Posts tagged ‘LA TImes’

Saving Normal?

A recent opinion piece by Allen Frances for the LA Times is plainly pointing out the dangers of the new DSM’s broad strokes and the potential to paint too many “normal” people as mentally ill. It’s notable enough that mainstream press is presenting any criticism at all about psychiatry in general and the DSM in particular but Allen Frances was one of their own and no silent partner or low level underling either. He was the chairman of the committee that created the DSM-IV.

Our panel tried hard to be conservative and careful but inadvertently contributed to three false “epidemics” — attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many “patients” who might have been far better off never entering the mental health system.

The first draft of the next edition of the DSM, posted for comment with much fanfare last month, is filled with suggestions that would multiply our mistakes and extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal. This wholesale medical imperialization of normality could potentially create tens of millions of innocent bystanders who would be mislabeled as having a mental disorder. The pharmaceutical industry would have a field day — despite the lack of solid evidence of any effective treatments for these newly proposed diagnoses.

Where the DSM-versus-normality boundary is drawn also influences insurance coverage, eligibility for disability and services, and legal status — to say nothing of stigma and the individual’s sense of personal control and responsibility.

It’s interesting to see someone in psychiatry addressing the notion of false epidemics of mental disorder when a committee decision and ever changing public opinion are all that separate a “real” epidemic from a false one. That said, committee decisions and public opinion have proven quite powerful and if you look back, the release of each DSM has brought on a rash of newly mentally ill. If history proves a good indicator, there will be millions of people who are normal today and mentally ill in 2013 — all thanks to a book with the power to categorize and medicalize the human condition. How much sorrow is too much? How excited can you be about everyday things before you are manic? And now with the proposed introduction of psychotic risk syndrome, anyone who isn’t deemed mentally ill can be subject to the book’s reach simply out of fear that they may be in time.

What are some of the most egregious invasions of normality suggested for DSM-V? “Binge eating disorder” is defined as one eating binge per week for three months. (Full disclosure: I, along with more than 6% of the population, would qualify.) “Minor neurocognitive disorder” would capture many people with no more than the expected memory problems of aging. Grieving after the loss of a loved one could frequently be misread as “major depression.” “Mixed anxiety depression” is defined by commonplace symptoms difficult to distinguish from the emotional pains of everyday life.

The media seldom addresses views critical of psychiatry but for psychiatrists to come out against the new proposals in such a public way is truly indicative of what’s at stake with the new DSM. You can bet that if psychiatrists are picking sides on this, it carries huge implications worth looking at. It doesn’t take much to see the power inherent in handing over our culture’s ability to define “normal” to a small committee comprised exclusively of people with something to gain and Frances is not exaggerating when he calls it “wholesale medical imperialization.” How much control are we willing to hand over? How far are we willing to let anyone go in defining us? How widely cast will the net be before it captures you? This is not an issue of special interest only to those marked as seriously mentally ill. Every label of mental illness is serious and with an ever broadening range of perceived illness encroaching upon a shrinking concept of normal, you may not be off the hook. Frances’ article says that it may not be too late to save ‘normal’ but I question whether ‘normal’ is worth saving.

See also: Allen Frances’ Opening Pandora’s Box: The 19 Worst suggestions for DSM5 in Psychiatric Times.

March 4, 2010 at 10:24 am 3 comments

Antipsychotics as a Deadly Weapon

While the use of antipsychotics as chemical restraints is nothing new, charging health care professionals with assault with a deadly weapon for their misuse is. From the LA Times:

In an elder abuse case described by one investigator as the most outrageous he has ever seen, three former top managers at a Kern County nursing home have been arrested in the deaths of three residents who allegedly were given needless doses of psychotropic medications.

The state attorney general’s office contended in a criminal complaint that more than 20 residents at a skilled nursing center run by the Kern Valley Healthcare District were drugged “for staff convenience.” Many of them experienced side effects that included dramatic weight loss, slurred speech, tremors, loss of cognition and even psychosis, according to the complaint.

Arraignment is scheduled this morning for the center’s one-time medical director, Dr. Hoshang M. Pormir, former nursing director Gwen D. Hughes and former chief pharmacist Debbi C. Hayes. They were jailed in Bakersfield on Wednesday.

“These people maliciously violated the trust of their patients by holding them down and forcibly administering psychotropic medications if they dared to question their care,” state Atty. Gen. Jerry Brown said.

All three have been charged with elder abuse. Hughes and Hayes, who are accused of administering shots by force and without consent, also face charges of assault with a deadly weapon.

