Friday, June 4, 2010

Prisoners, patients, human beings?

From the Times of London--today:

Satellite tracking for the most dangerous psychiatric patients
David Rose, Health Correspondent

Some of Britain’s most dangerous psychiatric patients, including murderers, rapists and paedophiles, are being fitted with satellite tracking devices to stop them escaping and reoffending.

A leading NHS trust has become the first to fit patients with an ankle bracelet containing global positioning system (GPS) technology, so they can be tracked if they abscond. The device, worn on a lockable, steel-reinforced, ankle strap, allows authorities to track a patient’s movements to within a few metres anywhere in the world.

More than 60 medium and high-risk patients detained at the South London and Maudsley NHS Foundation Trust have been fitted with the device as a condition of day leave, or while they are transferred to and from hospitals.

The trust said that such measures were necessary to protect the public, after a series of high-profile incidents where patients absconded, fled abroad or committed violent crimes.

Mental health charities said that the secure cuffs, which can be forcibly removed only using industrial bolt cutters, resembled “virtual leg irons” and could violate the rights of vulnerable patients.

The GPS device, known as a Buddi tracker, was originally designed for carers to track dementia patients who wandered from their homes.

The secure version, remotely monitored by a private security company based in Pontefract, West Yorkshire, was approved in March for routine use after a pilot study showed that it could help to apprehend patients in a matter of hours rather than days.

A number of other NHS Trusts are understood to be considering use of the trackers, developed by Sara Murray, an entrepreneur whose previous projects include, the price comparison website.

The system was introduced in South London as a response to the case of Terrence O’ Keefe, 39, a rapist who escaped from the trust’s care in March 2008 and later strangled David Kemp, 73, in Great Yarmouth, Norfolk. O’Keefe was jailed for life after being recaptured and convicted of murder.

The trust opened a new £33.5 million medium-security unit at the Bethlem Royal Hospital, Beckenham, in February 2008, where there have since been 26 incidents of patients absconding or failing to return, including one man who was eventually found in Canada.

The new system will cost the NHS about £600 for each patient, including £250 for an ankle bracelet containing a mobile phone chip and GPS locator.

Last month it was used to successfully track a male patient who had travelled eight miles on foot from Beckenham and was apprehended within three hours near Biggin Hill airport, Kent.

If a patient wearing the device leaves a defined area, strays close to a school or otherwise breaks their curfew, police can be automatically sent an alert with their estimated location within 50 metres, along with personal details and a mugshot.

Police can then be directed to the tracker within a target response time of 12 minutes.

Use of the tracker was “mostly voluntary”, but was also a condition for some patients being granted day leave as part of their rehabilitation, Ms Murray said. Patients detained by a court order or under the Mental Health Act are granted leave only from secure units after detailed assessment by medical staff.

“We started talking to the trust at the beginning of last year,” she said. “They have a number of high-profile, high-risk patients that are allowed out on leave. If they get an opportunity to run off, they will.”

A spokesperson for South London and Maudsley NHS Foundation Trust said: “We have a duty to provide high-quality patient care while at the same time promoting public safety.”

But Paul Jenkins, chief executive of Rethink, the mental health charity, called the tags “demeaning” and said that patients with severe mental illnesses such as schizophrenia should not be labelled as criminals. He urged health regulators to monitor use of the tags and to ensure that patients gave consent to being tagged.

“The best way to help people to get better is to invest in treatment, and we would rather see money spent on improved mental health services rather than wasted on demeaning items such as these,” he said. “Violence is not a symptom of mental illness and should not be regarded as inevitable.”

Wednesday, June 2, 2010


One of the best things about my job is that I get to work with social work students as a practicum supervisor. I don't know what they generally expect when they begin to work alongside of me, but I'm pretty sure that I shake them up a little bit. That's a good thing, right?

My current student is creating a presentation on Trauma and Mental Health. She chose the topic because she had written a paper on PTSD, a topic of interest to her. She's doing a lot of reading, and so am I.

(here comes the synchronicity part)

My student and I have been reading about the role of adverse childhood experiences in the development of mental illness. For that reason, it was great to see that giannakalli of Beyond Meds  found  a fascinating article "How a deprived childhood leaves its mark on the brain" from the Independent.

quoting gianna quoting the article:  
“If the maltreatment of children is altering their developmental pathways then we are not dealing with children who are morally flawed. The public perception is that these children are just like anyone else until they come to the point of doing something bad. Then the public decides these children have made a thought-through decision, when the vast majority will not have thought at all – their violence was almost instinctive.”
Of course, trauma isn't just about bad behaviour in children. We are beginning to see a raft of material being published about the role of trauma in people diagnosed with what we generally think of as serious mental illnesses like schizophrenia.

