Volume 62, No. 12 December 2006
THE PERILS OF "HEALTH CARE"
With the party of Hillary Clinton in the ascendancy, we will
expect more pressure to "just get it done" and enact a national,
monolithic (non-"fragmented") "health care delivery system," with
bipartisan support, of course.
We can expect endless repetition of the demand to spend more
on "keeping people healthy," instead of having a system focused
on disease. For years, a subtle change in language has helped to
drive policy in this direction. Instead of the "practice of
medicine" or the receipt of "medical care" we have the "delivery
of health care." AAPS avoids cooperating with this semantic shift
as much as possible.
"Health care" ought to mean accepting one's individual
responsibility to take care of one's health, as by following
Grandma's advice: Get plenty of fresh air, sunshine, and
exercise. Eat your vegetables. Don't smoke or drink to excess.
Wash your hands. Don't fool around; get married and be faithful
to your spouse. Grandma also may have made you take your
vitamins, and/or your cod liver oil. She frugally saved her
pennies so she could pay the doctor if somebody was really sick.
But she was just an old wife.
Today we have credentialed, government-sponsored "health
care providers" to substitute for Grandma or to shove her
aside and even to replace doctors. Increasingly, approved
providers are backed up with the police powers of the state. The
FDA and Codex may ban home remedies, while mental health
screening, disease registries, and mandatory vaccines and
psychoactive drugs proliferate. Everyone is to be protected
against second-hand smoke, messages promoting sexual morality,
nonconformist doctors, and direct payment of one's own medical
bills and subjected to the nanny state.
How U.S. Medicine and European-Style Health Care Differ
In privately controlled systems, infrastructures are
designed to cure maladies, promote full recoveries, and shorten
treatment times. But in politically controlled systems, money
flows to issues of concern to politicians, explains Linda Gorman.
At any one time, less than 5% of the population in most
industrialized countries requires sophisticated medical care. "In
terms of votes, the concerns of the sick are inevitably
outnumbered by the concerns of the well" (The History of
Health Care Costs and Health Insurance: a Wisconsin Primer,
Wisconsin Policy Research Institute Report, October 2006).
Under socialized medicine, everyone can visit a doctor
frequently, for minor ailments. But for procedures, waiting list
management is a major industry in Canada. Acute care facilities
deteriorate. Whether U.S. citizens are less healthy, or if so
whether that is related to the fact that the medical system
remains half private, is hotly debated. But 5-year survival rates
for cancer are distinctly better in the U.S., and adverse events
in U.S. hospitals considerably less frequent (ibid.).
As costs mount, once-private behavior becomes everybody's
business. It is said that 75% of health-care costs are lifestyle
related. Gorman points out that this must be exaggerated. After
regulatory costs eat up 10-20%, this would leave no more than 15%
of $1.88 trillion, or $285 billion, for sickness or injury
unrelated to lifestyle. Arthritic conditions alone cost $189
billion; Parkinson's disease, $25 billion; schizophrenia, $22.7
billion; bipolar disorder, $45.2 billion; gastroesophageal
reflux, $9.3 billion. But the lifestyle police are being
deployed, and the AMA has a new crusade to promote taxes on
sugared soft drinks, to fund obesity education.
Culling the Herd
The money is in reducing the number of sick or disabled
persons, and/or restricting their care, even if it is impossible
to eliminate the causes of sickness. The direct route is being
used with increasing frequency. One-third of British doctors
admit to having hastened a patient's death by more than a month.
Belgium has allowed euthanasia since 2002, and Switzerland
permits assisted suicide (Daily Mail 10/15/06). The
Royal College of Obstetricians and Gynaecologists is debating the
issue of killing disabled newborns (www.rcog.org.uk/). In the
U.S., AAPS receives "anecdotal" reports of hospice staff telling
families that patients are "forbidden" to have food or drink, or
of high doses of morphine being used in debilitated patients who
are not complaining of pain.
