Archive for October, 2009
NAMI Lies In NYT Letter To The Editor
Today, NAMI National’s executive director Michael Fitzpatrick penned a letter to the editor of the New York Times and objected to how NAMI had been portrayed in a recent article which outlined how the group had gotten about $23 million in pharma funding in recent years. The paper had claimed that represented two-thirds of NAMI’s budget and Fitzpatrick wrote to claim it only represented 50 percent.
Then he dropped this claim into the letter:
“NAMI maintains strict guidelines that govern all corporate relations and does not endorse or promote any specific medication, treatment, service or product.”
That’s a bald-faced lie. In December 2006, Fitzpatrick was quoted in a Janssen/J&J press release wherein he openly touted the company’s new atypical antipsychotic Invega:
“‘We are pleased that innovative delivery technologies are being applied to new treatments for schizophrenia,’ said Michael J. Fitzpatrick, MSW, Executive Director, National Alliance on Mental Illness (NAMI). ‘New and efficacious treatment options, like INVEGA, provide significant opportunities for more people with schizophrenia to manage their disease as they work with their treatment teams to live more fulfilling and productive lives.’”
Sadly, the press release itself is no longer online, but if Fitzpatrick wants to claim his group has been mischaracterized, then he needs to be more careful in what he states.
Posted in What I Learned Part 2
Notes from the second day of the American Academy of Psychiatry and Law.
The only psychiatric diagnosis not related to an increased risk of
suicide is mental retardation. Poor David Carradine got a mention
during the lecture on autoerotic asphyxia. Menninger talked about the
"three wishes" of suicide: to escape pain, to express rage, and to be
martyred (when provoking others to kill him). Five percent of all
suicides happen in the hospital. The legal idea of "proximate cause"
consists of the "cause in fact" (the poor treatment) and the issue of
foreseeability. HIPAA allows disclosure of information without consent
for purposes of treatment (like to do a risk assessment). HIPAA was
amended in 2002 to allow this. Many states allow disclosure without
consent in emergencies.
Humans and functional MRI are equally poor at predicting human
deception in an experimental poker bluff paradigm.
Georgetown medical school requires all their students to have an
iTouch or iPhone. Dang, that's progress!
The best predictor of competency restoration is the cumulative days of
length of stay. (Longer LOS means less restorable.) Predictors of non-
restorability are older age, mental retardation and a diagnosis of
schizophrenia.
The forensic sciences sampler is always the most fun and interesting
presentation for me. This year's topic was the investigtion of fires
and bombing. There is a local company, Combustion Science and
Engineering, which does computer modelling of these incidents.
Psychiatrists use psychodynamics, fire investigators use "fire
dynamics" or fire behavior. They consider witness reports, burn
patterns and electrical arc patterns to determine an origin and cause
of the fire. People who die within the compartment of origin tend to
die of heat injuries while outside the compartment they die of carbon
monoxide poisoning. Dr. Doug Ubelaker, a forensic anthropologist from
the Smithsonian Museum of Natural History, talked about human
identification of fire victims. When dry bones burn they get
longitudinal fractures, when flesh-covered bones burn they get
transverse fractures.
In the early days of the FBI the Smithsonian scientists were routinely
"loaned out" to help investigators.
Fetal kidnapping is when pregnant women are killed for their babies.
Out of 18 reported cases, only one defendant was legally insane.
It's never a good idea for your mistress to die under mysterious
circumstances even if you didn't kill her.
Kierkegaard today….
I’m trying to schedule my posts around ClinkShrink’s AAPL updates.
From the NYTimes, here’s a piece by Gordon Marino on….What if Kierkegaard were alive today? Would he YouTube, Facebook, Twitter, take Prozac and be done with it?
