Monday, October 3, 2016
I thought I would provide a counterpoint to the New York Times editorial entitled "Medicating A Prophet" written by Psychiatrist Irene Hurford (1). The opinion piece is available free online and I encourage anyone interested in the topic to read the article rather than accepting my summary here as adequate. I will say from the outset that I am not a stranger to any of the issues that Dr. Hurford discusses either clinically or personally. The bulk of my career was spent treating people with severe mental illnesses and addictions. Once you have worked in that setting, it is clear that many people who are severely ill need involuntary treatment and that is one of the decision points that she addresses.
In her essay, Dr. Hurford describes an early call experience during her residency. She was asked to assess a man in the emergency department (ED) who had been delusional for 30 years. The delusions were religious and grandiose in nature. He was a college graduate but was homeless living on the street in Philadelphia. He also had AIDS and the complication Kaposi sarcoma. His reason for being in the ED was "to preach". Dr. Hurford encourages him to come in for voluntary treatment but he refuses. At that point she ponders involuntary treatment but in the essay decides to discuss the patient's right to psychosis. Later we learn that she made the decision but has decided to analyze that decision in retrospect based on factors that she has encountered since.
One of those factors was the influence of a professional colleague who based on her own experience with psychosis and that colleague's mother's experience suggested that thoughts about living "in psychosis" and outside of psychosis need to be challenged. She basically states that the problem may be within the beholder rather than the identified patient. Following that logic, it makes sense to show up in an ED to preach while ignoring serious health problems. It also makes sense to make decisions about the person's "in psychosis" experience knowing so little about them. In my experience, nobody in the ED calls the parents or family of a 50 year old street person, to get a clear picture of how the psychosis has truly affected him. When I have treated these people on an inpatient unit and made those calls, I have never heard that the patient was well served by the psychosis. Not a single time. In many cases, family members were surprised to hear that person was still alive.
Dr. Hurford advances a number of other arguments that I call into question. She uses a very loose definition of insight as a "failure to accept an alternative view of reality". She turns this around to suggest that anyone who does not accept this premise (implicitly the treating physician) also lacks insight. I don't think that you can practice psychiatry and not be comfortable with alternative realities. I would suggest a more appropriate definition of insight as a decision-making process. Can I accurately assess how I am doing in the world? Am I making decisions in my best interest? Are those decisions consistent with my ability to survive? If I realize that I am not doing well can I get help? Pretty basic decisions. Not a question of lifestyle choices. To have a lifestyle you have to live. That is the kind of insight that I am used to dealing with.
Dr. Hurford discusses a case of a young patient with a psychotic disorder who stopped taking his medications and started using cannabis on daily basis. He dropped out of college and became progressively incoherent and then mute. She is concerned about traumatizing the patient by "enforcing" treatment even though he cannot "eat, sleep, and talk." I don't follow the logic that some treatment intervention - even basic detoxification from cannabis is somehow more traumatic than not eating, sleeping, or being able to communicate. How is that a preferred alternative existence?
At that point she digresses to a very brief overview of the usual comments about mental illness being only peripherally associated with violence and the lack of evidence that forced treatment led to fewer hospitalizations, arrests, or a better quality of life. She cites a meta-analysis of three randomized-controlled studies of more than 700 people. There are a lot of reasons why meta-analyses are not superior to the actual trial data. There are also a lot of reasons why truly clinical samples with these problems cannot be ethically randomized or included in the studies. There are also reasons why I would expect the entry points into these studies to be highly variable as well as the treatment resources that are involved. In Minnesota, we have 87 counties and the rule is that there are 87 interpretations of the commitment act for involuntary treatment. There are two corollaries operating here. The first is that the courts will be very liberal in terms of dropping commitments until something bad happens. At that point the pendulum swings back in the direction of more frequent commitment. The second is that only the wealthiest counties in the state can afford to provide adequate resources to treat the severely mentally ill. Even then there is no assurance that the counties that can afford it will actually provide the care. Some currently function like managed care companies and ration the care. They can end up rationing care and commitments in order to save the county money. The lack of evidence that forced care does anything may be more of an indictment of the lack of quality or consistency in delivering care and interpreting the law and rationing care more than anything. I have personally treated many times the number of people with forced treatment than in the meta-analysis and there is no doubt that the outcomes were better than with no treatment.
The outcome variables cited by Dr. Hurford are also dreadfully lacking compared with what can be seen routinely in clinical settings. They include very adverse outcomes in encounters with the police including getting shot, dying from a treatable illness, suicide, loss of relationships with spouses and children, loss of a job and income, and acute loss of life due to poor insight and judgment. In Minnesota, all that takes is going outside in the winter time without adequate protective clothing and you are dead or in the Burn Unit with frostbite.
Right now we are in the midst of a sweeping cultural change that idealizes psychosis and suggests that hallucinogens and cannabis are therapeutic drugs. That will put the next generation or two of people with psychoses, mood disorders, and substance use disorders at risk for chronicity and every possible negative outcome. A point that should not be lost on anyone is how no care for psychosis is "cost-effective" care when the total impact on the patient is ignored. My point in writing this rebuttal is really advice for the people in these generations. Ask any psychiatrist treating you or your family member where they stand on this issue.
Especially if you value psychotic symptoms a lot less than your psychiatrist does.
George Dawson, MD, DFAPA
1. Irene Hurford. Medicating A Prophet. New York Times. October 1, 2016.