Crazy Talk

Vet the advisor BEFORE taking the advice

I'm not thrilled with the title but since it's been a while since I've posted I thought I'd get to the point instead of stressing over it.

In this age of information overload, time management is essential and I have been encountering a huge waste of time in my practice and in my life in general.  It has to do with coming across some piece of new information and springing into action only to find that the information was misleading or just plain wrong.  Sometimes looking back, I realize that the original source of the information may not have been the most reliable.  This can be a frequent occurrence when dealing with the internet.

But whether online or on TV (or in a blog), we have to get into the habit of considering the source before considering the information.  By actively seeking out trusted sources or at least having a basic method to evaluate sources, we can save an enormous amount of time otherwise wasted chasing "false leads". 

Advertisers want to sell you a product and they're getting more and more sneaky.  Product placements and "news" items that are actually promoting a specific product or service are everywhere. I'm not saying that anything that is advertised is of no use, but you have consider the source before you use the information to make a purchasing or consumption decision.

Choosing in Reality

Among many other things, the election of President Obama combined with the current financial crisis has brought the debate about the health care system back to the forefront.  We are quickly reaching the point where we cannot ignore the fact that the system has been broken for long time because, basically, we no longer have the money to throw into a largely corrupt and inefficient system. 

This Thursday, the President is holding a summit in Washington to gather information on how to fix the problem.  Unfortunately, thus far he has not included anyone who supports a single payer system.  He has invited representatives of the insurance industry and many politicians who support the status quo.  It is not clear that single payer is the solution but it certainly deserves due consideration. Opponents of single payer immediately invoke the idea of "socialized medicine".  They then point to all of the drawbacks of socialized medicine as it has been implemented in other countries, the main one being healthcare rationing.

I am by no means a health policy expert, but what I can say is that a single payer system is not what would trigger health care rationing.  Reality is what would.  We have been living in a fantasy world in which we pretend that there is no price on health.  Certainly, the value of life and good health is priceless in its importance, but the fact is that there are costs associated with providing health care services.  Not only do I think we should be willing pay this price but I think that it is feasible to do so while providing care to everyone, but it would entail making decisions not to pursue costly low yield treatments.

Whatever the solution ends up being, part of it is going to have to entail accepting that we have to confront the reality of death.  And all of us have to accept that health care, including paying for it, is a priority.  We can't simply demand good insurance without accepting that it has to be paid for.

Et tu Spitzer?

I don't often use this blog to comment on current events unrelated to psychiatric issues, but many of my patients have been talking about the recent events related to Governor Eliot Spitzer and his reported use of a high-end prostitution ring.  The Governor did apologize publicly without officially stepping down.  For those outside of the NY area, the current Governor was a very vocal prosecutor well known in the region for many high profile cases including several prostitution rings.  He was known for making statements condemning the actions of those he prosecuted, among others.

The question that has been brought up most often by patients is how could he be so hypocritical, especially given allegations that he was patronizing prostitutes at the same time that he was actively prosecuting prostitution cases. 

There is no full explanation for the contradiction.  Suffice to say that power is a corrupting force and it appears that eventually it makes those who wield it feel untouchable.  And it is difficult to blame them for this feeling.  In the words of one of my patients, "no one really thinks that OJ didn't kill his wife, but he got away with it."

Non-Mental Health Rant

I should probably reserve this forum for my thoughts on mental health but two recent news items have gotten to me and I thought I would reflect on them here.  Both reflect the decaying nature of our society.

The first has to do with a recent measure passed by Congress to mandate greater transparency in Congressmen's use of their influence to promote pet projects and for special interests groups.  This measure is being touted as a way to improve ethics in politics.  This is a gross distortion of the meaning of the word ethics and, from my point of view, more a publicity stunt.  What the measure shows is that there is no sense of ethics among our national politicians.  They are already millionaires and take gifts and in some cases outright bribes with very little shame.  The increased transparency does not confer any ethical obligations but rather expose those without any sense of ethics to public scrutiny.  Any changes that come about as a result of this measure have nothing to do with ethics; they just make people who do not want to look bad, stop doing bad things that might get exposed.  It's sickening.

