Silver Lining Playbook - Propsychiatry?

I went to see this film today for a couple of reasons.  Several people recommended it to me as a “pro-psychiatry” movie.  And I saw Robert De Niro interviewed about this movie with some of the cast and he was overcome with emotion and attributed it to the main character of the story and what he apparently went through with bipolar disorder.  As a film the structure and pace of this are well done.  It is enjoyable to watch.  The ensemble cast of Bradley Cooper, Jennifer Lawrence, Robert DeNiro and Jackie Weaver are focused at times on how depression and bipolar disorder affect people and their families.  I think it is generally known that the film focuses on Cooper’s character Pat, at the outset.  We learn that he has been court ordered to a psychiatric hospital.  In one of the opening scenes his mother picks him up and drives him to home to Philadelphia where he is supposed to comply with court ordered therapy, medications, and the conditions of a restraining order that prohibits him from contacting his wife or coming within 500 feet of her.  A police officer shows up to encourage compliance with the restraining order.

The first question in evaluating the movie and my friends’ comments is whether this very entertaining and well acted film is psychiatrically plausible.  Could the Cooper character (Pat Solitano) assault someone with the vigor we see in the film and end up being diverted to what appears to be a low security state psychiatric facility.  My understanding is that the film is based on the novel The Silver Linings Playbook by Matthew Quick.   There seems to be a general consensus that the film version is a very loose adaptation so I suppose I would need to read the novel to see the way this part of the plot was framed.  In real life, assaultive behavior in most states is handled as a criminal matter rather than court ordered psychiatric treatment.  It is one of the reasons that county jails have become large psychiatric facilities.  In some cases there is psychiatric care provided in jail.  In more enlightened systems competency evaluations are provided in jail and that may result in diversion to mental health court rather than criminal court.  An insanity plea has a low likelihood of success and defense attorneys are reluctant to consider it because the length of stay in a psychiatric hospital may be longer than in jail.

In this case Pat has been in the hospital for about 8 months.  We are told his mother made some kind of a deal to get him out.  In the process, one of his fellow patients leaves in the same car illustrating that security is not a priority.  While he is in the hospital, Pat spits his medication out after a mouth check by a nurse and when he gets home he proclaims he is not taking the medication because it affects his mental clarity and gives him physical side effects.  He is intense, wakes his parents up in the middle of the night, and creates a high level of tension in their home.  His parents seem at a loss in terms of how they can help him and invariably end up reminding him about the conditions of his release.  His apparent mental illness peaks with a scene where the entire neighborhood is disrupted and he physically injures his parents.  He eventually begins taking the medication.

His relationship with Tiffany (Jennifer Lawrence) begins in parallel with his initial stability and proceeds as he is getting more stable.  She also discloses a significant depression associated with her husband’s death and some sexual promiscuity.  She is portrayed as a very intense and at times angry and agitated women who is aware of the controversial parts of her character and says she has accepted them.  She has several angry confrontations with Pat and a very animated confrontation with his family about whether or not she is good for their home team’s juju.  Her emotional relationship to Pat as he recovers is one of the most compelling parts of the film.

At various moments, Pat is seen with his psychiatrist Dr. Patel (Anupam Kher) who does a good job of engaging a hypomanic Pat in movie psychotherapy.  Dr. Patel did have qualities that most people would like to see in a physician.  He listened, he was engaged, and he was able to relate to Pat.  In the first clinic scene, we learn that Dr. Patel played some music (or said that he did) to see how Pat would react.  Pat trashed the magazine stand in the waiting area.  This is dramatic license rather than actual psychiatry.  I can’t imagine any reasonable psychiatrist who would be eager to provoke a reaction from a person with a history of aggression who has been conditionally released from a state psychiatric facility.  The reality of these appointments for people with severe mental illnesses is that most of the time is not focused on psychotherapy.  In most public or managed care clinics Dr. Patel would have about 20 minutes to see Pat, discuss his symptoms, discuss medication side effects, order and review labs, and do the necessary documentation.  A casual armchair conversation like the one portrayed in the movie can occur only in special circumstances.

After the initial sessions we next meet Dr. Patel tailgating in the parking lot outside of the Philadelphia Eagle’s game.  He embraces Pat and utters a word that I have never heard a psychiatrist say.  There is an ugly scene involving racism and Dr. Patel and his fellow Indians and some of the locals.  Pat is back in the middle of this fighting to protect his brother.  Although he is arrested they all (including Dr. Patel) end up back at Pat’s parents home – a significant boundary problem.

I think that it is pretty obvious that I don’t really see this as a “pro-psychiatry” movie.  Psychiatrists don’t really act like Dr. Patel and many of the scenes highlighting problems with mental illness are more probably affected by dramatic license.  Some of those scenes were well done in terms of the chaos, aggressive behavior, anger and stress associated with mental illness.  Critics have faulted the film for not going far enough diagnostically, being an antipsychiatry film in that it demonstrates the failures of medical psychiatry, and generally seeing it as a random display of neurosis without enough details.  I think the outlines are there, but let’s face it.  This is not a clinical exercise.  This is art.  When I go to the movies, I am looking for compelling characters and good acting.  It is even better if those characters are acting out a fantasy that I can identify with.  Cooper and Lawrence clearly have a level of intensity that you don’t see in many places these days.  So while this film was really not about psychiatry (certainly not “pro-psychiatry”) it was very entertaining and it captured a lot of the reasons why I go to the movies.