Marino writes:
Each of us is subject to the weather of our own moods. Clearly, Kierkegaard thought that the darkling sky of his inner life was very much due to his father’s morbidity. But the issue of spiritual health looms up with regard to the way that we relate to our emotional lives. Again, for Kierkegaard, despair is not a feeling, but an attitude, a posture towards ourselves. The man who did not become Caesar, the applicant refused by medical school, all experience profound disappointment. But the spiritual travails only begin when that chagrin consumes the awareness that we are something more than our emotions and projects. Does the depressive identify himself completely with his melancholy? Has the never ending blizzard of inexplicable sad thoughts caused him to give up on himself, and to see his suffering as a kind of fever without significance?
If so, Kierkegaard would bid him to consider a spiritual consultation on his despair, to go along with his trip to the mental health clinic.
House Health Care Bill Pushes Mental Health Promotion, Nanny State In Workplace
There are many references to mental health in the House health care reform bill, 110 to be exact. Most of them use the term generically in reference to facilities and health care providers, but not so when it comes to “wellness program grants.” (The language begins on page 62 of the bill, downloadable here.) These wellness grants appear to be–as best as I can understand the bill–aimed at smaller businesses and would allow for a 50 percent grant of wellness plan expenses (presumably from a private plan) but only if said wellness program and said businesses institute a Nanny State program that goes far beyond the usual “smoking is bad” provisions and rushes right into the stomachs and moods of working Americans.
If you think I am joking, it’s clear that the federal government will be directing provisions of these plans, as the bill orders (on page 66) the secretaries of HHS and Labor to:
“compile and disseminate to employer health plans information on model health literacy curricula, instructional programs, and effective intervention strategies.”
Employees will pretty much be forced to play along (pages 66-67):
“EMPLOYEE ENGAGEMENT COMPONENT. An employee engagement component which provides for the active engagement of employees in worksite wellness programs through worksite assessments and program planning, onsite delivery, evaluation, and improvement efforts.”
Then it’s time for behavioral change (page 67) for one and all!
“(3) BEHAVIORALCHANGECOMPONENT. A behavioral change component which encourages healthy living through counseling, seminars, on-line
programs, self-help materials, or other programs which provide technical assistance and problem solving skills. Such component may include programs relating to
(A) tobacco use;
(B) obesity;
(C) stress management;
(D) physical fitness;
(E) nutrition;
(F) substance abuse;
(G) depression; and
(H) mental health promotion.”
That’s right, mental health promotion. That’s exactly what government should be doing.
“(4) SUPPORTIVE ENVIRONMENT COMPONENT. A supportive environment component which includes the following:
(A) ON-SITE POLICIES. Policies and services at the worksite which promote a healthy lifestyle, including policies relating to
(i) tobacco use at the worksite;
(ii) the nutrition of food available at the worksite through cafeterias and vending options;
(iii) minimizing stress and promoting positive mental health in the workplace; and
(iv) the encouragement of physical activity before, during, and after work hours.”
Wow, going after smoking on breaks, food at work, stress, mental health promotion and pushing exercise. This set of provisions in the bill is simply…breathtaking. There’s a Libertarian in me that just screams when I read that the feds want to get involved in creating positive moods at work and creating healthy lifestyles. That kind of thing is so far out of the purview of the feds–read the Constitution if you think I am kidding–that it makes my skin crawl that House Speaker Nancy Pelosi (D-Calif.) is pushing this kind of thing. But then she’s always struck me as someone who has spiked her office water coolers with Zoloft.
So the Nanny State has arrived. Enjoy. When I was still at Seattle Weekly in January 2006 and wrote this lengthy piece on Seattle’s Nanny State, I thought I was excessive in predicting what the Nanny Statists would come after. Looks like I understated things.
There is a provision on page 68 stating that employers cannot make participation mandatory, but if you’ve ever worked for a small employer (and I have for several), then you know how voluntary can become mandatory in two seconds. You like that paycheck, right? Well, go jogging with the boss!
House Health Care Bill Contains MOTHERS Act
The House health care reform bill rolled out yesterday contains most of the language and provisions of the long-stalled, much-controversial MOTHERS Act. Go to page 1418 of the bill, downloadable here, for the language. An earlier version of the MOTHERS act is here.
