Fostering Adherence to Psychotropic Medications

OK, I'm going to tell what is probably my best story from New Orleans. It's Mark Twain funny, like A Scientologist Lawyer in King APA's Court. (If only I could write that well...)

But first of all, several friends have asked me whether I was an "infiltrator" at the APA's convention. No, no, no ... I haven't spied on anyone for years....

Besides that, it's a misconception of the dynamics involved. There were probably 20,000 paid attendees at this annual meeting of the American Psychiatric Association, from all over the world. Nobody cared who or what I was, as long as my credit card authorized. I registered on line like thousands of other people, with my real name, address and personal info, including the fact that I'm an attorney with the email address: Randy@refusingpsychiatry.com. It was a very large enterprise with all kinds of people and no perceivable thought or measure against any "infiltration".

The death march (featuring a real coffin) and CCHR picket outside (Hey, hey, APA, how many kids have you drugged today?), and the elaborate, dramatic, "Psychiatry: An Industry of Death" exhibit, which was set up in the Riverwalk Mall directly adjoining the convention center, were all quite well tolerated, even assimilated, as part of the diverse festivities.

The two classes I took on Sunday were a tiny fraction of the information and viewpoints presented during the week-long event. My presence was basically unremarkable. Although in retrospect, there was at least one Aha! (or better yet, ACHA! - with a German accent) moment.

My afternoon class was Fostering Adherence to Psychotropic Medications: A Practical Resource for Clinicians. I had paid the $170 tuition for this figuring it was directly relevant to my work in Illinois state nuthouses, where everyone is simply told from day one that either they take the meds they're prescribed, or they'll never be let out. "Fostering adherence" sounded like a new slant for sure - maybe I could learn something useful.

Well, sure enough, the first discussion was about why we should use adherence rather than compliance as the correct term. This was just practical as all hell, and it showed how much psychiatry has improved.

It turns out that compliance means the act of complying with recommendations (whatdya know!), and that's not collaborative enough, because meds only work if the patient believes in them, and he's less likely to believe if you can't suck him into the idea gradually enough to make him think it was partly his own.

At least, I'm pretty sure that was the point....

My first question was way too basic for this specialist/professional group, although one other guy was at least polite enough to pipe up and say he agreed with me completely.

What about this definition of compliance? Isn't it always something a little more imperative than a mere recommendation with which people are asked to comply? I mean, if a psychiatrist is just recommending meds, then the patient can follow his helpful suggestion or not - right? There's no issue of compliance to begin with.

Anyway, there was a whole lot of research and statistics which proved adherence was a far better word, so the good doctors running the class didn't spend very long discussing my plebeian semantics. Even though everybody tried to call me "Doctor" while I was in New Orleans, I knew my understanding of real psychiatric issues was totally inhibited by my years of legal advocacy in state nuthouses. (It's a lower kind of psychiatry there, you know, it's paid for with taxes, of all things!)

The most exciting part of the afternoon class was when we broke up into groups of three or four students each, to actually drill building collaboration for adherence to psychotropic medications.

In each group, somebody volunteered to play a mental patient and somebody a doctor. Whoever was left was an observer. (For some reason there were only a dozen students all together, so we had less than a handful of drill groups. More people had been expected; the guys running this class had had to move to a smaller room. I can't imagine why the subject wasn't a huge draw.) I volunteered to be the patient.

The character I created for the drill was a composite, off the top of my head, of several clients I've had at Elgin Mental Health Center. But the guy who played doctor wasn't allowed to just say, "If you don't take Risperdol plus three other meds until you're a totally fried diabetic, you'll never get out of here." He had to implement what was called an "integrated adherence strategy." This was cool, but it didn't work. He couldn't get my character to improve his motivation for adherence above a red light level (i.e., I ain't takin' that shit!), even with the help of several very advanced assessments and instruments provided by the class directors.

