Illness, treatment, and tragedy

In the wake of the Connecticut killings, I have been asked many times “what did that guy have, you think?” I have no idea – smarter people than I have speculated he had a neurodevelopmental disorder, that he looked odd, and the history suggests he struggled socially – that he was something of a pariah. I don’t doubt any of these hypotheses – they all fit the bill. I’m just not so sure knowing really makes much of a difference at this point. Maybe, perhaps, ideally it might have helped to know his diagnosis prior to his snapping and murdering innocent people, but even then, I’m not so sure. Let my gratitude for the DSM V revisions not be overlooked – without some guidance with respect to categorizing symptoms and illness we are for sure swimming in ambiguity – but our nascent understand of fundamental psychiatric disease mechanisms makes definitive diagnoses alluring but also falsely reassuring.

The brain is an eloquent machine whose circuitry like so many sirens beckons our greatest researchers to its systematic study. From genes to environments, we spend our days wondering why a certain treatment works or how a particular symptom has come to be. Curious psychiatrists consider the roles of culture, society, poverty, families, history, art, and medical illnesses in the etiopathogenesis of our enigmatic syndromes. We image the brain, follow prospectively cohorts of patients, evaluate birth registries, and monitor clinically our patients with expectant and hopeful care. But do we have an “illness” per se when we treat? In some instances, yes. Melancholy, a state of abject, pained suicidal depression feels like an illness – an illness practitioners can touch, taste, smell, hold, and treat. Just like my third year medicine preceptor who in a flourish of feigned altruism threw his arms around a heart failure patient and pressed his ear to her fetid precordium reporting to us on her aortic regurgitation, so too can I know of the distinct suffering of a depressive. The same of certain other illnesses, no doubt: the gut wrenching anxiety that renders minds blank, the repetitive obsessions that plague OCD patients, the speechless fury of the autistic child, and the cold, callous, cruelty of the sociopath.

But what of the illnesses and symptoms that fall short of these elegant examples of psychopathology? Are we not supposed to treat worried patients whose minds function, but laboriously? What about the slow accrual of deficits that attend mild attention problems and learning disorders, the kind of slow burn that turns people away from their passions and into jobs they disdain, marriages they tolerate, and children they suffer along with? What about the rage that people with low self esteem nurture, gathering injustices about them wickedly? Are such people and problems worthy of screening, detection, and treatment? Untreated, can they not result in tragedy?

The combination of stigma, flawed health services delivery systems, and intra psychic resistance has set the bar for seeking treatment too high in America. We don’t have many so called third world problems any more – the water generally runs, the street lights remain lit, and the automobiles transport us from point A to point B pretty reliably. But our first world problems are intense. Economic pressures, sexual politics, political conflict, moral, ethical, and religious dilemmas, and the day to day disasters of family life are not unfortunate banalities – they are the stuff of our lives. And understanding our lives is not a self indulgence incumbent upon the wealthy, but rather a mandate to coexisting. Numbing ourselves with drugs and alcohol, deluding and evading inner demons with fearful rationalizations, and most of all avoiding treatment for uncomfortable symptoms is not a plan: it’s a recipe for disaster.

So let’s destigmatize, mobilize, and support mental health treatments of all kinds!
Looks like Biden is listening to this mandate (as conveyed by a trusted mentor from Columbia):

APA’s Appelbaum Meets With Biden Task Force On Gun Violence.
Medscape (1/11, Brauser) reports that Paul Appelbaum, MD, past president of the American Psychiatric Association (APA) and current chair of the APA Committee on Judicial Action, “met with members of Vice President Joe Biden’s Task Force on Gun Violence yesterday at the White House to discuss changes to the country’s mental health system.” Dr. Appelbaum “presented a four-part outline designed to address” the improvement of mental health in the US, including: “Appointing a presidential commission to ‘develop a vision’ for a better system of mental healthcare; designating a White House staffer as point person for facilitating responses from the Administration; improving early identification of those with mental health problems; and developing ‘sensible, nondiscriminatory approaches to keeping firearms out of the hands of dangerous people.'”
Psychiatric News (1/11) reports that Dr. Appelbaum told the Task Force that “despite evidence of the effectiveness of mental health treatment, funding for mental health services has plunged in the last few years, particularly in the public sector.” He also “stressed as well APA’s willingness to work with the administration and Congress in efforts to improve access to and the quality of mental health services and public safety.”
Associations Call On White House For Increased Mental Health Funding. The Daily Caller (1/11, Howley) reports that on Jan. 8, 52 “medical organizations…sent a letter to the White House on Tuesday invoking the Newtown, Conn. school shooting tragedy to request increased federal and state funding for medical programs, such as psychiatric care and an educational campaign that ‘reduces the stigma of seeking mental health services.'” Signatories to the letter included “the American Medical Association, followed by 51 other organizations that would benefit from increased government funding, including the American Psychiatric Association.” In addition to calling for increased funding for the prevention of violence, the letter states, “While the overwhelming majority of patients with mental illness are not violent, physicians and other health professionals must be trained to respond to those who have a mental illness that might make them more prone to commit violence.”