Should People With Mental Illnesses Hold Public Office?

After my post Depressed and Running for Governor post, one commenter (MWAK) asked if people with depression should run for governor. Novalis responded with his own post, Uneasy Lies the Head where he says No and gives his reasons for his thoughts.

It got me thinking. As a psychiatrist, we generally feel mental illness should be destigmatized, and life should be more 'fair' for those who suffer from mental illnesses. I have to say, sometimes I struggle with this--- it's nice to be accommodating, but if the symptoms of one's mental illness make one's companionship intolerable, or one's job performance erratic and inefficient, or one's behavior disruptive or dangerous, how much should others be expected to bend?

So Governor or President....in Doug Duncan's case, it seems he personally decided that the campaign itself was too stressful while he was actively symptomatic. Let's suppose that we can agree that we don't want someone with a symptomatic mental illness running our country. Actually, I don't want them driving my bus, train or airplane either, not while they're thinking about how to suicide or dealing with slowed reaction times or poor judgment.

For the sake of argument, let's say our would-be President or Governor, or pilot or bus driver or armed soldier or police officer has a history of mental illness. Let's suppose it was treated with full remission of symptoms and he hasn't been ill for a while.

Novalis says No: psychiatric illnesses are chronic and recurring (and for some reason he thinks hypertension and diabetes are more likely to stay control or be predictable, but I'm not going there), symptoms can be insidious, gradual, and hidden.

I agree, they can be all of these things and I don't want someone in the midst of an episode running a ship if there really are those buttons one can push to blow up the world. Or decisions that need to be made quickly. Here's my sort-of/maybe beef with this logic: people without mental illnesses can : 1) suddenly get them, 2) have bad judgment or make bad decisions in the absence of a psychiatric illness, 3) keel over and die or become disabled with no warning. We need to have provisions for such things, and the fact that it's higher probability with a history of mental illness doesn't change that we need to have perimeters to check on people involved.

One thing seems clear: If you take away someone's job simply because they seek treatment, then you limit the ability of someone to get treatment. I'd rather have a pilot on Prozac who is being closely monitored, then a pilot who's been afraid to tell anyone his dark thoughts about the plane I'm on.

Novalis says, "If or when our understanding of mental disorders progresses to the point where we can more reliably predict and modify their course, then a major mood or anxiety disorder might survive the vetting process."

We can't predict the behavior of anyone (remember that W guy?). If we know someone has a history and an increased likelihood of recurrence, at least it can be openly discussed and some checks can be put into place.

So no answers here. I do wonder why it is that people have been required to have psychiatric evaluations before all sorts of procedures (in vitro, bariatric surgery) and we don't require our presidential candidates to spend a couple of hours being evaluated by a psychiatrist before we let them run.

I will point out that many of our presidents have had serious mental illnesses, including some of the most popular of presidents.

I'm rambling. Hope I didn't say anything too objectionable.

[Edit 4/5/09 11:30: This is Roy. I just wanted to clarify something here. When I first read Dinah's post, I thought "OMG, she's saying people with, say, a history of bipolar disorder shouldn't fly planes or be President." After reading some comments, esp Nonstandard's comments, and then Dinah's reply, I realized that what she wrote does not clearly state what she seems to intend. So, as a way of either clarifying or distancing from what she said, here is what I think : A 'diagnosis' of anything should not -- in and of itself -- prevent someone from taking on a high-responsibility position (IMHO). The question should be about how they are currently functioning. And if a position carries enough high risk (say, the nuclear button-pusher job, prez, airline pilot), then there should be built-in safeguards that require some sort of ongoing assessment of functional capacity, regardless of one's presence or absence of diagnostic labels. Come on, even dealing with, say, a divorce or your daughter's breast cancer could have a negative impact on one's performance in certain positions. I'll put more in the comments, esp asking why the legal system has put us in the situation that Nonstandard Mind points out in the first place. Back to your regularly scheduled program.]
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Dinah's Addendum
Arg From Dinah! See my clarifying remarks in the comment sections.
Regarding pilots: I'm not the one who said they can't fly with a history of bipolar disorder, it's the FAA's idea. And the FAA is pretty picky about what meds pilots can take and still fly, psychotropics in general are not allowed, so this pretty much eliminates anyone with a chronic or recurring mental illness. Benedryl is a no-go as well, so no acutely allergic pilots. What surprised me is that they can be on blood thinners or anti-arrhythmics and people who need those medicines generally have underlying illnesses that make them susceptible to strokes or sudden death.

