CAM Jerks on PBS

I had read a week or so ago on Science-Based Medicine that PBS has been running what are essentially infomercials for quacks. SBM picked the story up from Salon. I thought my local PBS stations (one in West Virginia, one in Maryland) were immune. I was wrong.

I have a weight bench in the bedroom and I usually watch PBS while I lift. Of course, this is usually weekday evenings, not weekend mornings, so imagine my surprise when I turn on the TV and, instead of the gentle, soothing voice of Jim Lehrer, I see Dr. Mark Hyman peddling his UltraMind Solution.

I didn’t watch long because I read somewhere that it’s bad to vomit while weightlifting. But I wanted to touch on some of the stuff Hyman said. The first, that studies have shown that autism has been linked with diseases of the gut, had me in stitches. The problem is that those studies have been discredited, and considering that Wakefield did his study on a huge sample of 12 people, I don’t know how valid the results could be.

We now know that mercury is toxic.

Actually, we’ve known that mercury was poisonous since at least 1926. However, there are still commercial applications that need mercury, so we still have to use it and be cautious of its environmental effects. But don’t make it sound like mercury poisoning is a new concept.

We use special chemicals that bind with the mercury.

Chelation. He is talking about adults here, so I’m not going to go on a rant about chelating children. He is specifically talking about an adult who lived near a concrete plant. In this case chelation would be appropriate. However, Hyman makes it sound like everyone needs chelation. This is akin to comparing the effects of environmental radiation from someone who lived at Chernobyl to someone born and raised in Nebraska.

Stress shrinks the hippocampus.

This article from Harvard psychologist R.J. McNally refutes this mind myth, giving us a number of studies showing that the atrophy theory is bogus.

Stress lowers serotonin levels in your brain.

I have a problem here. While I can’t find anything reliable that directly relates high stress and low serotonin, it is logical. However, studies have shown that serotonin is released during exercise, and exercise is physically stressful.

But that’s not the real problem. The problem is: so what? People seem to think of serotonin as a miracle, cure-all neurotransmitter, like if they can just get more and more serotonin they would be fine (when, in fact, it makes people ill. It’s called serotonin storm). It’s the same irrational logic that steroid-users present after they’ve shrunk their testicles and grown bitch tits (thank you, Chuck Palahniuk, for such a wonderful term). There can truly be too much of a good thing.

We need stress. We thrive on it. Stop making stress out to be a demon. It is by facing stress that we change, and we face stress as we change. You can point to happiness as the key to a healthy life, but if you’re smiling and laughing in the middle of a firefight, there is something wrong with you.

I’m going to stop here before my head explodes from the stupid. I didn’t link to any of Hyman’s web sites (you’re welcome), but if you want to find this guy, just Google him.

Fatty Threw A Party: Week One

I weighed myself yesterday. I’m still at 324.

I came across a situation late this week that illustrates how difficult it is for people to lose weight. On Thursday evening I got a call from a close friend and spent the night talking, so I ended up skipping my 1/2 hour cardio. Last night the wife wanted to watch Rescue Me, as she still has to catch up to me, so I skipped it again. I also skipped weightlifting.

Now it’s Saturday. If I wasn’t writing this blog, I may skip the stuff today, too. Now I have someone (my readers) to answer to. So it’s weightlifting and cardio today. I was planning to do some outdoor jogging today, but we’re getting April Showers early, so I guess I’m working off the DVD again.

Fatty Threw a Party: Day One

I’m fat. I don’t like to say I’m overweight, because “fat” cuts a little deeper and motivates me. I have dieted and gone through exercise regimens in the past, and I see the same thing as many Americans; I lose a bit of weight and then I gain it back. I want to stop this.

So this will be a series on this blog. I figure if I make my wins and losses public, I may be a little more motivated. I’ll give you my stats: I am a white male, 28-years-old, my height is 5’11”, and I currently weigh 324 pounds (I just weighed myself this morning.) Last Thursday I weighed in a 331, so the first step, drink more water, is helping a little bit.

My plan is to combine a calorie-restrictive diet with an exercise regimen that involves a ½-hour cardio workout daily (I started on Monday) and weight-lifting 3 times a week (I started that on Monday, too). I’ll be posting my weight gains and losses on the blog every Friday or Saturday.

