Archive for December, 2012

What is going on ?

Sunday, December 30th, 2012

I have tried to ignore politics since the election. My candidate lost even though, from the enthusiasm at his rallies, I thought he was winning. I have trouble understanding why people would vote for Obama. Some of it is the 47% theory that Romney was so criticized for voicing. I agree that it had a big effect. Another factor was the drop in turnout among lower income white voters. They seemed to buy the argument that Romney was a rich man who didn’t care about them. Why they would believe that Obama, rich and intending to be much richer after his time in office, would care more is a mystery to me.

Now, we face a supposed crisis of the “fiscal cliff,” a manufactured crisis related to the negotiations over the debt limit and the ignored Simpson-Bowles Commission recommendations. I think the Republicans would have been well-advised to try to enact the commission recommendations into law but they have have consistently chosen the less wise alternative, in my opinion.

Dating back to the Clinton Administration, the GOP majority on Congress had the opportunity to assure the future of this country as a free market, prosperous nation. Instead, following Gingrich’s lead, they looked out for their own political futures. We now face the consequences and I see no more willingness to deal with it than before. Paul Ryan had a plan That might have avoided what is coming but the voters rejected it.

It preserves the existing Medicare program for those currently enrolled or becoming eligible in the next 10 years (those 55 and older today) – So Americans can receive the benefits they planned for throughout their working lives. For those currently under 55 – as they become Medicare-eligible – it creates a Medicare payment, initially averaging $11,000, to be used to purchase a Medicare certified plan. The payment is adjusted to reflect medical inflation, and pegged to income, with low-income individuals receiving greater support. The plan also provides risk adjustment, so those with greater medical needs receive a higher payment.
The proposal also fully funds Medical Savings Accounts [MSAs] for low-income beneficiaries, while continuing to allow all beneficiaries, regardless of income, to set up tax-free MSAs.
Based on consultation with the Office of the Actuary of the Centers for Medicare and Medicaid Services and using Congressional Budget Office [CBO] these reforms will make Medicare permanently solvent
Modernizes Medicaid and strengthens the health care safety net by reforming high-risk pools, giving States maximum flexibility to tailor Medicaid programs to the specific needs of their populations. Allows Medicaid recipients to take part in the same variety of options and high-quality care available to everyone through the tax credit option.

The plan would have addressed the Medicare issue that is coming in the near future.

The Social Security issue is a bit less urgent but was aggravated by the Congress use of Social Security trust funds in the 1990s. We hear about a “surplus” but that surplus was made up of Social Security trust funds that were not necessary at the time to pay benefits. Now, they are needed but have been spent.

I have no solution.

Christmas Day

Tuesday, December 25th, 2012

Merry Christmas to anyone reading this today. Winston and I are spending a quiet day and will go to my first wife’s house for dinner. Grandkids and most of my children will be there. Southern California has been cool and rainy this week. Today, it is supposed to rain again later in the day. Last year, I was still at Lake Arrowhead but that house is sold and I am back at sea level.

I hope everyone has a peaceful day and a pleasant evening.

Death Wish

Friday, December 21st, 2012

The Republican House members did not pass the “Plan B” legislation that would press President Obama to settle the “fiscal cliff” negotiations. They chose the perfect over the good or completely lost their nerve. It seems the revolt was mostly from the right, which demanded more spending cuts and increases in defense spending.

You would think that Romney had won the election and the GOP won the Senate. Boehner played a weak had well, and,if I were he, I would think hard about resigning.

Upstairs by the House floor, which was now closed after Boehner’s announcement, a handful of senior members discussed the whip count. They decided to go out for drinks near Union Station, in order to avoid their colleagues who’d be hanging at the Capitol Hill Club on the House side. “I don’t want to talk to the people who ruined this, at least right now,” a retiring House member told me. “They don’t get it.” Another senior member told me that Boehner was always going to struggle with the whip count since most House conservatives have little interest in seeing the speaker strike any kind of deal. “Boehner was trying to play chess and the caucus was playing checkers,” he said, sighing. “Boehner is willing to lose a pawn for a queen. I’m not sure about the rest.”

That’s how I see it. They wanted to act as if they had control when they don’t. Politics is often about image and “spin.” That was all Boehner had. Now the field is wide open for Obama to take control of the “tax cut” issue by letting all tax rates rise on January 1. Then a few weeks later, he can have the Democrat introduce a tax cut for the lower rate half of the public and take credit. The republicans will have to go along or face a real disaster in public image. They will have no leverage with the defense .

