By Harriet Brown
The New York Times
Originally posted on March 25, 2013
Mental-health care has come a long way since the remedy of choice was trepanation — drilling holes into the skull to release “evil spirits.” Over the last 30 years, treatments like cognitive-behavioral therapy, dialectical behavior therapy and family-based treatment have been shown effective for ailments ranging from anxiety and depression to post-traumatic stress disorder and eating disorders.
The trouble is, surprisingly few patients actually get these kinds of evidence-based treatments once they land on the couch — especially not cognitive behavioral therapy. In 2009, a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders. One survey of nearly 2,300 psychologists in the United States found that 69 percent used C.B.T. only part time or in combination with other therapies to treat depression and anxiety.
C.B.T. refers to a number of structured, directive types of psychotherapy that focus on the thoughts behind a patient’s feelings and that often include exposure therapy and other activities.
Instead, many patients are subjected to a kind of dim-sum approach — a little of this, a little of that, much of it derived more from the therapist’s biases and training than from the latest research findings. And even professionals who claim to use evidence-based treatments rarely do. The problem is called “therapist drift.”
The entire story is here.
Saturday, April 6, 2013
Friday, April 5, 2013
Do Antipsychotics Worsen Long-term Schizophrenia Outcomes?
By Robert Whitaker
Mad in America Blog
Originally published March 26, 2013
Martin Harrow and Thomas Jobe have a new article coming out in Schizophrenia Bulletin that I wish would be read by everyone in our society with an interest in mental health. Harrow and Jobe, who conducted the best study of long-term schizophrenia outcomes that has ever been done, do not present new data in this article, but rather discuss the central question raised by their research: Does long-term treatment of schizophrenia with antipsychotic medications facilitate recovery? Or does it hinder it?
This is a paper that needs to be widely known. I wish every psychiatrist in the country would read it, and I wish that it would be widely discussed in the media too.
Now, Harrow’s study produced findings that belied common wisdom. He and Jobe followed schizophrenia patients for 20 years, and those who got off antipsychotics, as a group, had much better outcomes. Over the long term, they were much more likely to be recovered, much more likely to work; they were much less likely to be experiencing psychotic symptoms; and they had better cognitive function and they were much less anxious. So how can you square that finding with research showing that when patients are withdrawn from antipsychotic medications, they relapse at a much higher rate? That is the evidence for long-term use of antipsychotics, and here is what Harrow and Jobe write: “We view the results from these discontinuation studies as involving a paradox.”
Within six to 10 months following discontinuation, they write, 25% to 55% of schizophrenia patients withdrawn from their medications relapse. But, they note, “relapse rates are considerably lower subsequently in discontinued schizophrenia patients who remain stable during these 6-10 months,” and that “patients with schizophrenia not on antipsychotics for a prolonged period do not show this tendency to relapse when they remain unmedicated.”
So the puzzle is this: Why is there such a high relapse rate in the immediate months following withdrawal, compared to the relapse rate when patients “remain unmedicated” after this initial discontinuation period?
The entire blog post is here.
Mad in America Blog
Originally published March 26, 2013
Martin Harrow and Thomas Jobe have a new article coming out in Schizophrenia Bulletin that I wish would be read by everyone in our society with an interest in mental health. Harrow and Jobe, who conducted the best study of long-term schizophrenia outcomes that has ever been done, do not present new data in this article, but rather discuss the central question raised by their research: Does long-term treatment of schizophrenia with antipsychotic medications facilitate recovery? Or does it hinder it?
This is a paper that needs to be widely known. I wish every psychiatrist in the country would read it, and I wish that it would be widely discussed in the media too.
Now, Harrow’s study produced findings that belied common wisdom. He and Jobe followed schizophrenia patients for 20 years, and those who got off antipsychotics, as a group, had much better outcomes. Over the long term, they were much more likely to be recovered, much more likely to work; they were much less likely to be experiencing psychotic symptoms; and they had better cognitive function and they were much less anxious. So how can you square that finding with research showing that when patients are withdrawn from antipsychotic medications, they relapse at a much higher rate? That is the evidence for long-term use of antipsychotics, and here is what Harrow and Jobe write: “We view the results from these discontinuation studies as involving a paradox.”
Within six to 10 months following discontinuation, they write, 25% to 55% of schizophrenia patients withdrawn from their medications relapse. But, they note, “relapse rates are considerably lower subsequently in discontinued schizophrenia patients who remain stable during these 6-10 months,” and that “patients with schizophrenia not on antipsychotics for a prolonged period do not show this tendency to relapse when they remain unmedicated.”
