A Tragic Mistake

Written 03.04.08

Am I too naive to think that the principal aim of a hospital should be to help its patients? Well, apparently I am, because during the last two years that I have been working at one of the nation’s top psychiatric hospitals, I’ve seen very few examples that would back up this idea. The overwhelming majority of people and procedures employed by the psych hospital have very different objectives, ranging from maximizing the profit to minimizing the effort, and culminating in an all-consuming urge to cover one’s ass. Among the people who genuinely tried to struggle with the system and help the patients, during these two years some have been fired, and some have “gotten used to it”, but no one lasted long. As a matter of fact, I am fairly close to losing my job right now, after an argument with a charge nurse yesterday, during which she tried to din into me that the most important thing for her was not to lose her license. Not that I cared too much, because I had already given the termination notice anyway.

Too many people assume uncritically that if they go to a psychiatric hospital they will get help; even more believe that their children/parents/spouses will be helped if they send them there. This is what all the propaganda is about. But it is a lie. A mental hospital in this day and age is not an institution of help - it is an institution of confinement, much like a jail. It is a place in which kept are people who have not committed a crime but have nonetheless made their relatives or friends very uncomfortable with their being around. This point is so obvious that it doesn’t even need to be proved; just look at all the door locks and security guards in any mental hospital. If this institution was helpful, people would want to be there, and none of this would be needed.

Really, think about all the homeless people, all the battered spouses, all the terrified youngsters going through a psychotic episode, all the misunderstood children and suicidal adults longing for understanding or at least for a pacific place to curl up in the corner and sleep it over. Think about everyone who needs to get away from their environment for a while. If the proclamations of the psychiatric industry had some truth in them, if there really existed a place where they could relax and get help, those people would line up to get into this kind of institution! Obviously, a psychiatric hospital is not such a place, because most of the patients hate it there and struggle to break out. Until, of course, they lose their life drive and become dependent on the system.

Now, this is of course not to imply that the mental hospitals are completely worthless. There are people, and many, out there who are either morbidly stupid or completely out of their minds. They cannot survive in a demanding environment of a today’s city and therefore need to be confined and cared for. But to assume that the same mental hospital is a helpful place for all the able people just going through a difficult time, is a tragic mistake.

People who send their relatives to a psychiatric hospital never find out what actually happens there. Parents are told all kinds of stories about how helpful the place is and how much therapy their children receive. They don’t know that the therapy is heartless and superficial, or that the place is extremely boring and unfriendly. They never see their kids crying and begging a nurse for a breath of fresh air after being indoors for days and weeks, or being dragged to their room on the floor by uncaring strangers. They never observe their kids’ free spirit being broken into submission; if they did, they would not forgive themselves.

If there is only one thing to be remembered out of this whole journal, it is this. Please, don’t put your children and loved ones in a psychiatric hospital for help. Put them there because you want to confine them, get rid of them, forget about them! Put them there because you don’t care, or because you hate them - but not because you love them. Don’t fool yourself thinking that you are doing them good. Because nothing can be farther from the truth.

Mania and Depression

It surprises me that the official psychiatry makes a philosophical distinction between the states of mania and depression, while it is quite obvious to me that the two are one and the same. That is to say, the similarity between them is wide and profound, while the apparent difference is only a superficial nuance.

Let us consider a traffic light as an example. When it is red, it is very different from when it is green. But think about all the forces in background that are responsible for the traffic light operation. The power plant that provides electricity, the cables that conduct it, the engineering of the light bulb, the physics of light and the physiology of vision, as well as the philosophy of the city traffic and its regulation - all are absolutely the same in both states, and what is different is only the position of a small relay on the very surface of the process.

In exactly the same way, both mania and depression stem from one common background force, and the difference is only in the way a person reacts to it. When a big black cloud starts to cover the sky and nothing seems to matter anymore, some people succumb to it and halt all activity; others choose to run away from it in denial, putting on a tremendous buffoonery of omnipotence and invulnerability. Sooner or later they are exhausted and the cloud gets them.

That is why there is depression without mania, but there is never mania without depression. That is why the symptomatic treatment of both is bound to be inefficient. What we have to deal with is the black cloud. And to deal with our patients’, we first have to come to terms with our own…

Best quote from AMIA-2008

"It doesn't mean that our systems are bad, it is just that the combination of systems and practice doesn't work."

No comments.

Defying the Statistics

- What is the chance that you meet a dragon on the street?
- Fifty per cent.
- ???
- Well, either I meet him, or I don't!
A joke

Statistics plays a large part in psychiatry, as in the rest of medicine, because it helps clinicians to make decisions about what is likely to be beneficial or harmful to their patients. Most of the guidelines for physicians are based on the statistically significant conclusions from the clinical trials. The argument goes like this: It has been found that, say 70% of the patients with a certain diagnosis and a particular set of other characteristics (age, race, height, weight, etc.) get better on a medication. Therefore, if you have a patient Ivan Johnson who fits all these characteristics, his chance of benefiting from this medication is seventy per cent, which means he should take it.

Here at the American Medical Informatics Association conference I constantly witness conclusions like this being drawn. They have become basis of medical expert systems and much of medical informatics in general. Yet, I am going to show with one simple example, that this logic is erroneous. It is a case of scientific confusion between the probability of an event observed in many previous experiments, and the ability to correctly predict the result of one next experiment.

