Conflicts of Interest

The following story was recounted to me by someone who was there:

He was indignant. Outraged, even. He was a department chair. A prominent psychiatrist and author of textbooks. A Key Opinion Leader in the field. How dare the New York Times question him?

The psychiatry residents sat in silence as he went on his rant. Every other medical specialty does the same thing! How come they didn't go after the orthopedic surgeons or the cardiologists, who made much more money from industry relationships than psychiatrists? They went after psychiatry and psychiatrists because of the stigma surrounding mental health. And what is this whole conflict of interest business, anyway? The New York Times even had an article on Michelle Obama's clothing retailer having a conflict of interest. It's ridiculous! And the senator who started all this, Senator Grassley? What about all of his campaign contributions? Does he have conflicts of interest?

He had more choice words for the Times and for Senator Grassley, but you get the idea. His mindset seemed to be that because what he was doing would ultimately help patients, he was beyond reproach as long as he was not committing any crimes. Since funding was limited, what was wrong with working with industry? When all the other specialities make more than psychiatrists, why shouldn't psychiatrists take part in entrepreneurial activities?

Not surprisingly, he is no longer the department chair. However, five years later, this mindset about conflicts of interest still remains with some (many?) of psychiatry's leaders. How else to explain the recent revelations about David Kupfer, chair of the DSM-5 task force? He failed to disclose that he was part of a company making a dimensional assessment for depression, both during the DSM-5 process and on an article that he co-authored with his business partner, statistician Dr. Robert Gibbons, who seems to be creating a commercial product with public money.

The ends do not justify the means. Just because someone else is doing it doesn't make it right. These may be rote lessons from childhood, but it seems that some people have conveniently forgotten them. In my opinion, this most likely happens not because of greed, but when people truly believe that they are doing good; therefore they must be good, and their critics must be bad. Narcissism is a powerful and dangerous thing.

The Risks to Adolescents of Legalizing Marijuana

2014 is a banner year for proponents of marijuana legalization, with cannabis becoming legal in Colorado and Washington state. The upcoming Super Bowl will go down in history as the Marijuana Bowl. Even President Obama has weighed in, saying in a New Yorker profile that he believes marijuana is less dangerous than alcohol "in terms of its impact on the individual consumer."

I acknowledge that there are probably going to be societal benefits to decriminalizing cannabis. Fewer people would be locked up on minor drug charges, police departments can devote their resources elsewhere, and there would be higher revenues for states. I also believe that most adults can smoke weed responsibly without abusing the privilege.

However, what I don't see mentioned much in the popular press is the deleterious effect of marijuana on adolescent brains, and how the drug could fundamentally alter a young person's life. As a psychiatric resident working in a university hospital ER, I saw a slew of college students who became extremely paranoid and had disturbing hallucinations after taking just a few hits of marijuana. At first, I and some of the other doctors thought that their weed had to have been laced with amphetamines, but all of their urine tests came back positive only for THC's. Since I've completed my training, I have seen numerous people in their late teens and early 20's with no family history of schizophrenia, who became very psychotic after months or years of regular cannabis use. Sadly, the psychosis does not always go away even after they stop smoking.

For the past decade, there has been convincing evidence that cannabis use is correlated with higher rates of psychosis. What was not clear was whether this correlation meant causation, as it was also plausible that people who go on to develop psychosis like to use cannabis to self-medicate. However, study after study has now shown that people who use cannabis earlier in adolescence (or use more of it) also develop psychosis earlier, with the same effect not being true for alcohol or tobacco, strongly implying that cannabis causes psychosis.

One of the latest studies, published in December 2013, had the following results:

The prevalence of psychosis and schizotypal personality disorder increased significantly with greater cannabis use in a dose-dependent manner. The associations between cannabis use and psychosis were 1.27 (95% CI 1.03-1.57) for lifetime cannabis use, 1.79 (95% CI 1.35-2.38) for lifetime cannabis abuse, and 3.69 (95% CI 2.49-5.47) for lifetime cannabis dependence. There was a similar dose-response relationship between the extent of cannabis use and schizotypal personality disorder (OR=2.02 for lifetime cannabis use, 95% CI 1.69-2.42; OR=2.83 for lifetime cannabis abuse, 95% CI 2.33-2.43; OR=7.32 for lifetime cannabis dependence, 95% CI 5.51-9.72). Likelihood of individual schizotypal features increased significantly with increased extent of cannabis use in a dose-dependent manner.

Even if the worst-case scenario of psychosis does not occur, there's the potential for other harmful outcomes. I have had patients who became physically dependent on cannabis to the extent that they felt nauseated and could not keep food down unless they have smoked. Not surprisingly, cannabis use also appears to be correlated with lower educational attainment, especially for those who started using before age 15.

