Human Rights and Managed Care: Part 4

Steven Moffic, M.D.

May 24, 2012

This leads us into discussing psychiatry per se, which managed care prioritized first. Unless you are early career psychiatrists, you are probably familiar with the anecdotal horror stories: too brief hospitalizations followed soon by suicides; the revolving door of re-hospitalizations; the escalation of the least trained psychotherapists to provide less psychotherapy; review of treatment by lesser trained clinicians or managers; denial of treatments like EMDR for PTSD that was deemed “experimental”, even if they were not; medication checks by psychiatrists being managed down to a 15 minute norm instead of the legendary 60 minute hour; and desparate polypharmacy to try to get faster results. Patients who recognized these changes sometimes called out in frustration: “Dr. X used to care about patients; now he cares about money”!

Yet, also in managed care and psychiatry, the human rights waters are muddy. If we take a step back in psychiatric time before managed care, we need to recall that in public sector mental healthcare for the poor, 15 minute med checks and inadequate hospitalizations (after deinstitutionalization) and the like were quite common in the 1960s and 70s. Managed care brought this to the social classes above the lower. Ironically, though, it is also the cost savings of managed mental healthcare that helped parity become politically acceptable, since it would not cost much extra if managed. Parity, however, may have turned out to be “Fools Gold” in terms of its treatment value.

But for managed mental healthcare, there seems to be even more than Article 3 and 25 to consider in terms of human rights. Why is that? One word may suffice: stigma.

So take Article 1: “All human beings are . . . equal in dignity”. Stigma reduces that dignity.

Article 23: “Everyone has the right to work . . .” We all know how those considered to have a mental illness get discriminated against being hired, and how they often need special help, such as that provided by Clubhouses, one of which I was most fortunate to Chair the Board. Housing has that same predicament, called “not-in-my-backyard”, which is mentioned in the previously cited Article 25.

Article 2 sets forth the various groups that need special protection, including “race, color, sex, language, religion, political or other opinion . . .” In the USA, progress was achieved in the appreciation of human rights for minorities, women, and others since the 1960s, though more progress is still necessary. But those with psychological problems were not mentioned in Article 2 as needing special protection and are lagging behind. And, if we want to make the Nazi association again, the mentally ill were the first targets. Globally, there is evidence that the majority of people with psychiatric disorders do not have access to evidence-based interventions. No wonder that the recovery movement has escalated recently, which emphasizes that we have to pay better attention and involvement as to what our consumer patients want as far as treatment goes. Yet, for all the philosophical and psychological worth of the recovery movement, it is also cheap and thereby welcomed by payers and managed care companies!

Managed care, by carving psychiatry out of medicine in terms of contracts, probably did nothing to lessen stigma, and perhaps contributed to worsening it. Then again, all is not so simple. One of the earliest rationalizations for the carve-outs of mental from general healthcare was because so-called bounty-hunters in the 1980s were rounding up adolescent and AODA patients for the for-profit hospitals for clinically unnecessary, but lucrative, hospitalizations. These Charter hospitals of the world were also profit-driven.

As my ignorance of this connection between managed care and human rights goes, I’ll plead guilty to the sin of omission, as perhaps could many, many others. Please accept my apology if this ignorance resulted in harm to patients.

(Stay tuned for the conclusion in Part 5).

Steven Moffic, M.D.

Sad in Psychiatry: Affectionately called a “gadfly,” and  known as “da man in psychiatric ethics,” Steven Moffic writes about what makes him sad about modern day psychiatry, and how to “treat” that condition so that we will become glad about what psychiatrists can do to help.

 

 

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53 thoughts on “Human Rights and Managed Care: Part 4

  1. Steve,

    “too brief hospitalizations”?

    Are you kiddging me?

    What… holding somebody captive for longer, to convince them they have a lifelong incurable illness that needs lifelong drugging is the answer?

    Hell, why not hold them indefinately, Steve?
    Especially, if they’re “non-compliant”…
    Oh, those nasty non-compliant patients, who get out and get well…. and stay well!

    This entire series, parts 1 – 4, sound more like an opportunity for you to expand on your first, introductory post, and “why we still need psychiatrists.”

    I obviously can only speak for myself, but I say, “I’m not buyin’”.

    Duane

    • Duane,

      I share your sentiments.

      I can’t help but see, that, with his blogging, Dr. Moffic aims to paint himself a defender of Human Rights – even as he wants more long psychiatric “inpatient” treatment (resources for so-called “hospitals” and “hospital beds” – additional locked wards).

      And, maybe he genuinely believes he’s defending Human Rights; but, he is confused.

      He wants to increase the practice of long-term ‘medical’ incarcerations – for those deemed “psychotic”; well, surely, you know of the era of the infamous Snake Pit, when a psychiatrist could reign as King. Dr. Moffic apparently recalls those days, of his youth, with nostalgia and is now pining for a Kingdom of his own.

      I read it in his other blog.

      In case you’ve not seen his posts on the psychiatrictimes.com website (or, if maybe you only read him there occasionally), I share the following lines (three brief paragraphs) which begin his recent (April 20, 2012) retrospective, entitled, “Is it Time for Re-institutionalization?”

      Dr. Moffic writes:

      “I can just sense the uproar now. Dr. Moffic wants state hospitals again? Has he lost it? Well, yes. I do, sort of. Here’s why.”

      “Recently, I was asked to write a request to possibly extend the outpatient commitment of a patient of mine. What for, I said to myself? This would be a waste of time because he had not exhibited any more dangerous behavior, was taking care of himself, and was compliant with his intramuscular medication. However, when as part of the ongoing monitoring of my patient’s improvement, I asked him to rate on a 0-10 (best) scale how well the medication was working, he said “0”. When I asked why, he said it was because he didn’t need the medication. Uh, oh, I thought. Could this be Anosognosia? Or, has he read or heard of Robert Whitaker’s book, Anatomy of an Epidemic (2010), which discusses the potential long-term risks of such medications.”

      “There’s no way he’ll be committed longer, but will he stay on the medication voluntarily? Without it he’d surely relapse into psychosis and possible dangerousness. If he then went inpatient again, would he only stay a few days, not enough to address his ideas about the medication? It didn’t help enough the first time around.”

      http://www.psychiatrictimes.com/blog/moffic/content/article/10168/2062591

      There’s so much absurdity in that passage, I don’t even know where to begin…

      “Without it he’d surely relapse into psychosis and possible dangerousness.”