I would like to have read what Robert De Niro read that gave him insights into the pain of the main character.  From what I saw today, they only scratched the surface on that issue.

George Dawson, MD, DFAPA         

Moralizing About Psychiatry and the Limits of Philosophy

This article came to my attention this week from the New York Times blogs.  The author identifies himself as a philosophy professor and scholar who is an expert in French philosophy.  He presents some viewpoints of Foucault and others to criticize the DSM and of course the clinical method in psychiatry.  I will be the first to admit his initial argument is confusing at best and is based on Foucault’s observation: “What we call psychiatric practice is a certain moral tactic….covered over by the myths of positivism.”  Indeed, what psychiatry represents as the “liberation of the mad” (from mental illness) is in fact a “gigantic moral imprisonment.”  In the next sentence the author  acknowledges: "Foucault may well be letting his rhetoric outstrip the truth, but his essential point requires serious consideration."

From my viewpoint whenever an author’s rhetoric outstrips the truth it means that at the bare minimum any observer should be skeptical of the biases involved and these appear to be the common themes that we see from antipsychiatrists.  It does not take the author very long to develop that angle:

“Psychiatric practice does seem to be based on implicit moral assumptions in addition to explicit empirical considerations, and efforts to treat mental illness can be  society’s way of controlling what it views as immoral or otherwise undesirable behavior.”

He gives examples of the previous treatment of homosexuality and women and uses this as a platform for suggesting “….there’s no guarantee that even today psychiatry is free of similarly dubious judgments.”  With no credit given to Spitzer’s role in both the DSM and eliminating homosexuality as a mental illness back in the 1970’s (where is the rest of America on that issue even today?) he latches on to the bereavement exclusion as the latest example of how psychiatrists are trying to dictate how people live and how various nonphysicians are better equipped to decide about whether the bereavement exclusion should be left in place.  Like every other commentator he waxes rhetorical himself using the well worn descriptor “medicalization” and suggesting part of the motivation for these changes is pressure from the pharmaceutical industry.  I recently posted a response to a less well written criticism from the Washington Post that addresses these issues and I would encourage anyone interested in finding out what is really going on to take a look at that post.

The question here is what have Professors Foucault and Gutting missed in their critiques about psychiatry?  It turns out they have missed a lot. The first obvious flaw is the misinterpretation about the role of psychiatric diagnosis and a diagnostic manual for psychiatrists.  The DSM (or any technical diagnostic manual) does not represent a blueprint for living and there is no psychiatrist who has ever made that claim.  This error is promulgated in the media by referring to the DSM as a "bible".  In fact, it is not a bible or blueprint for living.  Psychiatrists more than anyone realize that they are addressing a small spectrum of human behavior with the goal of alleviating suffering and restoring function.  The second flaw is that changing a diagnostic criteria in a DSM has any meaning with regard to treatment and diagnosis.  In the case of bereavement that ignores the fact that only a tiny fraction of patients with complicated bereavement or depression ever come to the attention of a psychiatrist.  Grief is a normal human reaction and everybody knows it.  Taken to an absurd level – if organized psychiatry said that everyone with grief needed to take an antidepressant for the simple fact that “we have special knowledge about how people should live”  we would have no credibility at all.  People everywhere know that grief is common and expected and severe mental illnesses are not.  At that level psychiatry is an extension of the common man’s psychology.  The third flaw has to do with impairment.  A diagnosis can be made only with an impairment dimension.  From DSM-IV:

“In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e. impairment in one or more areas of functioning) or with significantly increased risk of suffering, death, pain, disability or an important loss of freedom.  In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.” – DSM-IV

The critics never acknowledge that like all physicians, a psychiatrist’s role is to treat illness and alleviate suffering.  Further, the clinical method in psychiatry is the only specialty training that emphasizes clinical neutrality and recognizing emotional and intellectual biases that impact the physician patient relationship and offers ways to resolve them.  That is hardly a model for forcing value judgments about preferred mental states on people who other physicians are frequently unable to treat because of their own value judgments.

The author also erroneously concludes that it is dangerous to make psychiatrists “privileged judges of what syndromes should be labeled mental illnesses” based on the fact that “they have no special knowledge about how people should live”.   Since psychiatrists do not make that claim, and since various groups including governments and religious institutions have been making these judgments for centuries with very poor results, I would suggest that psychiatry has had some problems – but the progress here is undeniable.  That makes psychiatrists experts in their own field in their own field and the purveyor of their own diagnostic methods and not a claim that people should live in a particular way.  DSM-IV takes pains to point out that it is classification system for syndromes and NOT people.  The DSM is not designed for an untrained person to look at and make a diagnosis or get guidance for living.  It is designed to be a common language for psychiatrists who have all had standardized training.

