Monthly Archives: March 2022

In Recognition of World Bipolar Day, the Release of Navigating Bipolar Country

By Marvin Ross

Edited by Merryl Hammond, the author of Mad Like Me: Travels in Bipolar Country, comes a new collection of Personal and Professional Perspectives on Living with Bipolar Disorder (the subtitle). As explained in the preface, the intent of the book is to provide one stop shopping for all. Part One consists of essays written by people with bipolar who share their experiences with the condition. Part Two is a collection of the candid reflections of family members whose dedication and commitment to their ill relatives often goes unnoticed and unappreciated particularly by the medical profession. The third part comprises commentary from various professionals who share their expertise.

It is quite unique to have the views, experiences and recommendations of three different populations all together in one volume. I’m not familiar with any other book that does this although some may exist. The three groups all impact each other at various stages which gives the reader a more holistic view of bipolar.

What I particularly liked was that there were some essays by the ill person juxtaposed by an essay by the parent. The inclusion of two perspectives gives us the ability to see both sides of the same coin. I only know of two other books that do this and they both deal with schizophrenia. The first is Divided Minds dealing with one twin with schizophrenia and the other who became a psychiatrist. The other is Loves All that Makes Sense about a mother with schizophrenia and her daughter told from their own recollections.

One of the professionals who contributed is Mind You blogger, Dr Dawson who adapted some of the observations he wrote about here in his piece. Of particular note is his description of how to defuse a crisis situation peacefully. I was actually present once when he did this and his suggestions work well.

I highly recommend the collection which is a poignant and powerful view of a devastating illness.

Navigating Bipolar Country: Personal and Professional Perspectives of Living with Bipolar Depression, CAE Canada, 2022, ISBN 978-1989298046, 424 pages, $24.99 (US) $29.99 (Canada) and in kindle

Requiem

By Dr. David Laing Dawson

East Berlin

I took this photo in East Berlin in early January of 1961. It is clearer in my memory than in the digitized Kodak slide, the women digging and picking through the rubble of the Second World War.

And I wrote the lyrics of this song for MacBush, The Musical, in 2013. It was sung by the whole cast after my MacBeth/MacBush character sat alone on stage delivering the “Tomorrow and tomorrow, and tomorrow” speech.

These are the lyrics, written for the war in Iraq, but again, unfortunately, topical.

We speak words and make decisions

Without history, without vision

We do and can’t undo

A playground of revision

A butterfly in China

May cause someone angina

A drone in Pakistan

Could affect my pension plan.

Will there ever be

A time when we can see

Will there ever be

A time when we can see

Beyond our bed of roses

Beyond our freckled noses

Beyond at least tomorrow

When this will bring us sorrow

Beyond our bedroom walls

Beyond our hallowed halls

Beyond at least tomorrow

How this can bring but sorrow

Will there ever be

A time when we can see

Will there ever be

A time when we can see

War is just a three letter word

While death’s a little longer

Revenge can add a letter or two

While vengeance is even stronger

Will there ever be

A time when we can see.

The Carnage Continues

By Dr David Laing Dawson

He’s beginning to sound a lot like Hitler

Assuming the translator got it right, Putin used a chilling phrase in his football stadium rally: “the necessary cleansing of society”. And those to be cleansed he referred to as “scum.”

And it occurred to me that that phrase is a step beyond what we think of as racism, or “supremacy.” And even a step beyond psychopathy and narcissism.

It speaks to an assumption of God-like powers, of Old Testament wrath, of a self-assumed identity beyond human.

Hitler used such phrases. And Pol Pot did as well.

I suppose it is a natural progression when a narcissistic psychopath retains power for more than a few years.

Other wars and other attempts at genocide may have been just as morally bad, but this is 2022 and it is happening among the very countries that could ensure a future of democracy, climate control, and health and welfare for the entire world in the years to come.

So, I pray, (that is I earnestly hope) that behind the scenes, our Western Governments are doing everything possible, apart from nuclear war, to ensure Putin fails and is replaced.

Written for MacBush, the Musical, and the war in Iraq, but now tragically topical again.

