Is It Right For Physicians To Take A Parental Role With Patients?

A pair of recent studies looked at different modalities for following patients on weight loss programs. One study compared patients who received  in person follow up from primary care providers versus those who received telephone and web based follow up to those who got nothing at all.  Patients in either follow up group experienced twice as much weight loss after one year than those who had no follow up at all (there was no difference between either follow up intervention).  The other study looked at the effectiveness of in-person “life coaching” on weight loss results and also found it to be significant. 

While the impact of this in terms of weight loss indeed could be huge I also believe this study raises an interesting question about doctor patient relationships and boundaries that is worth exploring.

The overall message of the studies was that patients in both groups who had any kind of follow up with their primary care providers (be it in person, on the phone or web based) experienced better results in losing and maintaining weight than those who did not.  With 2/3’s of Americans overweight or obese, any intervention that can help patients maintain weight loss has the ability to improve millions of lives and should therefore be utilized. The authors hailed the study as a breakthrough in helping patients battle obesity.

“It could be considered something of a breakthrough in weight loss,” said Dr. Frank Sacks, a professor of Cardiovascular Epidemiology at the Harvard School of Public Health who participated in the second study.

While this intervention may be effective in the laboratory the question remains about how this impacts doctor patient relationships in the clinic and if this impact is ethical or fair?  If adult patients are reporting their weight loss to physicians does this not place the physician in a paternalistic or parental role to the patient and if so is it appropriate for doctors to take advantage of this role in clinical practice?   

The hidden dynamic among all human relationships, and especially those between doctors and patients, is a phenomenon called transference.  Transference is the process whereby one individuals unconscious emotional perceptions influences their participation and behavior in a relationship.  The perceptions are usually very powerfully influenced by early childhood influences.

For example a person who had a poor relationship with little verbal communication with a male caretaker early in life may have a difficult time communicating with other male authority figures later in adulthood.  

Transference is classically thought of as a part of psychiatry and psychotherapy, but all doctor patient relationships (and all human relationships) are deeply influenced by the unconscious subjective perceptions of the participants. 

In my coursework with the New England Society of Clinical Hypnosis I will never forget the words of the brilliant hypnotist  and former NESCH president Dr. Max Shapiro who surprised me in a seminar many years ago when he said: “If a patient comes to you with a deific or mystical transference  about hypnosis don’t be afraid to use that in your work with them.”  

Shapiro felt that using the patients unconscious feelings of awe or mysticism around hypnosis (which is often held in such mystical esteem) to their  advantage could be a useful intervention towards reducing symptoms and improving their lives.  Could the same be argued in this situation regarding a patients parental transference to the physician? 

The doctor patient relationship already intrinsically has a parent child tinge to it by it’s inherent nature.  Consider the things that physicians typically provide to patients.  Empathy.  Nurturing.  Moral, emotional and physical guidance.  The very essence of the relationship evokes a parent-child dynamic between the doctor and provider that is unavoidable.

When patients report their progress in weight loss to the doctors does this not place the physician even more in a parental role with the patient?   The physician becomes the source of praise and approval or of disappointment and disapproval like a parent around a critical issue in the patient’s life.  This takes advantage of the parental transference-countertransference between the doctor and the patient and may produce results but is it appropriate?.  Consider that patients with serious behavioral health problems often lack psychological maturity in some way.

There are no right or wrong answers to this question but it is worth thinking about: Should physicians be placing themselves in a position where they can take advantage of the parental transference countertransference dynamic that exists between them and their patients?    It could produce results but is it ethical and fair to adult patients who ultimately would be best served by empowering themselves to ensure their own wellness without reliance on a professional’s praise or approval?  Could taking on a parental role with a patient eventually provoke feelings of rebellion and disobedience (often a part of parent-child relationships) that may undermine the purpose of the intervention eventually?   Should doctors dare to take advantage of this mechanism in patients who lack psychological maturity?

It is likely that right or wrong these interventions will become more widely used because of the results they showed in these studies but I believe these are important questions to ask.  

A Fundamental Flaw In Modern Psychiatry?

