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Rally, the Excellence blog, gives voice to issues, ideas and news in mental health recovery

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January 26, 2015 by Sandra Steingard, MD

Bring Back the Asylum?

This week, a commentary written by members of the University of Pennsylvania Department of Medical Ethics and Health Policy and titled “Improving Long-term Psychiatric Care Bring Back the Asylum,” was published in JAMA online. I share my perspective on this provocative suggestion which is influenced by recent dramatic changes in my home state.

Sandra-SteingardThis week a commentary, written by members of the University of Pennsylvania Department of Medical Ethics and Health Policy and titled “Improving Long-term Psychiatric Care: Bring Back the Asylum,” was published in JAMA Online. The senior author, Ezekiel Emanuel is former Special Advisor for Health Policy in the Obama administration and brother of Rahm, Mayor of Chicago and Obama’s former Chief of Staff. This commentary with its provocative title published in a high impact journal by a well connected physician is sure to garner considerable attention and influence.

As the title suggests, the authors recommend a return to asylum care, albeit not as a replacement for but as an addition to improved community services and only for those who have “severe and treatment-resistant psychotic disorders, who are too unstable or unsafe for community based treatment.”

The authors seem to accept the notion of transinstitutionalization (TI) which suggests that people who in another generation would have lived in state hospitals are now incarcerated in jails and prisons. This notion arose from two sets of statistics. The first is that, as rates of psychiatric hospitalization declined, rates of incarceration increased with the total in 2000 being about the same as it was in 1960. It gives the appearance that we just transferred people from one setting to another.

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January 17, 2015 by Bob Nikkel, MSW

2015 Edition of Early Psychosis Intervention Projects National Directory

bnikkel_miaceThe Foundation for Excellence in Mental Health Care is very pleased to announce the arrival of the second edition of the Program Directory of Early Psychosis Intervention Projects, a joint venture of Portland State University’s Regional Research Institute and the Foundation. This national listing has contact and some basic program information for about 70 projects in 18 states.

Most of the credit for creating the directory goes to Elinor Taylor at Portland State University. She has constructed and updated this work on top of a heavy academic and clinical workload and deserves recognition for this important document.

As described in the introductory section, the purpose of the directory is to create a database and list of early intervention programs for psychosis within the U.S. Additional goals include facilitating a communicative network among these programs, creating tools for referral, comparing outcome measurements, and determining potential future research studies. This information is up-to-date as of January 2015.

My hope is that in a few years, we will have hundreds of projects in all 50 states. When that day comes, we will realize the expectation that young people will recover their lives and never give credence to the all-too-common and destructive “diagnosis” of a “chronic mental illness.” It’s the system that’s been creating that tragic, unnecessary outcome.

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January 16, 2015 by Beatrice Birch

Protected: The Inner Fire Story

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January 16, 2015 by Kathy Brous

Neurofeedback: Healing the Fear-Driven Brain

SebernFisherPsychotherapist Sebern Fisher gave a great webscast Oct. 14 in the National Institute for the Clinical Application of Behavioral Medicine series, about neurofeedback (biofeedback to the brain), which gives us access to our brain function frequencies. The brain gets organized from the womb in oscillatory patterns, and we with histories of early neglect and abuse, i.e. developmental trauma, suffer from disorganized and dysregulated brains.

Our fear circuits dominate. Neurofeedback can calm these erupting circuits, while encouraging neural connectivity, which helps us create a more coherent sense of self, so we feel safer and more centered.1

Folks with difficult parents often grow up with a “fear-driven brain” as I did — and it can be a huge relief to find out we’re not freaks; nope, we’re a chunk of the mainstream.  In fact, maybe 50% of Americans have some degree of this “attachment disorder” due to parents who were too scary to attach to. Of course it’s not their fault either, because odds are, our grandparents were too scary for our parents to attach to, and so on inter-generationally.

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January 16, 2015 by Bob Nikkel, MSW

New CEU/CME Course Available: Psychiatric Medications and Long-term Outcomes for Schizophrenia

bnikkel_miaceThe Mad in America Continuing Education Project is pleased to announce the posting of its second on-line course.

This course qualifies for 3.0 CMEs  approved by the American Academy of Family Physicians and 2.5 CEUs approved by Commonwealth Educational Seminars for psychologists, social workers, licensed marriage and family counselors, nurses and certified addiction counselors.

We are fortunate to have enlisted the expertise of one of the world’s premier researchers, Martin Harrow, PhD, of the University of Illinois Chicago Medical School as he presents his 26-year comprehensive outcome study of individuals diagnosed with schizophrenia and other psychotic disorders.

The course includes a one-hour discussion moderated by Bob Whitaker which includes Dr. Harrow’s chief collaborator, Dr. Thomas Jobe. The two lessons together focus on the improved outcomes for people who stopped taking antipsychotic medications compared to those on antipsychotics.

