Map of life expectancy at birth from Global Education Project.

Tuesday, June 06, 2006

There are pills that make you large . . .

But I'm going to begin by talking about the pills that make you small. Thomas A. Ban, in "Pharmacotherapy of Mental Illness -- A Historical Analysis" (Progress in Neuro-psychopharmacology and Biological Psychiatry. 2001;25:709-727) writes:

The first widely used therapeutically effective drug in psychiatry was morphine. Alexander Wood's finding in 1855 that morphine, administered by "hypodermic needle," promptly relieved neuralgic pain, led to the introduction of subcutaneously administered morphine during the 1860s, for the rapid control of agitation and agression, in psychiatric hospitals.

The second widely used therapeutically effective drug in psychiatry was potassium bromide . . . . The third . . . was chloral hydrate. . . . The judicious use of these three drugs provided the necessary means for day and night-time sedation. It also allowed the replacement of physical restraint by pharmacological means in behavior control . . . . By the dawn of the 20th Century subcutaneously administered morphine and scopolamine . . . became the prevailing treatment modalities of excitement and agitation in psychiatry. They are still among the most reliable and effective treatments for rapid control of behavior.

So, the use of drugs in psychiatry is firmly rooted in the problem of controlling patient behavior that personnel in mental hospitals found difficult. Drugs replaced the strait jacket. This is a powerful metaphor for a fundamental philosophical and ethical problem in psychiatry. Psychiatric "diseases," as we have seen, consist of nothing more than clusters of behaviors. The patient may or may not wish to change these behaviors. If the patient does not wish to change, then any form of treatment must, fundamentally, be coercive. Even if they do wish to change, and come to psychiatric treatment of their own volition, they may end up submitting to a coercive process.

I am not going to begin to discuss the extent, ethical and practical implications, and possible resolution of this problem in this post. I'm just raising it. Here are a couple of examples to think about.

Consultation-liaison psychiatry consists of psychiatrists who work on general medical or surgical wards and assist the physicians there who have primary responsibility for patients. They are frequently called because of patient management problems. Typically, the diagnosis and treatment of illness is not even at issue. There is considerable discussion in the literature about what determines when a psychiatric consult is called, and it is clear that, at least as far as C-L psychiatrists are concerned, the suspected presence of psychiatric illness is not the most important independent variable. Joan Gomez (Liaison Psychiatry: Mental Problems in the General Hospital. Free Press) says that the most common reasons for referral include "the staff are under strain over this patient."

George B. Murray writes that "Not infrequently the psychiatrist is called when there is a management or behavioral problem with a patient .... [M]any patients are quietly demented, delusional or delirious ... since these patients perdure quietly in their disorder, presenting no problem to the managing staff, the psychiatrist is never called." Murray receives support from Olson ("Depressed Patients who do and do not Receive Psychiatric Consultation in General Hospitals". Gen. Hosp. Psych. 13, 39-44 (1991)), who, through a chart review, found that many inpatients identified as depressed by their attending physicians never receive a psychiatric consultation. On the other side of the equation Hengewald, et al, ("Management of Patient-Staff and Intrastaff Problems in Psychiatric Consultation." Gen Hosp. Psych. 13, 31-38 (1991) based on a standard 30 item database used in the Netherlands, found that in that country, approximately 1/3 of psychiatric consults called in general hospitals, excluding suicide attempts, concerned patient-staff or intrastaff conflicts.

Shorter version: This patient is a pain in the ass, let's call the shrink and give him a shot.

Now, from today's Boston Globe, a story that you may find astonishing, but to those of us who work in the field, it isn't even particularly noteworthy.

By Scott Allen, Globe Staff | June 6, 2006

A 50-year-old woman filed a federal lawsuit against Beth Israel Deaconess Medical Center yesterday, saying she was forcibly undressed by five male security guards there last year after she refused a nurse's order to take off her clothes. . . .

Sampson said she went to the hospital for treatment of a severe migraine headache, but was moved to a psychiatric unit when she admitted struggling with self-destructive impulses. She said she pleaded to be allowed to keep at least her pants on before the strip search, but the nurse refused.

``Go ahead and rape me; everybody else has," Sampson said she cried out as the guards unbuckled her pants and removed them. ``They left me there with my underwear showing and my johnny up to my chest . . . I was crying, and [the nurse] said, `That's what you get for not listening to me.' "

In a letter to Sampson, hospital officials said they were sorry she had such a terrible experience, but stood by their strict policy of searching psychiatric patients for their own benefit. Yesterday, Beth Israel Deaconess officials declined to comment further, saying they can't talk about pending legal matters.

So, this is very simple. Woman goes to hospital for treatment of headache. Mentions that she is being treated for a mental disorder. Is thereupon unceremoniously abducted and assaulted. That's right -- under normal circumstances these actions constitute kidnapping, unlawful confinement, aggravated assault and battery, and sexual assault. But it's for her own good, and the hospital stands by its policy. It is not clear to me why this is not a crime. I'm unaware of any relevant legal exception to the laws that govern the fundamental norms of civilization. Can anyone help me out here?


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