The second has to do with the recent bridge collapse in Minnesota. I do not claim to have any special knowledge about structural engineering, but it seems to me that those responsible for doing the inspections do, or certainly should.  It has come out that several inspections revealed flaws in the bridge, and they were simply ignored.  If people did their job, this would not have happened. In our 'it's better to look good than feel (or be) good' society, there is no incentive to do the right thing.  We probably have to follow our Congress's lead and impose criminal penalties on people who are responsible for public safety.  I assure you, if the inspectors thought they would go to jail if the bridge they inspected failed in any way, they would have done more to make sure the problems were addressed.

Are Medications Over-prescribed?

This is a question that I am often asked by people when they first learn that I am a psychiatrist.  If I say 'No', then I lose credibility because the person asking the question generally believes that they are over-prescribed.  If I say 'Yes', then I feed into the distortion created by partial information.

The answer to the question is 'Yes and No'.   Because of a multitude of factors including aggressive advertising by drug companies, a desire from patients to be cured quickly and easily with a 'magic pill', and a desire among doctors to want to be helpful to those in distress, medications are often prescribed when alternative treatment methods could and should be tried.  HOWEVER, only a small fraction of those suffering from treatable symptoms have access to psychiatric care.  So overall, medications are under-prescribed because most of the people who need them don't get a chance to be considered.

The solution to this problem is routine psychiatric care for all (please see my post entitled Deliver Mental Health like Dental Health from April 27, 2007)

How Many Tragedies?

A 25 year-old mother of four apparently hung herself and her four daughters today (the youngest, an 8 month old infant survived)

I'm sure it is painful for most people to hear of the tragic death of young children and bewildering to think that they died at the hands of their own mother who then took her own life.  It's particularly painful for me, as a psychiatrist, knowing that we have safe and effective treatments for depression available, seeing lives unnecessarily lost.

I understand that there is a suspicion of big drug companies and there certainly are individuals for whom medications are prescribed too aggressively, but these facts do not justify the current state of affairs.  How many tragedies do we have to see before we let common sense prevail and make treatment available to everyone. 

In the case described above, the woman reportedly had no history of mental illness, but she was recently separated from her common law husband, had an order of protection against him taken out, and relatives reported that she had been depressed for months.  Any of these factors by themselves could have triggered a psychiatric evaluation, but the fact that relatives knew she was depressed and did not do anything is the real tragedy.  I do not blame the relatives, but the refusal of our society to recognize that depression is widespread and can lead to tragic outcomes.  How many needless deaths have to take place before something changes?

Braunstein found Guilty: Mixed Feelings

A highly publicized trial in New York City just ended with a guilty verdict.  The case involved a man, Peter Braunstein, who posed as a firefighter after faking a fire and holding a woman captive.  He was accused of sexually abusing the woman over the period of several hours.

The defense team sought to portray Mr. Braunstein as suffering from paranoid schizophrenia and therefore not responsible for his actions.  While there certainly were various strange details in the case, his treating psychiatrists did not believe he suffered from schizophrenia.  As the trial unfolded and continued to be reported in the media, I heard people asking questions about schizophrenia and wanting to understand mental illness, to better understand the case.

Since I have never met Mr. Braunstein, I will not offer an opinion about his diagnosis, but taking the conclusion of his psychiatrists, it appears that the jury got this one right.  In that regard, I am pleased that mental illness was not inappropriately used to excuse a criminal act.

But I am also troubled because now that the case is over, the issue of mental illness has fallen out of the public mind.  People have moved on to whatever else is on the front page and wont think about mental illness until the next bizarre court case or (hopefully not) tragedy involving someone with mental illness. 

