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« Fashion News -- Prejudice Has a Slick New Look (John Ballard) | Main | Bahrain Update -- September 2012 (John Ballard) »

September 05, 2012


Thanks for these two good links about Big Pharma. If nothing else is clear, it is that drug manufacturers may be in business to help people, but their first responsibility is making business profits, as much as possible in a competitive market. And sales and profit increases quarter over quarter, year over year is a far more important metric for them than the number of sick people they make well.

I wish I had more constructive ideas about how best to handle mentally unbalanced people who need help. There are many, of course, who would not be cooperative. But there are many who know they need help and would be grateful for it, but what passes for mental health care in the US is pitiful by world standards.

I see that Louise, as she does elsewhere, lays the entire blame on Big Pharma and its corrupt advocates. I do not agree that psychiatric drugs do not help severely disturbed minds and that there are no honest and caring mental health care givers. Yes, drugs have side effects and they may interfere with quality of life. But what is the quality of a life where you are fighting multiple unseen demons, depressed and sometimes so paranoid and full of rage that you have to kill a dozen or so people to find relief or some meaning in your existence?

I agree with John that we ought to have a far more organized system of intervention for severely ill mental patients. There needs to be the recognition that psychological health is as important as physical health. Patients suffering from disorders of the mind should be able to seek help as easily as they can for heart disease, arthritis or diabetes, also conditions which have to be managed throughout life. And just as we go to hospitals for life threatening physical afflictions, institutional care should be accessible to mental patients. A realistic and compassionate approach, not denial and blame, should be the answer. Psychiatric care is much more complicated than other medical treatments and it should not be dismissed out of hand just because some doctors are corrupt, negligent or the perfect drug hasn't been found for each disorder. Otherwise, prison would be the only answer for the likes of James Holmes and Jared Loughner.

Holmes' unbalanced mental state was evident to others, among them some who met him only for his post doc interview (Univ. of Iowa). It is a tragedy that people closer to him, family and high school friends, did not see it. It is not right to blame anyone for negligence. But if we had more awareness of mental health issues and easier access to care facilities perhaps intervention would occur at an earlier, more treatable stage.

I too will leave a link to a NYT article, this one about the sad and isolated life of James Holmes BEFORE he dyed his hair orange, dressed in fatigues and took high powered weapons to visit the movie theater.

Such a tragedy. I knew he had a descent into Hell but that article seems to have covered every step. As I read the questions kept droning in the background -- Who could tell? How could anybody know? And even toward the end, what, if any, were the signals that in the end he would be homicidal instead of suicidal? (And many cases end with both.)

I was not laying the entire blame on Big Pharma. I thought people would be interested to know how much of NAMI's funding comes from Big Pharma.

If you read Robert Whitaker's The Anatomy of an Epidemic, you would understand that drugs in themselves are not the answer to psychiatric problems. In fact, Harrow's study shows that those diagnosed with schizophrenia recovered better than those taking psychiatric drugs. Drugs tend to suppress symptoms, not resolve them.

The long-term side effects of the drugs can be severe. This can leave a psychiatric patient with diabetes, tardive dyskinesia, Parkinsonism, and, in the case of Seroquel, blindness.

The real tragedy is that children are now diagnosed and drugged with neuroleptics for things such as childhood onset bipolar disorder and other "recently discovered" maladies that supposedly afflict children and teens, such as oppositional defiant disorder. In some instances, psychiatric drugs can trigger violence.

The whole psychiatric care system is a failure or we would not have people like Holmes shooting up a theater and murdering people.

Elatia tried and failed to post the following comment:

"Hi John! Good post.

In San Francisco in the 1970s, there was a young man on a disability pension in my neighborhood. On his meds, he was just another freaky boy who spent his life avoiding work and hanging out in North Beach cafes. Everyone was kind to him, SF being the world capital of inclusiveness. When he went off his meds, he would kick high, and suddenly, and catch people under the chin with the tip of his boot. He created serious injuries, people crossed the street to avoid him. In a perfect world, he would be given a pension, a place to live, and round the clock attendants, two per shift, whose presence would obviate the need for meds that kept him non-violent. In a world where choices have to be made, I would set other priorities ahead of his total care. The premise that the only thing wrong with the mentally ill is the meds that are making them worse is academically interesting, until the very day someone mentally ill and unmedicated kicks you under the chin. That is actually where the rubber meets the road -- whether your right to be safe on the streets is dearer to you than the right of an acutely ill person to live free of the medication that he finds difficult and dislikable, but that keeps him from doing his worst.

