York state psychiatric institute, and author of shrinks, the untold story of psychology. Host hello. Im dr. Jeffrey lieberman here with art levine, a noted journalist and author and we are going to today his book Mental Health, inc. Its great to be with you, first let me thank you for your interest in Mental Illness in Mental Health care to few of your colleagues in the Fourth Estate have seen this is an area to really focus on and provide a public and interested parties with the information that is really needed, and the priority that it should have and you certainly seem to have recognized it. Its also take a gratifying for me to be interviewing you, art, because your a columbia alum having gone to the Journalism School which is not of the best schools of journalism in the country. Of course thats where i am faculty and currently employed. So the book guest thank you, doctor. Host please, call me jeffrey. Guest okay. Host when someone calls the doctor makes you feel old and stodgy. But the book is really a welltimed saving indictment of the Mental Health care system in this country, and overall im in complete agreement with you. At the same time let me give you a heads up, just for full disclosure and also for the purposes of a lively discussion, im going to challenge a little bit on the points you make in the book as a practicing psychiatrist and head of the largest, what are the largest psychiatry departments in the world. I knew something about the subject matter, but please know i do this in the best of intentions and in the interest of clarity and accuracy in the belief we are both soldiers in this very important, if historically neglected mission. Im going to orient my questions along three themes. First your background, second, substantive issues that you address in the book, and in third, what are the steps Going Forward that we can sort of advocate or aim for in order to provide some corrective measures and what you will be doing Going Forward in that regard. So to begin let me just ask, you are trained as a journalist. You come from one of the best schools in the country. You couldve picked anything as your area of interest. Why did you get into Mental Health care . Guest well, it started when i was a journalist for an alternative weekly called cd link run by the south florida sun sentinel, and i and Investigative Reporter and and a future writer. It was my only eight interest. And what happened in my case is i had three separate awakenings about what the scope of the problems were. It started in the early 2000s when i was working for city link and because i did reporting im about to describe i was honored as 2001 Florida National alliance of Mental Illness journalist of the year. Those looking at the criminalization of people with Mental Illness in south florida which was among the worst in the country, which is a a problem across the country. My interest started in, first, it was a raft of shootings of people with Mental Illness in both the city of miami and Miamidade County. This is still an ongoing host by the police . Guest by the police, right, by the police. So there was that host who are not trained to be First Responders to mental patients trying to write. Later on i began exploring the Crisis Intervention Team training work devised by the Memphis Police department, and either a section of my chapter, one of the chapters in the book describing that. But i had three separate arenas that sort of raise my awareness. From the very beginning i viewed it as a social justice issue. So the issue for me as a journalist who had covered other abusive arenas of misconduct, this struck me as something calling out to the tools of Investigative Journalism and future writing. So first with the shootings. Then there were the tragedies of people who had completely inept care or no care at all, every minority of them, but some people with untreated schizophrenia were in fact, killing loved ones. And i opened my initial story with a person who was let out of a facility over the objection of the psychiatrist but the facility wanted to save money, then he had a dream that he wanted to send his father to heaven by killing him with a baseball bat. And i profiled this example of the untreated. Then i learned, this is all in the same timeframe. And then i learned through the good offices of one of the countries great reformers, judge Stephen Lightman who has really changed host i know him well. Guest so the judge gave me a tour of a modernday hell, which is the ninth floor of the Miamidade County jail. It is, my original article at the photos, but the photos and even narrative feature writing simply does not do justice to the horror of what you saw. So its my view its not even 19th century Mental Health, its a bedlam circa the 1700s. So the were mostly minorities, mostly untreated and refusing the medication or not treated properly who were naked, surrounded by blue synthetic cloth that they couldnt use to rip or kill themselves, and they were spouting gibberish or they were locked behind these dungeon like cells and the only places for them to sleep on this rusted metal beds. And the judge told me at the time, it makes you wonder who is crazy. I we crazy or is a system crazy that this is existing . And even developed over the years of Reform Program that led literally like 15 years later to the closing of