Monthly Archives: July 2017

Ignorance and Depravity Goes to Washington

By Marvin Ross

Every week I think it can’t get any worse and it does. I’m talking about our southern neighbours of course. Just how low can it go? Well, it seems that there is no bottom to the ignorance and depravity of the Trump administration.

First, we have the attacks against the transgender community. If people are law abiding and civil, what they are or what they do is their business. And do normal, sensible people really care where others pee? I remember being in a hotel in the 1960’s in some small community in Guatemala. Down the hall were two doors – one marked damas and the other caballeros. They both lead into the same large room with cubicles and basins lining either side of the room. That would likely cause a stroke in South (or is it North) Carolina in 2017.

But then, to top off that bit of idiocy, we have the new communications director for the White House who has no idea how to communicate suggesting that another official is a fu@@@ paranoid schizophrenic. Words fail me at this total display of ignorance, indecency and lack of civility.

I’ve just finished reading White Trash The 400 Year Untold History of Class in America and I have to say that the author got it wrong. White trash extends into the White House.

Like most Canadians, I have friends and relatives in the US and they are intelligent decent people with whom, mostly, I share similar values. But those sensible, decent, civil people need to stand up and do whatever they can to get their country back and to help it move into the 21st Century. And lest we forget, that includes health care for your citizens. No one in civilized society anywhere can fathom how you can argue about the need to provide citizens with health.

Before you suggest that no one should throw stones, let me explain that other countries have grown. Racism and incivility exists everywhere and probably always will but most countries have gone beyond that being the norm and deal with it when it occurs. Canada’s record with Indigenous people is not very impressive but efforts are being made. The overt racism towards others and homophobia is no longer the norm. Just look at the minorities in the current Canadian cabinet or the Sikh with a full beard and turban running for the leadership of a national political party.

In Hamilton,  posters promoting Fringe Festival plays  about feminist and LGBQT topics were defaced with biblical anti-feminist and anti-gay graffiti. That was denounced in social media and by civic officials and festival officials have put rainbow coloured stickers over the graffiti saying “All for love. And love for all”.

I lived in England for a year during the Enoch Powell era when racism and anti-immigrant sentiment was very strong. Today, I marvel at the English cultural mosaic that is reflected in British TV mysteries and the BBC News. The vote for Brexit may have been a bit of a setback but gone are the days when BBC newsreaders and journalists had to be white and all talked with that upper class Oxbridge accent. Not anymore.

Countries evolve and also regress as liberal Germany did in the rise of Hitler. It is time for the decent Americans I know to actively work to take back their country and to evolve. I’m waiting for US organizations like NAMI, Mental Health America and others to speak up and and denounce the obscene insult to people with mental illness and  hopefully, they will by the time this gets released on Monday. I am writing it on Friday.

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The Ministry of Silly Walks

By Dr David Laing Dawson

We are living within a Monty Python skit. I must try returning my dead parrot to a Pet store and see what happens.

The American Congress has just granted Charlie Gard and his parents resident status in the U.S. so that Charlie can “receive the first rate American Medical care that he needs”.

This is the same Congress trying to repeal and replace Obamacare with a plan that would eventually deny health care for 30 million Americans, many of them children.

Polio is making a comeback. Measles is making a comeback, thanks to the antivaxers. Cholera is sweeping through Yemen.

Today, a child with cystic fibrosis in Canada will live, on average, ten more years than the same child in the United States.

A doctor from the U.S. flew to England to examine Charlie. The money spent to fly him there and back could feed 10 starving children in the Sudan for a year if he flew economy, perhaps 5 years if he flew first class. Or bottles of clean salty water and a dose or two of tetracycline for thousands of cholera victims.

This doctor, who has been experimenting on rats, would like to try his therapy on a human. He guesses at a 10% chance of “some improvement”.