The "Conclusions" portion of the article Correlates of Adverse Childhood Events Among Adults With Schizophrenia Spectrum Disorders Stanley D. Rosenberg, Ph.D., Weili Lu, Ph.D., Kim T. Mueser, Ph.D., Mary Kay Jankowski, Ph.D. and Francine Cournos, M.D.:
Important implications of this study are that most clients with diagnoses of schizophrenia in the public mental health system are likely to have been exposed to serious adverse events in childhood and that the social and psychological consequences of this exposure include worse health, mental health, and functional outcomes. Exposure to adverse childhood events is associated with elevated rates of comorbid conditions such as alcohol abuse, drug abuse, and PTSD, even though these diagnoses are already elevated in this population. These comorbid disorders have a deleterious effect on the course of illness and may add considerable complexity to treatment management. Tailored interventions to address the adult consequences related to adverse childhood events may be necessary to improve outcomes for many clients with schizophrenia spectrum disorders.
If you are up for reading things with words like "epigenetic" in them, then the article Time to abandon the bio-bio-bio model of psychosis: Exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms by John Read, Richard P. Bentall, and Roar Fosse is for you.

From the abstract:
Mental health services and research have been dominated for several decades by a rather simplistic, reductionistic focus on biological phenomena, with minimal consideration of the social context within which genes and brains inevitably operate. This ‘medical model’ ideology, enthusiastically supported by the pharmaceutical industry, has been particularly powerful in the field of psychosis, where it has led to unjustified and damaging pessimism about recovery. The failure to find robust evidence of a genetic predisposition for psychosis in general, or ‘schizophrenia’ in particular, can be understood in terms of recently developed knowledge about how epigenetic processes turn gene transcription on and off through mechanisms that are highly influenced by the individual’s socio-environmental experiences. To understand the emerging evidence of the relationship between adverse childhood events and subsequent psychosis, it is necessary to integrate these epigenetic processes,(...)
From the letter to the editor of the American Journal of Psychiatry, June 2010, also by Read and Benthal, Schizophrenia and Childhood Adversity:
Recently, researchers have found a range of adverse events in childhood to be significant risk factors for developing psychotic symptoms and/or being diagnosed with schizophrenia, even after controlling for family history of psychosis or schizophrenia in some cases. These adverse events include early loss of a parent; parental poverty; bullying; witnessing parental violence; emotional, sexual, or physical abuse; physical or emotional neglect; and insecure attachment.
Additional resources that are worth the read:

Trauma and Psychosis: theoretical and clinical implications

Childhood trauma and psychotic disorders: evidence, theoretical perspectives,and implication for interventions Antonio Lasalvia, Michele Tansella (I can mail you the full text PDF)

Biomarker research in mental disorders linking biomarkers to etiology (a dissertation) ramses, F.J. Kemperman et al.

Tuesday, June 1, 2010

Assisted Outpatient Treatment in NY (with a note)

"The Doody Man", E Fuller Torrey, has an op-ed in today's NY Times, Making Kendra's Law Permanent. In the article, Torrey cherry picks among the statistics that are available in studies of the laws effectiveness and ignores vital information entirely.
From the article:

In 2005, Kendra’s Law was extended for another five years. In all, more than 8,000 people have been treated under its provisions, and the results have been striking. A 2005 study of more than 2,700 people to whom the law was applied found that, after treatment, the rate of homelessness in the population fell by 74 percent, the number who needed to be rehospitalized dropped by 77 percent and the number arrested fell by 83 percent. And a study published this year found that people receiving treatment under Kendra’s Law were only one-fourth as likely to commit violent acts, had a reduced risk of suicide and were functioning better socially than members of a control group.

It’s hard to imagine a stronger argument for making the law permanent. And yet, as it comes up for renewal this month, the state Office of Mental Health is recommending only a five-year extension. Why the hesitation? Apparently, the Office of Mental Health is ambivalent about its star performer. In its latest five-year Statewide Comprehensive Plan for Mental Health Services, Kendra’s Law is not even mentioned, and the program it supports — assisted outpatient treatment — is referred to briefly only twice.