There is no question that as modern psychiatry has evolved it has become a powerful force in the United States.

The field underwent a major shift in paradigm the past 30 years.  Psychiatrists used to work mainly with behavioral modalities like different kinds of therapy to encourage self exploration and change, but modern psychiatry has focused on the use of powerful psychoactive drugs to alter behavior.  Psychiatrists previously spent hours in therapy with their patients but today most psychiatrists get less training in therapy in residency and in clinical practice usually only do 15 minute medication visits with patients.  In these visits they prescribe powerful medicines and inquire about side effects from drugs and leave the therapy to psychologists and social workers.  

Psychiatrists have left the therapy couch behind and transitioned mostly to drug based therapies based on the idea of biological psychiatry.  This is the basic concept that a "chemical imbalance in the brain" can be treated with a "precisely tailored" medicine.  While this concept sounds great in advertisements and commercials a closer look shows that the science is behind these "chemical imbalances" is not well defined and the drugs used are hardly precise and often have bad side effects.

The true causes of psychiatric illness goes beyond a simplified chemical imbalance and remains a nebulous combination of psychological, environmental and biological factors that probably varies tremendously among individuals.   The danger is that in actual clinical practice the treatment option most individuals get now from doctors is a drug that alters brain chemistry in a very imprecise way, but mental problems happen on many different levels.

These underlying chemical imbalances may not be well defined in mental illness, but psychiatric drugs have a place in medicine and if a doctor prescribes one a patient should NEVER stop taking it until they have an in depth conversation with the prescriber.   

As this paradigm shift has happened physicians are confronted with the danger of not considering the depth and complexity of most behavioral problems for the individual.  Advertisements and commercials make these drugs sound simple and many doctors place patients on these drugs without much thought, but be advised: Psychiatric drugs are complicated and have serious pros and cons that must be carefully considered.  The decision to start one should never be taken lightly or glanced over.

There is no doubt that part of mental illness is biology.  There are clearly functional, physiological and anatomical changes in the biology of the brain that are associated with different acute and chronic mental and emotional states.  Yet there is murky evidence that any of the biological mechanisms altered by psychoactive drugs actually cause  the "diseases" these drugs treat.  Altering these mechanisms may help change symptoms much like tylenol helps a back ache but that doesn't mean deficiency or disorder in these areas cause clinical disease.  After all, no one would argue that a lack of Tylenol causes backache. 

As Modern Psychiatry has become overly reliant and focused on drug therapy it has lost sight of the human side of behavior. It has stopped seeing the "forest for the trees" and forgotten that every illness occurs in the context of social, cultural, behavioral and psycho-spiritual factors, not simply biology.    Medicine and Psychiatry often try to drug people to meet our arbitrary cultural standards of normal and abnormal (and disease and health), when often the emotional and behavioral states of individuals are natural to that individual, appropriate based on circumstances and have potential for positive change through non-pharmacologial, human centered modalities.   

In a perfect world much thought would be given to the decision to start high functioning adults on any psychoactive medicine.  These drugs would not be routinely handed out with minimal consideration of the whole person's body, mind and spirit.   And the paradigms that doctors use to view behavioral problems would address the existential roots of human problems.


 Over the next few weeks we will present a series of topics in modern psychiatry where we look specifically at the pro and cons of drugs, investigate the science behind behavior and hopefully provide useful information to help people understand modern psychiatry better. The first topic is going to be on antidepressant use so stay tuned! 

Are People Who Take Vitamins More Likely To Die?

A recent study in the Archives of Internal Medicine has added fuel to the debate regarding vitamin use in healthy adults .  The study showed that vitamin users were more likely to die of any cause over several decades than non vitamin users.

The past several years has seen several journal articles about vitamins and minerals that have provided a wide array of information about their use to the general public.  The information these studies have given usually has been confusing, vague, often contradictory and the result of study methods that are confounded.    The general message of these studies has been that vitamins have not been proven to have great health benefits to healthy adults and may in fact be harmful.  This study does little to add concrete information to the debate about the benefits or harms of vitamin use.  The same questions that existed about vitamins last month persist today. 

