Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Treatment. Show all posts
Showing posts with label Treatment. Show all posts

Tuesday, May 14, 2024

New California Court for the Mentally Ill Tests a State’s Liberal Values

Tim Arango
The New York Times
Originally posted 21 March 24

Here is an excerpt:

The new initiative, called CARE Court — for Community Assistance, Recovery and Empowerment — is a cornerstone of California’s latest campaign to address the intertwined crises of mental illness and homelessness on the streets of communities up and down the state.

Another piece of the effort is Proposition 1, a ballot measure championed by Gov. Gavin Newsom and narrowly approved by California voters this month. It authorizes $6.4 billion in bonds to pay for thousands of treatment beds and for more housing for the homeless — resources that could help pay for treatment plans put in place by CARE Court judges.

And Mr. Newsom, a Democrat in his second term, has not only promised more resources for treatment but has pledged to make it easier to compel treatment, arguing that civil liberties concerns have left far too many people without the care they need.

So when Ms. Collette went to court, she was surprised, and disappointed, to learn that the judge would not be able to mandate treatment for Tamra.

Instead, it is the treatment providers who would be under court order — to ensure that medication, therapy and housing are available in a system that has long struggled to reliably provide such services.

“I was hoping it would have a little more punch to it,” Ms. Collette said. “I thought it would have a little more power to order them into some kind of care.”


Here is a summary:

California's new CARE Court (Community Assistance, Recovery and Empowerment) is a court system designed to address the issues of mental illness and homelessness. It aims to provide court-ordered care plans for individuals struggling with severe mental illness who are unable to care for themselves. This initiative tests the state's liberal values by balancing individual liberty with the need for intervention to help those in crisis.

Monday, May 13, 2024

Ethical Considerations When Confronted by Racist Patients

Charles Dike
Psychiatric News
Originally published 26 Feb 24

Here is an excerpt:

Abuse of psychiatrists, mostly verbal but sometimes physical, is common in psychiatric treatment, especially on inpatient units. For psychiatrists trained decades ago, experiencing verbal abuse and name calling from patients—and even senior colleagues and teachers—was the norm. The abuse began in medical school, with unconscionable work hours followed by callous disregard of students’ concerns and disparaging statements suggesting the students were too weak or unfit to be doctors.

This abuse continued into specialty training and practice. It was largely seen as a necessary evil of attaining the privilege of becoming a doctor and treating patients whose uncivil behaviors can be excused on account of their ill health. Doctors were supposed to rise above those indignities, focus on the task at hand, and get the patients better in line with our core ethical principles that place caring for the patient above all else. There was no room for discussion or acknowledgement of the doctors’ underlying life experiences, including past trauma, and how patients’ behavior would affect doctors.

Moreover, even in recent times, racial slurs or attacks against physicians of color were not recognized as abuse by the dominant group of doctors; the affected physicians who complained were dismissed as being too sensitive or worse. Some physicians, often not of color, have explained a manic patient’s racist comments as understandable in the context of disinhibition and poor judgment, which are cardinal symptoms of mania, and they are surprised that physicians of color are not so understanding.


Here is a summary:

This article explores the ethical dilemma healthcare providers face when treating patients who express racist views. It acknowledges the provider's obligation to care for the patient's medical needs, while also considering the emotional toll of racist remarks on both the provider and other staff members.

The article discusses the importance of assessing the urgency of the patient's medical condition and their mental capacity. It explores the option of setting boundaries or termination of treatment in extreme cases, while also acknowledging the potential benefits of attempting a dialogue about the impact of prejudice.

Thursday, April 11, 2024

FDA Clears the First Digital Therapeutic for Depression, But Will Payers Cover It?

Frank Vinluan
MedCityNews.com
Originally posted 1 April 24

A software app that modifies behavior through a series of lessons and exercises has received FDA clearance for treating patients with major depressive disorder, making it the first prescription digital therapeutic for this indication.

The product, known as CT-152 during its development by partners Otsuka Pharmaceutical and Click Therapeutics, will be commercialized under the brand name Rejoyn.

Rejoyn is an alternative way to offer cognitive behavioral therapy, a type of talk therapy in which a patient works with a clinician in a series of in-person sessions. In Rejoyn, the cognitive behavioral therapy lessons, exercises, and reminders are digitized. The treatment is intended for use three times weekly for six weeks, though lessons may be revisited for an additional four weeks. The app was initially developed by Click Therapeutics, a startup that develops apps that use exercises and tasks to retrain and rewire the brain. In 2019, Otsuka and Click announced a collaboration in which the Japanese pharma company would fully fund development of the depression app.


Here is a quick summary:

Rejoyn is the first prescription digital therapeutic (PDT) authorized by the FDA for the adjunctive treatment of major depressive disorder (MDD) symptoms in adults. 

Rejoyn is a 6-week remote treatment program that combines clinically-validated cognitive emotional training exercises and brief therapeutic lessons to help enhance cognitive control of emotions. The app aims to improve connections in the brain regions affected by depression, allowing the areas responsible for processing and regulating emotions to work better together and reduce MDD symptoms. 

The FDA clearance for Rejoyn was based on data from a 13-week pivotal clinical trial that compared the app to a sham control app in 386 participants aged 22-64 with MDD who were taking antidepressants. The study found that Rejoyn users showed a statistically significant improvement in depression symptom severity compared to the control group, as measured by clinician-reported and patient-reported scales. No adverse effects were observed during the trial. 

Rejoyn is expected to be available for download on iOS and Android devices in the second half of 2024. It represents a novel, clinically-validated digital therapeutic option that can be used as an adjunct to traditional MDD treatments under the guidance of healthcare providers.