Representative Justin Amash of Michigan, a conservative with libertarian leanings, was stunned. As he walked back to his office, he said the episode was unfortunate, even though he was planning to vote against the measure. For the past month, since House leaders booted him off the budget committee, he has been railing against Boehner for his management style. But even Amash wondered whether the House GOP was making the right move. “Too many people in there were arguing that this thing is a tax increase, and I don’t think that’s what Boehner was trying to do,” he said. As much as he disagrees with Boehner’s approach, even he regretted how the speaker’s plan was killed.

Even the opponents of Boehner’s plan are distressed !

Plan B was Mr. Boehner’s attempt to salvage some political dignity and a policy victory or two in return for conceding on tax rates. The bill wasn’t even technically a vote to raise taxes because the rates are set to rise automatically on January 1 if Congress does nothing. The bill also kept the estate tax at 35%, rather than going up to 55% as now scheduled, and it made the tax cuts on lower incomes permanent.

With a narrow deal on taxes, Mr. Boehner figured he could live to fight another day on spending. But it is a measure of the mistrust the President has engendered that many Republicans didn’t want to give up even this much on taxes in return for nothing at all.

The best scenario for the economy now would be for Mr. Obama to offer to extend all the tax rates for six months and start negotiating anew in January. That would give everyone the chance to decompress and back down from the barricades.

Does anyone believe that Obama will not overreach in the state of mind he seems to occupy ?

Schizophrenia and civil rights.

Wednesday, December 19th, 2012

In June 1962, I had just finished a year of active duty in the Air Force (actually 9 months) and was looking for a job until I went back to medical school in September. I had been pulled out when the reserves were called up by Kennedy in the wake of the Berlin Wall, built by the Russians in August.

I found an ad in the LA Times for medical students to work at the VA hospital in west Los Angeles. I was a medical student although I had had only one month of medical school. I had, however, been a corpsman in the Air Force so had a little more clinical experience than many first year medical students.

I applied and was accepted. I learned the job was to do annual physical exams on 200 chronic schizophrenics since the psychiatry residents, in the grip of the psychoanalytic phase of psychiatry, did not want to do so. I started about the 15th of June and soon met my boss, a professor of psychiatry at UCLA named George L Harrington.

He was a striking individual, a big man who walked with a pronounced limp from a previous femur fracture. The effect of this combination was powerful on the chronic schizophrenics of Building 206 at the Sawtelle VA Hospital.

Harrington was one of the two or three most impressive men I ever met in medicine. He had trained as an analyst and his father was one of the first lay analysts, a former Baptist minister. Harrington had met Sigmund Freud and actually sat on his knee as a child. He grew up near the Menninger Clinic in Kansas and went to Kansas Medical School. He told me that one of his first summers in medical school, he got a job at the state mental hospital and tried his psychoanalytic theories out on chronic psychotic patients. They didn’t work. When summer was over and the state psychiatrists returned from vacation, they treated one depressed female patient with shock therapy. Harrington had spent the summer trying analysis on her with no success. With one ECT session she was much improved. That was enough to convince him that analysis did not work, no matter that the psychoanalytic school of psychiatry had taken over the specialty and the departments of all the medical schools.

Harrington was sure this was all wrong and was convinced that schizophrenia was an organic disease. He told me that it might even be a deficiency of an unknown vitamin. It wasn’t so many years since beri-beri and pellagra had been discovered to be vitamin deficiencies. I have previously referred to this experience, and I am convinced that he was on the right track when most psychiatrists were wrong.

Unfortunately, the psychiatry profession held on to psychoanalytic thinking far too long. A friend of mine from medical school is an analyst and has made a good living from it in Malibu. That is a good choice of location since analysis works best on rich mildly neurotic patients. Psychotics tend to be poor and difficult to work with. Now, with huge advances in neurobiology there is more hope but the public is still reluctant to trust psychiatrists with any authority. I am afraid that the profession is still suspect from the years of the Freudian blind alley.

A fellow named Clayton Cramer, who has a schizophrenic brother named Ron, has written an excellent book about the legal history of the deinstitutionalization movement that emptied the mental hospitals since 1960. On his blog, he posts that the shooter in Connecticut may have been taking Fanapt, an antipsychotic drug that is prescribed for schizophrenia. A rather hysterical post on what looks like an anti-treatment site alleges that SSRIs, a class of drug that is unrelated to anti-psychotics, are responsible for mass shooting incidents. It is this sort of misinformation that muddies the waters around the issue of violence and mental illness. The drug, iloperidone is an “atypical anti-psychotic” which means it is a serotonin receptor antagonist. It was nothing to do with SSRIs, which are selective serotonin reuptake inhibitors. The effects are very different as are the mechanism.

The battle for intelligent treatment of schizophrenics goes on.

A summary of treatment options does not mention the most serious problem. That is that schizophrenics commonly stop taking the drug, either because they feel fine and believe they no longer need it, or because they have no insight into their condition and refuse the drugs unless coerced. This is the reason why commitment, even outpatient commitment which involves supervision of the drug taking, is desirable.

