Treating Social Ills to Improve Mental Illness a Mad Idea Pushed by Mad in America

By Dr. David Laing Dawson

Of course there are social determinants of mental health, just as there are social determinants for all health, happiness, longevity, and the outcome of all illnesses. This is not news. And those social determinants can be as individual and commonplace as loss of a parent or sib, some bullying, a bad marriage, divorce, assault, job loss, car accident with injury, failure at a task or ambition, and as broad and culturally and politically and economically determined as poverty, poor or absent housing, poor or absent medical care, poor or absent education, poor or absent employment, and, of course, war and discrimination.

The biopsychosocial model has been touted in Psychiatry for a century now, though I have often thought it should be the biosociopsycho model. For when it comes to the determinants of human behaviour, biology is primary, our social world and experiences come second, and actual cognitive processes such as thinking come in a distant third.

Through the sixties, seventies, eighties into the nineties much of psychiatric treatment was delivered within multidisciplinary teams. And as much as possible these teams would have connections with housing and other services. And I have often caricatured the team meeting about a given patient as:

Psychiatrist: He needs his depression treated with antidepressants.

Social Worker: He needs a job and better housing.

Nurse: He needs a relationship, someone who cares about him.

Psychologist: He needs to think differently about himself and the world.

Each could be right, but usually we would find that until the depression was adequately treated the possibility of successful job hunting or retraining, of engaging in the process of finding better housing, of establishing a relationship, and of viewing the world differently, was zero.

A few years ago at a conference someone was touting the benefits of exercise. I had to point out that I had been recommending exercise to all my depressed and anxious patients for precisely 47 years. My success rate at this was approximately 0.3 percent. At least 0.3 percent before their depression, schizophrenia or anxiety was adequately treated. Then it might improve somewhat.

As a psychiatrist and physician my prime directive is to relieve the suffering of my patient. That may mean treating an illness. It may mean calling in the social worker to ask if there is any chance of finding better housing. It may mean calling in the dietician to see if she can influence my patient’s eating habits, or referring to an exercise program, or talking with his teachers, or filling out forms to increase his disability pension, or encouraging him to see his family physician for better general medical care, or talking with the welfare officer, lawyer, probation officer……

And definitely, if one develops schizophrenia the outcome of this illness is likely to be better if that person lives within a good functioning family, has adequate housing, experiences no more “adverse events” than the average child, has opportunities for education and suitable employment, some kind of social support, at least one meaningful activity, good general medical care, and adequate finances.

But the suggestion that “we should diagnose and treat social adversity within our societies.” is paradoxical nonsense in that it actually suggests we take a biomedical approach to social ills (diagnose and treat), while at the same time being hollow virtue signalling.

We are citizens and voters in this democratic society and we can do what is possible to do to prevent war, reduce poverty, increase equity, eliminate racism, improve housing, banish guns from the streets, and improve the health care system. But as physicians it is still our primary duty to treat (reduce the suffering) of the ill and/or wounded.

Things a rural doctor has in his iPhone during Alberta’s COVID-19 pandemic – Reblog

Last week, Dr Dawson wrote about the incomprehensible anti-vax sentiment and then I came across this blog from an old acquaintance with a medical practice in rural Alberta. Dr. Greg Smith outlines what doctors are contending with because some people do not trust proven vaccinations and are willing to chance ending up in ICU’s, on ventilators and possible death to avoid a simple injection. Here is Greg’s account.

Doctors were early adopters of Palm Pilots. My in-laws gave me one as a graduation president from medical school more than twenty years ago.

The ability to carry large texts around in your pocket was revolutionary–it saved many medical students from carrying the telegraphic handbooks with which my lab coats were always too stuffed. (Hard on the shoulders! Plus they tend to spill everything out of your stupid little short medical student coat, which makes you look even dumber than you actually feel, which is saying something.)

We’ve come a long way since then. Like most people, I now carry a supercomputer everywhere in my pocket. Sometimes I use it to watch funny videos.

But, I also use it as an “auxiliary brain” for medicine. It’s particularly useful for stuff that I will rarely use, but if I need it, I need it right now.

One of those things wasn’t in my iPhone until the COVID-19 pandemic. But it is now.

It’s an article that appeared in the Canadian Medical Association Journal. It begins like this: “All physicians should be prepared to manage dyspnea, especially during the coronavirus pandemic.”

What’s dyspnea?

It’s feeling short of breath–of being starved for oxygen, like you’re smothering or drowning. It is a terrible way to die. Even with all the oxygen we can blow at you, it isn’t enough. Each breath is torture.

Usually, my patients with dyspnea get quickly transferred to Lethbridge for an ICU. I might intubate them (sedate them and put a tube into their breathing passage) to help.

Right now, that’s what my patients with COVID get. (All of them that I have had to transfer to Lethbridge thus far have been unvaccinated.)