Instructor

Martin-HarrowMartin Harrow, PhD

Martin Harrow is a psychologist and widely-cited expert on schizophrenia and bipolar disorders. He has published over 250 scientific papers and four books on these and related areas. As Director of the Chicago Followup Study, he has received several national awards for his research on thought disorder, psychosis, long-term adjustment, suicide, and recovery in schizophrenia. Recently his research has focused on longitudinal studies of the long-term effects of antipsychotic medications. He has been on the faculty at Yale University and the University of Chicago, and in 1990, moved to the Medical College of the University of Illinois as Professor and Director of Psychology in the Department of Psychiatry. He is now Distinguished Professor Emeritus there.

We look forward to sharing the work Dr. Harrow, Dr. Jobe and other colleagues in better understanding the relationship between long-term use or non-use of psychiatric medications and important outcomes like functional status, psychotic symptoms and rehospitalization.

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January 10, 2015 by Sandra Steingard, MD

Atul Gawande’s Being Mortal

Sandra-Steingard

Atul Gawande is a physician author whose work has been published in The New Yorker, among other places. Disclosure: I am a fan. What I love and respect most about his writing is that while he is unflinching in his critical view of medical practice, he writes with a deep humility and compassion. Medicine is, despite our aspirations towards technical mastery, practiced by humans. And all of us, even those privileged with years of schooling, are limited in various ways.

In his most recent book, Being Mortal, he explores the complexity of end of life care. He reviews the development of nursing homes in the US and describes some newer alternatives that are becoming available. He also writes about how people approach their final days. He describes with stunning clarity the extremely difficult choices people make as they loose their physical abilities and face their final days.

Why is this a topic I bring here?

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January 10, 2015 by Kathy Brous

California ACEs Summit

CA ACEs Summit Nov.2014At California’s first ACEs summit November 5-7, “Children Can Thrive,” over 200 health professionals, policy leaders and advocates gathered in San Francisco. They created a national model for a statewide dialogue on the biggest public health problem facing California today: Adverse Childhood Experiences (ACEs).  They focused on programs in health, education, juvenile justice and child welfare at the local and state levels, and how national policies can support those efforts. Also exciting, Google.org announced a $3 million grant November 3 to the Center for Youth Wellness (CYW), the clinic started by Dr. Nadine Burke Harris, organizer of the California ACEs Summit.  The grant is specifically aimed to get enough scientific documentation that childhood trauma causes adult onset diseases, to actually make toxic stress a diagnosis code billable for insurance.

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December 25, 2014 by Sandra Steingard, MD

Nitrous Oxide for Depression and Other Hazards of Modern Psychiatry

Sandra-SteingardThis week, Mad in America featured a news item regarding a recent “proof of concept” study conducted at Washington University of St. Louis that investigated whether nitrous oxide, commonly known as laughing gas, was effective in reducing symptoms of depression. In a press release, one of the investigators, notably the anesthesiologist on the team, was quoted as saying, “It’s kind of surprising that no one ever thought about using a drug that makes people laugh as a treatment for patients whose main symptom is that they’re so very sad.”

Surprising indeed. I think one needs to be in the rabbit hole of modern psychiatry to understand why a drug like this would be overlooked as a treatment for depression. I would argue that it is a reflection of what Joanna Moncrieff has called the disease-centered approach to understanding these drugs. We have the conceit that the drugs we prescribe rather than being generic euphoriants or tranquilizers target specific disease states. The narrative of modern psychiatry includes the notion that these states – or disorders – are ones that psychiatrists are adept at identifying. It would have been damaging to the basic premise of modern psychiatry – bolstered by the neo-Kreplinians at Washington University – to admit we were just giving out psychoactive drugs, i.e., substances that would impact most everyone in similar ways. If I were to inhale nitrous oxide, my mood would undoubtedly be elevated. I never tried it during its heyday when I was in college, but I knew many others who did and I did not need a rating scale to know they were – at least for a time – a pretty happy bunch.

There has recently been an interest in the use of ketamine, known as special K, to treat depression. This is another drug that has a dramatic effect on most everyone who uses it. It is used by anesthesiologists and not just for those who are depressed. If you scan the ads in publications aimed towards psychiatry, you will find many ads for stimulants. These drugs, along with the benzodiazepines (Ativan, Valium, etc.), are not disease-specific drugs. They may be particularly helpful for those who struggle in certain ways, but they effect us all in similar ways. I do not need to be suffering from any kind of disorder to be sedated by a benzodiazepine.

