Cannabis and Causation

Cannabis use is highly politicized in the US at this time largely due to legalization rhetoric that has spilled over into scientific research on the topic.  Despite the broad movement to legalize cannabis across the US, only a minority of the population are regular cannabis users.  More widespread use will undoubtedly lead to increased problems associated with wider exposure, especially wider exposure in populations with vulnerabilities to the toxic effects of cannabis.  The toxic effects of interest include addiction and psychosis.  It is common in clinical practice to encounter daily cannabis smokers who stopped using the substance after several years because they started to get panic attacks, paranoia, or both.  The people I see have all moved on to something else, but there are also a substantial number of chronic smokers who are addicted.  That number is about 9% of users, and that is comparable to the amount of people who have problems from drinking alcohol.  Inpatient psychiatrists commonly see people with florid psychotic episodes from smoking significant quantities of cannabis.  They also see repeat admissions from people who are either detoxified or treated for these psychotic episodes, are discharged and smoke more cannabis to the point of a repeat psychotic episode.  The longstanding controversy among people who are not doing the work and just speculating is whether any good observational studies can be done to show that cannabis does cause psychosis or if this is an artifact of observational methodology.  In other words,  could a reverse causality bias exist that makes people who are prone to schizophrenia or psychotic episodes more likely to smoke cannabis.  In my opinion, there have been excellent observational studies showing the association between cannabis use and psychosis, but as long as that is the technology these studies will always contain the old association is not causation qualifier.

A recent paper (1) in Molecular Psychiatry may have just illustrated the causation that psychiatrists have been experiencing firsthand for decades.  The authors use a novel genetic appraoch to look at the issue of causation.  The main assumption of this study is that using specific genotypes as the independent variable rather than observed individuals gets rid of the confounding demographic and environmental variables that could be casual.  They point out that any actual clinical trial looking at the issue of whether cannabis causes psychosis would be unethical, but that a model that looks at whether causation can be established by looking at single nucleotide polymorphisms (SNPs) from a Genome Wide Association Study (GWAS) looking at the any cannabis use phenotype.  They looked at the top 10 SNPs from that data that were used to calculate gene-exposure (SNP-cannabis) estimates.  SNP-risk of schizophrenia exposure estimates were calculated from available data from the Psychiatric Genomics Consortium.  Instrumental variable estimates were made by dividing the risk of schizophrenia/risk of any cannabis use.  The instrument variable analyses were pooled across SNPs and analyzed with fixed effect meta-analysis.  The authors provide a detailed discussion and rationale for their statistical calculation in the full text of the article and supplementary material.  At this point I am going to post their main graphics.  Click on any graphic to enlarge it.

The first graphic looks at prospective observational studies.  The authors were interested in determining whether their genetically based analysis was in the same direction of this meta-analysis. Ever use cannabis use was associated with a 43% increase in schizophrenia or psychosis.

Figure 1. Meta-analysis of prospective observational studies reporting an association between use of cannabis and risk of schizophrenia or related disorders. Meta-analysis uses a random-effects model. Studies are sorted by type of outcome (schizophrenia only vs schizophrenia and related outcomes). Odds ratios (ORs) and 95% confidence intervals (CIs) express the risk of schizophrenia or psychotic symptoms for ever use of cannabis (compared with never use). For additional information on each study, see Supplementary Table S1. Dunedin, Dunedin Multidisciplinary Health & Development Study; ECA, Epidemiologic Catchment Area; EDSP, Early Developmental Stages of Psychopathology Study; NEMESIS, Netherlands Mental Health Survey and Incidence Study; SC, Swedish Cohort.

Figure 2 looks at the Mendelian Randomization analysis of 34,241 cases of schizophrenia and 45,604 cases of ever use cannabis.  This shows a 37% risk of cannabis users versus non-users for schizophrenia/psychosis risk.  The authors did a sensitivity analysis of this same data by removing each SNP from the analysis to calculate a summary causal effect of 1.33 across all 10 SNPs or 1.88 when restricted to 2 functional SNPs.

Figure 4 is included here to illustrate the authors' sensitivity analysis showing a summary casual effect of about 1.37 (red line).

All things considered this may be a compelling story for causation.  I qualify that of course in a couple of domains.  First. there are a lot of statistical models and calculations operating here.  In my experience mapping complex statistical estimates onto the most complex object in the universe has not worked out very well.  My first hand experience was statistical modeling of quantitative EEG and claims that is was predictive of psychiatric diagnosis.  Those compelling calculations published in Science (4) did not pan out at all in the long run.  It will be interesting to see if the authors applications are more widely applied to other SNPs to determine disease causation from other risk factors.  The second potential problem is a slight variation on that theme and that is the overall imprecision of meta-analysis.  The known  approximate prediction/concordance rates of meta-analyses for clinical trials (2.3) suggests that it may not be good predictor of a reproducible result.  The authors themselves suggest that the potential limitations of their study start with the fact that none of the chosen SNPs met conventional genome wide significance thresholds.  The specific dose effect of cannabis could not be investigated in the study.  The age at exposure is may be a developmental variable of interest and that was unknown.  The Mendelian Randomization techniques may have not been powerful enough to detect pleiotropic (one gene affecting more than one trait) effects, but they discuss how an alternate analysis applies in this situation.

The other question I had was about epigenetic effects on this model.  The authors were certainly aware of smoking as a confounding variable.  The known epigenetic effects of nicotine on brain chromatin would seem to cloud SNPs as pure genetic risk factors.  But this is nonetheless one of the more interesting models and concepts I have seen in a while.

They conclude that their study is "the closest approximation to a randomized trial on the effect of ever use of cannabis and risk of schizophrenia" when such a clinical trial is unethical.   That is an interesting take on their method and causation.  Hopefully it will open up the way for other studies of causation using these techniques.  If that is the case, it is a good idea to study this paper and the supplementary material (26 pages) and have a good idea about its difference from observational/association studies.  The supplementary material is also very useful for the calculations used in the study, a Venn diagram of the overlap between the schizophrenia-GWAS group (N=79,845) and the ever-use cannabis GWAS group (N=37,957), and their review methods of the best observational studies of cannabis use and  schizophrenia/psychosis.  