the facility and some, diverting people away from the Mental Health system. So then about the same time, o this is a threepart answer to explain why uncovering these issues in this book. The second was my great interest in learning what works. Thats where i get interest in the work of dr. Robert drake and others in the early 2000s, there was a program being rolled out by the Substance Abuse and Mental Health services administration, nicknamed samhsa, that was looking at how to find out programs that of wr the most seriously mentally ill, and i get interested in covering that. I wrote a paper on it as a fellow with the progressive policy institute. And that was host what years which are explained in south florida and then with samhsa . Guest so i basically, i was in south florida from 942004, and when i returned, so i broke my stories in south florida, but then i wanted to understand what works and how can we do better. And thats right get interested in things like in terms of police, the Crisis Intervention Team training. I learned about family psychoeducation from doctor macfarlane. I learned about support employment to call these very valuable programs that, particularly in the psychosocial programs that are still unused by and large across america foe most seriously mentally ill people, and thats one of my big talking points and stresses in my book. So that was that, and at that time i had not yet become fully aware of the role of dangers over medication and offlabel medication. And that awareness came about because of the report i found i really dug into, which had to do circa 20092010 concerns the veterans were being heavily overmedicated for ptsd with antipsychotics in common is with antidepressants and tranquilizers. And just this barrage of chemicals as opposed to actually providing thoughtful, compassionate care, let alone evidencebased cognitive treatments. So those are three arenas that i stood with me since then. And then i began researching my book about 2013. So this is a very longwinded answer but i but i want to expe context of why uncovering all that. Then theres a fourth element which is the abusive troubled teen facilities which exists for parents who dont know how to deal with kids who are misbehaving or drug users. And i expose what amounts to teen torture facilities across the country that focus telling the story primarily of a program in alabama. These abusive facilities and inept residential Treatment Facilities flourish because Community Care is so awful, and families and people struggling with Mental Illness and families just talking with kids were misbehaving and experimenting with drugs, which probably does require them to be sent to some inhouse facility, they are all being victimized by a system that a president ial commission years ago rightly called is in a shambles. So thats obviously this is a lot of areas to cover and unpack, but that is the range of issues im thinking of covering in this book. Host all i i can say is god bless you. Buy your own journalistic curiosity, you stumbled into an area which obviously is assented to ive been doing my whole professional life, and you hit the nail, several nails in terms of what are the sort of glaring and egregious problems that exist in the fact that they can continue uncorrected, and attended for song because youre right it is a social justice issue. There are terms that are used in Public Health care, Public Health such as unmet clinical needs. When you dont have treatment for something like, lets say memory improvement in alzheimers disease, or healthcare disparities with certain segments of the population dont get the attention because of discrimination or whatever, like women historically were neglected, the children, pediatric pharmacology or underrepresented minorities whether its racial or ethnic, but Mental Health care or the lack of it, all of those but it is much worse like to say. I consider it to be a civil rights violation. Why there is no legal action is another matter, but this is just basically to concur with what you have been saying. I think youre struck paydirt. And then there is guest can i make one point . There is one area of legal action thats the Justice Department suing the jail systems, particularly in places like Los Angeles County that are notorious, 22 people been been sent to prison for brutalizing host but you have to be careful because the thing is society has to manage some out either in a humane or brutal way its constituents and the fact that we havent embraced the need to provide as good of Mental Health care as a general medical care has led to displacement, as you point out in your book, of these individuals to Nursing Homes, to prisons or to homeless shelters try to i agree with your points. This area is basically largely untouched and it is a National Disgrace and a national scandal. Youre absolutely right. The Broad Strokes of your sort of thesis and your argument are right on target. Im going to help you in the course of this interview and thereafter if youd like to really sharpen the fine points and to establish the scholarly evidence to support these points. So just to continue, excuse me for making these comparisons. You will correct me if there inappropriate. It seems like the territory you are covering it with Mental Health inc. Sort of relates to come on the one hand, what