Thursday, November 15, 2007

Is This Psychiatry?

In her post Why Shrinks Don't Take Your Insurance Dinah talked about insurance reimbursement for psychiatrists and the effect of patient volume on revenue. She speculated that someone who ran purely a medication management practice could make a fair amount of money, but then she added this caveat: "I'm not sure I'd call it psychiatry, and I'm not sure how long I'd survive or how much better the patients would get, but hey."

I think I'm pretty qualified to answer those questions because I have the kind of practice Dinah is talking about. My clinical practice is entirely a medication management clinic within a prison. I have a high volume practice---two months ago I had the most patient contacts of any correctional psychiatrist in the state. I don't do high patient volumes for the money. I get paid the same hourly wage whether I see one patient in an hour or four. On the average, I see about three patients an hour. I see a large number of patients because there are a lot of people who need care and the majority of them have at least three risk factors for suicide. I see large numbers of patients for medication management because any one of them could die if I don't. And I don't do therapy sessions.

So is this psychiatry? Absolutely. I didn't become a psychiatrist because I wanted to be a therapist. I had no interest in psychotherapy and I honestly still don't. I became a psychiatrist because I enjoyed neuroanatomy and was really good at it and because I was fascinated by the functioning of the human brain. I wanted to be a 'real' doctor who treated people with serious brain diseases.

Do my patients get better? Some of them do, some of them don't, just like in private practice or any other branch of medicine. I can say that it's easier to tell if my medication management patients get better because I know what I'm treating and I have specific symptoms I can monitor. I think it's a little tougher to say that for psychotherapy; how do you know the therapy is working---because the patient says it helps and they say they like it? Because they keep coming back for more? Hard to tell.

Most psychiatrists practice in a range of settings, with a variety of patients, using a combination of therapeutic interventions. I don't have therapy sessions but I do provide crisis intervention and brief supportive counselling because sometimes the patient needs it right then, and you can't just cut them off and walk them into a counsellor's office. Psychiatrists in private practice usually have some patients who come only for medication management, and there are some patients who don't want psychotherapy. Some people might feel that advocating a med management-only practice exemplifies all that's wrong with the profession today, the death of the patient as an individual and the constriction of the profession. I counter that to cling to a private practice therapy model at the expense of public service med management is to abandon the most functionally impaired, at-risk patients whom only we are qualified to treat.

25 comments:

Dinah said...

In clinic settings, I also see 2-3 patients an hour (in my setting, some don't show up, I hear you have a captive audience). The difference, well, I don't do it for as many hours as you do (You're amazing) for hour after hour and some folks see 4 or more patients/hour. I personally would find it exhausting to see 20 or more patients a day, day after day. In the clinic, I have some support in that someone else digs up the charts, often has gotten some information from outside sources ("the case manager says thinks are going fine at the day program... mom says he's not doing well")and writes the treatment plans, fills out the pain forms, deals with authorizations, etc...

FooFoo5 said...

Brava

wetnurse said...

I can't help but wonder why if you "became a psychiatrist because I enjoyed neuroanatomy and was really good at it and because I was fascinated by the functioning of the human brain.", you wouldn't think that exploring the depths of that same brain with a patient wasn't just as important.

I think that psychotherapy is the best way to get "in on the action" of behavior and brain function.

I know you feel that the effectiveness of therapy can't be adequately assessed because the process is too subjective. But do you really feel like you have anything resembling a complete picture with such a large piece missing? Are you able to put the control of symptoms into some sort of context beyond the lessening of the symptom?

I've been in psychotherapy intermittently over the years (and am currently). Years ago I saw an MSW, and for a couple of years a long time ago, a CNS. My last two therapists (including my current)were psychiatrists.

I've been a psychiatric nurse for most of the 24 years that I've been a nurse.

Personally, I give medical psychotherapy my highest endorsement. There's nothing like it.

Professionally, the BEST therapists that I know are ALL psychiatrists.