George Dawson, MD, DFAPA



References:

1: Vaucher J, Keating BJ, Lasserre AM, Gan W, Lyall DM, Ward J, Smith DJ, Pell JP, Sattar N, Paré G, Holmes MV. Cannabis use and risk of schizophrenia: a Mendelian randomization study. Mol Psychiatry. 2017 Jan 24. doi: 10.1038/mp.2016.252. [Epub ahead of print] PubMed PMID: 28115737.

2: LeLorier J, Grégoire G, Benhaddad A, Lapierre J, Derderian F. Discrepancies between meta-analyses and subsequent large randomized, controlled trials. N Engl J Med. 1997 Aug 21;337(8):536-42. PubMed PMID: 9262498.

3: Ioannidis JPA, Cappelleri JC, Lau J. Issues in Comparisons Between Meta-analyses and Large Trials. JAMA. 1998;279(14):1089-1093. doi:10.1001/jama.279.14.1089

4:  John ER, Prichep LS, Fridman J, Easton P. Neurometrics: computer-assisted differential diagnosis of brain dysfunctions. Science. 1988 Jan 8;239(4836):162-9. PubMed PMID: 3336779.

"The standard for psychiatric diagnosis and categorization in the United States and Canada is now DSM-III and soon will be DSMIIIR. The categories defined therein have often been criticized as nothing more than a compilation of symptoms. The results obtained with neurometrics have shown that at least the categories studied are much more than arbitrary groupings of symptoms. ............. Validity-the great deficiency of psychiatric nosology - is beginning to emerge and, thus far, to reveal an impressive concordance with biology." p. 169

5: Smith GD, Ebrahim S. Mendelian Randomization: Genetic Variants as Instruments for Strengthening Causal Inference in Observational Studies. In: National Research Council (US) Committee on Advances in Collecting and Utilizing Biological Indicators and Genetic Information in Social Science Surveys; Weinstein M, Vaupel JW, Wachter KW, editors. Biosocial Surveys. Washington (DC): National Academies Press (US); 2008. 16. Available from: https://www.ncbi.nlm.nih.gov/books/NBK62433/

Selected References on Mendelian Randomization

Attributions:  All graphics except my home-made one at the top are from reference 1 per a Creative Commons Attribution 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.




Supplementary 1:

With today's publicly available genetic technology it is possible for a person to search their own DNA for the SNPs found in this study.  When I do that using a database where my DNA analysis resides I found the following SNPs from this study from chromosomes 15, 4, and 12 respectively.  I have linked them  to the dbSNP database at NLM:

rs4984460

rs7675351

rs2099149

It is interesting to speculate on what it means to have 3/10 genetic markers for schizophrenia/psychosis susceptibility if any cannabis exposure.


Supplementary 2:  Click on my homemade graphic to see how beautiful it is.  Blogger does not do it justice.

Psychosis Idealized

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





References:

1.  Irene Hurford.  Medicating A Prophet.  New York Times.  October 1, 2016.

New England Journal of Medicine Discovers Assertive Community Treatment

I have been a reader and subscriber to the New England Journal of Medicine (NEJM) every year since medical school.  One of the first courses they taught us in those days was Biochemistry and being an undergrad chem major I had a natural affiliation with many of the biochem professors.  The format in those days was lectures focused on the major topics and seminars to take a more detailed look at the experimental and theoretical aspects of the field.  They were fairly intensive discussions and critiques of research papers selected by the professors.  The department head was the mastermind behind this technique and one days he discussed his rationale for it.  He hoped that every medical student coming through that course would continue to read current research.  He strongly recommended subscribing to and reading the NEJM not just in Medical School but for years to come.  In my case it worked.

One of the sections that you don't hear too much about is the clinicopathological exercise that comes out each week.  It is basically a publication of formal case records of Massachusetts General Hospital and the associated findings and discussions.  These case reports are interesting for a couple of reasons - they show patterns of illness that clinicians can familiarize themselves with and they show at least some of the diagnostic thinking of experts.  During the time I have been reading them, they also discuss psychiatric comorbidity of physical illness and medical etiologies of psychiatric symptoms.  At one point I was a member of an informatics group and was very interested in studying this section of the NEJM from a psychiatric perspective.  At that time it seemed that I was the only psychiatrist with that interest.  With modern technology a study like this is more possible than ever.  For example, searching the case records feature of the NEJM from December 1989 to December 2015 yields a total of 31 cases of psychosis.  The etiologies of these cases range from purely medical etiologies, to delirium associated with the medical condition to pure psychiatric disorders with no specific medical etiology.  I have never seen this referred to as a teaching source for psychiatric residents admitting patients to acute care hospitals or consultation liaison services, but I could see it serving that function.  Instead of the usual lectures on medical psychiatry that typically contain PowerPoint slides of the "240 medical etiologies of psychosis" - a discussion of common mechanisms noted in these cases might be more instructive and be a better source for acquiring pattern matching capacity to broaden diagnostic capabilities.  It also put the DSM approach to psychiatry in proper perspective.  Knowing the lists and definitions of psychosis is nowhere enough to be a psychiatrist in a medical setting.  A seminar including this material can make these points and teach valuable skills.

