But I'm going to try.

His editorial appears in the journal Current Psychiatry, of which he is the editor.  I respectfully disagree.

Following from my premise that the erosion of civil liberties and descent into fedualism necessarily coincides with the rise of psychiatry, I found a short article in the Economist, the magazine of record of the Whig Party, which explains that British Government runs a "Fixated Threat Assessment Centre," i.e. capturing stalkers.  It has 4 cops, and a forensic psychiatrist and psychologist.

You probably think that the shrinks are "profilers."  Maybe they are.  But their real value is in their  power to do what cops can't: involuntarily commit people who they feel are dangerous.    Quoting the Economist:

The Met [cops] defines its [suspects] as those who are "abnormally preoccupied with certain ideas or people."  The inclusion of "ideas" gives it wide remit.  Could those abnormally pre-occupied with the idea of jihad-- or, indeed, human rights-- be considered fixated individuals?

Disclosure: I actually think this is clever-- why not tap the legal resources of psychiatrists to help catch bad guys?  But that's exactly the point: no one should have the ability to use that power extra-psychiatrically. It's seductive and it has no recourse for appeal, no controls.

The article goes on to state the FTAC has been operating for 8 months with no official announcement; it won't say how many people it has caught or tried; and, of course, it can't, because of confidentiality of the "patients." 

Good luck, everybody. 

 

 

I'll take Paris any day. 

So Paris goes back to jail after the behind the scenes/cover of darkness/MK-ULTRA deal she made to get out of jail early was met by the public with consternation.

As near as I can tell,  a/her private psychiatrist (his blog here-- mine's better, dammit) visited her for two hours in jail, then made a plea to the sheriff that serving her sentence in jail was psychiatrically harmful to her.  So they let her out to serve it at home.

The argument here, of course, is that this is rich-white-girl gets special treatment; and the easiest  way to do it is to use psychiatry. And people say, "see?  This is they type of abuse we can expect if psychiatry is allowed to influence legal matters."

Fair enough.  I don't know Hilton's case, whether it was a appropriate or not, I don't know Dr. Sophy;  all I can say is, yes, the potential for abuse exists, but perhaps it is balanced out by the cases in which it is helpful to society.
 

But consider the reverse situation, and read it carefully because then I'm going to punch someone:

SELMER, Tennessee (AP) -- A woman who killed her preacher husband with a shotgun blast to the back as he lay in bed was sentenced Friday to three years in prison, but she may end up serving only 60 days in a mental hospital.

Mary Winkler must serve 210 days of her sentence before she can be released on probation, but she gets credit for the five months she has already spent in jail, Judge Weber McCraw said.

That leaves only two months, and McCraw said up to 60 days of the sentence could be served in a facility where she could receive mental health treatment. That means Winkler may not serve any significant time in prison.

 

Same gripe: look how people use psychiatry to manipulate the legal system-- "only two months for killing someone?!" and while I agree that's pretty pathetic, what's worrying me is this: who the hell spends five months in jail without getting a trial? 

This probably didn't occur to you, and that's why it still happens.  If I kill my preacher husband, I have the right to a speedy trial.  If I can't get a speedy trial, I get to pay a fee to be released, and then show up in court when the government gets their act together.  But what if I don't have bail money?  How can the courts justify indefinite incarceration in the absence of a trial?

Enter psychiatry.  You get a psychiatrist to evaluate the person and determine that he is not competent to stand trial.  They recommend 60 days involuntary commitment/treatment in a psych hospital in order to "restore them to competency."  If at the end of 60 days the evaluator comes back, and if he still thinks they're not competent-- they get (re)committed again.  Etc.

Trial competency has very specific requirements: understanding how you wish to plea, the possible sentences, working with your lawyer, etc.  Being depressed or psychotic, per se, isn't the determinant-- only if it seriously impacts your ability to, say, understand the charges against you.

But in the vast majority of cases I have been involved in, the report really only reflects the presence of a mental illness, not its impact to the case.  As if it is de facto proof of incompetency.  It's not.

But here's the move: the "psych hospital" they get involuntarily committed to is actually their cell. 

Technically, they are supposed to be committed to an inpatient hospital.  Many jails have them on the premises.  But if the commitment is for 60 days, and the psychiatrist treating them (i.e. not the evaluator) thinks they are cured, then they get sent back into population (their cell).  Maybe they continue on medication; maybe they see the psychiatrist weekly for "outpatient" visits.

Or maybe, maybe, the treating psychiatrist doesn't think they need any treatment.  So they spend their commitment in exactly the place they started. 

Worse, much worse, is how many people I see that I say are competent and still wind up recommitted for two months.  Six months.  A year.  Think I'm kidding?  It is impossible to even estimate how many charts I have read that indicate no psychiatric contact-- not medication, not therapy, not psychiatrist--  for the entire duration of their commitment.  And why should there be? The treating psychiatrist doesn't see anything to treat.

You're probably thinking about murderers and rapists; but the majority of these cases are theft, assaults, drug possessions. Can anyone explain to me what possible justification exists for locking up a guy charged with possession for eight months, no trial?  And I'll pretend the guy is whacked out of his nut psychotic.  Ok?  Any justification at all?

I'm not saying you can't sentence him to eight months-- cane him, for all I care;  I'm saying you can't jail him for eight months without a trial.  Is anyone listening to me? 

The system is designed with simply one outcome in mind: keep the poor with high recidivism rates and minimal social resources in jail-- a sort of half-way house for the disenfranchised-- until you can't possibly justify it any longer, and then give them a quick trial, accept the guilty plea ("what guilty plea?") and sentence them to time served and probation-- where you can add further controls.

It's debatable whether keeping potential terrorists in Cuba is a good idea.  But when the State starts using pyschiatry to manage their population...

I know you think I am exaggerrating.   I'll bet you're not poor. 

 

 

A reader asked me to read his book before saying that copycat suicides is not a real phenomenon.

