Genesee Valley Psychiatric Association
A District Branch of the American Psychiatric Association
J an u ar y 2 0 0 6 J an u ar y 2 0 0 6
Steven Scharfstein, M.D., Abdi Y. Tinwalla, M.D. and Angela M. Vuotto, D.O.
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
President’s Column Editor’s Column
Robert B. Young, M.D. Thomas E. Gift, M.D.
Since this is an occasional publication, we can‟t address Diversity is the theme characterizing the events
happenings in as timely a way as we‟d wish. But there were two announced below, and I am pleased to be able to state that we
recent accomplishments for our association in 2005 that certainly have more diversity of content in this newsletter then has the case
deserve recognition. with many of its predecessors. At the national and state level there
The first is the attainment of 100% membership continues to be a concern as to psychiatrists feeling they're getting
participation in the General Residency and in the Child and their money's worth from membership in professional organizations,
Adolescent Fellowship programs at the University of Rochester and I trust that astute readers will note that this edition
School of Medicine Department of Psychiatry. This is not a usual contains four additional pages with no change in dues. Evidence
occurrence, although we‟d wish it, and the advocacy b y the based medicine and the role of pharmaceutical companies continue
leadership to involve our trainees in this aspect of professional life to be a focus of our attention and, for better or worse, the public's ,
is much appreciated. Congratulations to the General Residency and I hope readers will appreciate the bit of satire which appears in
Education Co-Directors, Dr. Sue DiGiovanni, and Dr. Linda the midst of a number of more sober reports addressing these
Chaudron; the Director of the Child and Adolescent Division, Dr. matters. Our residency program achieving 100% is a very nice
Michael Scharf, along with the Department Chair, Dr. Eric Caine. accomplishment, and I would like to echo Robb Young in
We welcome the general residents : J. Andrew Adkins, Fareen congratulating the residents and fellows, and also those in
Malik, Jennifer Richman, Megan Toufexis, Robert Whelpley (PGY- leadership positions, who made this possible.
1); Sarah Armstrong, Timothy Beal, Nichole Bialas Harrison, Neha As always, we need more local news and members‟
Nirodi, Anola Tanga (PGY-2); Xingjia Cui, Nevena Dourova; Scott contributions, a request which Margo Fass makes elsewhere in this
McMahon, Arif Mirza (PGY-3); Roma Fortuna-Dwulit (PGY-4); ) and edition in the context of her addressing in several diverse ways the
the Child and Adolescent Fellows: Jonathan Beard, Shaili Patel, topic of psychiatrists and creativity. In addition, any volunteers with
Rakesh Shah (1 st Year); Gene Contreras, Ajit Ninan (2 nd Year); as skills in desktop publishing would be welcome.
well a the forensic fellows : Abdi Tinwalla, Angela Vuotto; and the Finally, I‟d like to thank Sandy Barry for sending me the
geriatric fellows : Lisa Boyle, I. Sagarika Narangoda, Elizabeth picture that graces the first page.
Santos! The strength and the future leadership of psychiatry begin
with our new colleagues in training, whose growth and opportunities
we need to support and promote.
The second is our having enjoyed another one of our
fascinating annual Steinberg Lectures this fall, with the President of
the APA, Dr. Ste ven Scharfstein. The photo on the front page was
Save the Dates
taken at that event. We are again trying to offer interesting monthly Wednesday April 5 - 7:00 PM - GVPA Dinner and
events addressing current topics. For example, we are presenting Reception for Dr. Annelle Primm, Deputy Director of the APA
a couple of talks focusing on the CATIE trial and metabolic issues
Department of Minority and National Affairs
in psychopharmacology. This spring, we are organizing a second (http://www.healthyminds.org/campaignbios.cfm), and Dr. Michael
annual conference in conjunction with Unity Health System‟s
Torres, Director of the Institute for Mental Health Ministry
Department of Behavioral Science.
Medicare has become an even bigger problem for There will be a roundtable discussion on outreach to minorities, in
physicians and patients this year. As of this writing, Congressional conjunction with monthly GVPA meeting.
action that was expected to prevent an average 4.4% fee reduction
for 2006 did not get completed in December. It is expected to get
addressed in late January or early February. But be sure to Thursday April 6 - Saturday, April 8th –
respond with messages to your legislators when called on by your Black Church Studies at Colgate Rochester Crozer Divinity School
state and national medical organizations. Patients are also Mordecai Wyatt Johnson Institute of Religion.
everywhere finding it impossible to use their new Medicare April 6 , 3:00 PM: roundtable discussion and reception
pharmacy benefits. As a result pharmacies are advancing needy with Drs. Primm, Torres, and Dr. Jacqueline Mattis,
patients medicines and states are adopting emergency stop-gap Associate Professor of Psychology at NYU, whose
measures to provide for their elderly and disabled. specialty is spirituality.
The GVPA continues to do everything we can to support (www.http://education.nyu.edu/education/steinhardt/db/fac
and promote all psychiatrists‟ profession and practice, along with ulty/1371)
our patients‟ welfare. Together with NYSPA and the APA, we‟ll April 6 th, 7:00 PM lecture by Dr. Mattis
continue to oppose discrimination against the mentally ill in health April 8 th, 9:00 AM, talk by Robert Michael Franklin, Jr.,
care and society. You can help, in many ways and degrees. An y Emory University ethicist and former president of the
member is welcome to attend any Council meeting, currently Interdenominational Theological Center.
scheduled each second Wednesday of each month at 7:30 pm at (http://www.thehistorymakers.com/biography/biography.as
the Rochester Academy of Medicine. p?bioindex=742&category=religionMakers)
Finally, we'd enjoy seeing the Newsletter used by
members to share news about their professional and personal lives Friday, April 7 Unity Health and the U of R Department of
with friends and colleagues in the Association. I'll start, with my Psychiatry and Behavioral Health will sponsor the 11 Annual
wife Anna, by very happily announcing the birth of our daughter Spring Conference, this year‟s focus being “Diversity and Person-
Danielle Rose on January 8, at 9 :03 am, 4 lbs. 10.5 Centered Care” 8:30 AM to 4:30 PM at the Doubletree Hotel
oz. Danielle seems pretty happy herself about this! (formerly the Holidome) 111 Jefferson Rd. Rochester, NY 14623
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
St. Joseph‟s Update like to test drive the clinic experience. Sheila Briody and I are
always available to you as well.
This report may, I hope, tickle an interest in some of you to
Rory P. Houghtalen, MD experience the pride and joys of professional volunteering.
This October marked the 4 th Anniversary of the Free
Psychiatric Clinic at St. Joseph‟s Neighborhood Center. To those Monroe County Medical Society‟s
readers participating in the clinic -, thank you! You are making a
huge difference in the lives of many of our “neighbors” who would Psychiatric Triage Roster
otherwise have no access to psychiatric care and impacting their
lives and the lives of their families with both your skills and caring.
Leon Canapary, M.D.
