WPA International Congress of Psychiatry -- Treatments in Psychiatry: An Update

November 2004, Florence, Italy

Sylvia Caras, PhD

A few highlights:

Unemployment is a feature not of psychosis/disability, but of the economic system in which the person with a disability is living.

PTSD accounts for a degree of disability and financial cost second only to major depressive disorder, especially events characterised by interpersonal violence involving the direct assault of individuals.

ECT use is increasing worldwide, particularly in the geriatric population.

Half of patients in recent study had experienced at least one coercive leveraging.

In December of last year I was invited to Florence to speak about partnerships. I have wonderful memories of visiting that city in 1953, had already done a great deal of work preparing a presentation on that subject and an accompanying web page, and was very pleased to accept the invitation and add on a few tourist days on my own. So this report will start with a bit of a travelogue.

I spent November 3 and 4 listening to election results, set my alarm for 3 AM, and early Friday morning boarded a plane for Florence via Dallas and Frankfurt. Going through security in San Jose, I had to show my boarding pass four times, id twice, was required to remove the outer-blouse part of my three part slacks/shell/blouse, the leg to Dallas was completely full and no food for the three and a half hour flight nor for those continuing on to Raleigh, the American Airlines lounge had hot water but no tea bags, plus cookies, pretzels, peanuts and fake cream, in Frankfurt even though there are no-smoking areas, there are also smoking areas and the smell is pervasive, there is no elevator to the upstairs lounge area - bump, bump, bump my wheel-a-board up the stairs, the distances between arriving and departing are far (good exercise after sitting for eight hours, and the signage is hugely confusing. But I have found a place for tea and typing and to wait for the next flight. The Frankfurt airport is huge - I bet I walked a mile and a half, escalators, elevators, staff on bicycles, moving walkways, and then an 18 minute bus ride from the terminal to the plane. As we descended to Florence I saw clusters of characteristic pumpkin colored tile roofs on creamy stucco homes. The lobby of my three star hotel is up two flights of stairs - staff helped with my suitcase, 22 rooms labyrinthed down corridors and up stairs, and 26 hours door-to-door later I am in my room, immaculate, wooden floors, high ceiling, cream walls, initially stark but not since I've unpacked, laptop on the desk, clock, books and reading glasses on the nightstand. In the sparkling bathroom are linen, not terrycloth, towels, the fabric I remember as dishtowels. (I liked them so much I thought to buy some to bring home and was told no, not in shops, made exclusively for hotels.) It's cloudy and mild outside and I took a short walk along narrow cobbled skewed streets to find the Convention Center, nearby, and the Duomo, the center of this part of town. Fifty years ago I was here with two school friends. Since I began planning, I have been remembering and looking forward to this visit. Now here, I am feeling an odd mix of strong anxiety, moderate depression, and enthusiastic, cheerful anticipation. The long term weather report I've been following on the internet has predicted mild weather and torrents of rain and thunder. So far neither have happened, but I am still wearing boots and carrying a small umbrella.

Breakfast is included, juice, coffee, hot milk, hot water and a variety of excellent tea bags, muesli, cornflakes, yogurts, individual packets of butter, soft cheese, toast, crackers, cookies, and chocolate candies, one hard roll and a croissant at each place.

The bells toll often, especially on Sunday, a good day for the $30 morning walking tour since the streets are less crowded. Though the original city plan oriented the main streets true to compass points, development has created a maze of curving alleys, even non-tourists use maps and ask for help, and in many cases, all roads lead to central points like the Ponte Vecchio and the Duomo. On the bridge, the bust of Cellini is protected by a metal picket guard rail to which are attached numerous small brass padlocks inscribed with names and dates, and then locked forever, the key discarded into the river, the equivalent of lovers carving their names into trees and desks. Ashcroft would run out of draperies in this city of full of statues famous and familiar. The zoning rules insist on symmetrical building facades using similar stone. I wandered for more than five miles, measured on a pedometer I had received from my family for my birthday last month.

The electricity just went off for a minute and this morning there was no hot water - some system in the hotel is broken and being repaired. It feels just like Santa Cruz, where fall wind and rains regularly bring down the PG&E power lines.

I rode the public bus for 30 minutes to Fiesole, a small city in the Tuscan hills, with grand views of the countryside, and then back in Florence looked at the jeweler windows on the Ponte Vecchio and walked along narrow streets between high buildings, dark, tunnels for the wind, cold. Another five miles. At the museum devoted to the shoe career of Salvatore Ferragamo, I was asked about Bush's reelection, told Italy was unhappy with our results. People from Australia and the UK have also volunteered this opinion. I have remained discreetly neutral, commenting on the appeal of Bush's religiosity and the plurality he received.

