Sunday, July 29, 2007

Driving Out Peds Will Also Increase Chronicity

The sole prevention of suicide lies with the long term treatment of its associated disorders. Peds will likely see mild or moderate severity ranges of depression. By driving out peds, by denying access to care for the mildly severe patients, delays in treatment ensue.

The longer the patient stays sick, the longer the toxic effects of the illness impact the brain. Such patients are harder to treat, more treatment resistant, take longer to recover. Suicide is only one fatal outcome of depression. The other is increased risk for heart disease and for sudden death.

The irresponsible FDA black box warning, by causing delays in the treatment of mild patients may result in greater chronicity of depression, and its associated medical consequences, including sudden death rate. The increase in sudden death may turn out to exceed the increase in the suicide rate.

Saturday, July 28, 2007

FDA Black Box Warning and Increase in Teen Suicide

The FDA issued a black box warning about SSRI's causing suicidal ideas. Perhaps, they occurred in 2% of placebo patients and 4% of SSRI patients. The counts included trivial self-injuries such as slapping oneself. No suicide took place in any reviewed study.

As a result of such warnings, pediatricians and general practitioners decreased their prescribing of the SSRI's. Psychiatrists, with more knowledge and confidence, ignored this idiotic black box warning. As a result of the decrease in total prescriptions to adolescents, the suicide rate stopped dropping, and for the first time in decades, increased. There have been 100's of needless, excessive suicides in teens, as a result.

Now, if one my decisions kills 100's of people, I should resign from my job. No? I made that point to a friend on that FDA Advisory Committee.

He replied. The Committee faced 80 raucous, threatening witnesses with extreme views. These included left wing ideologue doctor wackos. They included grieving parents blaming SSRI's for their child's suicide. They included parents of Columbine victims blaming SSRI's for the massacre.

The Committee faced loud calls for the banning of SSRI's entirely. The black box warning represented a middle ground decision made in the face of horrendous bullying.

The irresponsible bullies and wackos who testified now have blood on their hands. Beyond the few children murdered at Columbine, these vicious, bullying, scapegoating, misleading Columbine parents now assassinated a number of children 100's of times greater than the Columbine mass murderers.

SSRI's boost serotonin. It inhibits dopamine. Dopamine inhibition causes restlessness and an irritated mood that are very uncomfortable. People punch walls, drive at 120 mph, and can't stop yelling in order to get relief. If one has not been warned of agitation as a side effect, and one is depressed and impulsive, one does not tolerate the discomfort.

One should warn patient that 1 in 30 patients gets agitated, most likely the first day, and that the drug should be stopped.

Is there such a really useful warning to that effect? No.

When left wing ideologue doctor wackos, and vicious, vengeful parent bullies prevail at a hearing, 100's of innocent teens die, and the really useful warning does not appear.

Tuesday, July 3, 2007

Timing of Treatment and Suicide Attempts

This study shows the rate of suicide attempts highest before the start of treatment, followed by the rate the first month of treatment, and declining thereafter. The type of treatment correlates with the absolute rate, likely because of a correlation with severity of depression. Thus treatment by family doctors with antidepressants had lower rates of attempts than treatment with psychotherapy.

The study also implies, the course of depression determines the rate of suicide attempts. At long periods of treatment and improvement progress, the attempt rate decreases. The study rebuts any assertion that anti-depressants cause suicide attempts.

A reasonable editorial adds perspective.

Monday, July 2, 2007

Sunday, July 1, 2007

The Plaintiff Legal Case

From:Robert K. Jenner and Bryant Welch, Suicide watch: liability for negligent psychiatric care, Trial, 37(5), 2001.

1) Mentally ill patients receive negligent care for their life threatening behavior. The foreseeable result is death. Should the court allow defenses of contributory negligence or assumption of the risk when patients die from the very behaviors for which they sought treatment? The courts have said, no. (Brandvain v. Ridgeview Inst., Inc., 372 S.E.2d 265. Ga. Ct. App. 1988, and McNamara v. Honeyman, 546 N.E.2d 139. Mass. 1989).

2) A New Jersey patient flung herself from a height in the hospital. The defense appealed the failure of the judge to give the jury an instruction on the contributory negligence defense. The appellate court found, contributory negligence, in any sense, was not a relevant issue. The duty to exercise reasonable care to prevent her from engaging in self-damaging conduct; because it would serve to excuse defendants’ own failure to exercise reasonable care, such conduct by the plaintiff could not be the basis of a contributory negligence defense." Cowan v. Doering, 522 A.2d 444, 450. N.J. Super. Ct. App. Div. 1987. "The acts which plaintiff’s mental illness allegedly caused him to commit were the very acts which defendants had a duty to prevent, and these same acts cannot, as a matter of law, constitute contributory negligence."

The concurring appellate courts of other states want to prevent, "strict nonliability" for mental health care professionals. They "recognized a "special relationship" between mental health patients and professionals who are deemed to have training and expertise that enables them to detect mental illness or the potential for suicide and who have the power or control necessary to prevent attempts at suicide,... so long as the suicide was reasonably foreseeable, and the defendants breached the applicable standard of care."

The plaintiff lawyer authors assert, "With the assistance of expert testimony, the plaintiff attorney should be able to explain that a mentally ill person can be expected to care for himself or herself only to the extent that the patient’s diminished capacity permits. As the suicidal patient’s capacity decreases, the medical provider’s responsibility increases."

Then, the lawyers state, "A competent psychiatrist will take an extensive history of the patient and make an assessment of all the risk factors in the context of the other current psychiatric symptoms before agreeing to a discharge. If the doctor makes a cursory assessment and, as is often the case today, simply discharges the patient because of pressure from a managed care company, that psychiatrist may be liable for malpractice. If the assessment is done properly, in the vast majority of cases, suicide can be prevented."

They propose excluding jurors who believe in personal responsibility for one's intentional acts, or that suicide is a sin.

From Law and the Mental Health System, 4th Ed., by R. Reisner, C. Slobogin, A. Rai, West, St. Paul, MN. pp. 729-731.

The prediction of violence has an 80% false positive rate. The lawyer argues that predictive studies also result in intervention, preventing the violent act. The overwhelming majority of patients attempting suicide were glad someone stopped them. The suicide attempt is an attempt to improve one's life. The degree of compentency is irrelevant. The burden of proof is "clear and convincing" (about 2 of 3 times likely). There is no right to commit suicide, and the liberty to do so does not fall under the protection of the Due Process Clause. Nor is any right to receive assistance in doing so (Washington v Glucksberg, 521 U.S. 702, 117 S.Ct. 2258, 2269, 2271, 138 L.Ed. 2d 772 (1997)).