From the Editor
As stigma fades, we are as a society talking more and more about mental illness. And we are also writing more on the topic.
This week, the Reading features three essays that ask three provocative questions. Does naloxone access save lives? What’s it like to be depressed and in medical school? How do involuntary commitment laws affect the families of those with mental illness?
These essays are very different in part because they reflect very different perspectives on our collective experience with mental illness: the perspectives of providers, patients, and families.
Enjoy.
DG
Opioids and Medications
“Naloxone, Yes, But 3 Other Drugs Are Essential to Fight the Opioid Epidemic”
Sally Satel
Forbes, 19 March 2018
Up until a few years ago, only medical professionals were familiar with naloxone, a medication used to revive opioid overdose victims. Now librarians, school nurses, baristas, parents – anyone who might need to save a life – can carry naloxone and administer it in emergencies as a nasal spray sold as Narcan.
Now comes a provocative new study by economists Jennifer Doleac of the University of Virginia and Anita Mukherjee of the University of Wisconsin. Their paper, The Moral Hazard of Lifesaving Innovations: Naloxone Access, Opioid Abuse, and Crime, concludes that naloxone, which works by dislodging opioid molecules from the brain to jump-start breathing, may not increase the number of lives saved after all.
Doleac and Mukherjee’s argument is that by reducing the risk that abusers will die, the antidote makes opioids more appealing. And, ‘by increasing the number of opioid abusers who need to fund their drug purchases, naloxone…may also increase theft,’ wrote the researchers.
The research presents a classic case of moral hazard: insuring against calamity encourages the behavior that produces calamity. If you’re insured against losing a diamond ring, you are more apt to leave it in a drawer than in a safe.
Dr. Sally Satel
In a lucid essay, addiction psychiatrist Dr. Satel makes a few points about naloxone:
- “I, too, have wondered about the impact of naloxone on user attitudes and asked some of the patients in my methadone clinic whether having naloxone at home ever influenced their drug-taking behavior. A few told me that, yes, they probably took extra risks…”
- “In fact, a recent studyfound that one in ten Massachusetts residents who were revived by naloxone died within a year.”
- “Police and emergency personnel attest to the frequency with which revived individuals, now in a highly agitated state of induced withdrawal from opioids,walk off within minutes of being revived to use or purchase more drugs.”
To be clear: Dr. Satel isn’t anti-naloxone. But, in her essay, she emphasizes the role of “medication-assisted treatment” for opioids, and discusses the three FDA-approved medications: methadone, buprenorphine, and naltrexone. She also emphasizes the work that needs to be done – “A recent study found that only 23% of U.S. drug-treatment facilities provide two or more medications.”
If it turns out that there is indeed a moral hazard associated with naloxone, then our job is to mitigate that unintended consequence with enhanced access to treatment. For many opioid users, the efforts to get them into treatment and engage them in recovery begin with resuscitation from overdose. Naloxone brings drug abusers back to life. Methadone, buprenorphine, and naltrexone can help keep them there.
A few thoughts:
- Doleac and Mukherjee’s paper can be found here: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3135264
- For an interesting debate about this paper in real-time, check out the following Twitter discussion, which involves both co-authors, as well as several critics: https://twitter.com/jenniferdoleac/status/971053971266854913.
- There are controversial aspects to Doleac and Mukherjee’s analysis, but we can all agree that naloxone exists at “the intersection of harm reduction and emergency services” – to borrow a line from an excellent new paper by Buchman et al. on this topic. The Public Health Ethics paper can be found here: https://academic.oup.com/phe/advance-article/doi/10.1093/phe/phy001/4837138. (Thanks to Dr. David Goldbloom for the reference.)
- Regardless of your position on Doleac and Mukherjee’s paper, Dr. Satel raises good points about the need for evidence-based care for those with opioid use disorder. How many of these medications – to tie this back to Canada – are covered by provincial plans?
Depression and Medical School
“SIGECAPS, SSRIs, and Silence — Life as a Depressed Med Student”
Michael R. Rose
The New England Journal of Medicine, 28 March 2018
http://www.nejm.org/doi/full/10.1056/NEJMp1716893
SIGECAPS is the mnemonic we medical students memorize to learn the core symptoms of depression: sleep, interest, guilt, energy, concentration, appetite, psychomotor retardation, and suicidality. The practice questions we spend hours answering in preparation for Step 1 of the U.S. Medical Licensing Exam twist patient vignettes in tricky ways to fool us into misdiagnosing depression as insomnia in elderly women or attention deficit–hyperactivity disorder in inattentive adolescents. But despite their tricks, I would always nail those questions. The key was that if you looked hard enough, SIGECAPS was always hidden somewhere — an offhand mention of fatigue here, a seemingly unimportant reference to weight loss there. But despite my finely honed detective skills, I missed the diagnosis in a patient who was oversleeping alarms, couldn’t stop eating, had relentless fatigue, was always seeing the glass as half empty, and continually felt worthless. He even occasionally wished it would all end.
