Conscious States and Suicide.....

When I first starting writing this blog - I decided that I was not going to make the common mistake of using celebrity tragedies as a springboard for posts.  I have been very pleased with that decision.  Given recent events - it is evident that people who use that approach are speculating and either don't know enough of the details or make sweeping statements that they could have made without any specific reference to the person or their family.  It is also evident that in some cases, the potential for damage to the survivors is great and should be avoided at all costs.  The only rationale that I hear is they were celebrities and the people want to know.

I will comment on the mystery of suicide.  How is it that a highly accomplished person with ample resources and even supportive people and family in their life can make a decision to take their life?  The press has settled on a couple of unsatisfactory answers that flow from the risk analysis approach to suicide.  In other words, let's look at number of modifiable and unmodifiable correlates of suicide attempts and use those in an analysis of a specific death by suicide.  After the fact it is basically a fishing expedition trying to fit the pieces together in a way that there is a logical and linear story about how the incident unfolded.  If the person is famous enough there may not be a final judgment until the autopsy toxicology comes in many weeks later.  Even if a coherent story is constructed, the story may be debated for years on cable TV shows that have medical experts second guessing real time experts.

Serious and intractable disorders and impulsivity is a big part of the current media story.  I had somebody ask me today: "Is it true that people just make the decision and in 5 minutes they are dead?"  People tell me stories about Golden Gate Bridge jumpers who survived to tell about it and that is what they reported.  All of the stories are very linear - there is a precipitant and then depression with depressed moods and then an impulsive suicide attempt. 

Psychiatrists are trained to recognize and treat all of the major disorders that are thought to increase risk for suicide including substance use disorders.  We are also trained to be optimistic about the treatment and consider these diagnoses to be modifiable - if they are treated correctly they will respond to treatment and improve thereby reducing risk for suicide.  Overall psychiatrists are successful in that approach as evidenced by reduced suicidal thinking and in some cases behavior that is directly observable in hospital units.  Self report by patients is another valuable metric that is rarely talked about.  Patients can at some point say: "I seriously contemplating suicide and had a plan to kill myself until I came here for treatment." or "During my last pregnancy - at one point I was going to kill myself.  I don't want that to happen again.  I want to have a plan this time to prevent that from happening."

From an epidemiological standpoint, psychiatrists in general treat people who are at much higher risk than the general population for suicide.  The CDC, just came out with data to show that the suicide rate in the USA from 2014 was 13 per 100,000.  Many of the disorders treated by psychiatrists have lifetime suicide rates of 10-15%.  In a cohort of 100 people with the disorder, 10-15 are expected to die by suicide over the course of their lifetime.  Suicides by people in active treatment by psychiatrists is rare relative to those numbers but they do happen.  They are more likely to happen during transitions between care settings like hospital discharges or when care is fragmented. They are more likely to happen when there are destabilizing factors in the person environment and easy access to highly lethal methods of suicide - like firearms.

Even in the case where a person has survived a potentially lethal suicide attempt it may be difficult to piece together what has happened.  Consider the following case.  John M. is interviewed in his hospital bed by a consult psychiatrist.  Three days earlier he shot himself through the left shoulder with a handgun and barely survived.  He has extensive damage to the structure of his left shoulder and it will be a while before his surgeons can advise him on whether to not it can be reconstructed.  It is clear that he has been depressed and somewhat paranoid for years.  The psychiatrist asks him about the injury.

JM:  "I guess I shot myself?"
PSY: "Can you tell me about the sequence of events?"
JM:  "Well - I was feeling very depressed.  I thought about calling my parents but they have done too much for me already.  I started to think that I was not worthy of their help anymore.  I feel worthless and like a burden to my family.  I knew they would miss me - but at some point you realize sure they will feel bad for awhile, but they will get over it in a while and the burden will be lifted.  At that point I thought I would get out my .44 and shoot myself in the chest..."
PSY: "Tell me exactly what you were thinking.."
JM:  "Like I said I felt hopeless and like I was a burden. At some point I realized that I was pointing the gun at myself.  I knew I did not want to shoot myself. I have a nephew and I wanted to see him again. And then the gun just went off.."
PSY: "The gun went off?  Don't you remember pulling the trigger? Were you holding the gun in your right hand or your left hand?"
JM:  "I am right handed.  I was holding it in my right hand and pointing it at the center of my chest."
PSY: "Do you remember what you thought when you pulled the trigger?"
JM:  "I don't remember pulling the trigger.... One minute I see my hand and wrist and the gun barrel and then it goes off and I am on the floor bleeding."