I felt bad afterwards, like maybe I should have gone along to give my "doctor" a win. But the character I played was genuinely unconvinced. The only reason he would ever consider taking meds or (much more likely) pretend to do so was because a judge had ordered that he be treated. He was actually worried that his judge would keep sending him back to the hospital if he didn't at least pretend to go along with treatment. But that wasn't good enough. It was too much compliance, too little adherence. In this class, it wasn't allowed. So my "doctor" got nowhere with me.

During a break, I suddenly realized how he could have fostered my adherence. He could have told the patient, "Hey, are you just going to be afraid of being sent back, and have to lie and fear discovery all your life? Why not just try the meds long enough to say you tried, and maybe get even better arguments for why you don't like them and shouldn't have to take them? You might actually be able to talk us out of this treatment, if you try it for a little while and really know about how it affects you from experience..."

That sort of appeal might have gotten my character started at least. And if he'd taken that first step, the next one and the next one would be progressively easier. He might have gotten sucked into the idea gradually enough to think it was partly his own.

The student who had drilled the part of my "doctor" listened to this, and suddenly realized that it probably would have worked! He was impressed that I had learned the four steps (or maybe it was ten, I don't quite remember) which a medication provider uses to foster adherence, so quickly and so well.

I was proud of myself momentarily. Then I decided that, being a lawyer and not a psychiatrist, I really wasn't at the same specialist level of technical competence as the other people in this class.

So I took the rest of the afternoon off to cruise the exhibit hall. I got to see MECTA Corporation's newest Electroshock machine.

And (paraphrasing Twain) I wondered whether psychiatry is full of smart people who are putting us on or imbeciles who really mean it.

The Vanishing Oath and the APA

Immediately upon returning from the American Psychiatric Association's annual meeting in New Orleans, I saw an excellent film entitled, "The Vanishing Oath" - all about the intensely discouraging conditions and changes in the profession of medicine, from the point of view of its very noble and hard-working (if you suspect irony just because I'm a lawyer, forget it - I honestly mean this) practitioners.

I hope I can do justice to the connection here.

Back in January, I wrote that the economics of our love affair with modern psychiatry are inexorable. The broad context of that thought was actually national security. As I watched "The Vanishing Oath" I was filled with apprehension that my instincts in this regard are not paranoid at all; they might even come too late to warn.

Western Civilization, or American Civilization (whatever one wants to name this first cultural superpower since the Roman Empire), has incorporated a fundamental and potentially fatal error: the utter invalidation of individual intuition, free will, responsibility, original creativity and spirituality as the motive force for human improvement, in favor of acquired materialistic data and perfected technical process.

This is obvious in the sad complaints by doctors about the recent ruination of the medical profession. I could be quite unsympathetic, because these same people were perfectly willing to allow the psychiatric charlatans to claim status as healers, when they were never anything but enforcers and punishers.

The degradation of medicine into commoditized "health care" is just one outcome of our conviction that applying rationality and science to human biology is the obvious way to solve the whole human condition and make everybody happy forever.

The ultimate expression of that same conviction may be mandatory psychopharmacology. But the psychiatrists in New Orleans this week were all about collaboration and "Fostering Adherence (N.B., not compliance) to Psychotropic Medications". This was in fact the title of course 36 on Sunday, directed by Luis Ramirez, M.D. and Richard A. McCormick, Ph.D. Dr. Ramirez gave a telling indication of how toxic the prospect of forcibly medicating anyone is these days, with a grinning, almost devilish statement: "I personally LOVE long-acting injections and implants!" When you only have to dose a patient once a month or so, this issue of adherence - or compliance or coercion - needs to be confronted only rarely.

The broad demoralization of doctors is a canary in a coal mine. The increasing complexity and skyrocketing need for great subtlety and ever more creative euphemisms with regard to forcing people into treatment with psychotropics is another one. Maybe something is about to blow up ... "Things fall apart, the centre cannot hold, mere anarchy is loosed upon the world."