Minus the original bill’s prologue about depression in new moms, much of the Act’s provisions are in the House bill, but with slightly softened language. Postpartum depression screening is no longer, in essence, mandatory but is now something that “may” be included in a national education campaign for health professionals and the public. The bill also calls for research on the causes and treatments for PPD, studies of differences in PPD between different ethnicities, “[t]he development of improved screening and diagnostic techniques, Clinical research for the development and evaluation of new treatments.”
So that ought to make Big Pharma and the Act’s proponents happy.
As for the education program, the bill specifies:
“Information and education programs for health professionals and the public, which may include a coordinated national campaign that
“(i) is designed to increase the awareness and knowledge of postpartum conditions; (ii) may include public service announcements through television, radio, and other means; and (iii) may focus on (I) raising awareness about screening; (II) educating new mothers and their families about postpartum conditions to promote earlier diagnosis and treatment; and (III) ensuring that such edu-cation includes complete information concerning postpartum conditions, including its symptoms, methods of coping with the illness, and treatment resources.”
That sounds similar to what critics of the Act have objected to in the past (see Evelyn Pringle and Martha Rosenberg), seeing the Act as disease mongering by pharma companies, so it’ll be interesting to see the reaction this time out.
I’ve learned through bitter experience that it’s best for me not to have an opinion of the MOTHERS Act or to even ask fairly innocent questions about why we seem to have so much PPD these days. But I will point out that I find it odd that the House is using a bill that’s supposed to reform health care access and delivery to fund various research studies which ought to be broken out into NIH’s regular budget funding. These studies aren’t going to affect health care delivery and access and just add to the cost of an already-costly bill. Just my opinion.
House Health Care Bill Contains End-Of-Life Counseling
The AP reported last night that the House health care reform bill indeed contains provisions for end-of-life counseling, which generated so much controversy over the summer when it was included in earlier version of the bill. Former Alaska Governor Sarah Palin dubbed this counseling “death panels”–a bit of an overstatement I think–and it was off to the races.
I figured the Democrats were smart enough to strip these provisions out of the House bill, but no. The reality is the counseling likely wouldn’t make its way into an eventual combined House-Senate bill because over in the more adult chamber the Dems are struggling to land votes. You can read the language of the end-of-life counseling beginning on page 641 of the bill, downloadable here.
While the language does state that such counseling would be strictly voluntary, I can appreciate why some people object to the Congress legislating much of anything about end-of-life because it seems just as weird to me as the bill’s many Nanny State provisions–yay, the government is going to tell me how many calories are in restaurant food because I’m too stupid to figure out that a Big Mac is fattening!–and its provision encouraging workplace wellness plans to create positive mental health in the workplace. Can’t business owners work that kind of thing out for themselves? Or is the government to regulate our moods now, too? I feel roughly the same about the end-of-life counseling–it’s something the government is best keeping its nose out of.
Interestingly, the prime backer of the counseling is Rep. Earl Blumenauer (D-Oregon) who I dealt with many times when I was a reporter in Portland. I found him to be very smart, very quirky (bow ties, biking everywhere, showing up for endorsement interviews in biking shorts) and very committed to whatever his particular position was, often to the point where you couldn’t ask legitimate questions.
He told the AP:
“‘There is nothing more basic than giving someone the option of speaking with their doctor about how they want to be treated in the case of an emergency,’ said Rep. Earl Blumenauer, D-Ore. ‘I think the outrageous and vindictive attacks may have backfired to help raise awareness about this problem, which is why it’s been kept in the bill.’”
Blumenauer knows damn well that there’s a lot more in this portion of the bill than emergency treatment. There’s consulting on wills, living wills, and “[a]n explanation by the practitioner of physician orders regarding life sustaining treatment.”
I bet you this blows up all over cable news and the blogosphere later today. Stay tuned.