Further discussion of the incident does not provide any further degree of clarity.  The psychiatrist has to come up with a diagnosis and a formulation as well as a risk assessment of future suicide potential.  There are several diagnostic possibilities including mood disorders with or without psychotic features including substance induced mood disorders.  Alcohol, stimulants, and opioids can all  cause acute suicidal thinking during intoxication and withdrawal states.  The suicide assessment is basically a collection of risk factors that at the time of this interview may not be entirely relevant.  For example, the patient in this case did not have any suicidal thinking at all and was pleased that he had survived at the time of this interview.  Irrespective of all of those considerations there may be some psychiatrists who would be comfortable discharging the patient at that point.  I am not one of them. In this case I would opt for a more detailed assessment and period of observation and an attempt to restore the person to his baseline level of functioning.

In acute care psychiatry, we talk a lot about baseline and cannot always achieve it.  People my not be aware of the fact that they are not at baseline, insist they are fine, and want to go home even if they are at high risk.  People may not want to access help in the first place for the same reason.  We can only assess baseline very indirectly.  The best current way is an extended conversation with a person who knows them very well.  Is their social behavior and personality the way it should be? How do they differ from that.

This baseline that we refer to and assess only peripherally is critically important when it comes to suicide risk.  We are actually referring to the person's conscious state.  There are no ways to assess baseline conscious states.  All of our energy has been focused on extreme psychopathological states and the handful of criteria that are used to define them.  By way of contrasts the human brain is designed to generate billions of unique conscious states - no two are ever alike because these billions of states have all had unique life experience to think about.  There is no universal agreement -even among researchers about how to define conscious states - but discussing the contents of consciousness is a fairly universal approach. I typically ask students to imagine their own stream of consciousness and why it night be unique. But that is only part of what defines a unique conscious state.  Subjective experience is another.  Unique subjective experience is diametrically opposed to the usual methods in psychiatry of trying to index disorders based on a handful of common features.  A person's unique experience is much less likely to be recorded anywhere in today's era of rationed psychiatric care and poor documentation.  Conscious states are also subject to perturbations that are transient  based on internal and external conditions.  In the case of suicidal thoughts, in my thousands of interviews of people the most common reply I get is: "Yeah - I have had a few suicidal thoughts -hasn't everybody?"

In this era of inability to assess and essentially predict a person's conscious state it should not be surprising that we have only the most basic knowledge about the assessment and treatment of suicide potential.  We are generally using a very crude risk assessment and many of the variables may be unchanged for years.  It is not like an actuarial assessment for insurance purposes where the outcomes and statistics are not that dynamic.  In the case of suicide assessment, we don't know all of the variables, the number of variables is large, and we may not even know the person's baseline conscious state unless we have known them for years.  To further complicate matters - they may not be able to tell us about their baseline state until they have recovered it and recognize that they have changed.  The change we are interested in is going from a state that would never consider suicide to one that would.

 The media storm around recent events, will seem to provide a number of pat answers based on society, culture, pop psychology, and special interests.  They seem to ignore the fact that in any given society, these rates rise and fall.  The current rate was the same in 1950 and 1970.  Moreover American society is intermediate relative to the rest of the world when it comes to suicide rates. Some countries with more psychiatrists per capita have higher suicide rates.

On an individual level, suicidal thinking especially if it is combined with of other psychiatric  symptoms is a red flag.  It suggests that a person should try to obtain professional help.  There is no easy way to discuss the consciousness issue on more than a fragmentary basis at this point.  I do try to discuss it with people as a risk factor, but if they are in an altered state they may not be able to hear what I have to say.  The current practical approach is to listen carefully to people who know that person well and have their best interest in mind. 

A reasonable pathway to assessment and treatment is paying attention to any changes that a concerned third party may have noticed and if that person with the problem can't see it - get a neutral third party professional involved and give them all of the information.