Three residents died and many more were drugged into a stupor in the interest of “staff convenience, ” truly being treated as members of a disposable class. I think you trade in convenience when you take on the task of caring for the elderly. When being vocal is read as being disruptive and being in disagreement is being combative and your rights have faded away over time, you don’t stand a chance. Questioning care is the cardinal sin of forced treatment but no one admits it — and it is force regardless of the age or state of mind of the patient/victim. Never mind the inherent danger and barbarism of forced drugging or that people have every right and reason to be unhappy separate from the lives and people they’ve known. It doesn’t matter that the drugs don’t make you happy, only quiet. The end result is the same — compliance. While this type of “care” is not universal, it is rampant and often with a kinder, gentler face making it harder to see. Hopefully, with cases like this coming to light and to trial people start to wake up to the scale of such abuses.

The complaint paints a bleak picture of a facility dominated by nursing director Hughes, 55, who is accused of seeking to drug all but the most docile residents. Medical director Pormir, 48, allegedly rubber-stamped Hughes’ orders for medication, failed to examine patients and was “either willfully or naively ignorant” of his proper role, according to the complaint. Pharmacist Hayes, 51, told investigators that she went along because Hughes had wide experience in psychiatric hospitals, the complaint says.

Hughes had been fired from a convalescent home in Fresno in 1999 for allegedly overmedicating patients there, according to state officials.

If Hughes was fired for overmedicating what may be the most overmedicated group of people in the US, she had to be doing the same thing then as now and should have been stripped of her license ten years ago. Clearly ten years and a dismissal have had little effect on her. While the other two might claim to be ignorant and deferential at best, any human being half paying attention can see when drugs are being administered carelessly, let alone aggressively and punitively — and when lives depend on what you do, you don’t get to plead ignorance.

At the Kern Valley facility in Lake Isabella, she ordered medications when the elderly residents — most of whom had dementia or Alzheimer’s — glared at her or spoke disrespectfully, according to Samuel Obair, a pharmacist who helped in the state’s investigation.

“It is beyond appalling to me,” he told state officials. “I have never gone into a facility and seen psychotropic medications and mood stabilizers . . . being used on so many patients, and so blatantly” without a legitimate diagnosis or careful documentation.

God help the generation that made us when they spend their last days being drugged — some of them to death — for not bowing and scraping when a self exalted staffer, just a kid in their eyes, barks orders, or if they don’t like the food, their roommate or knowing that they are at the last long portion of their lives. At what point in one’s life does it become mandatory to be compliant without exception? I hope for the sake of all who counted on these three for care, that they are held accountable. Also, I can’t help but think that if people can see drugs as weapons, there is a potential for greater implications in the future. If forced drugging is an assault to one body or twenty, it is an assault to millions.

• • •

California Advocates for Nursing Home Reform (CANHR)

February 22, 2010 at 11:03 am

FDA Warns Docs about Zyprexa

In news of the not-so-surprising, The LA Times reports that the FDA has issued a warning to doctors concerning increased metabolic risks in adolescents taking the drug olanzapine (Zyprexa). Risks include rapid weight gain and an increased likelihood of weight related physical concerns like diabetes and high cholesterol — serious problems that, you may remember, most doctors can’t be bothered to watch for. While this particular warning is limited to young people, you’ll find that the same risks are present in adults though it appears that adolescents are at a higher comparative risk. Interestingly, the warning applies only to those ages 13-17 being treated for diagnoses of schizophrenia and bipolar disorder, leaving out the growing number of even younger people for whom the drug is not approved but administered off label.

The agency has not approved the marketing of olanzapine — sold under the commercial name Zyprexa by the drug maker Eli Lilly — for use in children under 13 who are diagnosed with schizophrenia or bipolar disorder. But the medication, one of a class of psychiatric medications called the “atypical antipsychotics,” is widely prescribed for young patients, despite growing evidence that call its safety profile into question for this population.

The warning comes in the wake of the October publication in the Journal of the American Medical Assn., in which a study showed that children and adolescents taking their first-ever course of Zyprexa gained, on average, more than 17 pounds over a 12-week period, as well as dramatic increases in triglycerides and cholesterol levels — all factors that put them at higher risk of developing cardiovascular disease. While two other antipsychotic drugs — Seroquel and Risperdal — were implicated in significant weight gain and metabolic changes, Zyprexa was found to carry the highest risks of all three.

