Rapid cycling bipolar disorder is a turbulent and psychologically painful condition characterized by four or more major mood shifts in the course of a year (sometimes even in a week). Moods go up or down in this condition and are demarcated by a rapid switch to a state of the opposite polarity. Rapid cycling states can come at any time, and are known to appear and disappear.
Rapid cycling bipolar disorder is perilously vulnerable to outside influences, notably both those that are troubling and deleterious or, alternatively, uplifting and beneficial. Stressful events are famous for precipitating shifts into low or high states of mind. The condition begs for a stable environment and a predictable and reliable future.
This disorder is notoriously difficult to treat. Among the remedies used are mood stabilizers, anti-convulsants and anti-psychotics(!). When one intervention fails, as often happens, another is piled on; then another. In some tragic cases, all this effort is to no avail. In other cases, where the cycling abates, the myriad of interventions leaves little clue as to which one may have made a difference.
Lives are put in shambles, families rendered asunder, workplaces disrupted and resources dangerously stretched when rapid cycle bipolar disorder sets in and affects individuals and their communities.
Rapid cycling is typically associated with a poorer longer-term prognosis. One cycle, up or down, seems to trigger another, and another. The more cycles there are, the more likely another cycle will explode upon the scene leaving those affected thunderstruck and anxious as to whether they will ever escape the condition's grip. Over time, hope can fade. Over time, resources dwindle. With little to live on and scarce opportunity for a better future individuals may have little choice but to rely upon government entitlement programs.
You might think I am talking about my business, psychiatry, where we recognize a condition with these features and call it "rapid cycling bipolar disorder." But, instead, as I tuned into relentless media reports coming from Wall Street to Tokyo all this past week, I started wondering about the equity markets -- and our societies. What we are witnessing seems to meet all the diagnostic criteria for rapid cycling bipolar disorder. Without effective interventions, reductions in stress and a good dose of hope (see "Raising the Hope Ceiling") the prognosis is not good. We need a game changer for this condition wherever it may appear.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
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Originally published in the Huffington Post on August 26, 2011
After a disgraceful show of Washington blaming and shaming the US debt ceiling was raised at the 11th hour, deferring a default that no one could brook. This spectacle, coupled with a legion of global financial woes, has triggered a massive descent in stock values and a rush to find solid sources of capital -- witness the unending purchase of gold. What lies ahead? Prediction, as has been said, is particularly difficult, especially about the future -- though the clamor of commentators has grown deafeningly greater (in inverse relationship to the Dow).
I am no economist, just a psychiatrist. So I think about raising the hope ceiling, not just the debt ceiling. Hope is no ephemera, no wispy notion that lacks substance. It is the solid source of emotional capital necessary for we humans to bear misfortune and pain and find a way to recover from whatever hole we are in. As a doctor, I see my job to help my patients find sources of hope as they pursue whatever treatments and actions are most likely to bring relief and wellness.
In a stunningly clear and frank manner Dr. Drew Westen asked in the New York Times, "What Happened to Obama?" Put another way, what happened to the apparent man of conviction who stirred our hopes and rode into the White House upon them? I wonder who we have to raise our personal and nation's hope ceiling?
Why do I think days of prayer organized by politicians will not raise the hope ceiling?
Why do I think tycoons and talk show hosts proffering whatever (unregulated or regulated) fixes they admire will not raise the hope ceiling? It was Woody Allen who remarked that if you want to make god laugh, tell him you have plans.
Why do I think that sequestering gold or Swiss Francs will not raise the hope ceiling?
The course of history has been more defined by its leaders, good and evil, than by the circumstances that may have vaulted them into power. It was Adolph Hitler, despite his generals, who opened another front against his ally Russia and suffered defeat while Winston Churchill rallied his fellow citizens to stay the course in the darkest of days, keep hope alive, and triumph.
