This is the statement I [Nathaniel S. Lehrman, M.D.] presented last week. It describes overmedication as the major reason for mental patients' failure to recover as they did years ago, and its correction as today's major task.
Statement for NY State Assembly Mental
Health Committee Hearing
Albany NY, July 18, 2001
EST: Even More Harmful Psychiatrically
than Routine Over-Medication;
Stopping over-medication should be the mental health movement's first task
Nathaniel S. Lehrman, M.D.,
Chairman, Mental Health Committee, Humanist
Society of Metropolitan New York;
Clinical Director, Retired, Kingsboro Psychiatric Center, Brooklyn NY
10 Nob Hill Gate, Roslyn NY 11576,
516/626-0238; fax - 3896; e-mail: firstname.lastname@example.org
Iım Dr. Nathaniel S. Lehrman. As I mentioned at the May 18 hearing, I started in psychiatry in 1947, was Clinical Director at Brooklynıs Kingsboro Psychiatric Center for 5 1/2 years ending in September, 1978, and from then until 1981, a part-time staff psychiatrist at one Creedmoor aftercare clinic and consultant to most of the others. In 1983, after Mario Cuomoıs election as Governor, the only physician on his three-man search committee for Commissioners of Health and Mental Health submitted my name for the State Commissionership of Mental Health. I felt then, as I do now, that the OMH should greatly raise its sights: that its goal should be returning patients to useful and satisfying living rather than merely maintaining them as drugged cripples. But doing this requires medication reduction, which I shall discuss further below.
This is the second Assembly Mental Health Committee hearing addressing the question of electroshock treatment (EST), and its recent resurrrection in state and other facilities. That resurrection, and other aspects of psychiatry, are evoking increasing public concern. In May, over 400 people protested in front of Attorney General Eliot Spitzerıs New York City office against the forced electroshock being given Paul Henri Thomas. "Psychiatric survivors" and their allies have held huge meetings and demonstrations against psychiatric harm in Berlin, Toronto and Vancouver. These demonstrations will doubtless continue until the mental health care system stops harming its clients. That same concern with psychiatric harm evoked the creation of a Green party mental health caucus, with which I have the privilege of working - established to help formulate and, we hope, implement, an effective mental health program.
The reason for EST's recent resurrection is simple: to hide the brain damage caused by the endless drugging upon which todayıs psychiatry is based, by focusing instead on a treatment causing even more brain damage: EST. The best defense is a good offense. Whether or not you now place limitations on EST, and I hope you do, the focus on it has diverted attention from the economically more important, and the clinically much more harmful, gross, routine overuse of drugs - a subject also evoking increasing lay and media concern.
Why is the harm from drugs more important overall, although individually less, than that from EST? Because so many more people get the drugs! These medications usefully suppress symptoms while harmfully inhibiting the capacity to think. EST suppresses symptoms even more strikingly while also permanently inhibiting the capacity to think. After acute crises have passed, drugs should therefore be gradually reduced and, if possible, eliminated. Gradual reduction of useful but toxic drugs, such as cortisone, is standard throughout medicine. And the studies of the many patients who have recovered completely from psychosis reveal that they have stopped prescribed drugs. And having been in practice before the drug era, I can personally attest that chronicity continues much longer today than it did then.
Todayıs OMH treatment, based on the popular psychiatric notion of mental illness as merely "brain disease," is, in fact, directed toward a very different goal: the maintenance of clients in drug-crippled states by indefinitely continuing them on brain-numbing drugs. Brain changes had long been sought unsuccessfully in schizophrenia, the most serious mental illness. Changes in these patients - an increase in dopamine receptors - which were absent in normals began to be found in the 1970ıs. Closer examination of the data revealed, however, that these changes were found only in schizophrenics who had received drug treatment but not in those who never were medicated. This strongly suggests that the brain changes supposedly characterizing schizophrenia are actually caused by the drugs used to treat it.
The "intensive case management" for which OMH seeks over 10,000 new positions is nothing more than drug-pushing baby-sitting. This is demonstrated by the account of "a day in the life of an intensive case manager" in the June, 2001 OMH Quarterly. It clearly shows that the manager's primary goal is to maintain the client in status quo by ensuring that he takes his medication and seeing that he gets to pharmacies, doctors' appointment, food-pantries and the like. Since nothing is said about helping the client return to productive living, that is clearly outside the "intensive case manager's" scope.
