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Math

Canary Islands Health Service, for which work has developed from a few years ago Register Cumulative Psychiatric Case as an information system of health care in the mental health field. A few days ago, we asked the makers of this tool data which had long interested us, and we were supplied quickly and efficiently, so we want to record our thanks and highlight the usefulness of this system to see how we play our work in actual practice and under what conditions, do not always coincide with what our (more or less attractive) theories prescribe.

The data request was simple:

• Number new patients seen in mental health units (USM) on the island of Tenerife in 2010.

• Number of patients discharged in such USM during that period of time.

And then a little math, that not everything will be literature ...

• The USM de Tenerife (island with a population of approximately 850,000 inhabitants) in 2010 saw a total, including both adult patients as child and youth, people 7746.

• During the year 2010, USM was released to a total of 3754 patients.

• With a calculation too complex, we conclude that the population attending public consultations increased community mental health during the past year in 3992 people.

words, the USM of our public health system who have started 2010 with a considerable overload rather than care, inherited from previous years, finished the year with a net increase of nearly 4000 patients who attend. To give you an idea, if not already, several of these appointments with a psychiatrist USM are given every 2 or 3 months, if not more. With psychologist frequency is somewhat higher, but often exceeds the month. A psychiatrist may see a patient 4 or 5 times a year for about half an hour at most, with agendas that sometimes have 12 patients a day. We do not currently work at USM, but it seems difficult to see a person 30 minutes every 3 months and be able to remember what happens, as if to ask to do something to help, beyond adjusting or adding medications, which in turn will take 3 months to assess both efficacy and side effects. A psychologist must conduct psychotherapy sessions on a monthly basis, where indicated, in almost all therapeutic orientations, would be weekly at least.

However, this state of affairs, añádanle 4000 patients every year ... and so every year. Know the number of patients recommended to bring a psychiatrist in a USM, but we would say that beyond 500 would be too much, taken as a ballpark figure. By recalculation, even without great complexity, we would need new ones every 8 psychiatrists year (or mixture of psychiatrists and psychologists, to our argument is irrelevant and not at all intend to take up any flag in the boring old war psychiatrists, psychologists, we have always seen as non-combatants). Given the economic situation and the Canarian autonomous community, we can be happy if not trumped any that work now (and do not even tell if they also do not follow us down the salary).

overload seems clear that the welfare of the USM will continue to grow unchecked and that the era of new and abundant recruitment is over for quite some time. In addition, people dress in consultation on the USM are much more likely to go to the psychiatric emergency or to be admitted to the psychiatric facilities, which reaches more overload devices mental health network. All this in a context where, from various associations and by different professionals, not to be stressed in the early diagnosis of any discomfort conceptualized as mental illness, recommending to the people before any manifestation of sadness or anxiety, go to your USM . No need to insist here in our critique of the medicalization of suffering which has always been vital, with the consequent collapse of the system, resource consumption and iatrogenic that entails.

view our mathematical problem, if growing demand can not be absorbed by a parallel increase in supply (professional) seems to be only one solution: reduce that demand .

And before you accuse us, as has happened ever want to condemn people to suffer and not wanting to serve the suffering, we would like to make some clarifications.

According to data obtained from colleagues in informal conversations, and therefore not coincidental but clearly contrasted in various professional, places and moments, about three quarters of the pathologies treated in USM falls into categories such as: dysthymia, adjustment disorders, personality disorders, neurotic depression, mild depression , etc. Ie, they are not psychotic or melancholic patients, what we call today, with little grace, severe mental disorders. And there are places in this country where units are being created to cater exclusively to mental health psychotic episodes. And it seems a laudable effort to address this group of patients that both can benefit from appropriate intervention, if it were not for that you just created the USM, which are now collapsed basis, roughly what is human suffering.

and clarify our position: we do not like people to suffer. And if someone who is sad and worried because he has been out of work because their family life is hell, because they are lonely, and so on., Would be better to come to USM to take one (or two or three) antidepressant (s) or receiving therapy 30 minutes per month, then we would be in favor of trying to maintain the current state of affairs. But we think not. We believe that treating a patient who has an economic problem or a difficult life, or personality problems, causing it to be seen as sick people treat them as sick and end up behaving like the sick.

believe it is absurd that an unemployed person and concerned about how to raise her family, go to USM for us to send a list of drugs whose monthly cost will resolve many of their problems, but whose effect hardly get to feel good before I go back to work, not to mention the side effects appear and how the wait fact that the pill acts not promote precisely its effort to get out of their situation.

believe it is absurd that a person caught in a difficult family life will the USM to tell it what happens is that serotonin is wrong, you have to wait until the drug is the fix and should not make decisions until well ... When perhaps you need to be better is to take a decision.

believe it is absurd that a person immersed in mourning for a loved one comes to USM to be treated as a patient with a lot of anxiety to sleep and not be anxious ... Hindering rather than facilitating grief work to be performed.