When will we see our leaders attend to the hope ceiling? Leadership, and with it hope, is about the unwavering pursuit of what is yet popular. This moment of national and global crisis calls for leaders who will speak to us as much about the nature (and value) of hope as about the dangers of debt. We are all waiting, some more hopeful than others.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer's website at for questions you want answered, reviews, commentary and stories -
The Food and Drug Administration has issued a warning letter to Baked World, a Memphis, Tenn., company marketing brownies laced with melatonin. The FDA notified this company that their product, first called "Lazy Cakes" then renamed "Lazy Larry," is in violation of the law for its production of brownies with this food additive while representing the brownie as just a brownie, and not something that contains a food additive, namely melatonin.
Melatonin is a naturally occurring compound that the FDA described as "... a neurohormone that is used for medicinal purposes, primarily as a sleep aid in the treatment of sleep-related disorders." Their letter went on to say:
"You should take prompt action to correct this violation and prevent its future recurrence. Failure to do so may result in enforcement action without further notice."
Clearly, the FDA is not happy with this company's loading brownies with melatonin and not even saying so.
For good reason. Melatonin has side effects that include nightmares and sleepwalking, daytime sleepiness and confusion, and headaches. It also can interact with medications taken commonly, like birth control pills, anti-coagulants and drugs used to treat diabetes and suppress immunity (taken for conditions like rheumatoid arthritis, colitis and lupus). And who knows what doses of melatonin a person might ingest from a "Lazy Cake" or "Lazy Larry"?
Melatonin can be a helpful supplement, used thoughtfully, with careful dosing and mindfulness of its side effects and interactions with medications. The issue is not melatonin, it is slipping it into a brownie that lures youth into yet another promised state of mental alteration and makes no mention of how.
These are not your mother's brownies. Let your kids and friends know about these "lazy" products. You might want to remind them that old-fashioned brownies are really good with milk or coffee -- and are a lot safer.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company. Visit Dr. Sederer's website at for questions you want answered, reviews, commentary and stories: www.askdrlloyd.com
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Originally posted in the Huffington Post on August 5, 2011
A few years ago my wife and I went to our first "movie dinner." It was not an evening at the movies, nor were we sitting in front of a screen with plates of food precariously balanced on our laps. There was no need to eat quietly lest any noise disrupt the viewing. Instead, we were a group of 10 people at a different kind of dinner party. Friends asked us if we wanted to come to a movie dinner, so we said yes. We were instructed to view two films that had been selected in advance of the evening and be prepared to discuss the films over dinner, led by one person who would moderate the discussion.
The evening began with the customary meeting of familiar and unfamiliar people, the serving of wines and cheeses and varied small groupings in conversation as we stood about the living room. There was little said about the movies we had seen; in fact, when the films came up, there was the expectation that we wait until we sat down to dinner. When we did, Bob, our moderator and a university professor who teaches film, took over.
We had joined a movie dinner group that had begun some years ago, but Bob reiterated the rules, I think not just for the sake of the newcomers. We would speak about each of the two films in turn and then about the two of them. Only one person would speak at a time: in other words, there would be no breaking up into pairs or small groupings, as so often happens at a dinner party. While technical considerations about lighting, set design, use of cameras, script construction and the like were fine, we were not a movie industry group, so we need not try to do more than share our thoughts, feelings and experience of the films. Bob did not offer why he had chosen these particular films.
I have been to many dinner parties in my life, and many have been lovely evenings, with fine conversation and food. But this movie dinner (and subsequent ones) was different, better, if you will: the conversation was focused on the films, but the topics they evoked were broad and about what matters most to us, like family; loss; love and its perturbations; desire; freedom; virtue and human failing; evil; generosity and selfishness; faith; hope and despair; aging, loneliness and community; home and country; and living and dying. The talk was unremittingly lively and not abstract, because it was rooted in the people and stories we had watched. The conversation moved around the table, and no one monopolized or was quiet. The moderator kept us to the rules, encouraged our expression and was never pedantic. We came to know ourselves and our dinner partners all the more from what was said.
We all had our ideas, as well, about why Bob had paired the movies he selected, although he usually said that he had not been so calculating. But good movies, new and old, renowned or arcane, tell timeless tales that touch our hearts and unleash our musings, so we never had trouble offering our thoughts about how the two films connected.
