I’d be remiss not to point out that Medscape, in this context, is merely reporting medical news. Their article centers around a new analysis, drawn from the Columbia Mass Murder Database (CMMD), which suggests that mental illness is incidental in mass shootings.

“People with serious mental illness constitute only a small portion of the perpetrators of gun violence in this country,” Paul Appelbaum, MD, professor of psychiatry, medicine, and law at Columbia University in New York City. told Medscape.

The analysis covered 82 incidents of mass murder in academic settings including schools, colleges, and universities. The average number of victims of these incidents was eight. All 82 incidents were initiated by men (mean age 28), and 67% were Caucasian. About two thirds (63%) involved guns.

More than three-quarters (77%) of all perpetrators of mass murders in academic settings had no recorded history of psychotic symptoms. (emphasis added by author)

Swiss Cheese

To extrapolate data and draw conclusions from an existing data set, the cohort needs to be at least mildly historically similar. All this analysis suggests is that 77% of the shooters were not yet diagnosed as suffering from a mental illness or had insufficient coping mechanisms to deal with the stresses they faced. The authors conclusions, that only 23% of the shooters suffered from mental illness is an overreach of monumental proportions.

Most modern research suffers from these biased slants, which either lose sight of their controls or interpret data in wildly irresponsible fashion. All the more sad, as the true value of the data is lost behind an overriding narrative the authors wish to justify. What is clear from this analysis data, is that our systems for managing and identifying mental illness and related conditions are flawed. As is the care we offer to those diagnosed.

A significant majority of these shootings may have been prevented had individuals with a myriad of life challenges or psychological struggles been flagged. This begs the argument, why did the 23% slip through the cracks if they had been diagnosed and were, one would assume, under treatment?

These incidents, targeting young children by individuals who are themselves still just teenagers or newly minted adults, are a new phenomenon. Discovering the “why” matters almost as much as restricting access to weapons.

What can the 82 teach us?

Numerical data in this instance, used as it was, for the analysis above, is of little import and can be manipulated to suit any agenda. What researchers should instead be pursuing are the 82 lives that led to these horrific events.

Who were these young people, social backgrounds, family, schooling, infractions with law and authority, medical histories, friendships, potential triggers, medication, anything and everything that can be found that relates to their lives. Examine this and patterns will emerge. Patterns that may very well point the finger of blame to society, broken families, flawed mental health policies and the social stigma of reaching out for help – even in-patient care.

Identifying these patterns and potential triggers matters. Our human capabilities no longer limit us and AI can be incorporated to search social media for matches, allowing for early intervention. Teenagers or young adults do not just pick up a weapon and commit mass murder. They progress, in increments, to this course of action.

There are always signs.

Often we simply fail to see the signs and sadly, when we do pick up on them, we tend to ignore them – we cannot image that they will lead to something so horrible.

But, there is another challenge – access to mental health help. Ask anyone who needs to find a therapist how daunting the task is. It can take months, sometimes more than a year, to secure an appointment with someone with experience to address serious mental health challenges.

Again, this is unsustainable in a society where stable parenting is becoming an archaic concept, whether by design or necessity. Stable homes are in rapid decline.

The real indictment of this analysis are the diagnosed 23%. They represent the ever-increasing cost of our inability to help children who are crying out for guidance, care and a sense of belonging and purpose. How many lives could have been spared? How many lives will still be forfeit? We can, and must, do better.

Reaching for the closest solution

Mental health issues may be the motivating factor to committing mass murder. The preferred tool of choice for these murders is the assault weapon or other firearm. While we can debate the motivation for each individual heinous act, this choice of tool is far simpler to comprehend. Ease of access.

In countries where access to firearms is limited or non-existent, school shootings DO NOT HAPPEN. In America, gun ownership, legal or otherwise has reached pandemic proportions. It is even questionable at this point if tightening ownership laws and policy changes will have any impact whatsoever on teens being able to find and use weapons designed to maim and kill, so prolific is their distribution in American society.

While we struggle to find ways to prevent these tragedies from a mental health perspective, an arduous and difficult task, surely removing the preferred tool from the equation makes far more sense. No access to guns equates to no school shootings. A globally proven fact.

The post Why It is Imperative We Redefine Mental Illness and How We Treat It appeared first on Medika Life.

Elected officials quickly point fingers and prefer debating settled science for fear of antagonizing their base.  All in the interest of self-preservation or self-interest.  When it comes to public health, we need a bolus dose of radical purpose and a stiff shot of courage. We seem overwhelmed by health and ecohealth problems.  Yes, engaging and solving the endless list of issues appears impossible.  However, avoiding these “big three” – obesity, mental health, and plastics – only compounds the significant societal and business woes we’re already facing.

“Let’s start at the very beginning, a very good place to start…” as Julie Andrews sang Rodgers and Hammerstein’s uplifting Do-Re-Mi in The Sound of Music. It’s time we begin to rally to the beat of three public health priorities where investment of time and money will deliver outcomes:

Weight

1. America’s Expanding Waistline:  Some 40% of American adults aged 20 and older are considered obese. The domino effect of obesity-related conditions includes heart disease, stroke, type 2 diabetes, and some cancers. These are leading non-communicable causes of costly, premature death. According to the Centers for Disease Control, the estimated medical cost of obesity in the US reached $173 billion in 2019. Medical expenses for obese adults annually are almost $2,000 higher than medical costs for people with a healthy weight.

It’s simple to point the finger at the fast-food industry as a leading cause of the nation’s obesity problem. It’s also popular to blame overweight people for inflicting the problem upon themselves.  That’s not a good use of time or effort. It’s not even accurate,  Five contributors tip the scales: 

• Caloric intake
• Poor diet
• Lack of exercise
• Stigma
• Access to expert care

Social determinants of health influence obesity rates among adults and children. Poverty, racism, geography, and lack of access to preventive and expert medical care contribute to our ever-expanding waistlines.  Structural racism is baked into our institutions, policies and practices—from defining where people (are often forced to) live to how food is produced and priced. 