Anyway, these are just some examples to try to convey what we mean. Not only is that psychiatric and psychological consultations should not serve as many people as they do because there are no resources. Is that although there were, we think that many times that performance, but full of good intentions, is directly iatrogenic. Patients may benefit greatly from monitoring and Mental Health. For ejmplo, psychotic patients may develop an anchor point at USM, confidence, to influence their care and the focus placed on his recovery ... But this requires to see them often, available for visits after hours, for care at home ... And that takes time which is not available now because there is another claim to address.

Clearly, the influence of industry drug is not at all alien to all this. Professionals with more than curious conflicts of interest and sponsorship, as well as professional associations and even family insist diagnose masked depression , the ADHD without hyperactivity, behavioral addictions, etc., etc. Thus achieving greatly increase the prescription of super-selective molecules-to-serve-for-all and super-safe-but-no-you-read-the-art-tab-o-see-what- fright. And if the price is to sink the USM, burning psiquiatrizar professionals and all people, to whom he matter? And if we, because ultimately who makes the diagnosis and prescriber's us, the disease where there is pain, we take responsibility and then claim them back, do not benefit iatrogenic ... Who cares?

In short, our position (to then not be said that only pointing out problems but provide solutions) is that demand in the USM should be checked, if we want those devices, which marked the psychiatric reform can remain. Will not be able to hire more staff to absorb this demand (although we have made clear our view that this option as well as impossible, it would be undesirable), so there is only limited demand. That, or the explosion of the system: psychiatric consultations to 5 minutes every 6 months. It may sound exaggerated, but with math we're talking about, as we come in 10 years ...

Concrete:

could establish a timetable was closed many patients can be and how often, for example, 8 patients to see a psychiatrist every 3 weeks (obviously, these figures are only by way of example). That is, 5 days per week, 120 "holes" in the agenda for patients. And when the 121, will have to wait for any of the others are discharged. This may sound ugly, but start to shoehorn on the agenda to every patient who arrives, causing the 12 patients a day seen every 3 months. In hospital wards, where beds are not free, nobody would think to put stretchers in the hallways ... It is hoped that someone could go.

And speaking of waiting lists, we do not fail to note a curiosity: now in objectives of some priority USM soon see the first few times , the new queries. With which can then brag to the press by the political head of turn of the waiting list for psychiatric or psychological consultation is 10 or 15 days. But there are two problems: first, then the patient is again seen until 3 months, the second, and not least, a certain number of patients, according to various studies, improve their suffering before resorting to consultation if they had a little more time, are seen before, with all that implies medicalisation of discomfort or unnecessary use of drugs. But at the press conference before the election looks great reducing waiting lists .

The question is, in our opinion, that the USM should be dealing with cases of severe mental disorders and also those who, without being one, could benefit, but always providing adequate care. If a person in a difficult situation develops a major depressive syndrome may benefit from psychotherapeutic or pharmacological, should be given. But it must be properly: that is, weekly or fortnightly sessions of psychotherapy, medication if it is believed necessary to closely monitor possible side effects. But it makes sense to start to see 30 minutes every 3 months, maybe years. And if can not provide treatment the first type, then we should not providing the second. And the funny thing is that if we give this second type treatments and do not address these cases in these conditions, perhaps when we begin to have time for the treatments of the first type.

Imagine if we had 10 doses of a vaccine for a population of 100 people. "We vaccinate ten to be protected? Or dilute the vaccine to give something to each of the 100, but it will not protect anyone? We believe that the example, although picturesque, may be relevant. Although the question is obvious: who decides than 10?

occurs to us, for instance, offer the possibility of brief psychotherapeutic treatment to patients with adjustment disorder or reactive or neurotic depression. And after this treatment, proceed to discharge. Even no improvement. Because if there is no discharge, the patient often become chronic, in a spiral of psychoactive drugs and interventions, increasingly assuming the role of chronic patient, consuming resources, not just economic, but also in availability of hours will not be used more frequently to meet someone else maybe it will benefit from it. As one our friend, if you go to the orthopedist and, after a consultation, concludes that you're lame, seeing is not a lifetime. We know that sounds harsh. And, in an ideal world, there would be infinite in the infinite USM professionals, and all treatments would be effective and safe and all the suffering could be cured and everyone would be happy. But look at the world we live in and tell us if they think so.

