Weekends at Bellevue: Not an easy job to decide who is “crazy” or engage psych patients

Youtube Credits:  Uploaded by wnycradio on Oct 8, 2009

Listen to the whole interview:
http://www.wnyc.org/shows/bl/episodes/2009/10/08/segments/142211

Dr. Julie Holland talks about her work as the doctor in charge of Bellevue’s psychiatric emergency room in her new memoir, Weekends at Bellevue.

Youtube Credits:  Uploaded by  AeroLynda123 on Nov 14, 2009

Youtube Credits:  Uploaded by KnowDrugsdotNet on Oct 27, 2011

From http://www.knowdrugs.net Dr Julie Holland talks about her work using MDMA and cannabis to treat patients.

American Undercover – Bellevue: Inside a Non-Participatory Model of Mental Health Care

New York City’s Bellevue Hospital, the country’s most renowned psychiatric emergency center, treats as many as 7000 individuals annually. This documentary feature takes viewers for an exclusive tour inside the locked psychiatric wards of America’s largest public hospital, where they will have the opportunity to observe the sometimes tragic, sometimes comic, and always grueling struggle faced by the doctors and patients wrestling with symptoms of severe mental illness. Produced in 1998/1999, first shown in 2001.

Illinois Task force to investigate the Criteria for the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders

By Maria Mangicaro

Chicago, IL:  Allegations of deceptive practices among mental health care professionals is a concern for Illinois House of Representatives by Rep. Mary Flowers (D-Chicago).  Flowers has introduced a resolution calling for the establishment of a “Task Force on Mental Diagnosis and Illinois Law.” HR0898 is co-sponsored by Rep. La Shawn K. Ford (D-Chicago).

The task force was formed in response to allegations of deceptive practices pertaining to the formulation and diagnostic criteria of psychiatric definitions for mental disorders by the American Psychiatric Association that has resulted in “at least 3 false epidemics causing countless persons to be prescribed expensive, unnecessary, potentially dangerous psychotropic drugs.”

By consensual agreement within the American Psychiatric Association psychiatric diagnoses are descriptive labels only for phenomenology, not etiological or mechanistic explanation for syndromes. Thus, a psychiatric diagnosis labels a pattern of signs and symptoms, but offers no hypothesis concerning the mechanism(s) of the clinical phenomena.(Davidoff et al.,1991).

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies psychotic illnesses as “Psychosis Due to General Medical Conditions”, and “Substance Induced Psychosis”. (DSM-IV Codes 293.81 & 292.11). Distinguishing medical conditions and substance-induced psychosis from schizophrenia or Bipolar disorder through clinical presentation often is difficult.  Law makers must consider the treatment of mental disorders must include accurate assesment and best practice standards of care.

 

Short Description:  CREATES-TASK FORCE MENTAL DIAG House Sponsors Rep. Mary E. Flowers – La Shawn K. Ford Last Action

Date	Chamber	Action
3/28/2012	House	Referred to Rules Committee

Synopsis As Introduced Creates the Task Force on Mental Diagnosis and Illinois Law within the Office of the Governor. Actions

Date	Chamber	Action
3/27/2012	House	Filed with the Clerk by Rep. Mary E. Flowers
3/27/2012	House	Chief Co-Sponsor Rep. La Shawn K. Ford
3/28/2012	House	Referred to Rules Committee

HR0898 LRB097 20749 KXB 67264 r
1		HOUSE RESOLUTION
2		WHEREAS, Mental illness is a critical underlying concept in
3		various areas of our law affecting mitigation of criminal
4		responsibility and fundamental rights to property, individual
5		liberty, and personal privacy; and
6		WHEREAS, For at least 2 generations, mental illness has
7		been presumed to be brain disease which is best confronted as a
8		treatable medical problem; and
9		WHEREAS, Vast amounts of State resources and tax monies,
10		not to mention the creative energies and work of our citizens
11		and civil servants, are continuously expended in accordance
12		with Illinois laws and regulations dependent upon derived
13		psychiatric definitions, formulations, and diagnostic criteria
14		for mental disorders, in particular upon those definitions,
15		formulations, and criteria which are found in the American
16		Psychiatric Association's nearly 20-year-old Diagnostic and
17		Statistical Manual of Mental Disorders, Fourth Edition
18		(DSM-IV); and
19		WHEREAS, The head of the task force which developed DSM-IV
20		recently admitted that since it was published in 1993, that
21		manual has resulted in at least 3 false epidemics causing
22		countless persons to be prescribed expensive, unnecessary,

