In 1997, the National Library of Medicine (NLM) helped initiate a new era in American medicine when it made MEDLINE, its comprehensive online bibliography of published medical information, accessible to the public through the World Wide Web. That event may prove to be a symbolic watershed of 20th century American medicine. It will impact every aspect of medicine, from the manner in which physicians are educated to the way they run their daily practices.
Scientific, social or legal redefinition is only slowly reflected in changed practitioners and practices. It is not surprising that surveys continue to report high levels of ignorance and prejudice encountered by homosexuals in their contacts with health care providers. This also contributes to a negative feedback loop in which many homosexuals are reluctant to utilize, inform or confront their care providers, impairing collaboration in treatment.
Many of the factors purported to influence accessing mental health services by men and ethnic minorities are systemic in nature, ingrained within our culture, and consequently, difficult to change (e.g., gender differences in attitudes toward help-seeking, ethnic differences in the use of alternative healing resources). However efforts have been made within the mental health system to make services more acceptable to men and minority group members who choose to, or are able to, access the system.
What counts as participation in capital punishment? Is it possible for a medical activity to be ethical in one context, but a similar one not ethical in another? Is death different? Are there neat and universal ethical rules that will always guide us wisely, or are there inevitable clashes among various legitimate and important values? Is it ethically possible that a forensic psychiatrist is not a psychiatrist, as Dr. Paul Appelbaum has argued? How strongly should physicians protect their duty to always help and not harm all individual patients in the face of many pressures to do otherwise?
In its 1986 decision in Ford v. Wainwright, the U.S. Supreme Court found that death row prisoners had a constitutional right not to be executed if they were incompetent (477 U.S. 399 [1986]). Competence for execution-an odd concept, but one whose roots go back to biblical times-usually requires that a prisoner understand the nature of the punishment about to be imposed and why it is being imposed.
Peter Penna, Pharm. D. spoke on the future of drug formularies and how he sees them changing. Formularies in managed care evolved out of formularies in hospitals and have been around since drugs became relatively commonly used in patient settings, Penna explained. "Today, formularies are widely used by hospitals, managed care organizations, pharmacy benefit management companies, home health agencies and nursing home services."
Nelson Kull, executive director of Pathways, sees an additional benefit to consumer employment: it provides patients with a first-hand look inside the system, and this can help defuse the sometimes antagonistic relationship between consumers and caregivers. "Some people criticize doctors and pharmaceutical companies for making a lot of money," says Kull, "but they gave me back my life. I once told meeting [attendees] that yes, psychiatry and medical care cost a lot, but your car costs a lot. I can't drive my car without my medications, so which comes first?"
The stakes in the debate over recovered memories therapy ratcheted upward in October with the indictment of five health care professionals, including two psychiatrists, in Houston. Charged in a 60-count indictment-believed to be the first of its kind in the United States-the former staff members of the now defunct dissociative disorders unit at the Spring Shadows Glen Psychiatric Hospital are accused of perpetrating a "scheme to defraud by allegedly falsely diagnosing patients with multiple personality disorder caused by their alleged participation in a secret satanic cult."
Before the Malpractice Suit - Poetry of the Times
As a consultant and educator for various stakeholders in the delivery of managed mental health services, I see confusion, skepticism and demoralization in the mental health professions about the direction health care is taking. Many doubt their ability to achieve the objective of the managed care mantra: Better care at less cost. To the clinician delivering care, it feels as if there is no stable ground to stand on, or, in the words of a 1960s female R & B group: "Nowhere to run to baby, nowhere to hide." Our profession seems to be either frozen in fear or disorganized in struggle, not grounded and coordinated in response to the changes that are upon us.
There is an increasing body of data that suggests there may be relationship between certain forms of childhood-onset OCD and previous Group A beta-hemolytic streptococcal infections. They seem to have early-onset OCD, tic disorder, Sydenham's chorea and family history of tics. Sydenham's chorea, a major manifestation of rheumatic fever and a disorder generally limited to prepubertal children, is thought to be disease of basal ganglia, and the basal ganglia is thought to be involved in both Sydenham's chorea and OCD. Children with Sydenham's chorea frequently present with OCD symptoms.
In the spring of 1997, legalization of physician-assisted suicide seemed inevitable. In the space of a month, two appellate courts had declared a constitutional right to physician-assisted suicide, overturning long-standing state laws in New York and Washington that prohibited the practice. Many observers expected the U.S. Supreme Court to follow suit. Earlier, Oregon had become the first state to legalize physician-assisted suicide. Although that decision was still being contested in the courts, had the Supreme Court recognized and accepted a constitutional right to physician-assisted suicide, Oregon was ready to become the first state in which it was practiced.
It was a bad combination, I'll allow that. The call from the emergency room reached me the Saturday morning after I had finished reading Ayn Rand's Atlas Shrugged. I hadn't gotten a lot of sleep, partly because I finally reached page 1,168 around midnight, partly because I couldn't get my mind off John Galt, Hank Rearden, Francisco d'Anconia, Dagny Taggart and the rest of Rand's characters. Before I drifted off, I was already drawing parallels between the current state of psychiatry and Rand's fictional world in which the mind is denigrated, and autonomy and free will nearly stamped out.
It appears randomly in about one out of one million people. In the United States that means somewhere over 200 people get it, and die from it, each year. We know that they die because no one can survive it-mortality from the disease is 100%. It is Creutzfeldt-Jakob disease (CJD), among the deadliest, and least understood, of all brain diseases.