The only TV in my room in English is BBC and a bit of CNN, though there are some US movies dubbed in Italian.

I bought veggies for lunch and snacks at the nearby central market, a warehouse full of meats and cheeses on the ground floor and produce upstairs, bargained a bit for Pinocchio ornament souvenirs for board colleagues, gifts for family, and registered for the Congress. It's turned cold - the morning was clear and I was back in my room before the rain came in the late afternoon.

I went through several pounds of Congress materials, delivered in a useful alternative to the standard conference bag or briefcase, a cinnamon/red padded back pack, materials well organized and thought through, including abstracts printed on very thin paper so the 400 page book is no heavier than a magazine, invitations to sponsored (by pharma) sessions, and was struck by the enthusiastic tone appealing to the providers wish to help, be a successful healer, and by the organizational bonding and camaraderie, defense of the specialty to each other, stressing the uniqueness of the field and its work. It's made me thoughtful, wondering how to reach across what seems like an abyss, what words might make the leap before triggering defensiveness and dismissal.

I woke early to make a quick trip to the market for more veggies, walked through the rain to today's preliminary sessions. Canopies cover the site sidewalks and a huge hard to avoid puddle has collected just where one would first step. The site is a former fortress and this is obvious from the exterior. The interior is one vast space with moveable walls, and no electric wall outlets anywhere. Of course there are cords strung for microphones and computers and I am sitting by the AV desk to save my battery for later, comfortably working from my lap and now unasked, staff has just brought a table.

The Congress web page notes Eli-Lilly, Janssen-Cilag, Wyeth, Pfizer, AstraZeneca, Glaxo-SmihKline, Lundbeck, Innova Pharma, Bristol-Myers & Otsuka, and Novartis as early proposers of Satellite Symposia. The exhibit area is quite small and I'm not seeing many give-aways, so far only post-its and a small laminated map of Florence.

The session rooms are dim, with spotlights on the speakers, not good for reading the paper and an invitation to sleep.

Spirituality, treatment and health. Session started only five minutes late but to 13 people, maybe 20 by the end, one third women. Speck: absence of a belief system is a risk factor for prolonged/delayed grieving. Dein: exploring religion is psychiatry's last taboo; when asking about religion and spirituality in patients, ask about faith, it's importance, the patient's spiritual community, and then address the issues by talking "to" the patient about dying. (I was really struck that he didn't say talking "with" the patient.)

I didn't have to wait too long to use the dozen Acer computers available for the internet. I was stunned to read in a Breaking News alert in my email that Ashcroft had resigned and there wasn't another US person in that room with whom to raise an eyebrow.

Disability pension policy: Maybe 25 in audience. Warner: benefits; unearned income is a work disincentive; Colorado: 60 - 70 % of people with psychosis are living in poverty, social enterprise model, unemployment is a feature not of psychosis/disability, but of the economic system in which the person with a disability is living. Rapid placement more successful than extensive skills training. Rosenheck uses respectful, person-first, non-dismissive language in a smooth and integrated way! We can't have separate systems for people with mental health problems. Fioritti: Italian constitution: Italy is a democratic republic based on work. Employer reluctance to hire (people with psychosocial disabilities) because can't fire. Hwang: Korea, high discrimination so people don't disclose. Gioralamo: opportunity to carry out socially valued work is the reason that people in third world countries do better than those in first world countries after a diagnosis of schizophrenia. Audience: psychiatrist must tell patients what skills they have, what they can and can't do. (I remember post-hospital being told by the outpatient psychiatrist to whom I showed an essay that I had no particular creative or writing skills. And worse, I bought that!) Audience: If psychiatrists were to do job placement that would be a horrendous waste of resources (such an interesting value statement). Audience: when people start to behave strangely, the stigma from fellow employees, as a clinician I have those problems to deal with.

Implementing enterprises run by patients: There are three in the audience, which grew to seven. Harnois: The mental health system is not the most important element in community integration; the main problems are not medical, but social - housing, jobs, friends, … Europe especially uses social enterprise model, creating a commune or community of support plus business/income. Survivor is a name which they give to themselves; we must accept that and try to understand why. Tertiary sector - non-profits and social firms (drop-ins are a kind of social firm), shared decision making, profits distributed to members, service to community, cooperatives. Many examples in Europe. Canada has a courier service run by People Who. Phil Upshall, ED Mood Disorders Society of Canada.