I started this on Monday, and I was planning on doing my first post on Friday, but I read a story on the Huffington Post that I thought would be a good stepping-stone to introduce this series. HuffPo Columnist Kathy Freston writes that counting calories never works, and uses a recent Harvard study published in The New England Journal of Medicine as her proof.  The study looked at four diets in 811 individuals, limited their calorie intake to 750 calories below their daily needs, but no fewer than 1,200 calories a day. At six months the subjects had lost an average of 13 pounds and at two years they had kept an average of 9 pounds off their original weight and lost 1-3 inches off their waists.

Why is this not good news? Because, according to Freston, at 2 years people were consuming more than their allotted number of calories. So, low calorie diets don’t work when people consume a high number of calories? That’s a revelation. That should be on a billboard.

Freston then pushes a low-fat vegetarian diet that she read about in a book somewhere. After the post turned into an advertisement I stopped paying attention. I’ll be the low-fat vegetarian diet will stop working if people start consuming meats or high-fat nuts as well.

I’m going to het Dr. Harriet Hall, paraphrasing from this month’s Skeptic magazine, get the final work. Eat a little bit of everything, in moderation, mostly vegetables.

A Response to Harriet Hall on Psychosis and Civil Rights

Harriet Hall has an interesting piece about the right to refuse treatment for psychosis over at Science-Based Medicine. The premise of the article is essentially that the right to refuse treatment must be balanced with the potential danger to the public when someone with a sever psychosis is allowed to live in the community. I believe this is true, and I marvel at the modern mental health system where the word of a lawyer and a judge trumps the word of a psychologist or psychiatrist in deciding whether a person is dangerous, yet, as we saw in the Tarasoff case, the mental health practitioner is still responsible for contacting the family of a named potential victim if the legal side of an involuntary commitment hearing falls through.

So overall I agree with Dr. Hall in that, in some cases, it should be easier to commit someone long term, and we should build long-term treatment facilities. I do, however, have 3 points of contention that I would like to address with Dr. Hall’s post.

Number 1, Hall states that “anosognosia is part of their disease… If you can’t recognize that you are ill, why would you accept treatment for a condition you firmly believe you do not have?” In my experience, and I realize that anecdote is not the singular form of data, but this has been pretty across-the-board, most people with schizophrenia realize that they are ill, but the hallucinations and delusions that they experience are so real that they can’t help believe them. They don’t stop taking medications because they do not believe they are ill, they stop because medication is not perfect and paranoia can set in during brief relapses. Every person with schizophrenia that I have ever worked with has stated that they stopped taking their pills because they thought that the pills were poisoning them. This paranoid delusion also makes people with schizophrenias more resistant to therapy because they believe that the therapist is trying to harm them.

 I’m not saying that anosognosia  doesn’t play a role, but no client I have ever dealt with has stated that they believe they were not sick. However, most of my clients with schizophrenia have been older and in the system for a while. Perhaps it would be different for someone who is recently diagnosed.

Number 2, Hall at one point leads readers to believe that someone has to have committed a violent act before they can be involuntarily committed, stating “Society will do nothing to help you until he actually hurts someone.” Laws relating to involuntary commitment are different from state to state, and it really boils down to the will of the county mental health commissioner, but in my local system the law clearly states that the individual has to be “a danger to themselves or others.” That doesn’t mean that they have had to attempt a violent act, but they must be a viable threat. I’m not saying that it is easy to have someone committed, but it is not quite as hard as Hall states.

Number 3, Hall seems to forget that the ethos of deinstitutionalization was not just to shut down hospitals, but to put more emphasis on community-based treatment. It is possible to provide a high level of care for people with schizophrenia in a community-based setting. The Title XIX Medicaid Waiver program provides funding for in home care for three distinct groups of people, the MR/DD population, the elderly, and people with severe persistent mental illness. The problem is that most waiver funding goes into the MR/DD sector, with elder care and care for persistent mental illness splitting a very small pot. If we could increase funding for mental illness care, we could provide 24-hour staffing for individuals living with severe and persistent mental illnesses such as schizophrenia.

Of course, maybe one of the problems is one of categorization. We classify MR/DD disorders as Axis II disorders and schizophrenia as an Axis I disorder, despite the fact that both of these disorders appear, if current research is correct, to be fully caused by a person’s genetics and biology. However, the typical age of onset of schizophrenia, late teens to mid twenties in men, early twenties to early thirties in women, leads many to believe that schizophrenia has some sort of social/environmental cause. Mental retardation appears at birth. Schizophrenia takes a while.

Of course, as I type this, a group of doctors are meeting privately to decide the content of the DSM-V. Maybe this insulated group will change things. Then again, maybe not.