Music by Charles Humphreys

Performed by Wilhelmina van den Aa and Charles Humphreys

Words by David Laing Dawson

Bad Academic Research Does not Improve Schizophrenia Care

By Dr David Laing Dawson and Marvin Ross

As family members of those with schizophrenia will tell you, the care that we as a society provide is bad and has been getting worse for a number of years. The growing numbers of homeless in our cities many of whom have untreated mental illnesses is an indicator. Another indicator is the increasing proportion of mentally ill in jails. We have closed expensive hospital and high support residential facilities, kicked patients out of hospitals before they are properly stabilized and lack sufficient community programs. A study done in 2014 found that the psychiatrists in practice see too few patients and are reluctant to accept new referrals.

The end result of that, according to Kathy Mochnacki, President of the Board of Directors of Home on the Hill Supportive Housing a family driven Charitable Organization in Ontario, is that her organization spends a great deal of time supporting families who are often in crisis because of the lack of adequate services in the community.

This is the reality that exists today that is not addressed by a recent study out of the University of Calgary entitled 10 Year Trends in Health Care Spending Among Patients with Schizophrenia in Alberta Canada. The researchers looked at the amount of money spent from 2008 to 2017 on patients for hospitalizations, emergency department visits, outpatient physician visits, and prescription medications.

What they did find is that per capita ER costs remained about the same although in absolute dollars, it increased from $10.5 million to $21.7 million. In patient hospitalizations was way down at $13,397 per capita to $6818 per capita ($216.8 million to $226.1 million in absolute spending). The big increase in spending was for drugs that went from $2246 per capita to $8046 or a 3.6 fold increase.

This huge drug increase was attributable to an increase in the use of injectable Abilify. Not surprisingly, research has determined that compliance on anti-psychotic medication is much better when given in once monthly injections rather than daily pills or capsules. And because of this the relapse rate is lower.

This is especially true for patients living in less than ideal circumstances: unstable housing, roommates, communal living, boarding houses, marijuana, alcohol and other drug use. (I have had patients ask to go on monthly injections for these reasons)

So it is also not surprising that more and more patients suffering from schizophrenia are being put on monthly injections rather than daily pills. Especially now that we have injections that last one month rather than one or two weeks.

Doctors don’t pay much attention to the cost of medication in Canada unless it is not covered by the Province or other insurance.

So we researched the cost of aripriprazole (Abilify) which in the injectable form is Abilify Maintena.

For comparison, in Alberta where the study was done, a month’s supply of Risperdone or Olanzapine in pill form would cost between $10 and $40.

Abilify (made by Bristol-Myers Squibb) in pill form would cost $100.

The cost of Abilify in injection form for a 30 day period is $450.

So that would be a ten fold increase over maintenance on Olanzapine, and probably a twenty fold increase over maintenance on an older antipsychotic like Perphenazine.

And there are other costs associated with monthly injections as opposed to a doctor’s appointment every 3 months.

Of course the drugs making the most profit for the pharmaceutical companies are promoted and touted, and whether they are better or not, they get far more advertising than older drugs. And older drugs like perphenazine (an effective anti-psychotic with few adverse effects when small dose is sufficient) are almost forgotten because nobody is making money on them.

Which means two things: 1. That expensive research study was entirely unnecessary.

We know the prevalence and incidence of schizophrenia. We know it varies study from study because of methodology and diagnostic changes. And we could have determined the rest by spending a little time with Google.

So more and more patients are being maintained on monthly injectables, as expected.

Abilify is or is becoming the most popular of these.

Abilify in injectable form costs 10 times per month more than comparable medication in daily pill form.

And 2. clearly the provinces and/or Canada have not done a good job negotiating pricing with Bristol-Myers Squibb.

And, according to Dr Richard O’Reilly, a psychiatrist in London, Ontario:

“We are spending more on costly drugs, which large research studies suggest are not more effective. The newer antipsychotics offer a different suite of side-effects i.e. metabolic rather than neurological. They are a useful alternative for some patients who are sensitive to neurological side effects, such as Parkinsonism and tardive dyskinesia. However, the fact that many effective older antipsychotic drugs have almost disappeared from use is an indication of the marketing skills of the pharmaceutical industry – targeting both clinicians and family groups to advocate for their patent-protected medications. The metabolic effects of many so-called “atypical antipsychotics” increase the risk of mortality and studies show that life expectancy of people who suffer from schizophrenia continues to be markedly reduced in comparison to the general population: in part due to high rates of adverse cardiovascular events. We have closed expensive hospitals and high support residential facilities and invested those savings in expensive new medications with marginal benefits. We should be using those savings to pay for professionals and systems that provide high quality care for people with schizophrenia and other severe mental illnesses in community settings. My impression is that the only the winners are the pharmaceutical companies.”