Already, even before it had been legalized anywhere, there were some unsettling trends among teenagers when it comes to marijuana. The good news is that teenage use of alcohol, tobacco, and most illicit substances is trending down. However, use of marijuana has steadily increased in recent years, such that it is now the second-most abused substance after alcohol. Teens are also increasingly perceiving marijuana as being not so risky, with the percentage of 12th graders who see regular marijuana use as posing "great risk" decreasing from about 56% to 42% between 2006 ad 2012. And now, with the legalization of cannabis in some states and comments like those from our President, the perceived risk will only continue to decrease.

What are the societal and ethical implications of this? Perhaps marijuana is safer for most people than alcohol or tobacco. But for those who are susceptible to the psychosis-inducing effects of marijuana, its effects can be horrendous. Is it acceptable to permanently mess up some people's minds for the enjoyment of many? Strange how this is starting to sound like the NFL and the concussion issue. In the New Yorker interview, Obama had this to say about pro football and concussions:

"At this point, there’s a little bit of caveat emptor," he went on. "These guys, they know what they’re doing. They know what they’re buying into. It is no longer a secret. It’s sort of the feeling I have about smokers, you know?"

Do all these young people who are regularly using marijuana have a similarly informed view of what they're buying into?

My Favorite Blog Posts From 2013

As we approach the new year, I would like to reflect on some of my favorite posts from 2013. If you're new to this blog, I think these articles should hopefully give you a sense of what I enjoy writing about. Here they are, in chronological order:

A Most Influential Professor (5/19/13)
I probably would not have become a psychiatrist if not for how my undergrad Abnormal Psychology professor made the class so fascinating. And yet, the more I learn, the more I feel he had a very limited perspective.

Psychiatry Leadership: Uneasy Lies the Head that Wears a Crown (6/7/13)
I was disappointed — but not all that surprised — by how much more cogent psychologist Gary Greenberg was compared to APA president Jeffrey Lieberman and NIHM director Thomas Insel during an NPR Science Friday debate about the DSM-5.

A Chilling Encounter (6/11/13)
A story about interviewing a teenage psychopath in the psych ER. I hope I was able to convey why I felt chills down my spine during the encounter.

Movie Review: The Bling Ring (7/12/13)
I really enjoyed this movie and found it to be a funny satire of adolescent vanity and vapidity. I was surprised that some reviewers thought Sofia Coppola took a neutral stance toward her subject matter. I thought she was anything but neutral, and I even found some YouTube evidence supporting my view.

Hmm…looking at this list, perhaps I should stick to blogging during the spring and summer months…

Thanks to everyone for visiting this blog, and I wish you all a Happy New Year!

In Whom Does Mental Illness Reside?

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

Dara was a teenage girl prone to outbursts, mainly at home. Her parents have been divorced for many years, and she mostly lived with her mother, a well-heeled professional. Every single week presented another crisis. Dara would refuse to go to school if she did not get up on time. She would push or hit her younger sister Lisa for no apparent reason. She would get so mad at her mother that she would write "I hate you" on the side of their house in permanent marker. Her mother made an appointment for her after discovering that she had written in her diary that she wished she were dead.

When I met individually with Dara and asked her about these outbursts, she was always quick to blame Lisa for provoking her or her mother for being mean to her. She told me about how she feels her mother always favored her sister over her. She could not tell me one thing that she enjoyed doing with her mother, and she felt that her mother has never liked her. With her mother and sister, she was irritable, easily upset. However, when she was with her father or her friends, she was usually cheerful, and that was how she appeared to me during most of our visits. She has never been depressed most of the time for more than a day, and she explained that she wrote that she wished she were dead after an argument with her mother, but she has never thought about killing herself. She has never had any grandiosity, elevated mood lasting more than a few hours, or decreased need for sleep, although she stayed up late reading Harry Potter.

Dara's mother always showed up to our appointments with a stoic, unchanging expression. Over the course of several visits, I tried to find out more about her relationship with her daughter. I eventually learned that she had grown up with a mother who had an explosive temper and was verbally and physically abusive. She has not visited her mother in years, and it appears that she learned to control (or suppress?) her feelings without ever letting them out like her mother did. Dara's mother readily admitted that her daughter reminded her a lot of her own mother; she has felt this way ever since Dara was a colicky infant whose cries kept her awake most of the night for months.

When I asked Dara's mother what she thought was going on with Dara, she told me matter-of-factly: "I believe that my daughter has a mental illness, and that she needs help. I think she might have bipolar disorder, and she should be on a medication for her mood swings."

I did not end up prescribing Dara any medication besides recommending melatonin to help her sleep earlier. I tried to work with Dara and her mother on understanding each other better and de-escalating their conflict. Dara's outbursts gradually decreased in frequency, though I got the sense that both mother and daughter were still walking on eggshells. I began talking with them about seeing a family systems therapist, and neither one warmed up to the idea. After a few months, they stopped following up with me, and I do not know if Dara eventually ended up being put on medications.