I'm neither ignorant nor unsympathetic regarding the insurance issue. I can certainly understand the attractiveness of a med-only practice from a financial standpoint.

In my opinion, "full circle" psychiatry is a unique place in medicine where science meets art.

Psychiatrists who have received competent clinical supervision provide the highest possible caliber of psychotherapy, that when combined with the appropriate medication,in my opinion, produces the best possible outcome.

But psychotherapy is a craft, and nowadays it's optional. You have to want to learn it. Some might consider it a calling.

I'm know I'm projecting a lot into this. It's clear that you don't feel like anything is missing from your practice, and that you are fully and every bit a psychiatrist (and I'm not saying you aren't) as one who practices psychotherapy.

I just can't help but think that you were deprived of a critical part of psychiatry because perhaps there was no one around with those skills to provide you with inspiration.

This is my first post to your blog, though I've followed it with interest for quite some time.

I offer my sincere apologies to all of the shrinks that I have no doubt offended.

My profession probably does not entitle me to so strong an opinion. I can live with that.

It's just that I believe with all my heart that psychotherapy performed by psychiatrists is the gold standard, and I worry that soon there won't be enough of this species left to inspire and guide the next generation.

Zoe Brain said...

Everyone knows opinions are like.. certain anatomical parts, everyone has them.

It's also very easy to speak from a position of invincible ignorance, and as the only medical training I've had is a First Aid course on resuscitation, and a military course on Chemical and Biological Warfare defence, I reckon I qualify there.

It seems to me that Psychiatry is at a very early stage of development. A good comparison is medicine after the theory of blood circulation was formulated, but well before the Germ Theory of Disease. It's hard, it takes an intuitive and intelligent mind to do diagnosis in all but the simplest of cases, and frankly, psychiatrists aren't very good at it. Not because they're not bright (they are) nor dedicated to healing (they are again), but because we just don't know enough. The tools they use are as crude as flint axes, very blunt instruments for making gross changes to neurotransitter levels, and much of the many competing theories of psychoanalysis (to this complete ignoramus) seem indistinguishable from superstition. Sometimes they work, sometimes not, and the metrics for successful treatment are qualitative, not quantitative. "Did the person suicide, yes/no". "Is the patient a danger to others, yes/no". "Can the patient achieve some minimal functionality in society, yes/no". That's about it.

Now some links for Clinkshrink, and I'd be very interested in any comments:
Is This Medicine?
Under cross-examination, Claiborn said he has never researched gender identity disorder and doesn't receive journals on it. Several medical books list it as a mental disorder, but he said that as a psychologist, he doesn't find them useful because they are too medical in nature.

It seems to me to be ethically dubious at best to have to justify legally-forbidden treatment on the grounds that it costs more to deal with successful suicide attempts, let alone the far more costly unsuccessful ones, than to provide life-saving medication - as the mental health director for Wisconsin's prisons had to. I can't help but be reminded of some medical reports in the 1940's, stating that they'd get higher production by feeding slave labourers at subsistence levels rather than starving them to death.

Then there's stories like this one. Ok, a sociopath, probably a very obnoxious person (in the past, anyway) and certainly no innocent, but as they say in the military, "Whisky Tango Foxtrot Interrogative".

ClinkShrink said...

Wetnurse: Thank you for your thoughtful and tactfully worded comment and welcome to the blog. The main reason (probably the sole reason) I don't do psychotherapy is because I work in a prison. The average correctional environment has a very high patient volume with high acuity patients; longterm individual psychotherapy is just not an option. Many of them have enough on their hands just managing the environment; it would be a bit much to ask of my patients to also make them analyze their traumatic pasts as well. You've inspired me by your comment and if I have the energy I may need to do a post on Why I Don't Do Therapy.

On a personal level I need a work environment that provides some controlled chaos and challenge. I doubt I'd be a very good therapist if I were obviously bored by what I was doing. And the good thing about psychiatry is that there is a niche for everyone.

