Tuesday, December 29, 2009

Take A Hike!

As New Years' rapidly approaches, I offer some thoughts on those curious resolutions that predominate this time of year. Some of the most common resolutions, per most surveys (including the American Psychological Association), are lose weight, quit smoking, exercise more, reduce drinking, reduce stress, improve finances.

Why do we make resolutions? Maybe it is to justify (or as a response to) our indulgent behaviors between Thanksgiving and New Years? Perhaps it is the decreased structure of that same time frame. Biologically, maybe it's a response to a cyclical down time brought on by shorter daylight periods. Psychologically, there is something appealing about new beginnings; the idea of starting over with a clean slate--perhaps it's just optimism for the future. And that coincides with the looking back that occurs at the end of a cycle, so we have the knowledge of our transgressions, and the opportunity to make amends.

The ability to make these resolutions stick is covered commonly in many magazines and newspapers on the grocery store check-out aisle. I would direct you to Dr. Wallin's nice summary of advice in this area.

I offer only one suggestion: walk. Walking is an excellent form of exercise, that is not very hard on the body, and is second only to swimming in low impact bang-for-your-buck exercises. It makes an excellent distraction from cravings for nicotine, alcohol, or food, and can activate neurochemical pathways to directly assist in those areas. Similarly for stress reduction. Exercise has been shown to improve outcomes in double blind, placebo controlled studies of treatment of depression, as both an adjuvant and stand alone treatment. An interesting article on that can be found here.

So regardless of whatever other resolution you may be making, or if you're just looking to burn off some of that Holiday Fruitcake, I suggest slipping on a pair of sneakers, and hitting the treadmill or sidewalk for 20-30 minutes a day.

Happy New Year!


A note to those who queried: I have learned that in order to blog, I must be in the appropriate "headspace." Suffice it to say that life has sent enough medical issues (amongst persons close to me) over the past few months, that there was insufficient room in the headspace for keeping up with a medical blog. I appreciate all of the encouragement and well wishes. I shall attempt to resume normal programming- which means blogging on an irregular basis; i.e. whenever I darn well feel like it!

Thursday, September 10, 2009

Suicide Prevention Day

A couple of thoughts:

1. There are many who are killing themselves slowly, this is also a form of suicide in my opinion.
2. Many who complete suicide often tell others of their intention to do so beforehand. Please always take such statements seriously, and encourage immediate help.
3. If you are a treating physician, counselor, friend, family member or otherwise close to someone who has completed suicide, find someone to talk to about it.
4. They say there are two types of psychiatrists, those that have had a patient commit suicide and those that will have a patient commit suicide. For many of us, this is the ultimate sense of failure in our profession. That is sad, but understandable.
5. 1-800-273-TALK is the number for the National Suicide Prevention Hotline

Tuesday, September 8, 2009

Why I lose sleep

For the umpteenth time this year, I have received a request to change a medication from a prescription drug plan (this is a government-run one, but others are guilty of the same stupidity) that reads something along these lines:

Dear Doc,

We have reviewed the medications of your patient and would recommend that you switch him/her from the medication you prescribed (clonazepam-a benzodiazepine) for insomnia to zolpidem (a benzodiazepine-like medication). Studies have shown that chronic usage of benzodiazepines can lead to tolerance and addiction... etc, etc. A form (which looks almost identical to a standard refill request) is sent along for my convenience.

So, no big deal. Right? The insurance company wants to use the "safer" medication and ensure quality care for it's client. Except, over the past few years (until last summer), I was receiving letters from the same prescription drug plans that looked something like this:

Dear Doc,

We have reviewed the medications of your patient and would recommend that you switch him/her from the medication you prescribed Ambien (zolpidem) for insomnia to clonazepam(or other similar benzodiazepine). Zolpidem is not approved by the FDA for the treatment of chronic insomnia, and will not be covered... etc, etc. A form again is sent along for my convenience.

To review, the insurance company is requesting that I change their recommended medication to their previously rejected medication. What gives? Did the FDA approve zolpidem for chronic insomnia? Nope. Did benzodiazepines suddenly become more dangerous than previously thought? No. What DID happen is simple: zolpidem became available as a generic. And the benzos got sent back to the "bad drug" bin.