If the health care system becomes overwhelmed, and if we have to triage care (as described here), then that won’t happen. I even wonder if I might be sent patients from Lethbridge for whom there is no space in the ICU. The Lethbridge docs might decide that I can at least “palliate,” and so unclog their hospital slightly.

They help me so often with my patients, it would be nice in a way to return the favour.

What’s palliate?

To “palliate” means to treat symptoms for comfort until the patient dies. It is “keeping you comfortable.”

We can treat dyspnea.

We’ll give you things like morphine or fentanyl, and maybe drugs like Valium or Ativan if needed. Don’t worry, I don’t even need to look up the doses in my iPhone.

If things get bad enough, we’d put you into a medical coma. Not to save you–it won’t–but to spare you suffering. You’ll be unconscious as you drown to death.

Medical coma doses–those I would have to look up. But I’ve got my supercomputer to help. Won’t take long.

We won’t let you suffer. Your family might suffer–it’s hard to watch someone die of dyspnea. But, if you’re dying of COVID and the health care system is in the kind of crisis where a rural family doc is your top care provider, your family probably won’t be allowed at the bedside anyway. So they won’t have to hear you suffer, except as you say good-bye via Facetime before we sedate you.

I’m not trying to be dramatic. I hope it doesn’t come to this.

But this is the outcome we in health care have feared all along, and what we’ve tried so hard to prevent. And right now it is hard to see how this won’t happen to someone in Alberta in the next few weeks, maybe many someones.

Last thoughts

If it does come to this, the last thing you see will probably be the nurses’ and my gowned and masked faces (plus goggles or face shield and sweaty gloves). We drilled how to get in and out of all the gear safely at the beginning of the pandemic, since we knew we’d have to look after people while being vulnerable ourselves.

A nurse’s gloved hand will probably hold yours as we administer the meds. You won’t have to ask, and I won’t have to order it–it’s just what they do.

When I’ve done my part and moved on to the next patient, the nurses will watch you closely to make sure you don’t come out of sedation and suffer some more. I won’t have to order that either.

But, after you’re asleep and comfortable, we’ll probably think of all the people who told us COVID was a hoax, that vaccines don’t work, and masking was too inconvenient.

I might even think about all the people who’ve screamed at my clinic staff or the nurses I work with when asked screening questions. I hope not. Such people don’t bear thinking about.

We’ll be wearing masks. And yeah, they aren’t as comfortable as we’d like.

But we’ll be far more uncomfortable about everything else that’s going on. So we probably won’t notice the masks much.

You, at least, will be comfortable. We promise.

Anti-Vax Protests

By Dr. David laing Dawson

I should not be astonished by the anti-vax mandate protests. It is after all just an expression of the same instinct that lies behind much human progress and evolution. It’s that “Nobody’s gonna tell me what to do” thought that jumps into our minds occasionally for most of us and frequently for some. And it arrives long before any rational thought, research and analysis can take place.

I remember well that the only time I became suddenly interested in lighting up a cigarette was the moment it was announced that smoking was forbidden in public buildings. “Nobody’s gonna tell me what I can’t do.”

But I am still somewhat astonished. After all, the evidence for second hand smoke causing much harm to others was a bit iffy at the time. Though it was clear that choosing to smoke meant choosing to cut 10 to 20 years off one’s life and die in great discomfort.

We seem to have found a reasonable compromise for smoking. Our citizens can opt for emphysema, lung cancer and coronary artery disease, they just can’t give these things to others. And as an old medical statistician once pointed out to me, the idea that smokers cost the health system a great deal was erroneous; smokers didn’t live long enough to burden the health care system with all the chronic diseases that befall us between 70 and 95.

The same could be said for the unvaccinated. But they should know that getting vaccinated and having to prove this before sitting in a theater or teaching a class of 10 year olds, or selling me groceries, or giving me nursing care, is not for your benefit. It is for your family, my family and our community.

That instinct, that automatic mistrust of received wisdom, having doubts about the prime motivation of Big Pharma, that resistance to being told what to do – that is all good. In fact it is essential for progress and democracy. But it needs to be followed quickly by thought, by research and consideration, and by some empathy for others.

So, protesters, if you don’t want to get the vaccination or wear masks, you are welcome to do this in the comfort of your own home. You can smoke there too. Just don’t come anywhere near me, my children, my grandchildren, my friends or my community.

Guest Blog – Mental Illness and The Law

Last week, we featured a blog by Dr. David Laing Dawson on the need for immediate treatment which often gets derailed when lawyers become involved in the medical process. In response, Patricia Forsdyke recounted this event from her years of advocating for those with serious mental illness and their families.

I was called to a Review Board as a witness by a father who bravely took standing at his son’s first Board hearing. Ten years before, an attempt to hospitalize his son had failed in the Emergency Department, when he was not seen by a psychiatrist.