 

 

Medicine still doesn't really now much about the long term use of vitamins in healthy adults and the debate rages on about what the effects actually are. As the authors of the recent paper pointed out "Although dietary supplements are commonly taken to prevent chronic disease, the long term consequences of many compounds are unknown."

This particular study looked at a large group of woman from Iowa over several decades to assess what if any relationship vitamin use had on the woman's overall mortality.  Data was collected on over 40,000 woman who completed surveys regarding vitamin use in 1986,1997 and 2004.    The results seemed to carry a daunting message regarding vitamin use. All the vitamins and minerals studied (with one exception) were associated with a higher risk of all cause mortality.


Specifically the authors looked at Multivitamins, Folate, B12, B6, Magnesium, Zinc, Copper, Iron and Calcium. Of these only Calcium use was associated with a lower rate of mortality. All the other vitamins studied showed an increased rate of death.  The magnitude of the association in all cases was small but statistically significant.


So healthy adults are again deluged with another piece of information about vitamin use and are left to wonder if vitamins are associated with a increased risk of death and if healthy adults should stop taking vitamins?


Before we can assess this we need to look at the old paradox of association and causation. We can't assume that the association we see in this study is because vitamins somehow contributed to early death. A very likely explanation for some or all of these findings observed is that people who take vitamins are generally at baseline less healthy and more likely to have chronic disease than those who don't. By studying vitamin users the authors selected a group of patients who were by definition sicker and more likely to die than the general public for reasons that had nothing to do with vitamins.

It is imporant to note the authors did correct for Cardiovascular Disease and Diabetes in the results and the observed association held up. However they did not correct for many other chronic diseases that make people more likely to die and may also lead to vitamin and supplement use such as kidney disease, cancer, anemia, HIV, mental illness and many, many other medical problems.  

We can use iron as an example of the flaws in this study.  If you read the paper you will notice the strongest association the authors found is between iron supplemention and death rates. They even found a dose response relationship between iron and death rates, with the highest doses of iron leading to a 65 percent increase in death risk.  Does this mean iron is a dangerous thing to take? 


As always the true answer is unclear. Iron may contribute to mortality but some of the sickest individuals in the world today are on very high doses of iron because of severe chronic illness leading to low blood counts.   The authors speculate that perhaps iron leads to some "pro oxidative" state that contributes to disease and explains the results.  To me this is complete speculation and almost irresponsible to put in a paper. It may be worth investigating if iron causes disease and death based on these results, but it is hardly the most likely explanation.  The most likely explanation for why this study showed an association between iron use and death rates is that very sick people are often advised to take iron to help manage chronic, debilitating disease (because of low blood cell counts). It should not be a suprise to anyone that more of those people died over 2 decades of follow up.   I would expect to find similar relationships contributing to  (but not neccesarily invalidating) the observed results for all the vitamins and supplements looked at, including calcium which showed a beneficial effect on death rates

So where does this leave us for vitamin use? Can we completely ignore these results because the methodology of the study was questionable?  



While there is no doubt that vitamin use has been shown to be helpful in specific medical conditions (such as Vitamin D and Calcium preventing osteorporosis in at risk individuals) for the general public if you don't fall into a specific group that needs to take a vitamin or supplement for a medical reason than the wisdom of taking vitamins is questionable.  More and more research has failed to find a health benefit to vitamin use in healthy adults (including this study) and some have shown a potential harm.

It is possible that all the studies showing harms of vitamins had such flawed methodologies that they actually masked a truly beneficial relationship for vitamin use in healthy adults but this is unlikely.  It seems more plausible that evidence supporting benefits to vitamin use in healthy adults without medical problems is scarce and the harms may be real.   There are specific medical conditions where vitamins are definitely beneficial but until more is known healthy adults should have conversation with their physician about if vitamin use is appropriate for them.

What Creates a Back Injury?

Lower back pain remains a common and debilitating problem for many Americans because of it's ability to cause discomfort and disability in those who experience it.