Saturday, April 6, 2024

LSD-Based Medication for GAD Receives FDA Breakthrough Status

Megan Brooks
Medscape.com
Originally posted March 08, 2024

The US Food and Drug Administration (FDA) has granted breakthrough designation to an LSD-based treatment for generalized anxiety disorder (GAD) based on promising topline data from a phase 2b clinical trial. Mind Medicine (MindMed) Inc is developing the treatment — MM120 (lysergide d-tartrate).

In a news release the company reports that a single oral dose of MM120 met its key secondary endpoint, maintaining "clinically and statistically significant" reductions in Hamilton Anxiety Scale (HAM-A) score, compared with placebo, at 12 weeks with a 65% clinical response rate and 48% clinical remission rate.

The company previously announced statistically significant improvements on the HAM-A compared with placebo at 4 weeks, which was the trial's primary endpoint.

"I've conducted clinical research studies in psychiatry for over two decades and have seen studies of many drugs under development for the treatment of anxiety. That MM120 exhibited rapid and robust efficacy, solidly sustained for 12 weeks after a single dose, is truly remarkable," study investigator David Feifel, MD, PhD, professor emeritus of psychiatry at the University of California, San Diego, and director of the Kadima Neuropsychiatry Institute in La Jolla, California, said in the news release.


Here is some information from the Press Release from Mind Medicine.

About MM120

Lysergide is a synthetic ergotamine belonging to the group of classic, or serotonergic, psychedelics, which acts as a partial agonist at human serotonin-2A (5-hydroxytryptamine-2A [5-HT2A]) receptors. MindMed is developing MM120 (lysergide D-tartrate), the tartrate salt form of lysergide, for GAD and is exploring its potential applications in other serious brain health disorders.

About MindMed

MindMed is a clinical stage biopharmaceutical company developing novel product candidates to treat brain health disorders. Our mission is to be the global leader in the development and delivery of treatments that unlock new opportunities to improve patient outcomes. We are developing a pipeline of innovative product candidates, with and without acute perceptual effects, targeting neurotransmitter pathways that play key roles in brain health disorders.

MindMed trades on NASDAQ under the symbol MNMD and on the Cboe Canada (formerly known as the NEO Exchange, Inc.) under the symbol MMED.

Monday, February 5, 2024

Should Patients Be Allowed to Die From Anorexia? Is a 'Palliative' Approach to Mental Illness Ethical?

Katie Engelhart
New York Times Magazine
Originally posted 3 Jan 24

Here is an excerpt:

He came to think that he had been impelled by a kind of professional hubris — a hubris particular to psychiatrists, who never seemed to acknowledge that some patients just could not get better. That psychiatry had actual therapeutic limits. Yager wanted to find a different path. In academic journals, he came across a small body of literature, mostly theoretical, on the idea of palliative psychiatry. The approach offered a way for him to be with patients without trying to make them better: to not abandon the people who couldn’t seem to be fixed. “I developed this phrase of ‘compassionate witnessing,’” he told me. “That’s what priests did. That’s what physicians did 150 years ago when they didn’t have any tools. They would just sit at the bedside and be with somebody.”

Yager believed that a certain kind of patient — maybe 1 or 2 percent of them — would benefit from entirely letting go of standard recovery-oriented care. Yager would want to know that such a patient had insight into her condition and her options. He would want to know that she had been in treatment in the past, not just once but several times. Still, he would not require her to have tried anything and everything before he brought her into palliative care. Even a very mentally ill person, he thought, was allowed to have ideas about what she could and could not tolerate.

If the patient had a comorbidity, like depression, Yager would want to know that it was being treated. Maybe, for some patients, treating their depression would be enough to let them keep fighting. But he wouldn’t insist that a person be depression-free before she left standard treatment. Not all depression can be cured, and many people are depressed and make decisions for themselves every day. It would be Yager’s job to tease out whether what the patient said she wanted was what she authentically desired, or was instead an expression of pathological despair. Or more: a suicidal yearning. Or something different: a cry for help. That was always part of the job: to root around for authenticity in the morass of a disease.


Some thoughts:

The question of whether patients with anorexia nervosa should be allowed to die from their illness or receive palliative care is a complex and emotionally charged one, lacking easy answers. It delves into the profound depths of autonomy, mental health, and the very meaning of life itself.

The Anorexic's Dilemma:

Anorexia nervosa is a severe eating disorder characterized by a relentless pursuit of thinness and an intense fear of weight gain. It often manifests in severe food restriction, excessive exercise, and distorted body image. This relentless control, however, comes at a devastating cost. Organ failure, malnutrition, and even death can be the tragic consequences of the disease's progression.

Palliative Care: Comfort Not Cure:

Palliative care focuses on symptom management and improving quality of life for individuals with life-threatening illnesses. In the context of anorexia, it would involve addressing physical discomfort, emotional distress, and spiritual concerns, but without actively aiming for weight gain or cure. This raises numerous ethical and practical questions:
  • Respecting Autonomy: Does respecting a patient's autonomy mean allowing them to choose a path that may lead to death, even if their decision is influenced by a mental illness?
  • The Line Between Choice and Coercion: How do we differentiate between a genuine desire for death and succumbing to the distorted thinking patterns of anorexia?
  • Futility vs. Hope: When is treatment considered futile, and when should hope for recovery, however slim, be prioritized?
Finding the Middle Ground:

There's no one-size-fits-all answer to this intricate dilemma. Each case demands individual consideration, taking into account the patient's mental capacity, level of understanding, and potential for recovery. Open communication, involving the patient, their family, and a multidisciplinary team of healthcare professionals, is crucial in navigating this sensitive terrain.