With the goal being “some improvement” and the odds only 10%, most placebos do better. And I am not sure what “some improvement” looks like with an infant who cannot breathe or eat on his own, has brain damage at the structural and cellular level, and is dying from an incurable progressive genetic disease involving the mitochondria, one of those essential bits in every cell.

As with much of American culture and politics, I guess this isn’t about health care, saving and improving lives, treating illness, preventing disability. It is about money, self-aggrandizement, career, and celebrity.

In another real life skit NASA has had to officially deny that it is running a child slave camp on Mars. Or was that a child sex slave camp?

And in an open hearing a Republican Congressman asks “if Mars was different thousands of years ago, could there have been a civilization on Mars?” The scientist on the panel tells him Mars was different billions of years ago, but there is no evidence of any civilization ever existing on Mars.

The chairman thanks the congressman and says, “Looking forward to finding what’s up there, for sure.”

This last statement is interesting. Besides the notion that Mars is “up there”, this chairman doesn’t seem to know that with probes, orbiting satellites, and rovers, we have been receiving information about Mars for over 40 years.

Donald Trump thinks the “biggest crowd that ever gathered around the Eiffel Tower” came to see him dine, shortly after he made the “best speech any president has ever made on foreign soil.”

Ground Control to Major Tom.

More on Families, Privacy And Suicide

By Dr David Laing Dawson

Much of psychiatry is about convincing people to do things that will improve their mood, their health, and their lives. Exercise, better diet, overcoming fears, taking necessary medication, stop taking harmful substances, go to bed earlier, turn off electronics, find balance in your life, join something to overcome loneliness, stop procrastinating, call a relative, tell your husband, plan your day, stop worrying about things you cannot control, take baby steps, take medication regularly as prescribed, go for blood tests, enjoy small pleasures, scream at someone rather than cut yourself….

It is not in the DSM V (I think) but we know “no man is an island”. We are social beings. Maybe not to the extent of bees and ants, but no less than chimpanzees. We are never fully independent life forms. Even a hermit has a relationship (albeit a distorted and contrary one) with the community and family he or she is rejecting.

We also know that the quick impulse to say to the doctor, “Don’t tell my family.” or “I don’t want my family involved.” is often derived from shame, guilt, a sense of failure, and sometimes the opposite, a genuine wish to not burden the other. This is further complicated in the teen and youth years by an ongoing negotiation with respect to power, control, individuation, responsibility. We also know in these years the adolescent often says, in the same breath, “I hate you. Give me a hug.” “Get out of my life. Drive me to the mall.” “Don’t tell my dad. Please tell my dad so he can protect me.”

And we also know that persons suffering from severe anxiety and depression develop a sort of tunnel vision that excludes broad levels of social awareness and understanding. “Leave me alone.” And people suffering from a psychotic illness often harbour delusions about family members. “She’s controlling me.”

So, absolutely, when the young person says, “Don’t involve my family.” professionals should explore this, and then convince the patient otherwise unless there is good evidence that keeping the family (parents, sibs) away will be ultimately better for this patient.

Families, Privacy and Hospital Suicides

By Marvin Ross

One of the constant themes in my writing of mental illness is the need to involve the family. And so, when I read a lengthy account of the suicide of a young 20 year old girl that appeared in my local paper, what jumped out at me was that she had requested that her family not be involved with her illness or treatment. She wanted to spare the family grief and, it seems that the doctors went along with her.

The young girl had a number of suicide attempts while in hospital and the family was told none of it. Dr Peter Cook, one of the psychiatrists, told the newspaper that “We were obligated to protect the privacy of Nicole. She was an adult.” The other shrink said that confidentiality between patient and doctor is “sacrosanct.” Nicole did not want to share her medical information with her family.

Sadly, this young lady is not the only suicide in the past little while at this hospital. There have been 9 – 3 in hospital, 2 of patients on leave and 4 outpatients. To its credit, the hospital did commission an external review to see if things could be improved. One of the recommendations was for “closer collaboration with families.”

