Death Cults

That may seem like an odd topic for a psychiatry blog but I did not know where to put this.  Earlier this week my wife and I decided to stop watching a popular television show called The Following.  It is basically a fictional show about a death cult that involves a charismatic psychopath who engages other psychopaths to do mass killing.  They typically use knives as murder weapons and kill large numbers of innocent people at public gatherings like book signings in book stores.  In one episode last year, the main psychopath in the show happened across the camp of another death cult run by a different psychopath and it was the expected lethal battle for leadership.  The dramatic tension is created by a group of FBI agents trying to catch and stop the psychopaths and the personal stories in that group.  In the opening show this year, there was a murder scene that was explained to the audience and then implicitly done that was so sadistic and so sick that we decided to shut off the show and never watch it again.

Violence and aggression are always in the background in America.  We take violence and aggression for granted and it seems surprising when they are excluded from entertainment.  What no car chases or shootings?  And it has been there a long time.  I can remember being in East Africa in the 1970s and at that time many of the Africans that I met, had the idea that most Americans carried guns.  That conclusion was from watching American films.  There has always been the debate about whether or not the display of all of this violence affects people.  Like practically all research of this type, I would expect the results to reflect the biases of the researchers.  Typical research would look at a large group  exposed and not exposed to violence in the media and the results are mixed.  Mixed results lead to the status quo, but the status quo has gradually gotten worse.  Television shows commonly have sadistic serial killers as their plot line and in one case a serial killer is the main character and hero.  

According to a 2012 report by the Media Violence Commission (1) major medical (including the American Psychiatric Association) and the major psychological organization in this country support the argument that there is a casual connection between media violence and aggressive behavior.  This report also looks at the biases that may be in place that might obscure that connection.  The authors mentioned the belief that the effects must be immediate and severe is a common bias.  In other words, I see a violent movie and perpetrate a violent act within the next day or two.  Instead over time, exposure may decrease prosocial behaviors.  This report briefly summarizes the literature on possible psychological mechanisms that occur with exposure to violence but the most important  conclusion is:

"One conclusion appears clear-extreme conclusions are to be avoided. Not every viewer or player will be affected noticeably, but from understanding the psychological processes involved, we know that every viewer or player is affected in some way."

Many clinical psychiatrists have talked with people who have perpetrated violence based on some act that was portrayed in the media.  These stories are also described in the media with some regularity.  I think that if there are any factors containing a media effect it is the moral development of most people and that fact that a lot of the violence is hypothetical and it could not be enacted without considerable resources.  Factors that may facilitate violence after exposure would include a developmentally immature brain or a brain that would be more susceptible to the priming effects of violence.  That would include various forms of severe mental illnesses or personality effects like psychopathy or antisocial personality disorder.  In many cases the perpetrators of violence has no idea about how devastating injuries can occur from fictional portrayals where people get up after being hit over the head with a pipe.  They don't realize that in many cases that results in a fatal or disabling brain injury.

The overriding dimension affecting violence that needs to be addressed is at the cultural level.  A critical recent development is the resurgence of the death cult.  The concept of death cult is poorly defined at this time and as far as I know there are no definitive scholars.  They seem to come in two forms.  The first requirement is a cult or an organization with a charismatic leader and followers who are willing to uncritically follow the edicts of the leader.  There have been various studies of the dynamics of these groups and who might be susceptible to becoming a cult member.  Jerrold Post, MD has analyzed the dynamics of charismatic leaders and describes them as "mirror hungry" personalities that require constant admiration, convey a sense of omnipotence and grandeur,  have the appearance of certainty, and rely heavily on splitting as an adaptive psychological defense (2).   Death cults seem to come down to 2 varieties - those predisposed to mass suicide and those that are predisposed to homicide and mass homicide or in some cases genocide.  For the purposes of this post, I am focused on the latter, because they seem to pose the most immediate danger to the most people.

Prototypical homicide focused cults or movements in my lifetime have included the Nazis and Pol Pot.  The concept of "charismatic leader" can probably extend to larger groups of extremists that have been described as being responsible for genocides (3).  Over the past 30 years, we have seen many of these cults or movements commit homicide to various degrees often with loose religious rationalizations.  The killings have become increasingly vicious and sadistic.  The killings have reached a level of intensity that all of the religious justifications no longer seem to apply.  The international solution has been to mobilize against these groups and in some cases, explicitly threaten to kill them.  The media is always complicit with death cult propaganda and the resulting desensitization may have been one of the factors in the escalation.  This is an interesting parallel with television entertainment that seems to be in the same cycle of escalating to the most horrifically sadistic and brutal types of killing and torture.

What is missing in all of this mass exposure to violence and killing is an explanation of the driving forces and a plan for change at a cultural level.  There is a current and shocking increase in antisemitism spreading across Europe, to the point that one author has suggested that it may be time for the Jews to leave Europe (4).  There don't seem to be any pacifists any more.  There is no peace movement like there was in the 1970s.   I have not seen any explanations for this primitive behavior and why it occurs even though many explanations have been around for years.  Here is one from Lifton that has been available since 1986 and it is accessible to any psychiatrist trained in psychodynamics or any good student of English literature:

"Fascist ideology can have particular appeal for the survivor self fighting off disintegration because it holds out, at all levels, a promise of unity, oneness, fusion.  It deals with death anxiety, moreover by glorifying death, even worshiping it.  While one's own death as a warrior is idealized, the self mostly escapes death - achieves the death of death - by killing others.  There can readily follow a vicious circle in which one kills, needs to go on killing to maintain one's cure, and seeks a continuous process of murderous, deathless, therapeutic survival.  One can then reach the state of requiring a sense of perpetual survival through the killing of others in order to re-experience endlessly what Elias Canetti has called the "moment of power" - that is the moment of cure."  p. 499.

Lifton knows full well that the fascist thought process that he describes is not a diagnosis,  but it is the way that large groups of people can think.  It has been present since the time of ancient man.  You can find theories about how it is "hardwired" into the human brain with suggestions that it is adaptive.  The only real way we can combat it is through educating people about what is really going on, improving critical thinking and changing popular culture.  Teach them how to recognize biases and overcome them.  A basic skill would seem to be able to recognize a death cult and realize why participation may not be in your best interest.  It goes without saying that it could not be in the best interest of civilized society, but the philosophy behind that probably needs teaching.