HR0898 - 2 - LRB097 20749 KXB 67264 r
1		potentially dangerous psychotropic drugs; and
2		WHEREAS, A professor of psychiatry and author of a leading
3		reference book on psychopharmacology recently called the
4		entire chemical imbalance theory of mental disorders an urban
5		legend; and
6		WHEREAS, Experts in the field of mental health are
7		currently in major and substantial disagreement about the
8		general validity of psychiatric diagnosis itself; and
9		WHEREAS, Despite explicit admonitions in DSM-IV against
10		the use of psychiatric diagnosis for such legal purposes as
11		establishing competence, criminal responsibility or
12		disability, Illinois courts and agencies have nonetheless
13		habitually relied upon the formulations and criteria in the DSM
14		for the precise expertise which the text itself disclaims; and
15		WHEREAS, A new edition of the American Psychiatric
16		Association's manual, DSM-5, is scheduled for publication in
17		May of 2013, but proposed changes for this upcoming DSM are
18		provoking intense criticism from a diverse range of mental
19		health experts, more than 12,000 of whom have signed a petition
20		protesting the secretive and unscientific character of the
21		APA's proposals to expand concepts of mental disorder to a
22		point where normal human emotions and coping behaviors will be

HR0898 - 3 - LRB097 20749 KXB 67264 r
1		falsely pathologized as illness; therefore, be it
2		RESOLVED, BY THE HOUSE OF REPRESENTATIVES OF THE
3		NINETY-SEVENTH GENERAL ASSEMBLY OF THE STATE OF ILLINOIS, that
4		the Task Force on Mental Diagnosis and Illinois Law be created
5		within the Office of the Governor, and jointly supervised by
6		the Comptroller and the Attorney General, to
7		(1) thoroughly survey the Illinois Compiled Statutes and
8		Administrative Code to identify all instances where our
9		laws and government functions depend upon purported
10		understanding of mental illness or disorder, mental
11		capacity, mental health, behavior or psychology, which may
12		be recently discredited, or reasonably considered
13		incorrect or arbitrary in light of the current confusion
14		among mental health experts over the possible absence of
15		scientific validity in psychiatric diagnosis;
16		(2) forward initial recommendations of urgent legislative
17		actions which may be needed to avoid gross injustice or
18		waste of public resources to the General Assembly as soon
19		as possible; and
20		(3) produce a final report summarizing the task force's
21		findings and detailing recommended statutory or
22		constitutional strategies to correct negative impacts of
23		concepts and nomenclature now discredited or inconsistent
24		with current medical science, and to avoid future
25		immoderate scientism in our laws and public policy; and be

HR0898 - 4 - LRB097 20749 KXB 67264 r
1		it further
2		RESOLVED, That the task force shall consist of the
3		following members: 3 members appointed by the Speaker of the
4		House of Representatives, one of whom shall be appointed
5		co-chairperson; 3 members appointed by the minority leader of
6		the House of Representatives, one of whom shall be appointed
7		co-chairperson, one member appointed by the Comptroller; and
8		one member appointed by the Attorney General; and be it further
9		RESOLVED, That in appointing members of the task force, the
10		Speaker and minority leader shall consider that professional
11		experience in diverse mental health-related fields may be a
12		positive qualification; and be it further
13		RESOLVED, That the task force shall take voluntary
14		assistance and testimony from individuals and professional
15		organizations and institutions; and be it further
16		RESOLVED, That the members of the task force shall serve
17		without compensation but may be reimbursed for actual expenses
18		while serving on the task force from funds appropriated to the
19		Office of the Governor for that purpose; and be it further
20		RESOLVED, That the task force shall submit its final report
21		to the Governor and the General Assembly no later than December

HR0898 - 5 - LRB097 20749 KXB 67264 r
1		31, 2013.

The Participatory Medicine movement and Best Practice Standards: Are Psych Patients being excluded?

By Maria Mangicaro

“Participatory Medicine is a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.”

The Feb. 1, article “Participatory Medicine: Must You Be Rich to Participate?” published in the Journal of Participatory Medicine raises serious concerns about the Participatory Medicine movement and the exclusive nature of this trend that access to the internet and electronic devices has helped to propel.