I'm all for cost cutting in health care, and the reality is that benzodiazepine and nonbenzodiazepine sedatives have both risks and benefits, and both are acceptable classes in the treatment of insomnia. Zolpidem is even noted to have some abuse potential (especially for those who choose to use other chemical means to stay awake after taking it). However, phony-baloney excuses by the insurance companies only to save a buck are criminal. If the makers of these medications tried marketing using these practices, they'd be in court faster than you could say class action.

Don't believe me? Ask a doctor how easy it is to get approval for a switch to Ambien CR, Lunesta, or Sonata--some of the other nonbenzodiazepine sedatives--which happen to not be available in a generic. Oh, and by the way, Ambien CR is approved for the treatment of chronic insomnia.

I need a nap.

Tuesday, August 18, 2009

Music Update

Back to the chill-out Divas I go. Emilana Torrini is from Iceland, where apparently the geothermal energy leads to honey-like voices. She had a break into the western world with the album Love in the Time of Science, and her single "To Be Free." She can also be heard singing Gollum's song in The Lord of The Rings.
"Sunny Road" comes off her 2005 album, which was written after (and presumed influenced by) the death of her boyfriend in a car accident. Her work with Thievery Corporation and Paul Oakenfold is certainly more in the electronica-chill genre, but sometimes less is more, as her simple vocals and guitar play out on this track.

"Maa Tujhe Salaam," off the album Vande Mataram, is an interpretation of a very famous patriotic song. August 15th is Independence Day in India, to commemorate their seperation from British rule in 1947. Those who recall Slumdog Millionaire's soundtrack were treated to the fine work of A.R. Rahman, a true national treasure. Rahman has done for Bollywood "filmi" music what Eli Whitney did for cotton. Rahman brings together elements of Western and Eastern music, and incorporates themes of global cultural acceptance. There is no better medium in which to do that, than in music, in my book.

Tuesday, June 30, 2009

Jacko fades to Blacko

I have been trying very diligently to avoid the final act of the three ring circus of Michael Jackson's life. I suppose an interesting post would examine the mass hysteria/grief/outrage brought on by such events. Likewise the idea of "flash memory" (where were you when you heard?) could also provide a good excuse to discuss hippocampal neurophysiology. Certainly a psychobiography of the adult who was never a child, and the child who was never an adult, would provide paragraphs of material. But, as I said, I'm trying to avoid the topic.

That being said, The autopsy report (if one can believe anything that the media presents these days-and I have my doubts) suggests that Mr. Jackson was not going to win the Andrew Weil award for good health. With a diet of (per the New York Post) narcotics Demerol, Dilaudid and Vicodin; the muscle relaxant Soma; antidepressants Zoloft and Paxil; the anti-anxiety drug Xanax; and the heartburn medication Prilosec, it's quite easy conceive a serious case of cardiac suppresion in a person who already is likely to have severe electrolyte imbalance (as commonly seen in severe weight loss).

I imagine there will be an ongoing debate as to whether this was, one one hand, a tragic exploitation of Mr. Jackson, versus, on the other hand, a spoiled addict making very stupid decisions. Or something in between. I'll leave that to the rest of the blogosphere, mostly in disinterest. However, of interest is the fact that a doctor (or in Mr. Jackson's case, allegedly many doctors) are willing to pull out the prescription pad at all in these sort of cases.

To wit:

Marilyn Monroe took enough Nembutal and Chloral Hydrate (in her presumed suicide) to kill more than ten people. She had reportedly agreed to let her psychiatrist wean her off the Nembutal, with using Chloral Hydrate.

In 1977 alone, George Nichopoulos wrote Elvis prescriptions for 10,000 doses of uppers, downers and assorted narcotics.

Dr. Sandeep Kapoor was charged recently with eight felonies, for fraud and misrepresentation, in the treatment of Anna Nicole Smith. The "thousands of pills" included methadone, multiple antidepressants, and sleeping pills.

This pattern is not limited to California. Certainly the most recent generation of athletes (especially Major League Baseball players) are having to live under the cloud of the "steroid era." It is not uncommon that these abuses are with health care professionals as accomplices.