How did I miss it?
I missed the diagnosis because I was that patient.
So beings a short but moving essay by University of Minnesota medical student Michael R. Rose. He talks about his own “textbook denial” and his decision to seek care.
In the primary care clinic, they asked him to complete a scale. “A pleasant nurse led me into a room and handed me a PHQ-9, a patient health questionnaire that essentially systematizes SIGECAPS. She could have saved the paper: I knew my score already. I’d been filling out the forms online for a couple of weeks. Each time, I’d click the circles and hope somehow the numbers would fall without assistance. They never did.”
He describes his decision to take medications and work with a therapist. He notes a challenging journey: “I have made it through Step 1 of the boards, have persevered through the ups and downs of clinical rotations, and am now studying toward a master’s in public health before pursuing a career in primary care. I’ve had two more bouts with depression, but with treatment I improved each time.”
He also notes that many medical students and doctors hesitate to seek care. He closes by noting his decision to speak out:
The key to overcoming the status quo goes beyond institutions and policy. It lies with individuals and our willingness to share personal stories — and not a few, but many. That’s why I decided I had to overcome my own fear of telling my story.
A couple of thoughts:
- This is a beautiful essay.
- In terms of people’s “willingness to share personal stories,” I note how much more often we read about struggles with depression, and other mental illnesses. Just a few weeks ago, JAMA ran an essay by another medical student discussing her major depressive disorder. (It was discussed in a past Reading, and can be found here: http://davidgratzer.com/reading-of-the-week/reading-of-the-week-rahael-gupta-on-medical-students-depression-her-depression/.)
Laws and Families
“How a Bad Law and a Big Mistake Drove My Mentally Ill Son Away”
Norman J. Ornstein
The New York Times, 6 March 2018
https://www.nytimes.com/2018/03/06/opinion/guns-mental-health-baker-act.html
Ever since the school shooting in Parkland, Fla., law enforcement and other officials have been calling for changes in the Baker Act, a Florida law that allows involuntary commitment for 72 hours of people who are an imminent danger to themselves or others. If the Baker Act had been easier to deploy, they think, Nikolas Cruz, the accused shooter, would have been taken and treated before his horrible act.
However this law may be reformed, it will never be able to get people with serious mental illness the treatment they need.
I know something about the Baker Act. About halfway through my son Matthew’s decade-long struggle with serious mental illness, my wife and I invoked the Baker Act against him.
This kind, brilliant, thoughtful young man, who experienced the sudden onset of mental illness at age 24, was living in a small condominium we owned near Sarasota, Fla. One day the manager called us with alarming allegations about his behavior and insisted that Matthew was in immediate danger.
In a panic, we flew to Sarasota, went to the courthouse and filled out the forms to invoke the Baker Act. It was surprisingly easy.
Norman J. Ornstein
So begins a New York Times essay by Norman J. Ornstein, one of the most important political scientists of his generation.
The article describes the good intention of Ornstein and his wife – to help their son in need – and the bad result – his son grew more alienated from his own parents.
Our relationship with our son was deeply damaged by this incident, making any further efforts by us to help him infinitely more difficult. It did nothing to help him deal with his condition and only increased his sense of being stigmatized and hounded. He moved out of Florida and died in an accident at age 34.
He makes several points based his experience:
- “[T]he standard of ‘imminent danger to oneself or others,’ which is sufficient to order a short period of involuntary commitment in many states, is ludicrous and often counterproductive. It results both in mistakes like ours and in worse problems at the other end of the spectrum, when it requires the release of individuals who are truly dangerous but who don’t meet the ‘imminent’ standard.”
- “[A] system that keeps loved ones from any involvement in the treatment of people with serious mental illness, especially those who do not know or believe they are ill, is cruel and ineffective.”
- “[A] vast majority of those with serious mental illness are not dangerous. We need a way to treat them, while also recognizing that failure to treat the small share who might be violent can lead to tragedies like suicide and murder.”
Instead of changing the Baker Act, he champions other reforms, including changes to Medicaid.
A couple of thoughts:
- This essay ties into the larger debate about the Baker Act in light of the Parkland school shootings. Readers can judge for themselves the persuasiveness of the argument.
- That said, I chose this essay because it describes the deep challenges faced by families of those with mental illness as they attempt to help, walking the fine line between coercing and enabling.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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