So is Dara really mentally ill? Or do both mother and daughter have a mental illness? Would the issue best be characterized as a behavioral problem instead? Or a parent-child relational problem?

I had been thinking about this patient story for months now, but what finally motivated me to write about it was Dinah's recent post over at Shrink Rap in which she shared:

I'm a psychiatrist, and I confess, I have no idea who these "mentally ill" are.  I think if you asked many people in treatment about being mentally ill, they might think you are talking about someone else.  People may not think the term applies to them because they don't have the insight to realize they are sick.  Or, they may not think of themselves as mentally ill because with treatment, they've gotten better. […] It might not occur to a patient to identify themselves as "the mentally ill" even if they take medicine and go to therapy.

When I tried to take her poll on "Who are the Mentally Ill," I realized that I wanted to say "False" to most of the questions (e.g. "Anyone who takes a psychiatric drug prescribed a by primary care doctor is mentally ill"), but I could not fully explain to myself why or how I reached that conclusion. However, I gained some much-needed clarity from reading Dr. Steven Reidbord's very thoughtful post, which concluded:

Since "mentally ill" obscures as much as it clarifies, perhaps no one should be labeled this way.  Indeed, only in psychiatry can a person be declared ill by someone else.  In the rest of medicine, it’s self-descriptive.   In my view, "the mentally ill" harbors too many unstated implications and vaguely shared assumptions regarding whom we are talking about.  Legal restrictions and entitlements should be based on more concrete standards — and actually, they are.  "Mental illness" is more of a rhetorical flourish, a bit of hand-waving when it’s difficult or inconvenient to pin down specifics.

Dr. Reidbord articulated what I long felt, which is a discomfort with the term "mental illness." Thinking back on my own interactions with my patients, I cannot recall ever telling a patient that she has a mental illness. It's just not useful from a clinical perspective.

Brooklyn Castle Movie Review

I recently had the pleasure of watching Brooklyn Castle, one of the most delightful and moving documentaries that I have ever seen. It follows a group of students on the chess team of Intermediate School (I.S.) 318 in Brooklyn, which is perennially one of the best in the country, even though I.S. 318 is a public school where over 60% of families in the district are living below the poverty line. The New York Times review introduces us to the documentary's young subjects:

Rochelle Ballantyne dreams of being the first female African-American chess master; Alexis Paredes hopes to be a lawyer or doctor so he can ease the burdens of his immigrant parents. The dreadlocked newcomer, Justus Williams, might be a chess genius; Patrick Johnston, who has attention issues, just wants to raise his ranking. Pobo Efekoro helps his mother with her day care business.

Dovetailing with my last post, this film illustrates the importance of having caring adults involved in the lives of children and adolescents. Other reviews have highlighted the important roles that chess teacher Elizabeth Vicary and assistant principle John Galvin play in their students' lives, as well as how budget cuts threaten important programs like I.S. 318's chess team. Here, I would like to highlight another aspect of Brooklyn Castle that was striking to me, and that is the interaction between these students and their parents.

As a child psychiatry trainee, I attended multiple lectures on the importance of authoritative parenting, which refers to parents who have a warm relationship with their children but also set reasonable limits; who have high expectations and try to provide their children with the tools to succeed. The parts of this film that show the students interacting with their parents, while brief, are wonderful illustrations of the authoritative approach.

On more than one occasion, the film shows families sitting at a meal together having a conversation, which by itself is an important protective factor. Rochelle's mother repeatedly emphasizes the importance of her having an education. Alexis's mother reassures him that he does not have to find a job after high school, that he can go to college because that is why she and his father work so hard. She cries tears of joy when she finds out that Alexis had been accepted to a good high school. Pobo, who lost his father at a young age, shoulders his responsibilities at home without complaint. Patrick's mother acknowledges how hard things must be for him and participates in a fund drive to raise money for the chess team.

My favorite moment came when Justus lost a match and called his mother on the phone. He says hesitantly, "I lost a pawn, and then I just…fell apart after." She clearly hears how upset he is, and she validates what he is feeling, saying, "You're upset, right?" When he answers in the affirmative, she reassures him and encourages him to persevere: "Yeah, I can tell. That's ok. Just pick yourself up, it happened." She then says, "Boy, I feel down too I'm not gonna lie." She says this in such a way that is not blaming him for making her feel bad, but to share with him that she understands what he is feeling. This conversation, which lasts less than 30 seconds, can be used in a instructional video to show parents how they should approach their children who are upset.

As a whole, Brooklyn Castle is uplifting and joyous, but also a reminder of the dedication and effort that it takes to help children succeed. Just one last random nugget that I loved: where else are you going to see a kid rap about conquering his opponents in a chess match?