I would also like to suggest that the same philosophical criteria be seriously applied by philosophers to the pressing problems within the health care system.  The DSM is not even a gnat on that landscape.  We have had nearly 30 years of active discrimination by governments and insurance companies against persons with mental illness.  While much criticism has been heaped on the bereavement exclusion criteria, people with addictions and serious mental illnesses are routinely denied potentially lifesaving interventions.  This discrimination has been well documented and it has fallen disproportionately on the mentally ill.  Jails and prison have become de facto mental hospitals.  People are being treated with addicting drugs on a large scale to the point that many consider opiate use and deaths from overdose to be an epidemic.  Governments save money and pharmaceutical companies and the managed care cartel prosper.  Contrary to the author’s suggestion that “psychiatrists are more than ready to think that just about everyone needs their services” psychiatrists are rare and access is strictly controlled by managed care companies and the government.  Even if a person sees a psychiatrist, their medications, access to psychotherapy, and access to hospital treatment are all dictated by a business entity rather than their doctor.

It would seem that philosophers could find something to critique in that glaringly bleak health care landscape other than a trivial change in the diagnostic manual of a vanishing medical specialty.   If not, I would be very skeptical  of their arguments.

George Dawson, MD, DFAPA

Gary Gutting.  Depression and the Limits of Psychiatry.  New YorkTimes February 6, 2012.

Fulford KWM, Thornton T, Graham G.  Oxford Textbook of Philosophy and Psychiatry.  Oxford University Press, Oxford, 2006: 17.

"Some of the main models advanced by antipsychiatrists, mainly in the 1960s and 1970s, can be summarized thus:
1.  The psychological model...
2.  The labeling model...
3.  Hidden meaning models...
4.  Unconscious mind models...
5.  Political control models..." <-Foucault is located here. (p. 17)

Shorter E.  A History of Psychiatry.  John Wiley & Sons, New York, 1997: 302.   

"By the early 1990, DSM-III, or the revised version that appeared in 1987 (DSM-III-R), had been translated into over 20 languages. French psychiatry residents, initially taken with antipsychiatry and the doctrines of Jacques Lacan and Michel Foucault, began memorizing the 4 criteria (and 18 possible symptoms) 6 of which must be present for anxiety disorder." (Shorter: p 302) 


Addendum:

I made this interesting discovery several years after the original post (on May 22, 2019). Dr. Gutting has a chapter on Michel Foucault in the Stanford Encyclopedia of Philosophy and this is very consistent with his flawed analysis of the DSM-5.  Link.

Big Data and Psychiatry - Moving Past the Mental Status Exam

I was a fan of big data before it became fashionable.  I was a high tech investor before the dot.com bubble and became very interested in high speed networking, especially the hardware necessary to move that data around.  Even before that information was publicly available, electrical engineers were using that equipment to rapidly download large amounts of data (GB) from satellites on every orbit.  As an investor, one of the early flagship applications was large telescopes.  I wrote an article on high speed networks and the medical applications - digital radiology and medical records back in 1997.  At about the same time I made the information connection.

As a college student, I got my hands on the Whole Earth Catalog.  That led me to my small college library and my surprise to find  that they had Shannon's  seminal work on information theory on the shelf.  I was even more excited when I learned about entropy in my physical chemistry course three years later.  Since then I have been searching without much success to look at what happens when two people are sitting in a room and talking with one another.

My entire career has been spent talking with people for about an hour and generating a document about what happened.  It turns out that the document is stilted in the direction of tradition and government and insurance company requirements.  It covers a number of points that are historical and others that are observational.  The data is basically generated  to match a pattern in my head that would allow for the generation of a diagnosis and a treatment plan.  The urgency of the situation can make the treatment plan into the priority.  The people who I am conversing with have various levels of enthusiasm for the interaction.  In some cases, they clearly believe that providing me with any useful data is not in their best interest.  Others provide an excessive amount of detail and as the hour ends I often find myself scrambling to get to critical elements before the hour expires (my current initial interview form has about 229 categories).  This basic  clinical interview in psychiatry has been the way that psychiatrists collect information for well over a century.  In the rest of medicine, the history and physical examination has become less important due to advances in technology.  As an example, it is rare to see a cardiologist these days who depends very much on a detailed physical examination when they know they are going to order an echocardiogram and get data from a more accurate source.

In psychiatry, other than information from a collateral interview and old records  there is no more accurate source of information than the patient.  This creates problems when the patient has problems with recall, motivation, or other brain functions that get in the way of describing their history, subjective state, or impact on their life.   The central question about how much useful information has been communicated in the session, the signal-to-noise considerations, and what might be missing has never been determined.  The minimal threshold for data collection has never been determined.  In fact, every information specialist I have ever contacted has no idea how these variables might be determined.

Information estimates have become more available over the past decade ranging from estimates of the total words spoken by humans in history to the total amount of all data produced in a given year.  Estimates of total words ever spoken range from 5 exabytes to 42 zettabytes depending on whether the information is stored as typewritten words on paper or 16-bit audio.  That 8,400 fold difference illustrates one of the technical problems.  What format is relevant and what data needs to be recorded in that format?  The spoken word whether recorded or typed is one channel but what about prosody and paralinguistic communication?  How can all of that be recorded and decoded?  Is there enough machine intelligence out there to recognize the relevant patterns?