Congress opening to standing room only: five brief introductions, 6500 attending from 120 countries, speakers from 88 countries, outreach especially to low income countries, WHO a co-sponsor; Maj: treatment is a source of professional self-esteem; Sartorius: the context of treatment today is change. Musical interlude, three tenors (not those three tenors) and piano. Tasman: DSM/ICD are symptom-cluster approaches, role of trauma, starvation, torture not included, nor symbolic meanings or cultural norms. Symptom cluster emphasis leads to pharma intervention focused on symptom reduction. Empathy essential for full understanding; comprehensive care, multimodal interventions coordinated by single physician, biopsychosocial model must be ideal. Compliance - many prescriptions aren't even filled, so psychiatrists must understand the roots of maladaptive reactions and transference in order to ensure compliance (but the issue of changing the treatment isn't on the table).

I walked back to my hotel along brightly lit streets on a very dark night. Along the way a woman asked me in Italian where a number was on this street, which direction. I was able to understand, and point her in the right direction. For several months, I have been listening to Italian radio on the internet, understanding a word here and there, and it has paid off, for I can understand enough to ask a question, get an answer.

The pharma sponsored session and the biological psychiatry sessions are standing-room, and the others have sparse attendance.

Coercive Treatment: some 25 people comfortably scattered through a small room, today overheated because of complaints that yesterday it was much to cold inside. Kjelin: knowledge is still missing regarding under what conditions and in what way the use of coercion in psychiatric care may produce a more positive outcome of care than if coercion had not been used. Salize: conversion to voluntary changes data, justifications for coercion may be threat to others (which leads to more male patients), need for treatment, some states only justify medically, some legally, involuntary placement without treatment allowed in 6 European countries, practices differ widely, reforms are constant, we must stimulate international debate, ensure human rights for the committed (which sounds to me paradoxical), must clarify legal criteria before comparable research can be done. Bowers: relative evaluation of psychiatric containment methods ("containment methods" is a term new to me, makes me think of floods and crises, not people) are a property of wider national cultures. Monahan: Research Network on Mandated Community Treatment. 42 US states allow but used rarely until recently (NY, CA, FLA). Advocates have changed grounds on which they argue, moved to public safety arena, play upon fear of violence (which makes me think of the recent US Republican campaign strategies which also played on fear). 7 years ago there was one mental health court, in Florida; now there are 100. There are more than 1 million in the US who would be candidates for outpatient commitment. Half of patients in recent study had experienced at least one coercive leveraging, around housing, jail, money, or hospitalization. OPC plus leveraging resulted in the most patient dissatisfaction, the pile on effect of multiple leverages. The policy debate is much too narrow, since this kind of mandated treatment is pervasive. New leverages - income suspension, child custody denial. Coercion v contract law.

Africa Zonal Symposium - I announced WNUSP's intention of an Assembly in Africa in 2007/2008 and asked for contacts. Also, per Saraceno, WHO is funding user organizing in developing countries, working with David Oaks.

New Treatment Perspectives: partial compliance often limits treatment outcome; expect remission instead of relapse; relapse is a bad outcome, should not be expected, taken for granted.

Partnerships in Mental Health Care: some 25 - 30 in audience, also on panel chair of EUFAMI who spoke of suffering and stigma and asserted that when families are involved there is a better outcome for the patient, urged a redefinition of confidentiality, wanted facts not stories, and concluded that what we all want is better services. My presentation well received and is on the web. Saraceno commented when I asked for non medical language that demedicalizing would lead to defunding.

Several thousand attended an evening church organ concert arranged by/for the WPA.

Informed consent prevents internment of victims of psychiatric disorders, prevents forcing incompetent patients.

My email today is full of comments about the US election, asking Kerry to unconcede, asking for recounts. I realize I like challenging systems, deflating smugness, asking certainty to doubt.

Florence is the cradle of the Renaissance and today's visit to the museum and art school which now houses Michaelangelo's David emphasized this. The long corridor along which are some unfinished sculptures ends with the David and the power of the statue is dominating and dizzying - he is ideal, young, cute, curly-haired, the right side of his face confident, the left a bit grim as he readies for Goliath. The 500 year old statue stood outdoors until 150 years ago when it was moved to this site. Some erosion was discovered when it was recently cleaned. Entrance tickets are best by reservation, a 15 minute window to arrive, thus keeping the areas not too crowded.