      How can Dr. Moffic be so sure???

      Sadly, when the general public hears a doctor of psychiatry speak in such weighty terms, as “surely” something (‘X’) will happen (where ‘X’ is seemingly terrible), they are inclined to believe him, naturally.

      But, how can he be so sure of what he’s saying??

      Does the Universe offer not even the slightest probability of there being some alternate (less scarey) outcome, in the event of a so-called “patient” going off the psych-meds he’s being coerced into taking???

      We know it’s coercion, as it seems (from what Dr. Moffic is saying), this particular “outpatient” is an ‘involuntary’ subject (of Dr. Moffic and the State); i.e., if/when he, in deed, fails to answer the knock at his door (or fails to show up, in a “medical clinic”) for his injection, then the cops can be sent to pick him up and bring him in, to be injected.

      Of course, that would be a nerve-wracking time for one and all.

      In the course of such an encounter (and, potential confrontation) with police, perhaps, Dr. Moffic’s “patient” would exhibit behavior that seemed ‘dangerous’ and/or ‘psychotic’; but, would it really be that, at all??

      Perhaps, such behavior would signify nothing more or less than the fact that he’s understandably distressed (scared shitless – and, more or less flippin’ heated – as well as somewhat, at least minimally, disoriented) because he’s anticipated this moment with utmost dread, and he knows he’s not being treated with the least trickle of genuine respect, as a human being; his Human Rights are being wildly violated by the State, which has ordered his involuntary outpatient treatment (IOT), that amounts to slow poisoning.

      _________

      A note to Dr. Moffic: here (above), I have directed my words to Duane – because, from reading his posts, I trust he understands my disgust with your vision for the future of psychiatry (which, I see as quite literally *insanely* utopian); I speak to Duane because I was once treated in the way you’d apparently like to treat your above-mentioned “patient”; and, for my own good, I chose to speak to someone who can sympathize with my feelings of horror, at having been so disrespected.

      Did months of so-called “inpatient care” convince me to stay on meds? No, not for long; but, it did traumatize all hell out of me.

      I have spoken to Duane here, because I appreciate his genuine respect for Human Rights.

      Now, I am speaking to you, as well, Dr. Moffic, and I am inviting you to respond to this question:

      How do you presume to know, about your “patient”, that, “Without ['intramuscular medication'] he’d surely relapse into psychosis and possible dangerousness” ???

      And, here’s another question:

      What, in your view, would be the difference between ones being in extreme withdrawals as opposed to ones experiencing a “relapse into psychosis” ???

      I ask you that question, because, after all: more than two decades ago, everyone I knew was told, by ‘knowing’ psychiatrists, that I would surely, “relapse into psychosis” were I to stop taking so-called “antipsychotic” meds. I had been put on meds, forcibly, having been called, “a danger to himself”; I was not any kind of danger; but, the psychiatrist said I was.

      Psychiatrists nearly scared my mother to death when I went off those meds.

      (I was taking not just “anti-psychotics” – but other psych-meds as well.)

      I went off them, and, yes, I experienced extraordinary withdrawals.

      But, I toughed it out, went to Twelve Step meetings – joined a Buddhist group – and, eventually (after a few months), the worst symptoms passed.

      Never again, would I dare return to my psychiatrist, of course (nor allow any psych-med in my body).

      Thankfully, there was no such thing as “outpatient commitment” in those days – so, no need to worry about a possible court order directing me back into the grand realm of Psychiatry.

      So…

      What about Twelve Step meetings and/or a good spiritual program for your “patient” – in the event he decides that he seriously prefers quitting meds???

      Or, what about finding him ‘recovery’ oriented people who’d offer support, toward tapering off???

      My understanding of IOT is that you (as the “patient’s” doctor) really don’t have to prescribe meds at all.

      J.

      • “Never again, would I dare return to my psychiatrist, of course (nor allow any psych-med in my body).”

        But psychiatry reserves the right to enter your body any time they see fit. If you ever dare step out of line, dare become distressed, it won’t be up to you.

        You are only at liberty at until a psychiatrist decides you are unworthy of liberty. That’s how it works.

        Real doctors who are decent enough to actually look inside your biology and who unlike psychiatrists, actually don’t speak from a pathetic blind state of hubris when they make assertions about the body, don’t even have the sickening and degrading to all of humanity arrogance to reserve the right to take ownership of your body against you will.

        The drug and label brigade of quack shrinks do, however always reserve the right to rapidly take ownership of human bodies, regardless of what the former owner, the person trying to live in that body thinks about the matter. Like millions of people in the history of this quackery, you’ll know precisely how much empty lip service a psychiatrist waxing lyrical about human rights is when you feel the pitiless hands of their ‘psych nurse’ goon squad on your body as they take you down.

        When a psychiatrist hears the words ‘No!, get your hands off of me’, just like any common rapist on the streets, the cries of the owner of the body to be invaded are ignored.

        And that’s the point where a dialog becomes a sick joke.

        Always remember folks… ‘someone else’ killed themselves, ‘someone else’ committed a crime, ‘someone else’ has an adult kid and ‘someone else’s’ parents would rather their kid stay drugged, so always remember, because of this ‘someone else’, YOUR BODY, YOUR RIGHTS, will perpetually be on the chopping block.

        And if you DARE have the temerity to complain about being forced to live in constant terror of human rights abuses, you’re labeled a radical and hit with another anecdote from the bottomless well of ‘someone else’ stories.

        ‘oh but (someone else) killed themselves’

        ‘oh but (someone else) hurt someone’

        ‘oh but (someone else) was walking naked down the street’

        ‘oh but (someone else) insert scare story here’

        People who have never been on the sharp end of psychiatric coercion are living in ignorant bliss. If you’d all been violated so, we wouldn’t even be having a debate where a minority fights for their basic human rights, as it would be axiomatic to everybody that forced psychiatry is a deep offense to the human dignity of us all.

        Thank you to the poster below who copied and pasted what Dr. Moffic had to say about one poor sap who was legally obliged to submit his brain and consciousness for forced long term chemically induced alteration, the guy on ‘community commitment’. A living hell of indignity where dominant psychiatric ideology combined with state power has determined that not a single hour will be permitted to go by where that man does not have psychiatry forcibly meddling around in his brain. (reach for barf bag).