The less direct route is to cull physicians skilled in
caring for the sick. First, the Relative Value Scale makes it
impossible to reward higher competence. In fact, to receive
higher Medicaid funding, a facility must employ nurse
practitioners. Then, the "hold harmless" clause in managed-care
contracts makes it impossible for physicians to be paid at
all for rendering "covered" but "medically unnecessary" (for
example, "futile") services. Of course, screening visits, even if
they certify that care is unnecessary, are always paid for.
The latest scheme is "health plan tiered networks," which
encourage patients to see physicians in the lowest cost tier
through lower premiums or cost sharing. The high tiers are
narrow designed, as Dr. Huntoon explains, to assure that
everything eventually "goes to ground."
In a free market, people choose to pay more for higher
quality. In a socialized market, low cost is being defined as
high quality. Economic incentives in the free market are
deplored: patients are too stupid or distressed, and medical care
too complex or urgent to permit shopping. But if used to starve
out noncompliant "providers," incentives are applauded.
The price of "universal health care" is your money
and your life. Everyone must pay for the system. And it
will, as promised, reduce or eliminate the care of the sick.
Medicare, the American single payer, protects against
relatively small losses while providing no protection at all for
the small number of people who incur large losses by spending
more than 150 days in the hospital. Unlike virtually all
reputable private plans, there is no cap on personal liability.
In 1997, nearly 40,000 Americans enrolled in Medicare had an
average of $22,000 in liabilities per person, which might or
might not have been covered by a private supplemental policy.
Decreases in mortality rates for 55 to 64-year-olds began
several years before Medicare's inception, suggesting that
declines in 65 to 74-year-olds, beginning several years later,
were unrelated to the program. In the decade following its
founding, Medicare had no effect on mortality.
Under socialized medicine, patients don't receive a bill,
but also might not receive the care. Comparative 5-year cancer
survival rates for the U.S. and Europe, respectively, are: pros-
tate, 56% v. 81%; melanoma, 76% v. 86%; colon, 47% v. 60%; rectum
43% v. 57%; breast, 73% v. 82%; uterine, 73% v. 83%
(Cancer 2000;89:893-900). The percentage of hospitalized
patients with adverse events was: 7.5% in Canada; 2.9% in Utah
and Colorado; 16.6% in Australia; 3.7% in New York City; 10.8% in
London, and 12.9% in New Zealand.
See Gorman, Wisconsin Policy Institute, op. cit.
Shopping for Medical Care
Some assert that price comparisons are unrealistic in
medical care because of its urgent nature. But the leading reason
for office visits is general medical examination (65,000 of
889,980 in the 2002 National Ambulatory Medical Care Sur-vey),
followed by "progress" visit (41,000) and cough (26,000). Others
in the top 10 were routine prenatal checks, throat symptoms,
hypertension, knee symptoms, well baby examination, obtaining
medication, and stomach pains. Most of the top 20 (www.cdc.gov/nchs/data/ad/ad346.pdf) were also usually
elective and price elastic. Price competition for such services
is likely to have an impact on the cost of emergent care also.
At the annual meeting of the Massachusetts Health
Underwriters Association, the man in charge of The Connector (TC)
reported that it took 6 weeks to order a printer through the
bureaucratic process, and 2 weeks to remove the shrink wrap. It
took only 2 weeks to get the scanner ordered. There are six
employees, and they're adding one a week, but they didn't have
health insurance yet an oversight by legislators.
In an Aug 17 filing to support general obligation bonds,
Massachusetts officials said the plan will increase state health
spending by $276.2 million in 2007 a $151 million boost over
what the public was told the plan would cost as recently as
April. As writers on HealthyBlog noted, "They can say whatever
they want to the public, but they can go to jail for fibbing to
Wall Street" (Sally Pipes, Wash Times 11/5/06).