Now, maybe the outcome would not have been different if the family was involved but we don’t know that. And, the privacy legislation is pretty confining but there are ways to get around them if the medical staff really care. The hospital recently established a family resource centre as the result of a donation from a philanthropist friend of mine. It was difficult to get them to accept the gift but they did and it is being used and it is being well publicized to families.

At the time we were negotiating for a family resource centre at the hospital, I wrote an op ed for the local paper on the need that families have for inclusion with staff when their loved ones are being treated. Aside from pointing out the anger that families have towards being ignored, I mentioned the very sensible guidelines that were produced by the Mental Health Commission of Canada for family caregiver inclusion. And I mentioned this:

“Very few, if any, mental health facilities have adopted these recommendations despite the fact that about 70 per cent of those with serious mental illness live with their families according to the Mood Disorders study. And family caregivers spend 27 hours a week caring for their ill relative according to the EUFAMI survey. That is five hours longer than the average in other countries surveyed by EUFAMI.”

I don’t know if St Joes ever did adopt these recommendations and I do know that the Privacy Act is very restrictive. But, with a little effort, it can be sidestepped as I pointed out in a Huffington Post Blog.

I was basing what I had to say on an excellent paper on the topic that had recently been published by Dr. Richard O’Reilly, a professor of psychiatry, Dr. John Gray, an adjunct professor of psychiatry along with J. Jung, a student in the Faculty of Health Science at Western University.

I said this in my post:

They point out that clinicians often don’t even bother to ask their patients if they have permission to involve family.

If they do and the patient refuses, then they should take the time to explore the reasons for this refusal. Many patients don’t understand why it is important and do agree to allow their families information once it is explained to them. In some cases, there is some information they do not want shared (like sexual activity and/or drug use) and the staff can ensure that this information is not shared. Staff can also inform families of pertinent facts in meetings with the patient present. This often allays patient fears and is similar to the approach recommended in the UK and by the Mental Health Commission of Canada.

In those cases where no consent is given, the staff can give general information to the families and receive vital information from the family. The family can tell the doctors about new emerging symptoms, worsening of symptoms and medication side effects, all of which should be crucial information.

Until such time as political jurisdictions reform the privacy legislation, mental health staff can do far more to open the channels of communication with families for the betterment of their patients. It is time they do so.

I was pleasantly surprised that at a meeting with St Joes staff just after this was published, one of them told me that this blog was being read by staff and was being circulated within the hospital.

It seems that not sufficient attention may have been paid to that. I hope that more attention is paid to involving families so that these tragic events can be minimized going forward.

Drip, Drip, Splash.

By Dr David Laing Dawson

First Stephen Bannon and now Rob Goldstone. Both men obviously eat badly and bathe less often than desirable. I’m sure neither man picks up after himself. Goldstone may have been the image in Donald Trump’s mind when he said that the hacker could have been a 400 pound man in his mother’s basement. (Though in his actual statement Trump managed to attach the “400 pound” description to the bed upon which the man sat.)

Again I’m glued to CNN listening to the panels dissect the latest revelations, this time of Donald Trump Jr. and his meeting with a Russian Operative. And I know, looking at Don Jr., that if he were to emerge from the sales office on a Used Car Lot, I would take my business elsewhere.

I also think of the Kardashians, another name I cannot avoid, but about whom I need not waste a second of my time. I don’t need to watch them, read about them, think about them, despite their mastery of the celebrity game.

And Kanye West. Despite his crew’s mastery of Google algorithms, I can avoid reading, watching, or listening to him.

If only that were true of the Trumps. It should be. It should be.

Many politicians have lapses. The business of government can become corrupt. But it should always be serious. There should be some line between serious matters of democracy, of governance, of justice,  and the frivolous, infantile, adolescent high jinks of pleasure and titillation of Reality TV.

That line has frayed.