Potential Approaches:
  • Enhanced Supportive Care: Focusing on improving the patient's quality of life through pain management, emotional support, and addressing underlying psychological issues.
  • Conditional Palliative Care: Providing palliative care while continuing to offer and encourage life-sustaining treatment, with the possibility of transitioning back to active recovery if the patient shows signs of willingness.
  • Advance Directives: Encouraging patients to discuss their wishes and preferences beforehand, allowing for informed decision-making when faced with difficult choices.

Saturday, February 3, 2024

How to Navigate the Pitfalls of AI Hype in Health Care

Suran M, Hswen Y.
JAMA.
Published online January 03, 2024.

What is AI snake oil, and how might it hinder progress within the medical field? What are the inherent risks in AI-driven automation for patient care, and how can we ensure the protection of sensitive patient information while maximizing its benefits?

When it comes to using AI in medicine, progress is important—but so is proceeding with caution, says Arvind Narayanan, PhD, a professor of computer science at Princeton University, where he directs the Center for Information Technology Policy.


Here is my summary:
  • AI has the potential to revolutionize healthcare, but it is important to be aware of the hype and potential pitfalls.
  • One of the biggest concerns is bias. AI algorithms can be biased based on the data they are trained on, which can lead to unfair or inaccurate results. For example, an AI algorithm that is trained on data from mostly white patients may be less accurate at diagnosing diseases in black patients.
  • Another concern is privacy. AI algorithms require large amounts of data to work, and this data can be very sensitive. It is important to make sure that patient data is protected and that patients have control over how their data is used.
  • It is also important to remember that AI is not a magic bullet. AI can be a valuable tool, but it is not a replacement for human judgment. Doctors and other healthcare professionals need to be able to critically evaluate the output of AI algorithms and make sure that it is being used in a safe and ethical way.
Overall, the interview is a cautionary tale about the potential dangers of AI in healthcare. It is important to be aware of the risks and to take steps to mitigate them. But it is also important to remember that AI has the potential to do a lot of good in healthcare. If we develop and use AI responsibly, it can help us to improve the quality of care for everyone.

Here are some additional points that were made in the interview:
  • AI can be used to help with a variety of tasks in healthcare, such as diagnosing diseases, developing new treatments, and managing chronic conditions.
  • There are a number of different types of AI, each with its own strengths and weaknesses.
  • It is important to choose the right type of AI for the task at hand.
  • AI should always be used in conjunction with human judgment.

Tuesday, September 5, 2023

How does marijuana affect the brain?

Heather Stringer
Monitor on Psychology
Vol. 54, No. 5, p. 20

Here is an excerpt:

Mixing marijuana with mental health issues

Psychologists also share a sense of urgency to clarify how cannabis affects people who suffer from preexisting mental health conditions. Many veterans who suffer from PTSD view cannabis as a safe alternative to other drugs to alleviate their symptoms (Wilkinson, S. T., et al., Psychiatric Quarterly, Vol. 87. No. 1, 2016). To investigate whether marijuana does in fact provide relief for PTSD symptoms, Jane Metrik, PhD, a professor of behavioral and social sciences at the Brown University School of Public Health and a core faculty member at the university’s Center for Alcohol and Addiction Studies, and colleagues followed more than 350 veterans for a year. They found that more frequent cannabis use worsened trauma-related intrusion symptoms—such as upsetting memories and nightmares—over time (Psychological Medicine, Vol. 52, No. 3, 2022). A PTSD diagnosis was also strongly linked with cannabis use disorder a year later. “Cannabis may give temporary relief from PTSD because there is a numbing feeling, but this fades and then people want to use again,” Metrik said. “Cannabis seems to worsen PTSD and lead to greater dependence on the drug.”

Metrik, who also works as a psychologist at the Providence VA Medical Center, has also been studying the effects of using cannabis and alcohol at the same time. “We need to understand whether cannabis can act as a substitute for alcohol or if it leads to heavier drinking,” she said. “What should we tell patients who are in treatment for problem drinking but are unwilling to stop using cannabis? Is some mild cannabis use OK? What types of cannabis formulations are helpful or harmful for people who have alcohol use disorder?”

Though there are still many unanswered questions, Metrik has seen cases that suggest adding cannabis to heavy drinking behavior is risky. Sometimes people can successfully quit drinking but are unable to stop using cannabis, which can also intensify depression and lead to cannabis hyperemesis syndrome—repeated and severe bouts of vomiting that can occur in heavy cannabis users, she said. Cannabis withdrawal symptoms such as irritability, anxiety, increased cravings, aggression, and restlessness usually subside after 1 to 2 weeks of abstinence, but insomnia tends to persist longer than the other symptoms, she said.

Cannabis may also interfere with pharmaceutical medications patients are taking to treat mental health issues. Cannabidiol (CBD) can inhibit the liver enzymes that metabolize medications such as antidepressants and antipsychotics, said Ryan Vandrey, PhD, a professor of psychiatry and behavioral sciences at Johns Hopkins University and president of APA’s Division 28 (Psychopharmacology and Substance Abuse). “This could lead to side effects because the medication is in the body longer and at higher concentrations,” he said. In a recent study, he found that a high dose of oral CBD also inhibited the metabolism of THC, so the impairment and the subjective “high” was significantly stronger and lasted for a longer time (JAMA Network Open, Vol. 6, No. 2, 2023). This contradicts the common conception that high levels of CBD reduce the effects of THC, he said. “This interaction could lead to more adverse events, such as people feeling sedated, dizzy, [or] nervous, or experiencing low blood pressure for longer periods of time,” Vandrey said.