        One would think a society, a government, would not allow such violation of its citizens brains by a profession who don’t even examine brains nor have any pertinent objective or demonstrable insight into anyone’s supposed brain function or dysfunction. One would think wrong.

        And that’s the pathetic and sad reality we live in today. Quacks, empowered by force of law, to do mess around people’s brains by violent force, when they can’t prove nothin’ about nobody’s brains.

        And here you were thinking you grew up in a world with justice in it? think again.

        (if you’re lucky enough to own your thinking organ this week)

        *Rest In Peace, the millions of people lied to, led to think they were brain diseased without any evidence, who lived short and brutish lives filled with stigma, human rights abuses and hate, and learned helplessness, whose could have been transient personal distress, was compounded and worsened by psychiatry’s lies and unwanted and hubristic ‘interventions’. Rest In Peace the millions from last century who had their good names ruined, their dignity pushed to the side, in psychiatry’s great march to the pathetic mess that it is in today. Rest in Peace the dead, the iatrogenically disabled, the many who never felt the dignity of a fulfilled life due to being told they were less than, Rest In Peace the many people buried without their brains, as their brains were sent to be sliced up in labs by fanatics hell bent on proving the dead people were biologically inferior for having the temerity to suffer a breakdown under a life of stress, needless to say, countless dead peoples remains being desecrated later, the anointed class of ‘researchers’ have produced such amazing replicable evidence so as to bring about the amazingly technologically advanced scenario of a quack sitting across a desk ticking boxes from the DSM without testing anybody’s biology whatsoever.

        When the trajectory of a human life can be forever altered, when supposedly inalienable rights are worthless and can be smashed into oblivion by a quack simply signing some papers with his plastic drug company gifted Seroquel® ballpoint pen, then it’s a wonderful world isn’t it people? I see trees of green, red roses too.

    • Really! “Too brief hospitalizations followed soon by suicides?” Did it ever occur to you that locking up a distraught person, medicating them against their will, restraining them, and isolating them from their natural supports might increase suicide risks?

      • Something tells me that there is a significantly statistical amount of people who have been in the hospital for a long stay that then commit suicide. And as I have said more than a few times, Moffic isn’t coming from any possible objective stance. He believes that coercing others into believing they are ill because he believes they are; and then have them say they got better means that there’s some cure going on. There’s no free will that goes on in psychiatry, and you can not take their evidence as objective.

  2. I am shaking my head in wonder…

    You explain, that: “so-called bounty-hunters in the 1980s were rounding up adolescent and AODA patients for the for-profit hospitals for clinically unnecessary, but lucrative, hospitalizations.”

    I’m wondering why you say, “so-called bounty-hunters” ???

    Usually, when someone says “so-called” it’s to point to a questionable description; it suggest that the following label may be a misnomer.

    You say, “if we want to make the Nazi association again, the mentally ill were the first targets.”

    Why don’t you say, “the so-called mentally ill” ???

    Do you have any proof that the Nazis were accurately defining certain people as, “mentally ill” ???

    Do you have any proof that “mental illness” is anything but a metaphor, referring to the many varied effects of human distress – and/or, to the unwanted behaviors of ‘outsiders’ who choose to avoid mimicry of their society’s established ‘norms’ ???

    In this post, you decry the effects of stigma, yet you refer repeatedly to “those with mental illness” and “those with psychiatric disorders”; why not say, “those with so-called mental illness” and “those with so-called psychiatric disorders” ???

    To me, it seems, perhaps, the only people who are being protected from stigma, in this post, of yours, are these people whom you refer to as, “so-called bounty hunters.”

    They were engaged in activities that could accurately be described as crimes against humanity.

    Again, I am shaking my head…

    • Yeah, the man’s Tartuffery is intolerable. Linguistic philosophers have taught us that to understand many words you must understand what they are used for, who they are used against. The term ‘mental illness’ is a term of abuse, traditionally used as a political weapon against people much like theological concepts such as ‘witchcraft’ and ‘heresy’ were used against people in the Age of Faith, only in the Age of Madness, psychiatric concepts are the codewords allowing egregious abuses and infractions of rights and existential assaults, with evidence that is about as corroborative of their claims as a supernumerary nipple is for the existence of witchcraft.

      He metaphorically shakes his fists in frustration at the superlunary sphere, even though it is he and his fellow psychotyrants who were instrumental in the propagation and perpetuation of stigmatising atitudes towards this invented category of people, kind of like a slavemaster inveighing against the stigma that comes with being a so-called fractional human being, referring to his designated slaves with that very term.

  3. The carve outs allowed psychiatrists and now ‘less’ educated prescribers to IGNORE the negative effects of the drugs they insist are necessary medical treatment—The negative effects of the drugs cause real iatrogenic injuries which are then medically neglected and become disabilities, and the cause of sudden, and/or decades early death. The bio-medical paradigm of care has redefined ‘successful treatment’ to be ‘treatment compliance.’ Doing so consequently redefines ‘effective treatment’ in the Real World: chronic dysfunction, neurological, metabolic and/or cardiovascular illnesses, disabilities and early death–The public is constantly being told early aggressive treatment is best; begging the question, FOR WHOM?!

    I’ll believe psychiatrists are doctors and in HEALERS, when they provide medical treatment for the illnesses they inflict upon their patients. It is now Standard Clinical Practice to medically neglect psychiatric patients. Psychiatric drug-induced (taken as prescribed) death and ECT fatalities are classified as ‘natural deaths.’ This is despicable; an insult–a crime. It is a judgement that implies even in death, psychiatric patients are owed no ethical duty; and are considered to be without human dignity.

    If that isn’t stigma, I don’t know what is!

    ‘Psycho’ pharmacology reminds me of the movie Gaslight…

    This is personal for me. My comments are not directed at you personally.

  4. “”What, in your view, would be the difference between ones being in extreme withdrawals as opposed to ones experiencing a “relapse into psychosis” ???””

    As one who suffered horrific withdrawal symptoms from ADS, I would love to see Dr. Moffic answer this question. It is an issue that has been ignored by psychiatrists for way too long.

    Why do the hard work of tapering patients off of psych meds when you can just conveniently blame drug reactions on the person’s label?

    Also, while no one is 100% consistent in their views, I find Dr. Moffic’s columns in psychiatric times quite disturbing and question how much of a reformer he really is.