The impresario with no boundaries, a man who can’t tell the difference between using others and being used, emails Don Junior to tell him he can set up a meeting with a representative of the Russian Government who has dirt on Hilary Clinton. Don Jr., just as one might remark on a Facebook cat video, writes, “I love it.”

I can hear Putin saying, “Wow, that was easier than I thought it’d be. Make sure you get some video.”

Democracy can be slow, clumsy, frustrating, inept, but it is so much better than any other form of government. We have been told we need to be vigilant. We have been told we need to participate. We have been told how important the institutions of democracy are despite periodic scandals perpetrated by flawed men and women.

But it looks like we need to be told the operations of a democracy are serious. This is not reality TV. This is not Miss Universe promotion. This is not the bullshit and bafflegab of the entertainment industry. This is serious business, and it will affect the lives of my grandchildren.

Whatever their ideologies, from the freedom caucus to libertarian to liberal to socialism, it is time for American politicians to at least take their responsibilities seriously.

Now let me tell you what I think really happened one morning in the Kremlin a year or so ago:

“Vladimir, we have hacked the DNC server. We have many, many emails embarrassing to the Clinton campaign. Should we give them to Donald?”

“Nyet. He is stupid. He would boast about having them. Besides, we just give them to him what does that get us? Nothing. No. This is what we do. Find an intermediary to set up a meeting. Tell them we have dirt on Clinton and we want to share. This must be written. Go through Emin and that producer, Goldstone.”

“Who should they contact, my president?”

“Someone dumb enough to come to such a meeting. Donald Junior maybe, Manafort, Kushner, yes?”

“And when they come to the meeting we give them the emails?”

“No. No. That’s the beauty part. We get them to the meeting and record it but we don’t give them the emails. So then they’re compromised but we still have the emails and we can decide when or if to release them.”

“Mr. Putin, you are a genius.”

“I know. I know. Would you like to feel my bicep?”

More on ECT and Other Treatments

By Dr David Laing Dawson

Throughout medical history, every treatment that actually works becomes overused.

Examples today include treatment for high blood pressure, statins, mastectomies, arthroscopies, opioids for pain, antibiotics, aspirin…..

When a treatment is found to work, the criteria for use informally expands until large studies find this to be either detrimental or unhelpful and then the practice shrinks. The current opioid crisis is a good example. The struggle to control the overuse of antibiotics is another.

ECT was first used in 1938 and found to be dramatically effective for patients with very severe depression, intractable mania, and some forms of psychosis. This at a time when there were no other explicitly effective treatments. This at a time when most of these cases were thought hopeless and all other treatments constituted a mix of hocus pocus and wishful thinking.  The very first patient to receive ECT was a man found by police wandering in the Rome train station muttering gibberish to himself. After this first rather unrefined ECT treatment the patient was discharged from hospital fully oriented and talking sensibly.

ECT was also introduced at a time when depression could reach a point of severity to justify the adjectives “stuporous”, “vegetative”, “retarded”. People died in this state from the consequences of malnutrition, starvation, unrecognized infections, and all the problems associated with total immobility. For this subset of severe depression ECT is a miraculous and dramatic (sometimes temporary) cure. It similarly had stunning results with intractable mania and catatonia, and pretty good results with something called “agitated depression”.

Hemingway was hospitalized with a form of psychotic depression (severe depression with agitation and some paranoia), was treated with ECT and returned home to work. For eight months or more he wrote at his standup desk somewhat unsuccessfully, drank too much, relapsed, and was readmitted to hospital. This time he talked his way into being discharged without treatment. And then he killed himself.

Through the 40’s, 50’s, and 60’s ECT became overused, both excessively used for single intractable cases, and used to “treat” many problems that simply don’t respond to ECT. Then our new drugs began to replace ECT, attitudes changed, One Flew Over the Cuckoos Nest hit the big screen, and, perhaps more significantly, with our new drug treatments, very few people got to the late stage of depression and psychosis we called, “stuporous”, “vegetative”, “retarded”, “agitated” and “catatonic”.