Perhaps state mental health officials are responding to critics who consider the law politically incorrect because it mandates psychiatric treatment by court order, supposedly violating the patients’ freedom to choose or forgo treatment. But these are people whose illness interferes with their ability to understand that they are sick and need medication. They do not have the choice to live freely and comfortably, but only to be homeless, in jail or in a psychiatric hospital. 
What did he ignore?

Although Torrey mentions an article in the February, 2010 issue of the Journal Psychiatric Services in support of his position, he definitely doesn't quote the conclusions:
Outpatient commitment in New York State affects many lives; therefore, it is reassuring that negative consequences were not observed. Rather, people's lives seem modestly improved by outpatient commitment. However, because outpatient commitment included treatment and other enhancements, these findings should be interpreted in terms of the overall impact of outpatient commitment, not of legal coercion per se. As such, the results do not support the expansion of coercion in psychiatric treatment.
He also would prefer that we not think very much about some parts of the 2009 New York State Outpatient Treatment Program Evaluation report issued by the New York Office of Mental Health. 

From summary and conclusions:
The introduction of New York’s AOT Program was accompanied by a significant infusion of new service dollars and currently features more comprehensive implementation, infrastructure and oversight of the AOT process than any other comparable program in the United States. It is, therefore, a critical test of how a comprehensively implemented and well-funded program of assisted outpatient treatment can perform. However, because New York’s program design is unique, these evaluation findings may not generalize to other states, especially where new service dollars are not available.
From the section Impact of AOT on New York's Public Mental Health System:
In the first several years of the AOT Program, between 1999 and 2003, preference for intensive case management services was given to AOT cases–a finding corroborated by our key stakeholder interviews. In fact, some respondents stated that service and housing providers were more likely to accept clients with an AOT court order and all confirmed that AOT recipients were given priority access. An AOT coordinator made this observation:

"AOT doesn't make a big difference in some people’s compliance, but does help with community mental health providers’ willingness to provide services to people."
The report also looked at the issue of racial disparity:
We find that the overrepresentation of African Americans in the AOT Program is a function of African Americans’ higher likelihood of being poor, uninsured, higher likelihood of being treated by the public mental health system (rather than by private mental health professionals), and higher likelihood of having a history of psychiatric hospitalization. 
When I read this, it seems to me that it reinforces the idea that people who can purchase the mental health services they want don't end up under a community treatment order. I'm betting Torrey knows this as well, after all, he supported his sister Rhoda in a residential program in upstate New York, far away from the subway platform where Andrew Goldstein, a person unable to get the services he requested, ended Kendra's life.

(note: it may seem odd that a person living in Red Deer, Alberta is writing about a New York state law, but a similar change was recently made in our mental health act, and I am definitely not seeing any increase in funding for voluntary services or housing dollars or anything else that might truly make a difference.)   

Thursday, May 27, 2010

Shame, shame, New York Times (with update)

The May 26, 2020  New York Times included a Q&A with Dr. Harold Koplewicz, a child and adolescent psychiatrist. It included the following:
I haven’t read Mr. Whitaker’s book, so I’m unable to speak to the specifics of his argument. But I can tell you there is no evidence to prove that children and adolescents are overprescribed psychotropic medications in this country. The argument that parents and child psychiatrists are throwing drugs at children’s bad behaviors is just as reductionist and dubious as the claim that there is no conflict of interest in industry-backed research studies.
Kolewicz is careful to say that psych meds should be used in children only after they have had a complete psychiatric exam (which, even if supportable, doesn't seem to happen this way in the real world) and then he says more:
Here is the bottom line: If a child has properly received a diagnosis of a psychiatric disorder — meaning the child has experienced severe functional impairment and distress that meets diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV — then it is unfair to deny him the opportunity to try a treatment course that includes medication.

If your child had diabetes, would you say no to insulin? If your child had epilepsy, would you say no to anti-seizure medications?
I submitted the following comment to the article.  Comments are moderated. What I have written has yet to appear. Update: My comment appears here.

Clearly, Doctor Koplewicz needs to do some reading, maybe even including writing by people like Robert Whitaker with "mister" in front of their names.

From James Morris, George Stone. Children and Psychotropic Medication: A Cautionary Note. Journal of Marital and Family Therapy, 2009; as reported in Science Daily, April 20, 2010.