That brings me to the case this week A Homeless Woman with Headache, Hypertension, and Psychosis.  Two of the authors are psychiatrists and the third is an internist.  The authors describe a 40 year old homeless woman with a diagnosis of schizophrenia and severe hypertension and how they established care over a number of years using the Assertive Community Treatment (ACT) model of care.  The patient's history was remarkable for a 12 year history of psychosis characterized primarily by paranoid and grandiose delusions.  She was homeless sleeping in public buildings for about 4 years and that seemed to be due to the thought that she needed to stay outside to watch over people.  She had a brief episode of treatment with olanzapine during a hospitalization about 5 years prior to the initiation of care by the authors, but did not follow up with the medication or outpatient treatment.  She was also briefly treated with hydrochlorothiazide 4 years earlier with no follow up care or medication.   She was admitted for treatment of a severe headache and a blood pressure of 212 systolic.  At the time of the admission physical BP were noted to be 208/118 and 240/130 with a pulse of 95 bpm.  She had bilateral pitting edema to the knees and bilateral stasis dermatitis.  She had auditory hallucinations consisting of voice of God and Satan and grandiose delusions.  Lab data showed a microcytic anemia.  She had standard labs to rule out myocardial infarction and vitamin deficiency states.  Blood pressure was acutely stabilized and she was discharged on lisinopril, thiamine, multivitamin, omeprazole, and ferrous sulfate.  The final diagnoses include schizophrenia, cognitive impairment associated with schizophrenia, hypertension, and homelessness.

The authors provide a good discussion of diagnosis of primary and secondary psychotic disorders and provide some guidance on timely medical testing for metabolic, intoxicant, and neurological abnormalities.  Delirium is identified as more of a medical emergency and necessitating more scrutiny.  The idea that delirium can be mistaken for psychosis is a valuable point that is often missed during emergency assessment especially if the patient has a pre-existing psychiatric diagnosis on their medical record.  The authors sum up screening tests that are necessary for all patient with psychosis and the tests that  are reserved for specific clinical concerns like encephalitis, seizures, structural brain disease, and inflammatory conditions.  They also suggest screening for treatable conditions and inflammatory conditions.

There is a good section on the follow up care that this patient received.  She was seen in a clinic for the homeless, where problems were gradually noted and worked on with her full cooperation.  This is not the typical approach in medicine where it is assumed that the patient will tolerate a complete history and physical exam and then cooperate with any suggested medical testing and treatment.  In this case, the practical problems of foot care were addressed.  She was eventually seen in 60 visits over two years.  By visit 19 she described concerns about cognitive symptoms and by visit 33 she was accepting treatment for psychosis with olanzapine.  She eventually allowed a more complete treatment of here associated physical symptoms including an MRI scan of the brain and treatment for migraine headaches.  The authors point out that tolerating medical and psychiatric uncertainty is a critical skill in treating people who need to habituate to medical systems of care.  A more direct approach is alienating.  It does tend to create anxiety in physicians about what is being missed and not addressed in a timely manner.  There is always a trade off in engaging people for long term care in more stable social settings and pushing to maximize diagnosis and treatment in a way that they might not be able to tolerate.  The ACT model stresses the former.           

There are some very relevant ACT concepts illustrated in this article.  First and foremost the rate at which medical interventions are prescribed depends almost entirely on the patient's ability to accept them.  This is at odds with the timeliness of medical interventions that most physicians are taught.  I say "almost entirely" in this case because the authors were very fortunate that the patient cooperated with treatment of extreme hypertension.  One of the common hospital consultations for psychiatric is a person with a mental illness and life-threatening illness who is not able to recognize it.  Even on the subacute side of care there are many tragedies due to patient with mental illness not being able to make decisions that could have saved their life.

I think that there are also some very practical applications for psychiatry on an outpatient basis.  Most patients with severe mental illnesses are never going to see a primary care provider 60 times before starting treatment.  It only happens in a subsidized setting with physicians who are highly motivated to see a certain approach work.  The care model described in the paper is certainly not the collaborative care model that some authors, the American Psychiatric Association (APA), and the managed care industry keeps talking about.  There is also the obvious point that people don't go into primary care because they like talking with people who have severe mental illnesses.  Psychiatrists need to see these people either in ACT teams or community mental health centers.  It won't work in a standard managed care clinic seeing a patient who is this ill - 2- 4 times a year for 10 - 15 minutes. ACT psychiatrists need to know about primary care providers who work better with the chronically mentally ill or people with addictions and make the appropriate referrals.  All psychiatrists should be focused on blood pressure measurements and work on getting reliable data.  Funding for psychiatric treatment often precludes ancillary staff present in all other medical settings to make these determinations.  Existing collaborative care models in primary care clinics can get blood pressure measurements on the chart but restrict patient access to psychiatrists.  

This Case Report is a good example of what can happen with a real collaborative care model that focuses on the needs of a person with severe chronic mental illness.  It is a model of care that I learned 30 years ago from one of the originators and it is more relevant today than ever.  It is also a model of care that is currently rationed and provided in the states where it is available to a small minority of patients.  It is not the method of collaborative care that you hear about from the APA, the managed care industry, or government officials.  It should be widely available to all psychiatric patients with complex problems.


George Dawson, MD, DFAPA


References:

1: Shtasel DL, Freudenreich O, Baggett TP. CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 40-2015. A 40-Year-Old Homeless Woman with Headache, Hypertension, and Psychosis. N Engl J Med. 2015 Dec 24;373(26):2563-70. doi: 10.1056/NEJMcpc1405204. PubMed PMID: 26699172.

2:  New England Journal of Medicine Case Records of MGH x psychosis (on Medline).  Shows 101 references as opposed to 31 on NEJM search engine and 10 on basic Medline search.

3:  Marx AJ, Test MA, Stein LI. Extrohospital management of severe mental illness.Feasibility and effects of social functioning. Arch Gen Psychiatry. 1973 Oct;29(4):505-11. PubMed PMID: 4748311.

4:  Stein LI, Test MA, Marx AJ. Alternative to the hospital: a controlled study.Am J Psychiatry. 1975 May;132(5):517-22. PubMed PMID: 164129.

5:  Test MA, Stein LI. Alternative to mental hospital treatment. III. Social cost.  Arch Gen Psychiatry. 1980 Apr;37(4):409-12. PubMed PMID: 7362426.

6:  Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptualmodel, treatment program, and clinical evaluation. Arch Gen Psychiatry. 1980 Apr;37(4):392-7. PubMed PMID: 7362425.

