Friday, March 13, 2015

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.


Wednesday, March 11, 2015

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

Saturday, March 7, 2015

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.




Tuesday, March 3, 2015

Use Of "Medical Model" As A Pejorative Term







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

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

And:

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

George Dawson, MD, DFAPA


References:

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

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




Saturday, February 28, 2015

Abuse Deterrent Opioids - Are They The Solution?


I have a significant interest in opioids, specifically opioid use disorders or addiction to opioids.  We have seen an opioid epidemic in this country largely due to a naïve approach to chronic pain and exposing people unnecessarily to the risk of addiction.  At one level this is a failure of regulators who adopted the idea that chronic noncancer pain is best treated on a mass basis with opioids.  At another level it is a failure of American culture.  Americans are focused on abusable medications and they always have been.  This is not a recent phenomenon.  The reason that addictive drugs are regulated in the first place is that they were widely abused when they could be purchased over the counter from any pharmacy.  Advocates of legalizing drugs almost universally ignore that fact.  It is common to find people hoarding opioid prescriptions, giving them to their neighbors, and taking them for indications other than pain like insomnia, depression, or anxiety.  At the cultural level, opioids are generally regarded as magical pills that will cure whatever ails you.  But there is no such pill.

Physicians are not blameless in this process.  Around the turn of the 19th century, some physicians were maintaining large numbers of people in addiction as part of their medical practice.  At the turn of the 20th century, some physicians advocated “pain as the fifth vital sign” and the widespread practice of recording a patient’s pain rating in routine clinic visits with their vital signs.  In some cases this rating was mischaracterized as an “objective” measure like the other vital signs.  Any physician who is told that the pain rating is a “14” on a scale of 1-10, knows that little objectivity is involved.  The opioid epidemic is often viewed as a problem in physician education or a cognitive deficiency. I doubt that is the problem.  Every physician knows the basics about prescribing opioids by the time they leave medical school.  I can recall working in a clinic of chronic pain patients while I was a medical student in the 1980s.   In that clinic we prescribed hundreds of opioid prescriptions per month.  I also recall that none of those patients was ever asked about addiction or why they still wanted to take the medications even though their pain never seemed to improve.

This problem has also led to significant insights into the real function of the US Food and Drug Administration (FDA).  The FDA web site has three paragraphs on “What we do.”  The first paragraph highlights what I always thought was the main function of the agency:

“FDA is responsible for protecting the public health by assuring the safety, efficacy and security of human and veterinary drugs, biological products, medical devices, our nation’s food supply, cosmetics, and products that emit radiation.”

That seems like a straightforward definition.  In practice it is more complicated.  The best example I can think of to illustrate that is the FDA approval of the sustained release, high-dose hydrocodone product Norco.  The FDA’s own scientific committee overwhelmingly recommended against approving this product in the midst of an opioid epidemic.  They were overruled and the product was approved based solely on the manufacturer meeting regulatory requirements.  Despite concern about getting medications to market fast enough it seems like there are few obstacle to opioid preparations that are basically old medications repacked in a new form.

The financial considerations in this field are significant.  Several years ago speculation was that any successful abuse-deterrent opioid formulation would be a billion dollar a year drug for that manufacturer.  That is highlighted by the number of recent approvals for these drugs noted in the table below.

The current market for abuse-deterrent opioids is estimated to be about $7 billion.  The global pain market is estimated to be worth about $50 billion growing at a rate of 10% annually.  From the table above it is apparent that this is basically a patent extension market.  All of the main ingredients in these medications are generic opioids that are very inexpensive on their own.  By putting them in a special formulation or combining them with opioid antagonists (naltrexone or naloxone) the manufacturers claim they are producing a medication that is less likely to be abused. Whether or not that ultimately happens is anybody’s guess.  I tried to pull up one of the more notable prodrug use web sites and have not seen those compounds and so far no suggestion on how to defeat the abuse deterrence.  There are historical precedents.   Abusable drugs generally follow a predictable course of oral use to smoking or insufflation (snorting) to intravenous use.  Breaking up that chain of events is one strategy that may lead to less severe drug use, but the fact remains that the original oral formulation is still a potent medication that can lead to addiction.  The original case in point was the reformulation of Oxycontin in 2013.  The original capsule could be breached and the contents snorted, smoked, or injected.  The reformulation put the oxycodone in a hydrogel making it less available for snorting, smoking or injecting.  The detailed package insert still says that this formulation and the original formulation place the user at risk for addiction.