Since that night, we have gone to this movie dinner group two or three times a year. After talking it up with friends in Connecticut, we began another group there. Among the movie pairings we have watched are "Big Fish" and "Babette's Feast," "The Visitor" and "The Great Debaters," "The Magnificent Ambersons" and "Hannah and Her Sisters," "Hotel Rwanda" and "One Flew Over the Cuckoo's Nest" (not my doing!), "Cool Hand Luke" and "The Ninth Day," and "Joyeux Noel" and "The Bicycle Thief." Other notable films (that can be widely paired) are "Detective Story" (1951), "Chariots of Fire," "Twelve Angry Men," "Crash," "Dead Man Walking," and (of course) "The Godfather." So far, no one has chosen "The Hangover" or "Transformers" (or any of the "Harry Potter" films).
For sure, the choice of movies -- their subject, story, acting, meaning -- makes a difference. But it is the people that make the movie dinner an evening to remember, with the help of a good facilitator. The rules are important, especially one person speaking at a time so that the conversation engages everyone. An ongoing group with regulars and new additions grounds the evening in familiarity and comfort yet adds the garnish of welcome unpredictability. Food always helps, but the evening is not about the food, so don't get distracted by thinking there needs to be a gourmet meal. The dinner is actually about consuming and digesting the films, the conversation and the friendships. That's quite a meal in itself.
The opinions expressed here are solely Dr. Sederer's own as a psychiatrist and public health advocate. He receives no support from any pharmaceutical or device company. For questions you want answered, reviews, commentary and stories, visit Dr. Sederer's website at www.askdrlloyd.com.
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Originally posted in the Huffington Post on August 3, 2011
"Buck," a film about Buck Brannaman, directed by Cindy Meehl, in its own seemingly effortless and totally endearing way is a film about violence.
Violence comes in a variety of forms: physical, sexual, and emotional -- commonly in combination. Violence is visited upon fellow human beings -- young and old, family and friends, and random strangers -- and those creatures that fall under our control, be they dogs or cats and, case in point, in "Buck" it is horses.
Whole agencies are created, funded and staffed to protect against violence (e.g., child protection, elder abuse, cruelty to animals) and a vast criminal justice system of courts, jails, prisons, parole and probation exists to help contain it. Yet violence endures unmercifully.
The closer the perpetrator is to the victim the more corrosive the damage. Sadistic parents have a profoundly deleterious effect, as do siblings and other close relatives. The more persistent the abuse the greater its impact and without someone to step in to protect the deeper are the wounds. In the most chilling and counterintuitive of ways, people who are violent have been almost always themselves victims of violence, thus its transmission from generation to generation.
"Buck" is a documentary film about Buck Brannaman, nearing 50 and now a legend as a "horse whisperer" -- though that term hardly does him justice. He spends nine months of every year criss-crossing the USA doing four day clinics on how to be one with your horse. As one narrator put it, "... some horsemen have a handful of tricks, Buck has an arsenal." Though that too does not convey the essence of what he does, which is to inspire the person who brings his or her horse by teaching confidence and skill and compassion. To paraphrase Buck, it is not a problem horse he sees but a horse with a problem owner.
Rewind Buck's life, as the film does, and we see him as a blond haired, blue eyed boy, the younger of two sons, who was a child cowboy star at the remarkable age of four who even did ads on TV for a cereal brand. But this all-American family was ravaged by violence which reached full force after his mother died and his father, then an alcoholic, began to beat him and his brother every night, for years, until a football coach discovered the welts and called the local sheriff. He was taken in by the Shirley family (his foster mother is a featured character in the film) and given a chance to live without abuse and to learn a life of ranching and responsibility as part of a caring family that had as many as 23 (!) foster children, all boys. So begins his exit from the cycle of violence.
Buck finds his calling when as a young man he comes upon Ray Hunt, his great predecessor as a horse trainer. He witnessed that "breaking" a horse could be done without aggression or violence, long a tradition among horsemen. Buck's path was fashioned at that moment as he tells us in one of his many reflections throughout the film. He spends years learning from Hunt, modeling himself after what was 'the good father'. He would not be his father inflicting pain and terror but rather a person who could be firm, attuned, disciplined, kind and show how that could be done through the vehicle of training horses. And when you see that done, I assure you, it is a sight to behold.
