The Da Vinci Code of DSM-V revealed Wednesday

The Diagnostic and Statistical Manual of the American Psychiatric Association, or DSM, is the compendium of mental disorders that psychiatrists, psychologists, and social workers use to describe the state of their patients, clients, and sometimes their family members (though they really shouldn’t). The DSM is currently in its fourth edition, “DSM-IV.” However, after over ten years of meetings, a fifth edition is on the way, slated for May 2013, a draft of DSM-V will be released this Wednesday, February 10.

There have been a few concerns about the DSM-V and even accusations from former APA directors that the process has been shrouded in secrecy, a veritable Da Vinci Code of psychiatry! Anyways, all will be revealed Wednesday. In addition to being based more on models suggested by empirical research (research based on disorders listed in the DSM-IV), word has it that there will also be a severity dimension for symptoms (currently symptoms are dichotomous), some sort of accommodation to the frequent comorbidity a disorders (e.g., the reported 80% comorbidity for PTSD with major depression), a “hypersexuality disorder” (oh my), and some reconceptualization of how to deal with those “culturally-bound syndromes” (see January 10 post) at the back of the book.

Here’s the news story from The Economist. Here’s the site for the DSM-V from the American Psychiatric Association.

Richer refugees living in cities? A review of refugee trends presented in the Lancet

The Lancet’s special issue on Violent Conflict and Health (featured in the last three posts in this blog) includes required reading for refugee professionals examining trends in health-care needs among conflict-affected populations. The article, “Health-care needs of people affected by conflict: Future trend and changing frameworks,” is a collaborative effort between researchers at the UN High Commissioner for Refugees, the London School of Hygiene and Tropical Medicine, and the International Rescue Commission.

Recent trends include an increase in internally-displaced persons and a decrease in refugees — essentially due to an increase in intrastate conflicts. The concept of refugees fleeing across borders to escape wars between armies is old hat. Much more likely now is the armed conflict that happens within regions of countries, leading primarily to internal displacement. The best example of this is in a nation not often thought of in the refugee cannon. Currently, this country in home to the largest displaced population in the world… Give up? Colombia.

Two trends cited by the paper are worth thinking about a little bit: (1) the urbanization of refugees and (2) higher baseline development index of refugees’ countries of origin.

The urbanization of refugees refers to those people who flee their country and settle in cities rather than in refugee camps. You can think of Somalis in Nairobi (Kenya) and  Zimbabweans in Johannesburg (South Africa). Here’s a chart from the article showing the trend in the growth of urban refugees, 1996-2008. The aqua bar at the bottom is the number of refugees in camps, the next bar (is that khaki?) is the urban population, and the olive bar is the number in rural areas.

Where Refugees Live

Note the jump in the middle bar between 2005 and 2006 on to 2007. What major refugee crisis was coming to head these years? Well, the second largest refugee population in the world (1.9 million last I checked) was from Iraq, and many many many of those are in Damascus, Syria, and Amman, Jordan. So, the urbanization of refugees is certainly a trend in terms of numbers, but this chart doesn’t really tell us much beyond the fact that the Iraq War resulted in a large urban refugee population in neighboring countries. As Iraqis return home (as many have been doing for a year or so now) we shall see whether the urbanization trend is as strong as this article contends.

My guess is that urbanization of refugees is increasing, but that if you removed Iraqi refugees from these data, urbanization would be increasing at a lot slower rate than it appears here (perhaps at the rate urbanization is increasing in general). In any case increasing urbanization of refugees means that aid groups need to shift their strategies for needs assessment and service delivery; a group of refugees that is living dispersed throughout a city is much harder to find and help than a group living enclosed within the well-defined confines of a camp.

Contrast this with the trend examining the increasing baseline development index of refugee “sending countries” (i.e., the socioeconomic status of places where refugees flee has been increasing over time). Here the authors used the “human development index,” or HDI, presented in the chart below. The blue bar indicates refugees from “low human development” countries, the khaki from “medium and high development” countries.

HDI of Refugee Sending Countries

Here too we should think about how Iraq fits into this trend, as Iraq was a relatively well-developed country until recently. Note the general annual decrease of the blue bars from 1993 to 2008; here it looks like there was a trend before the emergence of the Iraqi refugee crisis, and so these data seem to present a more reliable trend than urbanization.

