DC Medical Malpractice & Patient Safety Blog

An article by Jane Brody in the New York Times, "When Your Looks Take Over Your Life," draws attention to a tragic mental health issue called "body dysmorphic disorder."

These are people who are obsessed about a "flaw" in some aspect of their bodily appearance, and who sometimes subject themselves to repeated rounds of cosmetic surgery to "cure" this problem. And of course the surgery never works because the problem is much deeper than the skin. A malpractice lawsuit is not the answer for these patients, as I explained in a comment on the New York Times' "Well" blog:

As a malpractice attorney who represents patients, I have been consulted several times by potential clients whom I later realized had body dysmorphic disorder. When they called for the appointment, the story on the telephone was that they had been grotesquely disfigured by a cosmetic surgeon, often with repeat surgery. Then when I met them, I would not be able to see anything wrong with their appearance, even when they pointed it out to me.

One man in his mid-20s had had his nose operated on three times by the same surgeon. All I could see was that one nostril was slightly larger than the other. He was talking about needing to have yet another surgery. I politely urged him to see a psychiatrist first, and told him I could not represent him in any legal action against the surgeon.

My personal belief is that an ethical cosmetic surgeon would decline to operate on anyone with obvious signs of body dysmorphic disorder (if for no other reason than that this will be a hard-to-please patient), but a willing patient with the means to pay for the surgery can be persuasive for some surgeons, it seems. (Witness Michael Jackson.)

The legal system does not have good answers for these patients. A lawsuit would only perpetuate the patient's idea that their appearance can be "fixed" and that it's the doctor's fault for not doing so. Still, my heart goes out to people with this disorder especially when they subject themselves to a fruitless round of surgeries. They definitely need counseling.

Read more comments on the Well blog here.

A new study that concluded that two commonly prescribed antidepressant drugs don't work for people with mild depression has opened an interesting discussion about the quality of mental health care in America. The quality score: C-minus, for lots of reasons.

Judith Warner wrote in the New York Times that the news media reports about the new study (which really wasn't an original study but a number-crunching of selected older studies) were too simplistic. She noted many of the shortcomings of mental health treatment, starting with the fact that general practitioners do a lot of the medication prescribing and aren't as skilled as specialists in screening who really needs the medications.

Ms. Warner concluded: "The trouble is not that the drugs don't work, it's that the care is not very good."

She also said:

This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or finding care that is ineffective.

Her Op-Ed piece brought a round of thoughtful comments in the letters">letters to the editor column at the Times, including:

* Brown University psychiatry professor Lawrence Price writes:

Medications that work for depression are commonly misused, and types of psychotherapy that work for depression are commonly not used at all. The reasons for this state of affairs include mistrust of authority, stigma, big-stakes health care economics, cross-discipline rivalries and simplistic thinking (within the mental health care field as well as the general public).

* James Brush, a psychologist in Cincinnati, writes:

While researchers can investigate treatments in laboratory conditions, few clients fit into simple categories. Try applying an “evidence-based treatment” for a depressed, sexually abused child from a divorced family in which one parent is alcoholic and the child has a learning disability. Such clients do not tend to show up for laboratory studies and don’t tend to respond to simple bromides.

* Neil Brooks, former president of the American Academy of Family Practice, argues that family practitioners by necessity have to treat patients with depression who might be better off with a specialist. Dr. Brooks writes:

Many of those who need treatment have no access to psychiatrists because of geographical distribution, restrictive insurance coverage, cost or a perceived stigma to being cared for by a psychiatrist. Thus, distortion or misinterpretation of the evidence about the treatment of depression will result in those who desperately need help not obtaining it.

The Times also published a rebuttal to the new study by psychiatry professor Richard Friedman, M.D. of Cornell, who cited a number of caveats that limit the usefulness of the new study. He concluded:

Every once in a while, a landmark study comes along and overturns everyone’s cherished ideas about a particular treatment. But the current study is not one of them. So it would be a shame if it discouraged depressed patients from taking antidepressants.

Experts may disagree about what constitutes the best treatment for depression, and for whom. But there is no question that the safety and efficacy of antidepressants rest on solid scientific evidence.

Bottom line: Don't throw out your antidepressants just yet. But if they don't seem to be helping, do talk to a good therapist about trying another approach.