has been done in writing, particularly in american psychosis, and also on the other hand, what maybe Robert Whitaker is done with matt in america and psychiatry under the influence. Would you take umbrage or agree . Guest i agree with that. Im a centrist who goes with the facts are and i dont like ideology. Essentially what i found is doctor torre downplays to a certain degree the impact of rampant over medication with antipsychotics because he favors a wider use of involuntary outpatient commitment. And in many cases whitaker doesnt pay as much attention on his side, and hes one of the endorsers of my book, but he doesnt pay as much attention as dr. Torre does to the side effects societally of mismanaged and poorly treated Mental Illness in terms of the homelessness, j lings and police encounters. I basically took in many cases the best of both of their arguments and im advancing what may appear to be opposite points of view in which of course they just opposite, but i see the wisdom in each of the points of view and thats what im trying to address as reporter, and i dont have an ideological agenda. Host im not religious but i had to say god bless you again. You really i think ive taken a very studious but also enlightened sort of approach to this allimportant topic. So just diving into the substance of the book, whats the implication of your title . By Mental Health, inc. , tht was maybe your publishers title but it connotes something kind of conspiratorial like eisenhower is militaryindustrial complex. Guest it was inspired by a book coauthored by their great investigative journalist morton minced called america inc. Which was come he was a guy who broke the scandals over unsafe auto and hes a famous Investigative Reporter, and it seems to me that the corporatization and dollar oriented orientation of companies has corrupted both for profit and even nonprofit Mental Health care in this country. In particular the pharmaceutical industry. So the subtitle of my book is how corruption, lax oversight and failed reforms in danger are most vulnerable citizens. So i am trying to paint what some of called the shock doctrine type approach to the arena of Mental Health care. Im trying to use as many vivid examples as i can about things have gone off the rails and thats it most of the book is about. And i look at of the department any lawsuits to explore the different schemes used a Drug Companies to promote offlabel and improper uses of these medications, look at the corrupting effect of the drug industry, of the fda and sort of pushing out for really risky uses that dont meet a real costbenefit analysis. These medications, and it extends to an arena doesnt get as much attention but i think his very, very central, and that has to do what the department of health and Human Services and the program that the agency that runs medicare and medicaid, they pay for dangerous offlabel use, thats the center for medicare and medicaid services. So regardless of the Justice Department getting over the years, the last 25 years, 35 billion in penalties and payments from Drug Companies for illegal marketing, it doesnt affect what hhs which oversees this agency does if they continue to pay for fraudulent uses that the Justice Department spent years building cases over the illegal marketing. Thats one side. And even less that is the fact that these Companies Sign what are called corporate integrity agreement with the Inspector Generals Office of the department of health and Human Services. What happens as a result of that is they violate one agreement. They pay lets say i have my dollars in a settlement. They agree to never go forth and do no wrong anymore and then according to settle lawsuits allegations he continued to violate those agreements. Host can interject here . I like to make a corrective statement if i could. Guest sure. Host so you are like an explorer who is trying to map my world, and you have hit on so many of the third rail issues that really constrain and vent Mental Health care providers that think they know what the right thing to do is and want to do it but cant. And youre trying to bring these to light to precipitate action in our country. What you are doing is so important and so on track, but ive got to tell you, the pharmaceutical industry, its cordial relationship with the fda, cms, thats a red herring. Those are red herrings. Those are not good. They are not laudable. They are in many cases prosecutable, but thats not the central, the biggest problem. Were going to get to that in a few minutes, in the course of the way i have laid out the questions i would ask you. I just want to interject to say you are on the track of this and will get you a Pulitzer Prize one of these days for sort of exposing the whole thing, but i just want to say that from the standpoint of pharma marketing schemes, cozying up to researchers, relationships with the fda, cms not having price restrictions, offlabel use, thats not where the actions, its like the deep throat, follow the money or follow whatever, the term was hit on going to have to do that and guest okay. One thing is im a report and aye where the facts go and an openminded to learn new things. I go. Host good. Just getting back to the more substantive issues, you break down the Mental Health system to kind of three coexisting systems, a Public Sector which the state