  5. I can imagine that some people released in the community all drugged-up and with no emotional support, could do with longer hospitalization but then those hospitals would have nothing in common with those we all know and have experienced. In those hospitals there would be no locked wards and no forced treatement. In those hospitals you wouldn’t be brain-washed into believing that you are mentally ill- quite the opposite. In those hospitals psychiatrists would know how to get you off the antipsychotics safely and there would be as much emotional support as needed. People like Dan and Corinna would be working there. Those hospitals would be safe heavens etc. etc.and would give one the courage and confidence to start out there afrech in the”real world”

  6. Well, the critics only have to smash one more Part, or just ignore it. This feels like what I wrote is a Rorshach Test; doesn’t matter what I wrote, just bash it.

    So, in case others are more open, the intent was to expand the use of human rights to the more everyday human rights problems what all of us may have as far as thinking and behavior that might seem unusual (I’ve had that, too). Human rights is an emotionally powerful concept, and I thought could be used to help the cause that Mr. Whitaker has highlighted.

    As to hospitalizations, if a hospital is needed, all I’m suggesting is that the time be enough to help rather than just warehouse. You all must know that there are scores and scores of people who do not get into a hospital,even when they want to, or get out too early, and then commit suicide. No meds have been used. If blanket criticism against hospitalization and medication causes this to happen, . . .

    • Dr. Moffic,

      Many people here are saying that their time being hospitalized by force was detrimental, wish they never had the experience, and the idea of more or easier hospitalization sounds like a terrible idea. Many believe that folks are better off not getting into the hospitals, and stand a greater likelihood of recovery, safety, and dignity not being hospitalized.

      Given the choice between the two options of forced hospitalization being helpful or forced hospitalization being useless or even traumatizing, I think people would vote for helpful forced hospitalizations. The bigger issues are that many feel that currently there is no evidence that forced hospitalizations are meaningfully helpful beyond their risk(as opposed to a being relic of 19th century psychiatry carried over without much investigation)and that in the framework of human rights forced treatment/hospitalization by particular people with particular degrees with State authority can be considered a human rights violation. People want better options.

      Your dismissal of people’s comments as Rorschach tests is concerning for me because I think many people have offered insightful criticisms of the ideas embedded in your posts, how they compare to some of your other writings, and the language you use. The Rorscach is invalid assessment of pathology used to find pathology where it doesn’t exist, and has been used to at the detriment of many people’s lives and freedoms. The comparison is hurtful, given that you seem to advocate for more forced treatment for people who are critical of treatment efficacy or validity of diagnoses. Folks who are commenting are being critical of your arguments and their relevancy, we are not simply bashing you for its sake.

      You do make a fair case for many of the problems of how managed care developed in a way that doesn’t seem to have improved overall treatment outcomes in mental health (though it has expanded access to treatment, kept cost low, but as you describe at the expense of poorer quality care). I think many here believe that many treatments available for disorders in a pseudo-scientific diagnostic system have not shown to be generally all that helpful and can cause all sorts of harm that it is disclosed to patients as a possibility. I certainly believe this now. I hope your next piece in this series gets to how you would change mental health care delivery systems, taking into account the many problems of diagnosis and treatment efficacy as they stand now.

      • Nathan is right – you just don’t seem to get what your critics are even talking about! Why do you dismiss out of hand the experiences of people who’ve been harmed by your profession?

    • Perhaps Part 4 suffers from being separated from Part 5; I am perplexed how it starts out seemingly to address the very interesting history of cursory psychiatric treatment, e.g. “med checks,” then takes a strange left turn into “stigma.”

      How the decrying of “stigma” is used in promotion of pharmaceutical treatment is, in my opinion, a subversion of a human rights issue by commercial interests. But it doesn’t look like you’re going to address that.

      Still unclear about where you’re going here, Steve. Looking for the big finale in Part 5 where you tie all of this together!

    • Dr. Moffic, yes, it does matter what you write. Otherwise, people wouldn’t bother to neither read nor ask some quite interesting questions that indeed arise, reading your post. Why don’t you answer those questions? I mean, if you for instance make a statement like that the “patient” surely will relapse, off his “meds”, I’d say it is only natural for people to wonder what scientific evidence you may have to support this view, and to be curious to see it.

      As for people wanting to spend time in “hospital”: you talk quite a lot about psychotherapy, so I presume, you have a certain knowledge in the field of psychology. I would expect someone with such knowledge also to know that traumatised people have a tendency to repeat the trauma, and, if the trauma was traumatising enough, to develop what then, with a label, is called “Stockholm Syndrome”. People who ask for hospitalisation, just as those who ask for a label and drugs, i.e. those who ask to be (additionally) victimised, should raise your deepest concern. They are the ones most likely to end up in chronicity.

      Ask those who’ve made a full recovery what it was that helped them, and the vast majority, if not all, will answer that shedding the label and getting off the drugs was something of, if not the, most important. Many will also tell you that coming to terms with their past played a significant role, while this was not possible for them while they were on the drugs. Not least because of the cognitive impairment these drugs cause. If you really want to help people in emotional distress, if you really care for “your patients”, you find these people, ask these questions, and you are open to the answers you get. It doesn’t look to me like you’ve done this before. Frankly, it doesn’t look to me like you’ve ever really listened to “your patients”. Isn’t it about time to give that a try?

    • If there is ANY deserving mention of a person NOT reading what’s been written, then it’s in regards to Mr. Moffic (see his comment in the “How Many Deaths Will It Take blog” by Alice Keys). And to insult intelligent people who actually CAN process information and not resort to repeating the same things out of fear, and make comparisons to them seeing blobs of ink on a paper which they have a subjective or emotional response to rather than they have the ability to take in objective information and HAVE responded to it intelligently; this is a personal attack from Mr. Moffic on EVERYONE he’s making reference to. And it’s inappropriate to this blog in to the EXTREME! I think everyone should feel free to complain about his behavior to those in charge of this blog.

  7. I guess there is at least one category of mental illness whose existence is recognized by everybody: delusional thinking.

    The only disagreement is about where you find the highest number of delusional people: in the mental health care staff, or in the mental health patients.

    And there is also a difference of opinion about what constitutes the most dangerous delusion: “the belief that involuntarily long-term treatment on anti-psychotics actually helps people”, or the belief that “every single mental patient in history was just acting normally and minding his own business when a bunch of people randomly picked on him, and conspired and lied to make the judge believe he was dangerous”.