"As an example, the diagnosis of early onset bipolar disorder and attention deficit hyperactivity disorder has climbed drastically in the past decade. Drugs designed to treat the above two disorders show a fair short term risk-benefit ratio, but a poor long-term benefit. Morris and Stone indicate, "If the psychiatric community has been misled by pharmaceutical companies in thinking that these drugs are safe for their children, the parents of these children have been in turn deluded into putting their children in harm's way."

From Julie M Zito, Daniel J Safer, Lolkje TW de Jong-van den Berg, Katrin Janhsen, Joerg M Fegert, James F Gardner, Gerd Glaeske and Satish C Valluri. A three-country comparison of psychotropic medication prevalence in youth. Child and Adolescent Psychiatry and Mental Health (Child Adolesc Psychiatry Ment Health. 2008; 2: 26.)

"The annual prevalence of any psychotropic medication in youth was significantly greater in the US (6.7%) than in the Netherlands (2.9%) and in Germany (2.0%). Antidepressant and stimulant prevalence were 3 or more times greater in the US than in the Netherlands and Germany, while antipsychotic prevalence was 1.5–2.2 times greater."

From Trends in the Use of Psychotropic Medications Among Adolescents, 1994 to 2001 Cindy Parks Thomas, Ph.D., Peter Conrad, Ph.D., Rosemary Casler, M.A. and Elizabeth Goodman, M.D. (Psychiatr Serv 57:63-69, January 2006)

"the proportion of office-based visits that resulted in a psychotropic prescription rose from 3.4 percent in 1994-1995 to 8.3 percent in 2000-2001 (p<.001). The U.S. population-adjusted rate of physician visits that resulted in the receipt of a psychotropic prescription increased from 54.2 to 141.8 per 1,000 youths aged 14 to 18 years in the same period (a 161.6 percent increase)"

Update: Robert Whitaker responded to the NY Times much more eloquently and convincingly than I ever could. 

Tuesday, May 25, 2010

Love you forever (mebbe not)

Although author Robert Munsch was born in the US, he is Canadian enough to have been awarded the Order of Canada in 1999. There may be Canadian children who have not had his book Love You Forever read to them, but I've yet to meet one. You can listen to Munsch read the book aloud here on YouTube.

Munsch is also a person who has been diagnosed with bipolar disorder and OCD. I'm not sure when exactly he first came out about this, but his psychiatric history, and his struggle with alcoholism,  was a focus of an October 2009 article in  the Globe and Mail.

From the article:
But the bouts of depression and related alcoholism grew ever worse, and Mr. Munsch finally got help – therapy and antidepressants – when he was close to 50.

While many artists fear that treatment for mental illness will rob them of their magical je ne sais quoi , Mr. Munsch had the opposite result: “Taking antidepressants didn't interfere with my creativity, the depression interfered with my creativity.” 
Recently, shortly before a planned tour of Western Canada, Munsch spoke about his mental health and about his use of drugs and alcohol. The news about his cocaine use was new. He had only four months of sobriety when he addressed it on his website in a note to parents. Generally, the Canadian press was kind and supportive, that is, until this weekend when Naomi Lakritz, writing for the Calgary Herald, took it on:

From the article Too much information, Robert Munsch!
Munsch, 64, may have gone public because he felt it would be noble to do so. Unfortunately, behaving nobly inevitably attracts those who behave ignobly. Baring your soul leaves you vulnerable to attack, and the only person whose awareness gets raised is you -- you quickly become aware that "none of your business" is a very useful phrase and you should have made it your motto.
The article is odd. Whilst making the point that many people struggle with similar challenges, and that it should not affect our regard for them as writers or artists, she also says this, as she attempts to make his disclosure into an example of "oversharing".
This sort of thing puts paid to the whole argument of raising awareness to help fight the stigmatization of those who suffer from mental illness. The result of Munsch's admission of his problems has been to stigmatize them even more, as in Landriault's response, which can be summed up as: "He took cocaine and drank! Get him and his books away from my children!"
The CBC website article reporting on Munsch's disclosure, decided to do a poll about his disclosure. Sheesh, leave it to the CBC.  You can write to Lakritz here:

Friday, May 21, 2010

Videos, videos and more videos

We have a long weekend coming up, and here in Central Alberta, it is (naturally) going to rain all three days. That makes it a terrific time to curl up in front of the monitor with endless hours of psychiatry videos, right?