What makes this film so extraordinary is not just how amazing a figure Buck is but the way the narrative illustrates how violence can be mastered. We witness Buck who leaves the legacy of violence behind (but not forgotten as he remarks) and the countless horsemen and women whom he has helped discover that you can make a horse dance or herd cattle without pain because in the end that horse wants to take pride in its work just as much as you do. The examples in the film of his skill with horses and people are arresting, each one a heartbreaker, even when he fails, as happens with one horse and its owner. We are treated to Will Rogers's philosophy that is not only voiced but undeniably shown in horse corrals, stables and training clinics while drinking in gorgeous footage of the cowboy life and the American West.
I wish I had a horse so I could go to one of Buck Brannaman's clinics. I don't. But then again, it's really not about the horse.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer's website at Ask Dr. Lloyd for questions you want answered, reviews, commentary and stories.
At a recent suicide prevention symposium hosted by the NYS Office of Mental Health (Disclosure: I am the agency's Medical Director), Dr. Lee Goldman, Dean of Columbia Medical School, began the day by remarking that there has been an 80 percent (!) reduction in deaths from heart disease in the past 50 years. Dr. Goldman was highlighting how what seemed like inevitable mortality rates two generations ago could be systematically and dramatically altered by reducing risk and intervening early and effectively; lives can be saved and pain and suffering for potential family survivors can be blessedly mitigated.
That was a heartening opening in light of why this meeting was called: 10 years ago a national strategy to reduce suicides in this country was launched built on a platform created by Former Surgeon General David Satcher. Yet despite many well considered efforts there has been no reduction in deaths, which now are greater than ever, about 36,000/year according to the latest statistics. NYS Mental Health Commissioner Mike Hogan called this New York meeting to consider what this state of near to 20 million people might do to reduce deaths by suicide, and the grim consequences they cast. Our work would build on and resonate with a national effort underway.*
We began by hearing several success stories. First, we heard how Henry Ford Health System in Michigan, a large health insurance plan with some 500,000 members that delivers medical services to its subscribers and others (~10,000 visits/business day), set a goal for what they called "Perfect Depression Care." The vast predominance of people who complete suicide have an active mental illness, particularly depression. Not willing to tinker around the edges, they pursued a radical approach that set zero deaths as their goal. They implemented screening, proven principles and practices for the care of all chronic illnesses (including diabetes, heart disease and depression), immediate access to appointments, and continuous and robust quality improvement -- and after several years of progressive reductions in deaths they achieved and maintained 2 ½ years of zero deaths by suicide.
We next heard how Kaiser Permanente of Northern California, an HMO with over 3 million members and 20 medical centers, instituted a remarkable plan for primary care suicide prevention (i.e. in general medical services not mental health clinics). They introduced screening for depression, anxiety, substance abuse, and intimate partner violence, coupled that with treatment practices known to work, and scrutinized every suicide for what improvements could be made.
Finally, we heard how Magellan Health Services, a large national mental health managed care company, implemented suicide prevention in Arizona by focusing on those people whose risk for suicide was 6 - 12 times the general population, namely those people with a serious mental illness. They trained clinicians, standardized the provision of best practices, stressed community based care, and engaged families and those who survived an attempt; they have reduced deaths by 48 percent and inpatient admissions among their subscribers by 51 percent, indicating risk reduction as well as cost savings.
What was so notable from the presentations was that "suicide ... was just the tip of the iceberg," as the last speaker remarked. The vast problem below the surface, one that can be avoided, is not doing the right thing. We actually know what is right: setting very high standards (don't be afraid of perfection); systematically identifying people at risk; relentlessly providing proven methods of intervention; crossing boundaries between general medical and mental health care and staying with people when they move from one care setting to another (like from hospital to home); regularly assessing performance with measures that are as clear and understandable to patients and families as they are to clinicians; and zealously pursuing opportunities for improvement when problems appear, as they always do.