What can be learned about the proliferation of abuse deterrent formulations?  There is a strong incentive both in terms of market size and low production costs.  All of the medications in the table are very inexpensive generics that are reformulated with an inexpensive antagonist or a different pill matrix.  The main safeguard is the FDA in terms of the total number of these medications on the market.  The FDA has the potential to decrease the incidence of opioid use disorders.  There is no evidence that is their strategy because they are approving medications over the objections of their own Scientific Committee.  In some cases they discuss post marketing surveillance as being a measure of whether the abuse deterrent medication is working.  Neither of those strategies would seem to be very likely to me.  It is well known that reports of signifiant medication related events are probably very low relative to the actual incidence of these events.  I have previously advocated for a pharmacosurveillance/data-mining solution that would produce results before the expected complications of opioid dependence and unintentional overdoses.  The FDA’s current approach seems to be that further education of physicians will solve the problem.  This is not a problem of physician education.

As the formulations of opioids continue to propagate, there needs to be an awareness that the FDA is not attempting to contain the number of new opioid products released and that a preventive approach is necessary and is more likely to save lives than waiting for people to report complications or waiting for the Drug Enforcement Agency to make arrests.  It is also time to consider what can be done at the level of American culture and focusing on some basic misperceptions that result in the overvaluation of opioids.  The idea that opioids can alleviate chronic pain, that they are the best treatment for chronic pain and that everyone can take them safely are primary among them.

There also needs to be a better understanding of opioid use disorders.  Recent stories in the popular press make it seem like addictions are easy problems to get over.  Just make a decision to stop and most people are able to.  Tell the old story about returning Vietnam vets and how easy it was for most of them to stop using heroin.  These are not the people who are seen in acute care settings or who are treated for drug overdoses.  Many of those people will say that they knew they were using a lot of the drug, that they were not thinking about suicide but they did not care if they lived or died because: "All I wanted to do was get high."

That is a powerful incentive for defeating abuse deterrent pills.



George Dawson, MD, DFAPA   


Supplementary 1: What is an New Drug Application (NDA)? This is the formal application to the FDA where the sponsor (usually a pharmaceutical company) proposes that a new drug be approved for sale and marketing in the United States. For detailed information from the FDA web site follow this link.   


  

Tuesday, February 24, 2015

Birdman



I was inspired to see Birdman from my Facebook feed after seeing this descriptor: "Birdman WTF?" Up until that point it was just another heavily hyped Hollywood movie.  The hype in this case was the usual promotional stuff combined with the tension of whether or not Micheal Keaton would be selected as best actor in a leading role.  I had seen most of his previous stuff and there were glimmers of my idea of greatness as an actor but always a lot of personality.  My choices were to see it at a theatre or try to stream it.  The only available streaming option was a place I had never used before that required the purchase of their coded streaming device and payment on their Internet site.  After taking care of the technical details, I was ready to roll with little time to spare.  I would see the final scene about an hour before the best picture was announced on the Academy Awards on Sunday night.   The full title of the film is  Birdman or The Unexpected Virtue of Ignorance.

Spoiler alert at this point.  Although it is difficult to give away the ending because it is largely interpretive, I am going to discuss all of the key details that will clearly alienate and anger a few.  So don't read this if you have to see a pristine and not previously described film.  I don't see any way around it.    The opening scene sets the tone for the film and the tone taps into what are typically considered the negative emotions - anxiety, anger, depression, and disgust.  Unlike most films there is nothing to protect you from this level of discomfort.  Riggan Thomson (Michael Keaton) is in a dingy room, seated in a lotus position but suspended in the air about 3 feet off the floor.  He questions himself about how he could have possibly ended up in this situation.  A voice answers him and about a minute later he gets an incoming call on his laptop computer.  The call is from his daughter and as the camera pans to the computer, the viewer realizes from all of the light bulbs around his mirror that this is a dressing room for an actor.  He steps out of the lotus and walks to his dressing table to answer the call.

I knew from the outset that I was going to like this film.  Unless this was an actual superhero film, the scene demonstrates the stream of consciousness of this character.  What he may be consciously aware of and what he is not consciously aware of.  We get some insights into his conflicts and defenses.  It is common to hear a discussion about alter ego or clash of egos as though these are all clear separate entities.  I prefer this presentation to the actor looking at the camera and telling the audience what is happening.

The plot develops fairly rapidly from there and the viewer pieces together the facts that Riggan was a previous star of three superhero movies.  He is divorced and still in an emotional relationship with his ex-wife Sylvia.  He is opening a play on Broadway and is under a lot of pressure financially and professionally to succeed.  He is more clearly defined in the relationships with the rest of the cast, his ex-wife, his daughter, and a hostile critic who at one points assures him that her review is going to close his play after opening night.  He and his daughter Sam (Emma Stone) have a relationship that is hostile at times.  We learn that Sam has a substance use problem and has completed treatment when Riggan confronts her about smoking marijuana.  She lashes out with a diatribe that suggests his struggle to remain relevant is meaningless and he should just accept that fact like the rest of humanity.  Riggan has several additional confrontations with that dilemma over the course of the film with his fellow actor Mike Shiner (Ed Norton) and theatre critic Tabitha Dickson (Lindsay Duncan).  The confrontations with Mike seem to highlight the fact that he is a rising star and Riggan is a has-been.  In the case of Ms. Dickson she brings in the bias that Riggan is just a movie star and that is not the same level of art as a Broadway actor.  The final confrontation with the critic leads to the emotional upheaval that results in the penultimate scene.    