As far as psychotherapy training goes, as I did receive it and I had some excellent psychotherapy supervisors. Jerome Frank taught me things I still use in my practice, even in prison. My favorite Jerome Frank quote: "Sometimes it's OK to tell people they're normal."

Zoe: I'm not ignoring you, I'm just rushing off to work and don't have time to give you the thoughtful response you deserve. I'll come back and follow your links, really I will.

Foo: We missed you; I hope you are well.

Zoe Brain said...

clinkshrink - I know you well enough to never consider the possibility that you'd ignore me. Disagree with me, maybe, but you'd no more discard what I said unread than I'd do the same to you.
Now please go have as good a day as possible, and don't fret about getting back to me urgently. You will do in good time, and the things I had to say weren't about short-term problems anyway.
Did I mention that you're only human too? And in a high-stress occupation that redefines "high" to a stratospheric level I can't begin to comprehend? No? Well, consider it said.

Oh, and thanks for the re-assurance. That was thoughtful, even if un-necessary.

Anonymous said...

Okay, I am trying to follow the logic. Clink : You have no interest in doing psychotherapy and would find it very boring. Fair enough, but then you say that the sole reason you do not do psychotherapy is because you work in a prison. Wouldn't it be that you ended up working in a prison because it is one of the settings in which you would not have to do psychotherapy?
I am glad that you knew that you would not like it and chose not to do it. Too many shrinks find out after the fact that they do not like it but stick with because it pays the bills. Yes, same for many other professions.

ClinkShrink said...

Zoe: Interesting links. It's a very complicated topic and I'm not sure I'm going to give it justice (pardon the pun) in a short comment. Off the top of my head, this is what I think about giving hormones to transgendered prisoners:

* I've nevered prescribed hormones for any transgendered person, in prison or in free society. I wouldn't know where to begin. The internist in my facility has never done it either. I'm not sure it would be good for the inmate to have people treating/attempting to treat him with no experience in it.

* Being transgendered itself is a safety risk. You could make the argument (as I'm sure the Wisconsin DOC probably did) that withholding hormones makes it more likely for the inmate to "blend in", thus making her less of a target. Maybe a stretch, but it's one viewpoint.

* The Wisconsin law is interesting because it's the only one I've heard of that actually bans a treatment in prison. Most litigation surrounds the requirement to provide treatment.

* The idea that a transgendered person may harm him/herself if treatment withheld is not by itself a sufficient rationale for providing the intervention. Inmates will make threats or actually do things to injure themselves for a number of reasons in order to obtain things. It would be a bad idea to say that as a matter of precedent this should be proof that the request is justified.

So those are my thoughts. Maybe this should have been a post.

Anonymous: LOL!! No, I didn't start working in prison as a way of running away from doing psychotherapy. Interesting interpretation. No, I'm a forensic psychiatrist. I'm interested in mental health issues and the law, and by extrapolation mentally ill people involved in the criminal justice system. I started working in prison because I knew someone who was doing it and it sounded like it would be interesting. It is.

BrownChica said...

I would be interested in hearing the 3 docs opinions on psychotherapists prescribing....where will your profession be with this option? I personally dont want that job - too complicated and I dont want to be THAT type of Dr., although I think it would be easier on the clients. I, however, much prefer psychotherapy and am in school for that as we speak (Psy.D. which is heavy on the talk therapy vs. statistics/lab side of things aka Ph.D.)...

Gerbil said...

I'm with you, brownchica. Although I had a lot of people (including my own psychiatrist!) try to steer me toward medical school instead of grad school, I went for the PhD instead of the MD because I didn't want to be doing the medicating.

I'd like to think, though, that I know when to refer someone out for a med assessment :) and that the psychiatrists know when to refer someone out for psychological testing.

stevebMD said...