Deadly consequences happen, in effect, from suicide just like from heart disease, when we do not do the right thing as unfailingly as we can. Good medical care does not know the difference between illnesses. The same principles govern health care for every disease, physical and mental. Reducing rates of suicide is about improving health care. We will need to abide by these very same access and quality standards in order to manage the diseases that afflict our generation, especially those that derive from habit disorders and age, including diabetes, hypertension, asthma, obstructive lung diseases, Parkinson's and Alzheimer's disease, and the multiplicity of ails that derive from smoking, overeating, sedentary life styles and stress.
A colleague from the NYS Health Department, Dr. Foster Gesten, in the summing up at the end of the day suggested that strategies for saving lives could be "deep and wide." Deep are those that health care systems with accountability for identified individuals or populations could implement in NYS -- as we learned are going on in Michigan and Northern California (as well as the very notable work throughout Washington State). Wide are the practices known to work universally that are ready for prime time and wide application, like screening to identify high risk people, treatment care paths, open access to appointments, careful attention to transitions from one service site to another, informed and 'activated' patients and families, and health information technology that provides decision support and communicates essential information to those who need to know. Reducing death by suicide would be one of many fortunate outcomes from improving our health care system.
Achieving change in health care is very hard to do. It entails an unwavering ambition for excellence and zealous attention to details. I am reminded about something Michelangelo was reported to have said: "Trifles make for perfection, but perfection is no trifle."
*Last year, Federal Secretaries Sebelius (Health and Human Services) and Gates (Defense) launched the National Action Alliance for Suicide Prevention bringing together government and military officials, experts, people with mental illnesses, family members, foundations, and others to fashion a plan that would be more focused and successful than the efforts of the past decade. Commissioner Hogan and a number of those who attended the NYS symposium are members of the Action Alliance.
The opinions expressed here are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer's website at for questions you want answered, reviews, commentary and stories -
I attended a meeting last week at one of the foremost departments of psychiatry in the country, if not the world: the Columbia Physicians and Surgeons/Psychiatric Institute's department, led by the eminent Dr. Jeffrey Lieberman, a colleague and good friend (disclosure: Psychiatric Institute is a research facility of the New York State Office of Mental Health, where I am Medical Director). A series of workshops offered faculty members an opportunity to learn about innovative and emerging science in what causes psychiatric illnesses and how to diagnosis and treat them.
I went to one session on personalized medicine in psychiatry. In short, personalized medicine is about what treatments are more likely to work with which patients. In psychiatry, for example, reliably identifying clinical features or imaging (brain MRI) or EEG or other markers would tell doctors whether a particular medicine for depression will be more or less likely to work. We really need biomarkers to improve response rates and reduce time to response by selecting a medicine that is more likely to work. My field needs more to offer than it does today. Some of the best scientists in the world, from Columbia/PI as well as Harvard and other academic centers, are searching for answers.
Other sessions included work underway on genetic testing, novel treatments for schizophrenia, perinatal mental health, eating disorders and cultural and social issues in mental health.
I was struck by the amazing creativity of the researchers and clinicians and the promise that they hold for a future where psychiatrists and other medical and mental health professionals will be ever more able to understand the underlying genetic and nervous system mechanisms of psychiatric illness; to provide novel and effective treatments with fewer side effects (whether these be from medications, therapy and safe brain stimulation); and to improve our capabilities to match patient to treatment. But while knowledge is exploding, true advances are still to come. I thought, once again, that the greatest advances in the mental health of people with serious mental illnesses (like depression bipolar illness, PTSD, OCD, eating disorders and schizophrenia) in the next five years, maybe longer, will be from more effectively delivering proven mental health treatments to more people who can benefit from them. Sometimes called the "science to practice gap," I like to think of it as closing the gap between what we know and what we do.
Mental illnesses, even without their major role in physical illnesses, are highly prevalent: more than one in five people in this country annually will experience a mental disorder. That is tens of millions of people. Yet a disturbingly low 20 percent of the millions of people who need mental health care in this country are receiving it. That means four out of five people who might benefit are not! When mental disorders are not treated, they cause great individual and family suffering, because the pain of mental disorders is no less than that of physical illnesses -- though it can be less visible. The greatest tragedy is suicide, which can appear to a person to be a solution and an escape from unbearable mental pain and hopelessness, when in fact it is a permanent "solution" to a temporary problem. Suicide among our veterans bears testimony to this tragedy, with the death toll from suicide among Iraq and Afghanistan soldiers exceeding combat deaths.
