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.