Annoying Habits of Therapists

I can’t believe I’ve never found PsychCentral before! This is a great site. There is a story on the front page that I thought I would touch on, The 12 Most Annoying Bad Habits of Therapists. I want to comment on a few of them.

1. Showing Up Late for an Appointment

This one should go without saying. I can’t believe that someone would have to tell you to be in time.

2. Eating In Front of a Client

Do people actually do this? I’m only a case manager, and the place that I work has a water tower and coffee that are free to the clients and staff, so we do a lot of drinking in the office, but eating? During a session?? That’s just crazy.

3. Excessive Yawning or Sleeping During a Session

Yawning sometimes can’t be helped. It’s all well and good to say you should get a good night’s sleep, but when you work a job that has on-call hours, it isn’t always possible. Of course, explaining this to a client would be good.

6. Distracted by Phone, E-mail, or a Pet

I know someone who works in the field who will answer her cell phone at any time, with a client or in a meeting with the boss. I know some of her co-workers would like to jam that phone someplace very uncomfortable, too. It’s annoying for everyone, clients and co-workers alike. If your wife is pregnant, and she’s in the third trimester, it’s okay to check the cell phone to see if it’s her number otherwise, don’t.

And pets? Do these people even think about allergies?

5. Inappropriate Disclosures

7. Expressing Racial, Sexual, Music, Lifestyle, or Religious Preferences.

These are really the same thing. I learned early on to not let clients too far into my life, but I have seen this happen before.

I like the music thing here. I could see myself getting into an argument with a client about the greatness of Pearl Jam, or, for you old guys, the Rolling Stones vs. The Beatles.

9. Hugging or Physical Contact

I’m not a hugger. And it really tells you something about the state of mind of some people that you have to explicitly state that having sex with your client is inappropriate. There’s an old saying where we work; every rule exist because someone screwed up in the past.

11. Clock Watching

12. Excessive Note Taking

Ah, the two things I’m probably going to be most guilty of. If you don’t keep track of the time, you end up with a Number 1 with your next client. I have cut back on the note taking, though.

I have a friend who works as a counselor, and he has a good way of doing things. He lets the client stay for a whole hour instead of 50 minutes if thy want to help recap the session for the note. I like that.

You should read the whole list. It’s rather good.

Fluoxetine in the treatment of depression with comorbid substance abuse disorders

Twenty to 30% of adolescents diagnosed with Major Depressive Disorder are also diagnosed with at least 1 comorbid substance abuse disorder. Moreover, reported drug use has been found to be a predictor of suicide attempts in adolescents, with a positive relationship being found between the number of drugs abused and the likelihood of a suicide attempt.

Fluoxetine (you may know it better as Prozac) is the only antidepressant that the FDA approves for use with children and adolescents, and fluoxetine has been found to be effective in reducing depression and comorbid substance abuse disorders in adults. Findling et al., publishing in the Open-Access Child and Adolescent Psychiatry and Mental Health, decided to study the effects of fluoxetine in adolescents with depression and comorbid substance abuse disorders.

The study originally included 18 patients in a fluoxetine experimental group and 16 adolescents in a random, double-blinded control group. Of the subjects, 26 reported that the depression started before the substance abuse and 6 reported simultaneous depression and substance abuse. Urine screens were used to assess drug use throughout the experiment.

At the end of the study, 12 subjects remained in the fluoxetine group and 13 remained in the placebo control. Both groups had reduced symptoms, but the placebo group had a greater mean reduction in symptoms. Fifty percent of the participants in each group met the criteria for remission. (There is a great graph in the article showing the difference in scores between the two groups, but I’m working off an old computer and can’t get a really good screengrab.)

This study gives us some good data, but it is important to keep in mind the small sample size and low statistical power of the study. I like that the authors didn’t let this study become part of the file drawer problem. It is just as important to see that a psychological or medical intervention is not effective as it is to see that something is effective.

Findling, R., Pagano, M., McNamara, N., Stansbrey, R., Faber, J., Lingler, J., Demeter, C., Bedoya, D., & Reed, M. (2009). The short-term safety and efficacy of fluoxetine in depressed adolescents with alcohol and cannabis use disorders: a pilot randomized placebo-controlled trial.

UPDATE: I just read in one of John’s posts on PsychCentral that the FDA just approved Lexapro for use in children, despite some misgivings. So fluoxetine is not the only SSRI approved for children. Check out John’s post for details about the controversy.