I didn't become a psychiatrist because I wanted to be a therapist. I had no interest in psychotherapy and I honestly still don't. I became a psychiatrist because I enjoyed neuroanatomy and was really good at it and because I was fascinated by the functioning of the human brain. I wanted to be a 'real' doctor who treated people with serious brain diseases.

ClinkShrink, it sounds like you should have been a neurologist, neurosurgeon, or neurobiologist. I've heard this argument from my colleagues, and I'm sorry, I just don't buy it. Mental illness is, by definition, a disorder of behavior, relationships, and communication. Meds are extremely valuable, but any doctor who just throws meds at the problem does the patient a great disservice by not helping him/her cope with their illness and how it affects their lives.

You then claim that "I know what I'm treating and I have specific symptoms I can monitor." Of course you know what you're treating because the (biological) meds you're prescribing are designed to treat (biological) symptoms like sleep, appetite, energy level, delusions, hallucinations, etc. Once these symptoms are addressed (or covered up), however, the patient is still left with a distorted self-image, maladaptive behavior patterns, the stigma of mental illness, and so forth. This is what therapy is designed to treat, and I posit that this is the most important part of recovery from mental illness. It sure was for me.

Finally, you state "...to cling to a private practice therapy model at the expense of public service med management is to abandon the most functionally impaired, at-risk patients whom only we are qualified to treat." Now I'm confused. Are you working in med management because you enjoy neurobiology, have no interest in therapy, and want to be a "real" doctor? Or because you're practicing some noble obligation to the underserved? Trust me, I know several med-management-only practitioners who still manage to "abandon the most functionally impaired, at-risk patients" in my community.

One final thought: In your response to anonymous you say that you're a forensic psychiatrist because you're interested in mental health issues and the law. I don't think any meds specifically target criminal behavior. I think the best treatment for that is lifestyle change, rehabiliation, and, oh yeah, therapy.

FooFoo5 said...

Here are the goals of Harvard's Residency Program in General Psychiatry:

The goals of adult psychiatric training encompass the comprehensive list of requirements delineated by the Psychiatry Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME). Our training programs are committed to training psychiatric residents who:

* are competent in the early identification of psychiatric disorders in all age groups, their differential diagnoses by clinical and laboratory methods, and their treatment by the full range of available psychological, biological, behavioral and social techniques;
* are sophisticated about the major theories and viewpoints in psychiatry; understand the psychological, social, economic, ethnic, family and biological factors that influence development as well as psychiatric illnesses and treatments;
* have a strong sense of responsibility and respect for clients, a commitment to high ethical standards and to one's continuing professional development, and a commitment to inclusion of clients in treatment planning;
* can function in a sophisticated manner in the changing health care environment which emphasizes cost effectiveness of care; and
* have skills in collaborating, teaching and supervising other personnel such as providers of mental health, medical, forensic and social services in a variety of community and institutional settings.

And here are the goals of Harvard's doctoral program in Clinical Psychology,:

The Clinical Psychology Training Programs prepare doctoral candidates and postdoctoral fellows in clinical psychology to understand and treat persons suffering with a broad spectrum of emotional distress. In addition, we aim to prepare psychology students in all of our programs to be future leaders in service and training. Using a scholar-practitioner model, our curriculum emphasizes a biopsychosocial approach to the understanding of people and values the use of psychological intervention and psychotherapy. Our talented and multidisciplinary faculty engage trainees in didactics and in individual and group supervision designed to teach about sponsoring change. With close faculty-trainee interaction, we provide a solid grounding in case formulation utilizing psychodynamic and developmental theories that take into account ethnic and cultural influences. We also teach all psychology students to integrate a variety of treatment modalities while working with persons with an array of psychological problems, including persons diagnosed with major mental illness and severe personality disorders.

Which medical school, exactly, is training & preparing psychiatry residents in the theory and clinical application of psychotherapy that even approximates what is being afforded doctoral interns in clinical psychology?