When I turned off my TV set the other day, I was not seeing it as a protest.  But if media producers realize that abhorrent violent content is less interesting that may be an important cultural change.      


George Dawson, MD, DFAPA




References:


1:  Media Violence Commission, International Society for Research on Aggression(ISRA). Report of the Media Violence Commission. Aggress Behav. 2012 Sep-Oct;38(5):335-41. doi: 10.1002/ab.21443. Epub 2012 Aug 10. Review. PubMed PMID: 22886500 (full text available online).

2:  Jerrold Post, MD.  Personality and Political Behavior.  Door County Summer Institute July 21-25, 2003.

3:  Alan J. Kuperman.  The Limits of Humanitarian Intervention - Genocide in Rwanda.  Brooking Institution Press.  Washington, DC (2001) p. 12.

4:  Jeffrey Goldberg.  Is It Time for the Jews to Leave Europe?  The Atlantic.  April 2015.

5:  Robert Jay Lifton.  The Nazi Doctors.  Basic Books, New York (1986) p. 499.




Supplementary 1:    I would not encourage anyone to watch the television program in question that I mention in paragraph 1.  I have seen plenty of media violence, but consider this depiction to be the worst.

What does it cost to stop marketing an addictive drug?

I won't bother to repeat the usual statistics on how addictive cigarettes are or the fact that nicotine is one of the most addictive drugs.  Cigarettes  have a special place in the hearts of psychiatrists in my generation because when we first started practicing they enjoyed significantly more status in terms of public opinion than they do now.  I can recall running a therapy group at a VA Medical Center where at least half of the group was smoking during the session.  The cigarette smoke was so thick that the ceiling panels turned from white to bright orange over the course of a year.  I asked one of the staff what kind of paint they use to make them look so good and he said: "Oh they don't paint them.  They just replace them and throw the old ones away."  Too bad you can't do that with lungs.  As activist attorney generals took over and got more and more smoking regulations, the last bastion of smoking in hospitals was inpatient psychiatric units.

They were two schools of thought on inpatient units that pertained to smoking.  The most benign was also the most paternalistic and condescending.  It went something like this: "Cigarettes are all that some of our patients have.  Taking them away will deprive them of their only sense of enjoyment."  Really?  The second was the theory that without cigarettes or access to cigarettes it was guaranteed to trigger increased anger and aggression if access to cigarettes was denied.  Some of the patients in question were compulsive 2+ pack per day smokers.  The politics of smoking on inpatient units was even more complex.  Battle lines were naturally drawn between staff who were smokers and nonsmokers.  That was complicated by what each faction wanted you to believe.  For example, the nonsmokers doubted that depriving a smoker of his or her heaters would have any effect at all.  People with acute mental illnesses would willingly stop smoking for days or weeks in the interest of everyone's health.  The pro-smoking faction of the other hand knew what going cold turkey was like and they predicted many more incidents of uncontrolled behavior.  I attended conferences where both parties produced data.  The data presented was consistent with the political orientation of the researchers.  The smoking cessation folks always posted data showing that people could acutely stop smoking without any major problems.

Reality always seems to produce a much different result than research.  I won't post any war stories, but I will say that the reactions covered the expected range of quiet resignation to rage.  The proliferation of nicotine substitutes, nicotine substitute polypharmacy, and "smoking passes" led to fewer problems.  Eventually hospitals banned smoking in any area of their campus forcing patients and staff to cross the street for a cigarette.  As the tide began to shift against Big Tobacco they sustained a number of setbacks.  In 1998, there was a record $246 billion settlement with state attorney generals.  Smoking rates began to drop and suddenly smoking in public places including bars and restaurants was the order of the day.  In 2010, the  Family Smoking Prevention and Tobacco Control Act was passed.  This Act set standards for labeling tobacco products and also rules about flavoring cigarettes and marketing them to minors.  It also established some limits in terms of what the FDA could do in their regulatory role with tobacco.  At the clinical level it is known that some psychiatric populations absorb nicotine per cigarette amounts on the higher end of the typical 1-3 mg per cigarette due to more puffs per cigarette and a shorter interval between puffs.  They also take a shorter time to resume smoking another cigarette.  Psychiatric populations are at much higher risk for smoking and increased cardiovascular mortality (Reference 1) and nicotine exposure potentially increase the risk of exposure to other addictive drugs (Reference 2).      

With all of the tightening in the area of tobacco regulation it was quite shocking to learn that these regulations not only do not apply outside the US, but in some cases where countries are trying to develop similar regulations, tobacco companies are fighting back.  In a number of these countries like Australia, Uruguay, and even the United Kingdom, tobacco companies are suing against the use of graphic health warnings and restrictions on advertising.  This legal action has led Bill Gates and Michael Bloomberg to set up a $4 million "anti-tobacco trade litigation" fund to assist with some of the legal costs.  That is not a lot of money but the fund also seeks to set up a network of attorneys, many of whom are going to work pro bono on this issue.  Tobacco companies argue that they are protecting their investments and intellectual property rights.  Gates and Bloomberg argue that it is the sovereign rights of nations to pass laws that protect the health of their citizens and believe it is necessary to support countries defending these rights against tobacco companies.

My take on this is a little different.  There has been a growing movement to liberalize the use of intoxicating and addicting drugs in this country.  The growing legalization and commercialization of marijuana is certainly the best example.  There is also more in the press about how benign hallucinogens are and how cognitive enhancement from stimulants may be a legitimate activity of students at all levels.  There tends to be less debate about opiates in the midst of an epidemic of excessive accidental drug overdoses, but I think it is important to recall that the epidemic started with a call to prescribe more opiates and diagnose more Americans with chronic pain syndromes.  It is one thing to talk about a person with a chronic medical illness smoking marijuana in a contained manner.  It is quite another to think about how the commercialization of addictive drugs works and how a business responds to regulation when there is clear evidence that their product has adverse effects and needs tighter regulation.   Elected officials also frequently get into the act and declare that tax revenues from the commercialization of addictive compounds will be a windfall for taxpayers without a careful analysis of the attendant costs.  