The interactions between CBD, THC, and pharmaceutical medications also depend on the dosing and the route of administration (oral, topical, or inhalation). Vandrey is advocating for more accurate labeling to inform the public about the health risks and benefits of different products. “Cannabis is the only drug approved for therapeutic use through legislative measures rather than clinical trials,” he said. “It’s really challenging for patients and medical providers to know what dose and frequency will be effective for a specific condition.”

Thursday, February 2, 2023

Yale Changes Mental Health Policies for Students in Crisis

William Wan
The Washington Post
Originally posted 18 JAN 23

Here are some excerpts:

In interviews with The Post, several students — who relied on Yale’s health insurance — described losing access to therapy and health care at the moment they needed it most.

The policy changes announced Wednesday reversed many of those practices.

By allowing students in mental crisis to take a leave of absence rather than withdraw, they will continue to have access to health insurance through Yale, university officials said. They can continue to work as a student employee, meet with career advisers, have access to campus and use library resources.

Finding a way to allow students to retain health insurance required overcoming significant logistical and financial hurdles, Lewis said, since New Haven and Connecticut are where most health providers in Yale’s system are located. But under the new policies, students on leave can switch to “affiliate coverage,” which would cover out-of-network care in other states.

In recent weeks, students and mental advocates questioned why Yale would not allow students struggling with mental health issues to take fewer classes. The new policies will now allow students to drop their course load to as low as two classes under special circumstances. But students can do so only if they require significant time for treatment and if their petition is approved.

In the past, withdrawn students had to submit an application for reinstatement, which included letters of recommendation, and proof they had remained “constructively occupied” during their time away. Under new policies, students returning from a medical leave of absence will submit a “simplified reinstatement request” that includes a letter from their clinician and a personal statement explaining why they left, the treatment they received and why they feel ready to return.

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In their updated online policies, the university made clear it still retained the right to impose an involuntary medical leave on students in cases of “a significant risk to the student’s health or safety, or to the health or safety of others.”

The changes were announced one day before Yale officials were scheduled to meet for settlement talks with the group of current and former students who filed a proposed class-action lawsuit against the university, demanding policy changes. 

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In a statement, one of the plaintiffs — a nonprofit group called Elis for Rachael, led by former Yale students — said they are still pushing for more to be done: “We remain in negotiations. We thank Yale for this first step. But if Yale were to receive a grade for its work on mental health, it would be an incomplete at best.”

But after decades of mental health advocacy with little change at the university, some students said they were surprised at the changes Yale has made already.

“I really didn’t think it would happen during my time here,” said Akweley Mazarae Lartey, a senior at Yale who has advocated for mental rights throughout his time at the school. 

“I started thinking of all the situations that I and people I care for have ended up in and how much we could have used these policies sooner.”

Tuesday, November 15, 2022

Psychiatry wars: the lawsuit that put psychoanalysis on trial

Rachel Aviv
The Guardian
Originally posted 11 OCT 22

Here is an excerpt:

In the lawsuit, the 20th century’s two dominant explanations for mental distress collided. No psychiatric malpractice lawsuit has attracted more prominent expert witnesses than Ray’s, according to Alan Stone, the former president of the APA. The case became “the organising nidus” around which leading biological psychiatrists “pushed their agenda”, he told me.

At a hearing before an arbitration panel, which would determine whether the case could proceed to trial, the Lodge presented Ray’s attempt to medicalise his depression as an abdication of responsibility. In a written report, one of the Lodge’s expert witnesses, Thomas Gutheil, a professor of psychiatry at Harvard, observed that the language of the lawsuit, much of which Ray had drafted himself, exemplified Ray’s struggle with “‘externalisation’ – that is, the tendency to blame one’s problems on others”. Gutheil concluded that Ray’s “insistence on the biological nature of his problem is not only disproportionate but seems to me to be yet another attempt to move the problem away from himself: it is not I, it’s my biology.”

The Lodge’s experts attributed Ray’s recovery at Silver Hill at least in part to his romantic entanglement with a female patient, which gave him a jolt of self-esteem.

“It’s a demeaning comment,” Ray responded when he testified. “And it just speaks to the whole total disbelief in the legitimacy of the symptomatology and the disease.”

The Lodge lawyers tried to chip away at Ray’s description of depression, arguing that he had shown moments of pleasure at the Lodge, such as when he had played piano.

“The sheer mechanical banging of ragtime rhythms on that dilapidated old piano on the ward was almost an act of agitation rather than a creative pleasurable act,” Ray responded. “Just because I played ping-pong, or had a piece of pizza, or smiled, or may have made a joke, or made googly eyes at a good-looking girl, it did not mean that I was capable of truly sustaining pleasurable feelings.” He went on, “I would say to myself: ‘I am living, but I am not alive.’”

Manuel Ross, Ray’s analyst from the Lodge, testified for more than eight hours. He had read a draft of Ray’s memoir and he rejected the possibility that Ray had been cured by antidepressants. He was not a recovered man, because he was still holding on to the past. (“That’s what I call melancholia as used in the 1917 article,” he said, referring to Freud’s essay Mourning and Melancholia.)

Ross said that he had hoped Ray would develop insight at the Lodge. “That’s the true support,” he said, “if one understands what is going on in one’s life.” He wanted Ray to let go of his need to be a star doctor, the richest and most powerful in his field, and to accept a life in which he was one of the “ordinary mortals who labour in the medical vineyard”.

Ray’s lawyer, Philip Hirschkop, one of the most prominent civil rights attorneys in the country, asked Ross: “As an analyst, do you have to sometimes look inside yourself to make sure you’re not reacting to your own feelings about someone?”

“Oh yes,” Ross said. “Oh yes.”

