wrestler, only bigger. He had a soothing, mellow, story-telling voice like Garrison Keillor. I swear he could have hypnotized a rabid dog with that voice. Whenever any situation came up on the unit that looked like it could have gotten out of control, he was there. If any of my patients got loud during rounds, he'd poke his head in: "You OK in there, doc?" When he moved down the unit it was like watching an ocean swell move toward a tropical beach. But more than his size, his demeanor set the tone for the milieu. He approached patients in a way that made them feel safe.

He was the ideal physician recruiter. Whenever I brought applicants through the unit I'd introduce them to X. "In case you're nervous about working here," I'd tell them. "Don't you worry," X would say. "You come work here, I got your back."

He was a big (pardon the pun) reason why we never needed to use physical restraints.

And now he's gone.

He got promoted to sargeant and moved to a different tier. Gotcha!

But I'm still sad.

**********************

**Not his real name. Duh.

I Guess You Had To Be There

Every psychiatrist knows the DSM criteria for major depression: low mood, decreased self-attitude, changes in sleep, appetite, concentration, memory or sex drive, excessive or inappropriate guilt (and how do you judge that in a correctional facility?), anhedonia and suicidal ideation.

I would like to propose one small additional criteria:

Humor latency. Yes, a delayed or absent response to humor. Particularly my humor. Some people would claim that loss of humor falls under the anhedonia category, but I disagree. Anhedonia could mean almost anything: inability to enjoy knitting, exercise (but then almost everyone would meet criteria), coffee (never!) or Japanese existentialist literature. Humor is universal. Granted, some research suggests there may be gender differences in humor. Other research done on twins suggest that environmental factors play a role. (Where can I get in on a research gig that involves showing Far Side cartoons to twins?)

I'll grant the fact that men and women may appreciate different forms of humor. A male colleague of mine used to be prone to practical jokes---of the 'hide the rubber cockroach in the patient charts' kind of humor---and he referred to April Fool's Day as "Amateur Day". He had a problem with my puns. Or rather, he suffered from "humor latency". This is how he explained it: "I used to think I was just too stupid and didn't get your humor. But then I realized I did."

Now I know he was just meeting criteria.

Off to APA

[posted by dinah]

Roy will be holding down the blog this week. ClinkShrink is already in Toronto (she says: "Bring a coat"). I will be going tomorrow, and yes, I will be flying with an Emotional Support Psychiatrist, let's see if I can get her to wear one of those signs around her neck.....

Roy: Warrantless Brain Scans

This whole search for terrorist collaborators thing is getting a little ridiculous. Tapping into millions of domestic phone calls (and probably blogs and emails and IMs) in the name of terrorism? That's legal?

So, here's my nightmare scenario. If this is legal, the next step is to force functional MRIs on people to determine what they know (about terrorism, of course). The technology is there. Functional MRI (fMRI) measures minute changes in blood flow in the brain, comparing areas to see which ones have more blood flow, and thus are more active. It seems that one must use specific brain areas to make stuff up. This technology is being used for good purposes (eg, controlling chronic pain), but could certainly be applied to darker motives.

Talkleft asked:

"Would the Court view an involuntary brain scan as a nonintrusive gathering of information rather than a search governed by the Fourth Amendment? Would the Court view brain scans as forcing an involuntary disclosure of thoughts prohibited by the Fifth Amendment's requirement that individuals not be made to testify against their will?"

fMRI is not "invasive" in the classical sense. No needles. No tubes. Sorta like going through an airport scanner, but lying down (you can even keep your shoes on). So what's to stop them from using this technology on Gitmo detainees (or on us)?

The chronic pain link above is interesting, BTW. It makes me wonder if real-time fMRI scanning can be used to learn how to better control obsessive thoughts or auditory hallucinations or anxiety.