The goals of National Coalition for Mental Health Professionals and Consumers are to educate the public about the problems of managed mental health care and to develop alternative health delivery models. I think greater media coverage has spawned greater awareness of the difficulties with managed care and has provided legislators with vital information. Certainly sharing their stories has made many people feel less alone and isolated within a system they find frustrating and depriving. I think media advocacy has helped doctors find support for their right to stand up to these abuses and band together in greater numbers to fight for integrity and quality in mental health care delivery.
In 1988 I was working as a general adult psychiatrist with a specialty in addictions. One day, a newly referred patient came to my office accompanied by his mother. Although he was well groomed, he was distinctly "nerdy." When I inquired about his chief complaint, his mother quickly explained that, although he had graduated from community college, he was unable to secure a job interview due to his obsessing on the details of his resume.
Two Portraits of AIDS - Poetry of the Times
Inspired, in part, by the initial success of treating young patients with new atypical antipsychotic medications, the National Mental Health Association (NMHA) has initiated a major consumer campaign to educate the public about schizophrenia. S.O.S. (Signs of Schizophrenia) is designed to help parents and children recognize symptoms and seek treatment, emphasizing the importance of early detection and care.
Only eight weeks after beginning treatment for trichotillomania (hair pulling) at Stanford University Medical Center, Christina Pearson found herself being invited to appear on a local television show in Seattle to discuss the disorder.
Only eight weeks after beginning treatment for trichotillomania (hair pulling) at Stanford University Medical Center, Christina Pearson found herself being invited to appear on a local television show in Seattle to discuss the disorder.
America's pop culture can send a dizzying blur of mixed signals. On the one hand, its massive restaurant and food industries serve up an abundance of calorie laden, often unhealthy processed meals that have turned Americans into the most overweight people in the world.
Lack of energy, recurrent thoughts of death and difficulty with concentration are viewed by more than half of medical decision-makers in families as natural components of aging rather than as symptoms of clinical depression, according to a Louis Harris and Associates survey. Additionally, 93% of all adults polled said they believe depression is a normal side effect for those suffering from a medical condition.
Over the past decade, cost containment efforts have pushed psychotherapy patients away from psychiatrists and toward the offices of psychologists, therapists and other less expensive mental health workers. The availability of new drug treatments for psychiatric disorders has shifted many psychiatrists' practices away from a long-term therapeutic focus to that of short-term drug treatment. If psychiatry merely reacts to these economic and political forces, rather than managing them with a plan, the future of the field is highly uncertain.
What started out as a solitary quest for justice by a veteran Orange County, Calif., obstetrician who was terminated without cause from two HMO networks operated by Metropolitan Life Insurance, has now blossomed into a major policy debate that has physician groups lining up to plead their global causes to the Supreme Court. And though Louis Edgar Potvin, M.D., a former president of the Orange County Medical Association, never expected to become the standard bearer for the medical profession, the case has grown beyond a mere effort by one physician to restore his practice and life savings; it has become symbolic of the increasingly heated debate that has enveloped the delivery of health care.
The psychologists appear to believe that large numbers of untreated mentally ill would get better if their psychologists could prescribe medication for them, thereby making up for a resource-poor and underfunded mental health system. There is no lack of prescribers. Psychiatrists know that the biggest problem for the mentally ill isn't a lack of medication, it is the dearth of supportive services available to augment, among other treatments, the taking of medication. So why are psychologists fleeing the duties they have long been mandated to provide? The answer is simple: Money.
The Americans with Disabilities Act of 1990 (ADA) was to have ushered in a new age of equal opportunity for individuals suffering from physical and mental infirmities. But rather than providing "a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities," the ADA often becomes the legal battleground upon which individuals' rights clash with the economic interests of businesses that bear the brunt of the costs associated with equality.
All of the forces affecting and influencing my professional life thunder through my day like these footsteps on the bridge. So many times we hear that private practitioners are "dinosaurs" in today's managed health care environment. At times, I admit, I do feel like a hanger-on in some evolutionary cul-de-sac. Yet, as referrals keep coming in, I find myself feeling more and more fit to survive the Darwinian challenges facing psychiatry. Sharing daily life with colleagues I trust and respect better enables me to live with or ignore the "footsteps on the bridge," which in my more optimistic moments I imagine to be the sound of the real "dinosaurs" rumbling off into the mist.
Prior to training in psychiatry, my practice was in a rural primary care setting where I routinely collaborated closely with physician assistants and nurse practitioners. I see prescriptive privileges of one form or another for psychologists to be an inevitability. I watched a similar struggle for nurse practitioner prescriptive privileges in Oklahoma during my stint in primary care. My recommendations to physicians in California would be to endorse prescriptive privileges for other mental health professionals in the format of the "physician extender" model similar to the traditional physician assistant.
Proponents of SB 694 argue that the doctoral-level training undertaken by psychologists qualifies them to deal with mental illness more so than most physicians. More than 75% of mental health prescriptions are written by general practitioners who have limited training in treating mental illness. They say it makes good sense to set up a system in which psychologists who meet additional educational requirements would be given the authority to prescribe medication. Opponents contend that the training provided for in the bill is inadequate. Many feel that as time brings new and significantly more powerful drugs for the treatment of mental disorders to the market, the arguments against psychologists prescribing will increase.
The role of psychiatry in primary care is an area of rapid expansion and increasing significance. Given the fact that inadequate diagnosis and treatment of psychiatric disorders are major public health problems, it is essential to integrate psychiatrists into multidisciplinary primary care teams. Since primary care physicians are increasingly called upon to act as "gatekeepers" in managed care programs, they will have to meet the important and growing need for broader psychiatric diagnostic and referral skills.