    Personally, I don’t believe in the DSM, I don’t believe much in drugs (except short-term use for crisis situations). But I do strongly believe in at least two categories of mental illness: “delusional thinking” and “emotional distress”. And it seems evident to me that the first category is present in both mental staff and mental patients.

    The whole problem is how to distinguish the delusional people from the non-delusional one, and if psychiatrists are unaware they are committing a lot of mistakes in that exercise, we could use anosognosia to quality their attitude (which proves anosognosia is a useful concept in many situations).

    In my humble opinion, one of the redeeming quality of psychiatrists over some of their most radical opponents, is that at least psychiatrists are trying to find a definition of mental illness that is useful. Saying that mental illness does not exists is like saying that human rights don’t exist: because something is hard to define, and is not an object that can be touched does not mean it’s not important concept.

    • Stanley Holmes: “Saying that mental illness does not exist is like saying that human rights don’t exist….”

      This is an important point. We have doctors saying there has always been a need for psychiatric intervention.

      AND we also have some patients saying they appreciate the interventions. In my opinion, we need to respect their testimony as much as we demand ours to be respected.

      AND we have patients saying they have been damaged by psychiatric interventions. This group needs to be heard.

      BOTH GROUPS OF PATIENTS ARE RIGHT.

      While doctors are proud of their successes, denial of injury by psychiatric treatment is the rule, across the board. They do not know what they do not know — anosognosia.

      The risk of injury is poorly quantified and research on the rate of injury — poor outcomes — has not been addressed at all.

      In Anatomy of an Epidemic, Bob Whitaker brings to the foreground the key question of whether, long-term, poor outcomes might not exceed satisfactory outcomes. (Other researchers, such as Irving Kirsch, suggest a huge swath of psychiatric treatment, at best, does nothing positive.)

      It seems to me that we can allow that for some people, the treatment of “mental illness” is helpful, while for others, it it destructive.

      An honest, ethical assessment of psychiatric treatment demands looking at BOTH sides, with the emphasis now on the negative outcomes, which have been disgracefully neglected for political and financial reasons.

      Surgeons want to know where they go wrong, so they can learn how to be better surgeons. As David Healy says, airplane pilots want to know where they go wrong, so they can fly more safely. Why should psychiatrists hide in anosognosia?

  8. I’m not clear what you are asking either, Altostrata, so I can’t answer it.

    One question that was clear is how to distinguish withdrawal from the return of “psychotic” symptoms. This is a crucial distinction that I have long tried to teach new psychiatrists and general physicians. It can generally be done, though sometimes there is overlap and confusion. When symptoms emerge very quickly after medications are stopped, that is virtually always withdrawal, though the patient often thinks it is the return of the psychiatric symptoms. Patients and relevant family need to be educated about that over and over. Often, the withdrawal symptoms are the opposite of usual side effects. As to the return of real symptoms, they should be like whatever was bothering the patient in the first place and usually take a week to months to years to re-emerge.

    Oh, I am hearing loud and clear from people here. But isn’t it also clear that those who have felt helped don’t participate in this forum, may be frightened away, and perhaps may not even be wanted to participate? If so, that is to all of ours detriment in trying to move forward.

    • The readers of MadinAmerica.com have mostly been brought here by Robert Whitaker’s books, which are not glowing accounts of the success of psychiatry.

      Patients who “believe in” psychiatry are not attracted to the subject matter.

      Steve, withdrawal symptoms that occur immediately are the easy ones to identify (not that doctors can do even this).

      Medicine’s understanding of psychiatric drug withdrawal syndromes, mostly based on publications sponsored by pharmaceutical companies, is incomplete.

      It can take some time, even a couple of months, for withdrawal symptoms to emerge, for several reasons:
      - The patient doesn’t see the doctor very often.
      - The neurological house of cards collapses slowly, or in fits and starts.
      - Initial symptoms may be a very mild hypomania the patient and doctor mistake for “feeling great!”
      - The patient initially attributes being unwell to other causes, such a cold or the flu.
      - Failure of the patient to communicate or the doctor to listen to the patient about initial symptoms.
      - Gradual worsening or consolidation of symptoms, starting out with vague unease developing into black holes of “depression” or unprecedented waves of intense anxiety.
      - Treatment with other drugs, such as sleeping drugs for withdrawal insomnia, that mask withdrawal symptoms, which progressively get worse.
      - Treatment with other drugs, withdrawal symptoms taken as adverse effects of the first drug.

      What I say is, you can distinguish withdrawal symptoms because they tend to come in waves and are more intense than anything the patient has experienced before. If the patients says “This doesn’t feel like my depression,” it’s withdrawal syndrome.

      Unfortunately, if intense withdrawal symptoms emerge over time, it may be too late to resolve them by reinstatement of the original drug. The neurological upset might be too far gone. Frequently, severe withdrawal incurs hypersensitivity to other neuroactive medications.

      Recovery can take many months or years.

      This is why I (and other patient advocates) recommend a trial taper of 10% per month for all patients and all psychiatric drugs, to save the nervous systems of those susceptible to withdrawal syndrome.

      The goal is to have no or slight withdrawal symptoms, and to keep the nervous system stable.

      If it takes more than a year for someone to get off a psychiatric drug with no more than mild withdrawal symptoms, so be it. Doctors should advise patients of the risk.

    • Dr. Moffic,

      I would love to talk to more people who feel helped by their experience with psychiatry. I certainly don’t know too many. The vast majority folks I know who take psychiatric medications have been on them for many years but say that they no longer think they are particularly helpful (either they feel fine or they don’t feel the positive effects anymore). What I do hear is that they remain on drugs mostly to avoid the problems with withdrawal, as that is more disruptive to their lives than anything else. Many mitigate the current side effects that still remain with recreational drugs which they did not use before starting the medications. People’s experience with psychotherapeutic interventions vary dramatically, though the most positive experiences I hear were from people who had other people paying for all of it.

      Again, for me, the bigger issues are the science underpinning psychiatric practice (the efficacy and effectiveness of treatments for what they are used to help, diagnostic systems, how science is used in clinical practice), corruption of medical/scientific literature and research, how political and economic forces structure the kinds of power and faith vested in psychiatrists, the discrimination and oppression experienced by people labeled with mental disorders, and how (if possible) can we engender changes to support all people’s wellbeing.