To those of you who have not yet heard about what‟s happening at For the past 20 years or so the Genesee Valley Psychiatric
St. Joseph‟s, or who have not made the step into participating, I Association has maintained a roster of psychiatrists for the Medical
hope that you will take the time to read on and consider whether Society. Lorraine Meli at the Medical Society maintains and keeps
you might be interested in getting involved with your “neighbors” as this roster, which consists of a number of psychiatrists who
a professional volunteer.
volunteer to serve the Medical Society. She notifies the individual
St. Joseph‟s is a free clinic providing primary care, mental psychiatrists when they are on call for their two week period. She
health and education/advocacy services via volunteer makes adjustments in the schedule when individual psychiatrists
professionals; its 7000 square foot facility at the base of South need to be away, become ill, and so forth.
Avenue has the feel of a private practice setting. The Free To serve on this roster, a psychiatrist must be members in
Psychiatric Clinic is staffed by seven committed teaching attendings good standing of the GVPA and the Medical Society (GVPA and
(Drs. Bottros, Guttmacher, Houghtalen, Lyness, McIntyre, medical society dues paid up, no pending felony investigations, no
Schubmehl and Redondo) and six residents (Drs. Adkins, ethical violations, etc.).
Armstrong, Cui, Dourova, Fortuna-Dwulit, and McMahon) through
The chairman of this group, Leon Canapary, M.D., as well as
the vehicle of an elective which provides us a structure for the the current roster‟s members, are looking for new members to
experience and liability coverage*. Trudy Haseley helps us manage serve on this roster. Anyone who is interested should please call or
the administration of the elective with the training program. email Sue Diesel (firstname.lastname@example.org or call 585-889-5577)
The Free Clinic is offered each Thursday evening from 6 and she will forward their names to Lorraine, who will incorporate
to -9 PM and is staffed by one or two residents and a faculty
them into the next roster.
member. Most residents and faculty contribute about shift a month, The Medical Society has appreciated this roster and
and what a difference those three hours a week as made! As of associated service over the years. The Medical Society uses the
June 2005, we had served 176 patients that would have never roster to refer prospective patients to the psychiatrist on call, who
been able to access psychiatric care and we provided a total of then can help these patients get into the psychiatric care system,
1072 patient contacts. The psychiatrists provide initial consultation
whether it be to the roster psychiatrist him or herself, to the
and collaboration to the large team of volunteer therapists providing appropriate clinic, or to whatever other resource might seem
treatment at the Center. Sheila Briody, DMin, directs the suitable.
Counseling and Mental Health Services at the Center and
cosponsors the elective for residents.
Recently the national “neighborhood” has heard about
what we are doing at St. Joseph‟s! You may have seen the front
GVPA Committees and
page of Psychiatric News on September 16, 2005 that featured a
picture of Dr. Briody and Dr. McIntyre hard at work. Inside the
article were quotes from Drs. Sarah Armstrong, Scott McMahon, Finance Dr. Young
and Drs. Briody, Wagner, McIntyre, Guttmacher, and yours truly. At Membership/Fellowship Dr. Satloff
the Psychiatric Services Meeting in Atlanta, 2004 the experience Quality Assurance Dr. Satloff
was presented by Dr. Briody, Craig Schoenecker, immediate past Practice Economics Dr. Mustafa
resident liaison, and yours truly as a model for service learning in
Education Dr. Singh
psychiatry. Newsletter Dr. Gift
When I started this elective in 2001, my wish was to Membership Benefits Dr. Marrocco
provide and opportunity for all residents who wanted a quality Medical Society Liaison Dr. Canapary
experience of professional volunteering and a place to do so with Public Affairs Dr. Young
support and excellent teaching/mentoring from a committed faculty.
Legislative Dr. Young
This is not something that has been done often or well in Psychiatry and the Law Dr. Ciccone
psychiatry, but it is done every Thursday evening at St. Joseph‟s. Member-In-Training Dr. Cui
We welcome any interested University appointed faculty member Early Career Dr. Scharf
and residents to discuss the possibility of sharing the experience Women Dr. Olivares
with us. To perpetuate the clinic we need a critical mass of faculty
Child and Adolescent Dr. Atkinson
and residents, and recruitment never stops. If you are interested in Aging Dr. Santos
volunteering, or have questions about the experience, please Ethics Dr. Dvorin
contact me. This is a liability co vered activity for University Public Psychiatry Dr. Mustafa
employees. If you are not a University employee, you will want to International Medical Graduates Dr. Olivares
clarify liability co verage issues with your carrier or health system. Practice Research Network Dr. McIntyre
Unity, for e xample, will cover these activities. I‟m sure that any of Alcoholism & Substance Abuse Dr. Rodic
the faculty now participating in the elective would be willing to share Impaired Physicians Dr. Rodic
their experience with you and/or to host you for an evening if you‟d
Religion, Spirituality & Psychiatry Dr. Fass
Psychotherapy by Psychiatrists Dr. Lewek
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
It had been my intention just to stop by and look at the exhibit, in
Calling All GVPA Creative the tiny space set aside by the APA at the very far end of the
convention hall. This area couldn‟t have been further removed from
Persons, the APA Arts any of the other many activities of the APA.
Association, Poetry and Then Something powerful instantly drew me to join the Arts Association,
which entitled me to attend the business meeting, to take place in
Some Prose an hour.
Margot Fass, M.D. At the business meeting, there were about 10 people, more or less
the number who make up the core group of psychiatrists
Creativity is a favorite theme of our Past President, Dr. Bill Lewek. responsible for most of the work. Otherwise, Dr. Al varez says,
We know there are rich resources and great talent in our psychiatric
members have come and gone. They leave either because they
community. Our GVPA President, Dr. Robert Young, and feel too inhibited to express themselves, or don‟t have the stamina
Newsletter Editor, Dr. Thomas Gift, have gotten feedback that to stick with their art.
members would like to see a broader representation of
contributors to this publication. Dr. Al varez is not exactly our NEW president. He has been
president of the APA Arts Association 8 times previously, including
If you would be willing to share whatever your creative talents may when he joined in 1970, most recently in 1999, and a 4-year stint
be with us, either in the newsletter, or at a GVPA e vent (as, for from 1988 to
example, Dr. Hannah Solky so kindly did with her video tribute to
Dr. Sandor Feldman), please contact Robb Young.
On the wall, 3 of the most appealing of the m any excellent works in
******************************************************* the display of the art of APA member artists, were all created by Dr.
A handsome newsletter, including color reproductions of art work Al varez, and later graced with blue ribbons:
and photographs, and original poetry is a significant benefit of being
a member of the APA Arts Association, (for only $30 a year). First prize in photography: A long shot color photo of a path through
the desert trodden by a single line of many camels, mounted by
Members also get early invitations to submit art work in the persons wearing Middle Eastern robes and turbans, entitled
categories of Ceramic, Computer Art, Crafts, Faber and textile, “Algerian Rush Hour.” At the business meeting, there were about
Glass, Jewelry, Painting-(mixed media, oil, water base, including
10 people, more or less the number who make up the core group of
acrylic), Photography-(B&W and Color), Prints & Drawings, psychiatrists responsible for most of the work. Otherwise, Dr.
Poetry, Sculpture, and Other. If you or any one you know has an
Al varez says, members have come and gone. They leave either
interest in participating in ANY way in the APA Arts Association, because they feel too inhibited to express themselves, or don‟t
please contact: have the stamina to stick with their art.