So the puzzle is this: Why is there such a high relapse rate in the immediate months following withdrawal, compared to the relapse rate when patients “remain unmedicated” after this initial discontinuation period?
The entire blog post is here.
Thursday, April 4, 2013
Large HMO Cited in Mental Health Care Cover-up
Nancy A. Melville
Medscape Medical News
Apr 03, 2013
California's Department of Managed Health Care (DMHC) has cited Kaiser Permanente for using a deceptive dual record-keeping system to cover up violations of the state's "timely access" law, which restricts the amount of time mental health patients should have to wait for an appointment, as well as for other violations.
In a report filed last month, the DMHC concludes that many Kaiser mental health patients faced extensive waiting periods for appointments, well beyond the 10 days for a regular appointment that the law requires.
(cut)
Clinician Whistle-blowers
The violations were discovered through a standard survey or evaluation process that the DMHC uses to review compliance by all California health plans.
After the review was underway, complaints regarding timely access violations were brought forward by a group of Kaiser Permanente's own mental health clinicians, who were represented by the National Union of Healthcare Workers (NUHW). Those complaints were considered and incorporated in the evaluation, Rouillard said.
Among the psychologists lodging complaints was Andris Skuja, PhD, who said the violations had been observed for years before the clinicians referred their concerns to the DMHC.
"Over a number of years, we tried many internal mechanisms with Kaiser to address some mounting concerns we had about the adequacy of treatment," Dr. Skuja told Medscape Medical News.
The entire story is here.
A previous news story about this topic can be found here.
Medscape Medical News
Apr 03, 2013
California's Department of Managed Health Care (DMHC) has cited Kaiser Permanente for using a deceptive dual record-keeping system to cover up violations of the state's "timely access" law, which restricts the amount of time mental health patients should have to wait for an appointment, as well as for other violations.
In a report filed last month, the DMHC concludes that many Kaiser mental health patients faced extensive waiting periods for appointments, well beyond the 10 days for a regular appointment that the law requires.
(cut)
Clinician Whistle-blowers
The violations were discovered through a standard survey or evaluation process that the DMHC uses to review compliance by all California health plans.
After the review was underway, complaints regarding timely access violations were brought forward by a group of Kaiser Permanente's own mental health clinicians, who were represented by the National Union of Healthcare Workers (NUHW). Those complaints were considered and incorporated in the evaluation, Rouillard said.
Among the psychologists lodging complaints was Andris Skuja, PhD, who said the violations had been observed for years before the clinicians referred their concerns to the DMHC.
"Over a number of years, we tried many internal mechanisms with Kaiser to address some mounting concerns we had about the adequacy of treatment," Dr. Skuja told Medscape Medical News.
The entire story is here.
A previous news story about this topic can be found here.
Fewer Hours for Doctors-in-Training Leading To More Mistakes
By Alexandra Sifferlin
Time
Originally published March 26, 2013
Giving residents less time on duty and more time to sleep was supposed to lead to fewer medical errors. But the latest research shows that’s not the case. What’s going on?
Since 2011, new regulations restricting the number of continuous hours first-year residents spend on-call cut the time that trainees spend at the hospital during a typical duty session from 24 hours to 16 hours. Excessively long shifts, studies showed, were leading to fatigue and stress that hampered not just the learning process, but the care these doctors provided to patients.
And there were tragic examples of the high cost of this exhausting schedule. In 1984, 18-year old Libby Zion, who was admitted to a New York City hospital with a fever and convulsions, was treated by residents who ordered opiates and restraints when she became agitated and uncooperative. Busy overseeing other patients, the residents didn’t evaluate Zion again until hours later, by which time her fever has soared to 107 degrees and she went into cardiac arrest, and died. The case highlighted the enormous pressures on doctors-in-training, and the need for reform in the way residents were taught. In 1987, a New York state commission limited the number of hours that doctors could train in the hospital to 80 each week, which was less than the 100 hour a week shifts with 36 hour “call” times that were the norm at the time. In 2003, the Accreditation Council for Graduate Medical Education followed suit with rules for all programs that mandated that trainees could work no more than 24 consecutive hours.
The entire article is here.
Time
Originally published March 26, 2013
Giving residents less time on duty and more time to sleep was supposed to lead to fewer medical errors. But the latest research shows that’s not the case. What’s going on?
Since 2011, new regulations restricting the number of continuous hours first-year residents spend on-call cut the time that trainees spend at the hospital during a typical duty session from 24 hours to 16 hours. Excessively long shifts, studies showed, were leading to fatigue and stress that hampered not just the learning process, but the care these doctors provided to patients.