      The full name of this blog is Mad in America: Science, Psychiatry, and community, and questions that interest me more than who says they have been helped and who hasn’t by psychiatry are whether or not that attribution of helpfulness has any scientific basis. Many people have also said they have been helped and hurt by astrologers, reflexologists, doctors before they actually pushing for better medical science (pre-Flexner), recreational drugs, homeopathy, and others, but the reasons why they are helpful may have nothing to do with why people say its helpful or that it is helpful beyond (or even at) chance or placebo. I don’t believe we should be investing a great deal of money, time, energy, into treatments and the people offering them without good data to support their use.

      I ended a relationship with a psychiatrist after he compared his work to that of a stage hypnotist, in that nothing in psychiatry would be helpful unless you believed it would be. He told me this right after getting angry and defensive when I asked questions about the efficacy of medications I was taking beyond placebo for why I was seeking treatment. Basically, he tried to hold his position as a respectable authority of a body knowledge while also admitting that it was belief in treatment is that was helpful in psychiatry, aka placebo, not that body of knowledge from which he derived his respect and authority. If it turns out that belief in treatment efficacy is the primary mechanism of effect for a lot of psychiatry’s helpfulness, this is not necessarily a bad thing. People just need to be informed of this, and people and payors need to decide if they are willing to invest in such treatments. I would make the judgement call that forced hospitalization and exposure to drugs are not warranted by such evidence.

    • And here we have again that Moffic bases his argument on something that he believes exists rather than on evidence, and that’s that people who have no choice in the matter but to take “treatment” by the psychiatrist and say and then say they are healed are “scared” to comment here. So again, he is some great hero who speaks out for people who supposedly can’t speak for themselves, all based on what they have said, after they have had the right to speak for themselves stolen from them when they weren’t allowed to say anything but what was in agreement with the psychiatrist or lose their freedoms and be seen as non-compliant and crazy.

      • This is also completely out of balance. This site is rare in that people can come here and NOT be banned or abused for sharing and witnessing the truths of what biological psychiatry does. And if people are”scared” to come here and post, it’s because they have to deal with logic rather than be given points for repeating what they have been told, or acting happy that they have disabled their mind and won the war against not being normal. And no one is banned here or told they are non compliant when they express THEIR view points rather than those that don’t put them in a place where they could have their freedoms stolen from them. In fact, no one is prevented from saying what they think here, only their “fears” prevent that!

  9. It took my son two years after stopping antipsychotics to recover his physical health which had been dammaged by those drugs: I mean: to recover normal thyroid and sexual function, to stop having twitching muscles around his mouth and eyes not to mention flashbacks related to the trauma of his hospitalisation etc etc. It took 6 months after stopping the medication for him to be able to concentrate again. It is not a matter of: stop the medication and all your mental faculties will be back in a flash- far from it.

  10. I wouldn’t disagree with your description of withdrawal symptoms, though in my experience the very delayed ones are much rarer than you indicate. As I’ve said before, I’ve been startled that in certain groups like prisoners, the withdrawal symptoms that I expect do not occur as they do not expect them and determinedly want to “tough it out”. Yes, there is important neurology here, which can vary individual by individual, but also psychological placebo effects in either direction, also varying individual by individual. It is even more complicated than you indicate.

    And, as I’ve said before on another topic, and as much as I admire advocates for the knowledge they have obtained,and taught me, you are playing with fire if your recommendation is followed by someone you know or don’t know, but doesn’t work, whether it is getting off medications or never trying them or psychotherapy or whatever.

    • I agree. I don’t like being called upon to help people go off medications because of the vacuum of knowledge in medicine. That is one reason I engage in conversations with doctors, in the hopes they might take on the responsibility and risk that rightfully belongs to them.

      The 10% taper is all over the Web in peer support groups. It’s a conservative harm prevention approach, to keep people from hurting themselves since so few doctors grasp even the basics of tapering, i.e. that it should be gradual. It should also be tailored to the individual.

      I’ve commented on that “tough it out” phenomenon before. Withdrawal syndrome is not a state of mind; your prisoners were either lucky or fooling themselves.

      Because some people get it and some (maybe most) do not, one theory doctors trade among themselves is that withdrawal symptoms are a product of the patient’s overactive imagination and can be ignored.

      Please examine your assumptions to see if perhaps this is lurking somewhere among them.

    • How do prisoners both not expect placebo-based withdrawal symptoms and “tough them out” at the same time (if they didn’t expect them, why would they have to tough them out at all)? Perhaps prisoners who want to go off meds don’t want anything more to do with them or psychiatrists and are willing to go cold turkey or not be so forthright with some of their withdrawal symptoms in order to do so? I know some people have found withdrawal from psychiatric meds are easier after they have also withdrawn from other meds, but that varies too. Perhaps withdrawing can be easier when symptoms of withdrawal aren’t interfering with managing your life (prisoners have a lot less say in what happens to them throughout their day)?

      No one here says withdrawal is always difficult but people do vary differently in their response to withdrawal. It is highly understudied though and doctors do not inform of potential withdrawal issues before medications are prescribed.

      • The number of prisoners Steve Moffic refers to may be very small. Severe withdrawal syndrome may be a 1 in 5 or 1 in 10 phenomenon.

        And, as you say, Nathan, the prisoners are clearly invested in machismo. Who’s going to complain about being dizzy, depersonalization, weepiness, anxiety, palpitations, etc. in that crowd?

      • I’ve thought of yet another reason prisoners might want to “tough it out” with withdrawal symptoms — they may believe, rightly, that if they complain, they’ll get re-plastered with a psychiatric diagnosis and re-medicated.

        This is probably the primary reason for “toughing it out.”

    • Never trying medication is like playing with fire!? Must we AGAIN point you to all the statistics from the WHO, from Open Dialogue from the Soteria project. And in another blog Mr. Moffic had to be pointed to the statistics that are already on THIS blog, which he hadn’t looked at. Or he talks about not having even listened to a talk by Whitaker and then starts questioning whether it really is the medications that are shortening people’s lives (and hadn’t looked at the data already available on the site). And as I said before, someone who is “psychotic” has a mental state that is more able to let or act out the fear based programming that needs to be let go of. Instead of understanding for this, and someone who understands such flexibility, recognizes it, can help someone to not be terrified of it but nurture them to blossom into the change that’s natural; we have someone who sounds like a broken record and lacks the kind of flexibility of thought that occurs in those HE would decide are “psychotic” and in need of treatment. And then yes not “trying” medications would be playing with fire because to HIM it’s the end of the world, because he might have to look at his inability to actually relate to what’s going on. I would suggest trying cognitive behavioral therapy and looking at the concept “Catastrophizing,” because that’s what’s going on here in making a solution out to be playing with fire. Further more, saying that people are treating what he “wrote” as a rorschach test, when they are people who have actually READ what he goes on about and know that there’s a difference between causing the problem and solving it; and that going around in circles causing a problem saying you’re fixing it and then saying you need more power to fix it ISN’T going to fix it; this is abusive! It’s patronizing. It’s self serving, it’s arrogant. And it’s quite typical and what one has learned to expect…..

