I suppose we should expect nothing less than a medical school believing in their medical model of psychiatry. That was in full evidence at the December 4 “grand rounds” at the Oregon Health and Science University, with a presentation on what they call “Interventional Psychiatry”—an interesting euphemism for Electroshock, Transcranial Magnetic Stimulation (TMS), and the comeback street drug, Ketamine.
First, what in the world are “grand rounds”? They were originally a method for teaching doctors in medical residency about specific patients, but evolved into presentations for a large group, where often an entire medical community is invited so they are not just limited to a particular hospital or medical school. Sometimes presentations are made about particular patients (with confidentiality strictly observed) but they are also often about issues of interest to a medical community. Grand rounds are frequently scheduled on a regular basis such as once a week or month.
Oregon Health and Science University is a major school of medicine in the Pacific Northwest of the United States. And a disclaimer of sorts: I still have faculty appointment in their Department of Psychiatry as Clinical Associate Professor although I have been inactive for several years.
For me, the tone of this grand round was frighteningly matter of fact. The two presenters appeared to truly believe in the beneficial effects of the brain damage caused by electroshock, and are apparently considering it and TMS with some individuals as young as adolescents. They declare no conflicts of interest, which is also scary—partly because they have come to accept implicitly the medical culture which justifies these “treatments.” There also seems to me an inherent conflict with one of their own cherished principles: First Do No Harm.
Did they show any evidence of recognition of these conflicts? None that was obvious to me. Did they show any awareness of the sordid history of abuse with these kinds of biological injuries inflicted on disempowered patients? Did they show any recognition of competent analysis and critique of research studies—i.e., who funded them, and was there any direct review of the actual data (a la Study 329)? Are they cognizant of the extremely loose and industry-infused standards for FDA approval, which only require two studies that purport to show “improvement” and only short-term at that? According to the presenters, the FDA approved Transcranial Magnetic Stimulation after reviewing only one short-term study. There was no information provided about who conducted or funded the study.
The presenters assured the audience (who listened with occasional laughter and applause) that they were screening for appropriateness of the treatments for each individual. They focused on patients with “refractory illnesses” which led to some very serious threats to life through self-starvation and catatonia. But more questions arose for me:
Do they screen for clearly ineffective psychiatric medications like antidepressants and neuroleptics? What about incompetent mental health clinicians who provide anything but well-conceived and delivered trauma-informed care or Cognitive Behavioral Therapy? Do they ask about whether peers who have ‘been there and done that’ have been involved in relating to the patients or sharing what they know about recovery?
Do they consider that their own beliefs in effectiveness may have as much to do with what I call the Provider Placebo Effect than anything else? What I mean by this can be seen in a story told to me by Dr. Dean Brooks, whose motto in his 27 years as Superintendent of Oregon State Hospital was: “It’s All About the Patients.” When I asked him about the introduction of Thorazine there, he told me they put a patient on it who everyone had said was a hopeless case, i.e. ‘refractory’ though he didn’t use this term. After six months, the staff came to Dean and told him that the drug had worked a miracle—they were now ready to talk about discharging the patient. Contrary to many current practices, Dean actually talked to patients privately in those days, and asked the patient about it—what did he think? And the patient, who knew he could talk openly and safely with someone who cared, looked at Dean and said, “I’ve been cheeking them the whole time.” After telling me this story, Dean asked, “So who in the hell are these medications for, the staff or the patients?” The answer is pretty obvious. So Provider Placebo Effect is a phenomenon that describes how a clinician’s own hopes and beliefs end up greatly affecting outcomes for their patients.
What isn’t obvious to the psychiatrists who administer these brain-damaging interventions is that they themselves may be suffering from PPE. And without appreciating that these dynamics could apply to them, they could be said to have a form of “anasognosia,” a term they so smugly apply to patients. Psychiatrists do find ways to protect themselves from all of these considerations—namely by not asking for critical feedback or allowing any kind of time for preparing counter-facts based on other considerations and research.
As a public policy analyst, I have other concerns, namely, that these treatments are expensive—Transcranial Magnetic Stimulation costs $20,000 per treatment. What is the cost breakdown, i.e. what does the inpatient or outpatient service cost? How much does the equipment cost? How much does the manufacturer make?
Another issue not to be taken for granted is how much the manufacturer might know about the brain damages caused. A recently settled lawsuit against the ECT equipment manufacturers showed exactly that—that the makers knew full well. While the settlement amount is not yet known, the manufacturers surely paid what for them was a paltry sum. I haven’t heard that any of them are going out of business because of it.
It is disturbing to learn that public funds in Oregon are paying for ECT for Medicaid-eligible people. Is this an appropriate use of state and federal funds when the damage to brains is clearly documented? Would public funds be allowed for adolescents to get shock treatment? Again, has anyone bothered to ask?
Wouldn’t it be a better use of public funds for a school of psychiatry to invest in improving trauma-informed care, high standards of mental health competence, and a careful review of the effectiveness of peer services and supports?
I doubt that many readers from medical schools will be reading this kind of questioning, so it will be up to those of us with lived experience to push these kinds of inquiries and issues. As I said, I suppose we shouldn’t expect much “grand” from grand rounds at a medical school.