The only reason I was not the typical bumbling, fumbling, fly-by-the-seat-of-my-pants (Shit! That's what I am now!) psychiatry resident attempting to provide "psychotherapy" was because I had a graduate degree in clinical psychology going in.

stevebmd, I could fill this site with what you don't know about treating forensic patients. Give me the choice of frontline treatment for a violent, impulse-disordered, ASPD patient, VPA or psychotherapy? I'm going with the VPA, handsdown. Why? Because the VPA just might make him available for CBT. That's why we have ClinkShrinks. They know these things.

Zoe Brain said...

Clinkshrink - thanks for getting back to me, and yes, maybe it would take a full post to explore the issue in depth.

Some of my own thoughts:

"Transgendered" covers a multitude of sins, so I'd prefer to restrict discussions to be restricted to "transsexuals", those diagnosable under DSM-IV, and adults too. Adolescent and child GID (Gender Identity Disorder) is a whole other can of worms.

Firstly, hormones should only be administered under the auspices of an endocrinologist, acting on advice from a psychiatrist trained in the area of GID. Should... but that won't happen, obviously. In practice, as long as the psych has read, for example, the Praeger handbook of Transsexuality, and as long as the usual tests described on the Internet (diabetes, liver function, thyroid, prolactin, and depending on exact medication, potassium balance) are performed every 3 months at ramp-up, then yearly, it's safe. Not just safer than the alternative, witholding treatment, but safe.

The Wisconsin authorities did indeed make the "blending in" argument, but the trouble is, there's no actual data to back up the supposition. Nonetheless, it seems highly plausible. It may reduce risk of assault (I think it does), but definitely increases risk of self-harm to a level approaching 100%

The Wisconsin law is indeed unique. No other medical protocol recognised by specialists in the area as "medically necessary" has been forbidden in that state or any other. The cost is on the order of $1000 annually, usually about half that. Compare with the cost of suicide watch over the period, and truly massive doses of anti-depressants and other medications, none of which are effective except to tranquilise the patient, making them physically incapable of terminating their distress.

Suicide rates without treatment in a non-prison setting are about 1 in 3, and that's a reliable figure. I have no data on prison populations (it's not gathered), but based on this, I think repeated suicide attempts until successful for those diagnosable as TS (rather than Transgendered) may even be the norm rather than the exception. Anti-psychotics do nothing, MAO inhibitors and SSRIs will give improvement in co-morbidities caused by GID, but the problem is neurological. A (mostly, partially, or completely) male neurology doesn't work very well with a female hormonal balance, and vice-versa. The condition is also progressive, with dysfunction increasing as time goes by.

Some more URLs to consider:
Zhou J.-N, Hofman M.A, Gooren L.J, Swaab D.F (1997)
A Sex Difference in the Human Brain and its Relation to Transsexuality. (PDF here)

Kruijver F.P.M, Zhou J.-N, Pool C.W., Swaab D.F. (2000)
Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus (PDF here)

A TS woman, with or without treatment, may be better regarded as an Intersexed female, as regards propensity to experience depression. Or may not, because for Transsexuality to be diagnosable, only some parts of the brain need be affected, and other parts may be typically male in terms of cellular receptors. There are degrees, and in many cases, relatively small doses of hormones may be enough to provide symptomatic relief, without somatic change.

Speaking as one who's never taken any psychotropic medication in her life - apart from some valium the night before various surgeries - and as someone who had Gender Dysphoria, I consider withholding hormones to be the very definition of cruel and unusual punishment.

If I can make analogy, and this is *exactly* how it feels to the patient, it is exactly like incarcerating a normal woman in a male prison, then giving her massive doses of male hormones, possibly using the rationale that it will enable her to "fit in" better, and reduce the incidence of sexual assault. The somatic changes that will result will last years after release, and some are permanent. The analogy is very close indeed if hormone therapy that was started outside is prohibited in jail.