George Dawson, MD, DFAPA 

The News Media and Mental Illness - A Continued Problem

Although the media can certainly pump up the volume on trivia like the DSM-5 their coverage of the critical day-to-day issues involving mental illness continue to be lacking in both depth and breadth.  It is weak.  From a depth perspective I will point to an article about a man convicted of shooting at people on the I-96 freeway in southeastern Michigan.  His reason for the shootings?  He thought he was getting coded messages from the Detroit Tigers to shoot people.  He also believed that military helicopters were hovering above his home and that his home contained "advanced technologies" that caused his daughter to develop a skin disease and his wife have a miscarriage.  The article contains a layman's description of a not guilty by reason of mental disorder defense and that defense was never advanced based on a judges ruling.  As a psychiatrist familiar with these criteria there is an overwhelming bias to convict people who are mentally ill and mentally compromised.  That is why the defense is generally a failure.  In this case the defendant did not have the opportunity to present that defense because as the article explains:

"Diminished capacity is a claim that says a defendant was unable to form specific intent required to commit a crime under the law by reason of mental illness, and as a result, the defendant’s responsibility in the alleged crime is diminished. The judge earlier ruled that the defense could not make this argument because it failed to give proper notice of a defense of insanity."

In other portions of the article we learn that he has been treated for an unnamed mental illness since 2009.  The symptoms are described as delusions that respond to medication and the delusions associated with the shooting incidents are currently in remission.  When the defendant is asked about whether he knew that firing a gun into an automobile might hurt someone.  His response was "In hindsight - yes".  I have not seen the final sentencing after a no contest plea but he faces up to 12 years in prison on firearms and assault charges after they decided to drop a terrorism charge.

From a breadth of coverage perspective, I will suggest a second article that points out the critical shortage in acute care inpatient beds with the capacity to address severe mental illness and aggressive behavior.  In those case Virginia State Senator Creigh Deeds discusses an incident where his son stabbed him and subsequently shot himself.  After the incident Senator Deeds states that the read his son's diary and it said that if he killed his father he would go directly to heaven.  In his taped discussion he talks about all of the relevant points that I try to cover here involving stigma, a lack of respect for providers, and diversion of resources to more areas of care that are viewed as more prestigious - like Cardiology.  Amazingly, Virginia apparently has a rule where you must be released from the emergency department if they can't find a psychiatric bed within 6 hours.  Based on his proposed reforms it doesn't seem like there has to be much of an effort to look elsewhere.  The sequence of events has been managed care companies shutting down psychiatric bed capacity by defunding it.  That is followed by states deciding to act like managed care companies and either shutting down their capacity or getting completely out of the field.  The end result is a pool of people who cycle in and out of short stays on inpatient units to overcrowded emergency departments to the street and back again.  Many permanently drop out of that cycle when they become homeless or go to America's newest mental hospitals - the county jail.  This is a problem everywhere in the United States.  I used to qualify that by saying it was a problem in areas of high managed care penetration.  Today that is everywhere.

Apart from the isolated pieces that are written with the obvious intent to get somebody a Pulitzer Prize, these stories are typical of what you see in the press.  The first article lacks basic information on what mental illness is and how decision making in a delusional state bears no resemblance to answering questions "in hindsight" after the delusions are gone.  It lacks psychiatric perspective.  Any newspaper reporter probably has access to acute care psychiatrists to tell them about those problems.  In that situation reporters always want a "diagnosis" of the person in the news and psychiatrists cannot speculate on that without having examined the patient and getting their release for that information.  But they can provide a rich perspective based on their clinical experience treating thousands of similar problems and the effect of delusions on a person's conscious state.  They can also provide an opinion on the mental illness defense in this country as well as the state of psychiatric services to treat the problem.  I know that I would be happy to provide those details.  At the minimum somebody in charge of journalism school curricula needs to examine how reporters can come out and ignore all of those facts.  I might even suggest objective criteria for coverage as at least 5 times the words used to cover the least relevant mental illness story that year.  I would give the least relevant story this year as anything having to do with the DSM-5.  On that basis a lot of additional writing needs to be done on these two stories.

In the case of Senator Deeds, his analysis of the problem in this brief soundbite is spot on.  He needs a broader platform to advocate for his plan and support against the people who are opposing him and the 6 hour rule in state of Virginia.  He should work the the American Psychiatric Association, receive their support, and have access to their social media venues.  The APA should come out with their own solution to this problem.  I cannot think of anything more absurd and more consistent with a managed business approach to treating severe health problems than this 6 hour rule.  At some point the patient and their severe problem is totally meaningless relative to business concerns.  And Senator Deeds is right.  That doesn't happen with any other medical problem in the emergency department.

It only happens with mental illness.

George Dawson, MD, DFAPA

Is it the economy?