“You who’ve locked yourself into one position for 19 years with no advancement in position other than salary, might you be a little resentful of this man who makes so much more money, and now he’s here as your patient?” Hirschkop asked.

Monday, October 10, 2022

7 tell-tale red flags of medical gaslighting

Ashley Laderer
Insider.com
Originally published 29 AUG 2022

Here is an except:

"Medical gaslighting is a term recently used to describe when health care providers dismiss a patient's concerns, feelings, or complaints," says Faith Fletcher, an assistant professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine and a senior advisor to the Hastings Center, a bioethics research institute. 

Numerous studies over the years have found examples of medical gaslighting, whether it's interrupting a patient or misdiagnosing them based on unconscious biases about race or gender. Gaslighting in the medical field tends to affect marginalized groups the most.

"These interactions don't take place in a vacuum and are rooted in long-standing structural and social injustices such as racism, sexism, and class oppression in the US healthcare system," Fletcher says. 

Here are seven signs your doctor may be gaslighting you and the consequences it can have on your health.

1. They interrupt you
2. They rush you 
3. They won't discuss your symptoms with you
4. They let underlying biases affect diagnosis 
5. They say it's all in your head
6. They question the legitimacy of your medical history 
7. They're uncollaborative on treatment options

Friday, October 7, 2022

Have American jails become the inferior replacement for mental hospitals?

Matthew Rozsa
Salon.com
Originally posted 5 SEPT 22

Here is an excerpt:

"We've known for some time that this country's chief response to serious mental illness is incarceration, a fact that stands out because prisons are so clearly unsuited to treating mental illness," Wanda Bertram, Communications Strategist at Prison Policy Initiative, told Salon by email. "Our organization recently found that even though 43% of people in state prisons have been diagnosed with a mental disorder, only 26% have received some form of mental health treatment, and only 6% are currently receiving treatment."

Bertram added, "The readiness with which our justice system fast-tracks people with mental illnesses into prison, despite knowing that jail and prison settings won't make that person any better, speaks volumes about the system's ability to deliver justice."

Dr. Craig Haney, a psychologist who has studied the psychological effects of incarceration for decades and a psychology professor at the University of California, Santa Cruz, offered some insight into why America tends to incarcerate rather than help people with mental illnesses.

"The structural origins start with the history of two simultaneous trends that began in the early 1970s," Haney wrote to Salon. The first was the widespread closing of publicly-funded mental hospitals "in part on the promise that they would be replaced by more humane community-based treatment, a promise that was never kept" and the second was "the beginning of a decades-long 'tough-on-crime' era in which politicians competed with each other on who could criminalize the most things and impose the longest sentences. So we shrunk our mental health system and increased the size of our prison system."

Bertram also attributed the trend to imprison people who are mentally ill to ideological choices.

"I think the major problem is an ideology that says that if you have some kind of illness, including mental illness, you ought to be the primary person responsible for your own care," Bertram explained. "That's the ideology that props up our healthcare system, where sick people bear extraordinary costs and crushing debts. And it keeps us from asking why mental health services like therapy, psychiatry, and long-term care are not only expensive, but difficult to access." Pointing out that their report revealed roughly half of people in state prisons lacked any kind of health insurance prior to their arrest, Bertram concluded that "we continue to send people with mental disorders to prison, because there seems to be nowhere else for them to go."

Wednesday, September 21, 2022

Professional Civil Disobedience — Medical-Society Responsibilities after Dobbs

Matthew K. Wynia
The New England Journal of Medicine
September 15, 2022, 387:959-961

Here are two excerpts:

The AMA called Dobbs “an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient–physician relationship, and a brazen violation of patients’ rights to evidence-based reproductive health services.” The American Academy of Family Physicians wrote that the decision “negatively impacts our practices and our patients by undermining the patient–physician relationship and potentially criminalizing evidence-based medical care.” The American College of Physicians stated, “A patient’s decision about whether to continue a pregnancy should be a private decision made in consultation with a physician or other health care professional, without interference from the government.” And the CEO of the American College of Obstetricians and Gynecologists called Dobbs “tragic” for patients, “the boldest act of legislative interference that we have seen in this country,” and “an affront to all that drew my colleagues and me into medicine.”

Medical organizations are rarely so united. Yet even many physicians who oppose abortion recognize that medically nuanced decisions are best left in the hands of individual patients and their physicians — not state lawmakers. Abortion bans are already pushing physicians in some states to wait until patients become critically ill before intervening in cases of ectopic pregnancy or septic miscarriage, among other problems.

Beyond issuing strongly worded statements, what actions should medical organizations take in the face of laws that threaten patients’ well-being? Should they support establishing committees to decide when a pregnant person’s life is in sufficient danger to warrant an abortion? Should they advocate for allowing patients to travel elsewhere for care? Or should they encourage their members to provide evidence-based medical care, even if doing so means accepting — en masse — fines, suspensions of licensure, and potential imprisonment? How long could a dangerous state law survive if the medical profession, as a whole, refused to be intimidated into harming patients, even if such a refusal meant that many physicians might go to jail?

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Proposing professional civil disobedience of state laws prohibiting abortion might seem naive. Historically, physicians have rarely been radical, and most have conformed with bad laws and policies, even horrific ones — such as those authorizing forced-sterilization programs in the United States and Nazi Germany, the use of psychiatric hospitals as political prisons in the Soviet Union, and police brutality under apartheid in South Africa. Too often, organized medicine has failed to fulfill its duty to protect patients when doing so required acting against state authority. Although there are many examples of courageous individual physicians defying unjust laws or regulations, examples of open support for these physicians by their professional associations — such as the AMA’s offer to support physicians who refused to be involved in “enhanced” interrogations (i.e., torture) during the Iraq War — are uncommon. And profession-wide civil disobedience — such as Dutch physicians choosing to collectively turn in their licenses rather than practice under Nazi rule — is rare.