From the APA Convention in New Orleans

Everywhere I went at the American Psychiatric Association’s 163^rd annual meeting in New Orleans, mental health professionals were in contortions over coercion and treatment. But most of the time they seemed almost completely unaware of it.

The contortions were semantic. E.g., in Course 17 on Sunday: “Treatment of university student populations must be based on a collaborative model; and your best ally will be campus security.”

That one came from Ayesha Chaudry, M.D., a psychiatrist employed by Duke University’s center for student counseling and psychological services. The question apparently never occurred to her, and was not asked during the course: What exactly is the role for the police within a collaboration between a student and a counselor? – or even more fundamentally: Who is a doctor and who is a cop?

Dr. Chaudry cited statistics that almost half of all college students have psychiatric disorders, but only 25% are ever treated. The number of these students prescribed psychotropic medications has gone from 9% in 1994 to 25% in 2006, but it’s not enough. Therefore, it has become the task of clinicians to develop every possible trick and contrivance to get those kids on meds in the face of the irrational and unfair stigma against it.

One of the best tricks has to do with getting around the pesky confidentiality rules, like HIPPA and FIRPA. It turns out that even if a kid refuses to sign a release of confidentiality for a psychiatrist to talk to his parents, he'll often allow her to talk to the dean, or a professor, because he may need permission to drop a course without penalty, or extra time for an exam. The dean or professor is not bound by doctor/patient confidentiality and can call the kid's parents without a release. What a clever betrayal of trust!

Dr. Chandry doesn't know if she's a doctor or a cop, really. Maybe no psychiatrist does, maybe that's the big problem and the reason the stigma seems so intractable. They ought to be more honest about it, at least with themselves.

DRUGS SOLVED

The whole social paradigm for drug regulation needs to shift. The bankruptcy of current theories and methods is widely recognized. We are wasting way too much blood and treasure. I say turn the whole thing on its head with two fundamental reforms:

1. Medical authority and control over legal access to drugs should be converted to a legally mandated education/consulting role.

Individuals would not need medical permission, and they would not be legally prevented from buying or using any drug - whether it be a psychotropic medication, a painkiller, marijuana - or for that matter, LSD or crystal meth - for any purpose. However, drugs of certain classes (perhaps DEA schedules I through IV) would be considered to have potential consequences significant enough in terms of individual health and community safety, that any person choosing to buy and use such drugs would be required to document basic competence and familiarity with potential risks and benefits.

Pharmacists could demand "informed certificates", even as they currently demand prescriptions, proving that a customer has consulted with and been briefed by a medical or other suitable expert regarding the particular drug they wish to buy and use.

Such medical consultations/briefings could be meticulously prescribed by statute, to require particular and balanced, empirical information about risks and benefits relevant to any drug consumer's own purpose for taking any particular drug.

E.g., if a parent wanted Ritalin to help a child get better grades, the law might require that the parent be told about evidence that it works and evidence that it doesn't work for that purpose, in proportion to what is generally extant in scientific literature. It would also require that the parent be told about possible addiction risks, common side effects, etc.

Or, let's say, if a twenty-something bachelor wanted meth to intensify promiscuous sexual encounters, the law might require that he be briefed about unpredictable efficacy, as well as various concomitant severe dangers and long term trade-offs.

But once a consumer would be certified as fully informed, his or her possession and free use of a particular drug would be a matter of choice. NO legal prohibition, NO enforcement.

2. Individual responsibility for accurate information, and for the consequences of behavior, should be strictly enforced.

Consumer drug consultations/briefings performed by medical experts who issue "informed certs" would be standardly video-recorded by law, and this documentation would have to be maintained for a time corresponding to statutes of limitations on tort or criminal (or contract) liability. Then, if a consumer wanted to claim any damages from false or insufficient information about any drug used, a court or jury could evaluate the claim with some objectivity, through a reliable evidentiary and legal process.