    • Steve Moffic said “the very delayed ones are much rarer than you indicate”

      I haven’t indicated any frequency for withdrawal symptoms that become apparent weeks after discontinuation.

      My point was that withdrawal symptoms do not invariably occur immediately after quitting, and if you’re talking to clinicians, you should let them know those symptoms can show up quite a bit later.

      This would forestall some misdiagnosis of withdrawal, which is endemic as it is, and indicate that the situation is much more complex than “withdrawal symptoms are always mild, transient, and self-limiting,” as most doctors believe.

      It was pharmaceutical company interests who did such a great job of propagating that myth.

  11. Steve Moffic,
    Your statement, “you are playing with fire if your recommendation is followed by someone you know or don’t know, but doesn’t work, whether it is getting off medications or never trying them or psychotherapy or whatever,” is more applicable, although apparently unrecognized, to psychiatrists and others who buy into the medical disease hypothesis.

    The fact of the matter is the biased pharma funded journal articles, Continuing education, and Higher Education where psychiatrists get their training has corrupted more than it has not evidently. My son is a Risperdal victim who was first given that particular poison off label without Informed consent in 1995—none of the lawsuits traced the illegal marketing back nearly far enough.

    My point is, that many have no point of reference for psychiatric diagnoses, treatments, and just as importantly, the HISTORY of psychiatry other than what they have been taught in the corrupted environment that has been shaped by those who continue to benefit the most from what is ironically bio-naive medical practice. The clear winners in the pharmacaust are the drug makers; the patients are clearly the losers; the prescribers are simply a means to the end.

    • To be absolutely clear, only those who have already decided to go off medication or have attempted it and failed visit my site. I don’t go out and encourage anyone to quit their medication.

      I don’t need to — millions of people are trying to do it all the time. All I do is give them information they can use themselves, since their doctors know nothing.

      I don’t question anyone’s decision to quit medication. I believe anyone with a so-called psychiatric diagnosis or is on these terribly understudied drugs for other reasons has the right to self-determination.

      I do caution them that if they choose to go off drugs, they will have to cope with withdrawal symptoms and any mood issues thereafter. They are very willing to do this and learn all kinds of self-help methods, such as meditation, and healthy habits, such as exercise.

  12. I’ve been reading all these comments and a rather off-the-wall thought suddenly popped into my head. When I was living in Atlanta about 15 years ago, I was unable to get health insurance, unless I signed a waiver that completely waived coverage to any sort of mental health care, which I readily did, needing health insurance. So my off-the-wall thought is – what if there simply were no insurance coverage for mental health care? Health insurance costs would plummet, mental health care costs would plummet, managed care wouldn’t control treatment to the detriment of patients, pharma wouldn’t push expensive patented (physically harmful) drugs because nobody would buy them. Psychiatrists who were in it for the money would quit. Statistically speaking, more coverage and more biomedical treatment options have only caused mental illness to skyrocket. Wouldn’t a more affordable, more caring, more sensible system emerge from simply removing insurance coverage / managed care from the equation? I feel like a nutcase, yet I don’t.

    • Hi Stacy,

      As an FYI, I went to regular doctor for a chronic medical condition. Even though she knew I didn’t have health insurance, she practically demanded (I am not joking) that I see a psychiatrist.

      She misinterpreted my frustrations with current treatment as a mental illness. Also, I had stupidly disclosed my previous psych med history in a previous visit which definitely was coloring her medical judgment.

      So if my experience is any guide as to what goes on and it may or may not be, I would say in answer to your question, not having mental health coverage doesn’t matter. It just seems to me that when regular doctors see a psych med history, their whole perspective is colored through that.

      AA

  13. I’m still really confused about how the “carve out” of psychiatry in managed care contributes to the “stigma” of psychiatric diagnosis.

    Did the “carve out” mandate 15-minute med checks for psychiatry? This doesn’t seem right to me, because I know from personal experience that psychiatrists bill insurance for higher-paid “psychotherapy” hours EVEN IF ALL THEY’VE DONE IS A 15-MINUTE MED CHECK.

    So, in ethical terms, you’ve got a bit of working the system right there.

    It seems to me that psychiatry readily accepted the concept of a med check in the belief that pharmaceuticals made treatment easy, safe, and fast. This was enthusiastically promoted by the APA and research leadership.

    The APA could have lobbied against the med check concept but did not because it would have exposed reservations about the “anybody can prescribe them” message selling psychiatric drugs.

    (With the slogan “medication saves lives,” psychiatry chokes itself with a rope of its own devising; David Healy calls it “auto-erotic asphyxiation” http://davidhealy.org/notes-on-a-scandal/ .)

    As for “stigma,” I don’t see how a pay scale for psychiatry affects how psychiatric patients are perceived out in the real world.

    However, in terms of self-image, psychiatrists may again feel they’ve been made the stepchildren of medicine, on a lower level than other doctors.

    So when we talk about “stigma” and managed care, are we talking about the perceived status of psychiatry vs other specialties?

  14. : too brief hospitalizations followed soon by suicides; the revolving door of re-hospitalizations; the escalation of the least trained psychotherapists to provide less psychotherapy; review of treatment by lesser trained clinicians or managers; denial of treatments like EMDR for PTSD that was deemed “experimental”, even if they were not; medication checks by psychiatrists being managed down to a 15 minute norm instead of the legendary 60 minute hour; and desparate polypharmacy to try to get faster results. Patients who recognized these changes sometimes called out in frustration: “Dr. X used to care about patients; now he cares about money”!

    Dr M I agree with you that these were really bad outcomes from managed care. As long as treatment is voluntary and informed, it should at least be the best available. I wonder if suicides that occur shortly after discharge aren’t side effects of the drugs that are desperately prescribed. That’s a very dangerous period of time.

