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.

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

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!

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

Taking a closer look at child sexual abuse

Each year, approximately 150,000-200,000 children are sexually abused, 70-80% of those cases involve a family member or a friend of the family that the child knows, including older children. It’s an appalling proposition to anyone who wants to work in the treatment of mental disorders. The people that we are supposed to trust, the “in group,” is more likely to do damage than any stranger. Even the most well-balanced counselors and therapists I know get floored by stories of child sexual abuse.

The Journal of Mental Health Counseling published an article by Frazier et al. covering some very good information regarding recovery from CSA. Here are some of the key facts regarding recovery:

• Primary symptoms of CSA include avoidance behaviors (including caregiver phobias), developmental delays, diminished responsiveness to the outside world, lack of interest in a previously-enjoyed activity, and feelings of detachment or estrangement.
• Survivors of CSA may lose developmental achievements. They may start bedwetting behavior, or they may become unable to feed themselves.
• When an abused child views their preabuse life as high-quality, they are more likely to have a positive self-view after the abuse.
• Survivors who believe that others do not view them as responsible for the abuse often feel empowered, leading to a more positive adjustment.
• Abused children who receive emotional support from a non-offending adult are less symptomatic.

Note that the emphasis of this article is on children. Adults who survived CSA are more likely to show symptoms of depression and anxiety, but children respond well to treatment. Frazier et al. recommends using an ecosystem approach in working with child survivors of CSA, and calls for counselors to be aware of transgenerational trauma, or situations in which a child keys into an adult’s behavior surrounding the adult’s experience with sexual abuse. Children are quick to pick up cues from parents. If we can assist these children as early as possible, we may be able to break that cycle.

Of course, CSA is not without its controversies. The biggest of which is probably the diagnosis of Dissociative Identity Disorder.

I’ve been reading bits and pieces of Science and Pseudoscience in Clinical Psychology, and last night I finished a chapter on DID (Lilienfeld & Lynn, 2003). It does a great job of highlighting the controversy surrounding DID.

Briefly, DID is a disorder in which a client presents with two or more distinct “personality states” that alternate in their control over the individual. It is one of the dissociative disorders, disorders which present with disturbances with memory, identity, or perception of the external world. The common belief regarding DID is that the development of separate personalities is caused by child sexual abuse. (note: this is a more recent development. The two famous early cases, those presented in The Three Faces of Eve and Sibyl contain no mention of CSA). The belief is that the child develops the second personality as a way of protecting the primary personality from facing the fact that they are being abused.

The other camp, the place where I hang my hat, claims that DID is the result of therapist cueing. Lilienfeld & Lynn point to a few facts: that a huge number of DID cases come from only a handful of therapists, the flexibility of memory as demonstrated by Elizabeth Loftus, the fact that a majority of the cases of DID begin treatment for other problems and do not report the expression of different personalities until later.

Lilienfeld and Lynn are quick to point out that they are not denying that DID patients experience these symptoms. The question is whether the symptoms are a natural reaction to trauma.

This leads me to a story. In an earlier job, I was treating a female with DID who claimed that her parents performed ritual sexual and satanic abuse. I was an undergraduate student at the time, and I happened to read one of Loftus’ memory studies around that time, and read the FBI statements that there had never been any documented cases of ritual satanic abuse in the US. I was confused, so I went to my boss. He was (and still is) a great counselor and he said “it probably isn’t true, but it is true to her.” This, or course, is a take on the old adage with schizophrenia, never challenge the delusion. Of course, it does beg the question, how do you treat someone who bases their life on events that did not occur?

(Original Photo by D Sharon Pruitt)

Frazier, K.N., West-Olatunji, C.A., St Juste, S., Goodman, R.D. (2009). Transgenerational Trauma and Child Sexual Abuse: Reconceptualizing Cases Involving Young Survivors of CSA Journal of Mental Health Counseling, 31 (1), 22-33

Washington DC mental health privatization sparks controversy

In Washington DC, public officials are attempting to privatize the provision of mental health care by transferring patients to private clinics and closing public clinics. This has sparked some controversy in the area.

According to The Washington Post, the city plans to close their six clinics and enter contracts with 30 private clinics by 2010. The city argues that this will save money, which will allow them to provide services for more people.

Critics are arguing that the public clinics provide a higher level of care than private clinics, who are worried about profit and the bottom line. They argue that doctors make less in private clinics and have a larger client load, prompting many doctors to leave.

Apparently DC was court ordered to provide mental health care through clinics after a 2001 court order which restricted confining patients to hospitals. The city says that it was never meant to be a perminant plan, and they are behind their orignial schedule to privatize the system.

Ken Duckworth, the medical director for the National Alliance on Mental Health, thinks this is a bad idea, asking “If the government doesn’t take care of the most severely ill people, who will?” It’s an interesting question that everyone in and around the field has been asking since the days of deinstitutionalization.  The real question is to what extent should the government be involved in the provision of healthcare versus paying for health care.

In West Virginia we have two hospitals that are owned and operated by the state. local services are provided through private non-profits throughout the state. Prestera serves Charleston and Huntington, United in Clarksburg, Eastridge in the Eastern Panhandle, and Westbrook in Parkersburg. So I’m kind of unfamilliar with the concept of public health care. I don know that private groups can do a good job with public money, so I’m not nearly as alarmed by this as some of the critics are. And if this frees up money to provide services for more poeple, I definately see it as a positive.

Predicting Behavior: Depression in adolescent girls

It is sometimes essential that we be able to correlate behaviors that may relate to mental illness. Research points to early intervention as being an important predictor of recovery. If we can correlate one set of mental health symptoms with something that occurs early in life, and if that correlation holds true, we can better predict who will need mental health care and get services to them in a timely manner.

A recent study in the Journal of Early Adolescence points to a correlation between antisocial behavior in young girls and depression in adolescents. This is based on a University of Washington study starting with first and second graders and following them for 7 years.

Antisocial behavior is most commonly seen as a problem in boys, but this study found that antisocial behavior and anxiety were predictors of depression in early adolescence. The researchers note that more girls than boys suffer from adolescent depression.

This all leads me to question: are the minds of children and adolescents well-formed enough to apply an adult disorder to their mind. This is a serious question, I’m not doing one of those rhetorical questions to try to show that psychiatry is misguided, etc. If we were to diagnose depression in a 10-year-old girl, just as an example, on what criteria do we base this decision? Is the DSM adequate, considering the mental abilities and emotional state of a teenager?