Suicidal Tweets, Demi Moore, & The Samaritans

RT John Grohol wrote on PsychCentral:

"I’m sorry, but I’m a bit aghast at this story of someone randomly twittering their suicidal thought to Demi Moore, and then a bunch of people who saw it retweeted by Demi called the police. The police found the person who said they were going to kill themselves, and that person is now under psychiatric evaluation.

I guess this is “news” because someone sent it to Demi Moore. Demi Moore is a celebrity, so anything that touches her is defacto “news.” Does this mean the only way we can get attention/help for mental health issues in the U.S. is by tweeting a celebrity? Really, has it come to that?"

Read the rest here.

In Treatment: What the NYTime Says.

To those who wrote in telling me how to get to the right click:

THANK YOU!!!

Everyone is jumping on the bandwagon. First I blog about In Treatment, now the New York Times has to write about it. I couldn't read it all, too many plot spoilers.

I'm going to give it a try, if I like doing it, I'll keep it up. ClinkShrink wants to stuff me in a closet somewhere. I'm trying to teach her to delete things unread.

Oh, and these people I blog with, they talked me into this MacBook thing. I finally figured out how to copy and paste. How do I save a graphic I see on the internet??? I miss my right-click mouse button so much.

April Fools!

It's a Joke, It's a Joke!!
Read Roy's Post.
It's a Joke!!

Oy, I got it, on the Mac it's command C/ command V, not control C....
I'm getting there.

Health Insurance Co's to Stop Listing Dead Docs in Online Physician Directories

All health insurance companies in the US have promised to stop their practice of including in their online provider directories all physicians and other health care providers who have at some time in the past taken one of their patient members.  Instead, they will actually include only those providers who can take new outpatients. 

"This should end the frustration of having to call, say, all 37 psychiatrists in the directory, to find that only 3 are taking new patients, because the rest are either inpatient-only doctors, retired, deceased, moved, or have stopped taking new patient members because of our low reimbursement rates or our burdensome bureaucratic hoops we employ to drag out the payment process," said Lyle Waggoner, president of Big Corporate Business Shield of America, the nation's largest health insurer.

"Of course," he adds, "that means that we now only have 3 psychiatric specialists in our directory, but that's all we really had before anyway."  The American Psychiatric Association has praised BCBSA for negotiating this change in policy, which takes effect starting on April 1.

Industry experts predict that more patients will actually receive treatment, because many used to give up in frustration after the 10th or 15th phone call.  "We were considering adding 'Insurance Frustration Disorder', or IFD, to the upcoming DSM-V," said APA president-elect, Dr. Carol Bernstein, referring to the upcoming fifth edition of the diagnostic manual of psychiatric diagnoses used by insurance companies.  "We may now have to reconsider the diagnostic criteria."

Health care consumers who are looking for new providers are pleased with the change.  "I only had to make three phone calls to get an appointment in 3 months.  I used to have to make thirty calls, causing me to go to the ER for homicidal ideation," said Anna B., a BCBSA member in Chicago.  "I've heard that they may also make it so my doctor gets paid within 3 days after completing a simple online form.  Now that's crazy."

Insurance companies plan to prove the providers in their online directories are taking new patients by including next to their name the number of outpatient claims for new patients submitted in the most recently available 12 month period.

Depressed and Running for Governor

Doug Duncan has a strong family history of bipolar disorder, and during his campaign to become Governor of Maryland, he became ill with Major Depression. Mr. Duncan dropped out of the race, and let the reason be known. In today's Baltimore Sun, there is an article about his symptoms and recovery. Apparently he made a good recovery with the trial of medication and therapy, and is now doing well. Could he toughed out the campaign? This is a personal decision.