William A. Alvare z, M.D. First prize in mixed media: A small 8” x 10”mirror, with a square
President, APA Arts Association
painted within its borders with red paint, beside which is a roughly
P.O. Bo x 14449
painted map with the designation of Iraq, also in red. Next to the
Long Beach, California 90853-4449 piece, instructions to the viewer to look in the mirror to answer the
email@example.com title question. “Who is responsible?”
First prize in poetry: On green construction paper, 12” by 16”, a
handwritten poem in English on the left, and Dr. Al varez is not
About Our New President, William A. Al vare z, M.D., exactly our NEW president. He has been president of the APA Arts
aka the poet Alan F. McCach: Association 8 times previously, including when he joined in 1970,
First Prize Winner of Everything most recently in 1999, and a 4-year stint from 1988 to 1991.
The then treasurer,
On the wall, 3 of the most appealing of the many excellent works in
(A stooped and bent man, the display of the art of APA member artists, were all created by Dr.
With a slight accent, Al varez, and later graced with blue ribbons:
A half head shorter
First prize in photography: A long shot color photo of a path through
Peering out from under the desert trodden by a single line of many camels, mounted by
The brim of persons wearing Middle Eastern robes and turbans, entitled
His checkered cap “Algerian Rush Hour.”
The rim of
First prize in mixed media: A small 8” x 10”mirror, with a square
His glasses, painted within its borders with red paint, beside which is a roughly
Who painted map with the designation of Iraq, also in red. Next to the
Spoke so softly that piece, instructions to the viewer to look in the mirror to
I had to lean in close
answer the title question. “Who is responsible?”
To hear him),
Took my check.
This was Dr. Al varez.
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
First prize in poetry: On green construction paper, 12” by 16”, a Dr. Al varez tries to paint for at least 4 hours a week, which is easier
handwritten poem in English on the left, and Spanish on the right. when he is in California, where he shows his work. While there, he
“Should I? also enjoys theatre and music (such as at the Los Angeles
Could I? Philharmonic Association at the Walt Disney Concert Hall and the
Might I? Long Beach Symphony Orchestra).
Can I?” He is in charge of the division of African and Latin American Movies
Alan F. McCach called “Love - An Anti Poem” of the Film Exposition of Los Angeles. As a result of this interest,
he has traveled to Havana (where he met Fidel Castro) and Africa.
Dr. Al varez was born in Argentina on October 27th, 1941. The Both cultures enliven him with their passion, closeness to nature,
creativity apparently comes from his father‟s side. His father, who spirituality, art and poetry. He also has participated in the
died in the mid-eighties, has published poetry in Spanish. Three experimental film program at the University of Southern California.
paternal cousins include a sculptress (whose son now plays the
flute in a symphony orchestra after Dr. Al varez put him through As if there were no end of time on his hands, Dr. Al varez continues
school), a poet (whose child is also a musician, of Latin American to maintain two full time positions. The first is at the University of
music), and a novelist. California, Irvine, where he teaches and does research on
alcoholism and addiction. He is on the team that introduced
His parents brought him to the United States when he was 14 years clonazapam for anxiety, found to be particularly helpful, because
old. They left him here for several years, but for financial reasons less addicting, for that population. He spends 3 or 4 months at a
he went back to Argentina for college, and then completed medical time in California. Between his California stints, Dr. Al varez spends
school at age 22 at Johns Hopkins University. 4 to 6 weeks at a time in Arizona, where he has a full time clinical
practice seeing patients. This is a busier and more tiring time for
When he became a resident at Queens University in Kingston him, and does not allow him to indulge in his artistic activities. “God
Ontario, he adopted his pseudonym, Alan F. McCach, which is on a Trip to the Virgin Islands”, which he says is the only time that
based on the first 1 or 2 letters of the 6 persons who worked he has translated the concept of God into a painting. A few years
together on the newsletter, of which he was the editor in 1966-67. later he exhibited for the first time at the APA Arts Association in
Miami Beach, rewarded for his efforts through the purchase of a
Dr. Al varez started his practice in the Virgin Islands in 1968-69, painting by a psychiatrist from New Orleans.
working in a small rural village. His first painting effort was there,
where the dirty walls in his rented rooms distressed him. He And he describes himself as “boring!”
decided to make improvements with a mural. At first his landlord
was angry to learn about this artistic exploration, but then loved the Submitted by:
results, and actually offered money for the work, and as a bonus, Margot L. Fass, M.D., Co Coordinator
also to help get the good doctor in touch with other area artists. Exhibit at the 2006 APA Annual Meeting
Toronto, APA Arts Association Committee
The first framed painting Dr. Al varez made was called “God on a 527 Linden Street, Rochester, N.Y. 14620
Trip to the Virgin Islands”, which he says is the only time that he 585 256 1105
has translated the concept of God into a painting. A few years later firstname.lastname@example.org .
he exhibited for the first time at the APA Arts Association in Miami
Beach, rewarded for his efforts through the purchase of a painting
by a psychiatrist from New Orleans.
Drugs and Ethics: a Dialogue
Dr. Al varez tries to paint for at least 4 hours a week, which is easier Dr. Sauber: Hello
when he is in California, where he shows his work. While there, he Dr Lowe; „Morning.
also enjoys theatre and music (such as at the Los Angeles Dr Sauber: I see you've got a drug company pen there. And what's
Philharmonic Association at the Walt Disney Concert Hall and the that - a drug company tie? And a drug company belt buckle?
Long Beach Symphony Orchestra). Dr. Lowe: Some of my best friends are drug reps. They‟re very
generous people, by and large.
He is in charge of the division of African and Latin American Movies Dr Sauber: You know, I've been busy trying to teach medical
of the Film Exposition of Los Angeles. As a result of this interest, students that taking things from drug reps distorts decision making
he has traveled to Havana (where he met Fidel Castro) and Africa. and compromises our putting our patients first.
Both cultures enliven him with their passion, closeness to nature, Dr. Lowe: I can understand how you'd be especially tuned in to
spirituality, art and poetry. He also has participated in the these issues; that check you receive from the medical center every
experimental film program at the University of Southern California. two weeks is kind of like getting a pen or a necktie, but a little bit
When he became a resident at Queens University in Kingston different, I guess. Why, I remember when I was a resident doing an
Ontario, he adopted his pseudonym, Alan F. McCach, which is inpatient rotation, the department chief said we had to reduce our
based on the first 1 or 2 letters of the 6 persons who worked length of stay and in almost no time we discharged a bunch of
together on the newsletter, of which he was the editor in 1966-67. patients whether they needed it or not. In fact, we were so good at
it that we all got coffee mugs. One side said “LOS = 4.7” and the
Dr. Al varez started his practice in the Virgin Islands in 1968-69, other side said “Treatment in the Least Restrictive Setting.”
working in a small rural village. His first painting effort was there, Whenever we saw consumer committee representatives in the hall
where the dirty walls in his rented rooms distressed him. He we held our cups so they could see the Least Restrictive Setting
decided to make improvements with a mural. At first his landlord side.
was angry to learn about this artistic exploration, but then loved the
results, and actually offered money for the work, and as a bonus,
also to help get the good doctor in touch with other area artists.
