Monday, November 27, 2006
Another post inspired by a New York Times article, 'Yours Truly,' The E-Variations. The article talks about how one signs off on their e-mails, what's warm and fuzzy, what's a cool blow off.
So sometime ago, I received an email from a colleague that was signed simply B. B? I knew who it was from, and in fact, the "Yours Truly" closer was very friendly, but I was left to wonder, why B? B is an important and busy man and maybe he signed "B" because he was too busy to type out his whole name. B, I will tell you, is short for for Bob, and just how busy could he be? Does it really take less time to type B then Bob? Around that time, another friend wrote some newsy e-mails addressed to "D" and signed off by "C." Another soul too busy to type out his own name??? I was a bit put off; I always have time to spell out my own name and I began to feel that to do so sends out the message that I'm not that important, I have all the time in the world, everyone else is working harder than I am. Finally, I got an e-mail from "T." Now T is a long-time good friend, she was a college housemate and a bridesmaid at my wedding. At last, I had an 'in' into the workings of the mind of someone who signs with a single initial. So I asked, and T sent me a long reply, noting that signing with an initial could indicate someone too busy to type their whole name, or it could indicate a friendly informality... I know you so well that my whole name isn't necessary. This cast an entirely new light on things, and I no longer felt that B and C were flaunting their busy importantness, now they were my good friends! The e-world was suddenly a friendlier place.
The article in the NYTimes, well, it didn't say much new (other than it's uncool to sign off with "Don't let the bedbugs bite"), but I was pleased to see that someone else in the world obsesses about these things.
Sunday, November 26, 2006
[posted by dinah]
I interrupt this cup of coffee to bring you yet another blog post inspired by an article in this Sunday's New York Times Magazine. This weeks inspirational piece is from The Funny Pages and is called "Celebrity Crazy" by Shalom Auslander. First, let me tell you that this piece won out --for the moment, anyway-- over the magazine story about the severely anorexic teenager, and the Times' ongoing series on diagnostic & treatment issues in severely mentally ill children. Something lighter, I suppose, in honor of the holiday weekend.
So the author seeks psychiatric treatment to deal with his anger issues. He is a reluctant patient and starts his narrative with:
"I'm not doing the couch thing," I said.
"You don't have to do the couch thing," he said.
"Good. Because I'm not."
"Should I do the couch thing?"
The author's therapy was going well, he reports, until the doctor referenced unnamed celebrity clients as examples of patients with similar issues. Mr. Aushlander liked this. "Cool, I thought, I'm as crazy as a rock star." Unfortunately, he began to see his relationship with his doctor in the shadow of this information. If there wasn't an available appointment on the day he wanted, well clearly he wasn't a colorful enough psychotherapy patient; his therapist was holding those hours for celebrities whom he assume had more exciting issues, perhaps even "heroin-fueled sex orgies." Rather than deal with his transferential feelings of neglect (--you'll forgive me here for making an interpretation on a patient I've never examined, I admit this may be a leap), the patient on the page decides to embellish his own life, to make it as interesting as one lived by the stars. When that doesn't gain the desired response from the therapist, the patient quietly decides to leave therapy.
So he's walking out the door when the shrink invites him to a family picnic in the Hamptons. Dinah-the-reader cringes, but okay, go on. Big party, busloads of people. Photos of the shrink on the wall with the celebrities. Poor Mr. Aushlander. But the shrink hugs him and takes him aside, asking that he be The First to read the book manuscript Dr. Shrink has written about one of the celebrities. Ah, Mr. Aushlander is special after all!! Oh, until he sees that the celebrity, not him, is thanked at the end. Oh well.
An amusing tongue-in-cheek tale, but who doesn't want to feel at least a little bit special to their therapist?
Saturday, November 25, 2006
I was at the grocery store this afternoon and as I was checking out I saw this week's copy of Weekly World News. The front page had a picture of three bug-eyed monsters dressed in surgical scrubs complete with masks and caps. The title of the story was:
I can't speak for my fellow bloggers, but I for one am not an alien. Not that I have anything particular against aliens---I would never require proof of terrestrial origin when hiring someone, nor would I support the idea of building a fence around Earth to keep them out. (After all, we're getting blown up to make way for an intergalactic highway anyway.)