 Child and Adolescent Psychiatry and Mental Health, 3 (1) DOI: 10.1186/1753-2000-3-11

Traumatic Brain Injury

Following the death of Natasha Richardson from a head injury, MSNBC is running a bit of information about Traumatic Brain Injury that they pulled from the CDC. It’s some good info for anyone who is interested in brain trauma.

Really, Mr. President? Really?

First it was Dick Morris saying “retarded” on The O’Reilly Factor, now it’s the freakin’ president! Obama was on Leno the other night and said something to the effect of I bowl like someone in the Special Olympics. Really, Mr. President? You bowl that well?

President Obama had the decency to call Tim Shriver at Special Olympics and apologize before the show even aired, but still… It leaves a bad taste in my mouth.

C’mon, can we please get rid of those parts of our vocabulary that are offensive to people with intellectual disabilities? Do we have to use retarded when we mean stupid, or make a reference to the Special Olympics when we want to say we’re bad at a certain sport? What if I said “I did as well on my science test as an inner-city black kid?” That wouldn’t be cool! Not cool at all!

So stop it! Stop! Think before you speak, for Pete’s sake.

And don’t think Sarah Palin is on my good side because she has spoken out about the same issue. She is the political equivalent of one of those D-list actors you always see on VH1, she’ll do anything to get press. Where was she on the Dick Morris thing? Nowhere, that’s where. Nobody cares what you think. Go back to Alaska and try to explain how we rode around on the backs of dinosaurs.

CBT for Eating Disorders

I’ve stated before that I am firmly in the cognitive-behavioral therapy (CBT) camp. I read in a paper assigned for my last class that people do not choose theoretical orientation die to efficacy. I disagree. I initially started reading books by Aaron Beck and Albert Ellis because CBT has a wealth of research behind it, and I found that it just seemed to make logical sense.

In a randomized controlled study by Fairburn et al. published in the American Journal of Psychiatry, researchers studied the use of a specific form of CBT designed to treat eating disorders. There are two forms of the therapy, CBT-Ef, which is a focused form that highlights issues directly related to eating disorders such as body image, extreme dieting, binging, and purging, and CBT-Eb, a broad form which also touches on other psychopathology, such as depression, low self-esteem, mood intolerance, and interpersonal difficulties.

When the results were tallied, researchers looked at complex psychopathology and simple psychopathology. Subjects in the complex psychopathology group tended to be assessed as having more mood intolerance, interpersonal difficulties, and self-esteem issues. The results are kind of interesting:

As you can see from the graph, CBT-Ef works best with simple psychopathology, but does not work nearly as well with complex psychopathology. The CBT-Eb group shows similar results with both simple and complex psychopathology.

It looks like the focused approach is not really necessary, but can give better results when used with clients with less complex psychopathology. The broad approach seems to be preferable, but less effective.

This study shows us the importance of clinical judgment. Clinicians need to be able to assess the complexity of their clients’ psychopathology in order to find the right emphasis for therapy. In these two therapies, the first four weeks are the same regardless of whether a clinician is using the focused or broad approach, giving clinicians plenty of time to assess their clients’ needs.

Fairburn, C., Cooper, Z., Doll, H., O’Connor, M., Bohn, K., Hawker, D., Wales, J., & Palmer, R. (2009). Transdiagnostic Cognitive-Behavioral Therapy for Patients With Eating Disorders: A Two-Site Trial With 60-Week Follow-Up American Journal of Psychiatry, 166 (3), 311-319 DOI: 10.1176/appi.ajp.2008.08040608

How do you treat the duck?

I’m reading Science and Pseudoscience in Clinical Psychology and in a chapter about recovered memories, I found this:

In 1997, Nadean Cool won a $2.4 million malpractice settlement against her therapistin which she alleged that he used a variety of techniques and suggestive procedures to convince her that she had suffered horiffic abuse and harbored more than 130 personalities including demons, angels, children, and a duck.

The emphasis is, of course, mine.

If anyone out there knows how to provide psychotherapy to a duck, please let me know. If breadcrumbs are involved I want to be prepared.

Of course, the other issue is that you could never tell with any validity if the woman was a witch.

John C. McGinley kicks ass!

Ever since I saw my first episode of Scrubs it has been one of my favorite shows. I knew John C. McGinley, the actor who plays Dr. Perry Cox and is well known for his roles in Platoon and Office Space, has a son with Down Syndrome and is very active in trying to raise awareness for people with mental retardation and developmental delays. Of course, that is very cool.