Attorney General Thomas Reilly has sued a company that sells
low-cost policies to small businesses and students. While noting
that MEGA Life needed to improve its consumer information,
Insurance Commissioner Julianne Bowler said she thought TC should
consider offering such plans. But "Healthcare advocates" promise
to fight inclusion of MEGA Life and similar limited-coverage
plans (Boston Globe 10/24/006).
Medical Justice Offers AAPS Members 10% Off
In his presentation at the 2006 AAPS meeting, neurosurgeon
Jeffrey Segal, M.D., described the ways in which his organization
helps fight frivolous litigation. Medical Justice will now offer
a 10% discount for AAPS members see enclosure.
If You Can't Opt Out, Help Those Who Do!
Bruce Schlafly, M.D., a hand surgeon in St. Louis, writes
that it is best for him to participate with a variety of
different private insurance companies because he frequently
provides emergent care to injured patients. He is a
nonparticipating physician in Medicare, but is not completely
"Nevertheless I recognize that the most effective force
right now in the U.S. for preserving private...medicine is the
self-pay, cash medical office or clinic. Every cash transaction
between patient and physician...is a blow for freedom."
Dr. Schlafly urges all physicians, even those who
participate with third parties, to support cash-based practices
through their AAPS membership, and "to recognize that these
medical practices are doing much to preserve the freedom that we
still have in our private practices."
Who's in the Driver's Seat?
It seems clear that government and third parties control the
agenda on how medicine is to be practiced. Physicians are there
as token representatives or mere facilitators to third parties,
writes David McKalip, M.D., a neurosurgeon in St. Petersburg, FL.
"The Third Parties insist that if they merely micromanage medical
care enough, they can solve [the] economic problems. What they
really mean is: deny care to patients, demonize and damage
doctors who refuse to cooperate with them, then take home the
profits and get reelected."
The AMA's Physican Consortium for Performance Improvement
(PCPI) seems to indicate that the individual needs or rights of
patients are secondary to larger "social obligations." It states:
"The tradition of physician professionalism is grounded in the
obligations to society and individual patients to achieve optimal
health outcomes and to responsibly use health care assets." Also:
"[U]nnecessary and inappropriate clinical interventions that are
delivered `inexpensively' serve no useful social goal."
"Are we in the Soviet Union?" asks Dr. McKalip. "What
happened to clinical goals for the individual patient living in a
free American society?" He notes that "arbitrary designation of
some procedures as `medically unnecessary' by payers and
government" show a view very different from physicians'. Cost
decisions need to be moved into the hands of patients through
Health Savings Accounts and high-deductible catastrophic
insurance, he concludes. And organized medicine should reflect
the values of free people, not of government dependents.
Exclusions Reach Record Levels
In FY 2005, the Office of the Inspector General excluded a
record-breaking 3,804 providers from Medicare and Medicaid an
increase of 15.5% over 2004 and 16.2% over 2003. The most common
reasons were license revocation (53%), health-care related crimes
(20%), and patient abuse or neglect (8.5%).
"Exclusion is one of the enforcement avenues that [OIG is]
emphasizing, in part, because they don't have to go through as
much red tape and they can do it on their own," stated attorney
Bill Maruca of Pittsburgh (MCA 10/16/06).
Convictions for fraud and abuse also reached a record
level 523 in FY 2005 and 1,689 health care fraud criminal
investigations were opened.
Medicaid Fraud Control Units (MFCUs) raked in a record $709
million in restitutions, fines, and civil settlements. MFCUs will
be hiring more prosecutors and investigators, and teaming up with
other local government agencies. The majority of prosecutions are
for alleged abuse, neglect, and poor care.
