hoping for silver bullets…

Posted on Saturday 11 May 2013

Maybe one would have to be an old psychiatrist to think this, but this paper is about what’s actually wrong in psychiatry right now. It’s where the problem starts – not the result of something else:

Prescriptions of antipsychotic [aka neuroleptic] drugs in North American children and adolescents have been rising rapidly in recent years. But why? Gabrielle Carlson of Stony Brook Children’s Hospital offers her thoughts in a brief paper:
Carlson is a specialist in ‘pediatric bipolar disorder’, which is a controversial topic at best, but I think this is still a thought-provoking piece:
    The 10-bed children’s psychiatric inpatient unit at Stony Brook University Hospital, which opened in late 1986, treats children between the ages of 5 and 12… The inpatient unit has experienced the same dramatic increase in use of neuroleptic medication as seen elsewhere, from 15.2% of patients receiving conventional antipsychotics in the 1988-1993 sample, to 68.5% use of atypical antipsychotics more recently [2002-2004, 2010-2011].
So the introduction of the newer, ‘atypical’ antipsychotics probably contributed to the rise, but there were other factors:
    Simultaneously, however, the mean length of inpatient stay dropped from 10 weeks to 5 weeks. The rate of rehospitalization increased from 17% to 42%. Rates of children needing isolation have increased… Fewer children now return home to a biological parent.
It’s just not like it used to be:
    Residents used to have a rotation of 3 months, meaning that they got to know and treat their patients; their rotations are now 1 month. Primary nurses used to spend time with the children; now they are shackled to their computers doing electronic medical records. When children are admitted now, the first words out of the mouths of the managed care gatekeepers seems to be, “what drug are you going to start?” regardless of the six drugs the child was taking at admission…
She concludes that doctors turn to these drugs thanks to insufficient provision for other treatments:
    Atypical antipsychotics clearly have important adverse effects. The question is whether society [and insurance companies] want to support the alternatives.

We spend a lot of time on the blogs talking about the sins of the academic/pharmaceutical complex. or about our drugs not being good enough, but the actual underlying problem is that we can’t actually give patients the attention they require. We can’t see them long enough, or often enough. We can’t hospitalize them when they need hospitalization. By signing on to insurance panels or managed care lists, we basically turn over treatment to the insurers whose primary goal is cost containment. They minimize psychiatric care because they can – so they do. I practiced outside that orbit so I know nothing about it except that if that’s all that had been available to me, I would’ve gone back to Internal Medicine or worked as a waiter in a meat and three. If Organized Psychiatry were functional, that’s where attention would be focused rather than hoping for silver bullets. I don’t know what else to say about that…
  1.  
    Annonymous
    May 11, 2013 | 1:20 AM
     

    Nice post.

  2.  
    May 11, 2013 | 1:48 AM
     

    I think this reflects the sad state of our society in that the focus tends to be on a quick “fix” that frees people from the need to truly commit to the hard work necessary to address the root of a problem. This seems to happen everywhere, ranging from to weight loss surgeries to government finances. I wish the problem were just limited to psychiatry…

  3.  
    AA
    May 11, 2013 | 3:13 AM
     

    While the “quick fix” society argument can’t totally be discounted, I am not completely buying it. Psychiatry has now gotten to the point where that anyone who enters a psych hospital (adult or kid) is getting an antipsychotic no matter what the situation is. I mean, it doesn’t take an extensive evaluation to realize that many people have no business being on antipsychotics. But yet, that is what is happening.

    Frankly, as someone who knows folks who are going through withdrawal hell thanks to these boiler plate practices, I am really getting tired of psychiatry throwing up their hands and acting like they can’t do anything about it. Until you stop blaming insurance companies and look hard at what you are doing in your prescription practices, nothing will ever change. Sadly, the patients like the people I know will pay a big time price with alot of heartache and lives destroyed in trying to get off of APs. And god only knows what it will be like for kids.

    AA

  4.  
    May 11, 2013 | 4:31 AM
     

    Organized psychiatry is both a mirror of attitudes in the particular society, towards people in dire straits, in need of the attention and assistance of others for a shorter or longer time, to be able to function to the fullest of her potential.
    Ignorance, fear and discrimination have almost always been what the greater society and the medical bio-psychiatrists have had to offer in our technologically developed West, as concluded by the WHO after the two rounds of multi-sites transcultural investigations of how schizophrenia played out in different regions of the world.