Wednesday, July 6, 2022

What happens if you want access to voluntary assisted dying but your nursing home won’t let you?

Neera Bhatia & Charles Corke
The Conversation
Originally published 30 MAY 22

Voluntary assisted dying is now lawful in all Australian states. There is also widespread community support for it.

Yet some residential institutions, such as hospices and aged-care facilities, are obstructing access despite the law not specifying whether they have the legal right to do so.

As voluntary assisted dying is implemented across the country, institutions blocking access to it will likely become more of an issue.

So addressing this will help everyone – institutions, staff, families and, most importantly, people dying in institutions who wish to have control of their end.

The many ways to block access
While voluntary assisted dying legislation recognises the right of doctors to conscientiously object to it, the law is generally silent on the rights of institutions to do so.
  • While the institution where someone lives has no legislated role in voluntary assisted dying, it can refuse access in various ways, including:
  • restricting staff responding to a discussion a resident initiates about voluntary assisted dying
  • refusing access to health professionals to facilitate it, and
  • requiring people who wish to pursue the option to leave the facility.
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What could we do better?

1. Institutions need to be up-front about their policies

Institutions need to be completely open about their policies on voluntary assisted dying and whether they would obstruct any such request in the future. This is so patients and families can factor this into deciding on an institution in the first place.

2. Institutions need to consult their stakeholders

Institutions should consult their stakeholders about their policy with a view to creating a “safe” environment for residents and staff – for those who want access to voluntary assisted dying or who wish to support it, and for those who don’t want it and find it confronting.

3. Laws need to change

Future legislation should define the extent of an institution’s right to obstruct a resident’s right to access voluntary assisted dying.

Sunday, July 3, 2022

Mental Illness Is Not in Your Head

Marco Ramos
Boston Review
Originally posted 17 MAY 22

Here are two excerpts:

In Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness, Anne Harrington argues that the current crisis is just the latest in a long line of failures to discover the biology of mental illness over the last two centuries. In this sweeping study, the history of psychiatry undulates like the boom and bust of a speculative market. First a wave builds with enthusiastic promises of revolutionary breakthroughs that will change psychiatry as we know it. Then the wave collapses, as psychiatrists fail to deliver on those bold promises. Crisis ensues, and after the requisite finger-pointing, the next wave of psychiatric revolution begins to build. Rinse and repeat.

The first “revolution” in American psychiatry that Harrington tracks arrived in the nineteenth century. At the time, large lunatic asylums dominated the psychiatric landscape, such as the Blackwell’s Island hospital on what today is called Roosevelt Island in New York City. These institutions were designed to cure patients with mental disorders by placing them in the hospitable environment of the asylum architectural space. However, a series of journalistic exposés revealed that these asylums were overcrowded and underfunded with patients living in deplorable, instead of therapeutic, conditions. For example, in 1887, journalist Elizabeth Seaman, who wrote under the pen name Nellie Bly, went undercover as a patient in Blackwell’s Island Hospital and exposed horrible acts of brutality in her best-seller Ten Days in a Mad-House. Asylum psychiatry faced a crisis of public trust.

As Harrington explains, European neuroanatomists came to the rescue. Unlike asylum physicians, anatomists were pessimistic about the potential for a cure. Building on eugenic theories, they believed that asylum patients were “degenerates” who were biologically unfit to cope with the stresses of modern life. But they also believed that the mentally ill could provide a service to society after their deaths by offering their brains to science. The dissection of their pathological brains, the anatomists hoped, could reveal the biological causes of mental suffering.

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But if the pharmaceutical industry has invested so heavily in psychiatry, why have there been no breakthroughs in drug treatment? A major reason is that the industry has spent billions of dollars more on advertising psychiatric medications than on research and development of novel drugs. As psychiatrist David Healy has shown, money earmarked for R&D is often not intended to produce genuine innovation. Almost all of the psychopharmaceuticals produced since 1990 have been “copycats” that mimic older, generic pharmaceuticals, with only minor chemical modifications. These (unfortunately named) “me-too” drugs work no better clinically than the drugs that came before them, but their slight biochemical novelty means that they can be patented, so that pharma can charge insurance companies’ top dollar.

Perhaps the worst news is that Big Pharma, having created and capitalized on psychiatric markets, is now jumping ship. Anthropologist Joe Dumit has shown that most psychiatric drugs will soon go off patent, so companies will be forced to charge less for them. With the market already saturated with pharmaceutical copycats and no significant scientific biological breakthroughs in sight, there is suddenly little room for growth. Almost all of the major pharmaceutical companies have decided to divest from psychiatric drug research and turn to more promising sectors, especially the development of “biologics” and other cancer drugs.

Sunday, May 15, 2022

A False Sense of Security: Rapid Improvement as a Red Flag for Death by Suicide

Rufino, K., Beyene, H., et al.
Journal of Consulting and Clinical Psychology. 
Advance online publication.

Objective: 
Postdischarge from inpatient psychiatry is the highest risk period for suicide, thus better understanding the predictors of death by suicide during this time is critical for improving mortality rates after inpatient psychiatric treatment. As such, we sought to determine whether there were predictable patterns in suicide ideation in hospitalized psychiatric patients. 