But it did get me thinking about Harvard psychiatrist Dr. John Mack. Although not definitively an extraterrestrial himself, he did write books about alien abductees (now available used on Amazon.com for forty cents). He interviewed many people who claimed to have been abducted by aliens and found that they had experiences in common like being subjected to medical experiments or being forced to breed with aliens. He used hypnosis to regress the abductees and enhance their memories of what happened.
It's interesting to see the parallels between the alien abductee phenomenon and people purported to have multiple personality disorder back in the 1980's. (The abductee phenomenon was a bit later, with Mack's books published in the 1990's.) MPD patients sought treatment for trauma related to organized Satanic ritual abuse. They were treated by therapists who used hypnosis to enhance memory and often reported being forced to breed by cult members. They referred to themselves as cult "brood mares". (I always wondered why no one was ever groomed to be the Satanic cult treasurer.)
I don't know how many of these therapists accepted the trauma history as literal truth and how many used the abductee/Satanic abuse schema as a metaphor in treatment; the more important question is the validity of the treatment that was provided. Alien or not, patients deserve treatment that is not out-of-this-world.
Wednesday, November 22, 2006
Tuesday, November 21, 2006
Once in a rare while I get a sick call slip that sounds pretty benign, only to find the inmate has had a severe clinical depression that went untreated for months at the sending facility. It's challenging to know how to triage these referrals when you have to factor in the magnifier-minimizer effect. The exaggeraters are easy to work with but I worry about the stoic tough guys. They're the ones who quietly stay in the background and won't seek help until they're really really desparate. And then they don't want you to know how desparate they are.
The only thing you can really do is work as quickly as you can and see as many as you can so you don't miss somebody who shouldn't be missed, similar to a paramedic working at the scene of a car crash. And to make sure they have a good enough experience talking to you so that when they do have a serious problem sometime down the road they can feel safe getting in touch with you. A good clinical reputation can go a long way.
The best way to find out where you stand with the inmates is through what I call the "hallway quality assurance program". That's where the inmates hangout in the hallway as a group while waiting for an elevator or waiting to move to somewhere else that they're being herded to. You hear the things that inmates say among themselves and get the 'real scoop' about your reputation. It's an oblique version of Questions For The Doctor----it's Comments About The Doctor. Here's what I overhear about my reputation with inmates (all real and unedited, even the negative ones):
- "You gonna see that lady? It's OK, she real nice."
- "I'm here to see the social worker."
- "What a waste. She talks to me for five minutes and tells me I'm OK." (from an inmate irate about not getting sleeping medication. And it wasn't five minutes.)
- "She actually listens to you. She seems to care."
- "She's the only one who does any work around here."
- "Yo, check out those legs. She a speed skater?"
That kind of balances out the leg comments. And by the way, it's all muscle.
I just read that, due to budget cuts and political brinksmanship, the MA state hospital system has to make severe cuts, resulting in them no longer taking any new admissions through the end of the year.
Will where they go if the state is not an option. Is there enough excess bed capacity in Massachusetts? Will the ERs fill up? Will they be transferred out of state or left out in the cold? How will this work?
Blogged with Flock
Saturday, November 18, 2006
There's really nothing good about this story at all. But I'm interested in it from the access-to-care angle.
A 16 yo kid in California, two days after being taken to a priest for help with voices, is being accused of beating his mother to death, and was being held in the psychiatric ER for over a week, waiting for an adolescent psych bed for further evaluation. Apparently, no one had been able or willing to take him in on their unit.
The psychiatric unit at Contra Costa Medical Center is reported to only be licensed for adult beds. According to the news article, the unit medical director, Scott Weigold, made a stink about the kid's clinical needs trumping policy constraints. Sounds like he made no secret of his concerns (broadcasting the email to staff), was accused of insubordination (are they in the military?), and is essentially being told to not let the door hit him on his way out.
He e-mailed Dr. Jeff Smith, the hospital's executive director, saying he planned to admit Mantas to the hospital's adult inpatient unit.