Any significant  back pain requires a medical evaluation because of the uncommon possibility of a serious problem but most back pain is caused by injury to the muscles and joints of the lower back. 

Because of the association between certain high risk occupations and back pain The National Institute of Occupational Health and Safety has investigated the conditions that create these injuries by studying the forces that act on the lower back to cause injury.  In doing so they give an important message to the general public about how to prevent back injuries.

What NIOSH has found is that individuals who develop back injuries do so usually because they place chronic repetitive forces over long lengths of time on the joints, bones and muscles of the back. 

NIOSH analyzed the process and found that three major forces act on the lower back during movement and lifting.  These forces consist of a rotational force and a compressive (downward) force on the muscles and joints from the weight of and technique used for the object lifted and the force of the individuals own upper body weight acting down on the muscles and spine during each act of  movement and lifting. 

NIOSH has adopted a complicated equation to describe these forces at play in occupational activities and to calculate them in order to prevent occupational lifting from exceeding forces that human backs can tolerate. For the purposes of understanding back injuries we don't need to crunch numbers or understand any math to see the take home message is that the forces that act on our lower back are proportional to what we lift, how we lift it and (quite importantly) how much force our own upper body weight exerts on our on back with every act of lifting or movement.

The NIOSH lifting equation shows that our own upper body weight is a big part of the repetitive forces exerting impact on our lower back muscles and spine. Every time we lift something or move we are putting a force down on our back that is proportional to our own upper body weight.

As Americans gain more and more weight it makes sense that lower back pain is among the most common chief complaint to doctor's offices. It is estimated that as many as 70-80 percent of adults will experience lower back pain at some point in life.

When the chronic repetitive forces on the back muscles and joints exceed the ability of body to heal itself injury develops.  NIOSH learned that cases of back pain are often preventable by reducing the impact of these chronic repetitve forces on the back muscles and joints and enacted rules to limit what and how much can be lifted in the workplace.  For most Americans who don't work in jobs that require repetitive lifting of objects excessive body weight is the main culprit in the development of chronic repetitive forces on the back.

Weight loss can reduce the magnitude of forces acting on our spinal joints.   In a country where it has become normal to be overweight or obese back injuries are becoming more and more of a problem.  By remaining at an appropriate weight people can minimize the impact of forces on the lower back.

The Western lifestyle is a medically dangerous endeavor that is creating many health problems for individuals that modern medicine can not overcome.  As individuals enter into a viscous cycle of poor nutrition, sedentary living, weight gain and stress medical problems are sure to follow. We can see in this instance one small example of this process. We can imagine how weight gain might be the result of a sedentary life style and poor nutrition leading to increased upper body weight and increased forces on the back.  When injury develops this could be a further roadblock to activity, weight loss and better health. 

The NIOSH lifting equation, while meant to aid in management of occupational back pain, gives an important message to all with back pain and the general public.  There is yet another reason to eat right, exercise  and stay active: Controlling your body weight can reduce forces on the spine and prevent the development of lower back injury.

Not So Fast: Drinking Coffee May or May Not Protect Against Depression

The Archives of Internal Medicine recently released a study that linked reduced incidence of depression with increased coffee consumption. While the actual study only touted an "association" between coffee consumption and reduced rates of depression, the popular media took the ball and ran with these findings to present a different picture to the general public.

The headline for the link for the story on Boston.com read "Can Woman Avoid Depression by drinking Coffee?" This headline is emblematic of a long standing trend in the popular media to categorize medical research in a way that is misleading to those without medical expertise. Of course the headline isn't entirely unreasonable but to most people who merely glance at it or perhaps read a few paragraphs the message may well be "Avoid Depression" and "Drink Coffee" but this is not exactly what the study says.

In very plain English the message of the study is "We observed a group of woman and those who developed depression reported that they drank more coffee than those that did not." If you don't have a backround in science it is easy to get from that the message that "Coffee protects against depression.". Yet the difference between these ideas is subtle but critical.