7:  Weisbrod BA, Test MA, Stein LI. Alternative to mental hospital treatment. II.   Economic benefit-cost analysis. Arch Gen Psychiatry. 1980 Apr;37(4):400-5. PubMed PMID: 6767462.


Attribution: 

Photo at the top of this post is by Jonathan McIntosh (Own work) [CC BY 2.5 (http://creativecommons.org/licenses/by/2.5)], via Wikimedia Commons.  Original photo at https://commons.wikimedia.org/wiki/File%3ARNC_04_protest_77.jpg

The Chai Man

Back in the 1970s I was in the US Peace Corps in Kenya East Africa.  I worked in an all boys school as a chemistry teacher.  The school was about 100 miles north of Nairobi on a high plateau next to Mt. Kenya.  On the weekends my fellow volunteers and I would drive over to the closest town for a Coke and an inexpensive snack at the White Rhino Hotel.  In those days a Coke or a bottle of beer would cost about a Kenyan Shilling (KES) and a meat pie or a samosa would cost about a Shilling and a half.  One Shilling was about 14 cents American.  Outside the hotel was an apparently homeless man.  He would beg for money often by creating disturbances.  He would obstruct people in the street going to and from the hotel.  He would shout out the word "Chai,  Chai..." repeatedly while spitting down the front of his shirt.  "Chai" is the Kiswahili word for tea.  He would appear agitated and tearful at times.  He was not tolerated very well by hotel security or the local people - people who could speak fluent Kiswahili and the local Kikuyu language.  Some of them would become physically aggressive toward him and cause him to run down the street.  At other times he would show up with a can of dirty water and try to clean auto windshields by wetting down a newspaper and wiping the water all over.  These attempts were always unsolicited and the drivers would become enraged because their windshields were always less clean than when he started.  We eventually referred to him as the Chai Man because nobody ever knew his name.  The Chai man clearly struggled, alienated practically every person I ever watched him interact with, and he got minimal assistance from anyone.  At the time he reminded me of homeless men I would see in my local public library.  It was the only they place they could go in a small town to get a break from the weather.  They would occasionally ask for money, but for the most part avoided people.  When  you are down and out and mentally ill, most people seem to know better than to ask.

By the time my fellow teachers and I made it to our placement north of Nairobi we had contact with hundreds if not thousands of people living on the street as beggars.  Many had physical deformities to the point that they were unable to walk.  Coming into town from the airport was enough contact to convince the most altruistic Peace Corps volunteer (PCV) that they personally did not have nearly enough resources to address the problem.  PCVs had to learn to not look at the people begging on the street and walk quickly by or risk people coming out and grabbing their leg or arm until they were given money.  Like the US, only certain streets and areas allowed for the aggregation of these homeless beggars.  PCVs were not rich by any means but when we got to our eventual destinations, they were usually places where there were no homeless people in sight.  We were rather scruffy ourselves but we could sit in classy places like the New Stanley Hotel and sip on a Coke.

I thought of the Chai Man last night as I listed to a program on "The World" on MPR about a mental health initiative in Kenya (reference 1).  The focus of the program was a young woman Sitawa Wafula started mental health crisis intervention service on her own.  It is a formidable problem.  The program describes how children and adults are "locked up" by their families and may not see the light of day.  Neighbors often do not know that a mentally ill brother or sister exists.  This is reminiscent of Shorter's description of the problem of psychosis in Europe and how it was handled in the early 20th century.   It also happened in my own family in the early 1950s.  In Kenya, there are currently 79 psychiatrists or one for very 500,000 people.  Ms. Wafula gets a number of calls to her crisis intervention service and says that if the problem involves suicidal thinking many people with that problem have had two previous suicide attempts.  The World Health Organization puts Kenya in the top quartile of suicide rates in all countries worldwide.    

I was picked up by a Kenyan physician once when I was hitchhiking back to Nairobi one  day.  I asked him what was available in terms of psychiatric services at the time.  He said there was only one hospital and that the basic medication being prescribed by physicians was chlorpromazine.  At that time, the chlorpromazine generation of antipsychotics were the only ones available and antidepressants were more difficult to prescribe.  Medical care in general was difficult to access.  I would typically get scabies at least one a month.  When I was initially infected I made the mistake of going to a local clinic and standing in line in the hot sun.  I was about number 300 in the line and it moved about 4 or 5 spaces every hour.  I realized that I could hitchhike 100 miles to Nairobi and back and pick up the appropriate treatment from the Peace Corps physician in less time than it took to go to the local clinic.  Eventually I just picked up a large bottle scabicide and applied it whenever I got infected.   At the time Kenya also had one of the fastest growing populations making it more difficult to provide medical and psychiatric care.

About 8 years after I left Africa, I was sitting in a seminar full of fellow psychiatry residents at the University of Wisconsin.  The topic of the day was whether or not the prognosis of schizophrenia was better in what was then called the "the third world" based on some outcome studies available at the time.  Our job was to critique the literature and it was apparent that there were technical differences in studies and in many areas the follow up and methodology was different.  At one point I suggested that exposure to antipsychotic medications may lead to negative outcomes and that raised an eyebrow or two.  I also pointed out that that at least half of the people I was treating had significant alcohol and drug problems and were not interested in quitting.  I doubted that many of the people in these studies had widespread access to street drugs that were known to precipitate psychotic states.  I remembered the Chai Man very well, but knew better than to introduce my anecdotal experience from Kenya.  That axiom about better prognosis in the developing world has since been re-examined (reference 2) and there are clearly more problems with that theory than originally thought.  Like many areas in psychosocial research it may depend more on your political biases before you read the research.  The Scandinavian research on brief psychosis and brief reactive psychosis from about the same time frame certainly suggested similar rates of spontaneous recovery.