We also need to take obesity seriously as a medical condition.  Physicians such as Katherine Saunders, MD, and Louis Aronne, MD, at Weil Cornell are at the forefront of this emerging discipline. But fewer than 6,000 physicians like Saunders and Aronne are certified in Obesity Medicine.  The millions of people confronting obesity need continued medical intervention and support beyond losing pounds.

Marshaling public health and medical expertise to address obesity – access to care, greater public education, access to healthier, affordable food options and reinvestment in primary and secondary school physical exercise programs will produce results that slow the obesity-related non-communicable disease cascade, sustain lives and reduce costs.

Mental Health

• Mental Health is Health:  We must stop ignoring the realities and stressors of life that contribute to other health problems.  “You’ll get over it,” is not a curative response. There is universal acceptance that the pandemic unleashed the mental health problem. It merely made mental health an inescapable issue.  Removed from distractions and living, learning, and working in isolation from others, what was beneath the surface quickly bubbled up to the visible top.

It’s time we face the music and accept that depression and other mental illnesses are manageable medical conditions when diagnosed promptly and treated. Likely the biggest obstacle to care is societal bias and stigma.  In recent years, rates have shown a marked increase in reported cases.  Young adults aged 18-25 years have the highest prevalence of serious mental illness (9.7%) compared to adults aged 26-49 years (6.9%) and aged 50 and older (3.4%).

“As more of us share our experiences, then the stigma starts to reduce, as we understand that this is a shared experience, and this is what is part of being human,” said John McPhee, CEO of the JED Foundation.

Worse than the statistics around mental health-related conditions are deaths by suicide and the endless trauma survivors – parents, partners and children endure.  Globally, one person every 40 seconds takes their life. The World Health Organization and the Global Burden of Disease study estimate that almost 800,000 people die from suicide annually. With timely, proven intervention, many suicides can be prevented.

According to the JED Foundation, mental health in teens and young adults is pressing. More than half of college students will go through a period of high anxiety and one-third of college students will experience some level of depression. The data are frightening.  Suicide ranks the second leading cause of death among ages 15 to 24.

Public and self-stigma is the primary disease we must overcome to set the groundwork to better assist people with mental health needs.  Along with expected basic vitals tracked during a primary-care check-up, health professionals can make a difference by conducting mental health screens and conversations.  Remove the embarrassing obstacles to diagnosis and treatment so that more people step forward to ask for and receive care.  It’s a start that likely will save lives.

Plastics

• Plastics – Reduce Use in Healthcare Settings:  Microplastics have been detected in human breast milk for the first time, according to a new study published in Polymers and shared in WebMD. The researchers shared that they are worried about the potential health effects on babies. Shouldn’t elected officials share that concern? Shouldn’t the global medical community? Most definitely expectant parents!

US hospitals produce more than 5.9 million tons of waste yearly.  There is no escaping the reality that the planet’s health and our own are joined, and the medical community must work closely with environmental affairs experts on what must be done to keep the planet sustainable.

World Health Organization Director-General Tedros Adhanom Ghebreyesus, Ph.D., wrote in the Healthcare Without Harm report, “Places of healing should be leading the way, not contribute to the burden of disease.”  The health industry can start by using alternative plant-based packaging and products whenever possible rather than plastics. It’s an essential start to supporting clean innovation.

Is this even possible?  Absolutely! There are market leaders that are role models and sharing sustainability data. Kaiser Permanente, the nation’s most extensive integrated, nonprofit health system, reports its efforts to prioritize environmental health and patient care have enabled it to become the first health system in the US to achieve carbon-neutral status. Mega not-for-profit health systems such as CommonSpirit are partnering with vendors to reduce the use of plastics in operating rooms. These efforts must become a social impact metric that defines the business sector that commands almost 20% of the national GDP and is dedicated to sustaining our health. 

Health standard bearers such as Kaiser and CommonSpirit have proven that change is possible.  These centers of healthcare excellence – caring for people and the planet – lay the groundwork for Federal and state policies that can protect our short- and long-term well-being.

The clock is ticking.  These problems cannot be wished away.  Weight, mental health and plastics are three priority health concerns contributing to a deadly domino effect where one crisis leads to another.  Of course, these are not the only public health issues of import we face.  At the foundation of these problems are poverty, racism and economic systems rooted in an unsustainable status quo.  Eventually, there will be no choice but to engage and change.  By then, what will the state of people’s health be?  I’d prefer we commit to taking the necessary action sooner to spare us from having to face that bleak future.

The post Let’s Kick the Can Down the Road Again. Or Not! appeared first on Medika Life.

Now it is time to put the fake news to bed regarding who are the individuals holding these weapons of death and slaughtering the innocents. No, they do not have a mental health condition, and to say that they are all mentally ill is incorrect and further stigmatizes persons with a mental health disorder. Statistics have shown us where the mayhem has been perpetrated regarding the states and who has been pulling the triggers.

The states with the highest incidence of firearms mortality include Alabama, Alaska, Arkansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, New Mexico, Oklahoma, South Carolina, Tennessee, and Wyoming. If you live in any of those states IMHO, you can be assured that you are at higher risk of encountering an individual with a gun who will kill you without hesitation. Then, there are the “stand your ground” laws.

Don’t chalk these murders up to mental illness. If you do, you are refusing to recognize that legally these murderers have the right to carry a gun, not just a gun, a military-quality assault rifle, anywhere they wish.