For if, as we believe, is to restrict the entries in the USM, we should establish clear criteria for it. And, of course, be dependent on the criterion of a professional or a USM isolation but should take place a process reflection among professionals and administarción and more national level, to determine these criteria. The advantages, in our opinion, such a process were to develop would be considerable:

• Many people would not really benefit from a mental health treatment, and may even become harmed by it, and not go into the USM.

• Many people who really could benefit from these treatments, USM would receive without the overhead of the current, much more effectively than we can now provide.

• current situation in the country, the savings that this would not be left to be taken into account. Especially since, if such savings are not caused by roads and treat only those in need and can benefit from it, along with pharmaceutical costs, then it must occur in hospitals closing plants, cutting staff and wages down (and this hypothesis is not tremendous because, in fact, already happening).

Finally, we will cite us to ourselves (you know, the article just published and we are so proud): We

another Psychiatry may be possible and indeed, necessary. A psychiatry that is devoted to an understanding of their subject (the mind, behavior, insanity or as we like to call it ...) without interference from commercial interests that skew our data. Psychiatry able to put a limit to itself and not try to treat it all, knowing that normally, in psychiatric consultation, often does not improve but becomes chronic, and if you try to sound like a sick person, most probably end seeing, feeling and behaving like a patient. A psychiatry that focuses mainly on the mad and the sick, suffering, and let the sane and healthy to fight for your happiness no false remedies.

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psychosis as a disease

Following previous entries in which summarize different texts about the vision of psychosis as syndrome or structure, we turn now to the vision of psychosis as a disease. Luque and Villagrán continue in his already cited work descriptive psychopathology: New trends .

One of the many approaches to the concept of disease is one that conceptualizes as a injury. The development of pathology and histology during the nineteenth century provided a range of evidence that the disease is accompanied by structural alterations. As increased knowledge of physiology and biochemistry, the concept of lesion was extended to include biochemical and physiological alterations without changes in the basic statement: the disease necessarily involves a demonstrable physical abnormality. In this context, it was almost inevitable that they consider essential attribute of the disease the presence of an identifiable lesion. This definition has been maintained for years and is the fundamental basis of known biological or medical model of disease which, without doubt, has a number of advantages: it provides a definition of disease that is not subject to social or fashion therapeutic as well as an explanation, though not always complete, the patient's symptoms. However, it also involves a number of drawbacks: the process of their physical condition is unknown can not, strictly speaking, be considered diseases do not distinguish between minor and serious illnesses or disabling, in some cases it difficult to establish where normality ends and pathology begins where, as there is a vast structural variability that can be tolerated by the human body without detection of any biological or clinical change, and it is becoming increasingly clear that the old concept of a single cause, necessary and sufficient for each disease, is not applicable and instead there are a number of factors acting together and determine the onset of the disease.

The vision of psychosis as a biological disease (and only biological) is the most common nowadays in professional or lay, whether explicitly or implicitly. This vision undoubtedly part of the concept of disease as injury that we have discussed and is part of the medical paradigm, dominant in psychopathology and psychiatry in a way that some feel stifling and impoverishing, possibly due to different causes, some of which , as Kuhn would say, are much more social than scientific, in relation to professional interests or commercial , perhaps not fully aware and certainly not at all confessable. Let us now come in a few words about this medical paradigm that dominates, and psychotic professionals alike (or perhaps more willingly than we them.)