More than 17 pounds in 12 weeks? Whether a parent or a doctor, you wouldn’t think you’d need clinical trials and an FDA warning to notice such rapid weight gain in a kid. A pair of eyes and even vague concern should do the trick and while the primary problem is not cosmetic, rest assured — if you don’t notice the weight gain, the other kids will. So in addition to battling the middle school years with a psychiatric label, they can now do it overweight and worrying about their heart health and diabetes. That should do wonders for their emotional well being in the formative years. Actually, the LA Times erred on the conservative side in reporting those numbers. From the JAMA study that prompted the warning:

Patients taking their first-ever course of drugs marketed as Abilify, Risperdal, Seroquel and Zyprexa experienced weight gains ranging from about 9.7 pounds for Abilify to 18.7 pounds for Zyprexa. (Seroquel users gained about 13.2 pounds and Risperdal users gained about 11.7 pounds over 12 weeks. A comparison group of children with a diagnosis of severe mental illness but who were not on the medications gained less than a half-pound in the course of the study.)

With the youth market for antipsychotics constantly expanding and these drugs being approved or used off label for a range of behaviors broadening well into the mildest end of the spectrum (attention deficit, irritability), we need to be taking these risks seriously. The shift from using drugs as a last resort to using drugs as a means of grooming children for desirable behavior can’t be ignored in a discussion about antipsychotics in children and little good can come from making a child’s physical health take a back seat to a theory on mental illness. Do we really want to expose young people to greater risks of cardiovascular disease, diabetes and high cholesterol to “correct” moods and behaviors?

With the influx in young people on antipsychotics you might think this is the time to be looking into these problems but I think the time was fifteen years ago when Zyprexa was poised to enter the market. Now here we are repeating an often seen pattern — downplay risks for the duration of a drug’s patented life and spill it all at the end when its exclusivity is about to sunset — making the older, cheaper drug poor competition for its maker’s new and exclusive replacement. I wonder what the kids think about all of this. Something tells me no one’s really asking.

February 1, 2010 at 10:53 pm 5 comments

January First?

January

The LA Times did a story on a 6 year old girl named January Schofield who was diagnosed with Schizophrenia–a shockingly uncommon age for an already uncommon diagnosis. The reporter, Shari Roan had an interesting take on the story, but what was even more striking was what she chose to omit.

The father, Michael, is a writer and has a blog detailing his life with a supposedly schizophrenic child. In brief, he admits to some horrifying behavior in the way of parenting and if this child is excessively violent, it doesn’t seem as though you’d have to go far to find the root of the problem.

“…We tried starving her. We did EVERYTHING we could to try and break her…at times Susan and I both lost it and hit Jani as hard as we could. We hit in impotent rage…We saw Janni today and she was at her most psychotic in several weeks. I have a nice welt on my arm where she hit me when I refused to call her toy rat “99.”Of course, I was goading her, but I wanted to see if she could deal with it. Of course, she couldn’t”

He later removed from his blog the part about starving her , oddly leaving the hitting in. He also appears to have gone from doctor to doctor until he got the diagnosis he wanted which now gives him carte blanche to administer an alarming amount of drugs to her including high doses of Thorazine and Haldol.

Children are complex and I don’t think you can take all of the undesirable behaviors of a child, find one cause, label it and medicate it away. It’s harder but I think you have to treat each behavior as its own action. Encourage imagination even if you don’t understand it, treat violence as violence, develop social skills even as social structure is questioned.

I urge you to read the story and the later commentary regarding it on both Furious Seasons (scroll down to it) and The Trouble with Spikol. That for me is where it gets particularly interesting and ugly. A number of readers on both of these sites are quick to defend the parents and condemn people for rushing to judgement. I have to wonder where we are as a society if we are not willing to judge people based on their actions. I don’t think we need reasons or mitigating factors here. We’re talking about adults hitting a six year old with all of their strength and starving her, talking about breaking her, referring to themselves as staff when they are in her presence, the list goes on. Some things are always wrong.

Upon being asked by a reader how Shari Roan could have written this story but omitted the abuse that both parents admit to she said, among other things:

“They have also hit due to sheer exhaustion and loss of self-control…I am certain this is not the case of a normal child who has been abused. This child has a horrible mental illness that has destroyed her and her parents.”

This sounds a lot like this supposed mental illness in some way makes January’s abuse more acceptable or understandable. “This is not the case of  a normal child that has been abused.” No, of course not, you’re not allowed to abuse “normal” children. I am not saying The Schofields are horrible, loveless people through and through. I do not know them. I am simply saying that they have abused their own child (prior to the diagnosis, if that makes a difference) in a manner that may have gotten her removed for her own safety if she were not labeled with schizophrenia. If we can’t judge people, may we always at least judge actions.

I have to believe it’s a statement about how we view people who are diagnosed as mentally ill. Treat them as you wish, you will not be held accountable. If we are to accept the notion, and I do not, that mental illness is a type of biological disease like cancer or epilepsy, then standards of care should be universal. I know of no disease that is routinely treated punitively and no sickness that makes it more tolerable for this to happen, if anything, less so seems to be the trend.

July 22, 2009 at 10:23 am 50 comments


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