Note here that the HDI is a measure of countries, not people. This matters becasue it’s often the poorest who become refugees. For instance, Sudan has a moderate HDI (lots of oil, decent roads in the north), so the destitute farming refugees from Darfur or the rural cattle herders from the South would be evidence of this trend. It’s not the case that refugees are getting richer, only that the nations they flee from are richer. Indeed, there may be evidence in there somewhere for the hypothesis that an increasing income gap between richer and poorer is an important predictor in modern refugee-producing conflicts.

Intimate-partner violence in the Palestinian Territories: Political violence or economic hardship?

The Lancet special issue on Violent Conflict and Health (which included the Darfur mortality report — see previous entry in this blog) includes research undertaken in the Palestinian Territories (the West Bank and Gaza) concerning the association between political violence and intimate-partner violence (i.e., domestic violence).

It’s a truism that violence breeds more violence. There are several versions of this in social science research. The most obvious of these, some version of “if you live by the sword you shall die by the sword,” really doesn’t need hypothesis-testing. A less obvious version involves the association between types of violence. James Garbarino is probably the most eloquent “big picture” writer on this topic, tying together political, criminal, intimate-partner violence (or “IPV”), and child abuse. Garbarino argues that as violence within a community increases, so these other, “lower-level” violent acts increase (“lower-level” in the sense that they involve fewer people, not in the sense that they are less impactful). Garbarino has applied his theoretical analysis to war-affected communities — Sarajevo in the early 1990s — and “urban war zones” — American cities in the late 1980s and early 1990s. A number of sociologists and community psychologists have provided statistical analyses suggesting these phenomena in violent urban neighborhoods, but until recently I’d yet to see this phenomenon assessed statistically during a political conflict.

The authors of the current paper — who include researchers from universities in the US and Israel — use census data collected by the Palestinian National Authority, which evidently included responses to a rather comprehensive battery of questionnaires: measures of exposure to violence (at the hands of the Israeli Defense Forces and settlers), financial hardship, and even the Conflict Tactics Scale — the standard measure of how couples handle disputes, which has an emphasis on intimate-partner violence (hereafter: IPV). The authors analyzed data from a stratified random sample of 3510 women across the West Bank and Gaza, specifically their reports of the types of violence their husband had been exposed to, their own exposure to violence, their families’ economic situation, and IPV perpetrated by their husbands. Of course this data was collected in Arabic using Palestinian interviewers, and done in women’s homes with their husbands elsewhere (as far as I can tell, husbands were also interviewed, but these data are not part of this article).

So, what did they find? The odds that women who reported that their husbands had been exposed to “political violence” also reported that they were subjected to IPV were 1.5 (for psychological IPV), 1.9 (for physical IPV) to 2.25 (for sexual IPV) times that of those who reported that their husbands were not exposed to political violence. In plain English, exposure to political violence was associated with a higher likelihood of every type of IPV as well. So, IPV was explained by exposure to violence, right?

Well, partly, maybe. If I read the tables correctly, rates of IPV were uniformly higher than rates of exposure to violence. 371 women reported some form of sexual IPV and out of 3510, that’s 10.6%; 538 physical IPV, or 15.3%; 1302 psychological IPV, 37.0%. The number of women reporting exposure of their husbands to any type of political violence was 289 — 8.2%. In other words, 63% of the sample reported some form of IPV, but 8% reported exposure to violence… so clearly violence was not the primary cause of IPV.

Following this little back-of-the-napkin, my first thought was, “Wait a minute, they surveyed Gaza and the West bank, included things like being ‘insulted or cursed’ in their definition of violence and still only came away with a rate of exposure to violence of 8%?” I admit to being pretty ignorant about the Israeli-Palestinian conflict, but… 8% seems pretty low. Also, how about other sources of violence? With Fatah and Hamas fighting each other, there must have been some respondents who were exposed to non-Israeli-perpetrated violence, and that too would have had an effect on their family lives, I would imagine. [Note: the data were collected before last year's war between Hamas and Israel in Gaza, so presumably rates of exposure would be greater now.]

My second thought was, “Hm. Perhaps I’m getting distracted by the title, which includes the drama-loaded “political violence” and “intimate-partner violence.” In all fairness, it’s not really the purpose of this paper to push the explanation that the cause of IPV in the West Bank and Gaza was violence, so let’s not ding the authors for not pointing out that IPV was much more common than exposure to violence.” And so, ding them I will not.

