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.

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.

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.

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.

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:

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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.

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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.

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.

Conscientious Objections?

H/T to Geoffrey for keeping me up on the news. The Bush Administration today issued an expansion of what are called "right of conscience" laws, which allows individuals to refuse treatment on the basis of religious or moral grounds.

From the article in The Washington Post:

"Doctors and other health-care providers should not be forced to choose between good professional standing and violating their conscience," said Mike Leavitt, secretary of the Department Health and Human Services, which issued the regulation.

Some Thoughts:

This is a sticky wicket. It is the opinion of most, that this action is to protect those pharmacies that wish to not have the "morning after" pill on their shelves; that they may do so without fear of retribution. Individual right of conscience legislation regarding abortion has been around and sufficient for many years. The current wording is simply god-awful for a few reasons:

1. Way too broad- it's a sledgehammer, when a scalpel is needed. It encompasses too large a group of providers.

2. It does not differentiate between the individual vs. the corporation. A mom and pop pharmacy does not have to stock the shelves with everything. But denial of treatment is not denial of access there, as it would be if a clinic group was the only one available within a certain radius. If there are sufficient available alternatives, then this could be viable in small numbers.

3. There are insufficient parameters regarding the specifics of the religious beliefs and types of procedures. I see nothing that prevents me from becoming a Christian Scientist or (gasp) Scientologist, and refusing to give care that I am being paid to give. A company that fires me for that would potentially face loss of federal funding. I hope that all hospitals will be prepared to have husbands or unmarriageable male relatives on staff in case their female Muslim physicians are required to treat a male.

4. It is unethical to knowingly deny information to a patient. Refusal to directly treat on the basis of ethical grounds has been fairly well protected, but refusal to provide known information and referral is a violation of allowing access, and against medical ethics and duty to treat. From Laura Katz, in a Physicians News Digest article on ethics of termination and refusal of care:

"If a physician decides not to provide services to a patient on religious, ethical or moral grounds, the physician should discuss the reasons for the refusal with the patient, inform the patient of other resources or providers that can competently respond to the patient’s needs, and document the discussion with the patient in the patient’s medical record."

5. It conflicts with other legislation, such as the Americans with Disabilities Act (ADA). In several cases, the courts have addressed the application of the ADA to a physician’s decision to refuse to treat a patient. For example, in the case of Bragdon v. Abbott, decided by the Supreme Court in 1998, the court found that asymptotic HIV infection is a disability under the ADA. Bragdon involved a dentist’s refusal to fill a cavity of an asymptotic HIV patient in his office, although the dentist was willing to treat the patient in a hospital at a higher cost to the patient. The patient sued Bragdon for violation of the ADA. The court ruled that asymptotic HIV constitutes a disability. The court’s decision speaks to health care providers’ legal obligation to treat HIV infected patients along with patients with other disabilities. Similar diseases or conditions could easily constitute a disability.

It is likely that this regulation will be short-lived. Although the issue will continue. We are seeing a greater number of physicians from different religious backgrounds. We continue to answer questions old (physician assisted suicide) and new (cloning, gene therapy). Defining the balance of a physicians individual beliefs vs. duty to provide treatment will spark debate for generations to come.