Nothing can normalise the neurology, or change the chromosomes (though in some cases where the patient is Intersexed and has been a victim of surgically-induced transsexuality as an infant, that's not necessary, some are chromosomally of the target gender). But complete symptomatic relief is possible, and even usual with the right therapeutic regime. Improvement rates exceed 97%. Complete symptomatic relief rate is about 80%, though co-morbidities induced by the condition may still be present after the cause is removed.

To give an idea of the scope of the problem, from Potential Therapeutic Errors When Using Binary Based Terminology to Explain the Gender Variant Condition : Typically, at time of presentation these individuals report that either their lives are in ruin, or they are very afraid that if their gender variant condition was to become known they would loose all that they cherish and be ostracized from family, friends and the ability to support themselves. High anxiety and deep depression with concurrent suicide ideation is common. One of the most extreme cases I have treated was that of a 50 year old genetic male, married and the father of 3 grown children with an international reputation as a scientist who reported to me that the reason he finally sought out treatment for his gender issues was because the number of times he found himself curled up in the corner of his office in the fetal position muffling his cry was increasing. That is not dysphoria, that is pure misery.
Been there, done that, and my case was the mildest I've come across. It's when the distress leads to prevention of functioning, rather than mere unhappiness and chronic depression, that treatment is sought. I never got to that point, endocrinal issues intervened.

stevebMD said...
This comment has been removed by the author.
stevebMD said...

foofoo5, thanks for pointing out that I don't know much about treating forensic patients (which is accurate). I do agree with you that if a patient is violent and still acting impulsively/erratically/unpredictably, then pharmacological intervention is appropriate. But I think I know enough that simply locking up the guy and loading him with VPA or the SDA-of-the-month does not serve as sufficient rehabilitation. It sounds like you agree, too ("the VPA just might make him available for CBT").

All I'm saying is that psychiatry is more than prescribing meds. Heck, even Harvard (thanks for posting the guidelines BTW) teaches its residents "the full range of available psychological, biological, behavioral and social techniques."

(Since you're a clinical psychologist, I'll also put in my $0.02 that I think psychologists should have the right to prescribe meds, with appropriate training in their biological mechanisms, indications, side effects, etc. If psychotherapy is a part of psychiatry, then it's only fair. After all, I have found psychotherapy to be just as rewarding to my patients as med management.)

Anonymous said...

this is so much funnier than the comics page or the funnies page, depends where you are from.Steve, you make some good points but don't go head to head with foo fighter. i don't need meds anymore;iam just so freakin happy that my 2 cents will buy more than yours (for now, and as long as i am willing to cross the border).

Ladyk73 said...

Wow....What a conversation here! Foofoo thank you for the post on the different Doctors....very cool.

Just to be a poop....
um...
Okay..you can get a Phd without ever taking organic chemistry. No med, no med, no meds....PLEASE!!!!
Again, psychotrophics are not candy. They can have serious adverse effects. That why we have doctors, pa's and nps...
(they have taken them chemistry classes)

FooFoo5 said...

Clarification: I am not a clinical psychologist. Sorry for the ambiguity. I went to a 5 year undergrad program that graduated you with a BA/MA in Clinical Psych. I worked in the practice of 3 psychiatrist as a family therapist, and they encouraged me to go to medical school. As I began a Fellowship, I became very ill, and was pretty much whack for 16 months. As an element of "recovery," and unsure as to what I would be capable of doing, I entered a local, manageably-paced MSW program to restore some academic and clinical disciple, and got the MSW. When I finally was prepared to return to my Fellowship, I had a recurrence of illness from which I am still recovering. Whatever... Nevertheless, I reiterate that I learned about the actual practice of psychotherapy outside of medical school.

Anonymous 2: I have been bitten by patients on 3 occasions; 2 were severe. To my recollection, I have never bitten anyone ;-)

wetnurse said...

First to Clink: Thank you.

It was pretty clear to me by your post that the reason you don't practice psychotherapy is not merely because of your practice setting.