And there were tragic examples of the high cost of this exhausting schedule. In 1984, 18-year old Libby Zion, who was admitted to a New York City hospital with a fever and convulsions, was treated by residents who ordered opiates and restraints when she became agitated and uncooperative. Busy overseeing other patients, the residents didn’t evaluate Zion again until hours later, by which time her fever has soared to 107 degrees and she went into cardiac arrest, and died. The case highlighted the enormous pressures on doctors-in-training, and the need for reform in the way residents were taught. In 1987, a New York state commission limited the number of hours that doctors could train in the hospital to 80 each week, which was less than the 100 hour a week shifts with 36 hour “call” times that were the norm at the time. In 2003, the Accreditation Council for Graduate Medical Education followed suit with rules for all programs that mandated that trainees could work no more than 24 consecutive hours.
The entire article is here.
Wednesday, April 3, 2013
Is It Ethical For Doctors To Prescribe Placebo?
By Alice Walton
Forbes
Originally published on March 22, 2013
A new British study out in the journal PLOS ONE is stirring up a lot of debate, as it gives some estimates on the number of doctors who are giving patients placebo to treat their various conditions. It finds that a resounding 97% of the 783 doctors surveyed admitted to giving patients some sort of placebo in their practice. But it would be misleading to say that doctors are giving patients sugar pills or saline injections at the drop of a hat – there are different kinds of placebos, and, as the survey found, doctors have different feelings about when each should be used. Not surprisingly, so does the public.
“Pure” placebos are indeed sugar pills or saline injections with no therapeutic value (aside from that stemming from the psychological effects – more on this later). This “pure” variety was used by about 12% of the general practitioners at some time in their careers. Among these doctors, there were various motivations, including the wish to generate psychological treatment effects, to calm patients, to appease patients’ wish for a treatment, and to treat “non-specific complaints.” Half the doctors only told their patients something vaguely promising, like “this therapy has helped many other patients.” About 25% told their patients that the treatment “promoted self-healing,” and less than 10% revealed that the treatment was actually placebo.
“Impure” placebos, on the other hand, are therapies for which there is no strong evidence that they work for a given problem – for instance, the use of antibiotics to treat a virus, off-label uses of medications, or probiotics for diarrhea. Impure placebos also include lab tests or physical exams that are given simply in order to reassure patients. This type of placebo was much more common, with 97% of doctors reporting their use at least once across their career, and 77% reporting “frequent” use, i.e., at least once per week.
The entire story is here.
The entire study, Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners, is here.
Forbes
Originally published on March 22, 2013
A new British study out in the journal PLOS ONE is stirring up a lot of debate, as it gives some estimates on the number of doctors who are giving patients placebo to treat their various conditions. It finds that a resounding 97% of the 783 doctors surveyed admitted to giving patients some sort of placebo in their practice. But it would be misleading to say that doctors are giving patients sugar pills or saline injections at the drop of a hat – there are different kinds of placebos, and, as the survey found, doctors have different feelings about when each should be used. Not surprisingly, so does the public.
“Pure” placebos are indeed sugar pills or saline injections with no therapeutic value (aside from that stemming from the psychological effects – more on this later). This “pure” variety was used by about 12% of the general practitioners at some time in their careers. Among these doctors, there were various motivations, including the wish to generate psychological treatment effects, to calm patients, to appease patients’ wish for a treatment, and to treat “non-specific complaints.” Half the doctors only told their patients something vaguely promising, like “this therapy has helped many other patients.” About 25% told their patients that the treatment “promoted self-healing,” and less than 10% revealed that the treatment was actually placebo.
“Impure” placebos, on the other hand, are therapies for which there is no strong evidence that they work for a given problem – for instance, the use of antibiotics to treat a virus, off-label uses of medications, or probiotics for diarrhea. Impure placebos also include lab tests or physical exams that are given simply in order to reassure patients. This type of placebo was much more common, with 97% of doctors reporting their use at least once across their career, and 77% reporting “frequent” use, i.e., at least once per week.
The entire story is here.
The entire study, Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners, is here.
When Harm in the Hospital Follows You Home
By Olga Pierce
ProPublica
Originally published March 21, 2013
A slip of the scalpel, an invisible microbe, a minute miscalculation. It's estimated that something goes wrong for more than one million people per year during a visit to the hospital. Some patients experience a full physical recovery. Some are never fully healed.