The motivation of tobacco companies could not be clearer - use proven marketing techniques to get people into smoking, all the while knowing that it will be difficult for them to stop.  The lesson here is that addictive drugs are good for business and marketing restrictions are not.  I would not be shocked to find that as marijuana and (possibly) other street drugs are legalized and commercialized that they would get some of the same early regulatory leniency that cigarettes had before there was overwhelming evidence that tobacco should be avoided rather than encouraged.




George Dawson, MD, DFAPA



References:

1:  Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA. 2007 Oct 17;298(15):1794-6. PubMed PMID: 17940236.

2: Kandel DB, Kandel ER. A molecular basis for nicotine as a gateway drug. N Engl J Med. 2014 Nov 20;371(21):2038-9. doi: 10.1056/NEJMc1411785. PubMed PMID: 25409384.

Supplementary 1:  Image is in the public domain courtesy of the CDC and Deborah Cartagena at the CDC Public Health Image Library.   Image #14541 accessed on March 20, 2015.

Neuroscience In Psychiatry Now - It Is A Lot Easier Than It Looks

I read the article "The Future of Psychiatry as Clinical Neuroscience. Why Not Now?" by Ross, Travis, and Arbuckle in JAMA Psychiatry and found little to disagree with.  I was in one of the venues a few years ago when Thomas Insel, Director of the NIMH talked about a clinical  neuroscience rotation for neurology, neurosurgery, and psychiatry residents to bring neuroscience to the clinical side of things.  Unfortunately he was a lot less enthusiastic about it when I sent him a follow up e-mail and at that time suggested it would probably have to wait for some time in the future.  

As a long time neuroscience enthusiast,  I have always found the reluctance to head in this direction puzzling.  On a historical basis, neuroscience has always has a prominent role in psychiatric theory.  One of the arguments against neuroscience has been that there are no clinical applications.  Even back in the day with Alzheimer, Nissl, Kraepelin and other German neuropsychiatrists were studying brain anatomy of patients in asylums, there were important correlations - most notably those consistent with both Alzheimer's Disease and Binswanger's Disease.  About two decades later, Constantin von Economo penned his treatise Encephalitis Lethargica - Its Sequelae and Treatment and described conditions that were relevant right up to the point that I started my training in the 1980s.

Being a practicing psychiatrist with an interest in neuroscience presents a variety of CME events ranging from behavioral neurology and developmental pediatric conferences in Boston to the annual Movement Disorders conference in Aspen.  There were the occasional very unique courses, like the brain dissection course run by the late Lennart Heimer, MD and a faculty of outstanding neuroanatomists.  But most of the neuroscience in psychiatry is typically packed into a course that focuses on the specialized diagnosis and treatment of specific disorders.  A good example would be the American Association of Geriatric Psychiatry (AAGP) courses that would include a detailed discussion of Alzheimer's pathology and vascular dementia and how they might not be that disparate at the microscopic level (that was also an ongoing debate in the movement disorder conferences).  In an AAGP event there would be 1 lecture out of 7 for that day devoted to neuroscience.  On the teaching level, neuroscience has always been there in the form of neurotransmitters, localization of cognitive and neuropsychiatric disorders associated with various brain lesion and insults, cell signaling, and plasticity.  In the past 20 years there has been an unprecedented integration of neurotransmitters and specific brain structures as seen in this diagram of the ventromedial prefrontal cortex.  

I have been fantasizing about a foundation and several years ago came up with the idea that it should fund neuroscience education in psychiatry.  This would be my preliminary plan:


1.  Contract with the top neuroscientists in psychiatry to come up with the syllabus.  

From the reviews in review edition of Academic Psychiatry (reference 4) there are already residency training programs that have come up with a systematic approach to this training.  There should be a place for all programs to post what neuroscientists and researchers consider the top areas for focus.  From the reviews mentioned in the above narrative it is very likely that there are fairly complete syllabi at this point but looking at the reviews in Academic Psychiatry they seem to be fairly disparate in terms of what faculty see as the most relevant.  The vignettes prepared by the NIMH (reference 2 and 3) are illustrative of what is possible.  If I was designing a curriculum, I would want every possible concept that could be illustrated in these vignettes and build the course work around that.


2.  Develop neuroscience teaching as a specialty.

I doubt that there are enough neuroscientists around to teach the subject to psychiatry residents.  A group dedicated to teaching neuroscience and neuroscientific formulations would be a logical approach.  There are currently plenty of nonscientist faculty with an interest and more than a passing knowledge of neuroscience.


3.  Develop a repository of graphics and teaching materials. 

There is no area of psychiatry that could benefit more from high quality graphics for teaching.  Current faculty engaged in teaching need to run a gauntlet of copyright related issues ranging from implicit copyright permission (yes you can use for teaching without going through Copyright Clearance Center) to repetitive licensing fees that are difficult to track.  All of those problems are from publishers controlling these rights and in some cases charging unrealistic amounts for reuse of some of these works.  Open access work is a potential solution but it is doubtful that enough graphics currently exist to illustrate key neuroscience principles.  A coalition of residency programs can potentially contract for the production of custom figures for a central repository that could be used in residency programs across the country.  There is already a precedent for this process with the psychopharmacology course available to residency programs from the American Society of Clinical Psychopharmacology (ASCP) who produce a large number of PowerPoints that are available to residency programs for a very reasonable fee.


5.  Don't forget about addiction science.

The field of addiction has contributed immensely to understanding how the brain functions.  In many cases psychiatry residents have minimal exposure to the treatment of substance use disorders and the associated syndromes and that could potentially strengthen both those areas in any residency program.



6.  Hold annual review courses. 

The field as it applies to psychiatry contains neuroscience spread across gatherings for psychopharmacology, geriatric psychiatry, general psychiatry, child and adolescent psychiatry, sleep medicine, addiction medicine and behavioral neurology.  There should be meetings across the country that focus on the necessary neuroscience and formulations presented by the top experts in the world with that focus.