I presented again about the role of non-psychiatric professionals. This was shorter and informal and I haven't posted a version of my remarks or outline. One thing I stressed was that I and others were against psychologist prescribing. Most UK psychologists are trained in Cognitive Behavioral Therapy, and have no wish to prescribe. In Africa, traditional healers are sometimes crushing antipsychotics into the herbs they prescribe. Bob Grove from the UK noted that onset is characterized by loss, loss of job, family relationships, friends. Loss of self too, or at least the familiar self.

Pharma invites/pays room and transportation for many (all?) psychiatrists attending many WPA conferences.

One of the things I enjoy very much about traveling is trying to communicate in another language, with gestures and mime and a word or two. I failed at dinner. I was seated between a couple who spoke Japanese and a couple who spoke Italian and was asked if I were a psychiatrist. "No, a user." But user didn't communicate in either language so I said patient, but wasn't believed. "Are you a psychologist?" I tried advocate and was asked if I were an attorney (avocat is the Italian word for lawyer). Again I said patient, then schizophrenia, DSM, ICD, … I was becoming uncomfortable finally wrote user=consumer=patient and was comprehended, "disturbed" is the word that is pretty much the same in Italian and English. I didn't know the Japanese name of the JNUSP so didn't get very far on that side either. If you have ideas about how better to do this, without using ugly stereotypes, please let me know. Maybe another time I'll just say I'm a psychiatrist <smile>.

Robert Hsiung dr-bob.org/talks/wpa04 is a study of the psycho-babble moderated support bulletin board.

At lunch, the fortress exit was almost blocked by a protesting anti-psychiatric crowd. Several police kept order while speakers in Italian sounded ardent. I looked at the magazine, scary pictures of receiving ect, and found CCHR in the corner of the front page - no black T shirts.

During a tour of the Pitti Palace I learned that I wasn't alone in feeling dizzy and faint in the museums. So many tourists visit the local hospital with complaints of faintness that this art overwhelm has been formally named Stendahl Syndrome after the author's depiction of his own experience.

There were very strong winds during the night and after I checked in (carry-on weighed) at the Florence airport Sunday morning and passed through security, I found a very crowded waiting area, many conference attenders, recognizable by the red packs they were carrying, stranded, missing connections, some stoic, some verging on hysterical (but I have to be at work tomorrow), compounded by Lufthansa not honoring the value of tickets on flights canceled for weather, requiring those traveling the next day to pay for a new ticket, and ameliorated by Lufthansa's bussing passengers to the airport at Pisa, about 40 minutes, and arranging flights from there to Munich, maybe other destinations, all-in-all very confusing. I realized I would miss my connection if I were much delayed and that since my tickets weren't linked, I might have considerable problems and was fortunate that by the time of my first flight, some planes were arriving and departing. At check-in, my carry-ons were again scrutinized and I was ordered to repack things into a less bulky arrangement (I like to take food, a cushion, a neck pillow, and enough t o read for the long trip back to California. Intra-European airlines are very strict. I keep trying to work their system to my advantage.)


Salkovskis: "evidence-based patient choice" (I don't know what this means. Maybe only choice for limited options offered? It sounds like another double speak, like assertive treatment, right to treatment)

McGorry: Early psychosis intervention shades from clearcut secondary prevention into intervention in subthreshold cases and ultimately further back to asymptotic but high risk individuals

Pietrini: a biochemistry of the soul?

McFarlane: PTSD accounts for a degree of disability and financial cost second only to major depressive disorder, especially events characterised by interpersonal violence involving the direct assault of individuals. (Author notes torture, violence against people with psychosocial disabilities after diagnosis and ignores abuse before diagnosis, abuse that might have been causal, sexual abuse, family violence, … More on this subject from other sources at
www.peoplewho.org/abuse )

Burns: Outreach (home-visiting) and the integration of health and social care at the level of the clinical team are the key features in successful support and rehabilitation of the severely mentally ill and that some of the other high profile (and expensive) features proposed for ACT may not be as vital. UK term for ACT is ICM - intensive case management.

Kellner: ECT use is increasing worldwide, particularly in the geriatric population.

Rutledge: those who chose no treatment had lower levels of understanding, appreciation and reasoning than those who chose oral antipsychotics. (I'd certainly like to see how "understanding" was measured.)

www.peoplewho.org/wpa web site with resources for those attending

Partnerships: the personal, the political, the practical - http://www.peoplewho.org/wpa/flrremarks.htm - presentation

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