and municipal finance care, private sector including academic, forprofit, everything nongovernment, within the va system. Then theres a shadow Mental Health system you identify which is your Nursing Homes, the prisons and homeless shelters. Am i characterizing what youre describing correctly . Guest i think that is in a general way a reasonable way to look at a very complicated system. However, i think under host let me interject. Let me reframe the question to give you the best opportunity to answer. So most countries thank that certain responsibilities towards their citizens, and whether we consider healthcare a commodity are right, presumably providing healthcare in some reasonable way, and we do it in terms of general medical healthcare, extensively and inefficiently but you can get it and its good, most cases. When it comes to Mental Health care its terrible and we had these come as a just enumerated, these different systems of care, you know, the standard and in the shadow. So you are trying to sort of understand how this works and whats not going right in it. My question to you is, is my conceptualization of what i i t of understood from the book accurate, or consistent or not guest i think its accurate up to a point but it misses this other, i wouldnt call it shadow, you know, whether the va or however you are defining, or Nursing Homes. I dont call those shadows. What is truly in the shadows is this completely out of control multibilliondollar troubled youth industry, and along with it a lot of the extremely poor quality residential treatment programs, and in general treatment programs, for people with drug addiction and Mental Health combined, but in drug addiction myself and thats one important. Spirit where facing the Biggest Health crisis since the aids epidemic with this Opioid Epidemic thats going on now with over 60,000 total overdose deaths. Most of them due to opioids, some legal, many illegal. And we have a Health Care System where, first it is acknowledged there is no access, but when you look at the quality, and i highlight the work of dr. Mark mcgovern of stanford university, we actually used these assessment tools to look at dual diagnosis patients, so about half the people with serious Mental Illness have a Substance Abuse and about half of Substance Abusers have some serious Mental Illness. So he went in, hes invited in by clinics that are advertising and are proud of their dual diagnosis. He goes in to the mental or Health Clinics in fines that 90 of them are not even minimally competent to do those services. Then he goes to the drug treatment programs and 80 are not minimally competent. This is a very valuable assessment tool. It can be handled in a half day by independent evaluator, and it is now being essentially abandoned by most states, and it was supported by samhsa up till 2012 the one getting at is we are facing this major addiction crisis and our central system is essentially incentivizing and allowing a relapsing illness to keep relapsing if they keep getting terrible care. And that is a very key thing. Host at all so i think what i hear you saying is that some less than up and up and scrupulous providers or organizations take advantage of this by trying to make profits from providing care thats not going to be effective. But, im going to give you an analogy that may or may not be appropriate. Ostensibly why are we in afghanistan, you know, fighting . Im going to answer my own question. Presumably its because they dont want to provide safe havens for bad guys to conspire and create terrorists imaginations. The things that you describe, like forprofit organizations, the Nursing Homes that load up on mentally ill or in from individuals and then use chemical straitjacket with medication, these things are allowed to flourish because the real culprit in this, in my opinion, the government, has not provided a framework for health care to be provided, including Mental Health care, financed. And it allows for these things, for pharma to misbehave, for providers that provide lousy care to make a lot of money and stay in business. This is what creates it. But i think you sort of ferret this out in a way that is unique and very insightful. Because most Mental Health advocates havent appreciated this fully, and you state this in the books i want to read a quote from the book, which i found to be very insightful. So on page 22, and you are talking about the usual analysis of Mental Health care problems in this country, and youre citing an article that was in the boston globe i think. Is that we dont find health care, Mental Health care enough. Theres not enough support for the va, for states, thirdparty payer reimbursements. And you say none of these have probed deeply into the quality of care itself after people get access to treatment and outside of noting problems arising from the shortage of trained healthcare providers. Mental health care as truly offered by both providers and clinicians continues to be portrayed as an unalloy to good as well as the more people need to receive more treatment regards of the actual quality. Unfortunately the furious political debate over repealing obamacare has speared a truth that helped us is such a fiasco that even have insurance does nature good, safe care. What you are saying basically is that funding needs be sufficient to provide