7.  Suggested readings.

I try to keep up with Nature, Science, and Neuron and the Science Signaling series as a cost effective approach to learning new developments about neuroscience and whatever open access journals that seem to have the best content.  There are top journals that are too expensive or require memberships where the threshold is set for researchers and not teachers.  A good general approach to how to approach the literature would be very useful for most of the teachers and some of the expensive journals might offer packages for teachers rather than researchers.  I can recall that when I interviewed for residency positions and asked about department recommended reading lists there was only one department who provided one in those days.  I will let readers guess about which department that was.


8.  Reviewing imaging studies and teaching files.

Some of the best neuroanatomical preparation and training in my career came from reviewing imaging studies with radiologists, neuroradiologists, neurologists and neurosurgeons.  Current electronic medical records make viewing imaging studies easier than at any time in the past.  There is no better learning procedure than to organize findings, order the test, and confirm the problem.  That is possible currently if you treat a lot of patients with apparent lesions on imaging but functional imaging is becoming more available it has the potential to revolutionize psychiatric practice.  As an example, listen to the story called How To Cure What Ails You and an enthusiastic Eric Kandel talk about the importance of the anatomical substrate (reference 5) in psychiatric disorders.

These are some of my current ideas.  I look forward to the day that a neuroscientific formulation about what might be relevant is contained in the same paragraph that includes social and psychological formulations.  It will also put psychiatrists back where most of us belong - seeing people with the most difficult problems rather giving out advice on how to prescribe antidepressants.


George Dawson, MD, DFAPA




References:

1: Ross DA, Travis MJ, Arbuckle MR. The Future of Psychiatry as ClinicalNeuroscience: Why Not Now? JAMA Psychiatry. 2015 Mar 11. doi: 10.1001/jamapsychiatry.2014.3199. [Epub ahead of print] PubMed PMID: 25760896

2:  National Institute of Mental Health neuroscience and psychiatry modules. 2012a. Available at http://www.nimh.nih.gov/neuroscience-and-psychiatry-module/index.html. Accessed on March 16, 2015.

3:  National Institute of Mental Health neuroscience and psychiatry modules: 2012b. Available at http://www.nimh.nih.gov/neuroscience-and-psychiatry-module2/index.html. Accessed on March 16, 2015.

4:  Coverdale J, Balon R, Beresin EV, Louie AK, Tait GR, Goldsmith M, Roberts LW. Teaching clinical neuroscience to psychiatry residents: model curricula. Acad Psychiatry. 2014 Apr;38(2):111-5. doi: 10.1007/s40596-014-0045-7. Epub 2014 Feb 4. Review. PubMed PMID: 24493360.

5:  How To Cure What Ails You.  Radiolab  Accessed on March 17, 2015.


Supplementary:

The header to this article is all of my copies of The Biochemical Basis of Neuropharmacology and the book I consider to be its successor  Introduction to Neuropsychopharmacology.  New editions of BBN came out in 1970, 1974, 1978, 1982, 1986, 1991, 1996, and 2003.  The copy with the white cover in the middle (a little faded) was the first copy I owned.  In those days I wrote the year I purchased books in the front jacket and that year was 1984.  This book with its elegant little drawings and low purchase price served as an introductory neuroscience text to many classes of psychiatry residents.

How The Ruling Class Impacts Your Health Care and Why They Need To Be Stopped

The truth crops up in unexpected places.  A colleague directed me to an article is USA Today that I found to be very interesting.  It clearly describes the central problem with health care in America.  From that article (see reference for full text, clinic map and video):

"This is the crux of the whole thing," said Wanda Kuehr, a psychologist who agreed to speak out about the problems after retiring Feb. 2 as the program's director of clinical services. Non-medical managers want to "get the reports in on time and fill the slots. They think that makes a good program. Our goal is to give treatment to soldiers. And (the bosses) see that as inconsequential ... What's happening to soldiers matters and the Army can't just keep pushing things under the rug."

The report details what happened when the Army's outpatient substance use clinics were shifted from medical oversight by the Surgeon General's Office to the Installation Management Command.  This change occurred in 2010.  Some of the changes noted are striking including a basic error in hiring an unlicensed counselor.  Since 2010,  90 soldiers committed suicide and 31 of those suicides occurred after reviewers concluded that there was substandard care.   They could not conclude that the substandard care was causal.  Review of additional data showed that 7,000 soldiers were identified as having a problem but not offered treatment.   Half of the 54 substance use clinics were rated as substandard, specialists identified "poor continuity of care" as a problem, and staff attrition as a significant problem.  Only 309 of 352 counseling positions are currently filled.  The same article estimates that 104,000 soldiers have drinking problems.

What is the significance of this report?  I don't think there is anything unique about what happened to the Army's substance use clinics when the management changed.  It has been happening everywhere else for at least 25-30 years.  Before that time, medicine and specialty departments were managed by senior clinicians based on merit.  The department heads were active clinically and they were valued for their clinical and research expertise.  Some of the most valuable teaching experiences I had during my training occurred due to direct contact with these department heads.  Reviewing brain and spinal imaging with the head of the Neurosurgery Department.  Doing rounds at night with the head of the Renal Medicine Department.  The list goes on.  The point is that all of these experts were engaged in treating patients and teaching medical students and residents.  They had an intimate connection with the provision of care and the profession.  Many of them also had great personalities.  So what changed?

They changes were subtle at first.  When the managers took over they decided to replace some of the department heads at the periphery.  Suddenly there was no longer a certain department that people counted on and their duties were subsumed by another department.  The dislocated clinicians either quit in frustration or were relegated to a more peripheral role in the clinic or hospital.  They could no longer support a teaching mission and suddenly that block of knowledge was no longer available to students.  These experts were consulted in complicated cases to back up the generalists who were now seeing their patients.  The next step by the managers was to suggest that productivity in the larger departments was uneven.  They suggested that they had a metric so that would assure that everyone in the department was pulling their weight.  When I first heard that explanation, I looked around and concluded it was a myth.  Everyone in my department was a hard worker and that was borne out by the actual numbers.  The numbers were the real story.  The rhetoric had allowed the managers to introduce a system to manage productivity that was completely subjective.  But that was all the managers needed to develop a system to manage knowledge workers like production workers even to this day.