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
Dr. Sauber: I see what you're implying, but you've got to realize Donegan, a lawyer for the State Commission of Correction who
that the medical center‟s different. You‟ve got to remember that attended the meeting. It does so, city officials said, by requiring jail
we‟ve got an ethics committee. doctors to work for a Prison Health subcontractor, called a
Dr. Lowe: That's true. I talk with the head of that group from time to professional corporation, that is controlled by a doctor.
time. She‟s in a good position to know what‟s ethical because the But Mr. Donegan, in an interview yesterday, said the city's
medical center pays her salary, so she can spend a lot of time argument was not convincing. "The contract provided for all sorts of
focusing on the issues. If there were a situation in which the controls by the parent company in Tennessee over the alleged
medical center‟s interests were pitted against a patient's , she‟d be professional corporation," said Mr. Donegan, who has read the
able to be even handed since she‟d have a connection to each one. contract. "Anything the P.C. could do, the corporation in Tennessee
She always says that her relationship with patients is particularly could undo, was my interpretation of the contract."
important because she sees them once and then never sees them Since then, however, city health officials have insisted that
again. It‟s always very moving, the way she says it. their rigorous oversight ensures that city inmates receive high-
Dr. Sauber: Well, I'm sorry you don't appreciate the basic nature of quality care that is determined by doctors, not by Prison Health
pharmaceutical company issue. I‟d like to talk some more about it executives. They said they had structured the company's three-year
but I've gotta go. The Quality Assurance and Formulary contract renewal, signed in December, so that there is no financial
Committee‟s got a big meeting starting in just a minute - we‟re incentive to deny or delay medical care.
spending way too much on medications for patients. See you. Assemblyman Gottfried, who has pressed state
Dr. Lowe: (contemplating his necktie and belt buckle) See you. lawmakers to create a public corporation, similar to the city's Health
and Hospitals Corporation, that would provide health care to state
prison inmates, said state law was "firmly rooted in a concern for
They Said That?!? promoting professionalism and accountability in delivering health
“Although I call myself an atheist, I am a Church of England atheist, care."
and a 1662 Book of Common prayer atheist, because that‟s the
tradition I was brought up in and I cannot escape those early "We work very hard in New York not to have in vestor-owned
influences.” corporations controlling health care," he said. "We rely very heavil y
New Yorker 12/ 26 05 p. 57 Philip Pullman, English author on either the judgment of individual practitioners, who are acting as
responsible professionals, or practitioners employed by carefully
"The bakery cafe concept is moving toward the lifestyle centers licensed institutions like a hospital or clinic.
near the Targets and Home Depots " New York Times 11/22/05
Democrat and Chronicle 8/26/05 Tom Ward, Atlanta Bread
The Short of It
Doctors to Win One? Several years ago, around the time the FDA was
considering the use of human growth hormone to treat extremely
short but otherwise normal children, researchers were working up
State officials have reached a preliminary conclusion that
the results of a large-scale psychology experiment involving
New York City's $300 million contract for medical care at Rikers
hundreds of middle-school and high-school students in the Buffalo
Island is illegal because it violates a state law regulating profit-
area - including some who were extremely short but otherwise
making medical companies, according to the State Commission of
normal. The students didn't know the study was about height. All
they knew was that each of them had been asked to be the director
New York law requires that corporations providing medical
of a class play. They were given thumbnail sketches of various
services for profit be owned and controlled by doctors, to prevent
characters in the drama - "a good leader," "teases others too
business considerations from influencing medical decisions. Prison
Health Services, the Tennessee company that has been delivering much," "gets picked on" and so forth - and were then asked to cast
the play by selecting classmates who best fit each role.
care since 2001 to the 100,000 inmates who pass through Rikers
If short stature is a ticket to social prejudice and
Island every year, is not run by doctors.
psychological purgatory, which has been the animating idea behind
Officials with the State Commission of Correction, which
expanded use of growth hormone in the last 20 years, you would
oversees health standards in New York's prisons and jails, said
have expected the shortest children in the Buffalo study to be lining
state investigators informed them in August that they had
up to collect their Tonys in victimhood; they would have been
tentatively determined that the city's multimillion-dollar arrangement
nominated by classmates for every beleaguered role: being picked
with Prison Health was improper.
on, behaving shyly, acting withdrawn, being left out. But that,
The agency investigating the contract, the State
surprisingly, was not the case. A team of psychologists, led by
Department of Education, said late last week that it had not
David E. Sandberg at the University at Buffalo, concluded that a
reached any "definitive conclusions" and declined to comment
child's stature, whether tall or small, had "minimal detectable
further. But the department, which regulates the practice of
impact" on his or her social standing among schoolmates. At least
medicine statewide, has in the past found serious problems with the
in this setting, even extremely short children (those around the first
way Prison Health was doing business in the state.
percentile) made friends and earned the respect of their peers as
State officials familiar with the city's contract with Prison
easily as kids of average size.
Health have said that it appeared to violate the state law because it
As the use of height-augmenting drugs is poised to
makes doctors at Rikers answerable to Prison Health executives in
explode in coming years - with cheaper generic versions of growth
Tennessee. Prison Health hires all doctors at Rikers.
hormone, shifting patterns of treatment that promise greater height
At a meeting with lawmakers and investigators last spring,
gains and new second-generation drugs like Tercica's recently
officials from the city's Department of Health and Mental Hygiene,
approved Increlex - Sandberg's "school play" study challenges, not
which hired the company, cited a letter from Prison Health's outside
for the first time, the conventional wisdom about the social and
lawyers that said the company's contract was legal because it
psychological costs of short stature.
made jail doctors answerable only to other doctors, said Michael
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
Growth hormone use has expanded in recent years to who were born small for gestational age. Increasing height, not
include children who are extremely short but not growth hormone improving quality of life, became the implicit FDA standard for
deficient, and part of the justification has been the belief that an medical success, and that set the stage for a most unusual
additional inch or two of height - and it is, on average, rarely more discussion in the summer of 2003, when an FDA advisory
than that - will make a psychological difference in their lives. committee met to consider the largest potential use by far for
Sandberg and his colleagues hadn't quite finished writing growth hormone: idiopathic short stature. At the same time, many
up the class-play study when the FDA approved an application by pediatric endocrinologists agree that pressure to use the drug has
Eli Lilly to sell growth hormone to treat children with idiopathic short grown more widespread.
stature ISS) who are at or below the 1.2 percentile on the standard What is a clinically significant increase in height?"
growth chart but have no discernible medical problem. Publication The question was posed by Dr. Paul D. Woolf, chief of
of Sandberg's research in Pediatrics last fall highlighted the odd medicine at the Crozer-Chester Medical Center in Upland, Pa., and
juncture we have reached in the growth hormone story. Even as it came up very early in the conversation on June 10, 2003, when
more children than ever are eligible for treatment and even as more the FDA ad visory committee began to weigh the pros and cons of
companies are vying to sell the drug, Sandberg's research growth hormone for short but otherwise normal children. "Is it one
continues to pose a fundamental question that undermines much of inch, two inches, five inches, eight inches?" wondered Woolf, a
the rationale for therapy in the first place. If short children, even member of the panel. "I don't know." The problem, excruciatingly
extremely short children, seem to be functioning normally in school apparent from the transcript of this meeting, is that no one else did,
and social settings, why do so many people (including many either.
