Ignaz Semmelweis Theory Induced Blindness the Etiology of - - PowerPoint PPT Presentation
Ignaz Semmelweis Theory Induced Blindness the Etiology of Psychiatric Disorders Steve Love, MPA, LMSW Clinical Social Worker Kalamazoo Psychiatric Hospital stevelove.net Miasma A theory of infectious disease An emanation or an
Steve Love, MPA, LMSW Clinical Social Worker Kalamazoo Psychiatric Hospital stevelove.net
“An emanation or an atmosphere, whether from the earth itself or from some particular area, that hovers in the surroundings and causes sickness in those exposed to it, by the pervasiveness of its malign presence."
Nuland, 2003, p. 66
“The very first canon of nursing… [is] TO KEEP THE AIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM”
Nightingale 1860, p. 12
Growing cities = growing squalor and smell
London’s Great Stink: ...The intense heat had driven our legislators from those portions of their buildings which overlook the river...
The Times, 1858
Vienna General Hospital 1774
Only Midwives working in Division 2
1. Division 1 was staffed by doctors - Division 2 was staffed by midwives 2. Women were less likely to die of childbed fever in the streets 3. Death rates were not linked to weather 4. Greater physical trauma resulted in greater chance of contracting childbed fever 5. Closing the ward and moving the patients would cease the deaths 6. Infants of mothers who died often died of similar symptoms
Nuland, 2003
In 1847, when Jakob Kolletschka died after his finger was pricked during an autopsy. Semmelweis realized the following
Nuland, 2003
After making his discoveries, Semmelweis “insisted that every entering medical attendant wash in [a bowl of chloride solution] before touching a woman in labor”1
Nuland, 2003, p. 101
Implementation of handwashing
data based on miasma - ascribed to the new ventilation system
the older physicians
admitted to a psychiatric hospital and died two weeks later from wounds likely sustained from a fight with the guards
Nuland, 2003
“Once you have accepted a theory and used it as a tool in your thinking, it is extraordinarily difficult to notice its flaws. If you come upon an
must be a perfectly good explanation that you are somehow missing. You give the theory the benefit of the doubt, trusting the community of experts who have accepted it.”
Kahneman, 2011, p. 277
Biological pathology = Modern miasma
Emil Kraepelin (19th century) “An understanding of the symptomatology of an illness will, we hope, result above all from GENETIC research."
Kraepelin, 1992, p. 516
search for the biological cause was renewed
○ “always a kind of urban legend, never a theory seriously propounded by well- informed psychiatrists”1
○ “this promise, which we have anticipated since the 1970s, remains disappointingly distant.”2
1: Pies, 2011, para. 1 2: Kupfer, 2013, para. 1
○ “Nevertheless, the spirit of a revolution— the sense that we are going to change things dramatically, even if the process requires a number of years— is very much present”1 ○ We hope to "at long last, reaching an inflection point at which insights gained from genetics and neuroscience would transform the understanding of psychiatric illnesses"2
1: Andreasen, 1984, p. 138 2: Insel, 2010, p. 1970
○ This theory would be able to “detect molecular effects of experience... [that] point to diverse molecular pathways that confer risk of mental illness"1
○ It is so complex that it requires “genetics, gene expression/epigenetics, changes in neuronal activity, and differences in dynamics at the micro and macro levels, depending
1: Insel, 2010, p. 1970 2: Akil, 2011, p. 711
1: Holden, 2003, p. 333 2: Insel, 2010, p. 1971
Division 1: Doctors Medicated ? Division 2: Midwives Unmedicated
1: Silverman, 1968 2: Healy, 2011
“Depression is, on the whole, one of the psychiatric conditions with the best prognosis for eventual recovery, with or without treatment. Most depressions are self-limited.”