To be fair, his book is really good.  It is worth the price even as a reference guide/catalog of suicides and homicides that share similar characteristics, which are striking.   While the majority of the information is a google search away, the fact is that he actually did the searches.   It's also a  good read-- it neither bores you nor crams the conclusions into your head.

But, I respectfully disagree.  I think.

The main disagreement I have with the book is that he conflates two phenomena.  His stated thesis of the book is that media reporting of violence and suicides begats copycats.  However, in support of this premise, he uses examples of the media itself (e.g. movies) causing copycats.

A perfect example of this is the Werther Effect, so named for the Sorrows of Young Werther, the 1774 comic book by Goethe in which the protagonist kills himself because he can't get the girl.    Subsequently, there were numerous copycat suicides-- staging it (same clothes, same desk) as Werther in the novel.  Ok, I get it-- that's a copycat.  But that's not an example of media reporting causing copycats.

In contrast, here's an example of a reporting-induced copycat: Coleman relates the Bergenfield Four.  For a few months, there were rumors that a bunch of kids who called themselves "The Burnouts" had made a suicide pact.  In September of 1986 their leader killed himself; in March of 1987 four others carbon monoxided themselves in a parking garage, leaving a note that clearly linked the deaths.  One week after that, a cop found two other kids trying to do the same thing in the same garage.  The day after the original four suicides, but in Illinois, two other teens suicided the same way (in a garage, in fact.)  Coleman writes that by checking newspapers, he counted 22 teen carbon monoxide suicides in two weeks-- 47 in a month.

But then there's the case of Barry Loukaitis, who in 1996 shot two kids and a math teach, and said he got the idea from Stephen King's Rage, Pearl Jam's Jeremy, Natural Born Killers and The Basketball Diaries.  Coleman writes that "the media attention...triggered a series of similar events."  So, in these copycats, was it  Basketball Diaries or the evening news?  It's hard for me to see how the news can be more influential to a suicidal kid than the movie itself-- do kids even watch the news?

In fairness, he does cite numerous examples of media reporting induced copycats (check out the chapter "Planes Into Buildings" for a wild ride) but overall the argument is weakened by using  both together.  I left the book reasonably convinced that media can inspire copycat violence, but not that they inspire violence itself.  In other words, I think those Werther scholars were going to kill themselves somehow, but they decided to shoot themselves (as oppposed to self-immolation) because of the book.

The distinction-- media or media reporting--  is important because the solutions are different.  Here's an example: the book opens with the story about how one month after Marilyn Monroe's suicide, 197 (mostly blonde women) "appear to have used the model," to suicide-- an increase in the suicide rate of 12%.  Furthermore, the suicide rate never went down after that.  "This is the copycat effect working with a vengeance."  Maybe.  Or maybe the graphic description of the suicide wasn't to blame, but rather that a huge icon had done it at all.  Are they copying her, or is society ripe for self-destruction?  Either way, should we not report that Monroe killed herself at all?  How much do you control information to protect the people?  If the government is doing the controlling, then I can't imagine the answer should be anything other than "not at all, get the hell out of my face."

I've always said that the "mainstream media" is neither liberal nor conservative-- they are sensationalist.  Of course I think they overreport, and overdramatize unusual violence.  But I see that as more of a symptom of our culture than the cause of anything.  You could close down all news portals, it won't change the amount of violence.  Sure, maybe you wouldn't have thought of playing Russian Roulette.  But you were going to come up with something. 

Coleman wrote a thorough book, using the type of diligent research the CIA is supposed to be good at: compiling open source information and forming links.  I only partly disagree with his conclusion, and I am still open to further arguments.  But I am against the solution.

It's worth remembering that, in response to the copycat suicides, Sorrows of Young Werther was banned in Germany.  I know I am one of only 8 people who has actually read it, but do we really want it banned?    Maybe "dangerous" books need to be delayed by a generation to be published?  And you see my problem.

Absent direct power or wealth, the only thing that keeps us free is information.  I believe it is worth the risk of copycat suicides, especially since influencing the choice of the method of suicide isn't the same as influencing the choice of commiting suicide. 

Have you heard about the nut who, after being diagnosed with a rare tuberculosis, takes two transatlantic flights?  Putting everyone at risk?  Especially after doctors managed to track him down in Europe to tell him his tuberculosis strain was "extensively drug [isoniazid and rifampin] resistant" and very dangerous, and ordered him into isolation?  Why would this nut do it?

The man told a newspaper he took the first flight from Atlanta to Europe for his wedding, then the second flight home because he feared he might die without treatment in the U.S.

He wasn't in the Sudan, or Kazakhstan-- he was in Italy. And he went to Prague to catch a plane to Canada SO THAT HE COULD DRIVE TO THE U.S.

I suggest everyone think long and hard about this, before we take any further steps down the road towards universal healthcare.   You can't give away what you didn't pay for.

 

5/31/07 Addendum:  AK (see comments) discovered that the guy is actually a personal injury lawyer.  That's irony.  And his new father-in-law is a CDC doc specializing in... go on, guess... 

 

 

 

 

Don't ask me about Iraq.

But I do know something about our collective response to the Iraq war, to the Bush presidency, and to our times, and it says a lot about our cultural psychology.  And it helps predict the future.

It's sometimes easier to evaluate one's personality, and thus make predictions about it, by examining the defense mechanisms the person uses.  In difficult situations, specific people will use a small set of specific defenses over and over; so much so that we often describe people  exclusively by that defense, e.g. "she's passive aggressive."

Taking Iraq and President Bush as starting points, and examining the defense mechanisms we use to cope with both, yields the unsurprising conclusion that we are  a society of narcissists.

While this discovery is familiar to readers of my blog, what might be a surprise is what this heralds for our society politically and economically.  It isn't socialism, or even communism, as I had feared.  It's feudalism.  It's not 2007. It's 1066.

Let's begin. 

 

 

As the thesis of this blog states: psychiatry is politics. 