doctors) see short stature, irrespective of cause, as a kind of Despite hand-wringing about clinical significance, the
psychological disability? And if, as Sandberg and others maintain, advisory committee concluded that the drug was safe and effective
there is not a single rigorous study to suggest that a few added and went on to vote, 8 to 2, to recommend approval of growth
inches improves a patient's quality of life, what benefit are short hormone for idiopathic short stature. The FDA approved it for that
normal children likely to derive from this enormously expensive use in July 2003.
treatment? In 2004, the first full year after the FDA approved
Says Dr. David B. Allen, a pediatric endocrinologist at the expanded use, drug-company sales of growth hormone went up
University of Wisconsin who has written extensively about growth across the board. Sales of Pfizer's Genotropin totaled $736 million,
hormone: "The underlying presumption has always been that if up 53 percent over the previous year. Eli Lilly sold $430 million of
you're outside the normal range when it comes to height - just like its Humatrope, up 16 percent. Genentech sold $354 million of its
you're outside the normal range with your blood calcium level or growth hormone products, up 10 percent. Novo Nordisk sold about
thyroid level - there should be some ramifications of that. And the $375 million of its Norditropin, up 9 percent. And Serono sold $182
presumption has been that there are psychological, sociological million of its pediatric growth hormone, up 20 percent. (Growth
and economic ramifications, and some of that has been borne out. hormone is prescribed for patients with AIDS and for other adults,
But in terms of the psychological disability, it's really been the case but companies do not typically disclose the breakdown between
that the more we've looked, the less we've found.” And as Dr. Alan pediatric and adult use; most experts think the major application is
D. Rogol, a professor of pediatrics and a growth expert at the for children.)
University of Virginia, puts it, "Short stature became a disease The increased revenues may actually represent a very
when unlimited amounts of growth hormone became available." interesting bioethical phenomenon that has escaped general
Moreover, the alarm bells that short stature can set off comment. When unlimited supplies of growth hormone first became
have an odd, gender-inflected clang to them. Earlier this year, Dr. available 20 years ago, bioethicists feared that pushy parents
Adda Grimberg, a pediatric endocrinologist at Children's Hospital of would demand the drug to make children of norm al stature even
Philadelphia, published a study showing that boys are referred to taller. That version of "cosmetic endocrinology" has never much
specialists twice as often as girls because of short stature - materialized, according to many doctors. But a backdoor version
although boys are not more prone to be short than girls. In fact, has occurred, according to David Allen, the Wisconsin
about 40 percent of the referred girls in Grimberg's study had an endocrinologist. Children with growth failure initiate treatment for
underlying disease that led to growth problems, while only 15 legitimate medical reasons, but they then continue treatment long
percent of the boys did. It is indirect evidence of something that after moving into what is medically considered the normal range.
doctors have recognized for a long time: that short stature is often "The track record is that most people who get on growth hormone
as much a cultural, and indeed familial, problem as it is a medical don't want to get off," he says. "So in many ways, that's a win-win
problem. But there is a considerable literature suggesting that taller situation for the pharmaceutical companies to get people to start
men receive higher pay than shorter men, and one recent study earlier, because they end up being on longer. And it doesn't lead
concluded that economic discrimination against short adult males people to discontinue their treatment earlier, because they're going
was equal in magnitude to racial or gender bias in the workplace. for maximum height and not for normal height."
Beyond the particulars of stature and treatment, the Finally, that red line on the new growth chart marks a
growth hormone story has als o become both paradigm and pioneering concept in medical economics. Increasing the height of
prototype for a new kind of medical economics - an "expansive children at the first percentile, of course, merely creates a new
biotechnology," in the words of Allen Buchanan, a philosopher at population of children falling into the bottom percentile and thus a
Duke University. Market forces that expand drug use beyond new population potentially eligible for treatment. As one medical
medical necessity, he has argued, "break down the conceptual journal noted in an editorial, "This may be the only circumstance in
boundaries we draw between disease and health, between health which treatment of one group of children creates illness in another
care and other services, between treatment and enhancement, previously healthy group."
between what social justice requires and what individuals should be
free to choose and between what we regard as fate and what we New York Times 10/16/05
regard as subject to individual or social choice."
But over the past dozen years, the FDA approved
additional uses of growth hormone for children with Turner
syndrome, chronic renal insufficiency, Prader-Willi and for children
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
“They Said that?!? studies and even unsystematic observations from single cases are
also important evidence. Position on the hierarchy is not the only
factor to weigh when considering evidence. The quality of the
What I should really like to do right now, in the full blaze of evidence is also significant. It has been noted that “it is never true
lights, before this illustrious assembly, is to shower every one of that there is no evidence concerning a specific treatment” since
you with gifts, with flowers, with offerings of poetry - to be young there is at least the report of the originator of the treatment. In most
once more, to ride on the crest of the wave. . . . Today riches and of psychotherapy practice we are dealing with evidence that is
honors have been lavished on me, but one gift has been lacking, lower on the hierarchy than the RCT.
the most important one of all, the only one that matters, the gift of Accessing the evidence, such as it is , is also a challenge for child
youth. “ and adolescent psychiatrists, particularly in the practice of
Norwegian writer Knut Mamsun‟s Nobel Prize (for literature) psychodynamic psychotherapy. The AAC AP Psychotherapy
acceptance speech quoted in The New Yorker 12/26/05 page 132 Committee, is currently exploring the reasons for the difficulties
encountered in online searches of the psychodynamic literature.
The AAC AP Executive Committee has budgeted funds to support a
collaborative effort between our Psychotherapy Committee, the
American Psychoanalytic Association, the Association for Child
Psychoanalysis, the American Academy of Psychoanalysis and
Join the Rochester Academy of Psychodynamic Psychiatry and the Journal of the American
Psychoanalytic Association to make the titles and abstracts of its
papers searchable by DSM diagnosis.
EBM requires the practitioner to examine bodies of evidence. To
Medicine! be done well this requires that no studies be held back because of
unfavorable outcomes. EBM has helped to create a climate in
which, with a significant contribution from AACAP, pharmaceutical
companies have been pushed to make all their studies available.
271-1313 Synthesizing many studies into one, which is often done through
meta-analytic statistical techniques, introduces substantial
subjectivity in the form of judgments regarding the admissibility
(that is, is a particular study fatally flawed, and hence to be
ignored?), relevance, or importance of individual pieces of
evidence. Developing practice guidelines is even more challenging.
A practice guideline typically requires evaluation of several bodies
Child Psychiatry‟s Take on of evidence, each of which relates to a different „link‟ in a chain of
reasoning that, in total, underlies a guideline. The evidence base of
Evidence Based Medicine the final guideline is no stronger than the weakest links in the chain
Rachael Z. Ritvo, M.D. and Dov Fogel, M.D. of reasoning. As the links are fashioned together, political jockeying
and bias enter the process.