I got my start working in behavioral health working with the MR/DD population as part of a program called Title XIX/Medicaid Waiver. The Waiver program, as we called it, provides an alternative to hospitalization and institutionalization by providing funding for home care workers, nurses, case managers, and psychologists to provide services for people with MR/DD diagnoses. Waiver has a number of sub-programs, such as day-habilitation (or DayHab, providing assistance to individuals in the community, which includes providing transportation, helping people shop and pay bills, etc.), residential habilitation (ResHab, providing assistance in the home with chores, personal care, cooking, etc.) and respite services, which provide parents and other unpaid caretakers with a break so that they can take care of themselves.

This is a really good program. It is also the hardest and, in some cases, least rewarding work you can do in behavioral health. Improvement comes slowly, so you can never expect to see any drastic changes from day to day or week to week, and it is physically and mentally exhausting. But I would trust a great waiver worker over just about anyone else to do the right thing when needed. This is incredible front-line training for future behavioral health workers, and I would recommend it for anyone interested in a career in the field. To put is simply, if you can work waiver, you can do anything.

But enough nostalgia. John C. McGinley was on the Bonnie Hunt Show last month and he spoke about his son and about Special Olympics, and he touched on a controversy. Apparently Dick Morris was on The O’Reilly Factor and used “the R-word,” or retard, in an interview, and a bunch of kids at the Special Olympics sent O’Reilly a letter asking for an apology. Apparently, O’Reilly did apologize, which is cool. Here’s the clip:

And here’s the clip of O’Reilly apologizing:

What does it mean, though, when he says “Dick Morris is speaking off the cuff?” Why couldn’t he just apologize? What exactly does “off the cuff” mean? Is he saying that Morris didn’t prepare a statement? That it is okay to use “retarded” as a pejorative as long as you don’t do it on national television? I mean, it’s cool that the guy apologized, but why does he have to try to backhand the apology by trying to explain away the remark? Would saying that he is speaking off the cuff and apologizing be appropriate if he had said nigger instead of retarded? Actually, the producers and O’Reilly himself would have stopped him at the time if he had dropped a racial slur, but it takes three days to apologize about using retarded as a euphemism for dumb and slandering millions of people with intellectual disabilities, people who have to work harder to do the same things we do and still end up doing as well as the average American.

Anyway, enough with the rant. John C. McGinley, I salute you!

Can doctors learn something from a snake oil salesman’s pitch?

A co-worker of mine is going through some medical tests, and she is complaining. She says that doctors order too many tests, and that it is killing her to pay for all of them because she hasn’t hit the deductable on her health insurance yet. I point out that they only order so many tests because if they miss something, they open themselves up to malpractice lawsuits, and then their premiums go up. Doctors order extra tests for the same reason we look both ways before we pull out into an intersection while driving: they do not want to pay more for insurance.

There was an article in the Washington Post a couple of days ago talking about alternative medicine, written by a Dr. Manoj Jain. He states that a number of his co-workers who get both conventional and alternative medical care complain that doctors are too brief with patients. One of his nurses told him:

Judy summarized her experiences without mincing words. A conventional doctor “listens to my symptoms and is quick to prescribe a medicine or to order tests. My instructor listens to my story and works with me.” I asked her for another example.

“Well, do you remember two weeks ago, when I had a terrible cold, followed by a cough, low-grade fever and lots of sinus drainage, and I came to your cubicle? In less than a minute — listening to my symptoms — you said, ‘You have sinusitis’ and called in antibiotics.” The drugs worked, but she thought the encounter was a little too quick. “I am not criticizing you, but that is how conventional doctors work.”

Myself, I prefer doctors to give quick answers. But Dr. Jain points out that the placebo effects are powerful things, and that they can make the difference in quality of care.

Dr. Jain does not come off as being soft on alternative medicine, although he may be a bit of what the bloggers over at Science-Based Medicine call a “shruggie.” He seems to attribute the power of alternative medicine to the interest that practitioners take in their patients, compared to then”15-minute office visits, recurrent insurance denials and unnecessary diagnostic tests to avert malpractice suits” that patients see in conventional medical care.

Jain is not really talking about medical practice. He’s talking about the pitch (ironically, he refers to alternative medicine as “snake oil” in the title. Snake-oil is all about the pitch). He refers to alternative practitioners as “good used car salesmen…with little scientific proof,” but he doesn’t see that as a bad thing, and thinks that some of the pitch of alternative medicine can help doctors relate better with their patients, and help the patients trust conventional treatment more than they currently do.