I'd like to offer an idea for consideration.

The reason there's so much give and take about whether Cho was ill or not, and whether he was culpable or not, has to do with what psychiatry actually is: the pressure valve of society.

Our society does not have a good mechanism for dealing with poverty, frustration, and anger.  I'm not judging it, I'm not a left wing nut, I'm simply stating a fact; ours is not a custodial society, and it does little to "take care of" (different than help) these people.

So it has psychiatry, it fosters psychiatry, and it creates a psychiatric model in which these SOCIAL ills can be contained.

The inner city mom who smokes daily marijuana to unwind, with three kids who are disruptive, chaotic in school, etc-- society has really nothing to offer her.  But it can't let her fester, because eventually there will be a full scale revolution.  So it funnels her and her kids and everyone else like her into psychiatry.

Whether she "actually" has "mental illness" or not is besides the point.  Without the infrastructure of psychiatry, hers would be an exclusively social problem with no solution.  But with the infrastructure of society, her problem is no longer a social problem, and no longer the purview of the government (or fellow man, etc)--it is a medical problem.

Consider that one of the fastest ways for this woman to get welfare-- and ultimately social security-- is for her to go through psychiatry. 

So, too, the angry, the violent, the frustrated... 

Hence, discussions about whether mental illness reduces culpability are red herrings. It's about reducing culpability, it's about reducing society's obligation to deal with it.

Society is basically saying this (I'll quote myself):

...if they're poor or unintelligent, we will never be able to alter their chaotic environment, increase their insight or improve their judgment.    However, such massive societal failure can not be confronted head on;  we must leave them with the illusion that behavior is not entirely under volitional control; that their circumstances are independent of their will; that their inability to progress, and our inability to help them isn't their (or our) fault; that all men are not created equal.  Because without the buffer psychiatry offers, they will demand communism.

 

 

 

 

I know it looks like one, but it's not.  And why it's not makes every difference in predicting what will happen next. 

My previous post described the modern narcissist, which is slightly different than the kind described by Kohut and others.  In short, the narcissist is the main character in his own movie.  Not necessarily the best, or strongest, but the main character.  A narcissistic injury occurs when the narcissist is confronted with the reality that he is not the main character in his movie; the movie isn't his, and he's just one of 6 billion characters.

The worst thing that could happen to a narcissist is not that his wife cheats on him and leaves him for another man. He'll get angry, scream, stalk, etc, but this doesn't qualify as a narcissist injury because the narcissist still maintains a relationship with the woman.  That it is a bad relationship is besides the point-- the point is that he and she are still linked: they are linked through arguing,  restraining orders, and lawyers, but linked they are.  He's still the main character in his movie; it was a romantic comedy but now it's a break-up film.  But all that matters to the narcissist is that he is still the main character.

No, that's not the worst thing that can happen.  The worst thing that could happen to a narcissist is that his wife cheats on him secretly and never tells him, and she doesn't act any differently towards him, so that  he couldn't even tell.  If she can do all that, that means she exists independently of him.  He is not the main character in the movie.  She has her own movie and he's not even in it. That's a narcissistic injury.  That is the worst calamity that can befall the narcissist. 

Any other kind of injury can produce different emotions; maybe sadness, or pain, or anger, or even apathy.   But all narcissistic injuries lead to rage.  The two aren't just linked; the two are the same.  The reaction may look like sadness, but it isn't: it is rage, only rage.

With every narcissistic injury is a reflexive urge towards violence.  I'll say it again in case the meaning was not clear: a reflexive urge towards violence.  It could be homicide, or suicide, or fire, or breaking a table-- but it is immediate and inevitable.  It may be mitigated, or controlled, but the impulse is there.   The violence serves two necessary psychological functions: first, it's the natural byproduct of rage.  Second, the violence perpetuates the link, the relationship, keeps him in the lead role.   "That slut may have had a whole life outside me, but I will make her forever afraid of me."  Or he kills himself-- not because he can't live without her, but because from now on she won't be able to live without thinking about him.  See? Now it's a drama, but the movie goes on.

So if you cause a narcissist to have a narcissistic injury, get ready for a fight. 

Saddam is not experiencing a narcissistic injury: he is still the main character in the movie.  If he was sentenced to life in prison, to languish, forgotten, no longer relevant, no longer thought about, that would be a narcissistic injury-- then his rage would be intense, his urge towards violence massive.  But who cares?  There's nothing he could  do.

But remaining the main character, he has accomplished the inevitable outcome of such a movie: he has become a martyr.  Even in death, he is still the main character.  That's why the narcissist doesn't fear death.  He continues to live in the minds of others.  That's narcissism.

I'm not saying executing Saddam wasn't the right thing to do, and I'm not sure I have much to add to theoretical discussions about judgment, and punishment, and the sentence of death.  It doesn't matter what your political leanings are,  what matters is we look at a situation that has occurred, and use whatever are our personal talents to try and predict the future.

I understand human nature, and I understand narcissism.   And I understand vengeance.  Saddam was a narcissist, but this wasn't a narcissistic injury. 

This was a call to arms. 

We should all probably get ready.

 

 

 

 

from Pharmagossip, but also Dr. Peter Rost's site, edrugsearch (which actually has several rep-models), etc, etc.  She's a rep from Miami (where else) who won Miss FHM 2006.  

Meanwhile, Sunderland at the NIH plead guilty to "conflict of interest" charges-- he had received about $300k over 5 years from Pfizer while he was a director at NIH, but never disclosed the money. 

All of medicine has rules about disclosing financial relationships.  Any academic center, for example, requires you to list all financial entaglements that could be perceived as conflicts of interest, including grants, honoraria, stock holdings, etc.  The idea, of course, is that money can exert undue influence, and at the very least the people around you should be aware of any potential conflicts of interest.

This includes conflicts of family members.   If you are giving a Grand Rounds about how Zoloft is better than Lexapro, but your wife is a Zoloft rep, you could be benefiting financially by getting people to write more Zoloft which gets her bigger bonuses, so you have to disclose this relationship. 