    Living in a “developed” country predicted the far worse outcomes of impaired functioning, marginalization and early death than seen in less technologically advanced and poorer countries – with more intact families and labour markets open also to people of more uneven capacities.
    There are lots of examples of how to do things better, the Quckers’ Tykes’ retreat, the Soteria houses, but if and as long as everything and everyone is to be made a source of profit by professional and industrial interests, things play out as they are, I think. That’s why POLITICS factors so descisively into the picture, into which everyone has some say, however miniscule. We are the majority, together we are strong.

  5.  
    May 11, 2013 | 6:34 AM
     

    Quakers,!! The Society of Religious Friends! Please excuse my spelling.
    I once visited a museum in Chatham NY, left as the Quakers had left their home and farm a few generations earlier. The the simplicity and calm of that place, in contrast to the clutter most of us are surrounded by today, even then, in the late sixties, made a lastingt impression on me.
    The Quakers did not diagnose distressed people. They saw fellow human beings they did not have to “treat” in any other way than humanly. Most got well and could leave the Retreat. Only a few were permanently disabled. Maybe those few might have had, or had been traumatized to develop, some biological-genetic expression or variation/anomaly to be uncovered, some time in the future, or perhaps never. We are a complicated species – yet surprisingly, simplemindedly hubristic, most of all, I think, in the ivory towers/corporate circles of academia, big business and big politics. I never liked flying.

  6.  
    Nick Stuart
    May 11, 2013 | 7:17 AM
     

    Drugs are the way society wants to control children… pure and simple. And also to control all those that are different and difficult to manage. That is all.

  7.  
    jamzo
    May 11, 2013 | 9:29 AM
     

    ” in a meat and three.”?

    first time i have encountered this metaphor

    meaning?

  8.  
    jamzo
    May 11, 2013 | 10:12 AM
     

    FYI

    May 8, 2013
    The New Criteria for Mental Disorders
    Posted by Maria Konnikova

    “With the introduction of the R.D.O.C., Insel and the N.I.M.H. are trying to ensure that the D.S.M.’s accomplishments evolve with the times, instead of being left behind in a clinical vacuum that hurts research as much as it hurts patients. ”
    http://www.newyorker.com/online/blogs/elements/2013/05/the-new-criteria-for-mental-disorders.html?mbid=nl_Daily%20%28239%29

  9.  
    May 11, 2013 | 10:23 AM
     

    Jamzo,

    A “meat and three” is a rural Southern thing. It’s a cafe where the waitresses all know you and they serve breakfast and lunch. Lunch is a choice of one of several meats and three choices from a list of vegetables plus biscuit or cornbread. They have names like “Annie’s” or “Meg’s.” In an unfamiliar place, just look for a parking lot full of trucks…

  10.  
    jamzo
    May 11, 2013 | 11:22 AM
     

    FYI

    time magazine take on nimh-dsm5

    Mental Illness
    Mental Health Researchers Reject Psychiatry’s New Diagnostic ‘Bible’
    By Maia SzalavitzMay 07, 2013

    Mental Illness
    Mental Health Researchers Reject Psychiatry’s New Diagnostic ‘Bible’
    By Maia SzalavitzMay 07, 2013

    Read more: http://healthland.time.com/2013/05/07/as-psychiatry-introduces-dsm-5-research-abandons-it/#ixzz2SzvneM00

    Read more: http://healthland.time.com/2013/05/07/as-psychiatry-introduces-dsm-5-research-abandons-it/#ixzz2SzvneM00

  11.  
    jamzo
    May 11, 2013 | 11:44 AM
     

    FYI

    Lost in Medication
    Psychiatrists who take time with their patients are not the norm. It’s not because others don’t care. Rather the system rewards efficiency, not empathy.
    Sarah Mourra May 10 2013, 9:02 AM ET

    http://www.theatlantic.com/health/archive/2013/05/when-psychiatric-care-is-reduced-to-medication/275612/

  12.  
    Annonymous
    May 11, 2013 | 11:55 AM
     

    Jamzo,

    Thank you for sharing this Atlantic piece.