This first EBM step of gathering and evaluating the evidence
The volume of scientific evidence relevant to patient care has
available is relatively straightforward compared to the second step
mushroomed over the past 30 years. Despite equally impressive
of EBM, which requires integrating the evidence into the mix of
expansion in the technology for accessing this information, information in the patient encounter in order to arrive at a treatment
researchers and thoughtful practitioners are rightfully concerned plan. The model that underlies EBM is from public health and
that the evidence may not he put to use effectively in the care of
clinical epidemiology. This model utilizes population based studies
individual patients. Evidence based medicine (EBM) is a two-step
and outcomes research that predict the greatest benefit over large
practice. First, it describes a hierarchy for ranking the quality of the
groups of patients. While this approach has inherent value in
existing evidence. Second, it addresses the translation of the seeking to promote health for the many, as well as gathering
empirical scientific knowledge into clinical practice, attempting to important information about diagnostics and therapeutics, its focus
bridge the gap between clinical research and practice.
is different from the traditional primary focus in clinical medicine,
AAC AP has a role to play in educating our members about this
the individual patient. Clinical medicine is ultimately a personal
developing approach to the practice of medicine and in providing
discipline, where one person in need of healing engages another
leadership in the best practice of evidence based medicine. A who offers to heal. There is an intrinsic gap between the
responsibility of AAC AP leaders is to think critically about the epidemiologic endeavor and the individualized care of a patient. As
application of EBM in AAC AP programs, activities, and products.
AAC AP seeks to promote the integration of EBM into the field of
EBM is a heuristic tool, a guiding concept and set of procedures.
child and adolescent psychiatry, we must be careful to “mind the
We need to learn about this tool and how to use it. We also need to gap.” Child and adolescent psychiatrists must not overvalue EBM
learn when it is the appropriate tool and how to use it in concert skills at the expense of our more individually focused clinical skills.
with our other tools, non-evidentiary information such as The application of knowledge gained from clinical trials to
psychological, biological and developmental theories; cultural and
individuals is fraught with practical, conceptual and ethical
individual values; and communication skills, to name only a few.
difficulties. For example, the strength of clinical trials, large
Psychotherapy, which deals intimately with subjective experience, numbers, is also its weakness. It is by accumulating abundant
presents unique challenges in the application of EBM. The AAC AP evidence about a specific hypothesis that researchers reach
Psychotherapy Committee is examining what EBM can contribute conclusions that are definitive. Yet, b y eliminating variables not
to the practice of psychotherapy and what its limitations are.
under study through statistical methods and study design and by
The randomized control trial (RCT) is commonly known as the
limiting study to those phenomena that are quantifiable, detail that
“gold standard” in EBM. Although a well-designed and well- might be important in an individual case may be obscured.
executed RCT sits at the top of EBM‟s evidentiary hierarchy, non - Additionally, the “e vidence” cannot tell a clinician what is the “right”
randomized and uncontrolled observational studies, single case
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
decision because the “right” decision requires value judgments that Standau never reported the witchcraft therapy to officials
cannot derive from facts directly but must be passed through the at Delnor because she trusted in the hospital, Stavins said, but
subjectivity of the value system of the clinician, the family and the other staff should have recognized the bizarre proceedings and
patient. Furthermore, EBM tends to put emphasis on empirical interceded. Delnor officials said they investigated Standau as soon
reasoning. In emulating EBM we should not lose sight of the fact as they got the first of two patient complaints. She was investigated
that clinical reasoning also involves reasoning by analogy whereby internally and staff contacted the Illinois Department of Professional
the clinician compares the patient with similar patients, paying Regulation and the Geneva police. Hospital officials declined to
attention to relevant similarities and differences. The corpus of comment on the outcome of the investigation or if Libman left
clinical research that is the evidence base of EBM ob viously voluntarily.
provides a sizeable source of clinical material for making Later the same hospital was hit with a two more lawsuits
comparisons. Unfortunately the manner in which the material is of a similar nature. The second suit was filed in Kane County court
presented in scientific articles emphasizes the methods and by Deanna Whetstine, who underwent therapy for pain
statistics more than the clinical details that are useful for the management because of a neurological condition. It alleged
comparisons made when reasoning by analogy. Clinicians struggle psychologist Libman claimed to possess psychic powers. The third
to find this literature helpful. Clinicians frequently draw on their own suit lawsuit alleged the former staff psychologist practiced
earlier experiences, clinical case conferences and discussions with witchcraft under the guise of therapy. The suit by Kathleen Carlson
colleagues to prime their reasoning by analogy. Examples of of St. Charles was filed in Kane County civil court against Delnor-
healthy development and normative functioning are also used to Community Hospital, Geneva.
determine by analogy what is missing or failing to occur in the According to court documents, Carlson sought therapy for
patient at hand. emotional distress from her divorce. Libman asked her for a
For child and adolescent psychiatrists who value psychotherapy, sample of her ex-husband's DNA so that the psychologist could
EBM presents an opportunity and a challenge to pursue the "perform a spell" on him, the suit contends. The suit also claims the
empirical study of psychotherapy more assiduously. therapist told Carlson "men were a lower form of life than women
Psychotherapists need to understand the many forms of evidence and that men would soon die off the planet," counseled her to stop
in the EBM e vidence hierarchy and develop those appropriate to taking medications, bragged about her sexual prowess, told her
psychotherapy. EBM offers great promise in expanding our that Libman had special powers, and discussed Carlson's mental
knowledge base but its limitations need to be acknowledged as health problems with other patients. Carlson was under Libman's
well. In the context of EBM, clinicians need to be more explicit in care at the St. Charles branch of Delnor's medical health center
their approaches to values, conceptually guided practices, and from September 2002 to January 2005. The suit states that she
reasoning by analogy. suffered severe depression, mental injuries and loss of family
relations. She seeks more than $50,000 in damages.
July August 2005 AAC AP News As in the two prior suits filed against Delnor-Community,
this litigation did not name Libman as a defendant. The forth
involves Kenneth Sutter asking for more than $50,000 in damages
Witch Way Sanity? as a result of psychological services he received for several months
in 2003 from Dr. Libman. He claims that the hospital failed to
Shelley Standau went to Delnor-Community Hospital, monitor Libman, who he says tried to "induce him into witchcraft"
Geneva, for help with her depression and ended up a witch. under the guise of therapy, instructed him in speaking with dead
The former Woodstock resident filed a federal lawsuit people and suggested that in lieu of his prescribed medications he
against the Geneva-based hospital alleging it did nothing to stop a should smoke Native-American herbs.
licensed clinical psychologist on staff, Letitia Libman of St. Charles, Libman is no longer employed by Delnor and has not seen
from using witchcraft on her and eventually inducting her into a patients in the psychological services program since January, said
Wicca coven. "This is about as far from the normal psycho- hospital spokesman Brian Griffin. "We take patient complaints of
therapeutic care you can get," said her Chicago attorney Richard this nature very seriously," he said.