There are many aspects of the mental health care system that infringe upon a patient’s basic civil liberties, placing them in need of strong advocacy and alliances.  For many reasons individuals suffering from symptoms of severe mental illness are at a disadvantage to the general population to become empowered, engaged and equal partners to their providers.  An agenda that focuses on advocacy dependant on electronic technology and devices excludes the large population of individuals who do not have the skills or access to obtain empowerment strategies through e-patient status.

The concept of mental illness itself is fraught with difficulty as mental health professionals from various backgrounds and disciplines of study have conflicting opinions regarding the accepted diagnosis and treatment of symptoms.   Some advocates feel the psychiatric diagnostic system has created an imbalance of power and reinforces the power of the psychiatrist to diagnose and treat patients often against their wills.

Concepts that are evolving from the Participatory Medicine movement and consumer-driven care are becoming widely accepted as “best-practice” standards.  The division is becoming apparent even to the founders of the Participatory Medicine movement that “e-patients” are either among the empowered, or the excluded.

In order to ensure patients suffering from psychosis are afforded every opportunity to recover, advocacy must ensure clinicians are adhering to best-practice assessment of symptoms.  Far too often the failure to recognize and treat the underlying conditions of the psychotic behavior can lead to long-term use of potentially harmful medications and recurrent bouts of psychosis.

I encourage mental health advocates to become familiar with the wide array of medical conditions and substances known to induce symptoms of psychosis and mania that can be misdiagnosed as bipolar disorder or schizophrenia.

The following is the British Medical Journal’s guideline for Best Practice Assessment of psychosis, click here for more information on Best Practice Assessment of psychosis and mania.

Best Practice:  Assessment of psychosis

BMJ:  helping doctors make better decisions

Step-by-step diagnostic approach

The evaluation of the acutely psychotic patient includes a thorough history and physical examination, as well as laboratory tests. Based on the initial findings, further diagnostic tests may be warranted.

Organic causes must be considered and excluded before the psychosis is attributed to a primary psychotic disorder.

The most common cause of acute psychosis is drug toxicity from recreational, prescription, or OTC drugs.

Patients with structural brain conditions, or toxic or metabolic process presenting with psychosis, usually have other physical manifestations that are readily detectable by history, neurological examination, or routine laboratory tests.

Brain imaging is reserved for patients with specific indications, such as head trauma or focal neurological signs. The routine use of such imaging is unlikely to reveal an underlying organic cause and is not recommended.

Medical history

A careful medical history should be taken to identify possible organic causes of the psychosis. This should be considered even if the patient has a known primary psychotic disorder, as organic and psychiatric causes can co-exist. Key features of the history include:

• History of recent or past head trauma: a recent head trauma should raise suspicion of a subdural haematoma. Previous head trauma may cause a seizure disorder and increases the risk of schizophrenia.
• Recent seizures or a known history of a seizure disorder: it is important to establish the timing of psychosis in relation to seizure activity (postictal, ictal, and interictal).
• Neurological symptoms: key symptoms that should prompt suspicion of organic CNS disease include new-onset headaches or changes in headache pattern, focal weakness or sensory loss, visual disturbance (double vision or partial vision loss), and speech deficits, including dysarthrias and aphasias. Abnormal body movements, memory loss, and tremor in older patients should prompt suspicion of dementia. Fluctuating consciousness suggests that delirium is present.
• Recreational drug use: any recent use of alcohol, cocaine, cannabis, amphetamines, or phencyclidine should prompt suspicion of drug-induced psychosis. A history of heavy alcohol, benzodiazepine, or barbiturate use followed by abrupt cessation should raise suspicion of a withdrawal syndrome, especially if the onset is abrupt.
• Prescription medications: common offending medications include anticholinergic drugs, dopamine agonists, corticosteroids, adrenergic drugs (stimulants, propranolol, clonidine), and thyroid hormones. It is important to establish when any new drugs were started, or when doses were changed, and how the timing relates to the onset of symptoms.
• OTC medications: common offending drugs include dextromethorphan, antihistamines, and medications containing phenylpropanolamine, especially if used chronically or at very high doses.
• Exposure to heavy metals: if the main water supply is from a well or the patient has any occupation or hobby that involves chemical or heavy metal exposure, heavy metal poisoning should be suspected. Physical symptoms of lead toxicity include nausea, vomiting, diarrhoea, anaemia, weakness in limbs, and convulsions. Common symptoms of arsenic poisoning are vomiting, diarrhoea, kidney failure, pigmentation of soles and palms, hypersalivation, and progressive blindness. Mercury toxicity presents with symptoms of metallic taste, hypersalivation, gingivitis, tremors, and blushing. Psychosis with mercury toxicity is rare.
• Exposure to organophosphates: a history of the use of pesticides (especially in farm workers) should prompt suspicion of organophosphate poisoning. The diagnosis is clinical. There is often an initial acute cholinergic crisis and an intermediate phase of respiratory paralysis (24 to 96 hours), followed at 1 to 3 weeks by neuropathy. Physical symptoms and signs include bronchospasm, nausea and vomiting, blurred vision, diaphoresis, confusion, anxiety, respiratory paralysis, and extrapyramidal symptoms.
• Dietary history: the use of extreme diets (such as vegan diets), eating disorders, or malnutrition related to alcoholism, drug dependence, or deprivation increases risk of vitamin deficiencies. Deficiencies of vitamin B12, folate, thiamine, and niacin can all cause psychosis. A malabsorption syndrome may produce changes in bowel habit.
• Recent surgery: hypoxia should be considered if an acute psychosis occurs during the postoperative period.
• Family history may reveal a genetic-based neurological, metabolic, or autoimmune disorder in a first-degree relative. Wilson’s disease is the most common inherited cause of psychosis. A history of a primary psychotic disorder in a first-degree relative may also be present.
• Travel history: if infectious encephalitis is suspected as the cause, a travel history is important to assess the risk of exposure to infectious causes, such as parasites (rare in the US).
• Click here to view full article