But if you are dating a Zoloft rep, you don't have to.  There would be no way you could be profiting financially from her increased sales, and thus no need to disclose that relationship.

But there's the cryptosocialist hypocrisy.  If it was really about protecting the public from conflicts of interest, we'd have to disclose dating reps as well.  History is full of examples of people behaving unethically for the sole purpose of bedding a woman.  Want examples?  They all come from politics.  Still want examples?

So why aren't we worried that I'm praising Zoloft because my rep is hot?  Perhaps we should mandate all reps be ugly?  You know, to protect society?

This sounds silly not because hot reps don't have influence, but because we're lying: it's not the influence that actually bothers us.  It is specifically the money.  "It's not fair that a doctor gets all that money from..." 

So let's stop kidding ourselves, it's not about protecting the public after all; it's really about resentment that the doctor makes so much money off the people; that they get sent on trips first class while others can't afford healthcare; about the rich getting richer at the expense of the poor.  &c., &c.  Pick up any copy of the New York Review Of Books for further examples.

Taking the convenient moral high ground just because it has better soundbites ("the public has the right to know!") and saves us from having to perform any critical thought is lazy and unproductive.  If you want to argue that doctors make too much money or Pharma's profits are excessive, we can go down that road and try for an honest and productive debate.  But let's stop pretending these disclosure rules have anything to do with protecting the public from bias.  They have everything to do with the current zeitgeist of income redistribution and class warfare.
 

---

As an cultural observation, look for the drug rep to become the next fetishized job, like cheerleader and nurse.   A profession becomes sexualized not because the members are themselves hypersexual, but because they represent a particular balance of the "unattainable slut:" "sleeps with everyone but me."  "e.g. the only reason that bitch (nurse or rep) isn't sleeping with me is that I'm not a doctor."  In this way suppressed misogyny is given a cover story to make it acceptable.  It's narcissism protected by an "if only" delusion.  Violence is never far behind.

 

--- And there's your free association bringing me back to what I was really thinking when I saw Diana Chiafair's photo: marxism and healthcare reform.  Hot rep--> fetishized--> commodity fetishism.  Because we never see the labor that went into the objects, we never see that social relation; the laborer disappears, all that is left is the commodity to which we ascribe value-- fetishize it. 

 

 

This was an op-ed I had written two years ago.  In light of the 12th trial win for Merck (they chose to fight each suit individually, rather than settle a class action), I'm reposting it here.

 

Note the caption at the bottom.  This is an interesting cover.  No one would ever have thought to create a similar warning about the disastrous consequences of a poor fit for, say, Depakote.  We know it has side effects, but using it would never be disastrous, right?

But why would bad therapy be disastrous?  If psychiatry is so biologically based that the a bad  environment is not the main cause of illness, why should bad therapy be so powerful? If bad parenting can't cause ADHD, how could bad therapy make it worse?

 

"The Art of Psychotherapy".  Ok.  But why the "science of pharmacology?"  Because we sling "5HT2A" around like we know what we're talking about?

The sentence following that says, "Selecting patients for psychodynamic psychotherapy."    Young, attractive, white females, perhaps?  But they didn't mean that, of course.  It's just a picture. 

Almost no one appreciates-- and no one at all verbalizes-- how deeply the bias in psychiatry penetrates.  It is no coincidence that psychiatry has been mixed up with SSI, welfare, criminal responsibility, etc.  The "nature vs. nurture" debate is a red herring, a magician's distraction. It allows us never to have to say the following:

If they're rich and intelligent, and can understand how their behaviors impact their moods, we can help them to help themselves.  And they won't want to take meds that cause side effects anyway.  

But if they're poor or unintelligent, we will never be able to alter their chaotic environment, increase their insight or improve their judgment.    However, such massive societal failure can not be confronted head on;  we must leave them with the illusion that behavior is not entirely under volitional control; that their circumstances are independent of their activity; that all men are not created equal.  Because without the buffer psychiatry offers, they will demand communism."

Turns out that  Plan B emergency contraception does not reduce pregnancy rates.  Big surprise.  But the one difference was that those with easy access took it more often.  (News article here.)  So I stand behind my earlier question: why do oral contraceptives require a prescription, but this doesn't?

Coupled with the fact that 50% of abortions are done by women who have already had one abortion at least, and 18% are on their third or greater,  and you have a social policy problem on your hands.  While everyone is busy with political nonsense, we are missing an important segment of the population that is simply not taking responsibility for their behavior.  Having three or more abortions in the United States has exactly nothing to do with abortion rights or women's health issues or access to contraception.

 

Oh, but it will be okay, won't it?  OB/GYN will lead the charge?   Sure.  Context is everything: in the same issue of Obstetrics and Gynecology from which the above study came is an editorial by Douglas Laube, MD, President of ACOG.  He suggests that OB/GYN has lost its way: med schools are not attentive to "differences in gender biology" (seriously.)  And he suggests doing something about it:

I will create a task force to assess whether our specialty should adapt behavioral assessment techniques to evaluate candidates’ suitability as women’s health care providers.

I wonder if "suitability" will include social/political beliefs?

Well, he does quote Isaiah Berlin, who

"set in motion a vast and unparalleled revolution in humanity’s view of itself." 

Unparalleled?

"His lectures helped to destroy the traditional notions of objective truth and validity of ethics..."  

So, even if true (it's not,) is that supposed to be a good thing? 

He's also upset that America doesn't pay its elementary school teachers enough.

Oh, and he closes his editorial with a quote "by the prophet Muhammed." Outstanding.

-------

Addendum:  Let me explain what I mean by that last sentence, again, it's context:  he's not a  Muslim.  He is (was) a Lt. Commander in the Naval Reserve.  Are you telling me that in all of literature, the only quotation he could find to express his point is that one?  Does he have a copy of the Hadith handy?   What would you say if Mubarak (Pres. of Egypt) closed a speech with a quote from Augustine's Confessions?  This is obviously a ploy, a pretense, he wants to show he transcends the childishness of politics and religion, he's about humanity.

