June 20, 2007

Dr. Nasrallah Asks Questions That No One, Including He, Wants Answered

But I'm going to try.

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

  • Why did TV commentators assume the crime was caused by “evil” and “psychopathy,” instead of a medical illness in a young man with many psychiatric manifestations?

Because that’s the logical assumption.  The two are not mutually exclusive as implied by the question, and, while "evil" and "psychopathy" are attributions, medical illness requires a basis in pathology.  Commentators could not have known whether or not he was medically ill, nor if this illness had anything to do with the violence, but it is definitional that the act was evil.

Reversing the question reveals the fault in logic: why didn’t commentators assume he was mentally ill?  Is that the default assumption in the absence of evidence?


  • Why do most people assume that a psychotic individual driven by delusions is too “incompetent” or “confused” to plan and carry out a complex series of deadly assaults?

Does anyone assume this?  This is a straw man argument.  What is really being asked is: why do people assume that if the attack was complex and deadly, it had to be done by an evil mastermind, not a psychotic person?  And no one assumes that, either.  The question is sleight of hand; it tries to make the issue binary, psychosis vs. evil.  The two are not necessarily correlated in either direction (right?)  

As above, reverse the question to see the logical flaw: should people assume that complex, deadly attacks are the work of someone who is psychotic?   Is psychosis—or, indeed, any mental illness-- a risk factor for extreme violence?  That doesn't bode well for a society with "25%" mentally ill, as  claimed below.


  • Why did the mentally ill student receive no follow-up care before the crimes, even though he had received psychiatric treatment?

Perhaps he didn’t want any follow-up care?  I know: “but look what happened!”  Perhaps we can envision a scenario where a group of experts make a judgment about someone’s dangerousness in the absence of a crime or any concrete evidence (which would allow ordinary legal channels to be used), and then can commit, or restrict this person’s freedom, until they are no longer considered dangerous.  We already have this: it’s called Guantanamo.  And before you say there’s a difference, let me assure you there is not.  Quis custodiet ipsos custodes?

(NB: the context of the quote by Juvenal has an interesting parallel: it is about enforcing morality.   “My friends always tell me, lock her up! Restrain her! But who watches the watchmen? The wife will then start with them...”)

Several issues are being mashed together to extract the favored response, “we need better mental health care.”  But it's not valid.  If a psychiatric patient commits murder, he goes to jail. If you have good reason to suspect he is about to murder, you commit him. If you feel he is about to murder, but do not have enough evidence to commit him, you contact whomever is necessary (potential targets, etc).  And if he is a student, you tell the administration so they can put him on temporary leave.  

This is key: it is morally wrong, not to mention illegal, for a psychiatrist to force a person to get treatment he does not want.   But it is entirely legal, and desirable, for a school to insist that a person receive treatment as a necessary condition of returning to the school— if and only if there exists a risk towards others.


  • Do medical record requirements in the Health Insurance Portability and Accountability Act (HIPAA) protect individual privacy at the expense of public safety if a patient is seriously mentally ill?

No; did any one say they did?  If we have reason to suspect imminent risk of harm to self or others, we have multiple avenues/obligations to deal with the situation, confidentiality and privacy be damned.  In fact, if psychiatrists simply feel a person is dangerous in the absence of any concrete evidence (direct threats, storing weapons, etc), they can “violate” the patient’s (constitutionally non-existent) right to privacy.  They can tell anyone they need to—the school, parents, whomever.  What psychiatrists can't do is lock them up or commit them, or force them to take drugs, just based on their “feeling,” without a solid reason.  And thank God.


  • If the university administration had known about the student’s psychiatric disorder, would he have received better treatment and supervision? Or would he have been stigmatized or expelled, whether or not he responded well to medications and counseling?

What, exactly, is meant by “psychiatric disorder?”  Schools don’t expel people because they have a mental illness; they expel them because they are dangerous to have on campus.  If Cho had been determined to have been dangerous—regardless of the cause, whether it be mental illness, drugs, or Satan’s direct influence, why shouldn’t he be at minimum suspended? (This is very different than being suspended simply for having a mental illness.) 

I’ll repeat: it's not discrimination because he has a mental illness; it's discrimination because he is thought to be dangerous, regardless of the reason.

We can’t force him to get treatment, but neither do we have to tolerate his Oddboy, knife wielding nonsense.  Being on campus is a privilege, not a right.  He either stops, gets treatment, gets a girlfriend, whatever-- or he gets off campus.