Of course, addicts will find their way to fuel their addictions. And the rich and famous certainly have more resources for doing such, including creating a cadre of enablers. So, we know that the rich can fuel their habits, and surround themselves with "yes-men." However, why do physicians seem to be willing to be blinded by celebrity and money, even to the point of prescription Russian Roulette?

Friday, May 22, 2009

Indentured Servitude

"Back in my day..." As I am at year nine post-residency, perhaps the work shifts that we were forced to absorb do not seem quite as brutal. Perhaps not. A few years ago, ACGME-- the accrediting body for medical residency-- (amidst threats of class action lawsuits) put out recommendations regarding residents weekly work hours. After recommendations from the Institute of Medicine's report on resident duty hours, ACGME is considering further recommendations, namely to a limit of a sixteen hour work day. The Rand Corporation has published a report in the New England Journal of Medicine, to warn the public that this will be and expensive change: to the tune of an estimated $1.6 Billion per year. Here's a snippet of the coverage from HealthDay:

For years, legislators and patient advocates have called for less grueling hours for medical residents to reduce the chances of medical errors.

Now, new research shows that allowing doctors-in-training to work fewer hours and take longer naps during their shifts won't come cheap -- it will cost the nation's teaching hospitals an estimated $1.6 billion a year.

And there are no guarantees that shortening the shifts of medical residents will improve patient safety, according to the study in the May 21 issue of the New England Journal of Medicine.

Some studies have shown that less-fatigued residents make fewer errors, while other research suggests that more frequent patient hand-offs, which would come as a result of shorter shifts, could actually mean more errors.

Doctors whose shifts have ended may have to leave patients at a critical time, and new doctors who come on duty may not be familiar with the patient, explained Dr. Kenneth Polonsky, chairman of the department of medicine at Washington University and co-author of an accompanying editorial.

"When you make physicians work shorter shifts, there is a trade-off," Polonsky said. "The care becomes discontinuous. That's what we're worried about."

The hours of medical residents are legendary. Until recently, residents often worked 120 hours a week and shifts of up to 40 hours with little more than catnaps, said study author Dr. Teryl Nuckols, an assistant professor of medicine at University of California, Los Angeles and health services researcher at the RAND Corporation.

That began to change in 2003, when the Accreditation Council for Graduate Medical Education (ACGME) established rules for the nation's 1,200-plus teaching hospitals that limited residents to an 80-hour workweek, 30-hour shifts and lightened workloads.

But those rules are widely flouted, according to surveys of medical residents cited in this latest study.

In December, the influential Institute of Medicine (IOM) issued a report calling for greater adherence to the guidelines, increased supervision of residents, more attention to patient hand-offs and even shorter shifts. Among the most significant recommendations: shifts no longer than 16 hours or as long as 30 hours if residents were given five hours of protected nap time.

The IOM, however, can only make recommendations. It's up to the ACGME to enact the rules, which it has so far not done.


Some Thoughts:

1. The numbers are a bit curious. The suggestion is to limit the consecutive work hours only. An 80 hour work week would not change.

2. Dr. Polonsky appears to have concerns that there would be less continuity with handing off patients after 16 hour shifts instead of 24 hour ones. Hand offs usually occur to the night shift, with on call teams working up to 24 hour shifts and then leaving after early rounds. I cannot see where there would be more than three or four more hand offs per week, maximum. A shift from 10-12 to 12-14 hand offs would be most likely. But, if Dr. Polonsky is truly that concerned, I would also question if he is recommending the same continuity for all hospital employees, especially attending physicians.

3. Of course, the attending physicians would quit if told they had to work the same hours as a resident (in spite of getting paid three times as much, on average). But residents cannot quit (at least not easily, or unless they completely quit medicine), they have to accept the work hours handed to them.

4. While there are no "guarantees" that shorter shifts, or naps will help patient safety, many studies, including those reviewed in the IOM report do show that increased fatigue leads to increased medical errors. Good luck fighting that in court when your resident makes an error after hour 23. Basically the logic being used is, you can't prove it will work, because you haven't done it, so you better not do it because you can't prove it will work. Nice.