Why would anyone want to be a manager?  Well it seems like easy work if you can get it.  Instead of dealing with complex problems that require you stay current in a certain body of knowledge, interact with people in an ethical way, and have extremely high levels of accountability why not just manage numbers and tell people what  to do - especially people who are as politically inept as physicians and their professional organizations.  If I ask physicians that question, I usually hear that being a manager or studying business would just be "too boring."  That may be applying a medical metric to business that could be far from the mind of managers.  Some business educators and critics have pointed out that over the past 2 decades, there is evidence that managers have developed who are focused on short term results and in some cases "the pursuit of short-term shareholder interest, as well as naked self-interest on the part of managers, into managerial virtues." (reference 2).  Instead of a manager who knew and was promoted from within the business and who had a vested interest in the quality of the services and interests of the employees, we now have a class of managers who are mobile, highly paid, and have no particular expertise in the affected business.  Piketty notes that the United States has invented a "hypermeritocratic society" of "supermanagers".  These supermanagers are typically executives of large firms who have been able to obtain "historically high, unprecedented compensation packages for their labor."  He also concludes that "the vast majority (60-70%) of the top 0.1 percent of the income hierarchy in 2000-2010 consists of top managers."(p. 302).  I don't know Piketty well enough to say what his conclusions about why this meritocracy exists.  He does point out that it is twice as likely to occur in the financial services industry.

There are interesting parallels in the management of financial services and medicine.  In both cases, the managing class came about largely as an invention of federal and state governments.  The invention of the manager's tools in medicine (billing and coding, utilization management, prior authorization, managed care) parallels the development of credit reporting and the ability of financial manager to put your savings and retirement funds at risk all of the time without offering you any compensation for the use of your money.  Both of these systems are subsidized by huge hidden tax subsidies from American taxpayers.

When I try to talk with people about this problem their eyes glaze over.  Advantage to both the financial and business managers.

In the meantime, when you drive by your local hospital and it claims to be one of the "Top Hospitals in the US" - don't be surprised to learn that there are at least 600 hospitals on that list.              


George Dawson, MD, DFAPA


1:  Greg Zoroya.  Investigation: Army substance-abuse program in disarray.  USA Today.   March 12, 2014.

2:  Rakesh Kurana.  MBAs Gone Wild.  The American Interest.  July 1, 2009.

3:  Thomas Piketty.  Capital in the Twenty-First Century.  The Belknap Press of Harvard University Press.  Cambridge,  Massachusetts 2014.

Trauma in Psychiatric Hospitalizations

I read the Shrink Rap blog and found the recent post there on a reaction to one of the blog's posts on the violation that people feel after psychiatric hospitalization.  A direct attack on the author was certainly predictable especially given some of the sources quoted in the article.  As expected none of the author's intentions were captured by these responses.  Her intention was explicitly stated in the following 2 sentences:

"I realize that some people who are involuntarily hospitalized are terribly traumatized, which is why I'm writing the book. I don't think psychiatrists see that and I think if it were figured it into the equation, maybe less people would be involuntarily hospitalized (certainly, no one should be forcibly hospitalized for 'sadness' as one of the MIA commenters put it), other alternatives could be found, and more of an effort would be made to treat those where there are no options but involuntarily hospitalized with respect and kindness."

I worked in an acute care inpatient setting treating very acutely ill patients for 23 years and thought I would give my impressions to the statement about what psychiatrists see or don't see in people who have been acutely hospitalized, especially on an involuntary basis.  I think that there are several critical factors that determine what the experience will be like during those circumstances.  There will be considerable variation in the experience based on how these factors are approached.

1.  The pre-hospital experience

On the units where I worked, voluntary admissions were in the minority.  Most people were brought in to the emergency department (ED) by the police or paramedics.  They are usually involved when there is an acute behavioral change leading to a safety issue.  In that pre-hospital encounter some people are beaten up, maced or tasered by law enforcement.  If that happens and the person is in the ED wearing handcuffs that are too tight it can have an effect on the perception of the hospital and its staff following admission.  It is also an extremely traumatizing experience.  Years of observing this problem led me to problem solve with patients affected by these situations on how they could avoid confrontations with the police.  That is not the only source of trauma prior to admission.  Fights, accidents, self inflicted injuries, and near death experiences with suicide attempts and accidental overdoses can also happen prior to admission.  In some cases, people are transferred from intensive care units where they have been stabilized.

2.  Intoxication states

Intoxication states including alcohol,  cocaine, amphetamines, hallucinogens, and marijuana as well as the associated drug induced mental disorders are overrepresented in the population that gets acutely and/or involuntarily admitted.  People with substance use disorders have been systematically discriminated against by the insurance industry for the past thirty years.  At that time functional detoxification was not allowed and any patient who was intoxicated was generally denied care in psychiatric units by these same companies even if they had a significant psychiatric disorder.  They were supposed to go to "social detox" in county detox units, at least until most counties learned from insurance companies that it is cost effective to not have any resources and just deny care.  That means that today more people never get sober and are more likely to have increasing numbers of encounters with the police.  All it takes is an episode of aggression or suicidal statements while intoxicated and it can lead to transportation to specific psychiatric hospitals that receive patients from the police and paramedics.  In many cases, the hold is dropped after the person is detoxified and they no longer have the behaviors that occur in the intoxication state.  In other cases, there are semi-permanent or permanent changes secondary to the substance use and that results in a longer hospitalization.