Housekeeping
I just cleaned the refrigerator because Michelle (not her real name) from Blue Cross Blue Shield called to inform me that because I am a “high volume” provider; they’re coming over to audit my charts.
That will be the start 0f one of my upcoming posts.
And you want to know why I don’t blog more often. You know I want to talk to you, and it kills me that there’s not enough time. I’m not even responding to comments and am late in posting them, too, intend to do it, still plan to get back to them, for sure. But the road to hell is paved with good intentions, or something like that, and all I can say is that there’s a lot of stuff on the proverbial plate, it’s spinning madly, and
I’m sorry.
That said, please know that I read every comment and appreciate every one of them, and believe me, I learn more from you from this process than you could possibly realize. Indeed, one reason some therapists last in this field, don’t totally burn out, get infected from so much pathology, is that we learn from every person we see, from everything we hear, everywhere. We might complain on occasion, but everyone does, you know.
It’s been said before, this job is interesting, challenging. You have to stay on top of new knowledge, although you might rely on a foundation. Professionals have to keep learning, that’s what differentiates them. Our WOW! really is a wow. It isn’t placating, it isn’t fake; there’s no agenda. When the learning comes from others, it’s illuminating. And a lot more fun.
So we’re grateful that people share their lives with us, feel privileged. The first thing we tell patients as they button up their jackets to leave, maybe after the first visit, the second, third, fourth or fifth, etc.
Thank you for sharing all of that. It can’t be easy, I know that it isn’t. Thanks for trusting me.
When I started this blog, honestly, I did not know what to do with comments. They freaked me out.
Oh, no! This person thinks I’m her therapist! What will I do with this comment/email? What if she takes something the wrong way, uses it as personal advice, isn’t seeing someone else, a real flesh and blood human being who can intervene and go,
Call 911! You need to be in a hospital!
Meaning, I could be responsible for something bad!
This blew me away, more-so than an occasional stalker threatening me and my family, or a BCBS auditor.
Which is why there are all those caveats in the margins that say,
I ain’t your therapist, get one somehow, please, please, please. This is for your edification, is all, and it’s fun for me, okay?
And you know I mean it, get therapy if you can, hence the title of the blog.
And yet, by all means, we can talk, we can share information. There’s no one shutting us down, and why would there be? It’s a mutual admiration society. So what I’m saying is No, to those of you who have asked if I’m giving it up.
And one day, no promises, I’ll blog about it, tell you everything. You did sign that HIPAA form on the sidebar, right?
therapydoc
Being Right Part Two
I thought there might be a Part Two when I posted Part One of Being Right. Sometimes there has to be a Part Two.
In Part One we find me hopeful about people changing. It takes time, but even people who have to be right all of the time can change, can yield the point with or without therapy, if you play them right. A family systems approach works better than CBT, a cognitive behavioral therapy that falls with defensiveness on deaf ears, as in, What do you know?
Part Two, I’m sorry, is more depressing. I find that I can’t change some people, not without medication to chill them down. They’ll never yield the point, never be wrong. They’re simply too afraid. And they have a disorder, probably.
If it’s Schizophrenia, Paranoid Type, an Axis I disorder, you can’t blame a person for being quite sure that there are enemies out there, that people are persecuting him. He’s right about this, absolutely sure; they’re listening through the telephone, the computer. Voices and imagined events are real, no convincing otherwise.
These are delusions. Even with help, without medication delusions can be hard to dislodge. Try and convince people who suffer from them that they’re wrong. Good luck.
Being right is also a feature of Paranoid Personality Disorder (PPD), an Axis II, and we can’t blame people for personality, either.
Nowhere does the word “delusion” appear among the diagnostic indicators of PPD (listed below) but the features imply that sufferers are delusional by virtue of their unfounded distrust. Because they hear no voices they’re not technically delusional. It is their faulty construction of reality that makes them suspicious of others, not voices in their heads.