In psychotherapy, we occasionally see news stories that point out that what we call the therapeutic alliance, the bond that forms between a therapist and his client, is a better indicator of successful therapy than the use of any particular technique. This is old news that gets rehashed as “news” every time a new study is released. The client wants a therapist who will take time to listen to his client, male recommendations, and work with the client. It shouldn’t be stress-free because there is no change without stress, but it shouldn’t be contentious.

Doctors may be able to take some lesson from this. Perhaps If doctors could spend more time with each patient, talk to them more, and make the same recommendation they would have made in five minutes under the current system, patients would feel better about their care.

Of course, the question is how do you fit that into the current system?

JAMA editor DeAngelis is actually Joe Pesci, circa Goodfellas

Okay, my hiatus is over. Class is finished, and I’ve got three weeks to kill with work, blogging, and playing Lego Batman because I’m just that kind of geek.

Of course, the first blog I check when I come back is Mind Hacks, because it is one of the best psychology blogs out there, and I found the first story a bit troubling. I followed it back through all of the sources, and now I’m presenting it here. Furious Seasons has reported on this story, twice, so I also recommend you read that site for anything I may have missed.

In 2008, Robinson et al. published a piece in JAMA testing the use of the antidepressant escitalopram (Lexapro) versus Problem-Solving Therapy as a treatment for post-stroke depression. More specifically, Robinson et al. were testing whether either Lexapro or therapy would prevent depression within the first year after a stroke, stating that depression occurs in more than half of stroke patients. They studies the effects in a randomized, controlled, partially double blinded experiment. (Let me explain: it is virtually impossible to double-blind a therapy comparison, especially when one is comparing the effects of therapy with medication. What Robinson et al. did was blind the Lexapro trial with a placebo group. And when I say virtually impossible, I mean impossible, but I want to leave myself open in case I’m wrong).

Robinson et al. found that fewer people in the Lexapro group (8.5%) were diagnosed with depression after 12 months, compared with the therapy group (11.9%) and the placebo group (22%). These results were paraded through the media.

However, this is not as simple as it seems. Jeffery Lacase and Jonathan Leo published a letter in JAMA in October, stating that, while the study states that while the study finds that the Lexapro results were statistically better than placebo and the therapy results were not, the study did not assess whether the Lexapro results were statistically better than therapy. In a response in the same issue, Robinson et al. stated that “a Cox proportional hazards test did not demonstrate a significant difference between the two treatments.”

This month, Leo and Lacase published an article in the British Medical Journal (BMJ) stating that Robinson et al. did not make full financial disclosures. Specifically, Robonson did not mention that Robinson had a financial relationship with Forest Laboratories. Forest, for those who may not know, makes Lexapro. This seems like a pretty big deal. Robinson chalks it up to an “erroneous recollection” of the dates that he worked for the Forest speaker’s bureau. I don’t buy this. JAMA asks for disclosures going back five years, in this case between 2003 and 2008. Robinson states that he worked for Forest in 2004 “and perhaps 2005.” This is well within the reporting window.

If it were me, and I don’t think I’ll ever have to worry about pharmaceutical money as a lowly counselor and psychologist, I think when I filled out the disclosure form the first thing that popped in my head would be that I worked for the company that is making the drug I am supporting, not that I got money from a bunch of other drug companies.

And I’m not criticizing doctors who take money from pharmaceutical companies. From what I read, if this practice stopped it would almost halt medical research. The NIH only gets about $12 from Congress (as opposed to the billions we use to stop those pesky potheads from getting stoned and passing out while watching anime terrorizing their neighbors. What I’m criticizing here is the non-disclosure. Even if the results of the study are spot-on, it makes things look shady.

But this isn’t the end. Leo received a phone call from JAMA editor Phil Fontanarosa, who, depending on which side of the story you hear, either banned Leo from ever publishing in JAMA again, or, as a spokesperson says, ” It was something along the lines of not setting a good example for students. He didn’t say he would be banned. He didn’t think Leo was taking a very good approach by taking this confidential process within JAMA out to media and another medical journal. It’s just not the way things are handled here.”

JAMA’s Instructions for Authors state that it is best to submit a letter within four weeks of original publication.  It is unlikely that Leo’s article would have been published anyway. In fact, Leo stated that he warned JAMA about the lack of disclosure 5 months ago.

The Wall Street Journal reports that Leo then received a not-so-friendly call from JAMA editor-in-chief Catherine DeAngelis. Le states that DeAngelis first called his supervisors to try to get him to retract the BMJ piece. Leo characterized DeAngelis as “very upset.”

