“A Lebanon County man admitted that he drank a 6-pack a day. A Pa. law required PennDot to be alerted.” (Philadelphia Inquirer )This article is doing the weblog rounds as a heinous example of Big Brother coming to the doctor’s office. I beg to differ, and I am surprised that people so uncritically have that take on the issue.

Driving under the influence is a heinous offense placing the innocent public at large at enormous risk, as any number of tragic incidents should remind us. Anyone who tells you that someone who drinks 6-10 beers a day can be trusted when they assure you that they can safely avoid driving under the influence is whistling in the dark. “I’m just a regular Joe six-pack,” the article quotes this hapless Joe as saying, and then goes on to opine that a man so large can be trusted to keep his blood alcohol level within legal limits by pacing his drinking. (The rule of thumb we are taught in our medical training is that an accurate estimate of a patient’s drinking is around twice what they admit to.) This is nothing so much as colluding in the minimization and denial that accompanies heavy drinking, a world in which, if you listen to the drinkers, no one is an alcoholic or in any way impaired by their drinking.

The problem in this case is that doctors and other professionals allow a naive notion of confidentiality to reign unchallenged in the eyes of the lay public. Preserving confidentiality always take a back seat to averting an imminent harm, but doctors entering into a treatment relationship with a new patient rarely go into the nuances of the limits and exceptions to doctor-patient privilege as they should. The problem, of course, is the fear that an accurate description of the situations in which a doctor will violate her patient’s confidence will have a chilling effect on patient honesty. So what is most common, instead, is a blanket assurance that anything said in the office will remain confidential. <

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While the article takes pains to inform us that only six states have laws requiring doctors to report unfit drivers to the motor vehicle authorities, the ethical and public health burden lies no less heavily on the physicians in the other forty-four states, IMHO. To complain that including alcohol abuse as a reportable offense without adequately defining what constitutes abuse is unfair ignores the fact that this achieves precisely what it should — to allow a doctor to exercise her professional judgment on whether an impairment ensues from her patient’s pattern of use. This, I think, is far preferable to codifying inflexible criteria in nonnegotiable laws. It is pitiful to hear the psychiatrist and medical ethicist quoted in the article complain that the judgment of the individual physician opens the way to arbitrariness and relativity. It is a sorry reflection on the state of modern medicine that the call for standards is really the stalking horse for a phobic avoidance of relying on one’s own professional judgment. In this vein, those whose license is revoked can, in Pennsylvania and elsewhere, get their license back on a doctor’s say-so that they are safe to drive. The sobering (forgive me) effect of a wrongful death lawsuit if a physician restores a license to someone who later commits vehicular homicide while drunk will surely be a more effective hedge against the physician taking her obligation frivolously than many other incentives!

The other apparent failing of the physician in this case was in doing the mandatory reporting and springing the license revocation on the patient as a surprise. When I am faced with a competing harm-avoidance need that supersedes the confidentiality right of a patient of mine, the first thing to do is to talk about it with my patient, not the last! This goes a long way toward avoiding the potential sense of betrayal, enhancing the patient’s insight about the risk they are presenting and may well have been denying. Equally important, one encourages the patient to take preventive action themselves — installing a breathalyzer ignition interlock or cutting down significantly on one’s alcohol are both discussed in this article — and maintain their control and dignity, rather than making it a matter of law enforcement at all.

The situation in which violating a patient’s confidence comes up most often for me is not reporting a patient as a potentially unsafe driver but the so-called Tarasoff duty — to warn a prospective victim or take other appropriate harm-avoidance measures if I have learned in confidence that a patient of mine intends to do harm to a specific other individual. But in discussing my considering doing so, the patient will often choose to preempt my plan and take measures themselves to diffuse the risk, certainly a far more therapeutic outcome.

The article’s conclusion is further confused, suggesting that the incident led the man to cut down on his alcohol abuse “not just to get (his) license back” but for his health. While this may have been a by-product of the situation described, I hope the reporter who wrote this story is not suggesting that the benefits to the man’s health justified the means. The end that justifies the means here is the enhancement of public health and safety, not that of the individual.

What may hang in the balance is literally nothing less than whether talk therapy survives as an accepted treatment for emotional distress. Increasingly, the insurance companies that pay for treatments demand “evidence-based” proof of their efficacy, and research into the effectiveness of psychotherapy over the past decade has led to the ascendency of cookbook approaches which are easily standardized and controlled. The increasing penetration of this instruction-manual approach, even into some topnotch clinical psychology training programs, has stimulated outrage.

“Some therapists say that the healing they offer in their offices every day is too complex to be captured in standard studies, and that having to justify it to a third party is a breach of patient privacy. They argue that to insist on proof that a therapy works denies many people adequate treatment, or the forms of treatment that they most need.”

The empiricists insist that the move to evidence-based treatment has augmented the credibility of the field. Indeed, to the extent that it serves as a basis to differentiate reputable treatment from fringe therapies promising miraculous and instant results, it is tempting to agree. But the more crucial threat of evidence-based treatment is that it will take the art, the inspiration and inventiveness, the empathy and sensitivity out of treatment techniques that depend on them. The more crucial differentiation it achieves, at least in the eyes of the third-party payors, is from the open-ended exploratory treatment such as psychoanalysis, already a dying art because the only clientele who can afford it are the worried affluent self-paying. While various psychotherapeutic approaches — from the interminable self-indulgent open-ended to the structured problem-centered evidence-based to the brief and ultrabrief focused interventions to the unsuitability for any psychotherapy at all — ought to be stratified by the nature of the patient’s clinical presentation, severity and desire to change, insted they are coming to be stratified entirely by ability to pay and extent of insurance coverage.