Over the years I have received heart felt thanks from a few people for whom I recommended ECT.

And it seems clear to me that all or most of those people who complain of the barbarity and after-effects of ECT are victims of that overuse mentioned above.

There are many human conditions for which ECT is not helpful, but, in some of those cases, once used, ECT becomes the perceived cause of all succeeding problems.

In reality ECT remains a very safe and effective treatment for serious depressive illness. Today it is mostly used when trials of medication have failed. Curiously, though pilloried and thought to be barbaric by some, ECT is actually one of most dramatically effective and safe treatments in all of medicine.

On ECT and The Variability of Bodily Experience

By Marvin Ross

ECT or shock therapy has to be the most contentious treatment in all of medicine, in part, due to its depiction in films which is highly negative. My initial view of it was coloured by my favourite aunt when I was a kid. She had what in those days (1950s or 1960s) was a nervous breakdown. Her husband had died and then her brother (my father) died suddenly of a heart attack.

One of her symptoms was unusual pains in her chest and back for which no organic cause could be found so her physician nephew had her admitted to a private sanitarium rather than the infamous Toronto Hospital for the Insane at 999 Queen St W ( actually the Ontario Hospital and now the Center for Addiction and Mental Health). She underwent a series of ECT treatments and was eventually discharged.

After discharge, she confessed to me that after each treatment, the staff asked her how she felt and if she was still experiencing the pains. She told me that if she said yes, she got more shocks so she told them she was fine, the pain had gone away and she was discharged. But, she told me, she still had the pains. I can’t recall how long after but she died of a stroke. I’ve always wondered if they had missed atherosclerosis as diagnostic skills were quite primitive in those days as was treatment for heart and stroke compared to today.

Fast forward to the late 1990s and I was a regular visitor to the psych unit at our local hospital. One of the patients was a young mother with schizophrenia who, I was told, attempted to kill herself and her young children. She was getting ECT. A few months later, I was picking up a coffee at the hospital snack bar when an attractive woman said hello to me.

“You don’t recognize me, do you” she said.

“I’m so and so and this is the new me post ECT. I was discharged, I feel really well and I’m here for an outpatient visit with my psychiatrist”

Psychiatric Times just ran an interview with the author of a new book called Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy by Jonathan Sadowsky, PhD. The one question he was asked that I found very interesting was this:

“Patients have both attested to damage it has done and expressed gratitude for the relief and hope it can provide.” How do you explain this seemingly paradoxical disparity in the experiences and opinions of patients?

The answer was what I have tried to say about medical treatments and recovery in schizophrenia in general but not as elegantly as this author. This is what he had to say:

“The human body is not a mass-produced machine, where given inputs such as therapies produce automatic and predictable results. Most clinicians and lay people know this but often act as if they don’t. One result of this mechanistic conception is resistance to the variability of bodily experience. But this variability is easy to show.”

And so, some people do well and others do not just as some drugs work well for some people and in others not only don’t work but have horrific side effects. We are all different and good clinicians have to recognize (and do) that trial and error is required to find the correct treatment for any given individual.

In a recently released study out of the Karolinska Institute in Sweden, it was found that there is considerable variability in the efficacy of anti-psychotics to prevent relapses in patients with schizophrenia. This study involved 29,823 patients aged 16 to 64 years with a median follow-up of 6.9 years. It was also a naturalistic study where each patient served as his/her own control to avoid selection bias. Long-term injectable antipsychotics, paliperidone and zuclopenthixol and the oral clozapine had the lowest risk of rehospitalization.

Going back to ECT, another recent study found that remission rates for patients with severe mood disorder are lower among those who have had ECT as inpatients. Earlier studies had shown that ECT leads to better remission rates in people with major depressive disorder and results in reduced mortality.

The bottom line is that despite the bad press that ECT and other treatments may have in the media or among the general population, many will experience positive outcomes. Keep an open mind.

“Is Donald Trump Human?”