4. There are approximately 110,000 residents, of whom, approximately 50,000 are actively involved in direct hospital care. Given the average salary of $50,000 per year (Jeez! this is about double what I got ten years ago!), $1.6 Billion could hire approximately 32,000 more residents. Or almost 20,000 Nurse Practitioners. Are we really seeing a 30 to 60 percent increase in uncovered work load with these proposed changes? No chance.

Thursday, May 21, 2009

Music Update

1 Giant Leap is a project from a couple of blokes in the UK. It's sort of a United Colors of Benetton for music (without the shock value). They traveled around the world, blending artists of different genres and nationalities, and then doing some nice mixing back home. Asha Bhosle is the youner sister of Lata Mangeshkar, who is THE female voice of Indian film music for many decades. Asha has a smoother (read, less shrill, in my book) voice than Lata, and also has expanded her horizons to include the occasional foray into fusion or world music. Well into her seventies, Asha still is able to bring her mellow and talented voice to the studio. Her duet here is with Michael Stipe, who I think is best known for singing "Furry Happy Monsters" on Sesame Street. This video is a composite/promo for the project, but has the song throughout, and I think it presents a great view of what 1 Giant Leap is trying to accomplish.

As I have mentioned in the past, some artists have so impressed me with their later work, that I was able to become a fan of their earlier work. Beck comes easily to mind; and so it has been with Green Day. I used to wonder, in their early years, how they defied statistical probability by creating more songs out of three chord permuations than mathematically possible. The album American Idiot changed that. Billie Joe Armstrong and company really stretched their horizons with a modern rock opera (mostly punk, nonetheless!) and while still putting out good sounds. Their new album, 21st Centure Breakdown is a more than adequate sequel. Divided into three parts, it follows a similar rock opera (or perhaps broadway musical?) type feel. Green Day continues to rail against the corporate and government establishment, but hey, it's what they do! The music culls from even more influences, one can almost here Floyd, Queen, Metallica, Harrison, The Offspring, and ELO at times. A couple (at least) of those influences can be heard on my current favorite track on the album, Restless Heart Syndrome.

Tuesday, May 19, 2009

Musing for the Day

Whomever discovered that light has mass, must have suffered from migraine headaches.

Tuesday, May 12, 2009

Doin' the District

While on Lenten Hiatus from the laptop, I had the pleasure of getting up to DC to do a bit o' lobbying fro the American Psychiatric Association. Being so close to the Capitol, I try to get up there once a year to make the rounds. A few of this year's talking points, and comments:

1. Parity has started to make it into the legislation: Finally! For years, the a person going to a psychiatrist (an M.D. in an office or hospital) would only get reimbursed at 50% rates compared to a non-psychiatrist (an M.D. in an office or hospital, with often little training in psychiatric illness) treating the same patient for the same condition. Invariably, some of those costs are often sent down river to the patient's bill, and also probably have contributed to a severe shortage in mental health access from trained specialists.

2. Privacy. There is a push to move towards more electronic records. While I'm certainly strongly in favor of improving health care and using electronic tools to do so, in psychiatry, this always presents a challenge due to the sensitive nature and type of notes (i.e. therapy notes) that may be out there. (I used to scoff at some of these concerns, and would often spout about 64-bit encryption and whatnot--- that was until the entire Health Practitioner Database for Virginia got hacked recently!)

3. A continuing issue that I brought up with our Virginia legislators is the need to continue to be vigilant in treating the mental health needs of our Veterans. Never is this more important than during times of active deployments. It's not a hard sell in the Commonwealth, given our very large percentage of servicemen and women, but it's always an important topic.

Overall, the staffers looked very tired; the transition, economy, and budget are a serious stress on the congressional building inhabitants. (I felt like offering a free half hour on a couch somewhere for some of them.), D.C is still hectic, and double talk is still the native tongue. All-in-all, though, not a bad day in the beltway.

Tuesday, April 28, 2009

If you got them?