Let's not go as far as medical predictions. Let us take the simplest model of probability - a tossed coin. The probability of the heads is 50% - everybody knows that. Indeed, if we toss a coin a billion times, we will probably observe the heads in something very close to 50% of the cases. But that is all it means! You can't go any further in your conclusions! In your ability to predict what the coin will fall next, in your one-billion-and-first experiment, you are as helpless as you were when you'd thrown it for the first time. You simply don't know what it will be - all you can say is that it will be either one or the other.

It is not because the probability is 50% that you don't know. Take an experiment with the chance of outcome A being 90% and the outcome B being 10%. What is the probability of the outcome A in the next experiment? Nine out of ten, very well. But what outcome will the next experiment have? You can't ask this. You don't know. It will be either one or the other.

So what does this nuance mean for the system of psychiatry and health care in general? Not much, because the system operates on statistics, it deals with patients en masse, and therefore the results of multiple experiments correlate well with the predictions based on probability. But it means the world for an individual patient; for you and me.

Even if we forget for a minute that the experiments in which the probability is calculated were not actually done on you and me, but on some other people; even if we forget that the medical outcomes are not binary but multidimensional and unpredictable by their very nature - even then predicting an outcome for a particular patient will be impossible because of the effect I've just described. If 99.99% of the patients like you die in a month without an operation, it doesn't mean that you will also die in a month. The probability of it is high; whether it happens is not known.

I admit of course that with a chance like that you might want to strongly consider the operation; I would probably do the same. However, the majority of psychiatric statistics operates with numbers quite remote from the extremes. People talk about reducing risks from twenty-five to fifteen per cent, of improving the outcome in sixty per cent of the patients versus forty. For the hospital and the insurance company these numbers are big business; for you and me, they are simply meaningless.

Ads removed

I decided to remove the ads from this blog. Due to their contextual nature, they were mostly about promoting various psychiatrists' services, which created a sort of irony that I tolerated for a while. But then it's ridiculous after all.

Now I can proudly say that I have no financial interests whatsoever in discussing my views about psychiatry. :) If you like this blog, however, please donate a comment or two.

Psychiatry needs a user's manual

Psychiatry may be a nice tool, but only if you know how to use it, and whether it is the right tool for your tasks. Unfortunately, modern psychiatry is usually sold to the customers without a user's manual; the patients have to figure everything out by themselves.

As with any powerful tool, such approach is bound to be dangerous. Many a patient have suffered a great deal from psychiatric enterprise, only because they didn't know what to expect from it. Everybody knows how to behave if you're stopped by the police, but very few people seem to have any idea what they ought to do in a psychiatrist's office or a mental hospital.

Will the gene of schizophrenia help you?

So why am I not being too enthusiastic about psychiatric genetics? Why am I not excited by the prospect of uncovering the genetic basis of mental disorders, despite the proponents' claims that it should make diagnosis more reliable and eventually provide avenues for effective treatment?

Because these promises do not sound realistic to me. I have to admit that the question of psychiatric genetics is very interesting academically, and it is also readily funded by both drug companies seeking profit and the government seeking some kind of solution to the overwhelming quantities of mentally disturbed citizens. Still, I find it difficult to buy that genetic advances will benefit the real-world patients, and here is why.

First of all, the genetics of mental disorders is subtle and multifactorial. Therefore, even if some genetic predisposition could be statistically proven, in any concrete individual the environment plays a dominant role in determining whether the disorder will appear. In other words, regardless of whether a particular person possesses the wrong genes or not, his being sick or normal will largely depend on his life situation (which is exactly what we've known for a hundred years).

Let's take an example from oncology. There is a gene called BRCA1 that, if mutant, has been recognized as carrying much higher risk of breast cancer development. Now, in oncology the diagnosis can be made much more accurately than in psychiatry; the genetic association with BRCA1 gene is also simple and straightforward. Nonetheless, oncologists do not usually make predictions about any particular patient; even though the risk may be significantly increased, we still cannot say to the carrier or the mutant gene: "You will have breast cancer", or to the carrier of the normal gene: "You're cool, go home."

Whatever gene associations are found in mental disorders, they will not be enough to make predictions, because the environment plays a major role in the fate of any organism. Hence, we can only afford hunting for genes after we've done everything possible to fix the environment. Talking genetics when there are major problems in people's psychological well-being (look around!) is like cleaning the carburetor when the car's wheels are missing. It could help, but it's not the biggest concern right now.

The second reason why genetics is unlikely to benefit the patients is that psychiatry has a tendency of rushing things into practice as soon as they are discovered (if it can be profitable, of course). It is theoretically possible that genetic discoveries will lead to the creation of the effective treatment for psychiatric disorders, but most likely this simply won't have time to happen. What will happen much sooner is that some type of genetic analysis will be implemented, and people who are at risk will be recommended to take the medications preventively.

This will be catastrophic, because the drugs can make a healthy person sick; so there will be no way of disproving that they were really needed. This will reinforce the sense of scientific correctness, and promote further treatment and propaganda efforts, supported by the drug manufacturers. The tradition of giving drugs to healthy people, mandatory genetic testing of children and adults, and the arising legal battles will change the whole landscape of psychiatry into something entirely different from what we know today.

In the resulting confusion the original goal of the genetic research (to develop treatment) will be postponed, as scientists of the day will concentrate on getting out of the current crisis. And everything will repeat again - only the counter of the innocent victims of psychiatric help will advance by a few tens of millions... but who counts them?