Cole, 1964, p. 448
“assurance can be given to a patient and to his family that subsequent episodes
more chronic course…”1 there was “no basis to consider that manic depressive psychosis permanently affected those who suffered from it… [since] in a significant number of patients,
Winokur, 1969, p. 19 Winokur, 1969, p. 21
○ 1 year out: 62% discharged ○ 3 years out: 73% discharged
○ 6 years out: 70% discharged
○ 40% recovery rate in those who discontinued medication post hospitalization.
1: Cole, 1959 2: Harrow, 2007
○ 4 groups: Thioridazine/Mellaril, Fluphenazine/Prolixin, Chlorpromazine/Thorazine, Placebo ○ 1 year out, placebo group was “less likely to be rehospitalized than those who received any of the three active phenothiazines.”
Schooler, 1967, p. 991
○ 1967 group ■ A “larger proportion of patients tend to relapse” ■ They are more “socially dependent” ■ “rather unexpectedly, these data suggest that psychotropic drugs may not be indispensable. Their extended use in aftercare may prolong the social dependency of many discharged patients.”
Bockoven, 1975, p. 801
Medication use (in hospital/after discharge) Number of Patients Severity of Illness (1=best outcome 7=worst outcome) Rehospitalization No meds/off 24 1.7 8% Antipsychotics/off 17 2.79 47% No meds/on 17 3.54 53% Antipsychotics/on 22 3.51 73%
Rappaport, 1978
○ “Drug failures appeared to have a considerably higher hospitalization rate than placebo relapsers” ○ “Patients who relapse on medications are sicker than placebo relapsers”
Gardos, 1976, p. 34
○ “It cannot be denied that there is currently no compelling evidence
○ Continuously medicated: 17% ever entered into a period of recovery ○ Went off medication at 2 years: 87% experienced two or more periods of recovery2
1: Stip, 2002, p. 117 2: Harrow, 2012
○ 1955: 1 in every 4681 ○ 1987: 1 in every 1841 ○ 2003: 1 in every 732 ○ 2013: 1 in every 592
○ 1987: 16,2001 ○ 2007: 561,5691
1: Whitaker, 2010 2: Social Security Administration 2004/2014 3: Department of Social Services 2001/2013 4: Thorlacious, 2010
○ Meta Analysis: depression, generalized anxiety disorder, panic disorder, social phobia, posttraumatic stress disorder, and other disorders1 ○ Initial onset2 and relapse prevention bipolar disorder3 ○ Schizophrenia4
1: Butler, 2006 2: Scott, 2006 3: Lam, 2003 4: Wykes, 2007
gray matter loss in schizophrenia2
1: Buchheim, 2012 2: Eack, 2010
“Music therapy as an addition to standard care helps people with schizophrenia to improve their global state, mental state (including negative symptoms) and social functioning if a sufficient number of music therapy sessions are provided by qualified music therapists.”
Mossler, 2011, p. 2
○ Exercise for ADHD “has been shown to be effective in controlling ADHD symptoms, has essentially no side effects… [and] produces physical, mental, and emotional advantages that are far reaching and more complex” in comparison to medications1
○ Meta-analysis: 11 studies showed “a very large combined effect size for the advantage of exercise”2
○ Meta analysis: There is strong “evidence for the use of exercise as a treatment for anxiety disorders.”3
1: Lenz, 2012, p. 308 2: Stathopoulou, 2006, p. 188 3: Wipfli, 2008, p. 404
beneficial for individuals in comparison to treatment-as-usual1
○ 73% working or studying in a formal setting ○ 29% exposed to antipsychotics
treatment-as-usual3
1: Alvarez-Jimenez, 2009 2: Seikkula, 2006 3: Castle, 2010
Meaning, Achievement1
1: Seligman, 2011 2: Emmons, 2003 3: Wilson, 2011
“Principles and procedures for the systematic pursuit of knowledge involving the recognition and formulation of a problem, the collection of data through observation and experiment, and the formulation and testing
Merriam-Webster, 2015
“the traditional Hippocratic moral obligation of medicine is to provide net medical benefit to patients with minimal harm that is, beneficence with non- maleficense.” “The obligation to provide net benefit to patients also requires us to be clear about risk and probability when we make our assessments of harm and benefit.”