I do, however, wish they had made more of another piece of data they collected: household financial data. It turns out that this too had an effect on IPV: odds for those reporting financial hardship were 1.4 for psychological IPV, 1.5 for physical IPV, and 1.6 for sexual IPV (compared to the 1.0 odds for those not reporting financial hardship due to the conflict). So what? Almost half of the women — 1695, or 48% — reported this hardship. Compare this to the 63% rate of IPV. Now we’re getting somewhere.

What’s the problem here? Well, it’s not the data, nor even the authors’ analyses. There are two things that are tricky here. First the effects of violence on IPV (1.5, 1.9, 2.25) are larger than those for economic exposure’s effects on violence (1.4, 1.5, 1.6), but exposure to violence is actually a much rarer occurrence (8% versus 48%). Effect sizes (here odds ratios) indicate the strength of an association, not the breadth of the occurrence of any one of the variables in the association. In other words, if you wanted to reduce IPV in the West Bank and Gaza and you wanted to bet that you would get have an effect, you would try to reduce exposure to violence; but, if you wanted to maximize your chances to reduce IPV for the most people, you would try to reduce economic hardship.

The second tricky thing here is really related to the first: political violence is much easier to sell than economic hardship, so the authors put it (and not economic hardship) in the title. After all, the special issue of the Lancet was not about the health effects of economic hardship, was it? (That’s not to say that the Lancet doesn’t do pretty well on that issue too; it does.) But the issue that draws our attention to conflict — violence — is often not the issue that affects the most people.

Death in Darfur: 20% violence, 80% diarrhea

The latest Lancet is a special issue on Violent Conflict and Health, and includes articles on the connections between political violence and domestic violence, surgery in conflict settings, and a review of mortality surveys from the Darfur conflict.

Darfur has produced more numbers than most conflicts of its nature. Numbers of the dead are at the core of the debate between so-called Darfur advocacy groups (SaveDarfur being the largest) and skeptics who have argued that claims of genocide are grossly oversold and get in the way of facilitating lasting solutions (Mahmood Mamdani being the most prominent of these). The article in the Lancet, by epidemiologists at the Catholic University of Louvain (that’s in Belgium), takes the 12 biggest studies of deaths in Darfur, statistically smushes them together, divides their findings into six time periods between February 2003 and December 2008 according to political events, and then divides deaths into those directly attributable to violence and those attributable to illness.

Although I usually find epidemiology to be a profoundly boring enterprise (although a nonetheless critical one), the data here are remarkably illuminating. The period September 2003 to March 2004 represented the height of violence with a mortality rates due to violence of 2.5 per 10,000, but following this time these rates fell dramatically to 0.3 (April to December of 2004) and then to less than 0.1 since then. Deaths in Darfur continued during this time of course, but the majority were due to diarrhea, not violence. The authors estimate that between 2003 and 2008, a full 80% of all deaths were due to illness among those displaced by the conflict. In other words, this crisis has been 20% violence, the the vast majority of which was done by mid-2004. For the past six years (or really five years in the data reviewed), the problem has been diarrhea.

As stark as these numbers are, this ultimately means that Darfur followed the common pattern of violent internal conflicts: Initial massacres were followed by massive displacement and the loss of protective health systems, and the problems of displacement ultimately affected the well-being of the population more than the direct experiences of violence.

Psychological first aid following the Haitian earthquake: Community support and education, not therapy

There has been a lot of talk among mental health professionals about the psychological consequences of the devastating earthquake that struck Port Au Prince, Haiti, two weeks ago, and just what should be done right now. The answer, it turns out, is not what you might expect.

Check out the National Center for PTSD’s “psychological first aid” suggestions. Their list is comprised of primarily educational measures. Notably, nowhere on the list of things to do in the first weeks following a disaster is psychotherapy as we traditionally think of it. Indeed, nowhere on the list is anything that needs to be done by mental health professionals. The suggestions are pretty much good common sense: seek emotional support from friends, family, religious and other community groups; maintain as predictable a routine as possible for your kids; and although you should stay informed, stay away from sensationalized media coverage. If people are acting anxious, that’s because they are distressed — and that’s normal following a disaster. For most people this distress will decrease when basic needs are satisfied and some measure of stability is reestablished.

