Money Talk Is Good

SEPT. 23, 2012

To the Editor:

Re “Don’t Show Me the Money!” (Sunday Review, Sept. 16):

It may be that our interest in money is a form of pornographic pleasure with a perverse interest in the very rich, as James Atlas suggests. But I would emphasize, as he notes only in passing, the potential value and necessity of being informed about the practices of a world most of us know very little about and have tended to trust, however naïvely, with money put aside for retirement, our children’s education or a rainy day.

This is not pornographic indulgence but essential reading. The inundation of financial news may serve as a corrective for those blindsided by the financial meltdown.

Most important, if it keeps pressure on our elected officials for true financial reform, perhaps it will be less likely that millions of innocent people, through no fault of their own, will have their lives destroyed by the actions of those who were trusted to take care of them. But of course, that may be naïveté kicking in.

LARRY S. SANDBERG
New York, Sept. 16, 2012

When Medicare Spending Is Wasteful

MAY 27, 2011

To the Editor:

Dr. Rita F. Redberg highlights the value of an evidence-based approach to medicine — enhancing the quality of patient care and reducing unnecessary cost. However, insurance companies can and do deny care based on a perverse misuse of an evidence-based model.

Not all clinical care can be guided by rigid adherence to evidence-based guidelines. Sometimes evidence involves knowing one’s patient and his particular situation. I have recently had insurance companies refuse to cover medications for patients with histories of severe mood disorders. In one case, it said the dose of medication was “too high,” in another “too low.” The fact that both patients had histories of doing well on these doses was deemed irrelevant.

The problem, of course, is not with evidence-based medicine per se. Difficult decisions need to be made to bring down spiraling costs in health care; insurance companies cannot be expected to support all treatments; and clinicians should strive to provide the best care possible based on the best available evidence. Rather, it’s important that the valuable evidence-based medicine paradigm not be used as a weapon to hurt the very people it was intended to help.

LARRY S. SANDBERG
New York, May 26, 2011

The Changing Face of Psychiatry

MARCH 8, 2011

To the Editor:

The psychiatrist featured in your article describes himself as a “mechanic” and his office as a “bus station” where patients, seen for 15 minutes, are discouraged from talking about their lives. What a sad state of affairs!

While he has figured out how to play the game, there are no winners here. Practicing a “mindless” psychiatry is dehumanizing for patient and doctor.

Some patients need medication, some talk therapy and some both; all need to be given time in an unhurried way to establish an empathic bond and strong working alliance with their doctor.

If we as psychiatrists devalue the importance of giving adequate time to deal with the whole person, or are corrupted by an insurance industry that does, we have lost our souls.

Larry S. Sandberg
New York, March 6, 2011

The Brain, the Mind and Mental Illness

SEPT. 20, 2007

To the Editor:

Sally Satel (“Mind Over Manual,” Op-Ed, Sept. 13) suggests that the diagnostic confusion within psychiatry is due to a lack of “a clear picture of the brain mechanisms underlying ... mental illnesses.” She says psychiatry “lacks a firm grasp of the causal underpinnings of mental illness,” suggesting the “staggering complexity of the brain” as one reason.

Her article suffers in its being biased by the current zeitgeist that overemphasizes brain-based mechanisms as causes. While this may, in fact, have explanatory power for some conditions, it is more likely that causal explanations will often include frames of reference that are psychological (including psychodynamic) as well as biological.

Ken Kendler, a prominent psychiatric researcher, has pointed out that straightforward causal mechanisms (like the spirochete bacterium causing syphilis) are unlikely to apply to any of the major mental disorders because of their complex nature.

If we only look at “brain” causes and neglect the mind and the social world our patients live in, we lose a balanced perspective that our patients deserve and need.

Larry S. Sandberg, M.D.
New York, Sept. 14, 2007

Psychoanalysis: A Thing of the Past? (4 Letters)

SEPT. 16, 2007

To the Editor:

Re “Patching Up the Frayed Couch” (Sept. 9):

It is not only psychoanalysis, but all intensive psychotherapies that have become less popular in contemporary culture. This is due, in part, to the introduction of alternative therapies like drug therapy and cognitive behavior therapy. But there is also a devaluation of time and an overemphasis on speed and efficiency that discourage many people who are in need from engaging in a deeply introspective process.

A competent and empathic therapist or analyst gives his patient time and attention uninterrupted by the intrusions of beepers, cellphones, BlackBerries and the like. How common is it these days for two people to engage in a meaningful and deep conversation for 45 minutes without such intrusions?

Larry S. Sandberg, M.D.

‘Is Mr. Trump Nuts?’ Analyze This.

To the Editor:

Re “Is Mr. Trump Nuts?” (editorial, Jan. 11):

If President Trump were clutching his chest or falling down repeatedly and the medical community were silent, the public would wonder what cardiologists and neurologists thought of the president’s physical health and why they were not speaking up.

In your editorial you problematically argue that the perspective of the psychiatrist is simultaneously irrelevant because the “obvious” is being stated and dangerous because of public misunderstanding and stereotyping. But these are not the only possibilities.

It is one thing for psychiatrists to assume the role of the armchair psychoanalyst, presuming to know the deep unconscious conflicts of our president without examining him. It is this kind of (mis)conduct for which the Goldwater Rule was put in place. It is quite a different situation for a psychiatrist to illuminate an aspect of President Trump based on his observable behavior and to raise legitimate concerns about his mental health.

As a psychiatrist and psychoanalyst I do not presume to know why President Trump has trouble staying in reality. But I do know, and the public should as well, that decision making is seriously affected when “reality testing” is impaired, and the consequences can be catastrophic.

This discourse is essential regardless of the practical impediments involved in having President Trump examined. It is a moral imperative and an act of conscience. It is also a public service — educating the electorate and daring to lift the veil of shame around mental suffering and its impact. The risk of misunderstanding and stereotyping is only exacerbated when mental health professionals are encouraged to be silent.

LARRY S. SANDBERG, NEW YORK

The writer is a clinical associate professor at Weill Cornell Medical College.