So what do you think-- in our efforts to destigmatize mental illness, would Mr. Duncan's history of depression be a reason people would vote for him in the future?

My guess: I think people would not vote for a President with a history of depression ("Will he push the button in a moment of helplessness? What if she becomes depressed after a terrorist attack?") Otherwise, I think he still has an open door. Just my opinion, do chime in.

And I just bought a brand new Mac Book. I can't seem to work the copy/paste (cntrl c/cntrl v) thing for links. Oy.
Try this if my link didn't work: http://www.baltimoresun.com/news/local/bal-md.vozzella01apr01,0,1621279.column?page=1

Oh, and I can't get a graphic in or put labels on the post. ClinkShrink!!!!!!!!

Shrink Rap: Grand Rounds is up at Paul Levy's Running a Hospital

This week's Grand Rounds is at Running a Hospital, a blog written by Paul Levy, the President and CEO of Beth Israel Deaconess Medical Center in Boston.

Paul's blog is well-known, as he is very open about the challenges of running such an endeavor.  He chose a theme about medical errors and related mistakes, told via the many stories he chose to include in the GR post.

This is a must-read.  Great job, Paul.

In Treatment Returns, Should We?

Last year, I ran continuous blog coverage of the HBO series In Treatment. 35 episodes of psychotherapy sessions with 4 patients over time. The therapists boundaries got blurred. It started out as fun, by the end it was a bit tedious. Readers were writing in, begging me to stop. Roy said our 'hits' went way up.

Apparently, it's coming back. I'm not sure I can do it again. Maybe. What do you think?

Oh Poo!

This a blog post about vulture poop. It's a long story, but let me just say that when you're a rock climber there are certain hazzards of the sport that you just have to accept: bats sleeping in crevices, nasty long spinning falls, copperhead snakes and, yes, vulture poop.

Vulture poop is probably the most vile smell I have ever come across, and that includes a four month stint crouched over a formaldehyde-soaked corpse in anatomy lab. It's bad.

The trick with writing a blog post about this is that you have to tie it in somehow with psychiatry. This is problematic since I haven't had any patients with delusions about vultures, vulture obsessions or vulture phobias (does anybody know the word for vulture phobia? Ornithophobia is for birds as a whole). I'm left grasping at nasal straws, so to speak.

I have had patients who smelled bad and patients who suffered from bad smells. If the smell doesn't actually exist, it's an olfactory hallucination. Olfactory hallucinations are rare, much less common than visual or auditory hallucinations. Typical olfactory hallucinations are very unpleasant experiences and are often described as resembling rotting meat, burning rubber or excrement (although not necessarily vulture poop). I've seen olfactory hallucinations in a patient with major depression and in one or two psychotic patients. Another "bad smell" illness is a rare but interesting delusional disorder known as olfactory reference syndrome. In this disorder the patient is convinced that he or she smells bad and that others around them can also smell them. Olfactory reference patients may shower multiple times a day to get rid of the "smell", or may seek repeated medical consultations to find the source of the problem. Like most delusional disorders, olfactory reference syndrome tends to be resistant to medication. I've seen two cases of this disorder and they both improved (but didn't get completely well) on neuroleptics.

Olfactory hallucinations can be seen in other medical conditions, specifically in migraine sufferers and in people with seizure disorders. In this case the smell generally precedes the onset of the headache or seizure and is sometimes described as a 'burning rubber' smell. Treatment of the odor depends upon control of the underlying condition.

So there's my vulture poop post. I even made it relevant to psychiatry. Climb on!

And for those without cathartophobia (my proposed name for vulture fear, after the genus cathartidae):

The Turkey Vulture Society

Who Are You?

