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.

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.

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