The Connecticut Massacre

Saturday, December 15th, 2012

There is information still coming to light about this awful case. Early reports, such as the name of the shooter and the alleged murder of the father, were predictably wrong. It turns out that the shooter, named Adam Lanza, a 20 year old with a history of odd behavior and some evidence of mental illness, such as autism, was living with his mother who was his first victim. There are a number of suggestive reports, that she decided to “stay home to care for” her 20 year old son.

The treatment of severe mental illness in this country has been altered for the worse by a movement that began in the 1960s when mental illness began to be described as a “civil rights ” issue. Several books and movies described abuse of power in commitment of the mentally ill. The first such movie was “The Snake Pit” in which a young woman is committed for what sounds like schizophrenia. The treatment of the time (1948) can be seen as barbaric but there was nothing else available. She did recover, although we know that without adequate treatment, recovery from schizophrenia is unlikely.

The movie that really devastated the mental hospital system was called “One Flew Over the Cuckoo’s Nest” and starred Jack Nicholson.

As I type this, a black professor of psychiatry is talking on the TV and discussing gun control !! His mention of mental illness is brief and noncommittal.

The movie was powerful in showing the Nicholson character as a guy who just is “different” and harmless.

The film was the second to win all five major Academy Awards (Best Picture, Actor in Lead Role, Actress in Lead Role, Director, and Screenplay) following It Happened One Night in 1934, an accomplishment not repeated until 1991 by The Silence of the Lambs.

In 1963 Oregon, Randle Patrick “Mac” McMurphy (Jack Nicholson), a recidivist anti-authoritarian criminal serving a short sentence on a prison farm for statutory rape of a 15-year-old girl, is transferred to a mental institution for evaluation. Although he does not show any overt signs of mental illness, he hopes to avoid hard labor and serve the rest of his sentence in a more relaxed hospital environment.
McMurphy’s ward is run by steely, unyielding Nurse Mildred Ratched (Louise Fletcher), who employs subtle humiliation, unpleasant medical treatments and a mind-numbing daily routine to suppress the patients. McMurphy finds that they are more fearful of Ratched than they are focused on becoming functional in the outside world. McMurphy establishes himself immediately as the leader; his fellow patients include Billy Bibbit (Brad Dourif), a nervous, stuttering young man; Charlie Cheswick (Sydney Lassick), a man disposed to childish fits of temper; Martini (Danny DeVito), who is delusional; Dale Harding (William Redfield), a high-strung, well-educated paranoid; Max Taber (Christopher Lloyd), who is belligerent and profane; Jim Sefelt (William Duell); and “Chief” Bromden (Will Sampson), a silent American Indian believed to be deaf and mute.

Here is the picture of mental illness as a matter of civil rights. It was shown in 1975 when the deinstitutionalizing was already well along and it convinced the public, few of whom know anything of psychology, that mental hospitals should be closed. State governors, like Ronald Reagan in California, were only too happy to oblige. This is why I was not a Reagan fan before he was elected in 1980.

The new drugs, like Thorazine made all this possible. Patients on Thorazine made almost miraculous recoveries. at least until the side effects appeared.

The introduction of chlorpromazine into clinical use has been described as the single greatest advance in psychiatric care, dramatically improving the prognosis of patients in psychiatric hospitals worldwide[citation needed]; the availability of antipsychotic drugs curtailed indiscriminate use of electroconvulsive therapy and psychosurgery, and was one of the driving forces behind the deinstitutionalization movement.

Actually ECT or “shock therapy” was, and remains, effective for severe depression. When used on psychotics like schizophrenics, it often provided a period of a “lucid interval” that lasted for hours when the psychosis seemed to relent. The symptoms recurred but the hope of longer intervals resulted in repeated sessions. It was often depicted with convulsions and other horrendous effects but, in reality, anesthesia and muscle relaxants were used to avoid such scenes. Even insulin coma, which has a risk of damage from low blood glucose, was effective for periods when nothing else worked.

The alternative offered was outpatient centers, in California authorized by The Short-Doyle Act of 1957. There was never enough money and governors saw the closing of state hospitals as a budget issue, not a medical issue.

Throughout the 1970s and 1980s counties contended that the state was not providing adequate funds for community mental health programs. In addition, several counties were receiving less funds on a population basis than other counties. This disparity was addressed, with varying levels of success, in both the 1970s and the 1980s with the allocation of “equity funds” to certain counties. Realignment enacted in 1991 has made new revenues available to local governments for mental health programs, but, according to local mental health administrators, funding has lagged behind demand.