That's where it all falls apart, that's where it stops being science and starts being dangerous.

I looked through six other articles/addresses by him; he seems to be a rigorous and thoughtful clinician and educator-- but-- and this is the but that is killing medicine and society-- he, like so many other doctors, wants to be a social policy analyst.  No, no, for the love of God, no.

Here's a question: can an antipsychotic be an antidepressant?  Why, or why not?

The correct answer is that the question is invalid, because there is no such thing as an "antipsychotic" or an "antidepressant."  We (should) define them based on what they do, not what they are.  Therefore, Wellbutrin and Effexor are both antidepressants if and only if they both treat depression-- not because of some element of their pharmacologies, which are anyway different.  Strattera, on the other hand-- which has a pharmacology (in some ways) similar to Effexor-- is not an antidepressant, only because it doesn't treat depression.

Following, just because something is called an antidepressant, or antihypertensive, it doesn't necessarily take on all the other properties or side effects of the others in its "class."   Not all "antidepressants" have withdrawal syndromes (only SSRIs do).  Not all antihypertensives cause urination (only diuretics do.)  You wouldn't dare put a "class labeling" on "antihypertensives" of "diuresis."

So you see where I'm going with this-- except you don't. 

I've previously yelled about the inanity of "antipsychotic induced diabetes" or "antidepressant induced mania" when they ignore pharmacologies, doses, and, of course, actual data.

But today I saw something that I now understand to be one of the signs of the Apocalypse.  It is the new package insert of Seroquel, which just got a new indication for the treatment of bipolar depression.  The new PI reads:

 

Suicidality in children and adolescents - antidepressants increased the risk of suicidal thinking and behavior (4% vs 2% for placebo) in short-term studies of 9 antidepressant drugs in children and adolescents with major depressive disorder and other psychiatric disorders.  Patients started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior.  Families and caregivers should be advised of the need for close observation and communication with the prescriber.  SEROQUEL® is not approved for use in pediatric patients. (see Boxed Warning)

 

Stating the obvious: in none of these 9 studies was any patient actually ever on Seroquel; Seroquel itself is not associated with a risk of suicide; it's not even been tested for major depressive disorder; and, well, this isn't very rigorous science, is it?

Just because a is now called an antidepressant, it carries the same risk as the SSRIs? (Whether even SSRIs have this risk is besides the point.)  Isn't that, well, racist?

This is not really about preventing suicide.  If we were worried about suicide, really, then why 24 hours before the FDA posted this warning, no one cared about Seroquel's doubling of the suicide rate?  Oh, because it doesn't actually double the suicide rate?  Die.

So the game is clearly not about science, it's about politics, it's about liability, it's about money. 

If this was honestly about about protecting children from suicide, we'd shrug our shoulders and say, "well, they're just very, very cautious, so we'll be careful and keep going."  But that's not what this is.  What this is factually inaccurate, misleading, and therefore more dangerous, more harmful.  In a simple example, this warning protects no one for a risk of suicide-- no potentially suicidal patient is going to look at this and say, "well, crap, I'm not taking this."  But it may prevent someone from taking it when they could actually benefit.  See?

This is Structuralism gone very badly awry, Saussure  just bought a pick axe and he's come looking for us all.

Psychiatry is politics, it is politics in the way that running for office is politics.  It is not a science, it is not even close to science, it is much closer to politics.

A doctor makes a diagnosis of a patient and writes it down on the chart.  If it were science, then I should be able to evaluate the patient myself and come up with the same diagnosis.  If it is a science but not an exact science, I should be able to come up with the same diagnosis most of the time, and the other times where I disagree I should be able to see why the other person thought what he thought.

But if I can guess the diagnosis without actually seeing the patient at all—but by knowing the doctor—then we do not have science, we have politics.

If you are watching the TV news with the sound turned down, and a Republican senator is talking, and the caption reads, “Tax Breaks for the Rich?” you can guess  his position.   In fact, the actual issue doesn’t matter—what matters is his party affiliation.  Everything follows from there.  Not always, certainly, but enough times that you don’t bother to turn the sound back up on the TV.

Psychiatry is the same way.  It is very easy to determine who is considered a “great” psychiatrist, or a “thought leader in psychiatry” based on who is making the evaluation, and not on any merits of the psychiatrist himself.  Down one hallway Freud is lauded; down the other he is villified; Kay Redfield Jameson is the hero.  But their value, of course, is not at all dependent on what they did—it is dependent on who you are.  Ronald Reagan was either a god or a devil depending on who you are, not who he was.  It doesn’t seem to matter that most people can’t  name one specific thing he did in office, what wars and battles he presided over, what he did or did not do to taxes.  Ronald Reagan isn’t a person, he is a sign.


It’s even possible for me to guess the medications a patient is taking based solely on who prescribed them, and not on the symptoms of the patient.  Importantly, the possible medications vary widely from doctor to doctor; it is wrong to think my predictive accuracy is based on any fundamental logic or science to medication selection that should be true across all psychiatrists.  It's just his regular, unthinking, habit.  "I like Risperdal."  Are you an idiot?  Are there internists  saying, "I like insulin?"

Let me be clear: I’m not talking about doctors having unique insights into which medication might benefit a certain patient.  (“I think Geodon could work really well here.”)  I’m talking about each doctor having a set of drugs he prescribes with such regularity that I can guess them.  

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It stems from a lack of appreciation that mental illness is not a genetic disease, or even primarily a biological one, or even, surprisingly, a psychological one.  It is a social disruption.  On a desert island, no one can tell you are insane.