These experiences make me smile at couple of levels.  Any time someone "confronts" me with the evidence of prognosis in schizophrenia and the World Health Organization (WHO) studies, I can point out I had a better and more thorough discussion about it with fellow psychiatrists in 1986.  I have also lived in a developing country and saw how people with presumptive mental illnesses were treated.  I have applied that experience and knowledge to clinical practice in this country.

There is the curious parallel of access to psychiatrists in both countries.  How do the citizens who need them the most get access to them?  The public radio story suggests that only people with resources (I take that to mean money) can get access to the limited number of psychiatrists in Kenya.  This country is headed in the same direction largely because rational psychiatrists do not want to be ordered around by insurance companies.  In the case of access for the severely disabled, individual states have different plans but the overall plan has been to ration access and incarcerate rather than hospitalize people with mental illnesses.  In the US, there is generally an order of magnitude greater number of psychiatrists, but that does not translate to more access.  I have talked to too many people who stop seeing a psychiatrist when their insurance stops.  The insurance industry, state governments, and the federal government all have an interest in restricting access to psychiatrists.   If people only see psychiatrists if they have poor insurance coverage and psychiatrists are fleeing insurance - this is a chronic problem that will only get worse.  

In the meantime, I hope that Ms. Wafula continues to be successful in her crisis intervention program and raising awareness that severe mental illness is a public health problem that needs to be addressed.  Families should have more resources and more help.  The WHO program to raise awareness about suicide also seems like a good idea.


George Dawson, MD, DFAPA


References:

1.  Emily Johnson.  Fighting the 'funk:' How one Kenyan battles her mental health problems by helping others.  PRI The World.  March 3, 2015.

2. Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008 Mar;34(2):229-44. Epub 2007 Sep 28. Review. PubMed PMID: 17905787



Supplementary 1: The map graphic is from the CIA Factbook in the public domain.

Supplementary 2: WHO Infographic on Suicide.

Supplementary 3:  I mention the New Stanley Hotel in this post, but sometime after I was there it was blown up by terrorists.  The replacement versions (at least according to Google) continue to be threatened by terrorists, who apparently want to target the tourist business in Kenya.

Use Of "Medical Model" As A Pejorative Term

Hearing “medical model” being used used pejoratively is quite tiresome.  I have heard it used that way for the past thirty years, usually to take a shot at psychiatrists.  I thought I would illustrate how this goes and what I disagree with by responding to a recent article authored by the British Psychological Society on how the system of care for psychotic disorders should be changed.  My interest is not in provoking an argument since I think that these errors are obvious.  The target audience is also relevant here and it is described as “service users, their friends and families, journalists, policymakers, mental health workers and the public.”  As such this is really a political document very similar in nature to the documents generated in the US by SAMHSA or treatment guidelines generated by other special interest groups like managed care companies.  That being the case, I will not spend any time on the technical aspects of psychosis alluded to in this paper.  As a political document it requires active refutation or the suggestions might be adapted as wholesale measures.  I don’t know if British psychiatry is any more successful in doing that than the American counterparts, but judging from what I have read in editorials – I doubt it.  Let me start out with a couple of the authors’ statements about the “medical model”.

"At least in the UK, most mental health services are currently based on the ‘medical model’ – the assumption that experiences such as hearing voices indicate illness and result from some sort of problem with the brain. (p. 103). This idea is also enshrined in mental health law and is the basis for compulsion. In the past many professionals have also believed that people experiencing distressing voices or paranoia are unlikely to recover without treatment (usually medication). This belief has led to a perceived ‘duty of care’ to provide treatment, and a tendency to view someone who does not want the treatment being offered as lacking in insight. As this report has shown, both of these assumptions are unfounded." (p. 103 from Reference 2)

And:

"In the past services have been based on what might be called a ‘paternalistic’ approach – the idea that professionals know best and that their job is to give advice. The ‘patient’s’ role is to obey the advice (‘compliance’). This now needs to change. Rather than giving advice, those of us who work in services should think of ourselves as collaborators with the people we are trying to help." (p. 104 from Reference 2) 

The authors definition of a “medical model” looks at three dimensions.  The first is the assumption that psychotic experiences are due to a brain problem.  That is partially true.  They limit themselves to what they describe as “idiopathic” causes of psychosis and ignore specific psychotic states and etiological factors.  They also exclude medical illnesses that are clearly associated with psychotic symptoms.  That happens to be the area that psychiatrists are trained to recognize and treat.  Trivializing psychiatric diagnosis as a list of symptoms that most clinicians do not refer to anyway is certainly consistent with the authors’ main points of contention, but fortunately that is not reality.  Finally, the diagnostic manual that they criticize has numerous categories that have been researched strictly as psychotic disorders (and anxiety and mood disorders) caused by social etiologies rather than brain problems per se.  Early in my career, I reviewed the predominately Scandinavian literature on brief psychoses or brief reactive psychoses so that I could provide necessary prognostic information to patients and their families.  More clear evidence that significant psychotic symptoms can spontaneously remit without any medical intervention.  That information is a critical part of any medical approach to a spontaneously remitting illness.

Secondly, they go on to say that this also means that “professionals” believe that people are unable to recover without treatment.  I don’t know about other professionals but psychiatrists since the time of Kraepelin have known that people recover without treatment, although in Kraepelin’s day they considered asylum care alone to be treatment.  Like many illnesses people can recover without treatment and the literature on brief psychosis is further evidence.  Psychiatrists have also known that specific types of psychosis (catatonia for example) have very grim prognoses without treatment. Some of the earliest studies showed that malignant catatonia had an 80% mortality rate at the turn of the 19th century.  By the turn of the 20th century the mortality rate approaches 1% or less with modern treatment. So the second part of the definition is clearly wrong.