As of Oct 1, any hospital with "specialized capabilities"
must comply with the Emergency Medical Treatment and Labor Act,
even if it does not have an emergency room. It will have to
create an infrastructure for accepting and stabilizing EMTALA
Error Leads to Criminal Charges
Wisconsin Attorney General Peg Lautenschlager's office took
the unprecedented step of filing felony criminal charges after a
patient died from an unintentional error. Nurse Julie Thao
inadvertently gave an epidural anesthetic intravenously, instead
of penicillin, to a 16-year-old woman in labor. Cardiac arrest
and death ensued. Thao was charged under a state statute normally
reserved for cases involving neglect of a nursing home patient
and could face up to 6 years in prison.
"The actions, omissions and unapproved shortcuts of the
defendant constituted a gross breach of medical protocol," stated
MFCU investigator Gregory Schuler.
Dana Richardson, VP for quality at the Wisconsin Hospital
Association, said "it is cruel to allege that this mistake
constituted criminal conduct." The charge "accomplishes nothing
other than to compound the anguish of this situation."
Nurses are already stressed by sicker patients, new
technology, increased paperwork demands, and requests for
overtime, said Gina Dennik-Champion, executive director of the
Wisconsin Nursing Association. The risk of prison time for
mistakes could discourage entry into nursing, decrease access to
care, and cause a setback in the trend toward more transparency
about mishaps. See: Wisconsin State J 11/3/06;
Insider, Wisconsin Medical Society 11/3/06.
On Blowing the Whistle: a Pharmacist's Insights
On Feb 6, 2005, Paul Kornak, a nonphysician employee of the
Stratton VAMC in Albany, NY, pled guilty to fraud and criminally
negligent homicide, and was sentenced to 6 years in prison. His
forgeries involved manipulating medical backgrounds so that
patients would qualify to participate in lucrative drug studies.
At least one veteran died, and 64 others were harmed by illicit
cancer research. Though Kornak deserved punishment, writes
pharmacist Jeffrey Fudin, he was a convenient scapegoat for a
decade of criminality that had preceded his employment.
Some patients were coerced into participation, and some
placed in studies without informed consent. Physically
incompatible drugs were given. Dangerous doses and unstudied
combinations were prescribed. When he refused to cooperate, Fudin
received a memorandum charging him with "patient abuse for
failure to dispense medication as required by the oncologist." As
he climbed the chain of command to report his observations, he
was told: "I will bury you." Eventually, he was fired. The
struggle consumed a decade of his life. For details see www.vawhistleblower.com
To survive, Fudin said he had to become the predator rather
than the prey, and "to make the message clear that anyone guilty
could potentially be exposed." He documented his findings
meticulously. He advises hiring an attorney who specializes in
employment law, not health care law (Am J Health-Syst
Pharm 2006;63:2262-2265). To assist other VA practitioners,
he helped form a coalition: www.vawbc.com.
Profits Allowed, Washington Court Rules
The Washington State Supreme Court held in an unanimous
opinion (9-0) that RCW 19.68.010, an antikickback statute, does
not prevent medical professionals from making a profit by
providing goods or services to patients. Plaintiffs in a Spokane
class-action suit had alleged that profiting from the sale of
medications violated the law that prohibits paying or receiving
anything of value in return for referral of a patient. A Superior
Court agreed. The Supreme Court in reversing took the "common
sense" position that the legislature intended to prohibit
kickbacks, not profits (WSMA memo 10/20/06).
Most Dangerous States
Public Citizen's Health Research Group has published a
ranking of states based on the number of serious disciplinary
actions against physicians, using 3-year averages to counter the
effect that in small states, one or two actions can greatly
affect the ranking in a single year (HRG Publication #1737). The
"worst states" are Hawaii, Delaware, Wisconsin, Minnesota,
Maryland, Nevada, Rhode Island, Arkansas, South Carolina,
Washington, Tennessee, Mississippi, Michigan, Connecticut, and
Florida, with disciplinary rates ranging from 1.44 to 2.46 per
1,000 physicians. The "best states" are Wyoming, Kentucky, North
Dakota, Alaska, Oklahoma, Arizona, Ohio, Montana, Colorado, and
West Virginia, with rates ranging from 10.04 to 5.33 per 1,000.