Throughout the film, we hear the dialogue between Riggan and a grandiose and self-centered Birdman.  At times we see the Birdman character in full costume.  In scenes where Riggan is angry he uses telekinesis to throw common objects against the wall and in one scene essentially trashes a room. In another scene he flies effortlessly above the New York traffic for several miles until returning to the front of the theater.  The camera stays on Riggan wherever he is in the scene and the presence and absence of the other actors depends on his trajectory.

What can be made of all of these supernatural occurrences in a movie that is not about a superhero?   I saw these events as narcissistic defenses against his growing vulnerability and an ultimate horror of aging - meaninglessness.  What better way to fight back than to be able to crush your enemies or provide immediate proof of your potency?  What better proof than to fly effortlessly above them?  Who hasn't had those familiar fantasies of unlimited wealth, power, or ability?  The ultimate way to deny dependence on the highly flawed opinions of others is to become an island unto yourself.  There is nobody left to marginalize you if you are living at that level.  As I was typing this, I also had the thought that blogging may be a lower level defense against this same existential crisis.  Is blogging an attempt to type your way out of meaninglessness and anonymity?  If it is - what are you prepared to do to appear to be unique?  What does it mean when there are tens of millions of bloggers out there generating parallel streams of information and minimal productive dialogue?  This kind of crisis can be explored at multiple levels.

Some of the folks in my Facebook feed ask the question: "Does the film glamorize suicide?"  I don't think so.  Suicide is after all part of the final act of the play that Riggan is trying to present.  There is enough ambiguity about the choice of the weapon and what actually happened to question the issue of suicide at all.  It is very difficult to survive the suggested suicide attempt even if the weapon was shooting blanks.  Most suicidal people pointing guns at themselves are highly ambivalent.  In survivors the gun often "just went off" rather than being fired on a volitional basis.  In the narrative with Riggan in the hospital, the description of what he is alleged to have done also seems unlikely when he peels off the bandages and inspects the damage in the mirror.  Even considering that scene as a suicide attempt, the critical question becomes, is it the prelude to another suicide attempt or something else?  The attitude of the film critic and the theatre goers seems to have turned around completely on the basis of the suicide attempt.  They are praising the play and Riggan's business partner Jake (Zach Galifianakis) suggests that the play will be running a long time in multiple venues.  He is suddenly and unexpectedly - a Broadway success.

Riggan's last act seems to be the most confusing.  He is in the hospital room where he is being cared for following the suicide attempt.  After he takes off the bandages, the walks to the window and stands on the ledge.  He jumps.  Sam comes into the room and goes to the window.  She naturally looks down and does not react, but then looks up into the sky and smiles.  Riggan is clearly not dead at this point.  His daughter is finally able to see that he is able to soar, in fact he always was able to - not as the result of conscious planned activity, but the combination of his collective unconscious and the less than ideal relationships he made in the Broadway debut.  In doing this Riggan demonstrates that he can engage the universal struggle through life and come out the other side unscathed and even temporarily transcendent.  In the scene where he says: "I can't do it anymore",  I have lost count of the number of times I said the very same thing to myself contemplating some unsolvable crisis at work.  I was ready to walk away and in one case I did walk away.  In those situations where there is no clear path forward there is a lot to be said for throwing yourself into the breech and seeing what happens, hence the alternate title.  It turns out that the illusion of certainty is not enough to live on - at least for some of us.

That's my interpretation and I'm sticking to it.  I did not read any detailed reviews before writing mine.  I did not go back and try to read a copy of the script, so this in entirely from memory and therefore I may have missed a lot and hopefully not embellished much.  The beauty of art is that many interpretations are possible and that the experience of the viewer is very important.

I found myself closely identified with Riggan Thomson in this film because his struggles are my struggles and I am just as ignorant.  I happened across some scathing comments on sites where I tried to stream the video.   With a film of this nature, I do not find that surprising.  In my experience there will be people who can identify with Riggan's struggles at every step of the way and many others who can not.  There will be people who are very aware of their daydreams, fantasies and defenses and others who are not.  A lot of people go through life experiencing it as a linear exercise in conscious decision making where all of life's major decisions are conscious choices and others do not.

These are some of the dimensions that may make this an enjoyable film.


George Dawson, MD, DFAPA