As Luque and Villagrán remind us, the medical paradigm (organic, biological, mechanical or biophysical) model is based on the anatomo-clinical disease that appears in the nineteenth century and extending until today. To this paradigm, psychopathology is considered a form of medical description of two fundamental principles: mental disorders are diseases and the conceptualization and study of mental illness must be fundamentally biological. The medical paradigm health equates total absence of symptoms and abnormal behavior considered a result of physical and chemical changes that usually occur in the brain. The disease is defined as the qualitative deviation of the statistical norm and the damage it causes to the individual. In psychiatry, this paradigm was championed by Kraepelin to be used as general paresis medical paradigm. In this defense influenced a number of facts: influence of anatomical-clinical method, the discovery of Treponema pallidum as the cause of syphilis and, consequently, the application of the infection in psychiatry, and the current influx of taxonomist, from previous centuries and other branches of science such as botany and zoology, which generated a movement in medicine that reached nosology in psychiatry. The medical paradigm for Maher (1974), implies: the person who shows some changes with respect to the traits considered normal in a population is ill, the disease is caused by a demonstrable etiology (or are supposed to be evident in the future) is in principle and by definition, biological or organic (the possibility of psychological or sociological is only allowed where it is found that is not organic, the organic nature of the cause may be at different levels (tissue injury or biochemical genetic disorder, metabolic , endocrine, infectious, etc..) organic etiology produces a series of signs and symptoms, along with complementary examinations, can reach a diagnosis and identified the disease, symptomatic treatment can be established, and ideally etiological, and assumed a course determined disease, allowing a prediction rule. This medical concept requires a series of successive steps to be taken before stating that mental illness belongs to the medical domain as the other disease entities. These stages are: description of symptoms and the main features of the disorder (clinical syndrome), identification of the underlying pathology, ie structural or biochemical changes that cause the disease natural history of the syndrome and determination of the causes . As a result of this process, the patient takes the sick role in society, with all the positives and negatives that entails. On the one hand, enjoys certain advantages and may require certain labor and social privileges, on the other, you are required to comply with the conditions involving the sick role.

Work on brain structure and function, facilitated by advances in medical technology, have revealed abundant evidence of biological abnormalities in different psychiatric disorders budgets that support the medical paradigm. However, it also has been some criticism of a draft. In general, the medical paradigm has been identified with a reductionist and biologist for which mental illness is caused by a biological disorder that do not translate into physical-chemical terms. Moreover, although the biological model of disease may be central, can not provide a complete description thereof. Therefore, the best futile and at worst leads to a distorted and unacceptable human. For these critical biological phenomena must be explained in terms of biological mechanisms, but diseases are not only biological entities. They do not only in biological organisms but also in humans. Another set of criticisms are epistemological break, noting that the medical paradigm seeks causal explanations, and they are not suitable for the study of psychopathological behavior. However, as stated by Luque and Villagrán, this assertion of a concept of causal explanation particularly close, inherited from the empiricist tradition, Hume and association or subject to hempeliana of universal rules, and forget, for example, the teleological explanation. For our authors, it is difficult to imagine a scientific endeavor with care and medical aspect of Psychiatry that investigates the causes. Causal explanatory activity, common currency in clinical practice from any paradigm, is denied in the epistemological level by advocates of the autonomy of the behavioral sciences, proponents of the exclusive pursuit of reasons or meanings that infuse sense of deviance. However, just as there are anomalies in a system is when the causal inquiry finds its raison d'etre. realistic vision of science has to accept that causal relations between events are objective features of the world we see, not just ideas in the mind of the observer. The scientific realist has to accept a generative theory of causation why we say that X causes Y if X contributes to Y through some mechanism. This theory, which in psychiatry should be applied to individual cases, no precise terms such as cause necessary and sufficient , and envisages a complex causal amounts to the sum of factors that produce the observed behavior. The psychiatrist must determine what factors are not redundant (an indispensable part of complex causal) and which are redundant or accessories, and this already requires interpretative activity.

must say, after this vision of the approach of Luque and Villagrán the medical paradigm, which, by definition, considers psychosis as a biological disease, which unfortunately often in our environment we are professionals and pundits since the pulpit, and on behalf of the medical paradigm and scientism, which really do is get away from the positivist scientific position and think they want or defend. An abundance of confusing information about genetics and neurochemistry fills many of those considered prestigious publications in psychiatry, with, in our opinion, a little (perhaps impossible) job of integrating in any coherent theory to account for reality. Guidelines are criticized as psychoanalysis for not being scientific , based on the sacred model of Newtonian physics and evidence of falsification of Popper, and possibly with some justification, but the science of selling (and with good benefits) rests about faith in a coming Messiah to come to the gene or the neurotransmitter of schizophrenia under his arm and a final remedy shaped molecule in phase III study in a world-class laboratory. The medical paradigm has contributed much to medicine and, we believe, not least in psychiatry, but it presents two dangers, at least from our point of view: the risk of being exclusive and not allow other potentially enriching visions (risk, moreover, shared with any other paradigm, including psychoanalysis), and the risk that said, taking his name in vain use it to carry out good business without respect for our discipline and care to our patients.