services for people but has to be good quality care which most of it now is not. Guest right. You as is anyone would know there have been discussions over the decade and various panels and organization, how do we have meaningful quality outcome measurements and they keep offering new methods to measure but its not really estimated and theres no culture of enforcement, and thats why i have argued that what we are facing in this country is what amounts to an epidemic of Behavior Health malpractice, even if it isnt acknowledged as such within the legal system and that is in part because the rally of malpractice attorneys is they dont take a case unless someone dies. Im glad you have noticed that point, because i do think that is a missing part of the debate, currently around a very legitimate fear that both medicaid could be undermined by the trump administration, and also of course obamacare, the Affordable Care act, various waivers, subsidy kids and so on. As many as three Million People or more with addiction and Mental Health issues were added to healthcare coverage as a result of these reforms and expanded medicaid that came in, and theyre all still vulnerable, and the waivers that are now being promoted by the current hhs secretary, could further gut and weaken medicaid benefits and programs to those who are already on medicaid before this program added. Unfortunately, these dangers obscure the fact that getting access isnt going to solve the problem by itself. Host exactly. Of course, many of the vast marlingity of the people called their persistent Mental Illnesses, bipolar disorder, their status leaves them to be on medicaid and if they dont have medicaid, they have in insurance. Theres al you could ad to your litany to just described the fact that the Mental Health parity bill passed in 2008, the final legislation not finalized and approved and signed until 2013, of that this is not enforced, either, Insurance Companies are not complying. Theyre not complying. The big private insurers have not complied with the parity bill, and it requires some organization, the American Psychiatric or psychological to sue them to do this, and theyve got such deep pockets they just drain resources of these organizations. So thats another area of noncompliance. Yeah, yeah. Theres a very good report that came out that showed because of the reality is, theres a shortage of providers, shortage of innetwork and out of Network Provider offered Mental Health care and theres no parity if the out of pocket costs are still extraordinary, and they feel free to continue in these practices that make it harder for the wellmeaning patient, unable to see a doctor of your skill set, would be very difficult for most Peoples Insurance to find, and over half of the countrys psychiatrists at this point are just not taking any insurance programs. Its like private pay, which is just leaving them to wander the fields of mediocre medicaid theyre going to have trouble getting on anyway. Youre absolutely right, and thats something unfortunately i feel badly about, that my profession, the sort of the leading one among all medical specialties in taking not not taking insurance, and you can say, oh, its because obenefites are too low, but on the other hand we have a responsibility to provide care. Ill just add to this the fact that its very frustrating, constraining, as i said before, that prior to 19 prior to second half of the 20th 20th century, there was little or nothing that medicine, health care could provide to people with serious Mental Illness. We didnt know very much about it scientifically and didnt have effective treatments. Latert par of the 20th century in the 21st century theres an array of farm psychology, psychosocial, stimulation treatment, albeit not perfect but that are effective, and whereas throughout history, until the lat effort part of the 20th century, you have a severe Mental Illness there was nothing for you, couldnt get any treatment. Now we have treatments and people cant get it because of lack of access, lack of payment, or unavailability of good, quality care, and its all part of what youre describing here. Listen, im trying to use our time efficiently and theres so much id like to talk about. Let me just move on to say that the book is organized in a fashion along the lines vulnerable, or abused patient populations. You have a chapter which talks about the children and how theyre now being drugged or treated promiscuously with medication, the elderly or infirm, who are in Nursing Homes and are managed also with excessive medication, the military, prisoners who are incarcerated, you seem particularly concerned about the mistreatment of the military. Understandably. And you devote six chapters to it. And first, let me just ask you, am i you seem that this was something that really was ripe for further discussion and exposure. Guest yes. Host is that accurate . Guest yes. My feeling about the department of veteran affairs, or va, handle offering the Mental Health issue is part of the mishandling including host is it just the va or is it dod . Guest no. Dod also. For instance, dr. Freedman has done very good reporting for the New York Times and a fantastic researcher and has shown that the overuse of stimulants and antiscottics for active duty troops helped increase by over a thousandfold the percentage of people