Stavins. "She gets witchcraft and ends up trying to commit suicide
three times." Material from various web sitess
The lawsuit asks for $1 million in damages from the
hospital. Libman, a psychologist, was employed with Delnor part
time from 1994 to 2002 and later full time.Libman isn't being sued Gimme an Rx! Cheerleaders Pep
because Standau is afraid of her, Stavins said. That fear also
forced the 45-year-old to move to North Carolina to escape Libman Up Drug Sales
and her spells, he said. As an ambitious college student, Cassie Napier had all the
During her therapy from September 2001 to June 2004 at right moves - flips, tumbles, an ever-flashing America's sweetheart
the St. Charles campus of Delnor, Standau was instructed to draw smile - to prepare for her job after graduation. She became a drug
a witch's pentagram, take a witch's name, use spells and become saleswoman. Ms. Napier, 26, was a star cheerleader on the
more promiscuous, according to the lawsuit. Her therapy consisted national-champion University of Kentucky squad, which has been a
of tarot cards, nudity and self-mutilation, the lawsuit contends.Along springboard for many careers in pharmaceutical sales. She now
with the witchcraft claims, the lawsuit also alleges Libman tried to plies doctors' offices selling the antacid Prevacid for TAP
buy illegal drugs from Standau's boyfriend, engaged in erotic Pharmaceutical Products. She says the skills she honed performing
behavior with another patient in front of Standau and talked of for thousands of fans helped land her job. "I would think,
drugging the drink of a doctor she had a sexual relationship with. essentially, that cheerleaders make good sales people."
The treatments lead Standau to become ostracized by her An yone who has seen the parade of sales representatives
family, suffer from paranoia and become suicidal, Stavins said. through a doctor's waiting room has probably noticed that they are
Libman could not immediately be reached for comment at frequently female and invariably good looking. Less recognized is
her St. Charles home. the fact that a good many are recruited from the cheerleading
ranks. Known for their athleticism, postage-stamp skirts and
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
persuasive enthusiasm, cheerleaders have many qualities the drug
industry looks for in its sales force. Some keep their pompoms Companies' Threat: Quit Smoking
active, like Onya, a sculptured former college cheerleader. On
Sundays she works the sidelines for the Washington Redskins. But or Leave
weekdays find her urging gynecologists to prescribe a treatment for With medical expenses rising, corporations are
vaginal yeast infection. increasingly focusing on the employees who they believe account
Some industry critics view wholesomely sexy drug for the majority of health care costs. Some companies have tried to
representatives as a variation on the seductive inducements like winnow the number of smokers in their work forces by offering
dinners, golf outings and speaking fees that pharmaceutical employees money and counseling help to quit smoking. In April,
companies have dangled to sway doctors to their brands. Humana asked its employees if they used tobacco in the previous
But now that federal crackdowns and the industry's self- 12 months. Those who said they hadn't got a $5 bonus in their
policing have curtailed those gifts, simple one-on-one human paychecks each pay period. General Mills imposes a $20 a month
rapport, with all its potentially uncomfortable consequences, has surcharge on the health benefits of smokers.
become more important. And in a crowded field of 90,000 drug Firing workers who won't stop smoking is illegal in the 30
representatives, where individual clients wield vas t prescription- states that have laws that protect smokers. But elsewhere, unless
writing influence over patients' medication, who better than workers fall into one of a few protected classifications defined by
cheerleaders to sway the hearts of the nation's doctors, still mostly state and federal laws, employers can fire them at will.
men. Wall Street Journal 12/20/05 page D1
"There's a saying that you'll never meet an ugly drug rep,"
said Dr. Thomas Carli of the University of Michigan. He led efforts
to limit access to the representatives who once trolled hospital Pills and PR
hallways. But Dr. Carli, who notes that even male drug To truly understand the efficacy/ safety debate about
representatives are athletic and handsome, predicts that the drug antidepressants for children and adolescents, we should consider
industry, whose image has suffered from safety problems and our exposure to the vast power of media advertising.
aggressive marketing tactics, will soon come to realize that "the Disguised with markers and signifiers, which are meant to
days of this sexual marketing are really quite limited." confuse the newness of a medication with a real need, drugs are
But many cheerleaders, and their proponents, say they constantly promoted subliminally and placed in our very
bring attributes besides good looks to the job - so much so that unconscious. We are surrounded by pens, pads, calendars, and
their success has led to a recruiting pipeline that fuels the country's clocks in our own offices all emblazoned with the corporate logos of
pharmaceutical sales force. T. Lynn Williamson, Ms. Napier's various antidepressants, stimulants, and antipsychotics.
cheering adviser at Kentucky, says he regularly gets calls from We as physicians are inundated on an almost daily basis with
recruiters looking for talent, mainly from pharmaceutical companies. marketing literature inviting us to educational dinners and offering
"They watch to see who's graduating," he said. "They don't ask to pay us for surveys. The Journal of Clinical Psychiatry’s
what the major is," Mr. Williamson said. Proven cheerleading skills Supplement Preview is usually the result of a “teleconference”
suffice. "Exaggerated motions, exaggerated smiles, exaggerated developed by a “Continuing Medical Education Institute” “pursuant”
enthusiasm - they learn those things, and they can get people to do to an unrestricted educational grant from a drug company. Most of
what they want." the physicians writing the articles for these very professional
Approximately two dozen Kentucky cheerleaders, mostly looking supplements are “consultants” to the very drug companies
women but a few men, have become drug reps in recent years. whose meds are being evaluated in these so called “previews.” Full
While there are no statistics on how many drug representatives are disclosure lists of the researchers‟ relationship to pharmaceutical
former or current cheerleaders, demand for them led to the companies are long and confusing.
formation of an employment firm, Spirited Sales Leaders, in Meanwhile the blitz of TV ads showing the benefits of quick, easy
Memphis. It maintains a database of thousands of potential chemical cures for depression with fast-talking, barely
candidates. understandable and illegible end qualifiers, presenting adverse side
"The cheerleaders now are the top people in universities; effects, has been a sensational success as measured by increased
these are really capable and high-profile people," said Gregory C. profits for the drug industry, where antidepressants are the number
Webb, who is also a principal in a company that runs cheerleading one advertised group of drugs, in terms of sales, in proportion to
camps and employs former cheerleaders. He started Spirited Sales advertising dollars spent. Ads in media like Good Housekeeping,
Leaders about 18 months ago because so many cheerleaders were GQ, People and Sports Illustrated are quite effective. Parade
going into drug sales. He said he knew several hundred former Magazine contains full page spreads declaring a parent‟s pleasure
cheerleaders who had become drug representatives. "There's a lot of “now seeing Matt rather than just his ADHD,” because of the
of sizzle in it," said Mr. Webb. "I've had people who are going right magic of a new long-acting psychostimulant.
out, maybe they've been out of school for a year, and get a car and As physicians we must further evaluate the more covert use of
make up to $50,000, $60,000 with bonuses, if they do well." product placement on TV that promotes the use of drugs for
Compensation sometimes goes well into six figures. children and adolescents. Popular culture often exaggerates while it
The ranks include women like Cristin Duren, a former reflects society, as an episode of The Simpsons devoted to the
University of Alabama cheerleader. Ms. Duren, 24, recently took a negative impact that Bart experiences upon taking a mind-altering
leave from First Horizon Pharmaceuticals to fulfill her duties as the drug, actually validates its use by its TV presence. The same can
reigning Miss Florida U.S.A. and prepare for next year's Miss be said with of an ongoing theme on Desperate Housewives where
U.S.A. pageant. a mother abuses her son‟s stimulant meds to gain more energy.