Don’t be in their fire line if you want to live. Perhaps, at some point, you’ll hesitate to leave your home. Indeed, you won’t want your children to go to school because you’ll wonder if they will ever return. No, this is not an advertisement for homeschooling, but that might realize an uptick in its popularity now.

And now, “open carry” is legal, so anyone wishing to have a sidearm with them when they go shopping, to the movies, or anywhere can have a firearm at their disposal. How many more instances of untamed violence, foolish behavior, or unintended slights will result in death for the intended and those who will be collateral damage?

If before we told people to “let the buyer beware,” now it’s “let everyone beware.” The genie is out of the bottle, and getting it back may prove nearly impossible.

A Brewing Death Storm

Usually, people don’t “snap” and become violent suddenly. There is a steady buildup of anger and a wish to get even many times, and some of the evident signs are frightening.

According to a friend, the killer in Uvalde, Texas, at the elementary school had a drug-addicted mother. His grandmother was evicting the latter from an apartment that the grandmother had rented for her.

The friend also told the media that the shooter had a pronounced speech problem, making him the target of bullies. On one occasion, he was seen by this friend with cuts all over his face and admitted that he had done it to himself. The situation was highly distressing, but nothing seems to have been done to remediate the problems.

The killings in Columbine also have roots in depression, suicidal thoughts, and lack of discovery by parents and schools. Blaming isn’t the way to come to some resolution of violent actions, as Sue Klebold, mother of one of the shooters, said in an interview.

She also noted that mental illness itself isn’t a risk factor for violence. It’s only through a combination of risk factors — including alcohol and drug abuse — that a person with a mood disorder is likely to hurt others.

What We Know About Guns

In the healthcare community, as I have known it, the thinking is that if guns are available, guns will be used. Responsible gun owners know that their guns must be secured and not always loaded.

But persons who fear for their safety, whether reasonable or not, may keep handguns in an area where they are easily accessible and loaded. Other gun owners, who use their weapons as intimidation, are a danger to everyone. I know someone who was never raised around guns and now sleeps with a loaded handgun under their pillow each night.

Overall, I believe that the mental health community understands that guns are a part of many American homes, especially in rural communities. There is no wish to outlaw guns, but there is a need for responsible use of guns, training in the use of guns, and careful consideration of gun ownership.

Legal gun owners are not those who are ordering ghost guns over the internet or trying to protect the interstate movement of Saturday night specials. There are legal gun activities used for sport, historic recreation events, and hunting. I once had a patient who belong to a historic events group. All the members loaded their own bullets and used historic guns in target practice contests.

But we do have to question the purchase of military-grade rifles by young persons or giving them a gift of such a weapon. These guns are a means to kill, not when hunting, but to inflate poor self-esteem IMHO. They are intimidating, and that’s the purpose. It is not only a foolish purchase or gift but a deadly one.

I am very concerned that loosening open carry as it relates to guns is a terrible precedent. It can only increase gun violence. We know that domestic violence begins with the first slap and then progresses to worse violence.

The same is true of the “peeping tom” who peers into windows and then goes on to rape and, possibly, murder his victims. These slow progressions are a danger to the entire community, and I think carrying a handgun wherever you go cannot end well.

The post The Subtle Signs of Brewing Violence May Be Seen, But Not Always appeared first on Medika Life.

Look in the back of the book, and you’ll find those for future consideration, many of them cultural in nature. This point indicates that the prior diagnoses in the earlier editions of the manual could too heavily load on American culture.

An interesting, unacceptable previously diagnosed in the “to be considered” category was nightmare deaths of Laotian men. How did they diagnose it? Perhaps some form of psychosis? In the Philippines, it is known as bangungut. And it has also been categorized as Oriental nightmare death syndrome. Is it a psychiatric disorder or a cultural belief?

The team that worked on the latest iteration of the DSM indicated that “more than 200 subject matter experts” worked on the book, including ethnocultural and racial concepts.

Questions arise regarding the reason these cultural and racial elements were missing in prior editions and whether they stigmatized patients in the past. The number of experts does not strengthen the book’s content, just as the number of subjects in a protocol doesn’t necessarily increase its validity. It’s illusory. Numbers alone are not magical.

Are there many as-yet-undiagnosed mental illnesses waiting to be discovered and treated, or is there too fervent an eagerness to find the obscure and plump-up, already burgeoning manual? One has to wonder at the expense of sounding skeptical of both motives and medicine.

Over the past few decades, psychiatry has undergone a seismic change from analytic practice to biological concerns and research. In the DSM, the specialization tends more toward psychology than biological medicine. We know thousands of healthcare personnel use the tome without medical degrees.

I recall working in psychiatry research where we saw psychiatry residents who were disillusioned because they thought they would learn how to practice psychotherapy, not look at blood draws or medication side effects. The department began to select only those interested in biological psychiatry, and any who found this unacceptable had to find substitute residency programs. To my mind, it seemed there should be a melding of the DSM and the then-current Physicians’ Desk Reference, now known as the Prescribers Digital Reference.

Perusing the DSM will quickly reveal no biological diagnostic indicators for a psychiatric diagnosis other than behavioral symptoms. There are no required blood tests, no serologic tests, and no imaging (even for Alzheimer’s). So, is this medicine in the true sense or psychology?

One point that also contributes to the existence of this manual is that insurance companies wished to have something on which to rely for reimbursement. And reimbursement may play a role in giving patients diagnoses other than the evident one. In family therapy, the mother may be the IP (identified patient). Should she be placed in that role, or is the diagnosis being skewed for the insurance?

There were two categories of physicians in a psychiatric hospital where I once worked: medical doctors and psychiatrists. All psychiatrists are medical doctors, so why the dichotomy? I never did get an answer because I don’t believe anyone knew how it came to be.