The DOC badge said his name was John X. Doe and that he was born on 1/1/81. The medical information system said his name was John Y. Doe and that he was born on 2/4/84. The legal information system said that John Y. Doe plead guilty to misdemeanor theft and was given six months. John X. Doe has an open robbery charge. John Y. Doe has been through the system three times and has always screened negatively for mental health issues and never needed psychiatric services. John X. Doe was in our forensic hospital for six months being restored to competency. The patient insists he's John X. Doe in spite of both information systems that link him through his DOC number.

I've never treated either of these guys before, have no old records of my own and have no way of knowing if they're actually one and the same person who just lies about different things at different times. Someone just shoot me now.

So is John Doe someone with no previous psychiatric history who is malingering now because he's facing a serious felony charge? Or is he a chronically mentally ill person who is going to relapse if I don't put him on meds? (And relapse in a big way if it required a six month hospitalization.)

Oh yeah, one more thing---he won't answer any questions other than to confirm his middle name and birthdate (which may be a lie). When I try to do a mental status examination he sits there and stares at me.

Gawd, ya gotta love this work.

Any suggestions?

Stigma, Advocacy, and Having a Really Rough Time of it: From Guest Blogger Retriever

Roy wrote about the NAMI mental health report card by states, Maryland got a "B." The post got a heartfelt comment by Retriever, and I'm borrowing (with permission, and some minor typo editing) that comment to use as a guest post. Retriever writes:

Stigma limits advocacy. The main one is that patients who are trying to pass as normal-- to hold onto jobs or not embarrass their children-- can't lobby politicians, educate peers at work or at church, because, if they have a family to support, they can't risk outing themselves.

We have a kid who is autistic and bipolar. High functioning, but spent nearly a year when 8 psychotic, manic, a danger to himself and others, with no meds working at all for him. My husband was laid off from a job because his company would have had their insurance rates doubled if they continued to keep him on the payroll and insured, because of our kid's diagnoses. Mental health care is expensive.

People still judge mental illness, especially in kids. Social workers at least initially assume that the parents are abusing the kid. Neighbors and coworkers assume that the child is ill because of bad parenting. Parents would actually like to blame their own bad parenting because that is actually under one's control as, say, mania is not. They'd be happy if they could just go to a course to improve and Junior would stop seeing snakes and hearing voices.

People like cute, grateful pitiful victims to help. The reality is that people pass the hat to collect money for a piteously bald kid with leukemia and his family, but nobody ever passes the hat for a psychotic eight year old whom the hospital will not admit because (I quote) "your insurance will only pay us 60 per cent as their reasonable and customary charge, but DCF pays 100 percent. " Hence the kiddie psych unit having 95 per cent DCF kids.

Increasingly the move is towards care "in the community" and to closing public facilities like the state hospital that saved my kid's life (when manic and psychotic) because it would actually admit him and keep him there long enough until he was no longer a menace to himself. Where I live (one of the richest communities in the country) none of the private clinicians are willing to treat severely mentally ill children, so one is sent to a child guidance clinic which limits the care and usually provides it with cheap, relatively new social workers who can barely spell the name of the diagnosed condition let alone have any expertise in it.

And my state got a B.

I do what I can in our church, to educate the SS teachers about how to work with our many kids with various mental health issues (we are the most hospitable in the area to them, and bend over backwards to include them, provide one-on-one shadows, and make equal demands of them so that they are not marginalized--this approach was what most helped my kid). And I talk with parents of the newly diagnosed kids, and badger them to take the various special ed courses on how to do battle with the school system.

But it's a drop in the bucket. You can't talk openly about the truly appalling behaviors of your beloved kid, or people would never feel comfortable around them. You can't tell people why it makes you yourself hideously depressed. You dread any phone call from the school lest it be the dear sweet Buddhist teacher telling you that Junior (hypomanic despite meds tweaking) just told him to STFU.

Most of all you can't testify publicly, or write except anonymously or lobby or preach (I am a former minister) for real parity, and greater compassion for these reasons (to recap):

• The ill child (and their siblings) are entitled to anonymity. I am uncomfortable with all the mommies writing first person accounts with their real names. I wonder how their kids feel? It may be therapeutic to the mom, but could mortify and increase prejudice against the kids.