And I LOVE your Jerome Frank quote. It's reassuring to know that there's someone out there who doesn't give everyone meds simply because they are asking for them.

Is your forensic practice limited to medicating inmates, or do you perform competency evals as well?

to stevebmd: what you stated in your first post is pretty much what I was thinking, even the observation about going into neurology instead. I was worried about how an approach like that would be viewed coming from a nurse, and so spent a much longer time figuring out how to word it.

Now regarding your second post and the idea of psychologists prescribing?


oh





my






GOD!!!!!!!!!!!

ClinkShrink said...

Wetnurse: I used to do competency evaluations when my practice was split between prison and a local court clinic. Now I do correctional work fulltime (med management only, therapy services provided by psychologists).

Stevebmd: Neurologists don't treat psychiatric illness so that's why I didn't become one. I don't think 'throwing meds' at a patient is what I do. Foo described forensic practice better than I could. Also, I don't agree that every patient is a potential psychotherapy patient-in-waiting. Some patients aren't interested it, some people truly don't need it.

Foo: It's amazing you can know what I'm thinking from 4000 miles away. Well done.

Brownchica: We address the issue of psychologist prescribing in podcast #38 (taped today, not sure when it's coming out). I am putting on my flack jacket.

janye said...

I would be interested in knowing what the difference between a pharmacist and a forsenic shrink is(such as clinkshrink working situation) other than one writes the prescrition and one fills it? And, just how are mental health issues different in correctional institutions? Aren't the same medications being used? I'm just trying to understand how psychiatry in a criminal setting is different from the general population settings besides the obvious of the patients being locked up? It doesn't appear to be a speciality when you get down to it! How does practicing psychiatry fullfill your interest in mental illness and the law when all you are doing is writting prescriptions? Maybe I have missed something?

Anonymous said...

psychiatry and "the law" have an interesting history.political dissidents being locked up, doped up, lobotomized in psych "hospitals".

certainly a large percentage of people who end up in the prison system suffer from some form of mental illness , but aside from those, how many psych symptoms are a direct result of being imprisoned? I know you can't really be expected to answer that but it makes sense that prisons would make many people "sicker" than they were before and then they are given even more drugs. the other question, which relates to what i said about history would be , to what degree are psychiatrists and related mental health professionals used by the system as agents of social control? same as asking this about teachers who want every disruptive kid to be diagnosed with ADHD and started on drugs. so to what extent are psych meds used to control the population? the doc could write: pt. agitated, and prescribe something to "calm" them. there has to be some element of that in any prison system because it exists outside the prisons as well. what an overmedicated society we live in with so many drugs prescribed on the basis of a clinical diagnosis that often changes every five years, in which case a new drug is needed.

ClinkShrink said...

Janye: I took my answer to your comment and turned it into a post. Your questions were great. Thanks for the blog fodder.

Anonymous: Actually, correctional facilities don't by themselves make patients sicker. Being in a correctional facility can be life saving. Inmates get their medical (and psychiatric) diseases treated, they get the drugs and alcohol out their systems, they get fed, they get cleaned up. In Maryland there was a prison mortality study done by the Hopkins School of Public Health. They found that Maryland prisoners live longer than an age-matched sample of men in free society. New York found the same thing a few years ago. The Bureau of Justice Statistics recently published mortality data that showed inmates were at two or three times higher risk of dying upon their release from prison.

Sometimes getting locked up is what saves the inmate from death-by-drugs.

Anonymous said...

They live longer than aged matched samples in free society? Does this refer to men in general (inmate vs out free) or only to those with substance abuse or psych issues? I really need to know because if the inmates are living longer I am taking all my kids out of school ASAP ,giving them beer and chips for dinner, and will never ever go to another parenting seminar.

ClinkShrink said...

Anonymous: Break out the beer and chips. Inmates in Maryland do live longer than free society men in general.