Public Citizen did not consider the possibility that the "worst
states" might have the best doctors. It recommends pressuring
legislatures and licensure boards to mete out more discipline to
assure that doctors practice in the "best manner." Apparently,
one out of 100 physicians need to be culled each year.
Powerful state licensure boards are subjected to absolutely
no oversight. The case of Dr. Terry Bennett, who spent $60,000
defending his right to free speech in New Hampshire (AAPS
News, November 2006), has raised
questions about how much money was spent on the state's side of
the battle. Bills asking for a judge to review which cases go
forward, or for a committee to hear appeals by doctors who think
they're being railroaded, have to date always failed. It's time
to correct the injustice (www.seacoastonline.com
, letter 10/22/06).
Lifelong "Certification." Expressing skepticism about
innovations such as "clinical pathways" is one of the quickest
ways to get certified as a "disruptive physician." Note that this
type of certification is the only type that requires no re-
testing, or re-certification. It's good for life.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY
Disparity. Reducing racial and ethnic disparities is
code for justifying single payer by saying that since we have
shown that the U.S. system is racist, the government must take it
over to ensure equal care for all. The racism is made clear by a
raft of studies comparing health outcomes for black people to
outcomes for white people and finding that black people are worse
off. As process equality is a prime aim of the socialist
progressive types, it doesn't matter a whit that the outcome is
likely to be equally lousy. They live in a utopian vision that is
not data driven. Never mind that their studies omit niggling
details like socioeconomic status, marital status, out-of-wedlock
births, illegal drug use, tobacco use, and the existence of
various comorbid conditions. Or that most measures are process
ones that haven't been shown to affect health outcomes at current
levels number of prenatal visits being the prime example.
If you wish to get rid of income disparity you have to go to
a pure communist system in which goods are given to people
according to their needs, as determined by their political
masters. Market economies produce income disparities via
different talents, technologies, and consumer demands yet even
the poorest tend to live pretty well. The biggest income
disparities occur in kleptocratic thug economies. And where has
confiscating wealth led to better conditions for the poor?
Linda Gorman, Independence Institute, Golden, CO
The Value of Insurance. As John Goodman noted, if you
left a $100 bill on the floor of the Parkland emergency room, it
would be snatched up in a flash. But if you left a Medicaid card,
worth many thousands of dollars in medical care, it would still
be there at the end of the shift. Why? Because Parkland gives
away care for free, and the uninsured are treated the same as
Greg Scandlen, Consumers for Health Care Choices
The Real Goal. "Health care reform" is not about
medicine which is just a pawn to advance a new form of
governance. If we lose here, we'll be debating another national
crisis. Other "broken" systems will be attacked one by one, until
the ultimate goal is achieved: can you say the United States of
Joseph Lee Pugh, Diamondhead, MS
We Need More Uninsured, Not Fewer. Mandates like those
in Massachusetts drive everyone into the hands of insurance
companies, which then proceed to take everybody's money, force
their will on doctors, and even more damaging on patients. In a
free market, people should have the right to determine their own
medical care without interference from either government or
Kenneth D. Christman, M.D., Dayton, OH
Mental Health Screening. All of the proposed plans,
whether for schoolchildren or the elderly, are misdirected and
dangerous. Claiming to be case-finding, they are actually case-
creating and drug-pushing. Except for the obviously insane, who
need no special screenings, "mental illness" is impossible to
diagnose on brief inspection. We all feel upset at times, but
those upsets are almost always reversible. Giving a mental
diagnosis to a person who happens to be experiencing some
emotional distress is likely to make him feel much worse
possibly for a very long time. The frightening notion that one
may be suffering from a mysterious "disease," which will somehow
be determined by "inspectors," tends in itself to produce mental
disturbances for which the main treatment today is addictive,
During the Middle Ages, witch-hunters searched for
birthmarks supposedly indicating a compact with the Devil.