Interesting news in the world of smoke:

From Live Science, an interesting article on the effects of nicotine on the brain. I seems that (at least for those who don't usually smoke) nicotine dulls the anger response mechanism. Subjects were given a (fake) opponent to race to click the fastest when a red mark appeared on the screen. The winner got to blast their opponent with a white noise, and could also see what level they were going to get blasted with if they lost. Those who were given a nicotine patch were less easily provoked by manipulated variables, and would also give shorter punishments.
The study postulates that those who are more likely to be easily stressed or angrier are more likely to smoke.

A Canadian study done based on interviews with 63 adolescents who regularly smoked marijuana had some interesting findings. This article appeared in the April 22 issue of Substance Abuse, Treatment, Prevention and Policy. But it's linked here from Forbes (of all places). About one-third of the adolescents reported that they were using marijuana as a medication rather than for getting high. The main substitute treatment was, not surprisingly, for emotional problems, but also teens reported usage for insomnia, chronic pain relief, and difficulty with concentration.

Some thoughts:

1. Why does the first study remind me of the James Bond movie "Never Say Never Again?" Ready for World Domination, anybody?

2. The first study was mean, man! Tricking people into thinking an opponent had it in for them! Using loud blasts of white noise! Good thing there weren't studying the effects of THC, they might have had a few paranoid subjects afterward.

3. Of course the study has to have the sciento-political (just made that word up, folks) caveat: "But in the long run, smoking boosts the risk of vascular diseases that lead to heart attacks and stroke, which kill more smokers than all cancers combined. And second-hand smoke has proven as deadly for pets as it is for human partners." As if people will read this and suddenly run out to buy a pack of Luckies.

4. A deeper look at the second study shows some significant misreporting. The actual interviews for this data was only in 20 individuals out of the 63 in the study, as noted in the original article. The current article does not provide much in the way of specifics, and uses fuzzy language throughout. It is "mostly" devoid of scientific methodology.

5. That being said, it is interesting that the teens reported experience with health care was "uniformly negative." Many studies have shown that there is likely significant co-morbidity to those who have chronic marijuana use, so this "self-medicating" number is probably conservative.

6. Difficulty with concentration? Tough sell on that one.

Musing for the day

Old Borderlines never die.
They just split.

Tuesday, April 14, 2009

Plugged Back In

Happy Easter Everybody! Some thoughts as I plug back in after Lent:

I once made a New Year's resolution/bet with myself the loss of which caused me to go vegetarian for one whole year. Worldwide, humans have holidays and traditions which call for self sacrifice. Fasting on Yom Kippur or Ramadan, Lenten Sacrifices, to name a few. Why do we periodically deny ourselves some pleasure? There are some overt answers: to make healthier choices, to save money, to focus on a particular religious component, such as the need for focus in prayer, to make a social/political point, or to commemorate some person or event.

At a deeper level, though, is the desire to control our passions. As a kid, I was taught, from a religious point, that this shows our dominion over our bodies, and separates us from animals. But how much of it is more of a psychological need to master the body? I wonder if there is not also at times a sense of a need to do penance, as absolution of guilt. This may be taken to a more pathological extreme in the self-deprivation or even self-abuse of those with, say, anorexia nervosa. Curiously, some seem to paradoxically find pleasure in the pain of self-deprivation, usually in the form of fasting. Social psychologists trained in the pleasure-pain theory often tangle their logic in a loop on self-deprivation.

I have no answers on this one, just many questions. Do share any thoughts, experiences.

Monday, February 16, 2009

Music Update

We catch up with a music update with a personal favorite of the downtempo angelic voices. Imogen Heap is the lead vocalist and one half of the chillout group Frou Frou, and has had a very successful solo career. This vocorded track "Hide and Seek," was featured on and episode of the TV show The O.C. a few years back. (She also performed a nifty version of Leonard Cohen's "Hallelujah" for The O.C). Heap's vocal range is outstanding, and she can wonderfully juxtapose anger, hurt, and beauty in one melodic phrase. When I first heard this song, I thought she was more digital than real (a sad reality in some of our current pop singers); this live version shows she's the real deal.