Any drug consumer would also be utterly responsible under the law for all consequences of his/her behavior while taking any drug for which a valid "informed cert" was issued. If crimes or misdemeanors are committed, if adverse health effects or harms are suffered, or if bystanders are offended or harmed, then traditional jail sentences, fines and/or financial liabilities would be unmitigable by any "intoxication" or "substance-induced" excuse.

Statutes of limitation might be tolled until majority, to enable children drugged for their behavior to bring abuse claims, if they suffer from earlier decisions made for them by adults. 

_________________

I agree strongly with Dr. Thomas Szasz that the basic problem with psychiatry is coercion, and that absent coercion, psychiatry as we know it will wither away and cease to exist.

I also agree with the Citizens Commission on Human Rights, The Law Project for Psychiatric Rights, and other groups who point out that psychiatric drugs are ineffective, dangerous and fraudulently marketed.

Maybe my philosophical allegiance to Tom Szasz's libertarianism can be reconciled with an obvious need to protect the public. If everyone were fully responsible for their own health and well educated about medicine, this would be easy enough. But for the present purpose of evolving in the general direction of such a golden age, these two fundamental legal reforms might serve pretty well.

One not-insubstantial advantage of this scheme would be that no one would be out of a job. Physicians would be as much in demand as they are now. Pharmacists, government bureaucrats, researchers, lawyers, etc., would all still be needed in large numbers.

For such a paradigmatic shift, very few completely new processes or institutions would have to be created. It would be a cheap evolution, and it could happen quickly.

The value, in theory, would be exponentially increased participation, awareness and individual responsibility regarding drugs, health and medicine, from all levels and segments of society. Even as wider diffusion of economic participation and production beginning in the Seventeenth Century dramatically improved basic human conditions which had stagnated for millenia, the intractable "drug problem" might be solved, and people might improve in a rather basic way.

This is really just trusting our own and our fellows' common sense over the authority and final beneficence of some mythical expert betters.

NAMI and BLAME

May is Mental Health Month. The usual advocates are out in full force. An omnipresent message is typified by a recent NAMI-Massachusetts statement on Twitter: "Mental disorders can strike anyone regarless of age, economic status, race, creed or color." I never have understood the point of this.

I responded to NAMIMass this morning with a tweet along the lines of, "Mental disorders (and lightening!) can strike anyone regardless of age, economic status, race, creed or color. So ... what?" Very quickly, I got a reply, "That's precisely the point!"

Well, I still don't really get it. It seems like the critical idea is that nobody should ever be blamed for mental illness, it just not their fault, because it's a disease you catch like a cold or cancer.

If this revelation were true or useful there would be some kind of positive results from it by now, but there are none. In the five or six decades since we all resolved that mental illness is really, definitely, brain disease, there have been no cures, no discovery of actual causes or etiology. Mental illness has grown and grown as a problem, there's just a whole hell of a lot more of it now than ever before.

When we talk about mental illness, we're talking about behavior, and that's all. There is not a single diagnosis in any edition of the DSM which is discussed, defined or accomplished in any other terms. And the forthcoming DSM-V does not list one objective medical test for any mental disorder whatsoever.

The people who are so insistent upon not being blamed for mental illness should just be asked whether they can be responsible for their behavior. If they can, society has no vested interest in what words are used. But if they cannot, society will continue to blame them despite their very best linguistic arguments. And it probably should.

NAMI might say a person's responsibility for his or her mental health includes taking meds when meds will help, when the benefits outweigh the risks. But this presumes that treatment is all voluntary and patients are adequately informed. Certainly while we have civil commitment, Kendra's Law and the insanity defense, treatment is inextricably intertwined with justice and the police. Psychiatry is a coercive arm of the state. Individual responsibility must vary inversely with coercion and ignorance.

I think this mysterious fixation on, "It's not your fault when you're mentally ill..." evidences nothing much better than some fear of being discovered (e.g., as a fraud or a criminal). "Stigma" is a smokescreen, it's not the correct project.

The real project of "mental health" should be improving human behavior, and it's not medical.