Today's proposed mental health screenings resurrect those
inquisitional tactics. Recall that Dr. Karl Menninger once called
the DSM the contemporary equivalent of the 16th century
Malleus Maleficarum, the witch-hunter's manual. It is
also an attempt to parse moonbeams.
In the Septuagint, the first Greek translation of the Hebrew
Bible, the key word in the statement "thou shalt not suffer a
sorceress to live" (Exodus 22:17) is "pharmacos," usually
rendered in English as "poisoner."
Nathaniel S. Lehrman, M.D., Roslyn, NY
Hubris. In the war on our civilization, true science is
corrupted, and ersatz science is replacing independence in
academia. The so-called science of psychiatry is medicalizing
issues hitherto governed by family, religion, and society. Would-
be philosopher-kings are taking on the responsibility for
husbanding the resources of the entire planet, and regulating the
balance of nature making such irrational pronouncements as the
need to reduce the human population by nine-tenths. These are not
aberrations but are gaining momentum. I did not expect help
there, but did verify the absence of the word "pride" in the DSM-
IV, the contemporary, consensus-defined catalog of psychiatric
Thomas Dorman, M.D., Federal Way, WA
from Facts, Fiction & Fraud in Modern Medicine,
Legislative AlertPsychiatry on the Couch:
The Federal Government's Plan to Transform
Mental Health Care in America
In April 2002, President Bush signed Executive Order 13263,
which established the New Freedom Commission on Mental Health.
The commission was charged with conducting a comprehensive study
of the mental health delivery system in the United States, both
public and private, and to make recommendations that could be
implemented at the federal, state, local, and private levels to
improve the system.
The Commission organized itself around a few key objectives:
improve outcomes of mental health care; promote collaborative
community level models of care; maximize existing resources and
reduce regulatory barriers; use mental health research findings;
and promote innovation, flexibility, and accountability at all
levels. The final report, which was released in July 2003, was
entitled "Achieving the Promise: Transforming Mental Health Care
in America." It emphasized building a system that is evidence
based, recovery focused, and consumer and family friendly. It had
six goals and a series of recommendations to reach each goal.
Goal #1: Americans should understand that mental health is
essential to overall health. A national strategy is
needed to reduce the stigma for seeking care and to prevent
Goal #2: Mental healthcare should be consumer and
family friendly. Comprehensive state mental health
plans, and individualized care plans for adults and children,
should be developed.
Goal #3: Disparities in mental health services should
be eliminated. Quality and access to care should be
Goal #4: Early mental health screening and assessment
and referral services should be common practice. School
mental health programs should be expanded and improved, and
screening for mental disorders should be done in primary health
care and across the life span.
Goal #5: Excellent mental health care should be
researched and delivered. Public/private partnerships to
promote evidence-based practices should be developed.
Goal #6: Health information technology should be used
to coordinate and improve access to care.
Two of the model programs the New Freedom Commission on
Mental Health promoted, among many, are the Columbia University
TeenScreen Program (mental health screening) and the Texas
Medication Algorithm Project (TMAP). The former was to ensure
that schools play a larger role in the mental health of students,
and that all youth are offered screening for a mental health
check-up using a computer-assisted questionnaire that screens for
mental illness and suicide risk. The latter was to develop
algorithms and guidelines as well as consumer education materials
for treating serious mental illnesses.
Of all of the goals and recommendations, the two that have
caused the most public outcry are goals 4 and 5, which concern
early mental health screening and evidence-based mental health
care, respectively. The mental health screening issue has
received the most public attention to date, while the evidence-
based goal in general and TMAP in particular have led to many
questions about alleged corruption in psychiatry. TMAP will be
addressed in an upcoming issue of AAPS News.
TeenScreen: Dubious Diagnosis
On its website (www.teenscreen.org/)
The Columbia University TeenScreen
Program is a national mental health and
suicide risk screening program for youth. The
goal of the National TeenScreen Program is to
make voluntary mental health check-ups
available for all American teens. TeenScreen
works by assisting communities throughout the
nation with developing locally operated and
sustained screening programs for youth.