And, because we all need some salsa sometimes, here's the late Celia Cruz. Other than cigars, salsa music is probably Cuba's most successful export. The grand dame of Cuban salsa is Celia Cruz. Singing since the 1950's, up to this decade (she's on and album in a duet with Dionne Warwick in 2003), Celia has been recognized worldwide. Fans of the movie "The Mambo Kings" can remember her performance well. Bill Clinton honored her in 1994 with the National Medal of the Arts. Oye, camarero! Un mas mojito, por favor.

Friday, February 13, 2009

Mental Health Mythbusters: Violence

In a longitudinal study done by Eric Elbogen, PhD and Sally Johnson at the University of North Carolina, Chapel Hill School of Medicine, researchers look at the link between mental illness and violence. 35,000 people were interviewed in two “waves” a few years apart, and correlations between mental health, substance abuse, and violence were examined.

From the CBS News article, a few snippets:

In all, 2.9 percent of participants said they had been violent in the time between the first and second interviews.

When Elbogen evaluated the possible associations between mental illness, violence, and other factors, having a mental illness alone did not predict violence, but having a mental illness and a substance abuse problem did increase the risk of violence.

The risk was increased even more if the person had mental illness, substance abuse problems, and a history of violence….

…"I think a lot of people think mental illness is the usual cause if not the foremost cause of violence," Elbogen says, citing a survey in which 75 percent of respondents said they considered people with mental illness as dangerous.

But his study concludes that the findings say mental illness is relevant and you can see that throughout the data. But it's not really one of the foremost causes of violent behavior [by itself] in our society."….

…Experts who reviewed the paper for WebMD say they hope the new research may change mistaken perceptions toward those who are mentally ill.

"Having a severe mental illness alone doesn't predict anything," as far as violence, says Philip Muskin, MD, professor of clinical psychiatry at Columbia University in New York. The new results, he says, confirm some other studies with similar results.

For those affected by the severe mental illnesses evaluated in the study, Muskin says, "You are no more at risk for committing a violent act than anyone in the population."

Some thoughts:

  1. As I have always stated, the single biggest challenge to mental health is that of stigma. Nowhere is that more overt than in the perception of the mentally ill as being arbiters of violence. The individual reports of mentally ill individuals having violent behaviors tend to make the headlines, and skew the public opinion. Our media reports from a sensational point of view, and violence sells. The mentally ill are more likely to be presented as dangerous than beneficial in TV, movies, and literature.
  2. The science here is fairly sound, using bivariate and multivariate analyses, and is about as good as one can get for a mostly prospective longitudinal study. The study is published in the Archives of General Psychiatry.
  3. This data is not new, as researchers have been studying this link for years, and most studies have shown similar results. The number of participants and design of this study certainly appears to give it more power than its predecessors.
  4. I would be interested in seeing data that looks at further subgrouping of those with mental illness. Some illnesses, such as antisocial personality disorder, have violence included as part of their criteria for diagnosis. I imagine that the diagnoses of depression, and anxiety disorders alone (which make up the vast majority of those will mental illness) would show significantly less rates of violence.
  5. What of those mental illnesses that do have violent or impulsive/explosive behaviors listed in their criteria?
  6. Substance abuse, previous history of violence and being younger, male, recently financially or socially stressed, and of low income were all positively correlated with and increased chance for violence. Add mental illness to any of those factors, and there is an exponential rise in correlation; especially with substance abuse and violent history. It is important to screen individuals in the offices of psychiatrists for these factors. Likewise, the domains of social workers, family doctors, and the judicial system should be active in monitoring for and promoting treatment of mental health needs.

Tuesday, January 20, 2009

Grand Rounds Topic: Healthcare Reform

Dr. Val is a very well known med-blogger. In honor of the inauguration, she has decided to present several excellent blog articles regarding the topic of healthcare reform. Many of these are worth perusing, so I encourage all of you to go there and take a look.

Tuesday, January 13, 2009

Back to the Future or: How I Learned to Stop Worrying and Love The Penal System

Here we go again!