I remember wondering why we did not give stimulants to depressed patients. As a resident, I was told they were ineffective. It was suggested that they might be helpful for older patients who had low energy but I would have been criticized as a psychiatrist if, thirty years ago, I had prescribed them to a depressed patient. But then the notion was heavily promulgated that children with Attention Deficit Hyperactivity Disorder (ADHD) did not grow out of their problems. We were told that in fact many adults missed out on getting properly diagnosed and were in need of treatment. And the flood gates of stimulant prescribing opened. I see people who have many reasons to be inattentive – on multiple drugs for their other diagnosed conditions, using substances, living in highly stressful environments. I know that it is considered legitimate practice – if they provide the correct history – to diagnoses them with ADHD. As psychiatrists, we do not tell patients that there are drugs that – at least in the short run – can increase focus. We say that we have determined that they have an illness and we can give them a drug to treat this. Since ADHD is accepted as a life long problem, when we follow this particular narrative, we create a life long customer for the stimulant industry. I do not think it is a coincidence that this interest in adult ADHD began to arise as most antidepressants were going off patent and their efficacy was being questioned. Although the stimulants have been around for a long time and are available in inexpensive generic forms, what is being promoted now are drugs that resist tampering. These drugs are addictive and often abused. So the market now is for drugs that doctors can prescribe but will be resistant to a problem we know is endemic – misuse, diversion, and abuse. It is interesting that stimulants are now coming back into fashion for the treatment of depression.

While it is not controversial to talk about the general effects of benzodiazepines and stimulants, the group of drugs classified as anti-depressants are thought to be specifically effective for those who are depressed. This idea is worth examining further. Before fluoxetine (Prozac) was marketed, the research focus in psychopharmacology was on determining which individuals would respond to anti-depressants. I was taught in the 1980′s that those individuals who had neuro-vegetative symptoms such as poor sleep with early morning awakening, thoughts of guilt, motoric slowing or agitation, were the ones who should be prescribed anti-depressant drugs. The older antidepressants had many noxious side effects. People – doctors and patients – avoided them. Fluoxetine was considered much safer and better tolerated. So physicians started to prescribe it more broadly, encouraged by the enormous hype surrounding this drug. And what did we find? Many people, not just those who fit the more narrowly defined “melancholic depression” reported improvement. Books were written about their broad effects. But never was the notion widely entertained that these drugs had general effects that most people would experience, the idea was that the drugs worked on people with an ever proliferating set of diagnoses: social phobia, dysthymic disorder, personality disorders, etc.

Why is this a problem? Isn’t it a good thing that these drugs have broader uses? Isn’t it a good thing to reduce suffering among a larger group of people?

Here is the rub. This is what we still do not know about drugs: What are the long term side effects? How hard is it to stop them? How do we deal with the corrupting influence of the profit-driven forces so powerful in medicine? Most of these drugs are still studied over weeks and then prescribed for years. With drugs like stimulants, ketamine and nitrous oxide, I have a particular worry because these drugs are known to cause psychosis. Colleagues of mine have told me that they do not see people who become psychotic on stimulants. If they don’t, they are not looking. I am not comfortable assuming when an 18 year old develops psychotic symptoms after several years of treatment with an antidepressant that these two things are not related or that the psychosis was inevitable because the person had a diathesis to Bipolar Disorder. Stimulants are used to create animal models of psychosis because we have known for decades that stimulants can cause a person to become psychotic.

I think these newer drugs have a huge potential for harm. This is due in the short run to the potential for abuse and diversion. But I remain equally worried about long-term consequences. Psychiatry has not begun to reckon with the unanswered questions concerning drugs we have been prescribing for decades. It is reckless to promulgate use of what appear to be even more dangerous drugs before we address these critical questions.
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Named to “Best Doctors in America,” Dr. Sandra Steingard is Medical Director at HowardCenter, a community mental health center where she has worked for the past 17 years. She is also clinical Associate Professor of Psychiatry at the College of Medicine of the University of Vermont. For more than 20 years, her clinical practice has primarily included patients who have experienced psychotic states. Dr. Steingard is Board Secretary for the Foundation for Excellence in Mental Health Care.

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December 18, 2014 by Bob Nikkel, MSW

Assessing the Cost of Psychiatric Drugs to the Elderly and Disabled Citizens of the United States

BobNikkel_lgProPublica is well known for creating interesting data bases that allow anyone hooked up to a computer to see by name whether a physician is accepting Big Pharma payments–from dinners to speaking engagements to consulting services. What may be lesser known is that occasionally ProPublica will publish other data that when carefully mined can reveal even more about the use of psychiatric drugs, especially when there is a public funding source available.

This past week, we got more than a glimpse into the costs of psychiatric drugs by mining ProPublica’s listing of Medicare Part D prescriptions. Part D is the federal program that Social Security uses to pay pharmacies for all types of medications, psychiatric and non-psychiatric. Their tables list all drugs and their costs for the most recent year available, 2012. If one separates out the data, it looks like this:

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December 18, 2014 by Lauren Spiro

Healing From Intergenerational Trauma: Facing the Unfaceable

Lauren_Spiro

I spent 15 years slowly preparing for a trip into the unfaceable. One of the most important processes that supported me on this journey was observing and being witness to a U.S. human rights advocate and coalition builder (who has German gentile heritage) do gut-wrenching emotional healing work particularly against anti-Semitism and white racism. She inspired me with her intelligence, tenacity and determination to be free from the damaging effects of these forms of oppression. Some members of her family supported the Nazis.

Two years ago, I told her I was ready to join her in going to Poland and the eight day Healing from War workshop.

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