Some therapists worry about the threat of lawsuits if they depart from “accepted” techniques. How about the threat of lawsuits if they refrain from using their inventiveness and creativity and tailoring the treatment to the unique requirements of each therapy client? There are precedents for a malpractice judgment when a therapist does not utilize a technique which is the standard of care for a given mental health problem. Studies cited in the article are only a small sampling of what used to be the consensus (in a generation of psychotherapy outcome studies designed by thoughtful ingenious competent researchers rather than beancounters) that it is the therapist’s competence, rather than anything about the specific technique she uses, that most closely correlates with therapeutic success. Instead, the new paradigm threatens to impose techniques, in the interest of being able to measure and replicate success, which mitigate against success. But at least the insurers will be able to economize on mental health treatment.

And, turning from psychotherapy to the care of the severely, chronically, mentally ill, here is an example of society’s treatment of them. (New York Times ) Believe me, obtaining redress as some of the clients mentioned in this story do is by far the exception.

The wonderful but, of course, quite fanciful Capitol Hill Blue is reporting that Bush is taking ‘powerful anti-depressant drugs’ to control his erratic behavior, depression and paranoia.’ The source of the report is not made clear beyond citing unnamed ‘White House sources’, but the ‘powerful’ drugs have reportedly been prescribed by Presidential physician Col. Richard Tubbs MD after the July 8th debacle, which I mentioned here, in which Bush stormed off stage after reporters questioned him about his relationship with the indicted Kenneth Lay. Added details of that incident are offered:

“Keep those motherfuckers away from me,” he screamed at an aide backstage. “If you can’t, I’ll find someone who can.”

This piece suggests that the unidentified drugs “can impair the President’s mental faculties and decrease both his physical capabilities and his ability to respond to a crisis, administration aides admit privately.”

The article draws heavily on the armchair diagnosis of Bush offered by psychiatrist Justin Frank in his recent book, Bush on the Couch: Inside the Mind of the President, which I have criticized and others have more thoroughly savaged. Frank’s book and the comments of several prominent psychiatrists who share his concerns about the President’s mental stability are the closest the article comes to citing an authoritative source. But, notice, those sources have nothing to say about the drug prescriptions. All that Frank is ‘confirming’, in the words of the article, are ‘increasing concerns’ about Bush’s ‘mood swings’ and outbursts.

I will reiterate that, while I feel diagnosis of a public figure without having a treatment relationship with that individual is irresponsible and unethical, I feel that expressing concern from a professional vantage point, from which certain signs of instability may be clearly recognizable, is abidingly in the public interest. What this calls for is transparency about the mental health of a leader such as the President, much as his physical health is a matter of public record. Of course, we are vanishingly far from that transparency, and left to vain speculation.

I can say as a psychopharmacologist that, if these reports are true rather than scurrilous propaganda, the article is painting certain unwarranted and irresponsible implications. First of all, if it is really an anti-depressant that is being prescribed, these medications do not impair one’s mental faculties or ability to respond in a crisis except in very limited respects:

• Some are sedating and sleep-inducing; while the anti-depressant benefit exerts itself round the clock, the sedation only occurs for a limited time after a dose is taken. The sleep improvement and overall benefit from an effective anti-depressant actually usually enhances daytime cognitive efficiency.
• Some SSRI antidepressants have been described as causing a tongue-tied feeling or word-finding difficulties. How one would know in George Bush’s case is a real question…
• Certain anti-depressants, by figuratively giving the user a thicker skin and stopping things from getting to them quite so much, can reduce motivation in someone who is largely driven by perfomance anxiety. Do we really think it is plausible that Bush is worried by not doing a good job?

No medical professional would describe one anti-depressant as more ‘powerful’ than another; it is simply not an adjective that is usually applied to this class of medications. All are equally ‘powerful’ when used correctly. None are second-rate in comparison to othes that are first-rate. And while one should properly refrain from using other medications with addiction and abuse potential (such as anti-anxiety medications) in those with a history of alcohol abuse and other substance abuse problems such as Bush’s, this is not a concern with anti-depressants.

If the term ‘paranoia’ is being used in an accurate clinical sense, this is not something that would be benefited by an anti-depressant either. Perhaps the President is being given an anti-psychotic (instead or in addition?), which would be the proper medication to target a psychotic symptom such as frank paranoia and which would more warrant the concerns about impairing mental capacities and responsiveness. Or perhaps he is receiving a benzodiazepine (Valium-like) anti-anxiety medication, although these would tend to disinhibit rather than contain his outbursts? Or a mood stabilizer, which might benefit emotional reactivity, impulsivity, irritability and outbursts, but might also dull mental acuity at least at the outset.

In any case, my suspicion all along has been that Bush is a figurehead, a creature of his handlers. This rumor, if true, may be just the latest technique of a vast repertoire being used to manage a puppet who was never qualified to rule and has never been leading in reality. If so, we need not worry about any further impairments in his mental acuity or capacity to handle crises. They will continue to be handled by the people behind the scenes just as well as they have been since his Cabal seized power three years ago.