From the News Leader in the Shenandoah Valley:

Children's center to close; 200 mental-health workers to lose jobs

This is part of a wave of cuts including closing a children’s unit at a state mental hospital and a proposed closing of a state training center and residential facility for the mentally retarded. We’re talking hundreds of beds, including some that have been homes for individuals for decades. Virginia is not a leader in trying a second (or third or fourth, depending on how you count) wave of deinstitutionalization. Florida, North Carolina, and Pennsylvania are years ahead of Virginia on this. Those states are also years ahead in crowding their jails with the mentally ill, and seeing the fallout:


From the Pittsburgh Post Gazette in 2001 regarding the high number of teen suicides in correctional custody (over 100 between 1995 and 2001):

"Now," he said, "you can find more mentally ill juveniles in jail than you can in hospitals."
When states like Pennsylvania closed their state hospital adolescent units, "we lost the capacity to provide appropriate treatment, pharmacologically and otherwise, and to hold these kids long enough to be able to turn them around," Torrey said. Unlike mental hospital patients, Pennsylvania teens 14 and older who are in custody can and do refuse to take their medications.
Ultimately, he said, even the best-managed lockup with the best-trained staff cannot replace structured, long-term psychiatric care in a safe setting. The percentage of jailed teens who commit suicide while confined to their rooms is one stark example of that.


How prevalent are mental health problems in prisons? In an epidemiological study done in 2006, 25,000 prisoners across the country were studied. More than half were noted to have reported mental health problems, 56 percent, specifically. Yet only one in four in prison, and one and six in jail actually received treatment—usually just medications. It has been shown in many studies that since at least 1997, there are significantly more persons with serious mental illness (schizophrenia, and the lot) in prison than in mental health facilities.

Furthermore, the quality of treatment in the correctional centers has a very high degree of variability. Specialists may be hard to come by (in many rural areas especially), formularies can be very limiting, and ancillary services are often non-existent. I worked at a local county jail for a time providing specialist services a few hours a week. Sadly, counseling services were not available for inmates; furthermore, I was astounded to learn that there were not even supportive services such as Alcoholics Anonymous or Narcotics Anonymous meetings.

Insufficient funding is usually the scapegoat. While states are encouraged at the idea of trimming the budget with the closure of a mental health facility, the thought of sending monies earmarked for mental health to the correctional system either eludes them, or perhaps just doesn’t make for good political fodder.

Sunday, January 4, 2009

Shrinks on Film: Slumdog Millionaire

With a slightly cheeky nod to a few predecessors (most particularly a comedy show called "In Living Color"), I will endeavor to start what will hopefully be an ongoing series (monthly, perhaps) of reviews from a perspective or two from those on this side of the couch.

Ideally, these postings will be on recommended films; and my first posting is certainly recommendable for the independent and foreign film fans, but also for those who enjoy a strong story line. The music is created by a personal favorite, A.R. Rahman; he rarely disappoints with his scores, and this is no exception. If you are expecting a classic "Bollywood" style of film, don't.

Slumdog Millionaire tells the story of Jamaal, an orphaned child of the Mumbai slums who has gone onto India's version of "Who Wants To Be a Millionaire." His life story is told in retrospective pieces which coincide with the questions that he answers on the show. Because Jamaal is a "slum dog," many are questioning his ability to answer the questions, and he is accused of cheating.

The movie is very touching, and similar to other films that have shown the underbelly of India's slums, "City of Joy," and "Salaam Bombay" come quickly to mind. How Jamaal's relationships manage to survive incessant trauma is fascinating, although there is a price to pay for almost all of them. The central conflict of love versus survival plays out repeatedly, and love itself gets redefined from extreme dependence to extreme devotion.

From a study of the characters, most show very complex layers, especially Salim, Jamaal''s older brother who is struggling with fighting to survive, self definition, and his responsibility. While one could certainly see overt personality disorders in the sociopathy of some of the villains, it is a more nuanced degree of damage shown in our protagonists: The untrusting hard mental exterior of Jamaal, the depressed hopelessness occasioned by his love interest, Latika.

Life and death are presented in constant contradiction: at times both are treasured and worthless, a gift and a curse, sacred and profane. Sex and love are given a similar juxtaposition. The misery meted out by the various social structures (read: caste system) such as the media, bureaucracy, and countless illegitamate and immoral business endeavors, leave one, in retrospect, with a sense that this is not so much a story of triumph, but of good fortune for a few souls, out of the millions.