A highly credentialed articulate POV can be had by reading Dr. Kay R. Jameson's books on her struggles to live with Bipolar I. She takes an enormous dose of Lithium that is barely sufficient to keep her on an even keel. I think she's an awfully good connoisseur of the difference between "barely sufficient" and "insufficient." Except that they enable her to be functional, she doesn't like the meds. Between 20 and 50% of Bipolar patients go off their meds for weeks, months or years at a time -- she's done that herself. Dr. Jameson has written orders to her spouse and children and doctors to institutionalize and stabilize her if she does that again. She appreciates that the meds save her life, AND she hates them. I would say this is a woman who know shite from deep shite. But maybe Robert Whitaker could get to her, and she would see things anew.

To anticipate a disagreement -- yes, it would be nice if everyone in as bad a bind as Dr. Jameson could choose for themselves. As far as I am concerned, if you are non-violent, and can show up to work, even in a set-aside job that people with disabilities don't find too stressful, then you should be able to make up your mind how you want to live wrt meds. The trouble comes when the lives you might ruin are not your own. Another type of trouble comes when you have a tremendous entitlement to the sacrifice of others to keep you attended and med-free. A friend keeps a daughter at Shepherds Pratt, not far from Tanglewood. Half a mil a year, and the daughter is safe and the family is safe and everything is as good as it could be. In her better days, the daughter would have asked: Can't you give the money to hungry children instead? It's a question that should indeed be asked, unfortunately.

I believe that all patients with serious maladies of any kind should be able to find out how little medication they can take and keep running. Diet and exercise can prevent overmedication. But sometimes, what seems to you like overmedication is, more simply, the minimum dose necessary to have a therapeutic effect. I am talking about all ills, not psychiatric illnesses."

A couple of links (Depression and ADHD connection) at the bottom of my post on 'A Theory of All Maladies' might be apropos in this discussion. Yes, I know, to someone with a hammer, everything looks like a nail. But I would request a reasoned consideration of my theory, which is that the sleep problems are in some ways able to start the slew of symptoms, which are diagnosed as one condition or the other, leading to medication that become a sort of vicious cycle.

There are alternatives to being on medication for a lifetime and being violent.

I can certainly understand why Kay Jamison hates taking lithium:

I guess people either believe the "broken brain" theory of mental illness or they don't. Jamison is looking to genetics to explain the whole thing.

Other people look to the social and cultural surroundings, as well as abusive childhoods, for explanation:

I've been contemplating your post and links since you posted it. I didn't leave a comment there partly to avoid disagreement, and partly because for the last several years I have tracked healthcare reform. A big part of healthcare inflation involves the proliferation of medical devices, and another part has to do with questionable diagnoses, many of which lean one way or another as the result of financial considerations. Treatments often tend to lean more in the direction of profitability than a second opinion or "bundled services."

This is not a good place for a general discussion of healthcare reform, but since you requested a reasoned consideration of your theory, my first reaction is the old rubric "correlation is not causation." Of course no one with sleep OSA should ignore it, if for no other reason than waking up refreshed and less likely to fall asleep driving. I have cared for a few people with CPAP machines and totally appreciate and see the importance of them. I approve of their use as part of a treatment and/or recovery plan, but it's a bigger leap than I want to take to suggest they may be the next silver bullet.

I want to point out my comment did not touch on explanations for madness. Maybe abuse in childhood and a hostile world create people likely to be called mad. If they did, many more of us would be mad than are mad, even.

The genetic component in Bipolar cannot be ignored -- there are hard data about its running in families, especially families where there is creativity -- artistic and otherwise -- and high intelligence, also heritable. Bipolar runs in my family, so mine should be considered an informed opinion. I think I understand the illness better than many who have not been affected by it. Because parents model coping styles as well as pass on genes, at this time it would be a difficult call to rule anything out. Some genetic research is promising, however, wrt Bipolar.