who are getting both these kind of psychiatric medications and stimulant medications and the rate of ptsds were skyrocketing. When they came out of active duty its a problem in both the active duty military and the va, but its a bigger problem in the va because the va has been more heedless and less willing to change than the department of defense. So the department of defense in 2012, approximately, said, were no longer going to allow combat troops to have like a friendly sleep aide, sarah seraquel in their backpacks and put road blocks to free, wheeling prescribing seraquel for anything on earth but the va has not done that. Despite their own research of excellent researchers, including a dough lab co collaborator offices you, showing that seraquel and they studied in general the class of antipsychotic is is not effective. The real harm is nicer no real effort to keep an accurate count of the degree to which the massive overmedication with psychiatric meds and opiates is contributing to needly overdose deaths, only sparing academic coverage, and theres very striking report that just came out by researchers at a south texas va hospital. Its not a mud book but going to be in a fourth coming piece that shows theres a 400 increase of accidental overdose likelihood or suicidal actions or suicide based on poly pharmacy 0, which means five or more Central Nervous stymied indication drugs, and i look at the scandal, which is known within some sectors but not on the east coast in general, where in wisconsin you had a drug oriented chief of staff who helped kill 30 or more patients by giving opiates freely to them, and people were dying and the va covered it up, and theyre still continuing to cover it up. So its a major problem thats not addressed. Host it is just nauseating to see this. I want to stick with this for a minute because i think its useful to, one, illustrate some question i had about your book and also a question to you that was not addressed in the book. So, youre a writer, im other scientist, clinician and i dont know how to communicate as well as you do guest your book shrink is very well done. Host thank you. Appreciate the plug. But you introduce a topic or an area, and then you provide Background Information to support or illustrate it, including many, many case examples of just horrible and tragic mistreatment and abuse that goes on in all matter of vulnerable populations, and as we have just been saying, the va and the military, whether its dod or post discharge, has been a prime area of this kind of inadequate care. But the real questions beyond why this bad care, overdrugging and medicating and heedless disregard of consequences going on, why isnt there an effort, if the military is such an important component of our population and society and we want to do everything we can for them, why havent we been able to figure out what is going on that is causing so many active duty or vets to need treatment . So, for example, we have known that ptsd has existed in combat since the civil war, since world war i, shellshock, battle fatigue. It wasnt legitimized until the vietnam war with ptsd, but why are there so many cases now . You point out, richard friedmans excellent article, which astutely showed you can farm coggal sense tithe somebody to be vulnerable with ptsd with unnecessary use of psycho stimulant medication. But the increase in frequency of ptsd in the psychological wounds of war that have occurred in the middle eastern wars, exceeds anything that would be imaginable. So, why is this happening . Guest i think in part it is the repeat theres several factors. One is it is more actively diagnosed now and acknowledged than used to be. For instance, the actual diagnostic category did not exist during the vietnam war. Its my understanding, its something that arose in the 1980s as opposed to even though people use terms like shellshock and actual clinical category that allowed for this, didnt exist. Then you have the actual nature of deployment, which these repeat deployments, where people who sign up and particularly lower income people who are in the military, sign up and its a way to keep getting access to benefits and a future in the military or a future in going into careers or college so they keep going back and theres this redeployment where they go back, and then you have then you have, it is allowed to continue to unwind and develop because there is still loads of stigma about getting help and getting hip within. So, one of my chapters, i do look at an alternative approach by very talents psychologist who has a prom that doesnt use any medication at all but compassionate psychology and a lot of stress reduction exercises for helping people get off these overwhelming amounts of medication, who do have ptsd, and she helps them look at it in a different way. This is a radical approach. It doesnt have loads of controlled studies but its certainly worth exploring. So, if you combine all of these missteps, it is a toxic fuel to sort of create ptsd. If you were designing a system to, lets overmedicate people, send them over and over and over again back into war situations. Lets not have appropriate clinicians who are trained in cognitive therapies to deal with it in response manner. All of these issues are something that is going to create what we have now, which is a lot of people with