It is presumptious to infer that coffee can protect against depression based on the results of this study because we don't fully understand the nature and direction of the association. The fact is the study does not offer concrete evidence into the observed relationship between coffee and depression. We can only say that for some as of yet unexplained reason, people who drink more coffee seem to have less depression than those who drink less coffee.

For all we know the association could be that coffee shops tend to be located near psychiatrists offices and people who seek psychiatric care (and therefore areless likely to develop depression) also just happen to stop for coffee when they visit their psychiatrists. It could be that people who can afford coffee come from a higher socioeconomic status or have access to better preventive treatments for depression.

Of course these explanations are somewhat ridiculous (especially considering that medical treatments for depression have questionable efficacy) but the point is clear: there are many explanations possible that could account for this association besides concluding that coffee protects against depression. For all we know coffee may actually even cause depression.

A more realistic potential snag in this study that I see is that caffeine use is not generally recommended in two important groups of people that have high rates of depression as compared to the general public. People with sleep disorders and people with anxiety disorders can not drink coffee and are told by doctors to avoid them because they worsen anxiety and insomnia symptoms. These groups also have higher a incidence of depression than the general population.

The study authors agreed with this and even commented in the article on this possibility saying "caffeine might induce sleep disturbances or insomnia or anxiogenic effects. It is possible that sleep sensitive or anxious woman are aware of the stimulatory effects and may lower their consumption accordingly." While the study did include asking the subjects to complete an index assessing mental health, it did not gather data on anxiety disorders or sleep disorders that could be controlled for in the final results.

So is the effect we see in these findings really that drinking coffee caused a reduced chance of developing depression or was it that people with other medical problems strongly associated with depression also tended to avoid coffee because it would exacerbate their symptoms of anxiety and insomnia? Or is it something else? We simply don't know.

In the past some of our best medical discoveries have come from observations such as this association. But this method has also created some of our most massive medical blunders (ever read the story of hormone replacement therapy?). Individuals should continue to be skeptical of how findings of medical evidence are presented in the popular media.

The reasonable conclusion from this study is that coffee is probably not harmful to humans and may indeed have health benefits so if one enjoys coffee they should continue to enjoy it in moderation. We can also say that coffee is associated for an unknown reason with reduced risk of developing depression, that this effect could be real but it could also be artificat (we don't know). We can definitvely say that coffee will definitely make symptoms of sleep disturbances and anxiety, often found in depressed individuals, much worse.

The take home message is that if you are interested in preventing depression you may want to hold off on buying that big bag of coffee beans, especially if you have trouble sleeping or are anxious, until further studies can be done to to explain the true nature of this association. The real danger of how studies like this are reported is it may cause someone with anxiety or insomnia, in addition to depression, to binge on coffee thereby making their anxiety/insomnia symptoms worse and that is definitely not the right thing to do in this situation.

When Perception Is Reality

Perception is reality.

When it comes to physical health this ancient mantra of eastern philosophy seems distant and unimportant. In western culture it is considered scientific to think of the universe as a mechanical device where our perceptions are irrelevant to what happens in the world, our lives and our bodies. To a western mind the phrase “perception is reality” seems far-fetched and unrealistic, especially to those touched by disease and suffering.


The matter over mind thinking that increasingly dominates our scientific, medical and even popular
culture has banished our perceptions tbo a place of unimportance in how we think about the universe and ourselves. The question of whether our perceptions create external reality is one best left to the
quantum physicists and the philosophers.

However in my personal experience in health care I have come to see that the perceptions that people hold in their minds are critically important to the experience of their bodies. Even though it was barely mentioned in my formal medical education, experience has taught me that things in our mind profoundly influence not just how we experience our bodies but also our physical health.

Contrary to what was emphasized in my training I have learned that every disease, symptom and cure has a powerful subjective component as a part of it's course. This is not to say that all diseases are psychosomatic, but rather that some diseases and symptoms certainly are. Furthermore, even when suffering has a real medical basis there is powerful subjective component that very much influences the experience of the illness.

As anyone who has worked in health care or even merely observed human behavior has learned, different people will react to and experience very similar medical problems in different ways.