The key evidence against my position is that biology is so obviously relevant. There is a hereditary component to many mental illnesses; twins raised apart still often have higher concordance rates than non-twins.  But this misses the point of the problem entirely.  Consider diabetes: it is obviously a biological disease, with a heritable component.  Much more biological than any mental disorder, because you can point to the dysfunctional biology in diabetes, but you can’t do that in bipolar disorder.  But despite this biology, the environment is so massively important as to often overwhelm this biological component.

We can consider even further the actual relevance of genetics.  Things that we assume are simple genetic outcomes are often more complicated than they seem.  Eye color is every 7th grader’s primer for Mendelian genetics.  But—surprise—there is no gene for eye color.  There are in fact three genes for eye color, and the color is determined by the interplay of all three.  So while you can guess eye color based on the parents, you are not always right—because each parent is giving three different genes.

It may be, in fact, true, that bipolar disorder is genetic.  Perhaps overwhelmingly genetic, let’s say 40%.  We go wrong because we consider genetics a “fixed variable”—we think we can only affect the other 60% of the factors.  Right?  Wrong; genetics is not fixed.  Having a gene may be a fixed, but whether you express this gene or not is most certainly under outside control.  Consider gender; absolutely genetic, correct?  Not much one can do about it?  But lizards can alter the sex of the progeny by changing the incubation temperature of the egg.  Think about this.  Now, is it not probable that the expression of the genes for bipolar have a lot to do with how you are raised?  And we already know that environment affects gene expression, so I’m not speculating here.

I was emailed a link to a 2003 article in the Psychiatric Times, which describes a maddening report out of California is so blatantly politicized that Arnold himself is embarrassed.

The report says, insanely, that there are not, and will not be in the future, enough psychiatrists to meet the needs of California.   (Actual report PDF here.)

Well, not exactly true, is it?

When you say shortage, what do you mean-- 5000 psychiatrists for one state isn't enough?  Oh, you mean that for some inexplicable reason, 63% of the entire state of California's psychiatrists work in the Bay Area or LA?  Sounds like you have plenty of shrinks, they're just not distributed very evenly.  Why would that be?

48% of all psychiatrists in California are in a solo or 2 physician practice.  Hmm. 75% were male, 65% white.  Hmm.  Perhaps the problem is that your solo psychiatrists want to work in a nice area with good pay, and not in an inner city where-- ironically or tragically, your choice-- the need is greatest but the pay is least?

The nuts filing the report continue to lament that there aren't enough child and geriatric psychiatrists.  Enough for what?  Oh-- enough for Medicaid and Medicare.  What did you expect?  After suffering through a Child psych fellowship, why would go work for peanuts in a community mental health clinic, where you have a better chance of getting stabbed than getting rich?

Their complaints are misplaced and deluded.  They do not reflect reality.  Let me give you reality: the shortage exists in community (read: Medicaid) mental health, primarily because the pay sucks.  But even there, the problem is not as dire as they make it sound.  

First, even if there are numerically more psychiatrists seeing private patients, the community mental health psychiatrists see many, many more patients in a day.  I'm going to guess the ratio is five to one. (Oh, you're upset they see them in ten minute intervals? When you give them a case load of 3000, what did you expect them to do?  Psychoanalysis?)

Second, psychiatrists aren't the only ones providing "community mental health."  Advance practice nurses (APN) and nurse practitioners (NP) also prescribe medications; in some states physician assistants can prescibe; and very soon psychologists will be able to prescribe, as they already can in New Mexico (and I think Louisiana.).  (Care to retract your asinine prophecy, "the center predicts that there may actually be too many psychologists in the future.")

Third, primary care docs handle far more psychiatry than we can imagine. They just can't bill for it.  (And so how good a job are they incentivized to do?)

The shortage is for "psychiatrists" proper (i.e. MD/DOs), not "providers of psychiatric medications." 

The question then, uniquely, is whether we need psychiatrists proper at all to do community mental health.  Are community mental health psychiatrists, as a group, better at diagnosing and treating than anyone else, for example an NP?  Sadly, the answer is currently undeniably no. No one reads anymore, no one studies, and worse, the half-learned information that still lingers is so incomplete as to be misleading.  Post residency, we get our info exclusively from drug reps and throwaway journals.  Ergo, most residents are better psychiatrists than someone in practice ten years.

Woah-- be careful.  Think long and hard before you hurl "clinical experience is more important" at me.  Make sure you want to go down this road.

I am certain that I can take anyone with a college degree in any science, and in four months make them better than an above average psychiatrist.  This is an open challenge to the APA.  I'll repeat it: I'll take any person with a B.S. and in four months make them an academic psychiatrist.

But back to our "shortage" problem, or more accurately our distribution problem.  The solution to this is elementary, but bitter.   Either raise the standards necessary to be a practicing psychiatrist-- more audits and tests, greater documentation in notes, recertification exams with consequences to failing, and outcome/performance evaluations graded against other psychiatrists-- but also raise the pay, dramatically-- you can use the prescription drug savings when you implement my other plan-- so as not to lose the smart people to internal med or neurology; or lower the requirements so that more people can be prescribers, and lower the pay so that you can afford more of them.  Either of these two will satisfy the growing "need."  Which is better for the patient is up to California to figure out.

Merck's previous win in the Vioxx suit gets thrown out because the judge was concerned about the new criticism of the NEJM study.

What happened is an idiot's guide to forensic computing.  Greg Curfman, executive editor of NEJM, was going to give a deposition in the trial of Frederick Humeston, an Idaho postal worker (or he was just curious about the data after Vioxx was pulled-- depends on which story you read) and so pulled the manuscript.  Back in 2000 you'd submit a paper copy and a disk; NEJM says they worked off paper, so the first time they looked at the disk was Oct 5, 2004 (days after Vioxx was withdrawn.)

 

Here's the fishy part: on the disk was a table called "CV events," which was blank. 

Time stamps in the software indicated that the table was deleted two days before the manuscript was submitted to The New England Journal on May 18, 2000. "When you hover the cursor over the editing changes, the identity of the editor pops up, and it just says 'Merck,'" Curfman says.