these issues about 30 , if you look at all the different major recent wars, about 30 of people who have been in active duty have some form of these issues. Of course the personals vary but thats an estimate. Host the statistics are staggering. At one point there was more soldiers dying by suicide than by enemy combatants. The point that i was getting at with this question is, if the health of your Service Persons is so important, why havent we figure out ptsd . You talk about a treatment, but the point is that ptsd is a known condition, we can actually model it in animals. When the aids epidemic came about in the late 70s. In five years after he first emerged, two scientists identified the hiv virus because of the huge amount of funding put into the best laboratories to do research. So why dont we know what they pathow fit physiology ways to inoculate soldiers going into active combat or First Responders who go into harms way routinely, against it, why dont we have support mechanisms, whether theyre pharmacologyic or psychosocial that are reading for individuals when they come out of a combat high stress area . This could happen. It simply requires an effort, like a Manhattan Project for military psychological health. Guest i agree with you on all of these points, except theres no culture of accountability in the va or in many some respects but the guest the va and dod report to congress, and the president. They should be holding them accountable. Host they chute shoo but they dont. Guest when president kennedy said, let put a man on the moon, we did it. The aids epidemic occurred go ahead. Host i agree. Just think its significantly more come mex, also, your former collaborator, gave me some big picture points, while not being critical of the va and does some work there. He said that theres a general culture of allowing doctors to essentially do how they feel fit and he also argues that the host no. No. The va culture is clearly abysmal. Theres no question about it. But if David Sharken who is currently the second, or general mattis, if they wanted to take this on full bore, like if this was ebola, or some type of infectious disease, and launch a fullthroated, allout assault on psychological casualtocombat, im the science test here. Its this is not like a global warming, impossible to figure out. Guest i agree with you. But let me make two points on that. There are solutions that could be implemented now, and theyre not. And this applies for a range of Mental Health issues and va. In the va you have a culture against whistleblowers, failure to take responsible action in the fives major health scandles that has not yet been solved. Whatever good intentions might exist, and why essex osay is whatever is on paper about guidelines, has no meaning at all in the real daytoday practice. Host youre absolutely right. And thats something but you say is actionable, just takes somebody asserting the authority to do the right thing. Guest i think it could happen. Rosen said to me, he referred to psychiatrists not throwing you personally as useful pat South Carolina the farm suit al patsies of the pharmaceutical industry and referred to the culture host let me i know bob better than you do. Guest of course. Host a great productive researcher, also an idea idealog and pharma can have its way with farmer us but its not like everybody is a pushover or a pat ie itch want to get to couple of thing that are important and controversial. To put you on the spot. Guest okay. Host here we go dont take it the wrong way. Theres parts of the back that sound almost antimedical model. Antiscientific. Kind of a favoring of nonpharmacologyic forms of treatment. Do you believe psycho tropic drugs are more harmful than helpful. Guest im trying to draw a stipulation which puts me, i believe, sort of in this radical centrism of this kind. I believe its very dangerous to have offlabel, irresponsible use of psychotropic, particularly antiscottics forks population for which theres no a shred of medical justification to use them. That includes some veterans with ptsd, young children, and the use of chemical restraints in measuring homes that accord together the fdas best estimates kill 15,000 Senior Citizens needlessly a year, who shouldnt get it. On the other hand, sensitive, compassionate prescribing like i describe, and i highlight a wonderful psychiatrist who is the medical director of the Village Program for longterm chronic Mental Illness and called the village in long beach, a very coverage compassionate skier andom for your book youre a compassionate user of medication for patients. And i make clear, despite the factionalism over medication and the biological role, i basically am i am not accepting the view theres no biological role. I refer to the different genetic understandings, the folds in the brain schizophrenia. Im not a critic of the medical model. Im not a critic of the use only psychiatric medications but eye ohm posed to irresponsible and dangerous use. That to me is a central unsolved and unaddressed issue. Host no question about it. Promiscuous prescribing i rail against me colleagues to providing stimulants to an as as citizennible adhd. I am with you. I think you go a little overboard let me just say, you have i dont have the quote marked but you have a wonderful quote from a paper of one Motor Vehicle colleagues, one of my faculty, mark olson, who has done great administrative analyses of trend inside treatment prescribing, and in it you and he basically say that theres too many people getting antidepressants, santa psychotics, antistimulants for conditions that dont warrant them but there are even more people with conditions that would warrant them who are not receiving treatment. Guest i think those idea differs. Host speaks volumes. Guest i agree with him. Was surprised to learn that most of the people who get depressants dont actually have the clinical signs that justify their use and those who do have them just justifying their use, based clinical assessment, nor getting them win. Antipsychotics its a different issue. People with schizophrenia are 1. 