  13.  
    May 11, 2013 | 3:31 PM
     

    AA, I agree with you that psychiatrists need to take responsibility for more sane prescribing practices. However, as an outpatient psychiatrist, my experience is certainly very different from yours. I see numerous patients every month who come to me feeling depressed and just wanting a pill that would help them feel better, despite having pretty severe stress from work, relationships, financial concerns, etc. When I tell them that a pill can’t fix those underlying problems, and that they should come back to discuss psychotherapy, many of them never come back.

    Even amongst folks who are not seeking a medication for their problems, there is a trend toward quick-fix solutions like “life coaching” (see this NYTimes piece) rather than doing a form of therapy that would take longer and require more work.

  14.  
    May 11, 2013 | 3:35 PM
     

    I think this time-crunch thing is just an excuse. I’ve had hour-long regular visits with elite psychiatrists (before I wised up) and, even given the opportunity for leisurely discussion (during which my intelligence and insight were consistently denigrated), all they ever did was throw prescriptions at me.

    Given all the time in the world, they still couldn’t practice as doctors. What does that show?

  15.  
    wiley
    May 11, 2013 | 4:39 PM
     

    Am reading a book on the rapidly established prison industrial complex in the U.S. and after reading a description of it as

    …a geographical solution to socio-economic problems:a response to surpluses of capital, land, labor, and state capacity.

    I thought immediately of biological psychiatry as a chemical solution to surplus capital, drugs, labor, and psychiatric/pharmaceutical capacity.

    Of course, there are people who suffer from may be well described as mental illness, who can benefit from medication; but what we’re looking at now is an industry that makes money by labeling as many people as it can with “mental illness,” and convincing them that they have to stay on those drugs for life because they’re biologically deficient. It’s an industrial psychiatric drugging complex, and it’s cronyism.

    The men at the top of the psychiatric food chain, are white, upper-middle class men who have no intention of recognizing their privilege as being the result of anything other than their own perceived brilliance. The fact that at the top, this profession won’t even formally recognize that life is really, really hard sometimes and that people faced with certain social ills, suffer in predictable ways is evidence of their privilege and solipsism. They keep pushing this one button because it’s their button. It has served them very well, and has made many of them millionaires and the toast of the town.

    Naomi Zack has described this cronyism well:

    Summing up: the defining characteristics of cronies and cronyism are that their decision-making process is shared only among themselves, and they make decisions based on what benefits them as individuals or a small group in power rather than what will benefit others in the larger context in which they have power, that is, the whole department [insert "field]. The power of cronies lies in their allegiance and loyalty to one another and they are interested neither in principles nor in the good of a whole unit. Cronies thus use social processes to form allegiances and produce outcomes that are anti-social concerning the well-being of larger wholes or other individuals who might have equally justified claims to leadership or power. Cronies hijack power for themselves and once they have it, everything they do is primarily about them. That is the present face of institutional racism and sexism in many daily working lives…

    She was speaking specifically about philosophy departments, but the mechanisms and the phenomena are the same. The problem in the field of psychiatry right now isn’t really “science,” it’s the neurotic and self-serving perspective and behavior of people like Insel. He thinks he’s got humans all sewn-up and all he has to do is get the data and imaging to prove it. He’s making a fortune off of his megalomaniacal delusion.

  16.  
    a-non
    May 11, 2013 | 5:01 PM
     
  17.  
    May 11, 2013 | 5:12 PM
     

    Re: “Simultaneously, however, the mean length of inpatient stay dropped from 10 weeks to 5 weeks.”

    That’s a positive.

    What possible good comes out of locking a child up against their will?
    Other than scaring the ever-lovin’ crap outta them?

    These are not “hospitals”… they do *not* treat underlying physical conditions!

    Duane

  18.  
    May 11, 2013 | 5:14 PM
     

    A safe, loving environment… a holistic approach… helping *heal* the person – mid, body and spirit…

    That approach would work.
    But psychiatric “hospitals” do nothing of the sort.
    They scare the *crap* outta folks!