And when medical doctors in the hospital noted a sharp uptick in diabetes in patients on the units, there was little to no discussion with psychiatrists about psychotropics playing a role in its incidence. It did have a role they later discovered. Some patients on specific drugs gained an inordinate amount of weight without an intake of additional calories.

One voice calling out against what he indicates is the “medicalization” of normal life is the eminent psychiatrist, Dr. Allen Frances, once the chairman of the committee to establish the DSM in its overall position of power of diagnosis. His concern regarding the current issues resulted in writing “Saving Normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life.”

The book was a shot over the bow of those promoting the DSM as the ultimate text for diagnosis. But this isn’t the only area where Dr. Frances has expressed his concern because he believes that the diagnosis of ADHD in kids is far too common.

We’ve seen the prior wave of diagnosis of children with bipolar disorder begun by Dr. Joseph Biederman, a well-known child psychiatrist. “Dr. Biederman’s work helped to fuel a fortyfold increase from 1994 to 2003 in the diagnosis of pediatric bipolar disorder and a rapid rise in the use of powerful, risky and expensive antipsychotic medicines in children.” Would most of us question, without a medical degree, the use of powerful drugs that act on a child’s developing brain?

I wonder what Dr. Frances thinks about the latest diagnosis of Prolonged Grief Disorder (PGD) added to the current edition known as DSM5-TR. The new addition is described as “the bereaved individual may experience intense longings for the deceased or preoccupation with thoughts of the deceased, or in children and adolescents, with the circumstances around the death. These grief reactions occur most of the day, nearly every day for at least a month. The individual experiences clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

The concern among some healthcare professionals is that this new inclusion will be the tipping point for pharmaceutical interventions in a process that should be permitted its normal action. One research project for grieving consisted of a specific 16-week protocol with an antidepressant. The researchers believe that the new PGD disorder applies to about 4% of the population, but the pandemic may have increased the numbers.

While mental health professionals may wish to see PGD as treatable with medications for depression and anxiety and psychotherapy, there is agreement that little is known about the biology of grief. The missing pieces in the puzzle would seem to present a major impediment to effective care of those engaged in prolonged grieving. Where research exists, it has found a formidable negative connection with the immune system.

Additional protocols noted the increased mortality of spouses after the death of their spouse and the relationship between depression and cardiovascular disease. Undoubtedly, grief includes degrees of depression which can be long-term in nature. It affects an individual’s ability to function normally and may not wane sufficiently without intervention, but which persons need the intervention and for how long still requires investigation. Most will see grief gradually lessen over a six-month period without intervention, but others may take one to four years. The question is one of serious impairment in daily life.

Besides adding a new diagnostic category, there needs to be a proviso about combining medication with psychotherapy, not simply medication alone. The reverse is also true; psychotherapy without medication where it may be indicated.

The post The Time Is Now to Closely Question Psychiatry’s “Bible” — the DSM appeared first on Medika Life.

Test anxiety and bullying are only two of the challenges students must face to succeed. We’ve seen sufficient evidence of self-harm and suicidal thinking during exams or before graduation in college students.

The need for mental health services for students has never been greater. Even among preadolescents, there is a need for suicidal kids to receive help sooner. If school was unsettling and upsetting in terms of mental health services previously, now we see it has proven to be subjected to urgency by the pandemic. The need is there, but the resources are scarce.

But not all mental health issues are immediately apparent. The body, however, has a way of revealing mentally troubling aspects of life, and it’s in physical symptoms of our health. Effectively disguised, the unspoken torment of mental health distress can be “read” if we know where to look for it and permit ourselves to see the not-so-obvious symptoms. It’s not a new idea but one which is often missed.

Sifneos first suggested the concept of alexithymia, emotional dysfunction or inability to verbally express emotion disturbances, before 1980. The medical implications are now established and should be apparent to everyone in healthcare.

“Alexithymia is associated with heightened physiological arousal, the tendency to notice and report physical symptoms, and unhealthy compulsive behaviors. Alexithymic patients may respond poorly to psychological treatments, although perhaps not to cognitive-behavioral techniques, and it is unclear whether alexithymia can be improved through treatment.”

The difficulties of diagnosis and treatment have been outlined in the literature, but it is unclear how this information has been disseminated to staff. Although the idea of lack of available knowledge being utilized in medical settings may be disturbing, it is not unusual as experienced staff will understand.

What are some of the medical patient complaints associated with this “hidden” disorder? The literature tells us it’s multi-factorial and found in pain perception without obvious origins, cardiac outcomes in patients, illness perception in cancer patients, psoriasis self-management. fibromyalgia in adolescents, and chronic illness in the young, among others.

The question that begins to form regarding alexithymia is whether or not anyone has researched the state of the immune system in persons diagnosed with this psychological disorder. Currently, there is a scale to measure only alexithymia, but that’s a psychological measure, not a biological one.

We know that emotional stress affects the immune system leaving us prone to illness. If the physical illness is stress-related, doesn’t it seem reasonable to use multiple, different biological, psychological, and physical health measures along with cognitive-behavioral therapy? How can you treat one part of a person and neglect a contributing factor?

The theoretical perspective of PNI (psychoneuroimmunology) seems to have gotten lost over the past few decades, or are healthcare professionals still utilizing it in practice? In trying to become highly specialized, I believe that we have lost the ability to function in a more cohesive team approach to treatment.

In 2002, the American Psychological Association had great hopes for PNI; what happened? One paper in 2008 predicted an explosion of interest and research in the field. Again, what happened to PNI?

The body is still speaking to us when words fail us, but those who would be helpers/healers are still failing to see the forest for the trees. Of what use are new approaches that have promise and biological-backing if they are “interesting” but disregarded? PNI is one such instance, in my humble opinion.

Yes, some specialists will refer patients to psychotherapists, but where’s the immune system follow-up as therapy progresses? Wouldn’t it be interesting to see how the immune system responds to psychotherapy? Would this be too expensive and not covered by insurance because we haven’t helped the insurance regulators see the value?