• Employers lay off people with high insurance costs, although they do not admit it. Sometimes, if one is a valued worker (as I have been), the employer will look the other way. But in cost cutting times, if one advocates publicly, the bean-counters at HR will find a way to get one axed.

• At least with pediatric psychiatry, the shrinks really don't know how bad it is or how much stress is on the family or the other kids caring for violent, manic, agitated kids at home. They don't care that spouses lose their jobs because of having to keep picking up an agitated kid from school, or stay up all night with one and getting too many phone calls at work from MDs.

Community care is like all the " I want a pony" stuff back when people abolished the snake pits in the fond hope of lovey dovey community group homes, etc for the mentally ill. In reality people said NMBY, there weren't the funds, and it is actually harder to prevent abuse and bad care in group homes than in large institutions.

"Dumping Grounds"

The Chicago Sun-Times has an article today by Carla K. Johnson about a tragedy occurring in a nursing home where an older man is beaten by a younger resident who has a mental illness.  She refers to how "nursing homes across the nation have become dumping grounds for young and middle-age people with mental illness."

Am I the only one bothered by the use of the term dumping grounds?  Like people with mental illness are trash, or are unworthy.  Yes, this was a tragic situation, but demonizing all people with mental illness as dangerous, violent ticking time bombs is yellow journalism at its worst.  I understand the point, that younger people with no where else to go are being sent to nursing homes, but must we resort to this poor use of terms?

Take a look at the headline currently being run: "Deadly mix: mentally ill in nursing homes".  If you have an opinion on this, please let the Sun-Times know.

Family Passing

In our prison system we get blast emails. Dinah recently has listened to me rant about how much I hate random blast emails from the many organizations I belong to. I get blast email from my professional organizations (two of them), the local symphony, my car dealership, two academic institutions and any company I've ever done business with. I spend more time deleting email than I do reading and responding to email I really want.

But anyway, I get blast email from prison. The majority of it are press releases about various and sundry governer or secretary initiatives, but for some reason they also send out emails about deaths in the system. Not prisoner deaths, not anything work related, but the deaths of anybody who works in the system or is related to a DOC employee. These are called "family passing" notices, after the subject heading of the email.

Today I got three "family passing" blast emails. I don't know any of the people who died and all of them were relatives of DOC employees, and I didn't know the employees. They work in institutions on the opposite end of the state from where I am and it's unlikely I'll ever meet them.

I'm not sure why DOC officials decided I needed to know about these deaths. I'm not sure what I'm supposed to do with this information. I don't understand how they think it will help morale to know that people are dropping like flies right and left. I wonder if they realize that for most people this just reinforces the idea that when you die the majority of people will have no clue that you ever even existed.

I have my email rules set up now to automatically delete any message with "Family Passing" in the subject heading. I suppose I could send in a request to be taken off the notification list but in the bureaucratic world I live in, I know that would only last until the next employee comes in and takes over the death notification job. I'm sure I'll get a blast email to let me know when that happens.

Do We Care?

A reader wrote in the following:

At least with pediatric psychiatry, the shrinks really don't know how bad it is or how much stress is on the family or the other kids caring for violent, manic, agitated kids at home.

Actually, when I initially read the comment, I thought it said the kiddy shrinks don't really "care how bad it is".... as I've re-read it, I realize it's a more accurate portrayal: "the Shrinks don't know how bad it is..." Oh, if it's okay, I'm going to springboard off the "don't care how bad it is"...it's likely quite true that the docs don't know how bad it is.

It is a regular sentiment, however, that people feel their docs "don't care." I'm always perplexed by that because caring is an internal emotion, how do you know if someone cares? You could ask-- hey do you care that I'm miserable? Oh, of course, the answer will be yes. Maybe a doc cares but doesn't quite know what to do, and feels internally squirmy at the inability to fix a patient's suffering. Maybe the patient has a low-key personality style and doesn't adequately convey that they are suffering. One can say they are tormented, but if they say it wedged in between a discussion of NCAA pics while they are knitting, sometimes the tenor of the suffering is attenuated. And one can scream and rant and rave about their suffering, but if they've screamed and ranted and raved about the poor service in a restaurant, well, there's that whole crying sheep issue that makes it hard to filter.