    Duane

  19.  
    wiley
    May 11, 2013 | 9:04 PM
     

    Yeah, an-on, in the book I was just finished reading, the author talked about how after WW II, a lot of medical research and pharmaceutical testing was done on prisoners. She quoted one doctor (I’ll paraphrase) that was ecstatic about “the perfect controls” that the prison environment provided.

    Now that so many prisons are privatized and their prisoners are working for corporations. I have to wonder if there may be some clinical trials being conducted on prisoners again and being considered ethical because they pay the test subjects.

  20.  
    May 11, 2013 | 9:07 PM
     

    Mickey,

    The mental health battle (over validity in diagnoses) heats up in the UK. -

    http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health

    Duane

  21.  
    a-non
    May 11, 2013 | 10:09 PM
     

    wiley-perfect controls
    “Intervention includes both physical procedures by which data are gathered (for example, venipuncture) and manipulations of the subject or the subject’s environment that are performed for research purposes. Interaction includes communication or interpersonal contact between investigator and subject. Private information includes information about behavior that occurs in a context in which an individual can reasonably expect that no observation or recording is taking place, and information which has been provided for specific purposes by an individual and which the individual can reasonably expect will not be made public (for example, a medical record). Private information must be individually identifiable (i.e., the identity of the subject is or may readily be ascertained by the investigator or associated with the information) in order for obtaining the information to constitute research involving human subjects.

    Institution is defined in 45 CFR 46.102(b) as any public or private entity or agency (including federal, state, and other agencies).

    For purposes of this document, an institution’s employees or agents refers to individuals who: (1) act on behalf of the institution; (2) exercise institutional authority or responsibility; or (3) perform institutionally designated activities. “Employees and agents” can include staff, students, contractors, and volunteers, among others, regardless of whether the individual is receiving compensation.”
    http://www.hhs.gov/ohrp/policy/engage08.html

  22.  
    a-non
    May 11, 2013 | 10:24 PM
     

    The problem is systemic:
    -Dr David Healy:
    “When faced with the growing Fascism in healthcare, we can retreat to the wilder shores of conspiracy theory and claim the problems are down to the Germans, the Jews, or a Socialist cabal. Or we can attribute the problems to some evil people somewhere in pharmaceutical companies who break laws.

    But if we accept that the Board of GSK and other companies are populated with people just like you and me, who are perhaps even less likely to break the law than you or I, the $3 Billion fine for GSK notwithstanding, then the problem must stem from and the remedy lie in the system.”
    http://davidhealy.org/witty-a-report-to-the-president/

  23.  
    AA
    May 12, 2013 | 6:46 AM
     

    Psych Critic, I don’t disagree that there are people wanting a quick fix solution with meds. And by the way, kudos to you for not wanting to use them as a first line treatment.

    However, that still doesn’t negate the fact that antipsychotics are routinely given to people who end up hospitalized who have no business being given the meds. And by the way, I forgot to mention another scenario under which this happens. People taper too quickly off of SSRIS and have a manic reaction which is falsely labeled as bipolar when they end up needing hospitalization. And antipsychotics end up being the “perfect” remedy.

  24.  
    May 12, 2013 | 9:24 AM
     

    AA’s point is highly relevant in this rich country (Norway). .”… antipsychotics are routinely given to people who end up hospitalized who have no business being given the meds.”
    Norway is in the top league in Europe in commitments and coercive treatment. It’s standard, in spite of years of political activism by the community of survivors and (ex)users of psychiatry. Only recently has the goverment woken up – officially – to the elevated rates of iatrogenic illnesses and early death, witnessed by patients and families for years and years.
    The culpability of the Norwegian psychiatric association is clear, as the doctors’ primary responsibility is the best possible treatment and care of their patiensts.. There are a few more enlightened and cooperative psychiatrists, but I know from some that they feel they must thread a thin line to avoid being shunned by their colleagues in the public hospitals. The truly independentminded are in private practice or in the local council system of public health.
    But the fact that psychiatric diagnoses have been officially admitted to be scientifically invalid, by the US director of the NIMH, must lead to rethinking and an end to inhumane coercive drug treatments in breach of UN’s CRPD. I hope…

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