ProPublica
Originally published March 21, 2013
A slip of the scalpel, an invisible microbe, a minute miscalculation. It's estimated that something goes wrong for more than one million people per year during a visit to the hospital. Some patients experience a full physical recovery. Some are never fully healed.
What follows is a conversation of sorts between some of the 1,550 members of our ProPublica Patient Harm Facebook community and Dr. Gerald Monk, a professor at San Diego State University who specializes in dealing with the aftermath of patient harm for both patients and providers. We asked group members to share their questions and thoughts about the aftermath of patient harm, and then got Monk’s response. What emerges is a portrait of the long journey that begins after the unthinkable happens.
The entire interview is here.
The entire interview is here.
Tuesday, April 2, 2013
The Ethics of Care: An Interview with Virginia Held
3:AM Magazine
Interview by Richard Marshall
Here are some excerpts:
3:AM: You’ve developed an ethical theory around ‘care.’ You see this as an alternative to the dominant ethical theories of the last couple of centuries. It’s important to you that it isn’t an ethics to be added on to Kantianism or utilitarianism or virtue ethics. Can you say something about why it is so important that a care ethics is not an adjunct but is a fresh start? The Kantian Christine Korsgaard has placed reciprocity and human relations at the heart of Kantianism. Onora O’Neill has argued that justice and care are not opposed. In the light of these views, would you still defend the break, or would you be happier to see it as a continuation?
VH: I don’t find it satisfactory merely to add some considerations of care to the traditional moral theories for reasons similar to why it is not enough to simply insert women into the traditional structures of society and politics built on gender domination. Feminists should understand that the structures themselves have to change. The history of ethics shows it to be a very biased enterprise. Very roughly, what men have done in public life has been deemed important and relevant to moral theory, and what women have done in the household has been considered irrelevant. I think it plausible to see Kantian ethics and utilitarianism as expansions to the whole of morality of what can be thought appropriate for law and for public policy.
I have come to see, in contrast, caring relations as the wider network, and the ethics of care as the comprehensive morality, within which we should develop legal and political institutions. Caring relations should be guided by the ethics of care, which we can best understand and which is most applicable in contexts of families and friendship. But we can and should also have weaker forms of caring relations with all persons, and within these, the more limited institutions of law should be guided, roughly, by Kantian norms, and the more limited political institutions by utilitarian ones. Yes I see the legal and political as importantly different, and both as significantly different from the contexts of family and friendship. This is a very oversimplified statement of a complex position but I try to clarify and delineate these matters in my written work.
3:AM: So ‘care’ is at the heart of this new ethic but it isn’t to replace justice. So how do you get from care to justice in your system? Do we end up losing the common use of ‘care’ for a more term of art, technical use, as is the wont with philosophers? And isn’t that a cheat?
VH: Yes, various Kantians are trying to acknowledge the concerns of care, and various philosophers interested in the ethics of care are trying to combine it with Kantian ethics. I think the ethics of care has the resources to be an alternative moral theory that can include persuasive aspects of Kantian ethics and also of utilitarianism and virtue theory. It’s nevertheless a feminist ethics that includes the goal of overcoming gender domination, in our thinking as well as our institutions. And I see it as the more comprehensive view. Korsgaard and O’Neill are still Kantians, though more persuasive ones than some traditional Kantians. I think ethics should start with a vast amount of experience (the experience of caring and being cared for) overlooked by traditional moral theories, and see how the many important and valid concerns of other moral theories can be brought into care ethics. I think it is a strength of care ethics that it is based on experience. It is experience which everyone has had: no one would have survived without enormous amounts of care, in childhood at least. Most women, and increasingly men, have also had a great deal of experience providing care, especially for children.
The entire interview is here.
Virginia Held has written: Feminist Morality: Transforming Culture, Society, and Politics, Justice and Care: Essential Reading in Feminist Ethics, and The Ethics of Care: Personal, Political and Global.
Interview by Richard Marshall
Here are some excerpts:
3:AM: You’ve developed an ethical theory around ‘care.’ You see this as an alternative to the dominant ethical theories of the last couple of centuries. It’s important to you that it isn’t an ethics to be added on to Kantianism or utilitarianism or virtue ethics. Can you say something about why it is so important that a care ethics is not an adjunct but is a fresh start? The Kantian Christine Korsgaard has placed reciprocity and human relations at the heart of Kantianism. Onora O’Neill has argued that justice and care are not opposed. In the light of these views, would you still defend the break, or would you be happier to see it as a continuation?