New York Times 11/28/05 Psychiatric medication has become highly visible in shows like The
Sopranos (Prozac), and Huff (Clozaril). There have even been
storylines about psychiatric drug trials on Law and Order. The
downside of a drug‟s abuse on TV is often minimized and
reversible, while the positive is promoted. Like alcohol and
cigarettes of popular culture‟s past, the use or abuse of
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
psychotropic medication embedded in a dramatic TV or film • What sustains military personnel on a dangerous deployment is
narrative becomes a powerful message legitimizing its use. Freud devotion to duty, a close connection with fellow soldiers and the
certainly was correct when he spoke of the way we “think in desire to return to the comforts of home, family and community.
pictures.” Our unconscious operates in imagery, rather than in • The returning family member may seem preoccupied with the
words, thus making the power of electronic imaging a significant experience of their deployment. They may be unable to talk
and influential force. Ads pushing psychiatric drugs for children, of
about it or may excessively talk about it.
course are also a large source of revenue for general medical and
• The returning family member may have suffered physical or
psychiatric journals. My fa vorite begins with the eye-catching “From
emotional injury or disability.
ABC to SAT.” It draws attention to a full page picture of happy kids
reading books, one younger and one older, next to a prescription • The returning family member may expect extra attention and
pad whose face sheet has a prescription for a widely used support for some time after their return.
psychostimulant. This is an effective ad as your attention is first • The returning family member may have serious concerns about
grabbed by the SAT phrase. The association of the pictures of the their financial or employment future.
happy kids reading and the prescription pad with a script for a
psychostimulant becomes a marketing slam -dunk. In the very same Understanding the Adult that Stayed at Home
medical publication, a physician could see a similar ad that asks the • Life has gone on and the adult at home has had to keep the
reader to “Aim Higher,” next to a picture of a father and son gazing family moving forward during the deployment. They may have
into space with a telescope, as the logo for yet another had to take over many functions normally performed by the
psychostimulant is prominently displayed all over the glossy page. deployed family member.
While the phrase “Aim Higher,” is particularly offensive, given the • Often the adult at home has handled many small and not so
possibility of abuse that these drugs are known for, the real abuse small crises. These problems are old news at home but may be
is how vulnerable physicians are to marketing. Even with our big surprises for the returning family member.
graduate degrees and intellectual powers, most of us do brush our • The adult at home may expect e xtra attention and credit
teeth with Crest, because that‟s usually the only brand of
regarding the performance during the deployment. They also
toothpaste that we see advertised. Physicians are not immune to
may expect the returning family members to automatically accept
advertising, especially for the drugs we prescribe. In fact, the
marketers know and target their medical audience well, with ads the family as it now exists and begin to perform a role with which
that offer symbols like the SATs and telescopes, which are they are uncomfortable or unfamiliar.
seductive and plug into the high regard we have for education.
These ads promoting the medicating of children and adolescents Understanding the Children
do pay off for the drug companies, even in so-called peer reviewed • Children generally are excited about a reunion with their
medical journals, where apparently the articles are carefully returning parent. However, the excitement of the reunion is
scrutinized but not the advertisements. stressful for children. Children may also be anxious and
As physicians we need to become more media literate, uncertain about the reunion.
deconstructing these seductive messages. We need our • Children‟s responses are influenced by their developmental level.
prescribing practices to be based on medical evidence not Madison Toddlers may not remember the parent well and act shy or
Avenue spin. strange around them. School age children may not understand
Michael Brody, M.D. Chair of the American Academy of Child the returning parent‟s need to take care of themselves and to
and Adolescent Psychiatry’s Television and Media Committee. spend time with their spouse. Teenagers may seem distant as
they continue their activities with friends.
• Children may need a period of time to warm up and readjust to
Facts for Families the returning parent. This should not be misinterpreted or taken
Coming Home: Adjustments for Military Understanding the Family
Families • Couples may find the deployment has strained their relationship.
AACAP News July/August 2005 Time and negotiation will help the couple work toward a new
Military families look forward to being together after a long • Family problems that existed before the deployment frequently
deployment with many mixed emotions. Each family member will reappear after the deployment.
have different expectations. Every family situation is different. But, it • Extended family members such as grandparents, aunts and
is important to remember the needs and feelings of the returning uncles may have provided support and service to the family
family member, the adult at home and the children. during the deployment. They may have difficulty redefining their
role with the family.
Understanding the Returning Family Member
• Military deployments, especially in a combat zone, can Give Everyone Time
significantly change an individual‟s life. • All family members will need time to adjust to the changes that
• The deployment involved the loss of many comforts that people accompany the return of the deployed family member.
back home take for granted: contact with family, comfortable • Open discussion of expectations prior to the return home are
living conditions, a variety of good food, time to relax, etc. helpful if they are possible.
• The deployment involved hard work and enormous responsibility. • Families should utilize the help offered by the military and other
If in a war zone, there was the constant threat of loss of life or organizations to readjust to the reunion.
injury. The family member may have witnessed injuries, deaths • Most families will change. Children have been born or have
and destruction. grown. An adult at home may have become more independent.
J an u ar y 2 0 0 6 Jan u ar y 20 0 6
The returning family mem ber had a life changing experience.
The goal is to form a healthy, new life together.
Reunion of a military family after a long deployment is a cause for
celebration. Some patience and understanding will go a long way to
help the whole family successfully reunite with a minimum of
Psychoanalyst and CEO
Daniel L Vasella, the chairman and CEO 01 Novartis, has
a reputation as an impatient competitor—a style that seems at odds
with his previous career as a psychoanalyst and physician.
Dr. Vasella first sought analysis when he was 17 years
old, emerging from a childhood marked by illness and loss. At eight,
he contracted tuberculosis and spent a year in a sanatorium away
from his family. At 10, his eldest sister died of cancer, and three
years later his father died.
Unable to afford treatment as a teenager, he waited until
he was a 26-year-old physician and had some patients whose
illnesses had psychological roots. While working as an internist, he
began analyzing under supervision, some patients with
But in 1988, when he was 34, he decided to switch from
medicine to business. “I didn‟t change because of analysis, but
analysis allowed me to change,” he says - “It gave me the self-
assurance to be self-determining rather than determined by
circumstances,‟ he says. “I was aware that life can be very fast
paced, and I had a hunger to do a lot in a short period of time.
If he says he prefers business to medicine, it's because he can be
more openly aggressive.” “In business, you ask „how are we going
to beat our competitors,‟ and aggression is expected,” he says - In
hospitals, competitiveness can be more underhanded and “the
politics can get nasty.”
Wall Street Journal 6/14/46
If he says he prefers business to medicine, it's because he
How‟s the View from Up There?
Members of Congress are calling for major shifts in intelligence
spending, by transferring spending to human spying efforts from
New York Times 9/30/05