On Decriminalizing Marijuana

On Decriminalizing Marijuana

I wrote a piece for PajamasMedia on why I no longer support decriminalizing marijuana, because of the large number of studies demonstrating that marijuana use precedes schizophrenia, and the enormous social costs that this imposes. Not surprisingly, there are several groups commenting:

1. People arguing (sometimes quite calmly) that the social costs of prohibition are higher than the social costs of having it legal.

2. People arguing that this is all lies, marijuana isn't a problem at all! (Acolytes of the herb god, I think.)

3. People arguing that we should let mentally ill people die in the gutters if marijuana causes them mental illness problems. The libertarian ideal is so strong to such people that they do not realize that most Americans do not buy this argument.

4. People arguing that marijuana laws don't have any influence on behavior--no matter what the laws are, the same number of people will smoke pot. Yet, at the same time, they acknowledge that having it illegal drives up prices, attracting the violent criminals into the trade. Somehow, rising prices don't affect demand or consumption.

One of the strongest arguments for keeping marijuana illegal is to prevent it from getting such a strong toehold that, like alcohol, it becomes impossible to keep from becoming dominant, with the negative consequences of widespread use. It would appear that perhaps it is too late--that is already, like alcohol, a fundamental part of our culture.

UPDATE: By the way, this recent article in Archives of General Psychiatry, "Association Between Cannabis Use and Psychosis-Related Outcomes Using Sibling Pair Analysis in a Cohort of Young Adults," also concludes that marijuana use, especially prolonged use, increases the risk of psychosis:

Compared with those who had never used cannabis, young adults who had 6 or more years since first use of cannabis (ie, who commenced use when around 15 years or younger) were twice as likely to develop a nonaffective psychosis and were 4 times as likely to have high scores on the PDI. Further analyses demonstrated that these findings were not due to a small group of individuals with psychotic disorders nor to individuals who were acutely intoxicated with cannabis when completing the PDI.

While the study agrees that there are people with mental illness problems who use marijuana for that reason, it also points to a feedback loop:

The nature of the relationship between psychosis and cannabis use is by no means simple. In keeping with previous findings,33 we confirmed that those with early-onset hallucinations were more likely to have longer duration since first cannabis use and to use cannabis more frequently at the 21-year follow-up. This demonstrates the complexity of the relationship: those individuals who were vulnerable to psychosis (ie, those who had isolated psychotic symptoms) were more likely to commence cannabis use, which could then subsequently contribute to an increased risk of conversion to a nonaffective psychotic disorder.

Did This Cost-Cutting Save Any Money?

I'm told that part of why Idaho Health & Welfare, about five years ago, adopted a much stricter interpretation of their current standards for Medicaid reimbursement of mental health services, was to get spending under control. You might criticize this as a skinflint approach--except that it seems not to have worked. From Budget: Mental Health and Substance Abuse in Idaho (2006), p. 3, we can see that the Medicaid portion of the mental health services budget rose from $59,388,281 in FY 2003 (actual) to $115,447,200 in FY 2005 (estimated). That means Medicaid budget for mental health services almost doubled in a period of limited inflation and at most, a few percent growth in the state population. Huh?

My guess is that the problem may be that by effectively cutting off mental health services in rural Idaho, this strict interpretation meant that a lot of people with mild mental health problems received no services--and by the time their problems became acute, requiring hospitalization, the costs were much higher.

I'm a tightwad on government spending, but there are times that a short-term view of the problems is not only inhumane, it's more expensive.

Interesting Conversation Today

I had a conversation today with people involved in mental health services in Boise County--such as those services are. What they told me seems inconceivable--unless the objective of Idaho's Department of Health & Welfare Department is to demonstrate the truth of the statement, "Never underestimate the power of stupid people in large groups."

I was told that the rules that Health & Welfare has for Medicaid reimbursement (since states actually administer the Medicaid program) require that mental health counseling must be done in a permanent facility, with at least two counselors, supervised by at least one psychiatrist, also in that facility.