Alexithymia is a fancy word that some say means the person is somatizing. I think that’s a patient put-down. It reminds me of Freud seeing women as suffering from hysteria caused by a wandering womb, not the real sexual assaults by men in their lives. Psychosomatic disorders are real disorders, possibly related to immune system dysfunction caused by stress, that needs treatment in more than one specialty.

A reassessment of patient care is in order if only one aspect of a person in need is receiving attention.

The post Unspoken Emotional Distress and Its Role in Physical Illness appeared first on Medika Life.

Recently, a young woman living in New York City returned to her apartment, and a homeless man slipped through the locked entrance before it closed behind her. Following her up the stairs, he would murder her with a knife from her own kitchen.

Exhibiting a lack of escape plan, he barricaded himself in her apartment, forcing the police to break down the door. Calls to 911 by neighbors hearing a woman’s screams alerted them to the situation. The man was arrested and taken into custody, and he may be charged with a hate crime; the woman was Asian-American. Sources investigating the case found the man had multiple instances of criminal behavior and was released on his own recognizance.

This man is one of many who have fallen through the cracks in a mental health system in tatters and created by the well-meaning but inadequately managed deinstitutionalization movement after 1955, which picked up steam in the 1970s.

Unfortunately, it’s not the first time an individual in dire long-term need for care and treatment was left wandering the streets to assault and, in one case, murder a therapist in her office in New York City. The trial and that man’s insanity defense failed to place him in a hospital, and he went to prison.

With the closing of large, self-contained psychiatric hospitals that functioned much like small towns, many patients were sent to live in supervised housing or apartments or with their families. Promises of ongoing care and careful follow-up never materialized to the extent needed, and patients became homeless.

In some cases, repeated incidents of street or subway attacks never resulted in long-term care under strict supervision. Prisons became the “hospitals” for these patients who were now criminals. However, press coverage can lead the public to believe that all patients with a psychiatric illness are potential criminals or murderers, not so.

If the system is failing both the patients and the public, what possible solutions might there be that would meet the needs of both? One, of course, would be a return to the former hospital system where patients could live out their lives. I’m not sure the bucolic moral treatment existence related to me by old-time hospital staff was accurate, but it may have been better than our current state of affairs. Unfortunately, that wasn’t a time of intense data collection, so we have nothing to go on regarding incidents of criminality by the mentally ill.

I’ve worked in these hospitals, I’ve seen patients who could be safely returned to the community and ones that might never recover a rational ability to function outside the institution. One patient who was delusional and had killed his mother kept muttering that all women must die.

Patients on wards where I’ve worked had received treatment from insulin coma therapy, ECT, lobotomy, psychotropics, and behavioral therapies of many types.

Management at the hospitals wasn’t akin to anything resulting from an MBA. Some patients were “treated” with questionable psychotherapeutic techniques as they cycled through the wards. Therapists were unlicensed, physicians weren’t necessarily psychiatrists, and some were pediatricians in a hospital for adults.

The diagnoses ranged from mental developmental disorders, drug-induced delusions, to paranoid schizophrenia. And some of them had murdered one or many people. I worked with those patients, and I know some, who killed their entire families, did so by psychotic reasoning brought on by severe, extended stress. One wanted to die so he could join his family in heaven.

Today, I’m sure many of them live in communities near or far from the hospitals. I am not sure whether some of them would not have another break in their reality testing ability. Often, taking prescribed medication requires a level of care that is either lacking or there is resistance and discontinuance.

Do the mentally ill have constitutional rights regarding psychotropic medications and hospitalization, and how should these individuals be protected? One significant case brought before the US Supreme Court was a clever test of the issue of involuntary detention in a psychiatric hospital.

The case of Kenneth Donaldson was simple. Donaldson refused to take psychotropic medication, and because the hospital was not treating him, he argued he should have been discharged.

After the case was decided in his favor and the court agreed that Donaldson could sue those who took his freedom from him, he would write a book and be interviewed for a podcast. Today, in hospitals, we have legal procedures where psychiatrists decide whether a resistant patient needs meds, and they may then be forcibly administered.

Involuntary hospitalization remains one means of protecting those with mental disturbances from harm to themselves or others, but the question of competence remains. The statutes for obtaining orders to forcibly detain them vary by state, and they are known by many names. In Florida, it’s “Bakering” or the Baker Act. Most provide for several days of hospitalization before a person may request discharge if the medical staff agrees the current need for stabilization is over.

Where do we go from here? One aspect of this serious dilemma remains questionable; funding. If inadequate funds are authorized or poorly utilized when authorized, who will protect both patients and the public? Who is responsible for deaths and destruction of property when a patient is left to wander the streets and had been discharged to a community residential facility?

How much supervision do they receive in those residential housing units? I know of some places where staff leaves at 4 pm each day. There is no overnight coverage in the residence.

I remember a hospital worker once commenting on the excessive discharges of patients unready for release. “She’ll discharge them to a crate in the middle of the street.”

Civil rights and mental health issues clash frequently, and the outcomes are not precisely what is needed unless knowledgeable, caring, and prolonged planning is created. I once offered training for judges hearing mental health disability cases and never received a response. What type of training do judges receive in this area? I question whether they receive any.

The current state of affairs ensures that people will wander, people will be seriously injured or die, and the media will howl each time. But who will step up and attempt to fix the broken system? Anyone who presents themselves must be prepared for a rain of ire and accusations. It is not a pretty picture.

The post Senseless Murder Mandates Prison or a Psychiatric Hospital Admission? appeared first on Medika Life.