Screening can take place in schools, doctors'
offices, clinics, youth groups, shelters, and
other youth-serving organizations and
After the release of the NFCMH report, many family groups,
professional associations, education groups, legislators,
doctors, and watch-dog organizations publicly opposed mental
health screening in general and TeenScreen in particular. These
groups included AAPS, Eagle Forum, International Center for the
Study of Psychiatry and Psychology, Alliance for Human Research
Protection, Liberty Coalition, Citizens Commission on Human
Rights, EdWatch, Able Child, Texans for Safe Education, and
Citizens for Health. AAPS expressed a number of concerns: (1)
screening instruments are not validated or effective; (2)
children may be over-diagnosed with mental illness and overly
medicated with potentially dangerous drugs; (3) the program
violates constitutional limits on government and interferes with
the right of parents to raise their children.
According to a study of some 1,700 high school students who
completed the Columbia SuicideScreen, the specificity was 0.83
and the positive predictive value only 16% (Schaffer D et al.
J Amer Acad Child Adolesc Psychiatry 2004;43:71-79).
False positive tests mean that normal children could be labeled
and given therapy, probably including drugs, for nonexistent
problems. Additionally, the U.S. Preventive Task Force found no
evidence that screening reduces suicide attempts or mortality (www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htm).
Currently available data strongly suggest that the screening
instruments do not work and can cause more problems than they
might potentially solve. In fact, according to the Centers for
Disease Control and Prevention (CDC), there is actually a decline
in teen suicide and not an increase as those who support the
mental health screening programs suggest. As reported by the
Associated Press, the CDC says that suicide among American
teens fell almost 24% in the decade preceding 2004. The
suicide rate for those aged 10 to 19 fell from 6.2 per
100,000 in 1992 to 4.6 per 100,000 in 2001. The number of
suicides also fell during that period, from 2,151 to 1,883 (www.psychsearch.net/teenscreen_cdc.html).
A lawsuit has been filed against TeenScreen by parents
whose daughter was allegedly screened at her government school
without parental consent and as a result was falsely diagnosed
with an obsessive-compulsive and social anxiety disorder.
(Rhoades and Rhoades v. Madison Center et al., U.S.
District Court for the Northern District of Indiana, South Bend
Division, case number 3:050CV-00586-JTM-CAN: see www.psychsearch.net/teenscreen_lawsuit.html.)
Not only does the data suggest that the screening
instruments do not work but there is also great concern about the
psychiatrization of everyday life. There is not much if any
research at this time to support the biomedical model of mental
illness, i.e. chemical imbalances or genetic causes, which is
foundational to psychiatry. There are also questions about the
validity of the diagnostic tools used in psychiatry. In reference
to the former concern, mental health criteria are quite vague and
subjective. Even the Surgeon General acknowledged the same in his
1999 Report on Mental Health, which stated: "What it means to be
mentally healthy is subject to many different interpretations
that are rooted in value judgments that may vary across
cultures." The report continued:
[T]he diagnosis of mental disorders is often
believed to be more difficult than diagnosis of somatic
or general medical disorders since there is no
definitive lesion, [or] laboratory test of abnormality
in brain tissue that can identify illness.
The very committee in the American Psychiatric Association
that created the Diagnostic and Statistical Manual stated in the
1994 version of the DSM-IV:
DSM-IV criteria remain a consensus without clear
empirical data supporting the number of items required
for a diagnosis. Furthermore, the behavioral
characteristics specified in the DSM-IV, despite
efforts to standardize them, remain subjective.
Thus, the lack of supporting data for the diagnostic tools
and screening instruments used in mental health programs should
lead those who have the power to promote them to be very careful
and conservative especially when it comes to bringing young
children into the mental health system.