Method: 
We examined a sample of 2,970 adult’s ages 18–87 admitted to an extended length of stay (LOS) inpatient psychiatric hospital. We used group-based trajectory modeling via the SAS macro PROC TRAJ to quantitatively determine four suicide ideation groups: nonresponders (i.e., high suicide ideation throughout treatment), responders (i.e., steady improvement in suicide ideation across treatment), resolvers (i.e., rapid improvement in suicide ideation across treatment), and no-suicide ideation (i.e., never significant suicide ideation in treatment). Next, we compared groups to clinical and suicide-specific outcomes, including death by suicide. 

Results: 
Resolvers were the most likely to die by suicide postdischarge relative to all other suicide ideation groups. Resolvers also demonstrated significant improvement in all clinical outcomes from admission to discharge. 

Conclusion: 
There are essential inpatient psychiatry clinical implications from this work, including that clinical providers should not be lulled into a false sense of security when hospitalized adults rapidly improve in terms of suicide ideation. Instead, inpatient psychiatric treatment teams should increase caution regarding the patient’s risk level and postdischarge treatment planning.

Impact Statement

As postdischarge from inpatient psychiatry is the highest risk period for suicide, better understanding the predictors of death by suicide during this time is critical for improving mortality rates after inpatient psychiatric treatment. Clinical providers should not be lulled into a false sense of security when hospitalized adults rapidly improve in terms of suicide ideation, instead, increasing vigilance regarding the patient’s risk level and postdischarge treatment planning. 

Sunday, May 1, 2022

Why So Many Middle-Aged Women Are on Antidepressants—Scientists are gaining a better understanding of women’s midlife depression

Andrea Petersen
The Wall Street Journal
Originally posted 2 APR 22

For years, middle-aged women have had some of the country’s highest rates of antidepressant use. Now, scientists are starting to better understand why—and to develop more targeted treatments for women’s midlife depression.

About one in five women ages 40 to 59 and nearly one in four women ages 60 and over used antidepressants in the last 30 days during 2015 to 2018, according to the latest data from the National Center for Health Statistics. 

Among women ages 18 to 39, the figure was about one in 10. 

Among men, 8.4% of those ages 40 to 59 and 12.8% of those 60 and older used antidepressants in the last 30 days, according to the NCHS data.

The figures are drawing increasing attention from scientists and doctors. Many are alarmed at how high depression rates were among midlife women even before the pandemic, now that the past two years have exacerbated mental-health issues for many Americans. 

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Researchers at NIMH who have been following 90 women since 1988 have found that the incidence of women’s midlife depression is concentrated in the two years before and after the last menstrual period, says Dr. Schmidt. 

The quality of women’s midlife depression is distinct, too, Dr. Schmidt says, in that it often involves intense anxiety, irritability and sleep problems along with the more typical sadness and loss of pleasure in once-enjoyed activities.

Doctors speculate that antidepressant use among middle-aged women is being driven in part by the reluctance of women—and many of their physicians—in recent decades to use hormone-replacement therapy for menopausal symptoms. In 2002, a large study, the Women’s Health Initiative, was stopped after women taking hormone therapy had an increased risk of breast cancer, heart attacks and strokes. 

Later analyses found that the risks were largely concentrated among women who were older when they started hormone therapy. For women in their 50s, hormone therapy actually reduced the risk of heart disease and death from any cause. 

Hormone therapy, either estrogen alone or combined with a progestogen, is the most effective treatment for hot flashes and night sweats, according to the North American Menopause Society and the American College of Obstetricians and Gynecologists. 

Some research has found that it can also improve mood.

Tuesday, March 8, 2022

"Without Her Consent" Harvard Allegedly Obtained Title IX Complainant’s Outside Psychotherapy Records, Absent Her Permission

Colleen Flaherty
Inside Higher Ed
Originally published 10 FEB 22

Here are two excerpts:

Harvard provided background information about how its dispute resolution office works, saying that it doesn’t contact a party’s medical care provider except when a party has indicated that the provider has relevant information that the party wants the office to consider. In that case, the office receives information from the care provider only with the party’s consent.

Multiple legal experts said Wednesday that this is the established protocol across higher education.

Asked for more details about what happened, Kilburn’s lawyer, Carolin Guentert, said that Kilburn’s therapist is a private provider unaffiliated with Harvard, and “we understand that ODR contacted Ms. Kilburn’s therapist and obtained the psychotherapy notes from her sessions with Ms. Kilburn, without first seeking Ms. Kilburn’s written consent as required under HIPAA,” the Health Insurance Portability and Accountability Act of 1996, which governs patient privacy.

Asked if Kilburn ever signed a privacy waiver with her therapist that would have granted the university access to her records, Guentert said Kilburn “has no recollection of signing such a waiver, nor has Harvard provided one to us.”

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Even more seriously, these experts said that Harvard would have had no right to obtain Kilburn’s mental health records from a third-party provider without her consent.

Andra J. Hutchins, a Massachusetts-based attorney who specializes in education law, said that therapy records are protected by psychotherapist-patient privilege (something akin to attorney-client privilege).

“Unless the school has an agreement with and a release from the student to provide access to those records or speak to the student’s therapist—which can be the case if a student is placed on involuntary leave due to a mental health issue—there should be no reason that a school would be able to obtain a student’s psychotherapy records,” she said.

As far as investigations under Title IX (the federal law against gender-based discrimination in education) go, questions from the investigator seeking information about the student’s psychological records aren’t permitted unless the student has given written consent, Hutchins added. “Schools have to follow state and federal health-care privacy laws throughout the Title IX process. I can’t speculate as to how or why these records were released.”

Daniel Carter, president of Safety Advisors for Educational Campuses, said that “it is absolutely illegal and improper for an institution of higher education to obtain one of their students’ private therapy records from a third party. There’s no circumstance under which that is permissible without their consent.”