Gillon, 1994, p. 185
Thinker image: https://www.flickr.com/photos/sidereal/349496270 Nuland S. The doctors' plague. New York: W.W. Norton; 2003. p. 66 Nightingale F. Notes on nursing: What it is, and what it is not. New York: D. Appleton and Company; 1860 Great Stink Quote: The Times on June 18th, 1858 Kahneman D. Thinking, fast and slow. New York: Farrar, Straus and Giroux; 2011. Kraepelin E. Die Erscheinungsformen des Irreseins: (The manifestations of insanity). History of Psychiatry. 1992;3(12):509-529. Pies R. Psychiatry’s New Brain-Mind and the Legend of the “Chemical Imbalance” [Internet]. Psychiatric Times. 2011 [cited 1 March 2015]. Available from: http://www.psychiatrictimes.com/blogs/couch-crisis/psychiatry-new-brain-mind-and- legend-chemical-imbalance Kupfer D. Statement from DSM Chair David Kupfer, MD [Internet]. Psychiatry.org. 2013 [cited 1 March 2015]. Available from: http://www.psychiatry.org/advocacy--newsroom/newsroom/statement-from-dsm-chair-david-kupfer-md Andreasen N. The broken brain. New York: Harper & Row; 1984. Insel T, Wang P. Rethinking Mental Illness. JAMA. 2010;303(19):1970. Akil H, Martone M, Van Essen D. Challenges and Opportunities in Mining Neuroscience Data. Science. 2011;331(6018):708-712. Holden C. NEUROSCIENCE: Deconstructing Schizophrenia. Science. 2003;299(5605):333-335. Silverman C. The Epidemiology of Depression. Baltimore: Johns Hopkins Press; 1968. Healy D. Mania. Baltimore: Johns Hopkins University Press; 2011. Cole J. Therapeutic Efficacy of Antidepressant Drugs. JAMA. 1964;190(5). Winokur G, Clayton P, Reich T. Manic depressive illness. St. Louis: C.V. Mosby; 1969. Cole J, Gerard R. Psychopharmacology problems in evaluation. Washington: National Academy of Sciences, National Research Council; 1959.
Harrow M, Jobe T. Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15- year multifollow-up study. The Journal of Nervous and Mental Disease. 2007;195(5). SCHOOLER N, GOLDBERG S, BOOTHE H, COLE J. One Year After Discharge: Community Adjustment of Schizophrenic Patients. AJP. 1967;123(8):986-995. Bockoven J, Solomon H. Comparison of two five-year follow-up studies: 1948 to 1952 and 1967 to 1972. American Journal of
Rappaport M, Hopkins H, Hall K, Belleza T, Silverman J. Are there schizophrenics for whom drugs may be unnecessary or
Gardos G, Cole J. Maintenance antipsychotic therapy: is the cure worse than the disease?. American Journal of Psychiatry. 1976; 133(1):32-36. Stip E. Happy birthday neuroleptics! 50 years later: la folie du doute. European Psychiatry. 2002;17(3):115-119. Harrow M, Jobe T, Faull R. Do all schizophrenia patients need antipsychotic treatment continuously throughout their lifetime? A 20-year longitudinal study. Psychological Medicine. 2012;42(10):2145-2155. Whitaker R. Anatomy of an Epidemic. New York: Crown Publishers; 2010. Social Security Administration, Office of Policy, Office of Research, Evaluation, and Statistics. Annual statistical report on the Social Security Disability Insurance Program, 2003. Baltimore: United States; 2004. Social Security Administration, Office of Policy, Office of Research, Evaluation, and Statistics. Annual statistical report on the Social Security Disability Insurance Program, 2013. Baltimore: United States; 2014. Department of Social Services. Characteristics of Disability Support Pension Recipients. Canberra: Business Data and Analytics Branch; 2001. Department of Social Services. Characteristics of Disability Support Pension Recipients. Canberra: Business Data and Analytics Branch; 2013.