This is not to say that mental health professionals should not volunteer their time to help in this crisis. They might work in Haitian communities to educate people about normal reactions, or even organize events to help raise money to rebuild hospitals and schools. An effective mental health professional’s expertise in immediate post-disaster contexts is limited to education. Sending American psychologists to Haiti to do mental health work is not worth the money, given that (1) this type of education can be done by people already there and (2) the resources they would take up in terms of their housing and sanitation would be a net draw on relief efforts.

Why can’t mental health professionals come up with something better than reassuring us to follow our common support mechanisms in immediate post-trauma contexts? Well, two answers: (1) We actually do have the beginnings of what to do in the immediate aftermath of trauma in recent pharmacotherapy research (e.g., previous blog entry), but it’s still pretty uncharted territory. In Haiti applying this research would be impractical in any case as hospitals were destroyed, let alone medications not being available. (2) Attempts to do “emergency psychotherapy” — like critical incident debriefing, which was big in the 1990s and used following 9/11 — have shown to actually over-sensitize people to trauma, resulting in higher rates of trauma-related problems later on. So, as we know that most people exposed to a trauma recover, and indeed, natural disasters result in some of lowest rates of PTSD relative to other types of trauma, our best bet at this point is to educate, and leave people to marshall their own psychological and community resources.

So, support relief efforts in Haiti — but let’s not send the shrinks just yet. They will be needed later on, when it becomes clear who is in the minority that suffers long-term distress. And let’s hope that the urge on the part of mental health professionals to do something hasn’t passed by then, as that’s exactly when it will be needed.

Article review: Morphine as prevention of PTSD among Marines in Iraq

Making minor waves this week is a study in the New England Journal of Medicine (NEJM) showing lower rates of posttraumatic stress disorder (PTSD) among injured soldiers given morphine during emergency medical care. The credibility of the study is strengthened by its use of 696 (i.e., a “large sample”) recent medical records from a well-designed Naval trauma registry used in Iraq (for those of you don’t know the structure of the US military, this would include Marine Corps data as well).

The NEJM morphine article is predicated upon the theory that PTSD is the result of experiencing a traumatic event plus your interpretation of the immediate aftermath of that traumatic event. The worse your immediate reaction to a given traumatic event, the more you associate the memory of that traumatic event with debilitating anxiety (a negative “memory consolidation”), and the more likely you will be to develop PTSD. Several researchers have posited that breaking the association between the trauma and the “peritraumatic” distress (the anxiety “around the trauma”) is the key to preventing the development of PTSD. Most have proposed to do this using medication.

The primary aim of pharmacotherapy is to decrease or impede memory consolidation and the associated conditioned response to fear after a person goes through a traumatic event. (p. 111)

This means that everybody who experiences some traumatic event would have to get the medication — even though not everybody in that group is expected to develop PTSD. In fact, most are expected not to develop PTSD. Numerous studies have shown that no matter what type of traumatic event is considered, none makes more than half of those exposed to that type of event develop PTSD. Among Iraq war soldiers, for instance, rates of PTSD are in the 20% range. Remember that PTSD is a collection of symptoms — intrusive thoughts, flashbacks, etc. — that persist after a month has passed (up until a month, these symptoms are not considered pathological, and for most people, they subside without long-term disability). So, giving medication to everyone who experiences a trauma is a “secondary prevention” strategy — you know someone in the group will develop the problem, but don’t know who, so you give the “cure” to everyone.

Small does of morphine are often used in trauma centers (medical trauma, that is), and lower levels of opioids have been implicated in the development of PTSD (morphine is an opiate, opioids are the human-produced equivalent), and thus the idea that soldiers treated with morphine for their injuries would be less likely to develop PTSD makes sense. Of the 696 injured soldiers, 243 eventually developed PTSD and 453 did not. Of those 243 who developed PTSD, 147 (60%) had received morphine; of those 453 who did not develop PTSD, 346 (76%) had received morphine. Sixty percent compared to 76% may not seem like a big difference to you, but when you do the statistics you come up with an odds ratio of .47, meaning that the odds of developing PTSD were half when given morphine than when not given morphine.

These results stood up to the usual battery of accounting statistically for things like type of combat event, injury severity, amputation, and whether the soldier had a concussion or not (soldiers with more serious traumatic brain injuries were excluded from the review of records). Notably, the rates of serious injury were somewhat higher among those who did not develop PTSD, supporting work by Delahanty (Kent State) showing that the body’s chemical production (specifically cortisol) during more serious injuries actually counteracts the development of PTSD; the presence of injuries on its own (i.e., compared to no injuries) makes it more likely PTSD will develop, but the more serious those injuries are, the less likely it is that PTSD will develop.