VH: I don’t find it satisfactory merely to add some considerations of care to the traditional moral theories for reasons similar to why it is not enough to simply insert women into the traditional structures of society and politics built on gender domination. Feminists should understand that the structures themselves have to change. The history of ethics shows it to be a very biased enterprise. Very roughly, what men have done in public life has been deemed important and relevant to moral theory, and what women have done in the household has been considered irrelevant. I think it plausible to see Kantian ethics and utilitarianism as expansions to the whole of morality of what can be thought appropriate for law and for public policy.
I have come to see, in contrast, caring relations as the wider network, and the ethics of care as the comprehensive morality, within which we should develop legal and political institutions. Caring relations should be guided by the ethics of care, which we can best understand and which is most applicable in contexts of families and friendship. But we can and should also have weaker forms of caring relations with all persons, and within these, the more limited institutions of law should be guided, roughly, by Kantian norms, and the more limited political institutions by utilitarian ones. Yes I see the legal and political as importantly different, and both as significantly different from the contexts of family and friendship. This is a very oversimplified statement of a complex position but I try to clarify and delineate these matters in my written work.
3:AM: So ‘care’ is at the heart of this new ethic but it isn’t to replace justice. So how do you get from care to justice in your system? Do we end up losing the common use of ‘care’ for a more term of art, technical use, as is the wont with philosophers? And isn’t that a cheat?
VH: Yes, various Kantians are trying to acknowledge the concerns of care, and various philosophers interested in the ethics of care are trying to combine it with Kantian ethics. I think the ethics of care has the resources to be an alternative moral theory that can include persuasive aspects of Kantian ethics and also of utilitarianism and virtue theory. It’s nevertheless a feminist ethics that includes the goal of overcoming gender domination, in our thinking as well as our institutions. And I see it as the more comprehensive view. Korsgaard and O’Neill are still Kantians, though more persuasive ones than some traditional Kantians. I think ethics should start with a vast amount of experience (the experience of caring and being cared for) overlooked by traditional moral theories, and see how the many important and valid concerns of other moral theories can be brought into care ethics. I think it is a strength of care ethics that it is based on experience. It is experience which everyone has had: no one would have survived without enormous amounts of care, in childhood at least. Most women, and increasingly men, have also had a great deal of experience providing care, especially for children.
The entire interview is here.
Virginia Held has written: Feminist Morality: Transforming Culture, Society, and Politics, Justice and Care: Essential Reading in Feminist Ethics, and The Ethics of Care: Personal, Political and Global.
Monday, April 1, 2013
Doctors and Their Online Reputation
By Pauline Chen
The New York Times
Originally published March 21, 2013
When a doctor I know recently signed up for a Twitter account, his colleagues began teasing him. “Are you going to tweet what you eat?” one joked.
Their questions, though, soon turned serious. How often was he going to tweet? What would he do if patients asked for medical advice on Twitter? Did he make up a name or use his real one?
(cut)
Since starting his blog, KevinMD, nearly 10 years ago, Dr. Pho has become a rock star among the health care set, one of the few doctors recognizable by first name only. A primary care doctor, Dr. Pho presides over a social media empire that includes his blog, now a highly coveted publishing place for doctors and patients, a lively Facebook page and a nonstop Twitter stream that has become must-follow fodder for the medical Digirati.
The entire article is here.
Ethics Education and Psychology has highlighted a number of articles from Dr. Pho's blog.
The New York Times
Originally published March 21, 2013
When a doctor I know recently signed up for a Twitter account, his colleagues began teasing him. “Are you going to tweet what you eat?” one joked.
Their questions, though, soon turned serious. How often was he going to tweet? What would he do if patients asked for medical advice on Twitter? Did he make up a name or use his real one?
(cut)
Since starting his blog, KevinMD, nearly 10 years ago, Dr. Pho has become a rock star among the health care set, one of the few doctors recognizable by first name only. A primary care doctor, Dr. Pho presides over a social media empire that includes his blog, now a highly coveted publishing place for doctors and patients, a lively Facebook page and a nonstop Twitter stream that has become must-follow fodder for the medical Digirati.
The entire article is here.
Ethics Education and Psychology has highlighted a number of articles from Dr. Pho's blog.
Physicians' Top Ethical Dilemmas: Medscape 2012 Survey Results
Physicians' Top Ethical Dilemmas
Would you fight with a family that wanted to withdraw care from a viable patient? Would you follow the family's directive to continue treatment if you thought it was futile? Would you date a patient? More than 24,000 physicians told us how they feel about this and other ethical dilemmas.
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