Thorlacius S, Stefánsson S, Ólafsson S, Tómasson K. Increased incidence of disability due to mental and behavioural disorders in Iceland 1990–2007. J Ment Health. 2010;19(2):176-183. Fork in the Road picture: http://www.ronniefloyd.com/blog/wp-content/uploads/Choices-fork-in-the-road3.jpg BUTLER A, CHAPMAN J, FORMAN E, BECK A. The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review. 2006;26(1):17-31. SCOTT J. Cognitive-behavioural therapy for severe and recurrent bipolar disorders: Randomised controlled trial. The British Journal of Psychiatry. 2006;188(4):313-320. Lam D, Watkins E, Hayward P, Bright J, Wright K, Kerr N et al. A Randomized Controlled Study of Cognitive Therapy for Relapse Prevention for Bipolar Affective Disorder. Arch Gen Psychiatry. 2003;60(2):145. Wykes T, Steel C, Everitt B, Tarrier N. Cognitive Behavior Therapy for Schizophrenia: Effect Sizes, Clinical Models, and Methodological Rigor. Schizophrenia Bulletin. 2007;34(3):523-537. Buchheim A, Viviani R, Kessler H, Kächele H, Cierpka M, Roth G et al. Changes in Prefrontal-Limbic Function in Major Depression after 15 Months of Long-Term Psychotherapy. PLoS ONE. 2012;7(3):e33745. Eack S, Hogarty G, Cho R, Prasad K, Greenwald D, Hogarty S et al. Neuroprotective Effects of Cognitive Enhancement Therapy Against Gray Matter Loss in Early Schizophrenia. Arch Gen Psychiatry. 2010;67(7):674. Music Therapy for People with Schizophrenia and Schizophrenia-Like Disorders. The Cochrane database of systematic reviews. 2011;(12). Lenz T. A Pharmacological/Physiological Comparison between ADHD Medications and Exercise. American Journal of Lifestyle
Stathopoulou G, Powers M, Berry A, Smits J, Otto M. Exercise Interventions for Mental Health: A Quantitative and Qualitative
Wipfli B, Rethorst C, Landers D. The anxiolytic effects of exercise: a meta-analysis of randomized trials and dose-response
Alvarez-Jimenez M, Parker A, Hetrick S, McGorry P, Gleeson J. Preventing the Second Episode: A Systematic Review and Meta- analysis of Psychosocial and Pharmacological Trials in First-Episode psychosis. Schizophrenia Bulletin. 2009;37(3):619-630. Seikkula J, Aaltonen J, Alakare B, Haarakangas K, Keränen J, Lehtinen K. Five-year experience of first-episode nonaffective psychosis in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy
Castle D, White C, Chamberlain J, Berk M, Berk L, Lauder S et al. Group-based psychosocial intervention for bipolar disorder: randomised controlled trial. The British Journal of Psychiatry. 2010;196(5):383-388. Seligman M. Flourish. New York: Free Press; 2011. Emmons R, McCullough M. Counting blessings versus burdens: An experimental investigation of gratitude and subjective well- being in daily life. Journal of Personality & Social Psychology. 2003;84(2):377-389. Wilson T. Redirect. New York, NY: Little, Brown and Company; 2011. Merriam-webster.com. Definition of Scientific Method [Internet]. 2015 [cited 17 March 2015]. Available from: http://www. merriam-webster.com/dictionary/scientific%20method Gillon R. Medical ethics: four principles plus attention to scope. BMJ. 1994;309(6948):184-184. Star Wars picture: https://www.flickr.com/photos/jdhancock/3618602355