Okay, so what? Well, besides the obvious that morphine use following potentially traumatic events might be examined prospectively to get a sense of its potential to specifically prevent PTSD (and not as a by-product of medical care as it was in this study), this study puts into perspective the association of opiate abuse and post-conflict situations throughout history and around the world. From Odysseus in the Land of the Lotus Eaters to the heroin addicts among Vietnam vets and even the old Sikh men I met in Punjab chewing balls of raw opium to deal with memories of the multiple conflicts of that region of India, it seems that soldiers’ self-medication with opiates may have always been a an indication of something their bodies knew they had missed at the time of their trauma. Waxing poetic aside, perhaps studies like this week’s article in NEJM will be able to provide them relief at the time of trauma so that they don’t seek it out later with such debilitating consequences.

Flying monks, talking turtles, brain tumors: A cautionary tale in cross-cultural medicine from Laos

A few weeks ago, a young woman named Chloe Thomas contacted me in response to the placebo series. She has a fascinating real-life cautionary tale in global health: what the clash between Lao traditional medicine and globalized Western medicine means for a man with a potentially operable brain tumor. No easy answers, stories like these are important in illustrating the sticky points and pitfalls of cross-cultural health care.

Last year when traveling through Southeast Asia I was deeply inspired by the beauty of the people of Laos yet frustrated by their lack of access to basic health services. Small and landlocked, Laos routinely places among the lowest in many health and development indicators. I returned, college idealism in hand, dedicated to help in anyway I could. I found a volunteer opportunity with a NGO in the capital, Vientiane. The NGO’s work attempted to preserve Lao traditional medicine for both its cultural heritage and importance as the sole access to healthcare of any kind for most rural and impoverished populations.

I know many of you reading this may share my initial skepticism, traditional medicine as hokum, an almost ignorant naiveté. But approximately 60- 80% of the global population is dependent on medicinal plants to fulfill primary healthcare needs, and in Africa and Asia, this figure may be upward of 80%. This widespread use is most often attributed to confidence in efficacy, accessibility, and affordability. (For those needing further persuasion, information and/or definitions see the WHO’s Traditional Medicine Strategy.) Furthermore, the use of medicinal plants employed by these various cultures is often the first step in the discovery of bioactive compounds that lead to novel drugs[1] – think artemisinin.

As a medical school aspirant I was eager to explore the evidence-based efficacy of traditional medicinal plants and their potential health benefits, as well as understand different cultural perspectives in medicine. Armed with only a BA and having no experience in either the aid world or ethnomedicine, I was aware I needed to reach out to those more capable of undertaking research and inducing change. Promoting the safety and standardization of plants currently being used was, and should be, a priority. I hungrily began reading, researching, and contacting those in the field.

The first few months proved a crash course in aid politics, grant writing and how to tactfully navigate through the Lao bureaucracy. It was also during this time my Director (whom I will henceforth call Mr. Smith) slowly revealed himself as a self-proclaimed master in Lao traditional medicine (though seemingly without formal, or even informal training). I was not too concerned with this, as over 70% of Laotians routinely use traditional medicine. However, when he continued to talk about his ability in the same sentence with flying monks and talking turtles, and then spoke of his life goal of being able cure the sick by simply walking past them, it became clear that this religious conviction and personal ambition would pose a great challenge to any objective approach I made.

Several weeks later, I checked my email to find an attachment from my Director of the medical record of a mid-twenty year-old, complete with a CT scan noting a mass in the right posterior fossa. The clinical impression relayed to me by Mr. Smith (obtained from the patient) was that this was a brain tumor, which without surgery would give the patient only months to live. Although Mr. Smith admitted that he was told the patient would have a good prognosis with an operation, he insisted that he another local traditional medicine practitioner, they could cure him using solely traditional medicine, and that he wanted me to document the progress.

Most likely the patient sought my boss’s care because they could not afford the operation. If this was the case, I was uncomfortable sitting by idly and watching this vulnerable person be used as a human subject to substantiate an experimental treatment. Human lives should be more precious than tools to validate one person’s conviction or to further their ambitions.