An article in this week's Nature illustrates the relative scope of the problem.  Chris Mattmann makes a compelling argument for both interdisciplinary cooperation and training a new generation of scientists who know enough computer science to analyze large data sets.  He gives the following examples of the size of these data sets: ( one TB = 1,000 GB)

Project	Size
Encyclopedia of DNA Elements (ENCODE), 2012	15 TB
US National Climate Assessment (NASA projects), 2013	1,000 TB
Fifth assessment report by the Intergovernmental Panel on Climate Change (IPCC), due 2014	2,500 TB
Square Kilometer Array (SKA), first light due 2020	22,000,000,000 TB per year

That means that the SKA is nearly producing the total amount of information spoken by humans (recorded as 16-bit audio) in recorded history every year.   The author points out that the SKA will produce 700 TB of data per second and within a few days will eclipse the current size of the Internet!

All of this makes the characterization of human communication even more urgent.  We know that the human brain is an incredibly robust and efficient processor.  It allows us to communicate in unique and efficient ways.  Even though psychiatrists focus on a small area of human behavior during a clinical interview the time is long past due to figure out what kind of communication is occurring there and how to improve it.  It is a potential source of big data and big data to correlate with the big data that is routinely generated by the human brain.

George Dawson, MD, DFAPA

Dawson G.  High speed networks in medicine.  Minnesota Physician 1997.

Lyman, Peter, H. Varian, K. Swearingen, P. Charles, N. Good, L. Jordan, & J. Pal. 2003. How Much Information? Berkeley: School of Information Management & Systems.

Mattmann CA. Computing: A vision for data science. Nature. 2013 Jan 24;493(7433):473-5. doi: 10.1038/493473a.

Shannon CE.  A mathematical theory of communication. The Bell System Technical Journal 1948; 27(3): 379-423.

Treatment of chronic pain with opioids - back to the future

I thought I would wade in on this issue largely because I am not hearing a lot of rational discussion about the problem.  You might ask: "What does a psychiatrist know about this issue?" and the answer like most questions about psychiatry is "plenty".  I worked on a busy inpatient unit for 22 years and saw plenty of people with with severe chronic pain and episodic pain crises.  In that same facility, I also covered consults on medical and surgical patients many having problems with chronic pain and addiction.  As an addiction psychiatrist, I have talked with countless people who ran into problems with pain medications or relapsed to using another drug after being exposed to opiates for treatment of acute or chronic pain.  There seems to be very little reality based information out there to inform people about the risks and benefits of pain treatment with opiate medication.  The argument like most in our society is politically polarized to those who believe it is unconscionable to not treat pain even if it means a long course of opioids to those who believe that opioids are dangerous medications that should be conservatively prescribed.  So where does the truth lie?

I can tell you how it was in Minnesota in the 1990's.  There were very few pain specialists.  The wide spread prescription of opiate medications for chronic noncancer pain by generalists was uncommon.  In many cases if it seemed indicated, the generalist would refer their patient to a pain specialist who would provide them with a letter of agreement on the use of chronic opioids.  That all changed with a Joint Commission initiative on pain in 2000.  At least some authors see it that way and that was my experience.  Since then opioid prescriptions have been taking off with an associated increase in the production of these compounds.  This graphic from the CDC is instructive (click to enlarge).  The rates of increase of sales, deaths, and treatment admissions are all increasing at an astronomical rate relative to population growth.

The issue that is debated in the media and some government web sites is why is this happening and what is the best way to deal with it.  The FDA has recently incentivized drug manufacturers to come up with better tamper proof opioids.  The enforcement arm of the government is rigorously prosecuting some doctors.  The FDA has also initiated a course for doctors who prescribe opioids.  None of these measures addresses the core problems that were successfully addressed in Minnesota in the 1990s.  I will take a look at the specific issues involved:

1.  The genetics of opioid preference:   People at risk for abuse and addiction to opioids have intensely positive subjective experiences from taking opioids.  People not at risk have intensely negative experiences or the opioids make them physically ill.  We currently know nothing about the genetics of this response, but it makes sense to let patients know that if they do have an intensely positive response in terms of feeling euphoric or energetic that is not a good sign in terms of addiction potential.  It might even be reasonable to come up with a plan about what to do if that happens.  Seeing people back in a month who have no knowledge of this risk is probably not the best plan.  It is critical that there is a good therapeutic alliance between the patient and physician and that they are both focused on the full spectrum of problems.  

2.  The genetics of opioid response:  Individuals studies and reviews of studies generally show that a subset of patients respond to opioids.  There may be additional factors that should factor into patient selection such as the specific type of neuropathic pain.  The current concern and reaction to the opioid epidemic is based on the concept that opioid prescribing is a potentially high risk intervention.  If that is the case we need a better options for patient selection than a subjective report of pain.

3.  The public perception that opioids are the silver bullet of pain relief must be dispelled: This is the driving force behind escalating doses of opioids and the addition of benzodiazepines (an equally bad idea).  Excellent double blind placebo controlled studies of self titrated opioids in chronic neuropathic pain have showed moderate pain relief that is on par with non-opioid medication.

4.  Tolerance to analgesia and opioid induced hyperalgesia:  Education about these phenomena is needed because both lead to escalating doses of opioids.  The dose escalation may be appropriate, but in many cases the dose is increased with the goal of eradicating pain and that is an unrealistic goal.  In people who have analgesic induced hyperalgesia, they are often shocked that their pain improves with discontinuation of the opioids.