Creating opportunities for parent empowerment: program effects on the mental health/coping outcomes of critically ill young children and their mothers.

Pediatrics. 2004 Jun;113(6):e597-607.

Melnyk BM, Alpert-Gillis L, Feinstein NF, Crean HF, Johnson J, Fairbanks E, Small L, Rubenstein J, Slota M, Corbo-Richert B.

Source

School of Nursing, University of Rochester, Rochester, New York 14642, USA. bernadette_melnyk@urmc.rochester.edu

Abstract

OBJECTIVE:

Increasing numbers of children in the United States (ie, approximately 200 children per 100,000 population) require intensive care annually, because of advances in pediatric therapeutic techniques and a changing spectrum of pediatric disease. These children are especially vulnerable to a multitude of short- and long-term negative emotional, behavioral, and academic outcomes, including a higher risk of posttraumatic stress disorder (PTSD) and a greater need for psychiatric treatment, compared with matched hospitalized children who do not require intensive care. In addition, the parents of these children are at risk for the development of PTSD, as well as other negative emotional outcomes (eg, depression and anxiety disorders). There has been little research conducted to systematically determine the effects of interventions aimed at improving psychosocial outcomes for critically ill children and their parents, despite recognition of the adverse effects of critical care hospitalization on the nonphysiologic well-being of patients and their families. The purpose of this study was to evaluate the effects of a preventive educational-behavioral intervention program, the Creating Opportunities for Parent Empowerment (COPE) program, initiated early in the intensive care unit hospitalization on the mental health/psychosocial outcomes of critically ill young children and their mothers.

DESIGN:

A randomized, controlled trial with follow-up assessments 1, 3, 6, and 12 months after hospitalization was conducted with 174 mothers and their 2- to 7-year-old children who were unexpectedly hospitalized in the pediatric intensive care units (PICUs) of 2 children’s hospitals. The final sample of 163 mothers ranged in age from 18 to 52 years, with a mean of 31.2 years. Among the mothers reporting race/ethnicity, the sample included 116 white (71.2%), 33 African American (20.3%), 3 Hispanic (1.8%), and 2 Indian (1.2%) mothers. The mean age of the hospitalized children was 50.3 months. Ninety-nine children (60.7%) were male and 64 (39.3%) were female. The major reasons for hospitalization were respiratory problems, accidental trauma, neurologic problems, and infections. Fifty-seven percent (n = 93) of the children had never been hospitalized overnight, and none had experienced a previous PICU hospitalization.