The costs do not stop with human suffering: the economic cost of undetected and untreated mental disorders impacts our workplaces (through absenteeism, reduced productivity and disability) and adds extraordinary burden to our medical system, because people with chronic physical illnesses like heart disease, diabetes, high blood pressure, asthma and cancer commonly co-occur with depression and other treatable mental conditions -- which, unless properly treated, impair a person's ability to recover and manage their physical illness.
What do I mean when I say that health and mental health care are not doing enough of what we know works? For example, only half of people with depression who come to their primary care doctor have that condition detected, and of those, less than half receive treatment that follows recognized "care paths," or guidelines about how to best treat a condition. For example, in New York State, most people who turn to a mental health clinic for a serious mental condition do not stay for more than four visits, far too few visits to effectively improve their condition. For example, only a small fraction of people with an illness like bipolar disorder or schizophrenia receive comprehensive care, in an ongoing manner, where they are on medications, engaged in therapy, have family counseling and receive support to stay in or return to school or work.
Psychiatry has many treatments that work. In fact, its treatments rival those for chronic physical conditions in their effectiveness. But psychiatry's therapeutics only work if disorders are screened for and properly identified and then when patients come, stay in treatment and get proven (evidence-based) treatments. Efforts are underway -- but are too limited to date -- to reduce the barriers to effective care, which include stigma, insufficient knowledge dissemination (to doctors, patients and families), ambiguous standards for screening and treatment, too little attention to recognizing when care is not good enough and assisting programs with the quality improvement techniques that will change their provision of care for the better, and financing mechanisms that encourage doing the right thing, not just doing something, to name a few.
So, when I left my workshop, I thought that while there is great promise for the future, what we owe our patients and their families right now is improving the everyday practice of psychiatry. I promise to do my part to make that happen.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
For reviews, stories and questions you want answered, visit my website, www.askdrlloyd.com.
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Originally published in the Huffington Post on June 20, 2011
I am a psychiatrist who has treated patients for over 35 years, run all varieties of psychiatric services and worked in city and state government. But I still cannot bear to read or hear a story of a fatal outcome for a person with a serious mental illness who dies from neglect or some form of self-harm. I was especially distressed to read an article in The New Yorker (Rachel Aviv, May 30, 2011, Annals of Mental Health) called "God Knows Where I Am: What should happen when patients reject their diagnosis?" The article deeply troubled me because of the outcome for the person it profiled: Linda Bishop was found dead, presumably from starvation and hypothermia, in a home she had broken into in New Hampshire several months after she had a two-year psychiatric hospitalization. Her last journal notation was in January 2008, and her body was accidently discovered in May.
Neither Bishop's sister, a longtime advocate for her (who works in the justice system) whom a court years earlier declined to make Bishop's legal guardian, nor Bishop's daughter were informed of her condition during her extended stay in New Hampshire's state hospital -- nor were they told when she was discharged. Instead, a fantasy relationship that Bishop had for years in her head, with no contact with the man, was her plan for support, even marriage, upon leaving the hospital.
The story of Linda Bishop's multiple psychiatric hospitalizations, her misdemeanor (non-violent) offenses and time in jail, her abandonment of her teenage daughter, her assertion that she was not mentally ill and her refusal to follow any treatment plan, the lack of evidence that she could care for herself, and the self-imposed distance from her family was all too familiar to me and my colleagues working in public mental health, even if the details of her situation may vary in some ways from others. Recognized experts (and longtime colleagues) Drs. Tom Gutheil and Paul Appelbaum in 1979 (!) aptly called this type of tragedy "rotting with their rights on."
Our laws stipulate that Bishop had to consent to provide information to her family, which she did not. Privacy violations would have been the consequence of the hospital contacting her family during the hospital stay or at the time of discharge. Bishop's "right" to live where (and how) she wanted derives from legal rulings that stipulate a person's right to live in what is called "the least restrictive setting."