Want an example of past excess in psychiatry? Read how Freud and Wilhelm Fliess, his associate, almost killed a patient by operating repeated on her nose because they believe she masturbated excessively. And it’s not that long ago that tragedies in these hospitals were tossed off as “treatments” that didn’t work. I’ve heard tales from elderly workers who were there during those unbelievably cruel times.

I’ve seen the paint-chipped walls that were sealed off to hide the ugly truth of the chains on the walls, the tubs, and the fire hoses. And I’ve seen the result of four-year-old children being shuttled away forever to live their lives in these institutions.

One woman had never had a birthday card, a gift, or a visitor and didn’t know how to open a car door or that everything in a supermarket wasn’t free for the taking. Her diagnosis? Of course, it was schizophrenia at age 4, when she had a seizure disorder and diabetes and learned to talk like a patient.

“My feet,” she said to a mental health worker, “are talking to me.” How would you hear that? Actually, she had painfully distorted feet and large bunions, but she said the pain was “talk’” and they labeled her psychotic. How many children were raised in these institutions? Yes, raised. Once they reached 18, they were transferred to an adult facility. Do you know how sad it is to see seesaws at a psychiatric hospital?

I was taken to one in an East Coast state, and it was a forlorn horror worthy of something out of a Wes Craven film. The lights in the halls were from 25-watt bulbs, and the road leading to it was a mire of mud next to a filthy pond.

Today, I read that an impressive advocate for the mentally ill had died in October 2021 with little notice. How cavalierly we toss our heroes aside when it doesn’t suit us. Her name was Darby Penney. In addition to patient advocacy, she wrote The Lives They Left Behind, an examination of the wrenching contents of suitcases in a psychiatric hospital attic and the people who never left.

Those who died in these institutions were often buried in graves marked, if at all, with numbers. There, their remains lay in overgrown fields, forgotten by many, unbelievably, that these cemeteries existed at all. I knew a group that had set out to give all of them back their names in a tireless effort reading crumbled hospital notes left behind in abandoned buildings. They are heroes. The dead do speak to us if we listen.

Mental Health Progress

How far have we come from those dark days of whippings, rapes (a form of therapy by one of the medical directors), and starvation? The perspective and the research would seem to point to incredible advances supported by millions in grants. Much of the result has been to provide newer medications. But some researchers continue on a path that harks back to the age of mechanical interventions.

Do we truly understand the neurobiology of mental illness and, if not, what is to be done? Should we be seeking to bombard the scalp with light or yet more versions of electrical stimulation? When we still don’t know the precise mechanism, how can we know what to do to help bring the patients’ minds into some manner of normalcy? How much can artificial intelligence help in this effort? Are we using it sufficiently?

We seem to be taking a singular approach to a more complex problem similar to dear old Dr. Walter Freeman and his golden icepick. Even a Kennedy sister was one of his patients.

Perhaps the question should be directed first at diagnosis rather than treatment. Has the American Psychiatric Association’s DSM gone too far? It gives behavioral indicators only for diagnosing a mental disorder. How can that be adequate when we know there’s much more here than behavior?

Freud believed masturbation in women was a problem. How many know what was fact and what was fiction in his writings? Was Jeffrey Masson too close to the truth, and that’s why Anna Freud didn’t give him the care of Freud’s archive?

I suspect Freud was too full of himself not to see his own limitations and biases. When did he come up with the construct of Thanatos? When he was dying of mouth cancer from smoking too many cigars. Did he smoke cigars because of “oral fixation?”

The questions beg answers, and we are often footslogging without intense, lengthy questioning. Of course, you can see me as jaded, misguided, or too full of myself. That is your prerogative. I ask only that you ask. And that we never forget the forgotten lost in the mire of mental illness.

Thank you, Darby Penney, for reminding me that we need reminding.

The post The Forgotten in Mental Health Facilities Do Have a Few Advocates appeared first on Medika Life.

“One day, I made a remark that I might work with people with mental illness, and somebody in the press heard it, and it was in the paper. And the more I thought about it and found out about it, the more I thought it was just a terrible situation with no attention. And I’ve been working on it ever since.”

Mental illness is a hidden scourge that attacks far too many people, especially those who have schizophrenia. It grinds down people’s dignity, throws their lives into disarray, and leaves them vulnerable to misunderstanding and derision even by mental health professionals.

Too often, I have heard patients belittled by staff, including psychiatrists, who threatened them with forceable IM medication or seclusion and restraint because “you aren’t taking your medication.” When the patient pleaded that they were medication compliant, they were viewed as liars. Coercion is not unusual in some settings.

“If you were taking your medication, you wouldn’t be having symptoms now,” was the retort. But they were taking their medication. The problem was that the professionals hadn’t caught up with genetic research in their field. Ok, it wasn’t as advanced then as it is now.

Then began a seemingly endless process of prescribing serial meds or, on the other hand, polypharmacy which returned to favor after years of disrepute. Washout of meds was ignored as a new med was added in place of the existing one.

My quandary was how spectacular someone would have to be at biochemistry to know the interactions of all those metabolites in the brain. Too many patients developed tardive dyskinesia (TD), which never resolved. The symptoms of TD were hidden by prescribing yet more medications.

A Change in Understanding

The dark days of psychiatry, I would hope, are behind us, but I can’t say that definitively. Some serve as psychiatrists who had their medical residencies and experience in pediatrics, cardiology, and other unrelated specialties. I say this because I’ve seen it first-hand. At least one man failed the psychiatry boards three times and then gave up on them.

The dawn of medical understanding regarding the role of genetics has come, and with it, a new appreciation for what works and what doesn’t. Are patients still blamed when a med doesn’t work? Possibly.

“Pharmacogenomics is the branch of pharmacology which deals with the influence of genetic variation on drug response in patients by correlating gene expression or single-nucleotide polymorphisms with a drug’s efficacy or toxicity.”