What’s worse still is that if the patient had opted for surgery (assuming he could find the means) and it was unsuccessful, Mr. Smith would no longer accept the patient, citing that the traditional medicine treatment would no longer be effective, almost as if it was out of personal vengeance. Choosing to respect one form of treatment should not mean having to reject the other.

Echoing the South African controversy surrounding traditional treatment for AIDS (involving the now deceased Health Minister Manto Tshabalala-Msimang), a myriad of emotions ran through me, bafflement, hostility, frustration. After a heavily emotional argument in which I pressed that we should at least advocate for funds for the operation if money was the sole determinant in the patient’s choice, my Director accused me of not believing in traditional medicine or his ability to cure.

I am not a doctor and still remain unsure about the accuracy of the diagnosis or the validity of the medical team’s consultation. But, I do realize what I was presented with was irresponsible and potentially fatal. While some plants have shown promise in cancer treatments, too many unknowns still remain for me to allow myself to participate in such a high stakes gamble.

No doubt there has been and will continue to be cases such as this. The ethical implications remain thorny, and literature scant (see here for one of the few articles I have found). With the growing use and recognition of the benefits of traditional medicine systems, there is also a growing need for safety, efficacy, quality and rational use. In fact, nationalization of Lao Traditional Medicine is a goal of the Government, and this would undoubtedly necessitate regulation, standardize treatments and hopefully create a governing body to whom malfeasance can be reported. Professionalization among traditional medicine practitioners would also enable a body of educated primary health care providers in the most rural and remote regions. Unfortunately, discerning the tangible from the intangible in these often religiously contextualized treatments will prove harder still.

It’s a sad reality not every person can afford the care they may desperately need. While I will respect this particular patient’s decision, I will only do so if presented with clear and accurate information on his choice, I will not be involved in a situation in which a patient is mislead by the desire of one person’s goal of attaining supernatural ability. My dilemma left me wondering–when do we admit the most realistic options for medical treatment? What’s the middle ground between Western medicine and traditional systems? Can the two ever co-exist in harmony while still respecting the benefits and fundamental beliefs in both systems? Or are there too many differences, areas of profound misunderstanding that make them perpetually destined for conflict. Perhaps my dilemma was just an example of this.

Apart from this instance, most of my experiences working with traditional medicine were positive, forcing me to revaluate my own perception and views of healthcare and medicine. It was challenging finding the delicate balance between science and religion, and acknowledging that my Western train of thought is just one among many world-views. Though I remain without clear resolve on many of the ethical issues that have arisen with the growing use of traditional medicine and alternative treatments, I hope that with more education will come more clarity. However, what I will take into my medical education is the importance of mutual understanding and respect when treating patients humanely and effectively across cultural chasms, for no matter where I work, there is no doubt that I will continue to work with patients whose healing beliefs greatly differ from my own.

Ms Thomas is originally from California, and a graduate from UC Berkeley (2008) in Molecular and Cell Biology. She is currently in the process of applying for medical school in the United States.

————————————–

[1] R. Alves et al., “Biodiversity, traditional medicine and public health: where do they meet?” Journal of Ethnobiology and Ethnomedicine (2007), 3:14

ICE systematically hid the truth on immigrant deaths in detention

The other big story relevant for readers of this blog is the New York Times’ expose on Immigration & Customs Enforcement’s (ICE) systematic cover-up of persistent medical malfeasance in immigration detention facilities. The negligent healthcare available in immigration facilities has long been known and protested by a number of us, but only in the past few years with a number of publicized deaths has it got media attention.

I won’t go into this much, as you can connect to the article here . Make sure you watch the video along the sidebar, “What happened to Boubacar Bah?” I first saw the footage a few months ago (most of it has made the rounds of those of us concerned about detention conditions); it is chilling that this can happen in a land which calls itself a “land of immigrants.” Oh, and if you think this is some holdover from the previous administration, think again: ICE has been on a tear lately, detaining immigrants left and right, and several — one of them a patient of mine, in fact — have significant health problems.

The globalization of American psychology

I know it’s bad form, but I’m going to quote myself, from yesterday’s entry:

For those of us who are trained in the US system and interested in global mental health, I can’t think of anything more important than developing a critique of our own failures. Let’s not globalize American medication or our rejection of empirically supported treatments.

And today, I open up my New York Times magazine, and voila: The Americanization of Mental Illness. (Am I controlling the New York Times through my blog?)