    I also agree that there was an escalation of less trained therapists being given more responsibility and wonder if the insistence of some on “peer counselors” isn’t just more of the same escalation. They would certainly be cheaper.

    I think managed care in general gives people less choice and less access to alternative treatments.

    Do you see any role for psychiatrists in managed care other than the 15 minute med check?

  15. Right now, there is no other role for psychiatrists in managed care.

    It looks like no matter what I say, or what examples I give, such as prisoners, it will be discounted as impossible. Too bad. That is not a way to search for the truth.

    • I’m confused. What examples have you given regarding prisoners? Do you mean how they don’t need a doctor to cold-turkey off medications?

      How does that illuminate an additional role for psychiatry in managed care?

  16. Altostrata,

    I guess we don’t understand each other. Indeed, these are prisoners who have successfully stopped all psychiatric medications, cold turkey so to speak, on their own. I think that gives another dimension to this issue of withdrawal symptoms, which you can dismiss if you like.

    • Dr. Moffic,

      Many non-prisoners have also successfully stopped psychiatric medications cold turkey. I think the broader issues Altostrata is talking about (and correct me if I’m wrong, Altostrata) are that psychiatrists (and other prescribers) don’t have a very full understanding of risks involved with and likelihoods of experiencing withdrawal due to the fact that it is has been understudied and even that withdrawal is possible intentionally denied/obscured by drug makers (intentional use of terms like “SSRI discontinuation syndrome” as opposed to addiction/withdrawl), the risks associated with difficult withdrawals can be very serious, and at this point, we have little information how to predict who would have trouble with withdrawal and from what and who won’t. I think given the limited efficacy of many psychiatric medications for their indicated uses (and dearth of evidence for their off-label uses), this should be a concern to prescribers and patients. I believe it certainly should be discussed in preliminary informed consent procedures, and I don’t think it often is.

      • Thank you, Nathan.

        Steve Moffic, I’ve responded to your prisoner example before. It doesn’t prove anything about the ease or difficulty of withdrawal.

        We already know that many, perhaps most, people can quit psychiatric drugs with relatively mild transitory symptoms. It is from observation of this majority that psychiatry has drawn its conclusions (published in papers sponsored by Lilly and Wyeth) about antidepressant withdrawal.

        (However, misdiagnosis of withdrawal symptoms is a major flaw in all studies of antidepressant efficacy, so the incidence is probably under-reported in the literature.)

        But people some suffer much more serious, long-lasting damage from too-fast discontinuation. This is documented in hundreds of thousands of posts all over the Web, complaints to the FDA and other agencies, and in some more obscure scientific papers.

        It is unknown what proportion of the population is at risk for severe withdrawal syndrome. The FDA would consider 1 in 100 to be frequent.

        (In fact, the FDA warning about withdrawal plastered on all antidepressant packages was not put there because withdrawal is mild and transient. It was put there after a lawsuit involving 40,000 injuries from GSK’s Paxil.)

        Not knowing exactly what the parameters of your study are, I suggest your small sample of prisoners demonstrates only the experience of the majority — which we already know.

        We may also speculate some are hiding symptoms because they don’t want to appear to be wimps, or because they don’t want to be re-medicated.

        Again, I don’t understand what your prisoner example has to do with psychiatrists in managed care. Can you enlarge upon that?

  17. I’m still not sure what you are asking about as far as psychiatrists and managed care, so all I will say is what I think connects with prisoners. Psychiatrists who work under mananged care (and this will only increase) do not have an adequate amount of time to provide the appropirate informed consent, carefully diagnose, explain treatment options, monitor progress, and get to know the patient as an individual. This managed care control dovetails so nicely with Pharma. You are scapegoating the wrong the target. We know well be now the risks of withdrawal, having worked with patients in real life interactions. Anecdotes just won’t do anyways, as I could find as many to counter what you could produce. When such anecdotes are used to make recommendations (that are then followed), much as a psychiatrist would do, more harm than benefit may ensue.

    • Is this what you’re saying?

      Under managed care, doctors don’t have time to go into all the details that would fully inform consent, including issues with drug withdrawal.

      Withdrawal problems are low-priority anyway; if you have the right “tough-it-out” attitude like the prisoners, it’s a piece of cake.

      Is that right?

      You also say “Anecdotes just won’t do anyways, as I could find as many to counter what you could produce.”

      That’s the problem with gathering post-marketing data, isn’t it? At that point, pharma has no incentive to fund controlled studies, so reports of adverse events MUST be “anecdotal.” If they’re “anecdotal,” they can be ignored by psychiatry, because RCTs are the “gold standard.”

      David Healy is discussing this very issue at http://davidhealy.org/cri-de-coeur/#comments (You might note my comment on May 28, 2012 at 4:30 pm.)

      Dr. Healy has raised money for an adverse events reporting system, Rxisk.org.

    • “Pharma is a major problem.
      Bravo for Dr. Healy about medication issues, but ECT?
      We all can do better.”

      Dr. Moffic:

      Two points (A & B):

      (A) In all sincerity, I commend you for the lucidity in those brief lines (in quotes, above); I humbly concur.

      Dr. Healy is doing a great job of exposing the ugly underbelly of Big Pharm – especially, as pertains to its long history of deceitful and deadly practices, in the marketing of psych-meds; but, surely, Dr. Healy’s own promotions of ECT (a terribly brain-damaging procedure – with odds of ‘success’ that, at best, resemble a Vegas crapshoot) undermine his credibility as both a physician and a critic of Pharma.

      (B) You say, “Yes, then no.” That is not a clear response.

      You would be much better understood by your readers if – in such instances as this – you took the time to carefully engage in dialogue.

      (Note – a technicality – I suggest you might, at the very least, realize: when you reply to comments so curtly or concisely, as to say simply “yes” or “no,” it’s best use the reply button directly beneath that comment to which you are replying; otherwise, we cannot even be certain about what you are responding to…)

      J.

    • I suspect, Steve M., that you are viewing these comments on a cell phone, are missing some of the more focused questions, and answer in shorthand because of the restraints of the medium.

      This may explain why you haven’t responded to my question about post-marketing research, which I’ll now move over to the now-active Part V of your blog post.

  18. Another wrong assumption. I virtually never use a cell phone, and never for this. Given my lack of being able to constantly monitering comments, as well as the vitiolic nature of some of the comments, I can not and will not respond to all.

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