Legitimate concerns about the diagnostic instruments are
magnified upon consideration of the risks of pharmaceuticals used
in psychiatry especially their use with children.
The FDA recently included a black-box warning for
antidepressants used in children: "It has been determined that
anti-depressants can cause an increase of suicidality in
children" (www.fda.gov/CDER/DRUG/antidepressants/PI_template.pdf). There are also major concerns with the use of
psycho-stimulants such as Ritalin in children diagnosed with
attention-deficit disorder (ADD). Such drugs have been shown to
be ineffective in changing long-term outcomes such as peer
relationships, social or academic skills, or school achievement,
according to an article quoted by the Surgeon General. Worse, the
drugs are now known to be pose the danger of neurologic damage to
some children. A recent review found almost 1,000 reports of
mania or psychosis linked to the drugs including Adderall,
Concerta, Ritalin and Strattera, according to the Alliance for
Human Research Protection (www.ahrp.org/cms/content/view/112/28). The review
covered the period from January 2000 through June of 2005 and
included reports from the FDA and drug companies based on adverse
event reports. Not only were there reports of mania and psychosis
but there were also reports of hallucinations.
The concerns over misprescribing of psychiatric drugs in
children are not limited to psychostimulants and antidepressants.
There is also growing concern about the increased use of
antipsychotic medicines as well.
A recent study by William Cooper, M.D., M.P.H., associate
professor of pediatrics in the Child and Adolescent Health
Research unit at the Monroe Carell Jr. Children's Hospital at
Vanderbilt, found that the overall frequency of antipsychotic
prescribing increased nearly fivefold in just 6 years: from 8.6
per 1,000 U.S. children in 1995-1996 to 39.4 per 1,000 in 2001-
2002. The study used data from the National Ambulatory
Medical Care Survey and the National Hospital-based Ambulatory
Medical Care Survey. The focus of the research was children aged
2 to 18. During the period 1995-2002, there were 5.7 million
office visits by U.S. children during which an antipsychotic was
prescribed. The indication for 53% of these prescriptions was a
behavioral or affective disorder. Antipsychotic drug use for such
problems has not been studied in children. Moreover, almost one-
third of the antipsychotic prescriptions were written not by
psychiatrists but by pediatricians or family physicians. (The
Reporter, Vanderbilt Medical Center, Mar 17, 2006: see www.mc.vanderbilt.edu/reporter/index.html?ID=4601).
Although many states have moved forward with some of its
recommendations and federal funds have followed, the real power
lies with the Federal Action Agenda (FAA). The Substance Abuse
and Mental Health Services Administration of the Department of
Health and Human Services (HHS) released the federal plan
entitled "Transforming Mental Health Care in America: the Federal
Action Agenda First Steps" in July 2005. This contains the
recommendations from the New Freedom Commission that implement
the plan more broadly throughout the federal government.
According to the FAA, it is a collaborative product of HHS, the
Social Security Administration, the Department of Housing and
Urban Development, the Department of Justice, the Department of
Labor, and the Department of Veterans Affairs (see www.samhsa.gov/Federalactionagenda/NFC_preface.aspx).
It would not be surprising to find out, especially with the
interest in utilizing electronic medical records, that other
government agencies such as Homeland Security and the Department
of Defense are also involved in the federal plan.
Although both Columbia University's TeenScreen program and
the Texas Medication Algorithm Project are not included in the
FAA, possibly owing to grassroots pressure, those efforts are
still moving forward in the states with the blessing of the
The agenda is very ambitious. As the FAA states, "it implies
profound change not at the margins of the system, but at its
What You Can Do
For more information on mental health screening, see "The
Dangers of Universal Mental Health Screening" DVD with Karen
Effrem, M.D., from www.edwatch.org. Consider
signing and distributing the petition to stop TeenScreen: www.petitiononline.com.
Michael D. Ostrolenk is a member of the AAPS government
affairs team in Washington, D.C.