What's so terribly misleading about this and NEJM's "Expression of Concern" is this statement:

We determined from a computer diskette that some of these data were deleted from the VIGOR manuscript two days before it was initially submitted to the Journal on May 18, 2000.

This isn't true.  First, the missing MIs were never in the table to begin with.  Second, the table was deleted, but the data itself was still in the paper. 

 

Now it is obvious the study attempts to minmize the thromboembolic risks.  What do you expect from an academic study? Let me assure you-- if you think drug reps are biased, go find yourself a professor.   So I acknowledge the criticism that the study is misleading.  But.
 

But it's the social policy angle that gets me, the moralistic high ground of journal editors who are far worse than study authors.  The gateway to hell is peer reviewed. 

The article says Curfman was deposed by plaintiff's lawyers.  Was Curfman paid by them?  It doesn't mean he's biased, but if you have to disclose Pharma sponsorship, don't you think you should disclose lawyer sponsorship?  (and I am looking to find out if he was indeed paid.)

As I have absolutely no interest whatsoever in the actual outcome of these trials-- my interest is really about how doctors butcher science and promote themselves to senators-- but, we should take a look at what this revelatory missing data says.

What they found was that with the inclusion of the missing data, the rate of heart attacks would have been 5 times greater than naproxen, not 4 times.  0.5% vs. 0.1%.

Just to put this in perspective, of course, you should know that the missing data was three more heart attacks, raising the number of patients with MI from 17 to 20 (out of 4000+ patients), vs. 4 in tha naproxen group.

BTW, "five times" and "four times" may sound like big differences, but they do not even approach statistical significance in this study. 

BTW, strokes were the same in both groups.  Not that anyone cares, of course.

"In a long overdue concession to science, the Food and Drug Administration could finally, grudgingly, be ready to allow an emergency contraceptive to be sold without a doctor's prescription." (USA Today Opinion 8/2/06)

"Concession to science?"  Wow!

I have admittedly almost zero interest in the way Plan B has become a proxy war for anti/pro abortion armies.  But when  doctors become social policy analysts I take note.  

Why are "scientists" saying that this drug should be sold without prescription?  Why should oral contraceptives require prescription, but this should not?  Or, to reverse it, if this doesn't need a prescription, then what does?  How do we decide what needs a script and what doesn't?  Expediency?  Political advantage?

The argument that this is an important option in the event of a pregnancy scare is premised on the notion that Plan B will be rarely used.  This is false. It overlooks a very key point: every unprotected sexual intercourse is a pregnancy scare.  And people usually have a lot of sex.

Look at it this way:

Before Plan B: you're a woman, you have sex.  You're worried-- not really worried, it's not the "right time of the month," he pulled out, etc, etc, but it's in the back of your mind.  But there's nothing you can do, too late now, so you just wait it out.

After Plan B: you're a woman, you have sex, etc, etc, but now exists a safe, non-prescription way to ensure you don't get pregnant. Why wouldn't you take it, just in case?  Even if the chances you are pregnant are really small-- Why not?  What does it hurt?  It's safe, the FDA said so, and even put it over the counter.  A little nasuea to guarantee you don't get pregnant?

See?  It's a no-brainer.

But what about the next night?  And the next?  What if you have sex-- 10 times a month?  It's not frequent enough to embark on the oral contraceptive-- after all, you don't have that much sex, you can't afford to go to the doctor, you don't have the time, etc-- but you know, Plan B is available in seconds...  Why not?

I know men who take Viagra "just in case."  (And that requires a prescription.)  You think this will be different?

Look, Plan B might actually be safe, even if taken every day.  But isn't every-day-Plan B chemically identical to an oral contraceptive-- which requires a prescription?  And if it isn't safe taken daily, why wouldn't a prescription be required?  I should point out that Plan B actually has three times more hormone in it than an oral contraceptive.  Hmm.  Is taking three birth control pills a day safe?  Anyone?

Again, this isn't about whether Plan B is moral or a social necessity-- something on which doctors are no better equipped than lumberjacks to pass judgment.  This is about whether Plan B should need a prescription, based on the drug's safety.

This isn't about women's rights or abortion or anything else.  It's about "scientists" picking and choosing what they want to believe; about becoming intoxicated with the power to drive social policy, and manipulating the infrastructure of the discipline to generate a smokescreen of science to support them.

Remember: these are the same people who discovered (read: decided) Vioxx causes heart attacks and Zoloft drives people insane-- years after their release-- but Plan B is so safe it doesn't need a prescription.

If I were a class action lawyer, I'd start clearing my desk...

 

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Levonorgestrel: WHO recommends 1.5mg as a single dose; "Plan B" is .75mg in two doses (12hrs apart.)

Assume the average OCP has 0.25mg of levonorgestrol. (a levonorgestrol-only OCP, called Microval, has only .03mg).

 

Addendum 11/24/06:  Turns out that  Plan B emergency contraception does not reduce pregnancy rates.  Big surprise.  But the one difference was that those with easy access took it more often.  (News article here.) My post about this here.

This time by one of our own (academic psychologist, Harvard) in an Op-Ed, entitled, "I'm Ok, You're Biased."

 

The premise is summarized here:

Doctors scoff at the notion that gifts from a pharmaceutical company could motivate them to prescribe that company's drugs, and Supreme Court justices are confident that their legal opinions are not influenced by their financial stake in a defendant's business, or by their child's employment at a petitioner's firm. Vice President Dick Cheney is famously contemptuous of those who suggest that his former company received special consideration for government contracts.

 

Which would be an ok, if not tired, set up, except for the very next sentence:

Voters, citizens, patients and taxpayers can barely keep a straight face. 

It's the populism of the message that is laughable.  So doctors, lawyers, Supreme Court Justices and others have no idea that they're biased, but the average joe does?  Seems pretty unlikely.  But-- maybe they are biased and it's okay.