Finally, the authors use “paternalism” to characterize the role of physicians.  This is a charge that frequently accompanies the so-called medical model often amidst the associated charge of authoritarianism.  It is also incorrect.  Medicine is based on the informed consent model of care.  Any psychiatrist is more aware of this than most other physicians.  Informed consent is based on the idea that the patient is provided with adequate information to make a risk-benefit decision and the patient and physician collaborate on the patient’s decision.  I have these conversations every day and many times a day.   Doing nothing, being referred somewhere else, and being denied the agreed upon care by a managed care company are all additional possibilities.  These conversations can occur with patients who are actively bleeding out on the floor and refuse to allow a trauma surgeon to intervene due to impaired judgment from psychosis.  In that particular situation surgeons are likely to remind anyone involved in the care that they would be assaulting the patient if they intervened and did not have informed consent.  Similar situations occur with people who have various forms of treatable but life threatening illnesses (operable cancer, impending paralysis, uncontrolled diabetes mellitus, etc) who were unable to make decisions in their best interest due to the effects of psychosis.

So - the authors’ definition of a medical model is wrong in 2 ½ of 3 dimensions. That is not a good starting point for a proposal to go beyond the “outmoded medical model”.  It is always good to know what the model really is before declaring it outmoded.  I think a lack of scholarship and experience in these matters in a common characteristic of people who criticize the “medical model” in psychiatry.  Of course it is generally not a scholarly endeavor.  For anyone interested in educating themselves in what a real medical model might look like I would suggest reading Systematic Psychiatric Evaluation (Reference 1) or any other guide to psychiatric evaluation.   Take a look at Appendix A and B for the quick story.   The fact that models like this one are widely emulated by nonphysicians may speak to their utility in understanding and treating psychosis and other mental disorders.

How do the authors do on their characterization of psychosis?   They seem to touch on the high spots. Mention of hallucinations, delusions, and formal thought disorder are all there.  They are obviously heavy on phenomena that would not typically come to the attention of psychiatrists, people who experience hallucinations and delusions or some grey zone phenomena that are not quite psychotic symptoms.  But what about the central feature of psychosis that generally comes to the attention of psychiatrists (the ones within the “medical model”)?  It turns out the authors have little to say about judgment or insight.  They have nothing to say about the conscious state of the individual.  These are the distressing and often life threatening aspects of the illness.  This is the aspect of psychotic illness that causes friends and family to state that they no longer recognize the person due to the disruption of their personality characteristics.  Are we really to believe that psychiatrists are having casual conversations with people intellectually curious and not bothered by hallucinations and delusions? Are we really to believe the affected person may not have experienced a profound change in their conscious state that makes them unrecognizable to their friends and family and unable to work or perform their basic life activities? Are we really to believe that change in conscious state may not possibly represent an acute danger to the person affected or their loved ones? Only people who have not been seriously affected by psychotic states and people who are not responsible for assessing and treating those states can make those statements.  Those people generally do not need to see psychiatrists.

The authors claim that a “lack of insight” can result in a person being detained for mental illness. That does not happen where I practice. I have to document “behavioral evidence” rather than a lack of insight and treatment refusal can also not be used as a basis for detaining someone.  In the USA, there is a strong financial incentive to discharge people from hospitals as soon as possible.  The businesses and governments who manage these facilities welcome treatment refusals.  The patient can be discharged immediately with no follow up demands.  From a business perspective that is "cost-effective care".  If any paternalism exists, it is at a societal level.  Society is the proper arbiter of how its most vulnerable citizens should be treated.  Should they be forced into treatment or allowed to die with their rights on?  Psychiatrists have no choice but to follow society's lead.  If psychiatrists have no vested interest in forced treatment, one of the critical questions is why it exists in the first place?  The obvious answer is that it is a far from perfect approach to help families get their loved ones treated and even then families are routinely disappointed.  Hospitals and courts can still have their own interpretations of these laws that will save them money but not provide necessary treatment.  In the end there is still no medical paternalism.

There are two other sections in this paper that merit commentary – dangerousness and etiologies of psychosis.  After their selective and inaccurate characterization of psychiatric assessment the authors drop this bomb:

"Some psychologists are reaching the conclusion that psychosis is often no more and no less than a natural reaction to traumatic events. For example one recent paper suggested that ‘there is growing evidence that the experiences service users report … are, in many cases, a natural reaction to the abuses they have been subjected to. There is abuse and there are the effects of abuse. There is no additional ‘psychosis’ that needs explaining’." (p 42 from Reference 2)


That is a very interesting observation to psychiatrists who screen all of their new evaluations for trauma history and post-traumatic stress disorder (PTSD).  Instead of a “recent paper” what if I am a psychiatrist seeing 500 new cases per year and I screen everybody I see for psychosis, PTSD, childhood adversity and other forms of psychological trauma.  What if over the space of 4 years and 2,000 new evaluations I observe that about 30% of my patients have significant childhood adversity or psychological trauma, about 5-10% have PTSD related to that trauma and about 5% have psychotic symptoms totally unrelated to previous trauma.  I pose that hypothetical because it would be the common experience of most psychiatrists.  The issue of trauma being a cause for symptoms should also lead to the examinations of previous errors postulating trauma as an etiology for symptoms most notably the Multiple Personality Disorder (MPD) fiasco and the associated phenomenon of Satanic Ritualistic Abuse (SRA).  I would recommend against even using highly qualified statements about this as a possible etiology for psychosis without ample evidence.  Although research bias is a frequent accusation in the area of psychopharmacology research, there is no reason to suspect that favorite theories in psychosocial research are less bias producing.

The authors fall back on the statement about mental illnesses not implying dangerousness.  In the vast majority of cases that is true.  It is also true that the population with the most significant illnesses need to be evaluated for suicidal and aggressive behavior.  Tragedies that occur as a result of impaired judgment and altered conscious states from psychotic disorders are commonplace.  People with these problems can be successfully treated and violence and suicide can be prevented.  It is not enough to suggest that people with mental illnesses may be stigmatized by any connection with violence.  People with psychotic disorders and aggression are among the most stigmatized people in our society.  The solution is not to deny that this problem exists but to identify this as a treatable problem and develop an appropriate public health response.  There is also a very strong bias in the American legal system to punish rather than treat anyone with a psychosis who commits a crime.  Escaping punishment as a result of the not guilty by reason of insanity defense (NGRI) is one of the most consistent urban legends in America.  This defense is hardly ever a success and even then it is likely that the patient involved will spend more time in a forensic prison/hospital than they would have if they were criminally sentenced without the NGRI defense.