There may be reasons why very young men are more vulnerable to schizophrenia than their sisters who share the same hideous parents and also have suffered horribly in school. Recent research shows structural differences in the brain-in-development of young male schizophrenics and their non-schizophrenic peers. No one's brain is fully developed before the mid-20s, and schizophrenia usually strikes in the late teens. I would not be comfortable in attempting to understand the illness through disregarding this research.

There are many who are "pretty odd ducks" and "highly oppositional" who get their personal quirks medicalized -- this is bad and unfair. We should tolerate people whom we don't much like and find difficult or inconvenient -- not call them names or suppose they need treatment. Everybody benefits from kindness, however -- probably most of all the person who has it to give.

My observations upstream were about the rights of ill people to refuse medication being, in my opinion, contingent upon how violent they are and on the cost of caring for them if a decision to spend less rather than more money must be made, where they are concerned. Is the right of the person on the street to be safe valued more highly than the right of a violent ill person to be ill in his preferred way? Should a child be taken from a violent and abusive mother, or do her maternal rights trump that? She too is being ill in her preferred way. Whatever is wrong with these people, however it went wrong for them, they are harmful to others and should not be free to use their judgment about treatment options, including the option not to be treated. I am not as moved by the individual liberties of the violent to be untreated as I am by making their victims safer.

@ John:

Of course, correlation is not causation. Nor is CPAP a silver bullet (compliance is dreadful, people don't like to use it ,etc.) What I am pointing out is that many disease states start with lack of restorative sleep, whether due to apnea (most common) or other similar sleep issues, precursors/confounders to a variety of conditions.
I don't know if you had a chance to take a look at the various links that I posted at the end. But there is a clear pattern there.
There could be simpler, more effective public health measures that would help maintain a healthy population, treating OSA is just a piece of the puzzle. Encouraging healthier eating and regular moderate exercise, for instance. Encouraging and supporting mothers breastfeeding children in infancy, for another. There is no reason to throw pharmaceuticals/medical devices at all problems, if we would just get people to adopt healthier lifestyles.

The fact that hundreds of thousands of people in an extremely rich country live with serious, untreated mental illness is a great shame. It's really low visibility, since these people don't have lobbyists or vote much, but it's also a really clean case ethically, and one that in principle could be addressed in a bipartisan manner. I suspect even tea party types don't think the mentally ill deserve to live in streets without family, community or government support, and there may be political support to gain from churches.

The fact that there are more than ten thousand gun homicides in the US each year is itself a scandal, but not (to my mind) fruitfully connected with the preceding one. Events like a mass shooting become media/popcorn/pundit fodder, but the total death toll from such incidents is probably under fifty a year. In themselves, they are too rare to have -any- significant policy implications. A gun control policy should address itself to the yearly 11k, not to news porn. When you see that a substantial (we're talking >70% for each year since 1975) portion of that 11k pa is gang related, the starting point would involve things like drug war, community support to the inner city, restrictions on youth gun possession etc. Not efforts to prevent crazy person du jour from going on a rampage.

Ack, I completely misinterpreted the link above re gangs. It actually says >70% of gang violence involves guns. The actual numbers are here:

They don't assign a cause to 40% of gun homicides. Of the rest, 45% come from escalated arguments, 25% are related to the commission of other felonies, and 13% are gang related.

Another interesting number I just saw:

Only 97% of the 34k gun deaths a year (suicides are counted, hence the high number) are intentional. [This is from 1996]

When children are taken from parents and placed in foster care, they are often drugged up with neuroleptics, including drug cocktails. It might not be as bad as being abused or killed, but it is not good.

My focus was on institutionalizing and treating a violent and abusive mother, if she liked it or if she didn't, rather than on treating her kids in any way except to separate them from her. I would prefer not to engage in a discussion of the merits of psychiatric medications -- some of us feel they are over-used, others feel they are evil. I am concerned mainly with what happens when the rights of society -- safety in the streets, the protection of children -- are brought into sharp contrast with the rights of impaired and violent individuals to make decisions about their treatment, including opting for no treatment, and about posing risks to others in the name of those liberties. I am looking at the greater good, and trying to see how that is served. Often, it is served at some sacrifice of individual liberties. The rights of execs at Goldman to do as they choose are not, to me, so different from the rights of mentally ill and violent people to risk others through their treatment preferences.

