Sunday, July 10, 2011

Must-must read: Angell on Mental Health

Here's a favorite bit from Cheers:
"Frasier: Carla, this psychic business is just a crutch to avoid reality. It's very easy for people to get hooked on this hocus pocus. Before you know it this woman will be holding your hand once a week, charging you $100 an hour, and filling your mind with all sorts of confusing jargon.
Carla: And how is that different from you?
Frasier: Well I can prescribe drugs."
Link.  I thought of Carla this morning when I finally yielded to Mrs. Buce's insistent hectoring and tucked into the Marcia Angell's magnificent two-parter in the New York Review of Books on the crimes and follies of the mind-bending trade.*  It's a must-read,  not quite a new topic but certainly the best wraparound you could hope for.  One of many things that struck me: how much the shape of psychiatry is tied up with the subject of my previous post, i.e., government largesse.  The core of the story is,inevitably, the pharmaceutical profession and the government process of approval/disapproval.   But I was struck by how much the rise in "mental illness" seems to track with increased use of government disability programs.  And I'm still haunted by the doctor who explains how he can get 3c$60=$180 an hour for pharma consultations, only 1x$100=$100 for a talking cure.

Another recollection: years ago I used to teach the law school class in "contracts."  One of my favorite cases was something called Ortelere v. Teachers Retirement Board.**  Mrs. O had made a pension election that turned out to be catastrophic for the husband who survived her.  The court takes "her" (="him") off the hook for this misfortune on grounds of "mental incapacity."  What sort of "incapacity?"  A shrink testified that she suffered from "involutional melancholia."  Invo-what?  "Involutional melancholia" turns out to mean being (a) not-young; and (b) female; and (c) not-happy.  Just how and why this qualifies as an "incapacity" was always the subject for a lively discussion--not least because I could tell students that IM had been stricken from the stone tablets of the mental health profession before I ever got around to teaching the case (also stricken: homosexuality, but that's another story). 

*"Why There Is an Epidemic of Mental Illness," June 23; "The Illusion of Psychiatry," July 14.

**Ortelere must still be part of the canon.  A Google search brings up a whole raft of case notes for student use.


New York Crank said...

Of course the rise of diagnoses (and psychiatric treatment) is tied to government largesse. Most people can't afford psychiatric help because the reimbursement rate is so low that many psychiatrists refuse to take insurance, insisting on cash for services, while most people can't afford to pay for months of treatment out-of-pocket.

When more money becomes available via government largess or any other means, more people are able to seek treatment, and hence the rise you discuss.

As for psychiatrists switching over to psycho-pharmacology, it's sad, but true. Again, the problem is making a decent (for a doctor) living in a society that on the whole, regards psychiatric problems not as the medical problems they are, but as some kind of weakness of will, or character and therefore not worth treating.

We need to fix a system in which reimbursing the physician is based mainly on doing something to the patient – surgery, cat scan, stress test, etc - rather than listening carefully to the patient, then examining, diagnosing and finally prescribing.

If they get paid mostly for procedures doctors will do rafts of procedures. If they get paid more for prescribing than talk therapy, they will prescribe. If they don't listen enough, or perform simple examinations enough, guess what they're not getting much reimbursement for?

No surprise there.

Yours crankily,
The New York Crnak

Taxmom said...

I think I suffer from intermittent involutional melancholia. I'm not young, I'm female, and I get into a blue funk. But only sometimes.