3.  Acute psychotic states

Some patients who develop acute psychiatric states can experience similar changes in their conscious state that result in violent or suicidal behavior.  It is common rhetoric to hear that patients with mental disorders are no more likely than non-patients to be violent or aggressive.  Averaged across the entire population that may be true but it is also true that there are very high risk groups of people with mental illness.  The civil commitment laws in most states were designed for this contingency and a lot of these stories make the front pages these days.  Acute agitation and aggression in public or at the time of an emergency call places the person at high risk for a confrontation with the police.  In these confrontations anything can happen.   One of the functions of the hospital staff is to come up with a plan that will minimize any future risk of this kind of confrontation and to immediately address any physical or psychological trauma that occurred prior to admission.  In some cases, ongoing high levels of aggression in the hospital can result in additional physical intervention.  The goal of that physical intervention is much different that the police goals and staff have to be trained to provide this kind of treatment.  Medication can also be administered in emergency situations and according to state statutes to reduce the risk of injury to patients and staff.
   

4.  Suicidal states

One of the more complex aspects of inpatient care is assessing suicide risk and attempting to reduce suicide risk on the inpatient setting.  The problem is complicated by the fact that a lot of people with chronic suicidal thinking are assessed as being acutely suicidal and they are admitted.  In many cases it is a fine line between thinking about injuring or killing yourself every day for years and then one day deciding that you are going to do it.  In many cases people will injure themselves and demand to be released from the hospital.  They will deny making the statements even though the documentation is very clear.  They will be unaware or dishonest about their potential for suicide or self injury.  They may be indignant about being in a hospital even after a serious suicide attempt.  Others have very serious suicidal thinking and are quiet and cooperative but may at very high risk for suicide if they are released prematurely.  The worst case scenario is the person who suicides in the hospital or shortly after release.  The majority of people are able to recognize that there is a problem and work with the staff on resolving it and get released on a voluntary basis as soon as possible.

5.  Friends and family

In many cases of acute involuntary hospitalization, the chain of events starts with a family member or friend long before there is any suggestion of hospital involvement.  Family members often find themselves in the precarious situation of being concerned about the future patient, but not able to do anything about it.  They may have false information and believe that nothing can be done until the person actually "does something."  They are fearful about the patient's behavior and the fact that they have become unpredictable.  In some of these situations the first event leading to the hospital is an act of aggression or a suicide attempt.  The police are called, a crisis intervention team is activated, and the person is placed on a transportation hold and taken to the hospital.

Family members respond differently when the patient is admitted to a psychiatric unit.   Some family members are angry that the patient was admitted and insist that the patient be admitted to a medical or surgical service.  These patients are often geriatric patients who become aggressive at home.  Some families are relieved that the admission occurred and their member is in a safe environment and treatment can start.  Some families do not want the patient to know that they were involved in getting them to the hospital.  Some families get angry and demand that the patient be immediately released.  In some cases family members can become violent and threatening themselves.  Communication with the family can prevent a lot of misunderstandings and give them a clear idea of what the assessment and plan will be.  In some cases, the patient will refuse to sign the necessary releases to allow this communication.        

6.  Probate and criminal court officials

Statutes vary from state to state, but in the two main states where I have worked probate courts make the decisions about involuntary hospitalization, civil commitment, guardianship, involuntary administration of medication,  and conservatorship.  The process is advanced by screeners who gather evidence that can be tested against the statutory language for civil commitment and other proceedings.  Contrary to a recent Internet post on the "medical model", impaired insight is not a criterion for commitment and neither is "sadness" as suggested in the original post.  The probate court staff and not the hospital staff need to come up with all of the actual behavioral evidence to proceed with the original hold order and any further legal proceedings toward civil commitment.

One aspect of these court proceedings that nobody pays much attention to is that (like all American legal activity) these proceedings are contentious.  There are two sides and both sides want to "win" according to that model.  If any paternalism enters into the picture it typically happens when the patient's attorney recognizes that they are too ill to function and strikes some kind of bargain with the court.   Speaking for the clinician side I can say that quality treatment is a more realistic goal than "winning" in any usual sense of the word.   The patient, their family, and their attorney can decide that they will advocate for a position that is the opposite of what the hospital staff recommends.  In that case, there will typically be a lot more emotion than if there is no apparent alignment opposing the treatment team.
   

7.  Medical staff

In addition to the usual medical and psychiatric tasks of diagnosis and differential diagnosis and treatment of these diagnoses, the main task of inpatient staff is to maintain a safe and therapeutic environment.  Given the marginal existence of some of these units that is no easy task.  I can recall working on units where all of the patients stood on the other side of the glass and the activity was dominated by young aggressive men with severe personality and psychiatric disorders.  If an intimidating environment like that is allowed to exist a significant number of people in that environment will be frightened and in some cases traumatized.  Patients who are disruptive due to inappropriate social or sexual behavior or because of dementia can also frighten or anger other patients and that can lead to some level of traumatization or a reactivation of that dynamic.  The staff all need to be acutely aware of these potential problems and act to address them.  This requires an physical presence of medical staff on the unit.  Given the current levels of acuity, inpatient units cannot be run remotely or by administrators.  The medical staff present has to be well trained, comfortable with treating severe psychiatric problems, cohesive, and proactive.

Physical interventions to prevent aggression or self injury are potential flash points for trauma.  Many people who are acutely hospitalized have a high likelihood of past trauma or abuse.  The best overall approach is to keep any physical interventions to the minimum and keep the staff well trained in the concepts or therapeutic neutrality and verbal deescalation. In the cases where physical intervention is required, strict protocols need to be followed and quality assurance programs need to be in place to assure that these measures are kept to the very minimum periods of time.

8.  Relevant demographic factors

The most relevant demographic factor on the part of the patient is a history of abuse, a diagnosis of post traumatic stress disorder and how those variables currently affect them.  Some studies suggest that as many as 30-40% of patients have one or both problems.  The is relevant not only in understanding their current presentation but it should also guide how the staff interact with them.  In an informed environment, with resources it can suggest a course of psychotherapy, but very little psychotherapy typically occurs in most inpatient units.  Sociopathy and psychopathy are also relevant variable, since it is unlikely that people with these problems can be integrated into a population of more vulnerable patients without the odds of victimization being very high.  Substance use issues can also be very disruptive, especially in environments that are not very secure and increase the risk of contraband being brought into the hospital.
     