The patient who’d been trapped in a psychosis for well over a decade had landed in hospital this time, so might get much needed treatment! My testimony was to describe how he had behaved very dangerously at a traffic intersection when he was clearly hallucinating. At the end of the hearing he said, pointing at me, that I had not seen the traffic screech and hit him.

The patient took over the hearing when I was called. He first demanded to know who I was. I told him my name: “Patricia Forsdyke.” He promptly told me that I was not HER, and he demanded that I get out my ID. As I proceeded to do so, the Chair stepped in while I fumbled through my untidy handbag. I was the President of the local Chapter of Friends of Schizophrenics and was on the Provincial Board, and pretty well-known in town. The patient told me that I was not Patricia Forsdyke, because “she” had black hair and black eyebrows ( obviously the female Lucifer). After I finished as a witness, I stayed for the rest of the proceeding. It was bizarre. His father did a wonderful job. It was excruciating for his mother.

Everyone there could see how ill and trapped in a psychosis the patient was. Yet the Lawyer won. His doctor was defeated. He was not to be treated. The young female lawyer looked very concerned and almost tearfully confided in me that she knew that he was ill, but that she was JUST doing her job!

The patient remained in hospital for at least a year untreated. But after the NINTH Review Board he was given treatment. And believe it or not, despite his paranoia, he responded pretty well to treatment, and was able to live thereafter, with support and good follow up, in the community. Later he was a great help to his elderly mother, who, in a few days time will be 100! He loves her dearly as she does him. From time-to-time I come across him walking downtown and he is always very polite to me. He gives me updates on his mother.

THE LAW IS AN ASS! And it has no mercy

Schizophrenia Resources

Since 2014, we’ve been providing weekly information for our readers on important issues in schizophrenia and serious mental illness. We’re pleased to say that we rate in the top 100 blogs and websites worldwide dealing with these topics according to Feedspot. From 2011 to 2018, one of us also posted regular blogs on serious mental illness on Huffington Post.

For those who are interested, we’ve produced a number of book titles since 2008 exploring various aspects of serious mental illness written either by those who suffer or their families. These books have been well received and favourably reviewed internationally and can be found in numerous libraries in North America, Asia, Europe and Australia.

See

This year, we’ve produced three new volumes exploring other areas of what we hope are of interest.

All of the books (save for the book on recovery) are available in print from major booksellers worldwide. They are also available in all of the e-book formats.

The Reality of Involuntary Treatment

By Dr. David Laing Dawson

Some years ago a very smart young lawyer helped the physician employees (Medical Directors of Psychiatric Hospitals) of the Ministry of Health of Ontario navigate the arcane legalese and complexity of involuntary admission for assessment, capacity to consent to treatment, involuntary treatment, and informed consent. Then one day, informally, she admitted to some of us she had just that weekend learned the true nature of “informed consent” for medical procedures. Her toddler son had fallen out of his high chair and cracked his head on the tile floor.

He was rushed to the hospital, moving quickly from emergency services, through imaging services, to the pediatric surgery department. And then the Chief of Surgery came to talk to the lawyer/mother of the boy, and told her that they would have to operate to relieve pressure on his brain.

The lawyer asked, “What will happen if you don’t operate?”

The doctor replied, “Your son will die.”

She gave consent.

And for the first time, I think, she understood that within the realities of disease, injury, urgent care, and medical treatment there really is no time for the protracted rhythms, ponderings, delays, appeals, postponements, and deliberations of the legal profession.

The social contract between doctor and patient is different that that between lawyer and client. The timing, rhythms and imperatives are different. The goal is different.

We must of course have in place transparent checks against the potential abuse of power by any person in a position of power, be it a doctor, priest, lawyer, police officer, or teacher. But our mental health acts tend to be written by lawyers who don’t understand the rhythms and imperatives of illness, disease and its treatment.

And the people who must abide by these “mental health acts” are doctors who have no spare time nor inclination to engage in the protracted theatre and language parsing of the legal profession.

The mental health act of Ontario would probably work well if every psychiatrist had but one or two patients at a time and enjoyed the theatre of review boards, hearings, courts, and writing briefs, and if every review board could be assembled within 24 hours.

Ultimately the mental health act of Ontario forces psychiatrists not to consider first and foremost the welfare of his or her patient, but rather the balance of probabilities of outcome and the cost (time, money, grief, rapport) of “trying the case” before a Review Board. These are adversarial systems and they are theatre.

Hence the present situation of untreated psychotic illness, homelessness, very short and repeated admissions to hospital, excessive police responses to mental health crises, and the dramatic expansion of Forensic Psychiatry. And now the same psychotic patient who should be receiving timely and thorough psychiatric treatment must wait until he or she commits a crime of sufficient seriousness to allow the lawyers and courts to decide on the issues of hospitalization, incarceration, competence, and treatment options.