Psychiatry in the News

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I came across a number of interesting articles today, and I'm wondering if anyone would care to discuss them. Here we go:

#1: Brain Mapping

http://www.msnbc.msn.com/id/46897519.../#.T3UW_Hh8vww

These images are just plain awesome, even if we can't use them clinically. Yet.

#2: 911 Dispatchers at risk for PTSD

http://www.huffingtonpost.com/2012/0...n_1388426.html

This does meet DSM criteria, correct? I have been taught two things...that you have to experience a direct threat to yourself, and that you don't (which seems to be what the DSM IV says...)

The person has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of oneself or others.

#3: Jet Blue Pilot + Questions

http://www.washingtonpost.com/busine...NjS_story.html

Yeah, so...wow. Goldwater rule notwithstanding, from reports, it appears this guy had a psychotic break. Why? Who knows...but, it's certainly shed light on the lack of mental health screening in pilots.

So...pilots. Psych exams? Yes or no? If yes, who should do them? Us? Their FP? For that matter, if we require them of pilots, what about doctors? Policemen? And on and on and on. Not enough of us to go around, certainly.

Originally Posted by digitlnoize

Yeah, so...wow. Goldwater rule notwithstanding, from reports, it appears this guy had a psychotic break. Why? Who knows...but, it's certainly shed light on the lack of mental health screening in pilots.

It depends on what you mean by "screening." Commercial pilots already have some of the strictest requirements out there when it comes to mental health. Until a year or so ago, you could not fly if you took an SSRI. There was a lot of pushing by mental health to lift this restriction. You are currently legally obligated to report any mental health issues and treatment. That's pretty thorough regulatory screening.

If you're talking about predictive screening, that won't fly (sorry, couldn't resist). Psychiatry is just not very strong at predicting who or who won't develop suicidal depression and psychosis other than based on past events which already disqualify pilots. Anything else would be tea leaf reading, which isn't valid enough to prevent someone from pursuing their livelihood.

Originally Posted by notdeadyet

It depends on what you mean by "screening." Commercial pilots already have some of the strictest requirements out there when it comes to mental health. Until a year or so ago, you could not fly if you took an SSRI. There was a lot of pushing by mental health to lift this restriction. You are currently legally obligated to report any mental health issues and treatment. That's pretty thorough regulatory screening.

If you're talking about predictive screening, that won't fly (sorry, couldn't resist). Psychiatry is just not very strong at predicting who or who won't develop suicidal depression and psychosis other than based on past events which already disqualify pilots. Anything else would be tea leaf reading, which isn't valid enough to prevent someone from pursuing their livelihood.

There have been a number of articles quoting various pilots as saying that they aren't asked about mental health problems during their medical exams and that everyone knows that if you disclose them you're done, so no one does...

Wasn't asking about predictive screening, just wondering if more meaningful overall screening would be in order (which is what a number of recent news articles seem to be implying.)

Originally Posted by notdeadyet

Anything else would be tea leaf reading, which isn't valid enough to prevent someone from pursuing their livelihood.

http://en.wikipedia.org/wiki/Tasseography

Very harsh. Just like all pschological tests the ability and skill of the tasseographer is everything. You can't just swoosh a grubby cup round with any old dusty tea and expect to get good results straight off the bat.....it takes years and years of study and careful practice.....proper equipment and so on....

Originally Posted by digitlnoize

There have been a number of articles quoting various pilots as saying that they aren't asked about mental health problems during their medical exams and that everyone knows that if you disclose them you're done, so no one does...

Very astute these young wannabe pilots....its like fight club....the first rule of mental illness is don't talk about your mental illness.

A problem with the Goldwater rule is that often times when mental health issues occur in the news, people without an understanding of mental illness want more information. This is a vital opportunity to give much needed information to those that want to hear it.

The way the Goldwater rule is, IMHO it makes it difficult to talk about these issues to those that want to know more. I completely agree we shouldn't be giving a thousand mile diagnosis, but I sometimes wonder if there are ways to slip a little education to the public about these things.

I thought it was okay to talk in generalities about a disorder, but not make any specific comments about a person you had not assessed yourself?

Incidentally, where I'm from it is acceptable to do this and there's usually some media whore of a psychiatrist or psychologist who gives some sort diagnosis to a celebrity in distress and disgraces the whole profession. Occasionally it's a neurologist who thinks he's a psychiatrist diagnosing some politician with a personality disorder or coming up with his own diagnosis and pseudo-psychoanalytic explanation.