9.  Personality and anger control factors

Anger is an interesting emotion for a number of reasons.  It is hardly mentioned in psychiatric diagnostic manuals but it plays a significant role in inpatient psychiatry.  An inpatient psychiatrist can walk in and find that most or all of the patients to be seen that day have significant problems with anger.  Anger is frequently seen as a non-specific symptom of psychosis, mania, or personality disorders but it is more complicated than that.  There are often different formulations of anger control problems on inpatient units.  Assuming the person is not intoxicated it can be paranoia, projection, projective identification, grandiosity, irritability and various symptoms associated with the psychiatric syndromes that correlate with anger and aggression.  But there is also the element of anger and how it affects decision making.  If you are angry (irrespective of the real cause) you will have a tendency to see your problems as being attributable to another person and to see that other person as being responsible for your problems.  This means that if you were angry before you were hospitalized you will see the inpatient staff as being responsible for your problems, even though they had nothing to do with the circumstances of admission.  It is also true that is almost all of the situations that I have encountered, the inpatient physician did not initiate the emergency hold.  It is typically initiated by an outpatient or ED physician or in some states - law enforcement.  Most people in this situation can recognize what happened, but some cannot.  Some will remain angry the whole time and for a long time after they are discharged.      

10.  Officials who monitor medical staff and hospitals

There is a long line of administrators whose only job is to make sure that patient rights are guaranteed and that no patient is abused or treated in a disrespectful manner.  The first official is usually a patient advocate who is a permanent employee of the hospital or clinic.  In the state where I work the next line of oversight is an Ombudsman for mental health and developmental disabilities appointed by the governor who has investigative oversight into any hospital or clinic activity that a patient or their family finds to be unacceptable.  The Ombudsman can come in to any facility and interview all of the people involved and make their own determination of the merits of the complaint and what corrective action needs to be taken.  In the case of physicians the Board of Medical Practice (BMP) has ultimate authority over any licensed physician in the state.  All it takes is a brief note on a complaint form to initiate a full investigation into a physician's behavior that involves all of the relevant medical records being sent to the BMP.  Complaints are never questioned as far as their accuracy or coherence.  The physician in question needs to respond in detail to the complaint.  Physicians are never exonerated, a complaint is never assessed as to whether or not it had merit, and complaints are kept on permanent file even if the complaint is dismissed.  A finding against a physician can result in fines and restriction or suspension of their license to practice medicine.

11.  A reasonable discharge plan

In the most straightforward scenarios people sober up and/or resolve their crises and they are discharged as soon as any hold can be dropped.  In the case of acute intoxication states that don't require extensive detoxification it could happen in less than a day.  People are frequently discharged as soon as they are admitted from the ED (they are essentially admitted for a second opinion from a psychiatrist).  In more complex crisis situations, collateral information is usually needed to corroborate the patient's baseline behavior and document whether the relatives have had any concern before the hospitalization.  As noted in the family section, relatives have varying degrees of anger.  Some may show up either demanding the immediate release of the patient or threatening to sue the medical staff if the patient is released and not treated.  In some cases there are threats that legal action will be taken if the patient commits suicide or harms someone.  All of these factors and any medical and psychiatric diagnoses and treatment plans have to be negotiated in the discharge planning.

12.  A general lack of knowledge and sophistication about emergency hospitalization

It should be well known in our society that people are conflicted about mental illness and its treatment.  At the level of the healthcare business there is no conflict.  Healthcare companies are in business to make money and to a large extent that is how people keep circulating in and out of psychiatric hospitals and emergency rooms.  To my knowledge, nobody is ever educated about preventing these kinds of emergencies and avoiding contact with the police and hospitalization.  Instead we seem to have plenty of advocates for more risk rather than less.  That includes the recent pendulum swing toward more permissive attitudes involving drug and alcohol use.  Recognizing that a problem exists that could lead to this pathway is critical for prevention of these episodes and by definition prevention of any trauma that might be incurred on inpatient units.

Conclusion:

All things considered, I encountered very few situations where there was a question of a person being traumatized on an inpatient psychiatric unit where I worked.  I agree that this is an area for further study and that study would need to be carefully done.  I know that many people do not disclose what they were thinking or feeling in the hospital until well after they have been discharged.  A possibly useful approach might be to offer a post discharge assessment that focused only on the issue of trauma that occurred in the hospital and was totally independent of a treatment plan for the primary diagnosis.

In any situation this complex is it possible that some people are traumatized by the experience?  Of course it is.  Is it possible that some people actually create trauma for their fellow patients and staff?  Most definitely.  Is it possible that some if not most people recognize that there were major problems before admission that led to this situation and are able to work with the hospital staff to resolve the situation in a timely manner?  The answer is again - very definitely.  There are a number of mechanisms available to people who feel traumatized or treated unfairly as outlined above.  These safeguards vary from state-to-state but similar agencies are available across the United States.  In the case of Medicare patients, each state also has a unit to investigate complaints of Medicare patients if they believe they have received suboptimal care or care that was in any way abusive.  All of the agencies outside of the hospitals are free of conflict of interest and in many cases they consider it a political plus to take action against any abuse that occurs in a health care facility.  As a past Medicare reviewer, all reviews are conducted by physicians who are carefully screened for any potential conflict of interest.

Utilizing these resources and conducting further research on this problem is the best possible approach.  It is far superior to political debates on the Internet or attacking a person who is interested in studying the problem.

    

George Dawson, MD, DFAPA



References:

1:  Bruce M, Laporte D. Childhood trauma, antisocial personality typologies and recent violent acts among inpatient males with severe mental illness: Exploring an explanatory pathway. Schizophr Res. 2015 Mar;162(1-3):285-90. doi: 10.1016/j.schres.2014.12.028. Epub 2015 Jan 28. PubMed PMID: 25636995.

Supplementary:

I am interested in any additional factors that I may have missed in terms of sources of trauma on inpatient units.  E-mail me what you think and I may include it in an updated table.