Ethan Watters presents a summary of his soon to be released book “Crazy Like Us: The Globalization of the American Psyche” and it’s worth a read. I won’t rewrite the whole piece here, but his essential argument is the good faith efforts of Euro-American mental health care practitioners is serving to change how people in other cultures view non-normative behaviors, and that’s not all good. He makes it clear that he is not belittling mental illness or the suffering that accompanies it, and that he respects Western medical science’s contribution to examining the mechanisms of mental illness. Here’s his follow-up:

Whatever the trigger, however, the ill individual and those around him invariably rely on cultural beliefs and stories to understand what is happening. Thoe stories, whether they rely on spirit possession, semen loss or serotonin depletion, predict and shape the course of the illness in dramatic and often counterintuitive ways… mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits, and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

This is good cultural psychology, and it’s great to see it’s getting fair play. Watters goes on to present research showing that the mental health literacy movement’s push to destigmatize schizophrenia by presenting it as a “brain disease” actually has the opposite effect, and how the medicalization of mental illness (as opposed to viewing it as a psychosocial problem) can result in the formation of a sufferer identity rather than as someone suffering from an affliction.

I encourage you to read the article, but I can’t resist a few quotes here. A Chinese psychiatrist is interviewed about an epidemic of Western-style anorexia in Hong Kong, and sums up the larger problem thusly:

As Western categories for diseases have gained dominance, micro-cultures that shape the illness experiences of individual patients are being discarded… The current is too strong.

Describing the anemic section of the DSM-IV given to non-Western mental illness categories:

Illnesses found only in other cultures are often treated like carnival sideshows. Koro, amok and the like can be found far back in the American diagnostic manual (DSM-IV, Pages 845-849) under the heading “culture-bound syndromes.” Given the attention they get, they might as well be labeled “Psychiatric Exotica: Two Bits a Gander.”

And here’s the kicker, on our exporting the culture that Judith Warner discussed yesterday:

The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence. These ideas remain deeply influenced by the Cartesian split between the mind and the body, the Freudian duality between the conscious and unconscious, as well as the many self-help philosophies and schools of therapy that have encouraged Americans to separate the health of the individual from the health of the group. These Western ideas of the mind are proving as seductive to the rest of the world as fast food and rap music, and we are spreading them with speed and vigor.

Judith Warner brings together three recent studies (and even placebos!) in biting critique of mental health care in US

In today’s Opinion pages of the New York Times, Judith Warner presents one of the smartest articulations of the problems facing mental health in the popular press that I have ever read. Its timeliness is based on recently released findings out of the University of Pennsylvania published in the Journal of American Medical Association that medication for depression on average doesn’t work better than placebos. Warner explains that it’s not that these medications aren’t powerful, but rather that usually what they are targeting is not that severe. In other words, if you are trying to treat a set of people most of whom are only a little depressed, you are unlikely to see much of an effect because the difference between a little depressed and not depressed is not much. Most people who receive medications are sad, troubled, the “worried well,” but not severely depressed. When you exclude these folks form analyses, you get a group composed of those who are severely depressed, and you see bigger effects of medication. Warner sums up the problem nicely:

And here the truer story about mental health care in America begins to unfold. The trouble is not that the drugs don’t work; it’s that the care is not very good.

Most medication is prescribed by general practitioners (“GP’s”), who do not have expertise in mental health. Without being able to tell the difference between a severe diagnosis and normative sadness or acute, situationally-based depression, it’s not too surprising that GP’s overprescribe. Combined with the ties between famous psychiatrists and drug companies (e.g., the 2009 case of a prominent Harvard psychiatrist taking a lot of money from big pharma over years to plug such meds), this sets up a perfect recipe for providing meds to many many many people who probably could do just as well finding other solutions for their problems.

Warner then touches on psychotherapy, which, it turns out, is cited as a more common treatment for depression than medication, according to another study in the Archives of General Psychiatry. So most depressed people avoid meds, making the previous problem moot… great! Well, Warner then properly turns to the recent damning study in Psychological Science in the Public Interest, which showed that most psychologists do not use empirically supported treatments despite the replication of their effectiveness and the dissemination of their methods through associations like the American Psychological Association. Warner:

This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or findings care that is ineffective.

For those of us who are trained in the US system and interested in global mental health, I can’t think of anything more important than developing a critique of our own failures. Let’s not globalize American medication or our rejection of empirically supported treatments.