The authors are certainly wrong about any “medical model” of psychosis or mental disorders that I am used to seeing.  My medical model is the model of Engel and Chisholm and Lyketsos informed by Kandel and others.  There are very few places it can be practiced in the United States because business interests run the field of psychiatry and medicine.  American managed care companies and governments can certainly reduce psychiatric assessment to a series of checkmarks in the electronic health record and documentation that may be unreadable.

A business model of rationing is not a medical model by any stretch of the imagination.  That business model is also not one that will prove to be receptive to any enlightened model of community care.  The best evidence of that is that the ACT (Assertive Community Treatment) Model invented by Stein, Test and others in 1974.  This model consists of active outreach, crisis intervention and housing, medical and psychiatric care, vocational rehabilitation, and peer counseling with a focus on helping individuals maintain stable housing in the community.  There is no insurance company that I know of that supports this level of care.  The ACT Model is cost shifted to state governments and they strictly ration who gets that level of care.  With regard to Cognitive Behavioral Therapy there is no insurance company that I know of that consistently supports research recommended course of therapy for the conditions that have long standing indications – the anxiety and depressive disorders.  What is the likelihood that it will be supported for the treatment of psychotic disorders and grey zone conditions?

I will hold my remaining remarks on the treatment implications of this paper.  This blog contains extensive commentary on that issue and the real limitations on comprehensive assessment and treatment.

None of those limitations are due to a “medical model.”

George Dawson, MD, DFAPA


References:

1. Margaret S. Chisholm, Constantine G. Lyketsos. Systematic Psychiatric Evaluation. A Step-by Step Guide to Applying The Perspectives of Psychiatry. 2012 The Johns Hopkins University Press. 243 pp.

2. The British Psychological Society. Understanding Psychosis and Schizophrenia. Edited by Anne Cook. Available on the web site of the British Psychological Society.

The Retirement Party

There aren't too many retirement parties that you can go to and spend a lot of time talking about violence.  I suppose it might happen with law enforcement and the military.  When I went in to psychiatry I never seriously thought about the fact that I might have to go to work every day and face people with serious problems with aggression and violence.  In some cases that would mean seeing people who had threatened to kill me and my family.  It would also mean seeing people with documented incidents of aggression toward others, toward themselves, and toward property.

I went to a retirement party yesterday for a nurse I had worked with in an acute inpatient setting for about 20 years.  Like most of the nursing staff I work with she has excellent skills but was also renown for her sense of humor and positive attitude.  She was the kind of person I counted on when things were particularly grim - a frequent occurrence on inpatients units.  I could only make it to the last 2 hours of the party, so I missed the evening shift who all had to leave and go to work.  There were about 20 people there including a psychiatric colleague who worked with me on that unit and who I have known for 30 years.  I always consider retirement parties to be very happy events.  I have known too many medical professionals who never made it to retirement.  I want everybody to make that goal, especially people I have been in the trenches with.  I previously posted here many times about the inpatient environment and its importance is treating and containing aggression and how that function has been subverted by political and administrative forces and rationed to the point of being minimally effective.  When you are working on an inpatient psych unit, it is a lot like going to war every day.  You are facing many patients who don't want to be there despite significant problems.  Many are involved in contested commitment hearings based on whether they have a suicide or aggression risk.  Many have severe substance use problems that intensify suicidal thinking and aggression.  They are generally not interested treatment for the substance use problems or do not see that as a significant issue.  There are minimal resources to work with.  The team social workers generally don't last too long because there are very few community resources that want to cooperate with discharge plans from acute care psychiatric units.  Everyone is working under an administration that is focused on restricting resources and providing suboptimal care.  Everybody at that party worked with me in that environment at one point or another for 23 years.  At times it was like we were in foxholes under siege for weeks at a time, just looking for a break.

It was good to see everyone in a much less stressful context, but like most groups of people who have been immersed in a high intensity work experience the conversation tends to gravitate back to the humorous and stressful events that we were all a part of.  One of the common threads was aggression.  I learned that one of the nurses had recently been assaulted and sustained broken nose and a traumatic brain injury.  She discussed the incident and her reactions to it.  My psychiatric colleague added her personal experiences with aggression directed toward her.  As I looked around the room, I was aware of the fact that significant physical aggression had occurred toward about 25 % of the people there.  In some cases there were episodes of repeated physical aggression.  At some point in my career,  I realized that there was really nobody who was interested in helping inpatient staff contain aggression.  There are always administrators around who are ready to assign blame.  I can remember one particularly unhelpful "consultation" that suggested that the problem was a lack of rapidly forced medications.  The most recent administrative initiatives have to do with not forcing anything.  Suddenly everyone was supposed to respond to quiet deescalation.  Sitting in a quiet office somewhere and looking at spreadsheets does not lead to any insights into containing aggression on an inpatient unit.  I guess the typical administrator does not realize that.  My realization was that as a team we had to discuss the issues with patients constantly, emphasize the violence risk, emphasize that we did not want anyone to take chances in these situations, and discuss a detailed plan that included ways to approach the patient and their family as much as medication.

About halfway through the party, one of the nurses handed me her iPhone with the the story about a psychiatrist who had shot a patient in a crisis clinic.  It reminded me of the time I had to consider about whether or not to arm myself.  I was after all a tree hugger and a Child of God from the 1970's.  The last thing I wanted to do was have guns in my house.  I was aware of psychiatrists who had been killed by patients, in several cases with firearms.  I had just read an article about a psychiatrist who was also a Sheriff's deputy who carried a handgun.  In my case it was a patient who threatened to shoot me when I was walking out to my car from my clinic.  He made the additional threat to burn down my house and kill my family.   He proved that he knew where to find me by reciting my home address.  Going to work under those conditions every day and treating other aggressive patients is stressful to say the least.  But it is expected of psychiatric staff, in some cases even after they have been assaulted and the patient who initiated the assault is still in treatment.