NAMI and the Clinton Foundation Take The Bait On Managed Integrated Care

My views on "integrating" behavioral health and primary care are fairly well known.  They run counter to everyone including the American Psychiatric Association (APA) who has been promoting the advantages of "collaborative care".  I use quotes here to designate loosely defined terms that have multiple meanings to different special interest groups.  I should have also included the term behavioral health because outside of managed care companies, the word really has no meaning.  I got a post today in my Facebook feed that stated  The Benefits of Integrating Behavioral Health into Primary Care.  I encourage any interested readers to search directly for this page on the NAMI web site and take a look at the content.  It is in press release format that contains little detailed information.  It presents the chronic disease concept and how chronic diseases cause mental illnesses and make them worse.  It talked about practice models that look at putting therapists in clinics.  It talked about a model that brought a mental health clinician into immediate contact with a patient and clinician in a primary care physician's office, but stated that model lacked sustainable funding.   It talked about the promise of telemedicine.  Since this was a NAMI event, stigma and destigmatization were also on the agenda and the release ends in a global statement about how this will lead to everyone admitting that mental illness affects us all and at that point the stigma will evaporate.

With all of that good news, what do I have against this love fest for integrated care?  Just responding to the news release there are obvious problems with the ideas being mentioned.  The first is that many of these ideas have been around for at least 30 years.  I was hired as the medical director of a community mental health center in 1986 and part of what I was supposed to do was telemedicine through a cable TV and satellite hook-up in the town that I worked.  That never materialized.  Granted the resources today are much more sophisticated, but how many primary care clinics are really going to dedicate resources so that their patients will be seen in their clinic by an outside mental health clinician?  And what about the cost of those services?  There are currently networks of mental health clinicians eager to do telemedicine, but they are not eager to provide those services for nothing.  The economics of telemedicine is that it needs to be supported and there is no evidence that I am aware of that managed care companies support it.  The Veteran's Administration has supported it in some areas, but most health care facilities are not funded like the VA.

Putting therapists in clinics has occurred for more than the past 30 years.  Part of the problem is what those therapists will be doing in those clinics.   Will they end up doing acute assessments for suicide or aggression risk?  If they do identify those problems, are patients going to be cared for in those clinics or sent somewhere else?  In today's landscape of having no functional psychiatric units, will the primary care clinic now start to accumulate people with acute, subacute, and chronic suicidal thinking? Will there now be security issues related to the same problem with aggression?  Is the expectation in these clinics going to be follow up in 3-6 months like many other medical problems?  Will there ever be any effective therapy done?  Psychotherapy after all is probably a better treatment than all of those patients being put on antidepressants for acute adjustment disorders and grief.  Most people in those circumstances notice little effects from the medication.  Psychotherapy is after all a better treatment than benzodiazepines for most people put on those medications for situational anxiety and insomnia.  Therapists can do great work, but they are also rapidly saturated when they have to see patients for 6 - 10 sessions in follow up.  Is there really a managed care company who is going to put enough therapists in a clinic to do some good or are they going to be there just for looks?  You know - look here is the therapist for our integrated model.  Isn't it great?

There seems to be a collective amnesia about how this integrated care model really works and what it is really about.  This is really about continuing to ration care for mental illness and psychiatric care.  Refreshers on that can be found here and here.  Giving everyone in a primary care clinic a very basic screening checklist for anxiety and depression is one of the basic paradigms for all of the integrated care advocates.  The patients mentioned in the press release will be especially likely to score positive on these screens.  That is true not because they magically developed a new anxiety or depressive disorder, but because they have complicated conditions that are associated with anxiety and depression.  If a person has paroxysmal atrial fibrillation when their heart rate suddenly accelerates to a rate of 220 beats per minute, they tend to get very anxious both during those episodes and anticipating the next one.  The same thing is true for patients with heart attacks and emphysema.  Is checklist screening a good enough approach for these patients?  Is following a certain protocol with antidepressants a good enough approach with these patients?  So far, the checklist implementation of the "integrated" approach is a low quality assembly line approach that guarantees more exposure to antidepressants  and a limited differential diagnosis of what else might account for any psychiatric symptoms.  At least one group has determined that broad "screening" for depression (also mentioned in the press release) - does the exact same thing and is generally not a good idea.

This is really all about the money.  Managed care organizations and governments are still very interested in providing the appearance of care for mental disorders and that is about it.  In order to believe that they have some grander plan, an extremely naïve approach is required.  The last thirty years of managed care would need to be ignored.  That history would include the elimination of functional detoxification units for addictive disorders, the general elimination of psychotherapy, restricted access to psychiatrists and limiting psychiatric treatment to a 20 minute "med check", the elimination of functional inpatient units where difficult problems can be treated in a safe and humane environment, the elimination of resources to treat patients with severe aggressive behavior, and restricted access to medications that people may need due to their unique treatment requirements.  The basic concept that managed care was invented and supported by the federal and state governments would also need to be ignored.  The ultimate result of having record numbers of people with mental illnesses incarcerated rather than receiving appropriate care for mental illness cannot be ignored.  Even as I typed this paragraph additional evidence was building to support my theory that this is a huge subsidy for the insurance industry.  A colleague recently posted that there is no "out of network benefits" in New York State and she discusses the ramifications for psychiatric care and psychotherapy.  I see this as a flat out continuation of government sanctioned rationing of psychiatric services by the managed care industry.  They may want you to go to an integrated care clinic, complete a checklist and take an antidepressant rather than seeing your regular outpatient psychiatrist who is providing more than a medication.

Handing someone a depression checklist when they come in to a primary care clinic to get their blood pressure checked is reminiscent of the 1990s approach to pain as the "fifth vital sign", and we all know how well that turned out.

A final word about the stigma buzzword.  What is more stigmatizing - giving you the medical resources that you need for recovery or having you come to a primary care clinic where those resources will probably not be available and practically nobody in the clinic has experience working mental health problems?

That is the basic case against integrated care or what is sometimes referred to as collaborative care.  At this point like everyone else I will be leaning back and watching it unfold.  The insurance industry and government has so much power they can essentially do whatever they want now.  We seem to have a national political forum in health care that leads to an endless stream of bad ideas.  And it seems like we always listen to that endless stream of bad ideas rather than anyone who might know what they are talking about.
    

George Dawson, MD, DFAPA

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.