Tuesday, January 25, 2022

Sexbots as Synthetic Companions: Comparing Attitudes of Official Sex Offenders and Non-Offenders.

Zara, G., Veggi, S. & Farrington, D.P. 
Int J of Soc Robotics (2021). 

Abstract

This is the first Italian study to examine views on sexbots of adult male sex offenders and non-offenders, and their perceptions of sexbots as sexual partners, and sexbots as a means to prevent sexual violence. In order to explore these aspects 344 adult males were involved in the study. The study carried out two types of comparisons. 100 male sex offenders were compared with 244 male non-offenders. Also, sex offenders were divided into child molesters and rapists. Preliminary findings suggest that sex offenders were less open than non-offenders to sexbots, showed a lower acceptance of them, and were more likely to dismiss the possibility of having an intimate and sexual relationship with a sexbot. Sex offenders were also less likely than non-offenders to believe that the risk of sexual violence against people could be reduced if a sexbot was used in the treatment of sex offenders. No differences were found between child molesters and rapists. Though no definitive conclusion can be drawn about what role sexbots might play in the prevention and treatment of sex offending, this study emphasizes the importance of both exploring how sexbots are both perceived and understood. Sex offenders in this study showed a high dynamic sexual risk and, paradoxically, despite, or because of, their sexual deviance (e.g. deficits in sexual self-regulation), they were more inclined to see sexbots as just machines and were reluctant to imagine them as social agents, i.e. as intimate or sexual arousal partners. How sex offenders differ in their dynamic risk and criminal careers can inform experts about the mechanisms that take place and can challenge their engagement in treatment and intervention.

From the Discussion

Being in a Relationship with a Sexbot: a Comparison Between Sex Offenders and Non-Offenders
Notwithstanding that previous studies suggest that those who are quite open in admitting their interest in having a relationship with a sexbot were not necessarily problematic in terms of psycho-sexual functioning and life satisfaction, some anecdotal evidence seems to indicate otherwise. In this study, sex offenders were more reluctant to speak about their preferences towards sexbots. While male non-offenders appeared to be open to sexbots and quite eager to imagine themselves having a relationship with a sexbot or having sexual intercourse with one of them, sex offenders were reluctant to admit any interest towards sexbots. No clinical data are available to support the assumption about whether the interaction with sexbots is in any way egodystonic (inconsistent with one’s ideal self) or egosyntonic (consistent with one’s ideal self). Thus, no-one can discount the influence of being in detention upon the offenders’ willingness to feel at ease in expressing their views. It is not unusual that, when in detention, offenders may put up a front. This might explain why the sex offenders in this study kept a low profile on sex matters (e.g. declaring that “sexbots are not for me, I’m not a pervert”, to use their words). Sexuality is a dirty word for sex offenders in detention and their willingness to be seen as reformed and «sexually normal» is what perhaps motivated them to deny that they had any form of curiosity or attraction for any sexbot presented to them.

Monday, August 9, 2021

Health Care in the U.S. Compared to Other High-Income Countries: Worst Outcomes

The Commonwealth Fund
Mirror, Mirror 2021: Reflecting Poorly
Originally posted 4 Aug 21

Introduction

No two nations are alike when it comes to health care. Over time, each country has settled on a unique mix of policies, service delivery systems, and financing models that work within its resource constraints. Even among high-income nations that have the option to spend more on health care, approaches often vary substantially. These choices affect health system performance in terms of access to care, patients’ experiences with health care, and people’s health outcomes. In this report, we compare the health systems of 11 high-income countries as a means to generate insights about the policies and practices that are associated with superior performance.

With the COVID-19 pandemic imposing an unprecedented stress test on the health care and public health systems of all nations, such a comparison is especially germane. Success in controlling and preventing infection and disease has varied greatly. The same is true of countries’ ability to address the challenges that the pandemic has presented to the workforce, operations, and financial stability of the organizations delivering care. And while the comparisons we draw are based on data collected prior to the pandemic or during the earliest months of the crisis, the prepandemic strengths and weaknesses of each country’s preexisting arrangements for health care and public health have undoubtedly been shaping its experience throughout the crisis.

For our assessment of health care system performance in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States, we used indicators available across five domains:
  • Access to care
  • Care process
  • Administrative efficiency
  • Equity
  • Health care outcomes
For more information on these performance domains and their component measures, see How We Measured Performance. Most of the data were drawn from surveys examining how members of the public and primary care physicians experience health care in their respective countries. These Commonwealth Fund surveys were conducted by SSRS in collaboration with partner organizations in the 10 other countries. Additional data were drawn from the Organisation for Economic Co-operation and Development (OECD) and the World Health Organization (WHO).

Thursday, June 24, 2021

Updated Physician-Aid-in-Dying Law Sparks Controversy in Canada

Richard Karel
Psychiatric News
Originally posted 27 May 21

Here is an excerpt:

Addressing the changes for people who may be weighing MAID for severe mental illness, the government stated the following:

“If you have a mental illness as your only medical condition, you are not eligible to seek medical assistance in dying. … This temporary exclusion allows the Government of Canada more time to consider how MAID can safely be provided to those whose only medical condition is mental illness.

“To support this work, the government will initiate an expert review to consider protocols, guidance, and safeguards for those with a mental illness seeking MAID and will make recommendations within a year (by March 17, 2022).

“After March 17, 2023, people with a mental illness as their sole underlying medical condition will have access to MAID if they are eligible and the practitioners fulfill the safeguards that are put in place for this group of people. …”

While many physicians and others have long been sympathetic to allowing medical professionals to help those with terminal illness die peacefully, the fear has been that medically assisted death could become a substitute for adequate—and more costly—medical care. Those concerns are growing with the expansion of MAID in Canada.