I would therefore urge that OMH discard its present hopeless attitude that clients are essentially incurable and raise its sights. Rather than merely maintaining clients in drug-crippled states, the agency should aim at helping them regain full capacity and functioning. But this will require major changes. Perhaps it can start with a legislatively-mandated medication reduction.
Medication reduction is difficult because it can evoke resurgence of earlier symptoms. Dosage-reduction therefore requires the closest collaboration between psychiatrist and patient. But such a close collaboration is almost impossible today because of the way OMH has organized care: psychiatrists, functioning almost entirely as drug-prescribers, rarely know their patients well enough to even think of reducing dosage. That must be changed, with psychiatrists becoming primary counselors for their patients (as they were in times past), an activity for which now they will need additional training inasmuch as that training has been dropped from psychiatry residencies.
Making OMH accountable requires regular statistical reporting, an activity in which the NYS OMH once led the nation. Its statistical reports, covering all programs receiving state funds, should particularly include the long-term or ultimate outcome of patientsı treatment. They should also reveal the number of patients beginning treatment (incidence) and continuing in treatment (prevalence); the numbers of ESTs given and the amounts of drugs prescribed. Such reports could make it possible to follow medication reduction as well as to show the overall effects of OMH-funded care on its patients.
While OMH is proud, for example, of reducing the state inpatient census from 93,000 in the 1950ıs, to a total of 73,000 in- and out-patients in 1983, and to its fewer than 5,000 in-patients today, it says little about its current 800,000 projected program enrollments per year. How many people are actually involved? How many "programs"is each patient enrolled in? If one enrollment per patient, OMH is treating 800,000 patients; if two, 400,000 patients are involved, and if four, 200,000 - at least twice as many patients as in the 1950's, and with most of them now getting drugs.
Have censuses been rising? Many patients have been on medication for years and therefore continue impaired. Do they leave the system other than by death or escape? Without clear reports, especially of long-term results, legislative mental health committees will continue to be ignorant of what's really happening and the system itself will continue its downhill, increasingly harmful course.
Another aspect of helping patients regain full capacity, beside reducing medications, is to restore to them full responsibility for themselves. Above and beyond the constitutional questions side-stepped for so long, treatment must therefore be made voluntary, as it is throughout medicine and was during the 1970s under Dr. Alan Miller's Commissionership, rather than based on compulsion. Involuntarily admitted patients were changed then to voluntary status, so they remained in hospital only when agreeing to do so.
Treating patients against their will degrades them, reduces their sense of responsibility and feelings of self-esteem, and their ability to return to normal functioning. That is another reason why involuntary commitment, both inpatient (except in case of psychiatric emergency - danger to self or others) and outpatient, should be banned; forced drugs prohibited; electroshock treatment (EST) over a patientıs objections banned completely, and an immediate moratorium instituted on EST in general.
Let me summarize:
(1) OMHıs treatment goal should be redefined: restoring clients to full functioning should replace maintaining them endlessly in drug-crippled states. This requires that (2) medications be consciously reduced as much as possible and often eliminated, (3) psychiatrist-patient relationships be restructured so doctors are in a position to reduce medication, (4) treatment be made voluntary rather than forced, and (5) OMH report regularly, relevantly and understandably on the statistics of long-term outcome, medication use and other significant information.
I have testified for over twenty years before various hearings of this Committee. My efforts have not been very productive because of legislatorsı uncritical acceptance of persuasive professionals. The net result of all that talk, and of all the pharmacological miracles we have heard about for decades, is that treatment results are getting worse. I am one of the few professionals left who has known the system from the inside for over half a century, and also knows how it could function properly. Because problems in the mental health system lie much more in matters of hospital policy and administration than in areas amenable to legislation, I would accept an invitation from the Committee to serve as an unpaid consultant, supplying a professional voice helping it to stand up to the professionals who have brought the system to its current unfortunate state.
Members of the Assembly, you have long gone along with a mental health system which has become increasingly harmful and costly. Will you improve it so it begins to help its clients or continue with surface changes?
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