And the proposed solution, of course, is the same knee jerk ineffectual nonsense proposed before:

In short, doctors, judges, consultants and vice presidents strive for truth more often than we realize, and miss that mark more often than they realize. Because the brain cannot see itself fooling itself, the only reliable method for avoiding bias is to avoid the situations that produce it.

 

There's that determinism so popular among those who feel powerless. 

I hope that the irony of the NY Times, through a psychologist, preaching about objectivity is not lost on anyone.  It is so bad at that paper that both the right and the left simultaneously blast it for overt bias.  No wonder that the NY Times stock has lost 50% of its value in two years.

Why not discuss the bias of journalists?  Or, more importantly, why are they assumed immune from it?  This isn't an idle political question, it is the very essence of this debate.

I'll state it explicitly:  first, the reason it doesn't matter if doctors are biased (and why it matters very much if journalists are) is because medicine is supposed to be a science. If it is a science-- receptors and all-- then it shouldn't matter what I think, it should matter what is true.  I can delude myself and say that seizure drugs are mood stabilizers for the long term; but that doesn't make it true.  But if you want to actually see if it is true, you have to look it up.  And don't come back with "one negative study doesn't disprove its efficacy."  This is science again: it's not up to me to disprove its efficacy, it's up to you to prove it has any.

So the real question isn't bias, it's whether medicine in general is paying attention to its own data.  Do we read our own studies, or hope the "thought leaders" will, and then write us a synopsis?  Do we believe it because Harvard said so? Is this science, or a cult of personality?

 

Second, when discussing medicine, the question of bias is not the important one. Yyou have to ask what the harm is.  Thie bias isn't harmful to science because science should be able to stand on its own.  The bias is only harmful to patients-- so the real question we should be asking is not if there is bias, but if it harms patients.  Ready: pretend a family doc gets paid $800,000 by Pfizer to prescribe only Lipitor, no Zocor, Mevacor, etc.  What, exactly, is the harm?  It's not snake oil: in all the anti-pharma controversy, no one is accusing them of selling a product that doesn't do what they say it does.  So unless you can tell me which patient shouldn't get Lipitor, but should get Zocor, then you can't argue this hurts the patient.  I'm not saying it isn't sneaky, or unethical.  But unless you can show the harm, you can't say it's harmful.  That's what's relevant.

 

But we're not really worried about patients, are we?  That's a screen.  What this is all about is our own impotence; anger against people who are perceived to have power.  We don't even actually believe our own nonsense.  This is the same argument against Vice President Cheney.  If everyone is so sure that the Iraq war was about oil and Halliburton, why didn't everyone buy Exxon and Halliburton stock back in 2002?  It's fun to criticise, I know.  But belief without follow through is pointless.  If you're not willing to act on your own beliefs, why should anyone else even listen to your crazy beliefs?

 

I'm not saying doctors and politicians aren't biased.  I'm saying we should worry about the things that actually matter.  Want to start somewhere, Daniel Gilbert? Academic medicine, and the journals that are their propaganda arms.  These people aren't scientists, they are science journalists.  And they are very much biased. Don't believe me?   Call me when you look up everyone's supporting references.

 

 

if CATIE is so important, and was funded by the NIMH (i.e. taxpayer dollars), why isn't it available free on the CATIE or NIMH websites?  Or anywhere else?  Snakes.  All of you are snakes.

For those who live and breathe the abortion debate, it may be worthwhile to personalize the issue and see if anything changes. Certainly, Rick Santorum has done this.

If you do not already know the story, Senator Santorum told it himself on Fresh Air in September 2004. Briefly, at approximately 20 weeks gestation, he and his wife learned the fetus had a terrible disorder that would likely result in the fetus’ demise. They had three choices: carry the fetus to term, when it would inevitably die; abort the fetus; or try a risky surgery on the fetus (which was still inside the womb) which had a low probability of success. The Santorums, true to their faith and their principles, reasoned thusly: if this was a five year old child, there would be no debate. They went with the surgery.

As tragedies go, this was a big one, as the surgery failed, the fetus died, and the mother suffered complications. However, the story clearly indicates how one should reason if one believes life begins at conception. This is the point for the Senator; it is illogical to argue any differently. If we are debating the abortion issue, this is a hard argument to rebut.

But I am not, here on this blog, interested in the abortion issue specifically; I am interested in another question. It is this:

Who pays for this surgery?

It is not an academic question. Senator Santorum has the benefit of almost infinite medical resources. If we are going to force Medicaid patients to make a similar choice, we have to ask this practical question.

Many are not going to like having, depending on your perspective, a moral or privacy question reduced to money; but that is precisely the problem. Accountability. In the end, someone has to pay.

Only the schizoid will argue that abortion should not be an option even when the mother’s life is in mortal danger; and only the amorally unrealistic will fail to realize that there is something psychologically wrong with a woman who has had three, four, five abortions. (This is not so unusual: it is 18% of all abortions.) You may think it is your right to have as many abortions as you need, and you may be right; but there is still something wrong with you.

Not permitting abortions requires an explanation of how we're going to pay for surgeries like the Santorums's. And if you want to keep abortions legal, you have to tell me how we're going to pay for them; or for any complications that result from them.

Either healthcare is a right, like due process; or it isn’t, like driving. Either one you pick, you must be accountable for the consequences of your selection, for example, its effect on the abortion question; similarly, your stance on abortion must include an discussion of cost. Even if this is,a fter all, a moral question, someone still has to pay for it. I recognize this tarnishes the purity of the academic dialogue. It’s not pretty, it’s not clean, but it’s reality. And if you think that money is not a relevant factor here, then it almost certainly means you are not going to be the one who will have to pay.

This applies to other questions beyond abortion, of course. If someone discovers a cure for AIDS, but it costs ten million dollars, does everyone get to have it?

When the universal healthcare nuts draft a plan that includes how they are going to pay for the unintended consequences of an insufficiently reasoned abortion provision (or restriction), give me a call. Until then, wovon man nicht sprechen kann....