I can somewhat see the point of having a psychiatrist providing supervision for mental health counselors. These rules might make sense in a county of several hundred thousand people. In a county with 7200 people, spread over several hundred square miles, this effectively prohibits Medicaid providing any mental health services in our county--and most others. The density just isn't high enough.

So what happens to patients who are having mental health problems and who are covered by Medicaid (people with very low incomes)? I suspect that they don't get services until they reach the point where they end up hospitalized in Boise. By that point, what was mild depression might have escalated to a suicide attempt--and schizophrenia or bipolar disorder has escalated from something just starting, to something full blown. Before the people I was talking to reached that point, I was suggesting what they want--someone "riding circuit" from town to town on a regular basis. It wouldn't conform to H&W's rules, but it would allow serious problems to be identified before they reach a crisis point.

I'm guessing that there is some legitimate motivation for these rules, and someone either is too stupid to see that they don't make sense in rural Idaho, or too inflexible to work around it. Even if the goal was to save money by preventing poor people in rural Idaho from getting mental health care (and that would mean that there are monsters at work in our state government), I am very skeptical that this even saves any money. A couple weeks in a mental hospital in Boise is going to run well above $10,000. You can pay for a lot of hours of a psychiatrist, psychologist, or counselor for that kind of money--and perhaps short-circuit at least some of those hospitalizations. The money might be coming out of a different budget--but the taxpayers still end up paying it.

I'm Hoping This News Story Is Inaccurate Or Incomplete

I'm Hoping This News Story Is Inaccurate Or Incomplete

Because if it isn't, I'm pretty upset at the Bush Administration. From the February 5, 2008 San Francisco Chronicle:

Veterans have no legal right to specific types of medical care, the Bush administration argues in a lawsuit accusing the government of illegally denying mental health treatment to some troops returning from Iraq and Afghanistan.
The arguments, filed Wednesday in federal court in San Francisco, strike at the heart of a lawsuit filed on behalf of veterans that claims the health care system for returning troops provides little recourse when the government rejects their medical claims.
The Department of Veterans Affairs is making progress in increasing its staffing and screening veterans for combat-related stress, Justice Department lawyers said. But their central argument is that Congress left decisions about who should get health care, and what type of care, to the VA and not to veterans or the courts.
A federal law providing five years of care for veterans from the date of their discharge establishes "veterans' eligibility for health care, but it does not create an entitlement to any particular medical service," government lawyers said.
They said the law entitles veterans only to "medical care which the secretary (of Veterans Affairs) determines is needed, and only to the extent funds ... are available."
The argument drew a sharp retort from a lawyer for advocacy groups that sued the government in July. The suit is a proposed class action on behalf of 320,000 to 800,000 veterans or their survivors.

Psychiatric Genetic Testing

Psychiatric Genetic Testing

An interesting article about a company that sells a bipolar disorder genetic test. Or more accurately, a genetic test that identifies for some people that they might be at heightened risk of bipolar disorder:

SAN DIEGO (AP) -- Dr. John Kelsoe has spent his career trying to identify the biological roots of bipolar disorder. In December, he announced he had discovered several gene mutations closely tied to the disease, also known as manic depression.
Then Kelsoe, a prominent psychiatric geneticist at the University of California, San Diego, did something provocative for the buttoned-down world of academic medical research: He began selling bipolar genetic tests straight to the public over the Internet last month for $399.
His company, La Jolla-based Psynomics, joins a legion of startups racing to exploit the boom in research connecting genetic variations to a host of health conditions. More than 1,000 at-home gene tests have burst onto the market in the past few years.

They quote some skeptics who are uncomfortable with these tests because the data isn't terribly complete yet on the claimed connection between the genes and the disease--and it turns out that only some people can use this test:

Psynomics will send patients' test results only to their doctors to avoid the risk of self-diagnosis.
The report that accompanies those results instructs doctors that a positive test means patients are two to three times more likely to have bipolar disorder. But the studies from which those figures come also show the gene variations themselves are rare even among those with bipolar.
The report also points out that for now, the test is valid only for whites of Northern European ancestry who show some behavioral symptoms and have at least one other bipolar family member.