5.  Assessment of functional capacity is critical:  Functional capacity is the ability to function in daily life.  It must be carefully assessed in anyone who is on chronic opioid therapy.  At moderate doses and in combination with other pain medications opioids can impair coordination, cause excessive sedation, and lead to significant impairment in daily functioning.  This is a sign that the dose of the opioid may be too high and reducing the dose is indicated.

6.  A hierarchical approach to pain treatment is still necessary and is the most rational approach to reducing the current epidemic of excessive opioid prescriptions:  If the degree of pain relief across a population is the same, why not use the drug with the lowest abuse and overdose potential?  That was the default model in the 1990s in Minnesota.  The National Health Service in the United Kingdom has operationalized that as their current pathway for treating neuropathic pain in the algorithm below (click to enlarge).  Note that the medications with no abuse potential are at the entry levels in this diagram and that pain specialists are the gatekeepers for opioids.

  
Like most political debates the current debate about how to stop the epidemic of opioid overdoses ignores that fact that the problem may have originated with a political initiative in the first place.  Using the NICE algorithm to get us back to the Minnesota practice model of the 1990s is a logical solution.

George Dawson, MD, DFAPA


Rowbotham MC, Twilling L, Davies PS, Reisner L, Taylor K, Mohr D. Oral opioid therapy for chronic peripheral and central neuropathic pain. N Engl J Med. 2003 Mar 27;348(13):1223-32. PubMed PMID: 12660386.

National Institute for Health and Clinical Excellence. Neuropathic pain: the pharmacological management of neuropathic pain in adults in non-specialist settings. NHS. March 2010.

Supplementary 1:

The Care Pathway Graphic is copyrighted © National Institute for Health and Care Excellence (2010) and is posted based on their allowance for reproduction for educational and not-for-profit purposes.  See their updated and revised guideline at: http://www.nice.org.uk/nicemedia/live/14301/65782/65782.pdf

"Anything worth winning is worth cheating for."

I used to speedskate in pack style races.  For a while one of my competitors would come to the line and make that statement just before we all took off.  Most of us thought that it was hilarious.  One day I was intentionally sandbagging, and told several people that I was really fatigued and did not anticipate that I would be very competitive.  When the gun went off I broke for the first turn as fast as everyone else.  They gave me a hard time for sandbagging after that race and I reminded them: "Anything worth winning is worth cheating for."

That brings me to the recent Lance Armstrong saga.  The Oprah interview followed by endless opinion pieces and man on the street interviews focused on the emotional response to his doping confessions.  That has continued this week with a skewering by comedians, indignant responses by journalists, endless analyses of his interviews, the looming threat of ongoing legal action, and the expected outrage from the process of being lied to.  But I wonder if there is not a lot more going on that just cheating and lying. 

A little context is important.  Bicycle racing has been associated with cheating for decades.  Most people don't realize it but one of the most widely used antipsychotics,  haloperidol was invented as an antidote to amphetamines by Paul Janssen in response to the following observation he made in the 1950s:

“Even when he was pulled off his bike and congratulated by a reporter, he tried to continue cycling” Janssen said. It was obvious, he added, that “finding a treatment for amphetamine intoxication would provide a cure for paranoid schizophrenia”.  Ivan Oransky.  The Lancet - 17 January 2004 ( Vol. 363, Issue 9404, Page 251 )

Haloperidol was invented in 1959.  A British cyclist allegedly under the influence of amphetamines died in 1967 during the Tour de France while ascending Mt. Ventoux.

Over the intervening decades doping has become more sophisticated and the anti-doping authorities have become more sophisticated.  Epo was probably introduced to cycling as early as the 1980s.  There were 18 deaths of young professional cyclists in the late 1980s and 8 additional deaths since 1993.  The commonest compounds in the news that are thought to give a competitive advantage include testosterone and testosterone derivatives and the cytokine - erythropoietin or Epo for short.  Erythropoietin the primary regulator of human red blood cell production, survival, and differentiation of bone marrow derived blood cells.  It has been known for some time that is also has potential performance enhancing characteristics in elite athletes:

“Administration of Epo, by increasing haemoglobin and haematocrit, increases the oxygen carrying capacity of the blood, thereby improving the athlete’s endurance.  The use of Epo in this manner can be dangerous, increasing the risk of heart failure, strokes and thrombosis.  A number of high profile cases have been reported in the press, including in 1998, the arrest on drugs charges of the doctors of the Tour de France cycling Team, Festina.   One of the Festina riders ……has only recently returned to competition after a ban after admitting to regularly taking Epo.”  The Cytokine Handbook. Volume 2, p 1267.

Testosterone and its derivatives referred to as anabolic steroids first appeared in 1954. The use of anabolic steroids or anabolic androgenic steroids (AAS) has increased significantly across the population over the past 20 years.  In the 1990s about 1% of high school students used these compounds.  This increased to 3% recently with as many as 10% of 15-19 year old boys (4).  Pope, et al (5) reviewed the evidence that AAS use resulted in addiction and came up with a figure of 30% across seven studies with the qualifier that selection bias may be a factor.  The most recent review of the evidence (6,7) indicates that AAS are widely abused and that most AAS users are engaged in polypharmacy.