By Dr David Laing Dawson

Men in Black, from 1997, with Will Smith and Tommy Lee Jones, is full of good moments. The particular moment that came to mind, for reasons that will become apparent, follows the recruitment of Will Smith to the very small and select team. Tommy Lee is showing Will Smith the ropes. He suggests they “check the hot sheets”. They stop by a News Stand to pick up a couple of tabloids, each with a lurid headline.

“These are the hot sheets?” asks Will.

“Best reporting on the planet,” says Tommy. “Go ahead, read the New York Times if you want. They get lucky sometimes.”

Smith spells out the gag: “I believe you are looking for tips in the supermarket tabloids.”

Their headlines include: “Pope a Father”, “Top Doctors baffled, Baby Pregnant”, “Man Eats Own House” and “Alien Stole My Husband’s Skin.”

The scene is played straight.

It is a very funny moment, I thought.

And I have always assumed that anyone reading these yellow sheets is engaging in a guilty pleasure. They are titillating themselves with implausible stories. Today those titles would be called ‘click bait’.

The publishers of these magazines, when they deal with celebrities, are marketing to our schadenfreude. Ah, how we enjoy reading that the lives of the rich and privileged may be as fraught with conflict and unhappiness, sin and regret, as our own.

But we know that when the story is not an outright lie, a gross exaggeration or invasion of privacy, it is still merely trivial. At least I thought we all understood that.

Hence the entire audience in the theater watching Men in Black got the joke.

But not, apparently, Donald Trump.

It is very distressing to learn that he and the publisher of The National Enquirer are good friends who influence one another. And that this publisher is thinking of buying Time Magazine.

There is a strange slippage afoot. I’m not sure whether we should be boning up on George Orwell or Lewis Carroll.

And I notice another thing entirely by accident. These Men in Black, American enforcement officers for true aliens, extraterrestrial aliens, of all shapes and sizes, some cute, some grotesque, some “legal” and some “illegal”, treat these aliens with much more decency and respect than Donald Trump and ICE treat human “aliens.”

Racism

By Dr David Laing Dawson

At least three times per week every week, between editorials in my local paper and the CBC I am made to feel guilty about any vestiges of prejudice I might have, or even my ancestors might have had, toward people of a different race. I often get to the point where I mutter, “Enough already”.

A fan of Star Trek has a vanity license plate with a form of “Assimilate” on it, the demand of The Borg. Someone objects for it is reminiscent of an attitude some of my ancestors had toward First Nations People. But we all know it is more complicated than that. To begin with The Borg are (or is) villain(s) in that Sci Fi series. And, despite the sense of loss felt by several generations, we all assimilate eventually, while retaining some ceremonial cultural practices and artifacts.

But perhaps we need to be scolded three times per week. For deep within the current political theater in the USA lurks the unmistakable venom of racism. Even the rush to a new health care bill is quite obviously being driven more by a wish to remove “The Stain” of having had a black president than any fervently held ideological position or humanitarian hope. It is there in the language used. It is there in the faces of the proponents of “Repeal and Replace”.

It is there in the stroke of Trump’s pen and the triumphant faces behind him when he signs off on orders to stop anything Obama started, no matter how innocuous, or, for that matter, no matter how obviously good it was. It is there in the tendency to excoriate anything achieved during the eight years Barack Obama was president. It is there in the ignoring of Sally Yates’ wise counsel. It is there in the attitude toward Sanctuary cities and Urban police. It is there in the sea of old white male faces standing behind Trump in the Oval Office. It is there in the soft and reluctant criticism of white supremacist groups. It is there in the activities of ICE.

When Trump claims the world “was laughing at us” this is code for “the world was laughing at us because we elected a black president.”

So, despite my first paragraph, despite my occasional irritation with excess political correctness, keep scolding us please, keep reminding us. It looks like we all need this if we are not to willfully or accidentally step on that slippery slope back to tribalism and contempt for those unlike ourselves.