It's not that docs don't care, it's that there is some professional distance. And if the kiddy shrink has lived through the same exact nightmare, he may or may not state this out load. There's an unpredictable element of trade-off in the perception the patient's family might have: 1) I'm so glad you know exactly what I've been through and it's comforting to have this kind of empathy 2) Your experiences color your ability to see clearly all the possible options and you're too caught up in your own kid's issues to fully appreciate my kid's issues, or 3) You've screwed up your kid, why do I want you near my kid? I've used the kid example because our reader provided it, but it could just as easily be a case of pneumonia-- yours got better in 3 days so you can't appreciate that I'm still sick 2 months later.

Some of what comes off as "caring" isn't really about caring at all, it's about the doctor's external display of concern. Some peeps are pretty reserved--they can be distraught, eaten up inside, thinking about a patient's problem, going home and reading about, calling friends for ideas, and still not convey this to the patient-- they can look uncaring and cavalier. Another doc can jump up and down and seem very concerned, but not actually change anything or do anything.

In medical school, I had a brief period where I got eaten up by other people's problems. The summer after my first year, I did a rotation in a psychiatric unit with some more advanced medical students-- it was a very psychoanalytically-oriented staff and we constantly being asked to process what had happened on the units, how we felt about things, and for weeks it seemed we were being asked how we felt about leaving. There was a suicide in the hospital, there was a long-term (meaning years) patient there who was being treated for borderline personality disorder, and she kept lighting fires. The drama was non-stop, the emotions were intense. By the end of the summer, I wasn't sure I should be a psychiatrist, not because I didn't like it, but because I was emotionally over-involved. It got better.

Medicine as a whole, requires some distance. You want your doctor to care enough to hear your pain, to address it, to explore a variety of treatment options, but you don't really need, or perhaps even want, your doctor to feel your pain. And my guess is that our reader is correct that the doctors don't really know how bad it can be.
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Note to Retriever: May I use your entire comment as a free-standing Guest Post?? It was a good synopsis of some of the policy problems behind the mental health system.

Here Ye! Here Ye!!

In medicine we're generally careful not to judge our colleagues harshly on paper. We may report what the patient or another doctor tells us, but we usually hold off on condemning people in a chart-- it makes for messy liability issues, and it's really just poor form to write "Can you believe that idiot prescribed this combo of meds" or "the last doctor never even listened to the patient's complaints."

In real life, I don't believe we're quite so generous. It's not at all unusual for docs to condemn-- in an off-the-cuff manner in casual conversation with friends-- their disdain for the practices of others. Can you believe his former doc prescribed 10 mg/hour of Xanax? Or what about the doc who demands every patient come for weekly therapy sessions even if they don't think they need therapy? Or the doc who only sees patients for 10 minute med checks and never really listens to the patients? How 'bout that doc who gave his suicidal patient a 90 supply of Hemlock? Or how could he start a patient with bipolar disorder on an antidepressant-- of course it de-stabilized him!

I think we're quick with our Can You Believe stories. More in psychiatry than in other branches of medicine? Maybe. Why? Perhaps because less of what we do is clearly defined and even amongst ourselves, we have no full consensus on exactly what it is we do, and in what units. We're certainly getting closer with our use of medications, but still, the guidelines don't take into account what to do if a patient fails many trials of many medications and still has a myriad of symptoms. Sometimes our patients are very sick and we get very desperate. And then too, our label says little about what exactly we do-- one shrink only does med checks, another only does therapy, and we amongst ourselves have not come to a consensus about what is the absolute 'right' thing to do, for whom, in what settings, with what staffing and reimbursement issues, how frequently, and when.

What do you think: are we gentle with each other or not?