Psychiatry has gained sophistication in the knowledge of drug-patient interaction, but not everyone in the field has kept up. Such a failure can only mean more patient blaming.

Movement in the direction of consideration of genetic differences leading to medication inefficacy has begun.

Individual Differences Are the Key

“Pharmacotherapy is one of the primary treatments for psychiatric disorders. Given the variation in individual responses, a more personalized approach is needed. This paper will discuss methods for user-friendly referrals, recruitment criteria, data storage and dissemination, biological sample and clinical questionnaire collection, and advertising.”

The suggestion of biological sampling has begun at how many sites, practices or hospitals? Has anyone provided research to determine this and, if not, why is this gap in the literature permitted to exist? Is patient-blaming too easy?

Undoubtedly, the tests take time and funding, and the metabolic difficulties presented by cytochrome P450 which is always a consideration. But there is literature pointing toward the importance of this research.

“It has gradually been demonstrated that genetic differences in ion channels reflect differences in the distribution of polymorphic traits, such as disease susceptibility and drug efficacy…”

This approach to evaluating psychotropic medications’ efficacy has been further underscored in additional portions of the medical literature.

“For most psychiatric diseases, pathogenetic concepts as well as paradigms underlying neuropsychopharmacologic approaches currently revolve around neurotransmitters such as dopamine, serotonin, and norepinephrine…the effectiveness of these medications is limited, and relapse rates in psychiatric diseases are relatively high, indicating potential involvement of other pathogenetic pathways…”

Absolving the Patient From Blame

How can patients with psychiatric or any other illnesses be viewed as non-compliant with their medical regimes when there is a persistent failure to investigate how their race and genetics are affecting treatment? The answer is obvious, and the blaming must stop. How can we treat patients when this type of neglect persists in the face of overwhelming evidence that is being ignored?

One example that might be remediated if psychiatric treatment were fully compliant with recommended protocols would be homelessness. If patients’ illness can be brought under control, would they choose to live and die on the streets and remain resistant?

The post Blaming the Psychiatric Patient When It’s a Drug-Genetic Interaction appeared first on Medika Life.

In my last article (Debunking 1 in 5 COVID-19 Patients Develop Mental Illness), I debunked a claim circulating around the world — that a Lancet Psychiatry study found 1 in 5 COVID-19 patients would become mentally ill in the first 3 months after diagnosis.

Researchers drew on the electronic health records (EHRs) from a US managed health care system to match 62,354 patients COVID-19 with patients with 6 other medical diagnoses.

Claims about mental illness were based on recording in the electronic health records of mental health diagnoses 14–90 days after diagnosis of COVID-19 or the comparison health conditions. These diagnoses of mental illness were originally made for administrative purposes — billing and documentation — and would be considered poor quality for scientific purposes.

I pointed out that the excess of mental health diagnoses associated with COVID-19 was almost entirely due to more adjustment disorders.

Patients diagnosed with COVID-19 were likely to be experiencing some anxiety (worried) or depressive symptoms (sad, pessimistic) that were not serious enough to justify a diagnosis of major depression or a serious anxiety disorder. So, a diagnosis of adjustment disorder was entered into their EHRs.

These do not seem like abnormal reactions to me. In fact, adjustment disorders were formerly called adjustment reactions and clinicians could not be reimbursed for treating them.

Dissenting from the portrayal of the study in the media

Why was my interpretation of the Lancet Psychiatry article at odds with almost all of the media coverage I could find, which proved to be remarkably similar?

I arrived at my conclusions by looking at the study design and closely examining the tables of numbers.

I applied knowledge that any journalist should have in writing about a topic that has great importance to readers facing a profound public health crisis like COVID-19.

America is facing a profound crisis of faith in democracy and in science. It desperately needs media filled with articles by journalists who think for themselves and consult experts when they need to.

In an ideal world, journalists should have called up their own independent experts and asked them about their impression of the study. Were these experts expecting a tsunami of mental health problems or did they think these authors might have overstated the importance of their findings a bit?

Journalists should have had the curiosity to ask how serious a mental illness an adjustment disorder and why there was not more depression associated with COVID-19.

In a bygone era, journalists were better able to play an important function in society. At their best, journalists buffered laypersons and policymakers from the self-promotion, conflicts of interest, and sheer overenthusiasm of researchers for their own work. Journalists provided independent assessments of science to satisfy readers’ curiosity, but also to guide their personal and collective decision making.

But journalists face different challenges than only a few years ago.

Most newspapers and magazines have laid off their full-time staff and depend on freelance journalists. Journalists can no longer assume researching articles will be reimbursed.

Often, journalists will not have the time to look at a scientific paper carefully or to consult their trusted sources. Few will have the courage or the recklessness to say that the authors of the Lancet Psychiatry study (from Oxford University, after all) are exaggerating the significance of their findings.

Editors will also not be pleased with a story on which they cannot slap a clickbait, screaming headline like “1 in 9 mentally ill!!”

Media have gone online, some abandoning print editions altogether. They need clickbait to attract and retain readers’ interest. Traffic to a media website and readers’ time spent there are tracked as altmetrics, which determine the advertisements the media get and what they can charge for ads.

This consideration matters for which articles from which journalists are published.

Science Media Centre of London (SMC_L)

Media coverage of the Lancet Psychiatry article was almost identical worldwide. If articles quoted an expert, it would likely be identical quotes from the same experts. A lot of the articles credited Reuters News Service. The articles that did not credit Reuters but named a journalist in the byline were generally quite similar, even having the same quotes.

Noting that some authors of the Lancet Psychiatry article were at Oxford University, I immediately suspected the Science Media Centre of London (SMC_L) was involved.

The SMC_L website welcomes journalists.