I'm not keen on the use of genetic testing to "brand" people--especially since we don't entirely know what causes particular people to develop the disease in a full-blown form--and others do not. But there is some advantage to knowing that you are risk for a particular disease. For example, if you know that you are genetically predisposed to colon cancer, you may want more regular colon cancer testing than the average person.

Hard At Work on the Deinstitutionalization Book

I'm at the point where I am doing three things simultaneously:

1. Going through and polishing the sentences, looking for bad transitions, and the like. This is a boring but necessary action.

2. Adding more personal accounts of both what went wrong with my brother's spiral down into mental illness, and that of other people I knew. This is sometimes quite painful as it dredges up memories.

3. Using books.google.com to search for additional sources, especially in the nineteenth century, to either fill in material or verify the accuracy of secondary sources. For example, Albert Deutsch's Mentally Ill in America characterizes Morgan Hinchman's 1849 civil suit for wrongful commitment in a way that didn't make much sense to me. Paul S. Appelbaum and Kathleen N. Kemp, “The Evolution of Commitment Law in the Nineteenth Century: A Reinterpretation,” Law and Human Behavior, 6:3-4 [1982], 345 argues that Deutsch was completely wrong about the role of the Hinchman decision in causing the development of Pennsylvania's commitment due process changes. I dug around a bit, and found Hinchman v. Richie (C.P. 1849) available in full. And yes, not only was Deutsch wrong about this, but way wrong.

Cost Alone Should Be a Reason To Be Concerned

Even if they weren't fellow human beings, and even if they weren't overrepresented in scary mass murder situations.

I've read that before deinstitutionalization, schizophrenics were the single largest category of hospital bed-days in North America. That's not mental hospital bed-days--all hospital bed-days. Why? Schizophrenics are about 1% of the U.S. population. But because most schizophrenics become ill in their teens to mid-20s, only about 30% recover, and it doesn't directly kill them--schizophrenics typically have 40-50 years during which they are sick.

I was digging around for more data to fill in one of my stubby little chapters, and I found this disturbing piece of data from a government agency called the National Quality Measures Clearinghouse about schizophrenia:

It accounts for more than 10% of all disabled people in the United States (U.S.) and 2.5% of all U.S. healthcare expenditures. The cost due to society of schizophrenia is enormous (more than $20 billion/year in the U.S. alone).

According to this table, the total monthly disability insurance payments for 2005 was $6,607,972,000--or $79,295,664,000 annually. Schizophrenia thus is costing us more than $8 billion a year just for disability checks. This page indicates that U.S. health care costs were slightly less than $2 trillion in 2005. So health care for schizophrenics (which isn't done all that well, since many are living on the streets) comes to about $50 billion.

Why is this not a major issue in the presidential campaign? I know that there's a lot of research funded to try and understand various mental illnesses. My first reaction to these numbers is that an investment of even $10 billion a year into understanding the causes and trying to find either preventative methods or cures would be a sensible investment.

I've mentioned previously that The Lancet, the most important British medical journal, a few years back reversed its editorial position about marijuana being harmless because they published a review of existing studies--and concluded that there was a 40% increase in psychosis among marijuana users--and the psychosis came after the marijuana use. This is merely a correlation--perhaps, for all we know, people who are going to become psychotic are attracted to marijuana, and it doesn't really have any effect.

Still, if that correlation does indicate causality, this suggests that Americans are paying at least $23 billion a year extra so that those potheads who don't go psychotic can get mellow and giggle stupidly.

Another Mental Illness Tragedy

I blogged about this on the Civilian Gun Self-Defense Blog last month. The first news accounts only described Marshall Fink as "mentally ill." There's a bit more about the tragedy in this February 26, 2008 St. Louis Post-Dispatch article:

WELDON SPRING — The veins in Marshall Fink's neck bulged with fury as he pumped his fist, telling his parents they should stick a shotgun in their mouths and pull the trigger.

His mother and stepfather begged Fink, 26, to take his medication and calm down.

That set him off.

Fink put his fingers to his head, pretending to have a gun, then pointed at his parents. He chest-bumped his mother into the garage, snarling and telling her she should die.