What is missing from this study is outcomes. Are these patients better off in 2017 compared to 2008? That is the key metric. The researchers did look at what they called material and social deprivation but how they derived those measures is inadequately described by using census data and postal codes as proxies. They did state that “a higher proportion of patients were classified as unstably housed, with a low of 5.0% in 2008 to a high of 5.8% in 2017”.

To reiterate, this study was totally unnecessary and did nothing to advance our knowledge or to help improve care to those who have been neglected for so long.

War is Stupid

By Dr. David Laing Dawson

We are an infuriating species.

We don’t deserve a planet like earth.

Arctic ice is melting faster than predicted.

We have maybe 15 years before we reach a point of no return.

Our current focus on reducing reliance on fossil fuels world wide is a slow, oft interrupted process.

The other possibility, that of carbon capture, would be very difficult and expensive to scale up. Outrageously difficult and expensive. How could we commit trillions of dollars and resources to such an endeavour? Where would the money come from? What would we do with the carbon?

And then I watch the war in Ukraine and I listen to talk of those inexpensive Turkish drones (about 1 million apiece) compared to the American drones and missiles (about 3 million apiece) and the destroyed 3 million dollar tanks, the 10 million dollar helicopters, the 100 million dollar planes. I imagine the cost of this war each day, and then the ultimate cost of rebuilding Ukraine, and the formidable cost of stabilizing a destabilized Russia.

If we didn’t go to war in Iraq and Afghanistan, and now in Ukraine, and if we didn’t have those enormous defense budgets, and if we actually put all those uniformed men and women to work building things……..

Carbon Capture infra-structure around the world.

New industries to use the captured carbon.

And alternative energy sources from wind to solar to wave now powering all our electric grids, along with batteries that charge quickly and last longer.

And we would still have a habitable planet for my grandchildren.

Music by Charles Humphrey Lyrics by David Laing Dawson Written for MacBush, The Musical But suddenly, unfortunately, very topical

For more on MacBush see https://artword.net/artwordtheatre/?cat=30 and https://www.thespec.com/news/hamilton-region/2016/11/11/mahoney-macbush-a-medicine-for-our-times.html

War Crimes – a Redundancy

Dr David Laing Dawson

Language is important. Words have meanings. They are symbols with referents. And specific words used also imply the exclusion of other words or meanings.

When we say something is red, we also are saying it is not blue or yellow. When we label a tree as being a Maple Tree, we are also saying it is not a Fir tree.

Words and phrases, in this day and age, become quickly fashionable and then get overused. There was recently a period of time when I could not read or watch any news report without encountering the word, “iconic.” (I think it has finally faded in popularity)

My current irritant is the redundancy of “the images we are about to show you are graphic.” or “warning, these are graphic images.” Doh. Graphic means image. It does not mean the phrase that would take more effort, “Warning, the images we are about to show you could be upsetting to you.”

Of course then we might be shown a corpse lying on a street in a village in Ukraine with the actual disfigurement and/or sexual parts blurred.

Another irritant is the ubiquitous term “innocent”. Always placed as a qualifier when reporting that women and children were killed. “Innocent women and children were killed”.

Which to me implies that there are other kinds of children and women, not so innocent, and that it would not be so bad if we killed them. And it certainly implies that it would have been fine if the bomb had only killed men.

And of course we label the people doing the killing as cowards. A cowardly act. Which does seem to imply that if we kill in an heroic fashion, that would be okay. If we go to war in an heroic fashion that would be okay. If we only kill one another at high noon, face to face, at the count of ten, that would be okay.

(As I recall Bill Maher pointed out that the perpetrators of the destruction of the Twin Towers were many things, but “cowardly” was not one of them, and lost his job because of this.)

But back to my first statement. I understand there is a history to this, and perhaps creating conventions to be followed in war and trying to draw a fine line between acceptable and unacceptable brutality was a good thing. Perhaps. Or did it make conventional, nice war, more acceptable in our minds?

War is the crime. If we go to war people are killed, both the innocent and not-so innocent. And atrocities occur. Let’s not pretend war is a sport with a referee.

War is a crime.

March 9 News Item: A Trucker “Freedom” Convoy is Heading to Victoria this Weekend.