When WSJ attempted to contact DeAngelis, she gave a remark that could have come from one of the mobsters in one of Scorsese’s best:

“This guy is a nobody and a nothing” she said of Leo. “He is trying to make a name for himself. Please call me about something important.” She added that Leo “should be spending time with his students instead of doing this.”

When asked if she called his superiors and what she said to them, DeAngelis said “it is none of your business.” She added that she did not threaten Leo or anyone at the school.

Of course, with all of the attention this is raising, I would guess that the story isn’t over.

Lacasse, J., & Leo, J. (2008). Escitalopram, Problem-Solving Therapy, and Poststroke Depression JAMA: The Journal of the American Medical Association, 300 (15), 1757-1758 DOI: 10.1001/jama.300.15.1757-c
Robinson, R., Jorge, R., Moser, D., Acion, L., Solodkin, A., Small, S., Fonzetti, P., Hegel, M., & Arndt, S. (2008). Escitalopram and Problem-Solving Therapy for Prevention of Poststroke Depression: A Randomized Controlled Trial JAMA: The Journal of the American Medical Association, 299 (20), 2391-2400 DOI: 10.1001/jama.299.20.2391
Robinson, R., Jorge, R., & Arndt, S. (2008). Escitalopram, Problem-Solving Therapy, and Poststroke Depression–Reply JAMA: The Journal of the American Medical Association, 300 (15), 1758-1759 DOI: 10.1001/jama.300.15.1758-b

The Tarasoff Case and what it means for confidentiality

It’s a sad case, really. In 1969 Prosenjit Poddar, a student at UC Berkeley, sought psychiatric counseling with Dr. Moore, a psychologist employed by the university. Poddar had become enamored with another student, Tatiana Tarasoff, and started stalking her when she rejected his advances. In the 9^th session Poddar threatened to kill Tarasoff. Moore discusses the case with his supervisor and informed the police, verbally and in writing, that Poddar was unstable and in need of civil commitment. The police detained Poddar, but released him when he appeared rational and stated that he would not go near Tarasoff. After the unsuccessful commitment attempt Poddar ceased going to therapy and Moore was directed to take no further action.

Two moths later Tarasoff returned from a trip abroad and Poddar shot and stabbed her to death. Her parents sued on the basis that Moore should have warned them. The resulting 1974 case, Tarasoff v. Regents of the University of California, created what is known as the duty to warn.

What is interesting, and often overlooked, in this woeful tale is the rehearing in 1976 by the California State Supreme Court, which held that mental health providers did not have a duty to warn, but instead a duty to protect. In essence, if a mental health provider is privy to a threat, he or she has a duty to protect the potential victim. This duty to protect can be discharged by warning the potential victim, warning the police, through a commitment, or a combination of strategies. This amendment meant that the defendants were off the hook for failing their duty to detain Poddar, but that they were liable for failing their duty to warn.

My take on this case is a little different. I wonder why, under the 1976 ruling, the duty to warn was not discharged o the police when they were informed by Moore that Poddar planned to kill Tarasoff? But I’m not a legal expert, and I don’t know, with the modern knowledge of the duty to protect, that it is even relevant.

Pabian, Welfel, and Beebe (2009) polled 1,000 psychologists, receiving 300 usable responses, on their knowledge of Tarasoff laws in their states. From the Abstract:

Most psychologists (76.4%) were misinformed by their state’s laws, believing that they had a legal duty to warn when they did not, or assuming that warning was their only legal option when other protective actions less harmful to client privacy were allowed.

I’m sorry to read this, but I’m not too surprised, considering that the Tarasoff case is one of the standard bits taught in Intro to Psychology classes. Pabian et al. also find that many sources, including the APAs PsycINFO database, still use the language from the first case, “duty to warn,” instead of the more modern language, “duty to inform.”

Tarasoff laws vary. Herbert and Young (2002) notes that my home state, West Virginia, does not have a duty to warn, but has an option to warn. What I found in West Virginia Code (§27-3-1 (b)(5) is, “Confidential information shall not be disclosed, except…To protect against a clear and substantial danger of imminent injury by a patient or client to himself, herself or another.” That reads a little more mandatory than Herbert and Young claim. But again, I’m not a legal scholar.

I checked the Client Rights and Responsibilities form from an old employer, which states that they may disclose information in order to avoid a serious threat to health or safety. That doesn’t mean that it’s law, though. If West Virginia says that you may disclose information, I supposed it is legal for a provider to state that they will disclose information.