Studies have repeatedly shown that if people were just pulled off the street and randomly given an MRI that a significant percentage of adults have legitimate back injuries such as bulging discs. However among these patients with medically similar injuries there would be a wide variety of perception of pain. Some patients would be pain free while others would have severe disabling back pain.

Anyone who has ever worked in a hospital knows from experience how impactful patient perception, attitude and expectation is. The nature of this relationship is no more magical than anything else in science. It is in fact very much related to a burgeoning field of study known as neuropsychoimmunology. Basically, this up and coming field is explaining how the psyche of human beings physically impacts the nervous system as well as the immune system and endocrine system. In this relationship we have an unexplored and powerful scientific basis for mind body medicine.

While neuropsychoimmunology is relatively new and unexplored, its implications are huge. The role of inflammation and the immune system in most disease processes in the body is critical. Pretty much every disease process from heart attacks to cancers to infections to ankle sprains to rheumtalogical diseases and pretty much everything in between is on a spectrum of somewhat modulated by to literally directly caused by our bodies immunology and the inflammation process.

How the psyche and the nervous system interact to modulate inflammation in the body I believe is the theoretical basis of mind body medicine. Through neuropsychoimmunolgy our perceptions are manifested in our bodies. This important truth is left outside of our cultural thinking and our medical heritage and I am quite certain most medical doctors would place it in the dreamy realm of philosophy and not as an integral part of the care of human beings.

The fact is that in a medical profession ruled by pills and surgery our perceptions are not routinely considered a part of disease and healing. But experience shows us that people are more than a collection of chemicals, tissues and electrolytes but also a collection of perceptions, beliefs, fears, regrets and loves. There is now a way of explaining how these two realms interact profoundly to modulate both health and disease. Right now in medicine, the management of those who are ill rarely involves exploration of the patient’s conscious and unconscious perceptions regarding their symptoms, but I believe this is valuable and one day science will back the importance of this up.

Albert einstein once remarked that "reality is an illusion, albeit a very persistent one." I can't speak to the validity of this statement in terms of physics, but I do believe that when it comes to our bodies Einsteins statement holds some truth. At least a part of what we experience in our body is no more than the illusion of our on minds very much framed by our own perceptions. Human beings are a collection of perceptions and experiences that manifest in the physical body and in this way human perception indeed becomes physical reality.

The Unintended Consequences of Curing Cancer

The history of science is littered with a recurring theme of unintended consequences tarnishing man’s great technological advancements.

As a physician I have often pondered the unintended impact that many of the advancements of medical science have had on our society. Our achievements have blessed us and improved lives but also have created conditions that cause problems for our system.

At present I can think of no issue in medicine that has more of an impact on human life and the health care system than cancer. Cancer is a disease that touches everyone’s life at some point. In popular culture a cure for cancer is something that is often imagined as a sentinel moral and scientific achievement for our species.

While I agree with this idea I also see a cure for cancer as a great challenge for our health care system. I believe that the unintended consequences of curing cancer would be unparalleled and potentially could be a tremendous shock to our health care system.

The system would have to absorb all the patients whose lives would be saved. One need only look at the recent history of medicine and the state of our health care system to assess the potential side effects that outright curing a disease that kills about 21 percent of Americans might have. Already the rapid increase in life span we have experienced (The average life span is 78.4 years, up almost a decade from the 1960s) has not come without unintended consequence of cost and strain on our system. As human beings live longer and treatments grow more and more sophisticated and expensive the costs of their care grow more and more.

For example 30 years ago a diabetic patient may have died from a heart attack at age 50, but today modern medicine now very likely will keep this patient alive through an emergency with clot busting drugs and procedures. Now he will live longer, perhaps much longer.

Imagine the cost and impact this will have considering the staggering cost of years of care for a medically complicated patient. He will need years or perhaps even decades of insulin, statins, beta blockers, ace inhibitors, anti hypoglycemics, follow up primary care visits, needed labs, urinalysis, hospitalizations when infections or complications arise, yearly podiatry visits, yearly opthamology visits, nephrology visits, endocrinology visits, cardiology visits, care for whatever else might come up in a medically complicated patient and perhaps even several years of nursing care at the end of the road.