By Dr David Laing Dawson

The Canadian Trucker protests, the “Freedom Convoys”, are a good illustration of why no form of governance will ever be calm, agreeable to all, and certainly not perfect. We are an egocentric species finding grievances easily. We lack perspective often. We are short sighted. We are always conflicted.

This latter trait, the conflict we carry in each of us between our own welfare, survival, and comfort, and that of our families, tribes, and fellow humans, is probably one of the human traits that took us to the top of the food chain. A fluid balance between self-preservation and concern for the welfare of others is a very good evolutionary survival instinct for any species.

We humans are probably at our best when our concern for the welfare of others dominates, or is at least in sync with our instinct for self preservation. And as a species we do celebrate this in others. It was a fine moment when Mr. Zelenskyy told the Americans that he didn’t need a ride, he needed weapons.

The fact we can think in symbols is another trait that took us to the top of the food chain. But of course we can distort this ability, as when somehow in the minds of some, a public health mandate to wear masks during a pandemic in certain public circumstances is akin to, or symbolic of, a total loss of FREEDOM, and evidence of a fascist government.

Still, after two years of a deadly pandemic that is now winding down, with mask mandates probably loosened or discarded within a couple of months, with about 90% of eligible Canadians vaccinated, and now the sudden and unexpected destruction of Ukraine by another country with a truly poor form of governance, an actual fascist state, and the suddenly serious threat of nuclear war hanging over all of us – surely at this time even the most selfish, egocentric person among us might notice that his grievance about having to wear a mask in COSTCO is rather petty. A small thing. An irritant. An inconvenience at worse.

Get over it. Please.

Ukraine and the Lessons to be Learned From the Spanish Civil War

By Dr. David Laing Dawson

This is actually an opportunity, if a terrible, unwanted one.

The Spanish Civil war was a complicated affair which began with a military coup led by Franco (the Nationalists) against a Republican Government. It quickly became an international conflict between the left and the right and a dress rehearsal for World War Two. The Nationalists were supported by conservatives, monarchists, and religious groups with help from Nazi Germany and Mussolini’s Italy. The Republicans were supported by Russia, socialists, anarchists and an International Brigade of volunteers from many countries including the Mackenzie Papineaus from Canada, the Abraham Lincoln Brigade from the US and many European groups. One of those fighters was our own Norman Bethune, a Canadian surgeon who developed mobile blood transfusion units.

Western governments were ambivalent, perhaps as spooked by communism as by fascism, maybe more so.

Hitler’s Germany and its Luftwaffe destroyed the small town of Guernica at the behest of Franco. It was most notable for its direct aerial assault on civilians, essentially an act of terrorism.

I came to know of the Spanish Civil War, like many of my generation, through the writings of Hemingway, Orwell and Lorca, and Picasso’s painting of Guernica, and some fascination with Dr. Bethune (a very early advocate for national health care).

But I also had the unusual opportunity of spending an afternoon in 1970 sharing some Spanish Brandy at a sidewalk cafe on the Mediterranean coast with a village policeman, a Guardia Civil, who had fought for Franco, and then fought in a Spanish Brigade for Hitler in the second world war, spending the last year of that war as a prisoner of Russia on the eastern front. (One of the odd things I remember was that he told me the Russians treated the Spaniards much better than they treated the German prisoners)

Though men from Canada, the US, and every country in Europe fought in that war, mostly on the side of the Republicans, our Governments remained on the sidelines. Six months after this war ended with victory for Franco and the fascists, Hitler invaded Poland.

Had the democratic countries of Europe and North America ensured the defeat of Fascism in Spain in the years before 1939 how might history have been changed?

And now. Ignoring China for a moment, the most important and powerful non-democratic country in the world, essentially a fascist state, is engaging in the destruction of a neighbouring nascent democracy. If we allow this to happen we may be back in 1939. This time our ambivalence does not stem from a fear of communism, but rather of nuclear weapons and some pain at the gas pumps.

The threat of nuclear war will not recede with the defeat of Ukraine. And some economic pain may be a small price to pay for what would otherwise come next.

But maybe, if we take this opportunity to ensure the survival of Ukraine one way or another, and the collapse of Russia which will follow, then maybe we can enter our version of 1939 with one less brutal dictatorship in our world, and more chance of maintaining peace and getting on with the task of saving the planet.

We had a similar opportunity in 1936 and did not take it.