INTERVENTIONS:

Mothers in the experimental (COPE) group received a 3-phase educational-behavioral intervention program 1) 6 to 16 hours after PICU admission, 2) 2 to 16 hours after transfer to the general pediatric unit, and 3) 2 to 3 days after their children were discharged from the hospital. Control mothers received a structurally equivalent control program. The COPE intervention was based on self-regulation theory, control theory, and the emotional contagion hypothesis. The COPE program, which was delivered with audiotapes and matching written information, as well as a parent-child activity workbook that facilitated implementing the audiotaped information, focused on increasing 1) parents’ knowledge and understanding of the range of behaviors and emotions that young children typically display during and after hospitalization and 2) direct parent participation in their children’s emotional and physical care. The COPE workbook, which was provided to parents and children after transfer from the PICU to the general pediatric unit, contained 3 activities to be completed before discharge from the hospital, ie, 1) puppet play to encourage expression of emotions in a nonthreatening manner, 2) therapeutic medical play to assist children in obtaining some sense of mastery and control over the hospital experience, and 3) reading and discussing Jenny’s Wish, a story about a young child who successfully copes with a stressful hospitalization.

OUTCOME MEASURES:

Primary outcomes included maternal anxiety, negative mood state, depression, maternal beliefs, parental stress, and parent participation in their children’s care, as well as child adjustment, which was assessed with the Behavioral Assessment System for Children (parent form). RESn (parent form).

RESULTS:

COPE mothers reported significantly less parental stress and participated more in their children’s physical and emotional care on the pediatric unit, compared with control mothers, as rated by nurses who were blinded with respect to study group. In comparison with control mothers, COPE mothers reported less negative mood state, less depression, and fewer PTSD symptoms at certain follow-up assessments after hospitalization. In addition, COPE mothers reported stronger beliefs regarding their children’s likely responses to hospitalization and how they could enhance their children’s adjustment, compared with control mothers. COPE children, in comparison with control children, exhibited significantly fewer withdrawal symptoms 6 months after discharge, as well as fewer negative behavioral symptoms and externalizing behaviors at 12 months. COPE mothers also reported less hyperactivity and greater adaptability among their children at 12 months, compared with control mothers. One year after discharge, a significantly higher percentage of control group children (25.9%) exhibited clinically significant behavioral symptoms, compared with COPE children (2.3%). In addition, 6 and 12 months after discharge, significantly higher percentages of control group children exhibited clinically significant externalizing symptoms (6 months, 14.3%; 12 months, 22.2%), compared with COPE children (6 months, 1.8%; 12 months, 4.5%).

CONCLUSIONS:

The findings of this study indicated that mothers who received the COPE program experienced improved maternal functional and emotional coping outcomes, which resulted in significantly fewer child adjustment problems, in comparison with the control group. With the increasing prevalence of attention-deficit/hyperactivity disorder and externalizing problems among children and the documented lack of mental health screening and early intervention services for children in this country, the COPE intervention could help protect this high-risk population of children from developing these troublesome problems. As a result, the mental health status of children after critical care hospitalization could be improved. With routine provision of the COPE program in PICUs throughout the country, family burdens and costs associated with the mental health treatment of these problems might be substantially reduced.

PMID:

15173543

[PubMed - indexed for MEDLINE]

Coming Off Psychiatric Drugs: A Harm Reduction Approach with Will Hall

Psychiatric medications can sometimes be very useful, but there is often little information or guidance when the risks and harm start to outweigh the benefits. Will Hall provides an introductory overview of how to come off psychiatric medication.

The Harm Reduction Guide to Coming Off Psychiatric Drugs can be downloaded for free here: http://willhall.net/comingoffmeds.

Also available in Spanish, Greek, and German. Disponible tambien en español.
Will Hall is a survivor of a schizophrenia diagnosis who today works as a therapist and teaches internationally on mental diversity, including psychiatric medication. This video provides some basic guidance for anyone considering reducing or coming off psychiatric medications and their supporters, and is discussed in greater detail in the Harm Reduction Guideto Coming Off Psychiatric Drugs.

You can contact Will at http://www.willhall.net



Disclaimer: This video is for educational purposes and is not medical advice. While everyone is different, coming off medications, especially abruptly, can sometimes be dangerous. Seek support when possible and use caution.

For more information on psychiatric medications and withdrawal, go to http://www.beyondmeds.com, http://www.willhall.net/comingoffmeds, http://www.madinamerica.com, http://www.comingoff.com, http://www.peter-lehmann-publishing.com, and http://www.theicarusproject.net/comingoffmeds.
This video is Creative Commons copyright 2012 BY-NC-ND; you are free to share.

Thanks to Kent Bye, Jen Gouvea, and Jonathan Marrs for production.

Voices of the Heart Conference 2011: Will Hall