When science hits the news agenda, it’s our job to pass on to journalists as much accurate information as we can, as quickly as possible. In order to do this, we send out quotes from experts and statistical analyses of scientific studies, in addition to running regular press briefings on the latest hot topics. Find our most recent Roundups and Rapid Reactions, briefings and ‘Before the Headlines’ analyses below…

Who are the experts that SMC_L consults? Can anyone submit their credentials and expect to be called?

We are always on the lookout for top experts, but it’s important that each scientist knows us before we call them. So, we generally don’t add scientists before we’ve worked with them at least once.

It sounds like British English for “Don’t call us, we will call you.”

SMC_L warns of storms around science stories in the media.

When science hits the headlines, it’s not only journalists and scientists who find themselves in the eye of the storm, but also press, media and communications officers, working to support their scientists and engineers whilst also providing journalists with what they need.

I expect that bad science will get into the media and even good science will get misrepresented. Such occurrences are inevitable. When it happens, controversy and criticism are healthy and necessary parts of fixing things.

You might get a sense that SMC_L disagrees. They seem to be offering shelter from such “storms.”

Expert reaction to study looking at psychiatric diagnoses after COVID-19

I don’t like authorities telling me how to think or what to write, even if, like Ringo Starr, they can call themselves Sir or Dame or wear medals at breakfast.

Searching for the Lancet Psychiatry study, I found a past Briefing and an Expert Reaction with seven of SMC_L’s usual suspects as experts.

Six of the seven mostly sounded like experts, but really did not get into the nitty-gritty of the study, content enough to demonstrate expertise.

One expert had “Sir” between “Prof” and his name. Another had “Dame” between “Prof” and her name.

I cannot understand why Brits bring up knighthood and damehood in these contexts. When Ringo Starr got to call himself Sir, it did not improve my appreciation of the Beatles.

There was not very much reference in this Expert Reaction to crucial methodological details of the study and the limitations of EHRs as scientific data.

It would seem that a grasp of these details should temper any recommendations for clinic or public health policy based on the study.

No expert conveyed any sense of the messiness of big data from an American health care system, especially if one is intent on making policy recommendations for organizing a response to mental illness associated with COVID.

Six of the Expert Reactions sounded like a string sextet accustomed to playing together, mostly without creating a fuss. The seventh, however, arrived like a tuba player, oblivious to not contributing to the harmony.

Prof David Curtis politely alluded to a lot of problems with the Lancet Psychiatry study. He seemed to wonder aloud why such a fuss is being made about it. He injects some uncommon common sense into the discussion

“It may be unsurprising that this happens a bit more often in people with COVID-19, who may understandably have been worried that they might become seriously unwell and who will also have had to endure a period of isolation.”

If there is any doubt about where he stands, he clarifies at the end:

“Overall, the results reported seem broadly plausible but I’m not sure that they have specific implications for patients or health services.”

My kind of expert. I hope Prof Curtis gets invited back by SMC_L.

Getting personal

I think my humility is still intact after decades of writing hundreds of scientific papers, some that deserve more criticism than they received. I welcome criticism from experts. I welcome peer-review by academics, but also feedback from patients who are experts on their experience and who have had to live with the modest clinical and public health implications of what I have written.

Yet, I think there is a vital distinction to be drawn between expertise and authorities. The good experts have the credibility to gain our attention by showing things we might not know, but that we would agree we should. The not-always-good authorities believe they have the power to enforce rules and tell us how to think and what to write.

I think that is what SMC-London is doing here. I am biased by my experience with them, but that bias is valuable because it is grounded in experience. I have seen their ways too often for my liking.

• One of the experts being cited in this Expert Reaction — the Dame — also endorsed an awful study that she claimed showed cognitive therapy for psychosis was effective for psychosis in the absence of medication. The study did not show that, but such claims encouraged some patients to refuse medication. The Cochrane Collaboration showed twice in systematic reviews that cognitive behavior therapy was ineffective.

• One of the experts who was cited — the Sir — advocated cognitive behavior therapy and graded exercise for chronic fatigue syndrome, which patients insisted was ineffective and harmful. Fiona Fox, Director of SMC_L organized a campaign that media that condemned the patients as militant terrorists. The press releases were picked up in British media. The patients were subject to considerable abuse and harassment as a result.

Whiskey, tango, foxtrot! The patients were often bedbound or confined to wheelchairs. I do not think anyone would recruit them as suicide bombers or even assassins.

• I decided to look into the matter. I requested data from the PACE clinical trial for reanalysis. I believed the PACE investigators were legally bound to make these data available. Fiona Fox, Director of SMC_L organized a letter-writing campaign to Parliament calling for researchers to be exempt from such requests.

As promised, SMC_L tried to provide shelter from the storm.

• More recently, patients with chronic fatigue syndrome and professionals from around the world convinced the UK National Institute for Clinical Excellence to issue draft recommendations that no longer endorsed GET as a safe and effective treatment. SMC_L has organized resistance from academics strongly invested in this treatment, including the Sir.

I am exceptionally lucky. I came out of public housing on a shitty mudflat in Chelsea, MA, and spent my high school years on welfare. By many accidents of circumstances, I somehow ended up an emeritus Ivy League med school professor.

I am painfully aware of my deficiencies in preparation and seek my corrective expertise where I can find it. But I don’t like authorities telling me how to think, even if, like Ringo Starr, they can call themselves Sir or Dame or wear medals at breakfast.

America is facing a profound crisis in its faith in democracy and in science. It desperately needs media filled with articles by journalists who think for themselves and consult whatever independent expertise they feel they need.

I don’t care that SMC_L gives lots of stuff away free and does not mind if journalists plagiarize them.

Journos, please find your own experts and write your own articles on which you can proudly stick your byline.

The post No Tsunami of Mental Illness Accompanies Covid-19 appeared first on Medika Life.