I have no personal knowledge of the shooting incident but the descriptions suggest common system wide issues that are never well addressed these days.  Rather than speculate about media reports there are some common safeguards that I have learned apply everywhere and serve to contain violence and aggression in clinics and on inpatient units:

1.  The atmosphere - you can't really expect to reduce the potential for violence or aggression unless the environment is adequately managed.  Psychiatrists used to talk about the milieu but that ship has apparently sailed.  The largest professional organization of psychiatrists is silent on inpatient treatment and the treatment of aggression and violence.  The American Psychiatric Association (APA) used to have guidelines on such matters, but nothing has been written in a long time.  I don't know if that is just giving up to the widespread managed care blight or an open acknowledgement of the hopeless situation.  The APA has been reduced to homilies about how increasing access may reduce violent events rather than speciality units set up to treat aggression and violence associated with severe psychiatric disorders.

Inpatient units can literally be staff on one side of the plexiglass and the violent and aggressive patients on the other.  I worked on a unit like that at one point.  We were all shocked one day to learn that we really were not behind plexiglass when a steel chair came flying through a shattering tempered glass window.  It sailed right over my head and I was standing up at the time.  It must take quite a bit of force to throw a steel chair that distance through glass and to that height.  Nursing staff dove for cover with the explosion of the glass.  In addition to the staff it took two Sheriff's Deputies to resolve the situation.   There are any number of reasons given for running units like this and none of them are good.  It puts the patients and staff at risk by eliminating one of the most important aspects of psychiatric care - the interpersonal relationship between patients and staff.  Without it a correctional atmosphere can develop that is more conducive to rioting than treating mental illness.

That same floor had a history of firearm related events.  There was the case of a patient who had a firearm smuggled in.  He held the psychiatric resident hostage and ended up shooting a Sheriff's deputy at the control desk out in the hallway.  When I worked there, I was surprised one morning  to find a number of men on the unit in suits.  I learned they were federal agents.  I was more surprised to find out they were carrying machine guns.  People armed with automatic weapons really do detract from the therapeutic atmosphere of a psychiatric unit.

2.  Relationships - one of the most dangerous situations I have ever been in was ending up on the wrong side of the plexiglass at the wrong time.  The wrong time was at a time I was being blamed for a staffing problem that I really had nothing to do with.  Many people don't know how the attitudes that staff have toward one another can be played out in an intensified version by patients.  I found myself surrounded by 4 young aggressive paranoid and antisocial patients who threatened to beat me up.  After I talked my way out of that situation, my solution at the time was to transfer off that unit with the idea that I would not let that happen again and hopefully pass that knowledge along to other staff.  Unfortunately that same pattern of behavior can occur if it is activated by someone outside of the treatment team.  When that happens it is impossible to deal with in a constructive manner.

3.  Systems issues - the lack of administrative support for any functional approach to aggression is often the biggest obstacle to solving the problem.  This is not an issue in many places where the approach is to kick the can down the road.  Many community hospitals don't accept violent or aggressive patients or even patients who are highly suicidal and may require 1:1 staffing.  They are transferred to tertiary care centers where these problems tend to concentrate.  In those tertiary care centers it is important to segregate patients based on their potential for aggression.  I have heard all kinds of arguments against this procedure  that do not hold water.  I think people may be confused about the segregation issue.  I am  talking about separating men with a high potential for physical aggression from other inpatients who are generally more vulnerable than the average person.  Trying to treat those populations on the same unit is a recipe for disaster.  If the most aggressive mentally ill people in the state are being concentrated in a few hospitals, it is the only safe way to proceed with treatment.  Even then, there needs to be considerable expertise on the part of the staff involved.

4.  Serious administrative deficiencies - I have never seen a clinician with the knowledge required to address any of the above issues in an administrative position.  In an a new twist, there are some hospitals where administrators with no experience at all are charged with running hospitals for patients with severe forms of mental illness and associated aggression.  The commonest excuse for not addressing any of the concerns on this list is finances.  There is not enough money to provide adequate staffing.  In many cases there are now elaborate methods to decide on adequate staffing.  At times the staffing differences between an all male unit housing patients with psychotic and personality disorders with aggressive behavior is not much different from a mood disorders unit where there is practically no aggressive behavior.  Security on the units with a high potential for aggression often depends on other staff being available by cell phone or alarm.  In some cases it is a 911 call to local law enforcement.  I have had to ask that the 911 call be made when an entire male unit essentially rioted and it was no longer safe for the staff.

5.  It is all about the nurses - A key lesson that nobody ever learned in medical school and few physicians seem to learn after is that the only reason anybody needs to be in the hospital is nursing care.  Doctors can go in and out for 20-30 minute blocks and write orders, do procedures, and write prescriptions anywhere.  The nurses are with the patients 24/7.  It follows that one of the primary tasks as a physician is to assist the nurses.  That ranges from taking care of medical and psychiatric problems in a timely manner to backing them up in highly contentious situations.   Nurses are not there to make physicians miserable.  Nurses have an incredibly hard job to do and they know it takes a team effort.  There can't be any "personality conflicts".  In the interest of the team they need to be set aside.

Those are some of the thoughts I had about this party.  Of course I thought about the person being honored and my direct and very positive professional experiences with her.

And I looked around and hoped that everybody there could function as a team, take care of one another, and make it to retirement.

They have nobody else looking out for them.

George Dawson, MD, DFAPA


Supplementary 1:  I had thought about posting the following disclaimer at the top of this post:

"In case you thought this was my retirement party and thought you would enjoy reading about that and rejoicing - you can stop reading right here.  I have not retired and this blog continues...."

But I thought it flowed better the current way.