5 thief population, and olson and others have son that adults get up to 75 of the adults get antipsychotics for conditions that arent justify and over 90 of kids are getting it. Then clearly things are out of control, and it causes more harm because theyre not getting really tailored personalizes therapies, not getting a appropriate medications. Im saying they shouldnt get some kind of psychological medication or carefully managed. If their willynilly pushing out antipsychotics without paying reel attention to what does this individual need . That is one argument. It is not host youre absolutely right, and it guess to the cardinal dictum for physicians, do no harm. Im going to get to the last part of your book but i want to say where i think you go overboard. Page 29 you say, another sort of scientific fraud is the development of corporate funded pharmaceutical slugs foods Mental Illness that rely on the cherished chemical imbalance theorieses for claims. This is insist serotonin and excessive amounts of dopamine. I think thats just wrong. Its like saying that the am ma lloyd eye moth this are so alzheimers disease is a ruse for Drug Companies to guest well, all i can say about this is first of all, its an area of great controversy within medicine and when dr. Marsha angel wrote her pieces, respect person who headed a primary host i know. I know. Guest what im saying, its an area of dispute that i am one thing i did so thats one thing. Also, spoke to doctors rosenheck about the issue. When i read the new york review of books piece, literally called him um and asked him could this possibly be true . I myself didnt really believe it. This chemical imbalance theory was as fragile as angela was arguing in her piece and he agreed with her. Host thats just plain well, first of all, bob, who is a close friend and colleague, is an idealog and thats just playing wrong. Cannot discredit guest i think a fair way to put it i cite in my 60 pages of end notes and the kindle version allows you to read the original paper i do link to the sourcing for these questioning, but i also point out that the dopamine hypothesis in particular is getting a very strong rethinking by very Good Research that is coming forward. So, what host but it isnt discrediting it. Its not vaccines and autism. Its simply elaborating or it rating around it, but this is like a guest me feeling host its a im getting a wrap sign. Guest okay. Host so, we dont have time, i apologize, just got so into it with you, youre such a fascinating speaker as well as writer. The last two chapters talk about what can we do . And you cite bob drake, another colleague of mine, and cite bill mcfarland and i think the point i take from this is that the Mental Illnesses skits schizophrenia and its disease management. And the term of art now is called collaborative multispecialty care, and that is exactly what we need, but that gets to the heart of your quality argument, need to have if available for people. The last thing want to say is what are your working on next . Guest well, next project is im doing i have newsweek piece coming out soon which is looking at additional problems with the va, particularly im building on my book but looking at the way theres been an overreaction with chronic pain patients in very abruptly taking them off opioids when they have been functional, and not dangerous to themselves ors could not engaging in addiction. So ive add that point to a forthcoming newsweek piece, and then also looking at abusive and corruption in the Family Court Systems where a number of deaths and abuses occurred when children have been turned back to abusers and some of those kids were then sent to the residential treatment programs i describe in my book. So, im still out there wanting to report on making things better, and i hope in the future to work and collaborate and work with rightminded medical doctors and psychiatrists to try to improve meant health care and build policy support for better care. And so im very glad of your interest in these issues. Host well, its been a real pleasure talk with you about your excellent book Mental Health care ink and i look forward to seeing your future works and talking about those as well. So thank you for the interview. Thank you for the audience. And thank you for invite knowing interview art levine for cspan. Guest thank you very much. Book of the has covered many books about moment health, including one by Patrick Kennedy and sue klebold, mother of mass murderer, dylan klebold. Can go to booktv. Org and check on Mental Health. All of these programs are available to watch online