An example, there was a local case where a gym teacher was having sex with her students--many of them, got them drunk, then had sex, and she was caught. This was going on for years.

She tried to use a not guilty by reason of insanity defense. Based on what I read in the paper it seemed bogus. 1) She was able to maintain her full-time job. Who is manic or delirious to the point of not knowing the difference between right and wrong and yet can go to work and have no one call her fitness to work into question? 2) Each victim was given alcohol showing a pattern 3) She wasn't a young woman, if she had a mental illness that would've robbed her ability to tell between right vs wrong (usually psychosis or mania) she would've had it for some time and likely would've had some understanding of this disorder. 4) She was getting psychiatric help and was never diagnosed with having a problem that could've explained this phenomenon she claimed to have.

I also happened to know that a forensic psychologist that I happen to respect that almost always works with the defense actually worked on the prosecution side.

And while I didn't again evaluate the defendant the forensic psychologist who acted as an expert witness for her side gave some very bull$hit testimony. He argued that this woman had bipolar disorder, couldn't tell the difference between right and wrong with no explanation as to how such a manic woman could still work full-time, pay for her bills, maintain her home, be a mother to a teenage daughter, among several other things, and I was able to read his testimony.

Okay, well maybe I didn't know anything going on in the case, after all I'm only reading about it in the paper, but several people I knew wanted me to explain to them what was going on, was this lady in fact NGRI because it didn't seem so from the paper.

But I couldn't tell them my opinion was that she truly was guilty, that the forensic psychologist for her side gave BS testimony and was likely a hired gun who was simply happy to be paid enough money to give any opinion whatsoever. It kinda takes the entire point of talking about it moot.

ccasionally it's a neurologist who thinks he's a psychiatrist diagnosing some politician with a personality disorder or coming up with his own diagnosis and pseudo-psychoanalytic explanation.

We got a saying in forensic psychiatry. Forensic psychiatrists fancy themselves as lawyers (they think they know the law because they had to memorize some law cases). Lawyers working on mental health cases fancy themselves as doctors (they decided to get a doctor involved because they noticed something wrong with the client so now they think they're an M.D.), and judges on these cases fancy themselves as social workers (the judge wants to help the defendant because he or she is mentally ill and may give a sentence such as forced treatment or face prison or jail).

Originally Posted by whopper

Forensic psychiatrists fancy themselves as lawyers (they think they know the law because they had to memorize some law cases). Lawyers working on mental health cases fancy themselves as doctors (they decided to get a doctor involved because they noticed something wrong with the client so now they think they're an M.D.), and judges on these cases fancy themselves as social workers (the judge wants to help the defendant because he or she is mentally ill and may give a sentence such as forced treatment or face prison or jail).

This problem has been around for many years.
The Case of the Pillow (watch 2:20 - 2:50)
This scene haunts me any time I'm in court or deposition.

CNN - Why we're changing Autism Dx

http://www.cnn.com/2012/04/06/health...ml?hpt=hp_bn12

The comments are the best part

This problem has been around for many years.

I think you completely got my point!

Now if I could only remember the saying one of my attendings told me when I was a resident...

It was something to the effect of "White coat=target, black coat= immunity" or something like that.

He was referring to situations where if you are the attending, you caught in the darned-if-you-do, darned-if-you-don't situations. E.g. discharging a guy you're convinced is dangerous but he's not showing objective behavior that can easily peg him as dangerous.

In cases like that, he said don't discharge them and let the court handle it. If it turned out the patient was dangerous, and he attacked someone after discharge, and the court discharged the patient, now you can't be sued. And as for the judge, you can't sue judges. If you discharge the patient, now you're liable.

Originally Posted by digitlnoize

#3: Jet Blue Pilot + Questions

http://www.washingtonpost.com/busine...NjS_story.html

Yeah, so...wow. Goldwater rule notwithstanding, from reports, it appears this guy had a psychotic break. Why? Who knows...but, it's certainly shed light on the lack of mental health screening in pilots.

So...pilots. Psych exams? Yes or no? If yes, who should do them? Us? Their FP? For that matter, if we require them of pilots, what about doctors? Policemen? And on and on and on. Not enough of us to go around, certainly.