Yvona L. Pabian, Elizabeth Welfel, Ronald S. Beebe (2009). Psychologists’ knowledge of their states’ laws pertaining to Tarasoff-type situations. Professional Psychology: Research and Practice, 40 (1), 8-14 DOI: 10.1037/a0014784

Who watches the Watchmen? I do

(Please, excuse the cheesy title. I had to do it!)

I saw the Watchmen movie on Saturday. I’m not going to review it. I’m not going to give it stars. Frankly, I think it’s unreviewable. It doesn’t matter to me that the pretentious reviewer at the New Yorker panned the film. I am going to talk about the film and the New Yorker piece. But this is not a review. This is an analysis.

 

First, the movie. I sat there and watched this thing on Saturday and I marveled at the complexity and the sheer beauty of the thing. What surprised me most was how the film changed my recollections of the book. Watchmen is a comic I’ve probably read 5 or 6 times in my life. I would say that there are only two or three books/series that I have read an equal or greater number of times than Watchmen (and those would be James Robinson’s run on Starman, The Dark Knight Returns, and the first Sin City book). I watched the early scene with the police officers in The Comedian’s apartment, and I remember thinking, “wow, the dialogue matches the book very well.” However, when I went home and re-read that part of the book, they were vastly different. This, to me, is a sign of a good adaptation. Snyder used some dialogue verbatim, and some he re-worded, but it was done so well that you think you’re hearing that was written on the page.

I came to realize things about the characters that I had not realized before. The sheer fetishism of the whole superhero concept that permeates Watchmen is splayed before you on the screen. I would recommend that you read the book, then see the movie. If you still don’t get it, you have some issues with analysis and interpretation that you should deal with.

Now, The New Yorker. Did you follow the link? Good. I hope you read this review, and if you think the same way I think, you are probably disgusted. I’m going to hit these points one by one, because otherwise my rants will blend together.

1. Stop calling it a graphic novel. I posted about this at the end of last week. Technically, it’s a trade paperback. More accurately, it’s a comic book. This is from the author’s own mouth: It’s a marketing term. I mean, it was one that I never had any sympathy with. The term “comic” does just as well for me. The term “graphic novel” was something that was thought up in the ’80s by marketing people … The problem is that “graphic novel” just came to mean “expensive comic book” and so what you’d get is people like DC Comics or Marvel comics – because “graphic novels” were ge tting some attention, they’d stick six issues of whatever worthless piece of crap they happened to be publishing lately under a glossy cover and call it The She-Hulk Graphic Novel, you know? It was that that I think tended to destroy any progress that comics might have made in the mid-’80s.
2. The Dylan thing… Look, I love Bob Dylan. I probably have a more unhealthy fanboy attitude about Dylan than I do about comics. But people really need to stop acting like the guy sweats gold and shits Tiffany cufflinks. “was Dylan happy to lend his name to a project from which all tenderness has been excised, and which prefers to paint mankind as a bevy of brutes?” Give me a break! His songs are in the comic (two of them, “Desolation Row” and “Watchtower”). Are we really going to say that a guy who licenses his songs for use in Victoria’s Secret and Pepsi commercials isn’t allowed to license them for a film adaptation of a comic that he also licensed the use of his lyrics? He’s Dylan! He can do whatever he wants, and don’t use your crappy review of this movie as a way to take a swipe at Dylan.
3. The reviewer’s name is Anthony Lane. After reading the review, I have come to the conclusion that lane either a), never read the book, or b), read it and didn’t get it at all. I know, that’s the thing to say when a reviewer disagrees with you, but Lane complains about things that are integral to the theme of the book and the movie. Watchmen works on multiple levels; entertainment, political, genre, deconstruction, etc. On one of those levels is a simple analysis of the superhero in which Moore determines that anyone who puts their underwear on outside of their pants an goes swinging around the night beating people up clearly has something wrong with them, from sociopathic tendencies to sexual fetishism to a complete disconnect from the real world. So yes, people do bad things in the movie, but they’re supposed to. Rorschach’s voiceovers are over the top, but they have to be. Otherwise there is no point. Changing that would be the equivalent of Charles Foster Kane having a happy childhood.
4. I’m over 25, and I thoroughly enjoyed this movie. Don’t be so condescending.

So there you go. Take away whatever you want, but don’t shit-can a film just because you don’t understand the subplot. And stop calling them graphic novels!