David Henley, MD,  has uploaded 59 videos in his "It's a Brain Thing" series. Video quality is not always terrific, but the information he gives is valuable if you are looking for information from a mainstream perspective. Most of the videos are about 30 minutes long, and there are multiple videos on each topic. This one introduces the series. He knows a whole lot more about psychiatry than about technology, so don't let the first few minutes discourage you, and he is not entirely about "better living through chemistry and electricity".

Not enough? Boring delivery bothering you? Then try a few of the 519 short videos on the same site uploaded by Dr.of Mind. This one on the Electronic Office gives you a sense of the series, which is in the comedy section of the site. Watch the whole video (less than 4 minutes) to get a better sense of the series.

My choice? I'm going to watch Johnny Depp in Alice in Wonderland.

Thursday, May 20, 2010

(Reading about) depression hurts

If you spend way too much of your free time perusing articles relating to mental health care, then one of the things you are no doubt reading today concerns a reappraisal of the NIMH funded STAR*D study on anti-depressant medication by Robert Whitaker in Psychology Today (Update on the STAR*D Report, the documented recovery rate in the STAR*D trial worse than thought?).

Although the seven year study was completed in 2006, it is still being reported on in the general press. An article in the March 2010 New Yorker, Head Case - Can psychiatry be a science by Louis Menard, added up the STAR*D numbers and reported a 67% effectiveness rate, while also reporting that psychologist Irving Kirsch suggests that the result in STAR*D is one big placebo effect. The numbers are repeated over and over again in both the popular media and in academic works.

Whitaker asks this important question: "How many of the 3,671 people who entered the trial remitted and then stayed well and in the trial throughout the entire 12-month follow-up? "

He finds an answer in an article by Allan Leventhal  and David Antonuccio. Levanthal sent the article to Whitaker, and Whitaker links to the abstract. With a little searching, I was able to find the complete article here.

The quote from the article Whitaker used is: "Although the study's reports make no mention of this outcome, their data show that after a year of continuation treatment following remission, of the 4,041 patients who entered the program only 108 (3%) had a sustained remission -- all the other patients either dropped out or relapsed. Yet STAR*D's authors and the NIMH have publicized the study as showing a 67% success rate for antidepressants."

Reporting on STAR*D is a very small part of this article, and although it is very, very long, it is well worth reading in its entirety.

The critics of STAR*D are legion, and they make some other important observations. Psychologist Bruce E. Levine, writing on the Dissident Voice website, titles his article STAR*D Wars - The Corruption of the National Institute of Mental Health and the Failure of Antidepressants.  Levine points out that many of the STAR*D researchers had financial ties to BigPharma.

It looks like Levine may be on to something, A. John Rush, MD, one of the lead researchers for STAR*D asks another question in the American Journal of Psychiatry article STAR*D: What Have We Learned?.  I looked at the bottom of the article and learned this about Rush...

From the article footnotes:
Dr. Rush has served as an advisor, consultant, or speaker for or received research support from Advanced Neuromodulation Systems, Inc.; Best Practice Project Management, Inc.; Bristol-Myers Squibb Company; Cyberonics, Inc.; Eli Lilly & Company; Forest Pharmaceuticals, Inc.; Gerson Lehman Group; GlaxoSmithKline; Healthcare Technology Systems, Inc.; Jazz Pharmaceuticals; Merck & Co., Inc.; the National Institute of Mental Health; Neuronetics; Ono Pharmaceutical; Organon USA Inc.; Personality Disorder Research Corp.; Pfizer Inc.; the Robert Wood Johnson Foundation; the Stanley Medical Research Institute; the Urban Institute; and Wyeth-Ayerst Laboratories Inc. He has equity holdings in Pfizer Inc and receives royalty/patent income from Guilford Publications and Healthcare Technology Systems, Inc. Dr. Freedman reviewed this editorial and found no evidence of influence from these relationships.
I stopped telling people what to do and what to think a long time ago, but if you are going to read more about STAR*D and draw your own conclusions, be sure to read the NIMH question and answer page on the study here. 

After doing all this reading, I have some questions that none of the articles mentioned above address--maybe you do, too. Here's my list:

  • STAR*D looked for remission from symptoms and spent a whole whack of money measuring that. Did anyone look at other outcomes? 
  • Were people "successfully treated" able to work, or go to school, or do the other things people do with their lives?  
  • How were their relationships with other people?  Did they have friends they enjoyed hanging out with, good family relationships? 
  • Did study participants report an improvement in their quality of life, however they, as individuals, define it? 
  • And why the heck did the study provide medication at no charge, but charge people for talk therapy? head hurts.