The actual effects of performance enhancing drugs are very difficult to evaluate largely because of the secrecy surrounding their use and the inability to investigate them on an systematic basis.  As I hear stories about what has been used a lot of it does not seem to make any sense.  For example, there was the famous incident where a Tour de France cyclist tested positive for testosterone after gaining 4 minutes on the field.  In the subsequent discussion he said initially that alcohol may have been the reason but eventually acknowledged using a testosterone patch.  The stage occurred well into the race and it made no sense to me why he thought that testosterone would be effective overnight.  An alternative explanation is that he was using more testosterone and the testing done was not accurate .  I have also heard recent comments on taking “hydrocortisone pills.”  I don’t understand how anyone would expect a glucocorticoid to lead to performance enhancing effects when it has a catabolic effect on muscle tissue.  There is some more clear cut documentation showing potential performance advantages from anabolic steroids, but much of it is anecdotal with little attention paid to minimum doses.  In fact some of the literature describes a natural tendency for escalation and uncontrolled use – a hallmark of addiction.  The literature on AAS use and whether or not they do enhance performance is varied.  The original literature originated in secret classified documents from the German Democratic Republic (GDR) and their Olympic efforts from 1966 through the late 1980s.  In over 150 documents, specific programs and dosing regimens were noted on thousands of athletes and hundreds of physicians and scientists.  An observation of the performance enhancing effects from this paper: 

“Performances could be improved with the support of these drugs within 4 years as follows: Shot-put (men) 2.5-4 m,  Shot-put (women) 4.5-5 m, Discuss throw (men) 10-12 m. Discuss throw (women)11-20m, Hammer throw 6-10 m, Javelin throw(women) 8-15 m, 400 m (women) 7-10 sec, 800 m (women) 5-10 sec, 1500 m (women) 7-10 sec….”

Without access to the original documents it is difficult to say exactly how carefully this was studied but I doubt that it was an A-B-A design with comparisons to placebo.  Nonetheless, if all of the performance enhancement was due to AAS, it would provide a clear advantage in events decided by meters or seconds and could potentially move an athlete from very good to world class.  Subsequent controlled studies like the first study (8) of the anabolic effects of supraphysiological doses of testosterone documented increases in both muscle diameter and strength during the administration of 10 weeks of testosterone injections.  They also commented that the widespread use of AAS at the time (1996) was unsubstantiated.  The authors documented strength increases of 22 – 38% during that experiment.

Another interesting document (3) of the widespread use of AAS by athletes and people interested in the body building aspects of these drugs was based on a hearing on the matter where doctors prescribing steroids were questioned.  The initial focus of this article was the 1988 disqualification of Ben Johnson after he won the 100 m event in the Olympics in Seoul, South Korea.  The physician in that case described a 5 year program of AAS use.  An estimated 20% of AAS were prescribed by physicians and one of the physicians in the report estimated that the size of his practice was 2000 patients and he thought there were 70 other physicians in the Los Angeles area prescribing these drugs.  At the time AAS use in international track and field competition and a “drug free athlete was considered a losing athlete.”

The politics and limited memory of the scope of this problem is also interesting.  Armstrong responded to the rhetoric of the officials who went after him and described his doping operation as the largest and most sophisticated.  A cycling team would not seem large compared with estimates of one million AAS users in the 1990s, 300 thousand of them active in any given year.  From previous estimates that number may be three times as large right now and chances are that many of these people are also using growth hormone and other polypharmaceutical approaches that they believe will enhance their performance.

The bottom line for me is that Lance Armstrong used performance enhancing drugs by his own admission.  Like practically all users of these drugs he lied about using them.  He used the legal system and his resources to his advantage to defend his positions.  None of this is very surprising given a culture that has used performance enhancing drugs for decades and one that is expanding to the use of cognitive enhancers (9).  So be irate with him if you want, but there is clearly a large segment of the population that practices performance enhancement and the population is also expanding into enhancers for intellectual performance as well as athletic performance.  It is not likely that either of these practices will be going away any time soon.

 

George Dawson, MD, DFAPA

1.  Lewis JL, Lotze GM (2003) Haemopoietic cytokines. In: The Cytokine Handbook, vol. 2 (Thompson AW, L. M., ed), p 1267 London: Academic Press.

2.  Franke WW, Berendonk B. Hormonal doping and androgenization of athletes: a secret program of the German Democratic Republic government. Clin Chem 1997;43:1262-1279.

3.  Breo DL.  Of MDs and muscles--lessons from two 'retired steroid doctors'. JAMA. 1990 Mar 23-30;263(12):1697, 1699, 1703-5. PubMed PMID: 2407878.

4.  Lukas SE. (2009) The pharmacology of anabolic steroids.  In:  Principles of Addiction Medicine, Fourth Edition, p 252, Philadelphia: Lippincott, Williams, and Wilkins.

5.  Kanayama G, Brower KJ, Wood RI, Hudson JI, Pope HG Jr. Treatment of anabolic-androgenic steroid dependence: Emerging evidence and its implications.  Drug Alcohol Depend. 2010 Jun 1;109(1-3).

6.  Kersey RD, Elliot DL, Goldberg L, Kanayama G, Leone JE, Pavlovich M, Pope HG Jr. National Athletic Trainers' Association position statement: anabolic-androgenic steroids. J Athl Train. 2012 Sep-Oct;47(5):567-88.

7.  Kanayama G, Pope HG Jr. Illicit use of androgens and other hormones: recent advances. Curr Opin Endocrinol Diabetes Obes. 2012 Jun;19(3):211-9.