You can have both, an Axis I disorder like depression, addiction, or anxiety, and an Axis II, a dysfunctional personality. The latter can cause the former. People can get depressed because others don’t like them; they can’t look in the mirror to see how difficult they are to love. Hospitalized for the whole gestalt, even CEO’s billionaires, people ostensibly doing just fine, functioning at the top of their game, get mentally sick.
Personality develops in childhood as our genetic predispositions are slapped with reality, the world out there. Some traits lie dormant until challenged by the hand we get, our families, friends, teachers, our luck. Yes, you actually can blame the family, and you can blame others (try that boarding school, orphanage, the Nazis, or a father who liked your little brother better) for bringing out the worst in you.
The problem is there’s no pointing any one finger at any one person. Everyone’s a product of someone else’s stress in transgenerational theory, people who victimize have probably been victims themselves. If you go genetic, you have to start with Adam and Eve and all those other mamas and papas.
Surely some features of personality, especially the cute ones, the positive ones, aren’t snuffed out with negativity, and they’re genetic, for sure, our cadence, how we talk, joke around. We see our mannerisms in our children and grandchildren, we know they haven’t copied us intentionally. There’s wiring in there. Yet we all talk like Seinfeld. Would I lie?
The environment gives the nod, the go-ahead to both the good and the bad.
In Part One we discussed how when childhood stress is bad, as it is under the roof of abuse and neglect, unconscious decisions to cope with it aren’t always good. Without parental coaching, how’s a kid supposed to know what to do? So children make decisions, as in, T
Trust no one.
Don’t tell me, I’m wrong. You’re clearly wrong, and you’re scary, and
You’re not the boss of me now.
We call attributing, or casting unwarranted negative aspersions to people paranoia, and we’re not talking the pot smoking kind. You can change that by getting straight, you know.
When paranoia rules in an otherwise normal personality, as in Paranoid Personality Disorder, there’s no yielding the point, no being wrong about people and their intentions. The person suffering from paranoia is sure, 100% sure that. . .
He stole that money!
She cheated me out of the property!
She has my ring and won’t give it back.
He thinks I’m stupid. I’ll show him!
Very difficult to convince people like this that they are wrong about this, no matter how much cajoling, flattering, affirming, validating, you do.
Okay. Maybe with a lot of sex. But even with physical affection, I don’t know, the odds are that the paranoia will come back again under stressful conditions.
This is why, by the way, medications are helpful, they help people buffer stress. It is also why some people don’t want to take them. They don’t want to be left vulnerable to exploitation and harm, psychologically “buffered” from the pain.
Here are the features of this intractable disorder.
301.0 Paranoid Personality Disorder:
A. A pervasive distrust and suspicion of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following:
(1) suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her(2) is preoccupied with unjustified doubts about the loyalty or trust-worthiness of friends or associates
(3) is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
(4) reads hidden demeaning or threatening meanins into benign remarks or events
(5) persistently bears grudges, is unforgiving of insults, injuries, or slights
(6) perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack
(7) has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
B. Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition.
No fun. Partners, spouses and children are often accused of cheating, lying, having affairs, manipulation. Friends and children of friends, housekeepers, baby sitters, business associates, deliberately plotting behind their backs. People look at them the wrong way, people wrong them, think they’re oblivious, stupid.
These are angry people. Suspicious. Not obviously, sometimes, they won’t always tell you their suspicious, but surely. Telling you might give you an edge.
There is a strong association with child abuse, and you can see why. If you can’t trust your own parents to take care of you and protect you, to show you that they love you, that they believe in you, who can you trust? Or if you lived in a concentration camp, and every authority was a killing authority, every uniform or bunk mate a possible snitch, you learn to read aggression in people, even when there isn’t any. You misinterpret facial signals, body language, tone of voice.
You learn to trust only yourself. You become impenetrable, are perceived by others as tough. Deep down you want others to adore you, to tell you that you’re wonderful, and you may behave as if you believe you really are, but you’re really not sure. This thread of insecurity runs through most personality disorders, you know.