And As a result of declining hospital population, three hospitals (Modesto, DeWitt, and Mendocino) were closed. Legislative intent was to have the budget savings from the closures go to local programs. The “money was to follow the patient.” This did not happen in 1972 and 1973 as a result of the Governor’s veto.

The patients released from state hospitals ended up living in the streets as “the homeless problem” exploded. Others filled the jails. In 2000 I was told by directors of homeless shelters in Los Angeles that 60% of the homeless were psychotic, 60% were drug addicts and half of each group was both. About 10% of the homeless are neither and are quickly moved to shelters and “SRO” hotels, especially if there are children.

What percent of shizophrenics are violent or capable of it ? A national study suggests that the number may be higher than we are usually told.

The 6-month prevalence of any violence was 19.1%, with 3.6% of participants reporting serious violent behavior. Distinct, but overlapping, sets of risk factors were associated with minor and serious violence. “Positive” psychotic symptoms, such as persecutory ideation, increased the risk of minor and serious violence, while “negative” psychotic symptoms, such as social withdrawal, lowered the risk of serious violence. Minor violence was associated with co-occurring substance abuse and interpersonal and social factors. Serious violence was associated with psychotic and depressive symptoms, childhood conduct problems, and victimization.

Since schizophrenia is life-long, usually beginning in teenage years in males and a bit later in females, the total period of exposure to the risk of violent behavior is high. Treatment with modern drugs reduces this considerably but most schizophrenics who are not under good supervision do not take their drugs.

The mother of the shooter was the registered owner of three guns, two of them pistols and one a “bushmaster” rifle. These are military lookalikes that are mostly in 5.56 NATO round calibres. They are also very expensive rifles. The rifle found in the shooter’s care was described as .223 calibre and the Bushmaster site does not include any of this calibre. UPDATE: I did not recognize the .223 as the same calibre as the 5.56 NATO round. It is the same. The .223 is in inches and 5.56 is millimeters. A momentary lapse.

He did not use the rifle anyway but what was the mother doing buying this for her autistic son? Pistols might have been for her own protection but the rifle doesn’t make sense except as evidence of enabling behavior by the mother.

I will add to this post as more information comes out. This looks to me like an incident of mass violence by a schizophrenic 20 year-old male with possible assistance by his mother in allowing him access to guns.

The mother is now being described as a “survivalist” and used to target shooting. That does not explain why she had guns around her psychotic son. “Autism” does not develop during teenage years. It is a phenomenon that is recognized in infancy. The term may have been used by the older brother as it is a less “disreputable” term for schizophrenia. If this represents a form of denial by the family, it may be significant.


Tuesday, December 11th, 2012

Tonight I watched, for maybe the 50th time, one of my favorite movies. It is called “Overboard”, and stars Kurt Russell and Goldie Hawn. There is an inferior movie made from a very good book of the same title.

It is amazing to me that 25 years have passed since this movie was made. Goldie Hawn first came to my attention in Rowan and Martin’s “Laugh-in in the 1960s. It is just amazing to me that she is still going strong.

Here she is at 67. God, I wish I could look that good at 67 !

Since the making of Overboard, she has been in a permanent relationship with Kurt Russell. Russell’s principle film role, as far as I am concerned, is as Wyatt Earp in the move “Tombstone.” He was a child actor and has made a number of movies but none that are interesting to me.

Goldie has two children from an earlier marriage, one of whom looks like her and is an excellent actress.

The movie was not well received at the time as it was a bit of a change from the usual movies that each would be expected to make at the time. With time, it has become a much more accepted film.

Hawn and Ruth Buzzi were prominent members of the cast of Laugh-In.

Here they are in 1968. Goldie Hawn is still beautiful at almost 70.

Blogging pause

Saturday, December 8th, 2012

I notice that I haven’t been posting for a couple of weeks. Mostly this is a result of my discouragement about the election. I fear our best hope of resolving the financial crisis that is coming is now lost. As a result, my interest in politics has waned. If the Republicans were showing any signs of life or intelligence, I might get a bit more interested but I fear we are going to see more proof of the “stupid party” theory.

For example, one of the dedicated enemies of the GOP is the entertainment industry. Movies and music all tend to be part of the cultural decline but, more importantly, the people who make huge fortunes from the industry are almost reflexively leftist and fund the Democratic Party. Recently, a disgusting example of the failure of the GOP to recognize who its friends and enemies are, was the firing of a GOP Congressional staffer for a suggestion that the party in Congress support copyright reform.

A Republican staffer who wrote a position paper suggesting that the current system of copyright legislation might benefit some market-based reform has been summarily fired.

Last month the Republican Study Committee, an influential group made up of members of the US House of Representatives, put out a position paper saying that the current system “violates nearly every tenet of laissez faire capitalism” and instead ensures government-enforced monopolies rather than competitive stimulation.