  • How can roommates or teachers receive adequate information to help a mentally ill student or monitor for treatment adherence when HIPAA rules prevent even families from knowing details of mentally ill adults’ diagnosis or treatment?

I’m not sure how many different ways this question is wrong, but six is a fair guess. Why should roommates receive any information? (Or, if things are so bad that they should be receiving information about the person’s mental state, shouldn’t someone else be involved?)  Is the dissemination of information for the benefit of the patient, or the protection of everyone else?  It's different information.  Why is it roommates’, or teachers’,  or the schools’ responsibility to help monitor treatment adherence?   If they are “helping” monitor for treatment adherence, are there any repercussions for failing to do this? 

This is the creep into a custodial society, the social consciousness flip side of Bush style privacy violations.  I know it looks like we want this; I swear to you we don't.


  • Because the home-to-college transition can be very stressful, should colleges require freshman courses on how to recognize distress and seek help?

My head just detonated.   How many credits will this be worth?  Is there a test?


  • Given that schizophrenia, bipolar mania, and psychotic depression often emerge between ages 18 and 25, why have colleges and universities not adopted early screening and intervention?

Because they are colleges, not health maintenance organizations.   They don’t screen for pregnancy, STDs, lymphoma… By the way, if the university administration did screen for students’ psychiatric illnesses, are you obligating intervention?  If the student refuses, then what?  Expulsion? 


  • Are mentally ill persons more dangerous than the general population, or is that perception based on highly dramatized media reports of isolated incidents?

This question should have been asked first.  If they are more dangerous, then this debate is really about screening for mental illness as a risk factor for violence.  It means that it is ok to expel people for having a mental illness; for more aggressive commitment and supervisory maneuvers; for, well, Kansas v. Hendricks.  If you want to go down this road, good luck, I’ll wait for you in Russia.  But if they are not necessarily more dangerous, then most of your other questions are moot; we should be treating mental illness, not violence; and we should be dealing with violence as violence, not as the inconvenient symptom of mental illness.


  • When will health insurance cover brain diseases that manifest as thought disorders or behavioral aberrations, such as schizophrenia or obsessive-compulsive disorder, in parity with brain diseases that manifest as muscle paralysis, such as stroke or multiple sclerosis?

When you can show that they are diseases, not heuristic labels of behaviors.  Schizophrenia is easy; what about ADHD?  Should it be covered in parity with strokes?  Asked another way: given finite resources, are they better allocated towards the treatment of strokes or ADHD?  I’m not making a moral judgment, I’m asking about practical outcomes.  Do you get the same outcome for your dollar in ADHD as in strokes?


  • Given that >25% of the U.S. population has a diagnosable and treatable mental disorder, why is our mental health system so fragmented, so inadequate, and so underfunded? And why is there no public outcry to fix it?


25% have a diagnosable mental disorder?  What definition are we using here?  If we are talking about the DSM, then does voyeurism count?  (NB: I refuse treatment.)

As evidenced by this editorial, more and more behaviors are classified as, or at least taken as prima facie evidence of, mental disorders.   Following, it is a simple exercise to determine that, in fact, 100% of people have a diagnosable mental disorder.  100% of people have a medical disorder as well, if it includes the disorder “pain.” 

It’s sleight of hand.  Psychiatry can help these 25% (or 100%), regardless of whether they really have a “disorder” or not.  But that doesn’t identify them as necessarily the realm of medicine or psychiatry.  This is the "mission creep" of psychiatry-- away from biology, as it claims it relies upon, and towards an instrument of social change.  Perhaps it can tackle poverty, globalization, and terrorism next?  Furthermore, labeling (not discovering-- labeling) something as a psychiatric disorder is done to imply exclusivity: e.g. if it "was" mental illness, than it wasn’t evil.  People will dispute me on this, but re-read this editorial, its point is exactly this distinction.


  • Finally, as a parent and husband, I have one last question: how can we console the bereaved families of the Virginia Tech students and faculty who suddenly lost a son or daughter, husband or wife in the prime of life?

One way would be to not reduce what happened to the simple result of an untreated illness.  “If only he had been in treatment.” Really?  Is that all it takes?


  • For them, improvements in mental health care on our college campuses will come too late.
And for the rest of us, these "improvements" come perhaps too soon.