Shirlee and John Gentles called 911 several times the night of Jan. 11.

The police were on their way, but by the time they arrived John Gentles had fatally shot his stepson.

...

Fifteen months after graduating from Francis Howell High School, Fink enlisted in the Navy, inspired by the Sept. 11 attacks to serve his country.

ILLNESS TAKES HOLD

Fink was stationed at the Naval base in San Diego as a mechanic aboard the Peleliu assault ship.

"It was a natural fit that he would go and work on engines," Shirlee Gentles said.

For more than two years, his service record was clean; his superiors even wrote him several letters of commendation. Fink wanted a career in the Navy, but a conflict of highs and lows was escalating inside his head.

"Something happened to him in the Navy," Heather Gentles said. "He just was never going to be the same."

Fink's illness developed quickly and was brought on in part by stress and lack of sleep, said his psychiatrist in St. Charles, Dr. Greg Mattingly. Fink's condition emerged about the same age as most bipolar patients, Mattingly said, and was not spurred by any specific traumatic incident.

"With bipolar, you can go from pretty much normal one day, to the next day being very, very, very sick," Mattingly said.

Fink mouthed off to his commanders, stopped eating regularly and lost 20 pounds. He grew increasingly paranoid, and in September 2005, doctors at the Naval Medical Center in San Diego diagnosed his condition as bipolar disorder, which often results in episodes of severe depression and mania. It affects more than 5 million Americans.

Most people who develop the disorder are genetically predisposed to it, Mattingly said. Along with stress and sleep deprivation, he said, substance abuse is another common trigger. Fink had begun taking legal stimulants as part of a body-building regimen.

Because of Fink's diagnosis, the Navy started discharge proceedings.

Fink challenged the diagnosis. He wanted the chance to return to active duty, but the Navy considered him unfit to serve.

About 2.6% of the adult population suffers from bipolar disorder. Not everyone with bipolar disorder ends up as out of control as Marshall Fink. A lot of people with bipolar disorder manage to lead productive lives--using the energy in the mania stage to get a lot accomplished, and sleeping or sulking during the depressive stages. I've read that CEOs are disproportionately bipolar, and there are some astonishingly creative characters out there, such as Sir Isaac Newton and Howard Hughes, who are believed to have been bipolars whose condition was not severe enough to disable them. (Although Newton, in his later years, seems to have collapsed into a pretty severe depressive state.)

From my reading, it appears that alcohol can pitch people with mild bipolar disorder over into acute bipolar disorder. I have watched several relatives whose acute bipolar disorder appeared shortly after they started smoking marijuana--and one of them has not recovered. Since marijuana appears to increase the risk of a psychotic breakdown by about 40%, I do not find it difficult to believe that it might play a part in aggravating bipolar disorder. This is part of the reason that I no longer regard legalization of marijuana as a great idea. Yes, most people who start smoking marijuana aren't going to suffer a psychotic break, or find their unrecognized bipolar disorder aggravated. But for those who do, it's tremendously bad news.

Another interesting problem is that SSRI antidepressants, if prescribed without a mood stabilizer, can aggravate the mood swings of someone with bipolar disorder. One of the advantages of Prozac, when it was first released, was that it was relatively low risk for side effects, and so a lot of GPs were encouraged to prescribe it. Unfortunately, people suffering from bipolar disorder would show up at their doctor when they were depressed--not when they were feeling energetic and powerful. Not surprisingly, GPs assumed that they were treating depression--not the depressive phase of bipolar. And the mood swings would just get worse.

If you have a really smart child who is also defiant and is rapidly getting out of control--you should at least consider the possibility that the problem is bipolar disorder. Until quite recently, psychiatry would not acknowledge that minors can suffer from bipolar disorder--partly because it is so difficult to easily distinguish from normal adolescent behavior. Demitri Papolos, M.D. and Janice Papolos's The Bipolar Child: The Definitive and Reassuring Guide to Childhood's Most Misunderstood Disorder is a good place to start. You may decide, after reading the Papalos's book, that you just have a strong-willed child. You may decide that it is time for psychiatric evaluation.