Obviously in moral terms we can all agree that it is a wonderful thing, but the facts are the facts and years more of care will cost precious, and limited, resources. As this scenario happens in vivo every day thousands of times over in our hospitals the strain on the system grows greater and greater. The proof is in the pudding: keeping sick people alive longer may be the right thing to do, but the costs of their care are taking a massive toll on our system. For example right now Medicare is set to run out in 2029. To me that is a terrifying fact.

Now imagine what happens if we cure a disease that ultimately kills 21 percent of the American population. That fifth of our population would live on to ultimately die of something else and in the meantime they will need nursing care, doctors, drugs and diagnostic studies.

We have already seen that as people live longer based on recent medical advances the rates of Alzheimer’s and other dementias is rising at a staggering pace. Many people now live in nursing homes for years at the end of life in a state of chronic illness, bouncing between nursing home and hospital. The costs of care in the last months of life especially for the chronically ill are staggeringly expensive and inefficient.

Keep in mind that while often times cancer strikes people with otherwise good health, it tends to strike older individuals as well as people with many other illnesses. We would be curing many people who were likely to have other chronic diseases. For every one otherwise healthy adult or child that cancer would save there would be at least as many very sick or very elderly who want and deserve treatment so they can live. After all, who should be the one to tell them they can’t have it? (curing cancer also raises countless social and ethical questions like this, which is another blog entry altogether!).

I believe a cure for cancer would be unprecedented not only as a moral and scientific achievement, but also as a potential major shock and threat to our already strained and faltering health care system. The burden a cure for cancer would throw onto our system could seriously tarnish the shine of what would be one of man’s greatest achievements. We have already experienced this effect with other medical advances.

It would be a shame if the consequences of curing a disease that is the scourge of mankind would be strained resources and worsened care across the board, especially for the 60 percent of people who will never have cancer in their lives. Like all great achievements the good of curing cancer would undoubtedly outweigh its harm and obviously man should do everything he can to achieve this. As a species we must continue to advance and find ways around the unintended consequences of our gains. In that way we can minimize the fall out and reap the benefits of our well intentioned efforts to improve lives and serve human kind.

How Does Society Deal With Violence and the Mentally Ill?

Another year. Another tragedy involving guns, violence and the mentally ill. The archetype of the sadly deranged misanthrope becoming disenfranchised and turning to serious violence has become all too routine for our nation.

This time the tragedy is in Arizona in a Safeway parking lot with 6 dead and dozens more wounded. As I watched the memorial service two weeks ago for the victims I can not help but recall the spat of memorial services our nation has watched and experienced over the last several years. From the massacre at Columbine High School to the horrors at Virgina Tech to this recent shooting at Congresswoman Gabrielle Gifford’s event our nation has suffered a seemingly continuous chain of high-profile and tragic gun massacres.

The reports detailing the alleged perpetrator Jared Loughner portray a disturbed individual. The excerpts from his writings and his social media pages detail an intelligent mind overcome with delusion, paranoia and disorganized thinking. In my opinion, from the information available I believe it is reasonable to question if this young man suffered from paranoid schizophrenia.

It is presumptious to assume we know anything about this person but whether he fits the diagnostic criteria of a schizophrenic there is a pattern in our society of high profile violence that takes it’s roots in mental illness. This recent shooting brings to mind some of the larger issues surrounding this pattern as well as calling into question some of the ways that our country is managing those with severe mental problems.

For those who don’t know much about it Schizophrenia is a tragic mental illness that ruins lives and destroys families. It is often miscategorized in the popular media, and many people with this diagnosis go on to lead functional and normal lives. That said, Schizophrenia is every bit as much a tragedy as a diagnosis of cancer, ALS or any other “medical disease.” Schizophrenia is categorized by disorganized thought patterns, delusions, auditory hallucinations, poor communication ability/social skills, occasionally paranoia and some other bizarre symptoms.