8.  Bhasin S, Storer TW, Berman N, Callegari C, Clevenger B, Phillips J, Bunnell TJ, Tricker R, Shirazi A, Casaburi R. The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. N Engl J Med. 1996 Jul 4;335(1):1-7.

9.  Greely H, Sahakian B, Harris J, Kessler RC, Gazzaniga M, Campbell P, Farah MJ. Towards responsible use of cognitive-enhancing drugs by the healthy. Nature. 2008 Dec 11;456(7223):702-5.

No applause from me

The APA came out with a press release today in response to President Obama's initiative to reduce gun violence and prevent future mass shootings.  Although the release "applauds" these proposals they seem to be short on the mental health side. From the APA release:

“ We are heartened that the Administration plans to finalize rules governing mental health parity under the 2008 Mental Health Parity and Addiction Equity Act, the Affordable Care Act, and Medicaid. We strongly urge the Administration to close loopholes involving so-called ‘non-quantitative treatment limits’ and to ensure that health plans deliver a full scope of mental health services in order to comply with the law. Such action will best ensure that Americans get the full range of mental health services we believe they are intended to receive under federal law.”

So I guess the APA is applauding the initiative but encouraging the closing of loopholes. Call me a skeptic but 20 years of rationing mental health services and cutting them to the bone through managed care intermediaries and aggregating those managed care intermediaries into accountable care organizations does not bode well for the "full range of mental health services". The APA seems to have the naïve position that you can support managed care tactics and provide increased access to quality mental health services.

The next point in the APA release supports school screening and enhanced mental health services in schools for both violence prevention and to identify children at risk or in need of current mental health services. Those are certainly laudable goals but there is minimal evidence that screening is effective. There is also the problem of a lack of infrastructure.  Twenty years of rationing and restricting access to psychiatric services has resulted in long waiting lists or completely unavailable services. If you talk with a child psychiatrist, they will tell you that the current system is set up to offer medications in place of a more comprehensive approach to psychiatric treatment. At the social services level, residential treatment for children with severe problems is practically nonexistent. As a recent example, I was informed last week of a school social worker who could not get a child assessed for admission to an adolescent psychiatric unit and when that was not possible could not get an appointment to see a psychiatrist in a major metropolitan area. Screening for problems does not make any sense unless there is an infrastructure available to address those problems when they are found.

The final point in the APA release addresses the issue of physicians being able to discuss firearms at home with their patients. This has been a standard intervention for physicians ever since I have been practicing and it is always part of an assessment for suicide and homicide risk. There was a state initiative last year making it illegal for physicians to discuss firearms in the home with their patients. Part of the rationale for that law was that it could result in firearm owners being identified and placed them at theoretical risk for their firearms to be confiscated by the state.  I can say from experience that my discussions with patients about firearm safety and the discussions of other physicians that I have been aware of have been highly productive and have probably saved countless lives. The best example I can think of is talking with a primary care physician who asked me to take a look at a closet full of firearms that he convinced patients to turn into him over the years before he turned them into the police. Those patients were all depressed and suicidal and at high risk for impulsive acts. He would not have been able to make that intervention with a gag law in place preventing those discussions.

What about the President's original release?  It had 84 instances of the word "mental" usually as "mental illness" or "mental health".  As noted above it has received some accolades from the APA and other members of the mental health community. It elicited a strong and poorly thought out response from the NRA  who produced a YouTube video accusing the President of being elitist and a “hypocrite” because his daughters had armed security but he expected that everyone else’s kids would be protected by gun free zones.  The White House responded quickly:

“Most Americans agree that a president’s children should not be used as pawns in a political fight,” said Jay Carney, the White House press secretary. “But to go so far as to make the safety of the president’s children the subject of an attack ad is repugnant and cowardly.”

The full text of the White House 22 page document is located at this link.  It is ambitious and covers a lot of ground in terms of the specific regulation of firearms, school safety, and increasing mental health services. The firearm regulation is most specific in that it closes background check loopholes, bans assault weapons, outlaws armor piercing bullets, and sets the maximum magazine size at 10 cartridges.  Part of this document is a "call to Congress" so it is not clear to me how much can be accomplished by the President's executive orders as opposed to Congressional action.  I am reminded of the NRA President last weekend stating that Congress would never pass a ban on assault weapons.  The Executive Order section of that part of the document lists the following activities:

1.  Addressing unnecessary legal barriers in health laws that prevent some states from making information available about those prohibited from having guns.

2.  Improving incentives for states to share information with the system.

3.  Ensuring federal agencies share relevant information with the system.

4.  Directing the Attorney General to work with other agencies to review our

laws to make sure they are effective at identifying the dangerous or untrustworthy individuals that should not have access to guns.

The school safety initiative seems more nebulous. There is funding for 1000 "school resource officers and school based mental health professionals" and the recommendation to train 5000 additional “social workers, counselors, and psychologists.”   Considering the fact that there are probably close to 100,000 schools, this seems like a drop in the bucket.   Ensuring that each school has an emergency plan for contingencies like mass shootings does not seem to be a novel idea.  Creating safer school climates and reducing bullying has already been initiated in many school districts. There seems to be a clear lack of public health measures in the school that would reduce the likelihood of violent events.