People who suffer from Paranoid Personality Disorder are often afraid to put themselves in situations that are intimate, it makes them feel vulnerable, weak. They won’t initiate an intimate conversation, and have buried their issues deeply, don’t participate, necessarily, or appear disconnected, laugh when they shouldn’t. Makes sense, right? How can you let a potential enemy get close? That’s just plain dumb.
You don’t make yourself vulnerable, tell people your true feelings, your fears, your sadness, if there’s a chance of being punished.
That’s another reason you have to be right, too. So you don’t get punished.
therapydoc
House Health Care Bill Mandates Study Of Mental Health Outcomes of Abortion, Adoption
Just putting this out there in as non-confrontational a way as one can: Beginning on page 1420, the House health care reform bill rolled out earlier today requires NIMH to study the mental health outcomes for women who have abortions or otherwise “resolve” a pregnancy. The bill is downloadable here.
“It is the sense of the Congress that the Director of the National Institute of Mental Health may conduct a nationally representative longitudinal study (during the period of fiscal years 2011 through 2020) on the relative mental health consequences for women of resolving a pregnancy (intended and unintended) in various ways, including carrying the pregnancy to term and parenting the child, carrying the pregnancy to term and placing the child for adoption, miscarriage, and having an abortion. This study may assess the incidence, timing, magnitude, and duration of the immediate and long-term mental health consequences (positive or negative) of these pregnancy outcomes.”
I have no idea why this is included in a bill that’s supposed to reform our health care system–for good or ill. Maybe I’m missing something. The bill requires NIMH to report back to Congress on study progress and findings within three years.
Of course, the relative psychological impacts of abortion are some of the most heated aspects of the abortion debate. Pro-lifers often claim that women who undergo abortions often end up depressed while pro-choicers often claim that there’s no psychological detriment. I’ve seen competing evidence in the medical literature on this point over the years. I’ll leave it at that.
House Health Care Bill Mandates Calorie Counts At Restaurants Nationally
House Speaker Nancy Pelosi earlier today rolled out the House’s version of health care reform. The bill is a 1,990 page whopper, downloadable here. I’ve been able to poke through it a bit and, beginning at page 1,510, I encountered something that will embiggen the hearts of public health advocates (and frankly the whole bill is a gigantic wet kiss to the public health crowd) and make haters of the Nanny State say, “Told you so.”
The House bill mandates for calorie counts of almost any item served at a restaurant (or similar food establishment) owned by a company with 20 or more restaurants in the US as well as on drive-thru menu boards. Currently, only a few cities and counties require such information in the US, notably New York City and King County (Seattle), Washington. So America is about to go from Nanny State cities to the Nanny State nation.
And the trouble with calorie counts is that they seem to have a fairly limited impact on what people eat, according to this New York Times account of a recent study of the calorie count law in NYC. (I have no idea how this is playing out in Seattle so far.) It perplexes me beyond belief that we have a government that doesn’t get that people already know a Big Mac is fattening and people are going to order one anyway, calorie count information be damned, because they like Big Macs. This calorie count thing nationally is going to be expensive to implement and will likely not change human behavior much. I cannot wait to see how the food industry responds.
Beginning on page 1515, the bill also mandates calories counts for items in a vending machine operated by anyone who operates 20 or more vending machines. And the nutritional information that’s already on the majority of food (chips, cookies, etc.) you can buy from a vending machine isn’t sufficient under the House bill. Instead, vending machine operators would be required to post a prominent sign next to each item, readable before a consumer makes a purchase. That is going to be a very expensive hassle for vending machine operators across the country, especially smaller operators.
I’m a bit lost on what American over the age of 14, say, doesn’t know that chips from a vending machine are high-calorie items, so why this provision exists in the bill is beyond me–except that I know it’s there to serve the true believers in the Nanny State.
There’s more in this bill that I’ll post on in a bit.