This is a really bad idea, the psychiatrists will be pressured to "see something coming" which would increase the number of false diagnosis. Nobody could have predicted that jetblue pilot incident.

Originally Posted by digitlnoize

Yeah, so...wow. Goldwater rule notwithstanding, from reports, it appears this guy had a psychotic break. Why? Who knows...but, it's certainly shed light on the lack of mental health screening in pilots.

So...pilots. Psych exams? Yes or no?

and who are the top 1%ers who are going to be able to pony up multiple thousands of dollars for psych evals on a regular basis? Maybe the big shots that fly for the top airlines like Delta could afford it, but your regular Sun Country airline pilot who spent ~100K on flight training for a $20K job isn't going to be too happy paying large amounts of money for mental health analysis

Regarding #1:

Interesting in dementia research, would love to see more DTI in shedding light into the anatomical progression of Alzheimer's, as I think its a bit more heterogeneous than assumed, which could have implications for where to start with meds and even behavioral therapies.

I'm skeptical with the Asperger's comment at the end. I dont know how much DTI can add to the differential in a two year old with questionable eye contact. We already "know where to start" with that one.

Originally Posted by whopper

forensic psychiatrists fancy themselves as lawyers (they think they know the law because they had to memorize some law cases). Lawyers working on mental health cases fancy themselves as doctors (they decided to get a doctor involved because they noticed something wrong with the client so now they think they're an m.d.), and judges on these cases fancy themselves as social workers (the judge wants to help the defendant because he or she is mentally ill and may give a sentence such as forced treatment or face prison or jail).

+1.

http://www.cnn.com/2012/05/08/us/cal...ing/index.html
'Help me,' homeless man begs as cops fatally beat him in videotaped incident

A graphic video played at a hearing Monday to determine whether two California police officers should stand trial in the beating death of a homeless man showed them kicking and punching the mentally ill man as he lay on the ground -- screaming in pain and begging for help.

Psychiatry Manual Drafters Back Down on Diagnoses

http://www.nytimes.com/2012/05/09/he...?smid=pl-share

The doctors dropped two diagnoses that they ultimately concluded were not supported by the evidence: “attenuated psychosis syndrome,” proposed to identify people at risk of developing psychosis, and “mixed anxiety depressive disorder,” a hybrid of the two mood problems.

Addiction Diagnoses May Rise Under Guideline Changes

http://www.nytimes.com/2012/05/12/us...iagnoses.html/

In what could prove to be one of their most far-reaching decisions, psychiatrists and other specialists who are rewriting the manual that serves as the nation’s arbiter of mental illness have agreed to revise the definition of addiction, which could result in millions more people being diagnosed as addicts and pose huge consequences for health insurers and taxpayers.

Diagnosing the D.S.M.

http://www.nytimes.com/2012/05/12/op...monopoly.html/

“Until now, the American Psychiatric Association seemed the entity best equipped to monitor the diagnostic system. Unfortunately, this is no longer true. D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription.”

Originally Posted by aphenomenon

Diagnosing the D.S.M.

http://www.nytimes.com/2012/05/12/op...monopoly.html/

Allen Frances sounds more like a whiny kid who just wants to take his ball and go home. Seriously, everything I read from him is so hypocritical. His critiques are superficial and the same sort of uninformed screeds that have filled the media by folks who are clearly anti-psychiatry. It's annoying. They sound like precisely the same sort of criticisms people were levying at HIM when they were working on DSMIV. It's like he just kept old NYT editorials and is now vomiting them up with the IV replaced with a 5.

The DSM5 process has been very open and well-documented. The people who say otherwise just haven't looked at the website or haven't read any articles. People want to be informed without doing anything to be informed, and then wonder why things are so "opaque." Kupfer at al. have pretty much done everything possible besides calling every psychiatrist personally and asking them for feedback on the phone.

Originally Posted by digitlnoize

CNN - Why we're changing Autism Dx

http://www.cnn.com/2012/04/06/health...ml?hpt=hp_bn12

The comments are the best part

Interesting. Does someone want to be the one to tell one of the moms quoted that drinking while pregnant does predispose to ADHD (often associated with FAS)--albeit, not proven that it "causes" it?