The lead story in this week's Psychiatric Times was sent to me in e-mail this morning under the subject "Economy Threatens Psychiatry Programs". It provides the news that the Cedars-Sinai Department of Psychiatry and Behavioral Neurosciences is essentially being phased out except for "staffing of psychiatric support that is an adjunct to patient care throughout the medical center." It quotes an unnamed academic psychiatrist as saying that the real reason that psychiatric programs are getting the axe is that they are the least profitable services offered at any hospital. The article goes on to suggest that declining Medicare funding of Graduate Medical Education may threaten additional programs.

The only real explanation and dose of reality in that article was the quote from their anonymous source. Psychiatric programs and bed capacity have been closing down for the past 20 years. It is the direct product of managed care strategies either being applied directly by the managed care cartel or through their friends and allies in the government. I have previously posted on this blog how psychiatric services have been marginalized from an economic standpoint.  That should be obvious from surveying any acute care hospitals in your state. In the state of Minnesota for example, a minority of the total hospitals have psychiatric units and fewer are staffed for chemical dependency services.  That has resulted in the need to transfer patients in crisis in emergency departments across the state or in some cases in different states. As a result any involved family members have to travel hundreds of miles to maintain contact with that person.  The economy for psychiatry has been bad for the last 20 years.

The evolution of this process is apparently so insidious that nobody pays attention to it. The only way that the minority of hospitals with psychiatric units can continue to operate and staff those units with psychiatrists is if they do a high volume, low quality DRG based business or they are subsidized to some degree out of the profit margin of other departments. In that case, an economic argument can be made that more severely ill psychiatric patients or medically ill psychiatric patients would never leave medical or surgical units if there were not psychiatric units available to receive them in transfer.

This process is easily reversed by providing adequate compensation for psychiatric care. The reimbursement levels for inpatient care are so trivial that an inpatient psychiatric unit is currently the least expensive place to maintain the patient.  At some point, treatment on a DRG based inpatient unit is cheaper than a group home and much cheaper than a state hospital.  That creates additional incentives and barriers to discharge from the hospital.

The bottom line is that it is not the economy.  There has been a systematic bias against mental health services for at least 20 years.  It is well past the time for psychiatrists and other advocates to remove the term "cost effective" from their dialogue. Psychiatric and mental health services have been the most cost effective medical services for at least the past 20 years and there is no reason for expecting them to get less expensive. Reversing that trend and providing compensation that is at least on par with the rest of medicine will allow for quality psychiatric hospital services and outpatient clinics.

George Dawson, MD

Stephen Barlas. Elimination of Psych Services at Cedars-Sinai Could Foreshadow Similar Cutbacks Elsewhere.  Psychiatric Times Vol 29, No2, February 8, 2012 

Endnote:  According to the Minnesota Hospital Association 29 of 136 acute care hospitals have beds staffed for mental health care and 6 of 136 have beds staffed for chemical dependency care.

Critical Article on the Efficacy of Psychiatric Medication

There is a seminal article in this month’s British Journal of Psychiatry by Leucht, Hierl, Kissling, Dold, and Davis.  The authors did some heavy lifting in the analysis of 6175 Medline abstracts and 1830 Cochrane reviews to eventually compare 94 meta-analyses of 48 drugs in 20 medical diseases and 33 meta-analyses of 16 drugs in 8 psychiatric disorders.  The authors have produced a graphic comparing the Standard mean difference of effect sizes between the general medicine drugs and the psychiatric drugs.  It is apparent from that graphic that the psychiatric drugs are well within the range of efficacies of the general medical drugs.

This is an outstanding study that merits reading on several levels.  The authors have used state of the art approaches to meta-analysis following suggested conventions.  They provide the summary of the studies reviewed and actual details of their calculations in the accompanying tables. (the document including references and PRISMA diagrams is 59 pages long.)  They have a comparison of standard criticisms of psychiatric drugs and illustrate how the criticisms are not fair and the toxicity considerations are often greater in the general medicine drugs than the psychiatric drugs. 

This paper should be read by all psychiatrists since it is an excellent illustration of an approach to large scale data analysis using modern statistical techniques.  It is a good example of the application of the discussion by Ghaemi of hypothesis testing statistics versus effect estimation.  The authors also have an awareness of the limitations of statistics that the detractors of psychiatric care seem to lack.  Their statements are qualified but they provide the appropriate context for decision making about these medications and the implication is that decision matrix is clearly squarely in the realm of other medical treatments in medicine.