Slipping through the cracks

There was an Associated Press blurb in the paper today that indicated that a man who killed three people and himself in Idaho recently had said that "if he committed suicide, he would try to take a large number of people with him".

Together with the fact that there had been a court ordered mental health examination in the history of the Virginia Tech shooter, I am curious what people think these reports mean about mental health treatment in general.

A knee-jerk reaction thinking that the system doesn't seem to be working is understandable, but it is important to keep in mind that only the treatment "failures" end up getting media coverage.  Aside from possibly distorting the reality of the effectiveness of mental health treatment, I think the one-sided coverage further adds to the stigma of mental health treatment; that there is a sense that mentally ill people are all deranged, angry individuals prone to random violence and suicide. 

I am curious what people think about this and would welcome comments.

NY Times article about Psychiatry and Drug Companies

Whenever I see psychiatry mentioned in the lay press, I always cringe because I usually read the article and feel some outrage over a distortion that often leads to increasing the stigma about mental health treatment and makes people more suspicious of psychiatrists.  I just don't want anybody to read things that make them think "Hmm, maybe Tom Cruise is right."

Yesterday's New York Times had a cover article with the word "Psychiatrists" in the title (the link is below), and now you know what my initial reaction was.  However, when I read the article, I had to admit that they were covering the issue well.  The article cited statistics from Minnesota (where such information has to be made public) that showed that psychiatrists that received $5000 or more from drug companies (usually for giving talks) prescribed atypical antipsychotic medications about three times as much as doctors who received less or no money. 

While several doctors were cited as saying that they don't think the payments affect prescribing habits, they reality is that we don't want to think that they do, but we have to admit in our heart of hearts that they do.  We may each have our own personal needs and justifications for associations with pharmaceutical companies, but I think we have to acknowledge the conflict of interest.  And the statistics are hard to ignore.  (But so is the money.  One doctor earned $689,000 from 1998 to 2004)

I wish the article pointed out that this issue cuts across all medical specialties and had not singled out psychiatry and a little girl who developed dystonia.  Apart from that, I thought this was one of the less inflammatory articles I have seen recently.

http://www.nytimes.com/2007/05/10/health/10psyche.html?_r=1&oref=slogin

With Mental Health, any publicity is NOT good publicity

There is a trial taking place in New York in which a former fashion writer, Peter Braunstein, is accused of posing as a fireman, faking a fire to break into a woman's home, and sexually assaulting the woman over the course of several hours. 

Coverage of the trial has focussed a lot of attention on the fact that the defense team is claiming that Mr. Braunstein is mentally ill citing two past psychiatric hospitalizations and suicide attempt.  As a forensic psychiatrist, I am called upon to do evaluations of defendants for a variety of reasons, including Not Guilty by Reason of Insanity (NGRI) pleas.  I have little knowledge of this particular case and my current interest is not in the politics of NGRI.

My concern is over the terminology used to describe what may have happened to Mr. Braunstein and the role that such a distorted and ill-informed view of mental illness has in propagating the kind of stigma that stops people from seeking help.  Just the idea that Mr. Braunstein was hospitalized should be seen as a minor detail rather than proof positive that he is deranged.  The defense attorney described Mr. Braunstein as someone "whose brain just broke".  Given the complexities of brain function and the multiplicity of factors that go into determining behavior, the idea of a broken brain lying behind such complex behavior as staging a fire and holding a person captive using chloroform to render her unconscious is absurd.  My point is that such descriptions do not do anything to inform the jury or the Judge about what may have led to such behavior but it does give the news-reading public a view of mental illness that is distorted.  It sends the message that to be hospitalized or pursue treatment implies a "broken brain", which is seen as equivalent to doing the kinds of bizarre things that Mr. Braunstein allegedly did.  With this kind of instant reputation, no wonder Russel Simmons's response to a reporter's question about whether he saw a therapist was something along the lines of "why, do you think I'm crazy?"  And no wonder people would rather suffer anonymously rather than get treatment and be put in the same category as Peter Braunstein.