This great article and the responses to it is one example of how it is difficult for people to think about these disorders as dimensional rather than categorical. Many of the comments discuss the categorical nature of a disorder--is Aspergers syndrome a different disorder or not, for instance. I don't blame parents for wanting a categorical label--certainly in order to get services for their children there is a need at some point to draw a line. I think that what DSM-V is trying to do here is just that--draw the line more clearly in a categorical sense (autistic spectrum d/o vs. not) and then also to incorporate the dimensional by having a "spectrum." It will be interesting to see how it all works out.

'Zoloft,' 'Twinkie,' and Other Debatable Defenses
http://abcnews.go.com/Health/Wellnes...y?id=16377016#

A former police officer accused of kidnapping and raping a 25-year-old waitress in 2010 will be allowed to use the Zoloft defense, a California judge ruled Thursday, claiming he was mentally "unconscious" during the attack because of the antidepressant.

http://latimesblogs.latimes.com/lano...t-defense.html

A former Westminster police detective accused of kidnapping a woman at gunpoint and raping her in 2010 will be allowed to present a defense that he was mentally “unconscious” during the attack because he was under the influence of the antidepressant Zoloft.

Oh Jeez.

http://www.telegraph.co.uk/health/he...therapist.html

She mentioned Spizters flawed research on an interview in the news yesterday. So happens old Robert seems to have had second thoughts.

http://www.nytimes.com/2012/05/19/he...pagewanted=all

Originally Posted by billypilgrim37

Allen Frances sounds more like a whiny kid who just wants to take his ball and go home. Seriously, everything I read from him is so hypocritical. His critiques are superficial and the same sort of uninformed screeds that have filled the media by folks who are clearly anti-psychiatry. It's annoying. They sound like precisely the same sort of criticisms people were levying at HIM when they were working on DSMIV. It's like he just kept old NYT editorials and is now vomiting them up with the IV replaced with a 5.

The DSM5 process has been very open and well-documented. The people who say otherwise just haven't looked at the website or haven't read any articles. People want to be informed without doing anything to be informed, and then wonder why things are so "opaque." Kupfer at al. have pretty much done everything possible besides calling every psychiatrist personally and asking them for feedback on the phone.

I have it on good account from one of my professors who is involved in DSM5 that Frances and Spitzer have been whining because they were excluded from DSM5. But this was for the same reasons they excluded anyone involved in the original DSM and DSM-II - to revamp the system without current biases. It is amusing he does not criticize the majorly flawed DSM-III or DSM-IV and just the new edition he has been excluded from. All the problems with the DSM can be seen in the current edition. As you say he ignores just what an open dialog this process has been unlike other editions - anyone can contribute or criticize. Also, he claims DSM should not be left to psychiatrists, but psychologists are involved too. It would be unusual to involve nurses or social workers since they do not tend to make diagnoses, indeed the latter are typically against diagnoses. I am no fan of the DSM but I agree he is a hypocrite - I think the current lot have done a good job about being transparent and there are far fewer conflicts of interest this time around. Once we acknowledge the DSM is just a guideline to be used by experienced clinicians and not a factual cookbook anyone can use, and a phenomenological approach is superior to the tickbox checklist approach, the revision of the DSM falls into insignificance and we can start talking about what really matters.

Risky Rise of the Good-Grade Pill

At high schools across the United States, pressure over grades and competition for college admissions are encouraging students to abuse prescription stimulants, according to interviews with students, parents and doctors. Pills that have been a staple in some college and graduate school circles are going from rare to routine in many academically competitive high schools, where teenagers say they get them from friends, buy them from student dealers or fake symptoms to their parents and doctors to get prescriptions.

http://www.nytimes.com/2012/06/10/ed...ants.html?_r=1

And a response in Forbes: http://www.forbes.com/sites/matthewh...mes-didnt-ask/

Originally Posted by splik

Once we acknowledge the DSM is just a guideline to be used by experienced clinicians and not a factual cookbook anyone can use, and a phenomenological approach is superior to the tickbox checklist approach, the revision of the DSM falls into insignificance and we can start talking about what really matters.

True

http://www.nytimes.com/2012/06/17/op...t.html?_r=2&hp

How Depressives Surf the Web

In a study to be published in a forthcoming issue of IEEE Technology and Society Magazine, we and our colleagues found that students who showed signs of depression tended to use the Internet differently from those who showed no symptoms of depression.