The mental health initiative is equally lacking. In addition to the deficiencies I pointed out initially in this document, there is discussion of providing mental health training to teachers and school staff. There is probably evidence that teachers and school staff may over identify mental illness rather than under identify it.  Is this really a problem and will this level of screening be effective?   The document describes the initiative here as "increasing access" to mental health services. Screening larger numbers of students and identifying them as having potential problems actually creates a bottleneck in the system rather than increasing access.  The suggested mental health interventions in this document fall short in terms of both primary and secondary prevention of mental illness and associated aggressive behavior. Depending on a managed care model that has an established track record of dismantling the mental health infrastructure and providing limited access to poor quality care will do nothing to accommodate increasing referrals other than assure that referred students will be rapidly medicated.

My final analysis of the President’s initiative today is that it may be a starting point.  He is certainly taking the issue seriously and deserves plenty of credit for that.  His support for reopening firearm safety research that was closed by the gun lobby is important. What will become of the firearm regulation is anyone's guess at this point. The school and mental health initiatives are largely symbolic and I would not expect them to have any impact. What is sorely needed is the American Psychiatric Association coming out with standards, quality guidelines, and medical education initiatives to improve the care of people with severe mental illnesses who also happen to be aggressive.  An important piece of those guidelines should include the public health measures that were previously mentioned on this blog and those measures should also play a much larger role in any Executive initiative.

George Dawson, MD, DFAPA

Assault rifles, high capacity magazines, background checks and reverting to form

That is what it is coming down to according to the talking heads on the Sunday morning TV circuit this week.  Both the NRA and several politicians agree that there are not enough votes for an assault weapons ban.  There may be enough votes for a high capacity magazine ban but both sides acknowledge that these clips are inexpensive and there are already a lot of them out there.  The background checks issue is also debatable.  The NRA and the pro-gun factions are talking a lot about mental illness and needing to have a mechanism to prevent people with mental illnesses from getting guns.  There is minimal discussion of improved mental health services.  On CNN Sunday  morning there was acknowledgement that during tough budgetary times the line items supporting mental health treatment are the first to go.

So basically despite all of the hype about how the Sandy Hook incident was going to energize politicians to actually solve a problem – they appear to be rapidly reverting to form and not solving anything.  The NRA President seemed confident that nothing would happen (the NRA opposes any assault weapons ban or high capacity magazine ban), but cautioned that the President has a lot of political capital and might be able to influence the high capacity magazines.

I wanted to file this post tonight before the final recommendations of the Vice President because I think that there have been two recent articles in the medical literature that are very relevant. At the legislative level Jerome Kassirer, MD has a recent article in Archives of Internal Medicine. Dr. Kassirer is a former editor of the New England Journal of Medicine and I corresponded with him on this issue nearly 30 years ago.  He clearly has not lost interest over the years and brings several concepts into focus in his editorial. The first concerns the fundamentals of screening and how any effort to identify potential shooters would result in the false positives greatly outnumbering the true positives and how that renders screening impractical.  His primary focus has to do with countering political initiatives.  As an example the National Center for Injury Prevention and Control at the CDC is currently prevented from studying gun related injuries.  He advocates for countering that.  He advocates for a comprehensive analysis of gun ownership.  He also advocates for resistance to any laws that restrict physicians being able to talk about firearms with their patients. He wants to see universal background checks from gun purchases, gun safety devices including coded weapons, and restrictions on large capacity magazines and sales of large amounts of ammunition. His article refers to firearms as "Weapons of Mass Destruction".  Small arms and light weapons are in fact a major global problem.  This Federation of American Scientists primer highlights the issue and the fact that there have been over 1 million deaths due to small arms in the past decade. Some advocacy organizations estimate that as many as 250,000 people per year are killed by small arms fire worldwide.

The second very important article comes from the Journal of the American Medical Association. The authors of this article emphasize the public health approach to curbing gun violence. This is a very important concept that people have a difficult time grasping. Whenever I bring up the issue of psychiatrists being involved at the level of primary and secondary prevention most people distill that down to whether or not psychiatrists can predict violence.  A public health approach to violence prevention is much more comprehensive and multidimensional.  The authors give several good examples in this paper including modifying sociocultural norms.  They use the example of tobacco being media symbol of “modernity, autonomy, power, and sexuality" and how that was changed.  They suggest an analogous campaign to equate gun violence with weakness, irrationality, and cowardice. The article has a table that has 18 evidence-based public health interventions that have been successful in other areas that could be applied to gun violence.  This is actually the preferred strategy that I have been advocating for the past decade and the authors of this article state it very eloquently.

At this point in time it will be interesting to see if the Vice President's recommendations include any of the interventions suggested by these two articles or the recommendations from the APA.

George Dawson, MD, DFAPA

1: Kassirer JP. Weapons of Mass Destruction. Arch Intern Med. 2012 Dec 21:1-2.  doi: 10.1001/jamainternmed.2013.4026. [Epub ahead of print] PubMed PMID: 23262523.

2.  APA Recommendations to the Biden Task Force

3.  Mozaffarian D, Hemenway D, Ludwig DS. Curbing Gun Violence: Lessons From Public Health Successes. JAMA. 2013 Jan 7:1-2. doi: 10.1001/jama.2013.38. [Epub ahead of print] PubMed PMID: 23295618.