Dostoevsky, Putin, Trump

By Dr David Laing Dawson

Lavrov and Putin

I have, in these blogs, described both Vladmir Putin and Donald Trump as narcissistic and psychopathic. These are not meant to be simply pejorative terms. Nor are they diagnostic labels. But as a psychiatrist I should explain what I mean by them.

In Fyodor Dostoevsky’s Crime and Punishment Raskolnikov is an impoverished student who talks himself into committing the murder of a nasty old pawnbroker for a few shekels. In the very Russian, dark and complicated story that follows one theme is constant: Raskolnikov is consumed by guilt and eventually confesses to his crime.

Raskolnikov is fully human. He talks himself (rationalization, projection, self-delusion) into a way out of his pain and impoverishment that includes murdering a person whom he has convinced himself is unworthy of living. But he has empathy for others and he is capable of shame and guilt. He is fully human and he will suffer. He has imagined that he could be as grand and ruthless as Napoleon but finds he cannot and is not. He is just not that narcissistic or psychopathic.

But there are men who are that narcissistic, who have themselves photographed naked, muscled, astride a steed, who spend an hour each day colouring skin and hair to appear as bronze Gods, and there are men who behave with no empathy for others, and who never lose sleep doubting themselves and their righteousness, and who do not suffer shame and guilt for their words or actions. And men who feel comfortable living in palaces, waited on by serfs, while surrounded by suffering.

These men exist, and perhaps there was a time we needed them to send our young men into battle, to ruthlessly build our kingdoms and corporations. But not now, no more, no longer.

I don’t know how we keep these men from positions of power. Democracy to start, plus an educated population, good social programs, free, critical, and ethical fourth estate, limited tenure, checks and balances, limited election spending, independent judiciary……

I do have a fantasy of finding a few hundred qualified men and women who do not want to become president or prime minister, who strongly doubt their abilities to assume those roles, who really don’t like hurting other people, and then run a short inexpensive election to chose one of them for a limited period.

Or maybe just let the good stand-up comedians and satirists run for office. We do know they at least have the skill of seeing through all the bullshit of politics and their own unwholesome instincts.

The Emperor has no Clothes.

By Dr David Laing Dawson

All too often when police encounter a mentally ill person, especially a delusional person, they expect that person to respond rationally to their demands and requests. Tragedy ensues.

At a geopolitical level we make the same mistake. Last week hearing the leaders of the free world talk about how small sanctions and the threat of more sanctions might make Putin think twice about the cost of his invasion of Ukraine (His decision to kill people), they seem to think it is a Sunday afternoon at a flea market and two sane, rational people are haggling over price.

Putin has not made a rational decision. His decision to kill people is based on the grandiose ideas of an aging narcissistic psychopath with developing paranoia. (I suspect the 20 to 30 foot distance he keeps between himself and others is not for COVID, but for the Novichok someone might sprinkle on his collar). The country he currently rules as a ruthless dictator is failing (apart from the oil and gas profits going to the oligarchs and military). His power in the world is waning. The economy of Canada, with a quarter the population, is bigger than Russia’s. He dreams of being an emperor of uncontested power, of recreating the glory days of the Soviet Union.

A few sanctions won’t cut it. For Putin they are a small cost to achieving his apparent ambition of being an emperor astride at least a third of our planet, and once again a very important man on the world stage. (Something Trump may have offered him on a silver platter)

His hardly veiled threat to use nuclear weapons makes the West’s decision to not send troops to Ukraine quite rational. On the other hand, if he succeeds in the Ukraine we are in a bigger mess, continually more dangerous; more people will be killed, global warming will continue, the threat of nuclear war will not recede.

Totally cutting off Russia from trade, money, travel, communication will cost us, the west. But I think this cost must be born, for the only way to deter Putin is to destabilize the country he now rules, to the point his own people rise up and decapitate him, and his armed forces stop.

And at the same time give him some kind of face-saving device, at least until he loses power in Russia. And this is where our wonderfully vague use of language may come in handy. Ukraine should sign a pledge that they will not join NATO if Russia removes its troops. Give him a land corridor to the Crimea as well, what the hell, it’s just a road. Much like the road I once traveled from West Germany through Soviet East Germany to Berlin.

Ukraine will thrive. Russia will continue to decline. And then we can get back to saving the planet and dealing with our own lunatics, anti-vaxxers, extremists, flat-earthers, lousy singers and grandiose truckers.

Not to mention advocating for better treatment of mental illness.