From the standpoint of the media and the associated politics it will also be interesting to see if this article gets coverage relative to the articles that have been extremely critical of psychiatric drugs.  I can say that I have provided the link to the article by Davis, et al on the issue of antidepressant effectiveness to several journalists including the New York Times and it was ignored.  The press clearly only wants to tell the story against antidepressants and psychiatric medications.

Never let it be said that any aspect of psychiatric treatment gets objective coverage in the press.  That problem and the lack of investigation of that problem is so glaring at this point that the press lacks credibility in any discussion of psychiatric treatment.

George Dawson, MD

Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective:review of meta-analyses. Br J Psychiatry. 2012 Feb;200:97-106. PubMed PMID: 22297588

S. Nassir Ghaemi (2009) A Clinician’s Guide to Statistics and Epidemiology in Mental Health: Measuring Truth and Uncertainty.  Cambridge University Press, New York.

Davis JM, Giakas WJ, Qu J, Prasad P, Leucht S. Should we treat depression with drugs or psychological interventions? A reply to Ioannidis. Philos Ethics Humanit Med. 2011 May 10;6:8.

Seemuller F, Moller HJ, Dittmann S, Musil R. Is the efficacy of psychopharmacological drugs comparable to the efficacy of general medicine medication? BMC Med. 2012 Feb 15;10(1):17. Free full text commentary on the main article from another journal    -      download the pdf.

Antidepressants - the limited analysis of a polarized argument

The current President John Oldham and President-elect Jeffrey Lieberman of the American Psychiatric Association came out with this press release today on a 60 Minutes episode characterizing antidepressants as no better than placebo.  They describe this characterization as “irresponsible and dangerous reporting” and “a message that could potentially cause suffering and harm to patients with mood disorders.”

It is good to see the APA finally taking a stand on this issue.  Antidepressants and the psychiatrists who prescribe them have been taking a pounding in the popular press for years.  The main proponent here was also featured in a Newsweek headline story two years ago.  This is a prototypical example of how the media and special interest groups can distort science and facts and politicize the discussion that must be nuanced.  The problem is that you have to know something and be fairly free of bias to participate in a nuanced discussion.  Like most issues pertaining to psychiatry, the issue is always polarized and poorly discussed in the media.

I got involved in this issue as a managing editor of an Internet journal and I solicited a paper from a world renowned epidemiologist to get his current view on antidepressant meta-analyses. In order to present the entire argument I also solicited response from a world renowned psychopharmacologist with broad expertise in this field. Both articles are available online for free and I think if they are both read in total they represent the most accurate picture of antidepressant response.  Both references are listed at the bottom of this page.

Rather than get into the specific details at this point I will say that it was extremely difficult to find a anyone willing to provide a rebuttal to the to the original article by Ioannidis, but anyone who reads that paper by Davis, et al and who follows the antidepressant literature will have a greater appreciation of the effectiveness of these medications.  I hope to post some information on the statistical analysis as well.  At some level people tend to view statistics as a hard mathematical science and there is plenty of room for interpretation.  The use of meta-analysis is a common approach to these problems and a detailed look at the shortcomings of meta-analysis are seldom discussed.  That might explain why one meta-analysis shows minimal effects and another shows that there might be some antidepressants with unique effectiveness (see Cipriani, et al)

A final dimension that is critical in the analysis of any source is potential conflicts of interest.  The only conflict of interest that is typically discussed is the financial interests of authors and pharmaceutical companies in producing positive trials.  That ignores the fact that many of these trials have been very public failures and that post trial surveillance limits the use of some of these compounds.  There are other conflicts of interest to consider when an author is selling a viewpoint and can potentially profit from it – either financially or politically.

The APA could provide a valuable service here in making the documents from the FDA and the EMA widely available for public discussion and analysis.

George Dawson, MD

 “60 Minutes” Segment on Antidepressants "Irresponsible and Dangerous" – APA New release Febrary 22, 2012.

Ioannidis JP. Effectiveness of antidepressants: an evidence myth constructed

from a thousand randomized trials? Philos Ethics Humanit Med. 2008 May 27;3:14.

Davis JM, Giakas WJ, Qu J, Prasad P, Leucht S. Should we treat depression with drugs or psychological interventions? A reply to Ioannidis. Philos Ethics Humanit Med. 2011 May 10;6:8.

Cipriani A, Furukawa TA, Salanti G, Geddes JR, et al.  Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis.  The Lancet - 28 February 2009 ( Vol. 373, Issue 9665, Pages 746-758 )