The letter of the law had been met. And the patient died.
Arguments have been made on the polar extremes of this dilemma. On one side are patient rights advocates who are stalwart about privacy and self-determination. In fact, legal organizations are present to defend these rights in state hospitals throughout this country. Considerable legal rulings now protect individuals from involuntary hospitalization and involuntary treatment by requiring court action to achieve both, with the exception of emergency situations. On the other side are advocates calling for increasing commitments of people with serious mental illness, including outpatient commitment (and requiring that those committed take psychiatric medications for their disorders), and longer hospital stays.
Never having been one for extremes, except maybe when it came to my playing sports, I believe there are viable middle grounds -- even if difficult to reach.
For example, nine years ago the first Mental Health Court was established in New York City, under the remarkable (and continued) leadership of Judge Matthew D'Emic. There are now seven such courts in NYC, about 25 in New York State and approximately 200 around the country (not counting drug and domestic violence courts). A mental health court accepts referrals from other courts where there appears to be a mental illness complicating the crime. Court mental health specialists evaluate the person for a mental illness, and if present, the defendant can plead guilty (in New York State) and be "sentenced" to court ordered treatment under the supervision of the judge; other states may divert the person from jail, have charges held in abeyance pending completion of the treatment program, or other procedures according to local statute. This form of supervised treatment is typically for a year (the maximum sentence for a misdemeanor). More recently, there are mental health courts working with felons where the court ordered treatment can go on for years.
For example, outpatient commitment already exists in almost every state (this has been the case in New York State for over 10 years, instituted after Kendra Webdale was pushed before an oncoming subway train by a man with a psychotic illness). The law, Kendra's Law, has been renewed twice, each time for five years. We don't need more outpatient commitment (though some state statutes warrant updating); we need more outpatient treatment that works.
Which brings me to my main point: outpatient mental health services in this country don't work very well, despite the dedicated people who work for them. The result is that early intervention and the provision of comprehensive, continuous, proven (evidence-based) treatments is being delivered to less than 20 percent (!) of people who need it. That means more than four out of five people are not getting what they need for their illness and recovery. Lack of good care coupled with lack of housing are the principal drivers for the clinical deterioration, chronic homelessness, use of jails and prisons as institutions to contain people with mental disorders, and suicidal and violent behaviors among those who are mentally ill. This country is in need of a mental health overhaul, as candidly portrayed in the President's New Freedom Commission on Mental Health (December 2002; disclosure: the Commission's chair was Michael Hogan, Ph.D., now Mental Health Commissioner for the state of New York, and my boss).
Mental health has treatments that work. It has mission-oriented professionhttp://askdrlloyd.com/als and provider organizations. But it lacks organization, accountability and financing that pays for what is accomplished rather than what is simply done. Sounds familiar? That's because mental health care is part of health care, where the same issues apply in capital letters.
As this country grinds its way to a more responsive, and hopefully affordable, health care system, what can be done now? For one, mental health clinics can be held to specific standards of care and their licenses made dependent on delivering those standards. Measurement-based care can be introduced (and required) where improvement from mental illness is tracked just like we track blood pressure, blood sugar and lipids. Incremental financing reforms can better support evidence-based practices as well as outreach and engagement of those hardest to reach and retain in care. People in recovery from mental illness (called peers or consumers) can be made a part of the public mental health system so they serve as navigators and trusted persons for those wary of mental health care. And no one stands a decent chance of getting better from a serious mental illness without safe and reliable housing with access to quality health and mental health services.
Indifference is cruel and costly. We can make a difference. People can have their rights and their lives -- and their families, too. That's what health care, including mental health care, is really all about.
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
I receive no support from any pharmaceutical or device company.
For reviews, stories and questions you want answered, visit my website, www.askdrlloyd.com.
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Originally published in the Huffington Post on June 7, 2011
References:
Appelbaum PS, Gutheil TG: Rotting with their rights on: constitutional theory and clinical reality in drug refusal by psychiatric patients. Bulletin of the American Academy of Psychiatry and the Law 1979; 7:308 317