The foster children being drugged with neuroleptic drug cocktails are being abused in a different way, often given drugs off-label that have not been approved by the FDA for use with children.

I also fail to understand why you or others here believe that people can be coerced out of violent behavior through institutional "treatment."

This is an interesting case of a former Marine who was handcuffed and admitted to a psych facility over his Facebook page. In playing a game with his brother and sister, he said that he was sharpening his axe and getting ready to sever heads. Sounds violent, so the police handcuffed him and took him to a psych facility. Rutherford Institute lawyers were able to obtain his release.

What's next? Reporting the violent among us to Homeland Security?

Whether people can be coerced out of violent behavior through drugs is not my issue here. Although I think they can be attended and accompanied in an institutional setting, and take fewer drugs therefore. My only issue here is weighing the liberties of the mentally ill who are violent against the safety of non-violent people of every stripe, and I think it's a difficult call.

I have been a counselor to girls at risk in a residential school here in the Boston area -- I left the job because of the risks to my safety. One woman who did precisely the work I did in the shift before me was nearly blinded by a girl who mounted surprise attacks on people from time to time. From the mental health delivery system's POV, the girl made progress because she "owned her behavior" in this latest attack. Which no one meant to tell me about but I alas showed up a bit early for my shift and saw. I gave one month's notice on the condition I would never be alone with a girl or closer to her than a distance of 10 feet -- my manager was grateful I didn't walk off the job.

Yes, I saw acts of kindness on this job, I saw girls emerging from deep illness, I saw astonishing skills used by people who were born for the work. I got some first hand impressions of the role of medication in treating conditions that would otherwise keep a girl in lock-up. It was a wonderful thing to see some of them try and even succeed in getting beyond their destroyed childhoods and into some territory where reason and reflection were possible. My deeper sympathy however is with the skilled helper who was nearly blinded, and who has serious vision loss to this day.

John, thanks again for posting this -- I need to leave this thread, AB having afforded me a chance to say what I had to say. See you another time, same place, different thread.

I can understand your deeper sympathy for the helper.

I also have deep sympathy for a woman who now has corneal neuropathy and excruciating eye pain as a result of taking Seroquel for years. She is functionally blind.

Louise, throughout this thread you have come back every time with examples of misuse of drugs, abuse of children, misconduct of care givers etc. as broad indictment of psychiatric care. The topic here relates specifically to how we can prevent violence resulting from mental illness. For common criminals we have jails. Instead of hijacking the discussion to showcase what you think is wrong with the mental health care in this country, not necessarily related to violence, please tell us what you think should be done with such patients whose illness endangers the lives and limbs of others, sometimes complete strangers.

"The challenge for medical practitioners is to remain aware that some of their psychiatric patients do in fact pose a small risk of violence, while not losing sight of the larger perspective — that most people who are violent are not mentally ill, and most people who are mentally ill are not violent."

If someone has demonstrated that he or she is violent, I think they should be isolated from the rest of the population through prison or a mental hospital. However, I also think they should retain their right to treatment options and not be forcibly drugged or electroshocked, which is common practice in this country.

I don't think people should be wisked away to a psych facility for things that SOUND violent without their having demonstrated violence.

Since psychiatric care in this country is so riddled with problems, it is difficult not to "hijack" the discussion, since such problems are interwoven with any solutions to violence in psychiatric patients.

Mark Chapman is in prison. John Hinckley is incarcerated in St. Elizabeth's. Neither of them is now free to go on another shooting spree.

After reading the NEJM link, I wonder which came first, the violence or the mental illness? Once upon a time, anybody who harmed another human would be summarily punished ( prison or death,depending on what kind of system was in vogue where they lived). Then at some point, it became the art of the day to perceive the mental conditions which underlie the violent action. Psychiatry/psychoanalysis took off in a big way. Etc., etc.
From blaming the perpetrator to moving to damning the illness which cause him/her to act violently is a huge shift, but does nothing for the victim. It merely leaves the latter with the sense that too much is being done to help the perp and not enough to help him/her. So, in a primitive way, it still requires an eye for eye to satisfy the victim's need for justice, or at least some equally significant reparation and promise that the perpetrator will never be able to repeat the misdeed.

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