Contrary to its categorization in the popular media schizophrenic patients do not typically experience visual hallucinations. Despite what drug companies or even some psychiatrists might insist, the underlying cause of schizophrenia is extremely poorly understood and there are no clear cut genetic or biological roots, though the disease does tend to run in families with a stronger predilection for twins.

This crime in Arizona taken by itself is a tragedy but in the context of a string of other similar crimes committed by similar minded individuals it also raises the larger question of what we as a society are doing with our mentally ill.

In 2011 for the most part the mentally live among the general population in the community. It has been almost a half a century since John F. Kennedy began the process of closing the insane asylums that, now abandoned, eerily dot the nation. Prior to the 1960′s the mentally ill were locked away from the rest of society but now serious mental illness today is usually managed with quick inpatient hospitalizations to stabilize patients for several days and outpatient psychiatric care in the community.

This approach was made possible by the development of the so-called ”antipsychotic” drugs, such as Thorazine and Haldol, which were used to treat schizophrenia and help schizophrenic people function so that they could theoretically survive in the community. A second “generation” of these drugs such as Seraquil, were released in the 1980′s and 1990′s because they initially advertised a better side effect profile than the older drugs, but subsequent studies have questioned that.

The drugs used to treat schizophrenia work by blocking Dopamine receptors in a part of the brain called the mesolimbic cortex. There is no concrete evidence that dopamine oversensitivity plays a role in psychosis, but this area of the brain is key in allowing communication between the frontal lobes of the brain, which processes judgement and cognition and the limbic areas which is responsible for processing emotions (this is extremely simplified). No one knows what makes a schizophrenic, but these medicines likely work by blocking neurotransmitters and therefore suppressing cognition, which to the tortured mind of a schizophrenic can produce symptom relief and improve lives.

Well this sounds all well and good, the problem is that these drugs come with tremendous side effects to some users. Some patients report that they make them feel unhuman and zombie like. Others suffer severe neuromuscular disorders or weight gain and other endocrine problems. While to some patients the medicines are a god send, some mentally ill patients won’t or can’t tolerate the side effects.

Furthermore, the medicines seem to show different efficacy in different people. For some the medicines work well, but for others they don’t show the same effectiveness. The truth is that for all we know, the disease we call schizophrenia is hundreds of diseases with similar outward traits, but very different underlying disease processes.

The end result is that many schizophrenic patients either don’t take these medicines or don’t experience a radical change in their symptoms and are untreated. This is a problem because studies repeatedly show that the schizophrenic people especially when untreated have a much higher incidence of violent crime than the rest of the population (as an aside the type of mental illness that has the most violent crime associated with it is substance abuse, including alcohol).

Considering the pitfalls of treating schizophrenia, the tendency of schizophrenic to violence and the rash of high profile violent crimes involving victims who appear to be suffering from the symptoms of this disease, I think it is reasonable to question if our strategy for managing the seriously mentally ill in the community is the best approach for our society to take.

As a former residential counselor for the Italian Home for Children, a former social worker for Massachusetts DCF and now a medical resident I can say that I have seen up close schizophrenia in all the stages of its natural history from in utero to early in life to adulthood and even to death. I believe that schizophrenia is a horrible tragedy and that the people who suffer from it are themselves very much victims. I like the idea of these people being included into society as much as possible because I think they suffer a real, terrible disease and I feel uncomfortable with them being punished for that. After all we don’t lock away people with AIDS or Cancer.

In my opinion there is no perfectly “just” way to manage this situation and the question is how do we as a society handle a sub-segment of the population that has a disease that is difficult to manage and makes them apparently more prone to violent acts. It is not ”just” to lock away the victims of mental illness but the question here is is it more just than the alternative. Is it more fair to restrict the freedoms of the mentally ill than it is to expose innocent people to violence? Is there a middle solution? What is the greater injustice?

I feel a tremendous amount of compassion for those who suffer mental illness but I also feel compassion for the victims of violence. When I see the faces of the victims of the tragedy in Arizona I can not help but wonder if we are doing the right thing and if it is preventable. I can say for sure that I do not have an answer to this question, but I do believe it is a question based on recent events that is worth asking