"I explained in very ham-fisted and emotional manner, that I was desperate to prevent a young man needing psychiatric hospitalization from being required to live in (psychiatric emergency services) for another week or more," Weigold wrote in a letter distributed to his colleagues this week. "I demanded that potential licensing and regulatory issues ... are not sufficient to prevent us from providing this young man the only form of inpatient treatment available."
[...] Contra Costa acute-care facilities for adolescents accept only people who meet strict criteria for being held against their will, including being gravely disabled by mental illness or posing an acute danger to themselves or others, Smith said.
Contra Costa Regional Medical Center is not licensed to provide inpatient treatment to youths and does not have staff members credentialed to do so, he said.
Smith e-mailed back to Weigold, accusing him of insubordination and stating that he considered the e-mail to be Weigold's resignation.
I don't have much to say about the kid, but I do understand Scott's frustration. We see less burdensome kids in ERs for a week or more around the state. It does sound like he went about making his case in a less-than-effective way. However, I'm guessing that there is more to this story than mentioned here. For example, Contra Costa was in the news last week about closing down nearly half of their psychiatric beds, citing insufficient community need (this hospital is in the San Francisco area). But advocates are crying foul:
[Danville resident and advocate Nancy] Thomas raised questions about a loss of federal money for the psychiatric unit because of a dispute involving the qualifications of people overseeing it.
The Times reported last week that the U.S. Centers for Medicare and Medicaid Services will deny a higher Medicare reimbursement rate for this year, a rate the county has received since at least 1998.
To obtain the higher rate, the federal agency said the director of inpatient psychiatric services should be a psychiatrist -- he is a licensed clinical social worker -- and the unit's nursing director should have a master's degree in psychiatric and mental health nursing or comparable experience in caring for the mentally ill.
"Why would you leave $2.8 million on the table to just slip away?" Thomas asked county officials. "Why not keep those beds open?"
They were also in the news yesterday being accused by CMS of inappropriately transferring uninsured patients with psychiatric problems to other facilities... the article suggests that Scott started that policy. CMS said it would terminate its Medicare contract if the problems did not get fixed soon.
Getting clearer now... Most inpatient units have a medical director; in part, because of the above reason, but also because it just makes good clinical sense to have the person setting the rules be one with full medical training. Apparently, the social worker runs the show. Now, I'm not knocking social workers, but an inpatient unit providing medical treatment and medications should have medical oversight. N'est pas? Perhaps this was merely Scott's last straw.
* * *
BTW, I also note that Scott backed up Dr. A 5 years ago in an exchange on an antipsychiatry site (http://www.antipsychiatry.org/e-mail.htm#debate2). Wonder if it's the Dr. A we all know and love.
Blogged with Flock
In prison if you have a gang affiliation it's important to show your colors. For my older inmates---over age 40---that would be grey.
In general older inmates are respected by younger inmates. They make good cellmates because they're not considered a threat and because they may have some good advice to offer. They're quieter and less annoying than young cellmates who are busy yelling to their friends down the tier.
Chronological age and physical age aren't always the same. The street lifestyle can add ten to twenty years to one's physical age. In between the substance abuse, head injuries and HIV dementia there aren't a lot of young neurons in my outpatient clinic.
By policy every inmate is required to have an annual physical. Beyond a certain age they also start screening for dementia with an annual Mini-Mental State Exam. Neurology consults are available and you can also do the basic dementia related laboratory work. Inmates can be sent to outside institutions for brain scans if necessary.
The biggest challenge in carrying for elderly inmates is the need for nursing services. No general population tier has nursing staff to supervise showers, dressing or feeding. Elderly prisoners with mobility impairments are at risk of falling because correctional facilities just aren't built for fall prevention. There are no geri-chairs or vest restraints or non-skid rubber mats in the showers. My most memorable fall-risk example was of an elderly inmate with Parkinson's disease shuffling along in leg irons with untied shoes. It was enough to make a geriatrician cry. (I did make sure his shoes were tied before returning him to the tier.)
Some jurisdictions have options for special parole for elderly prisoners. You usually have to document that the inmate has a six month life expectancy or else is too incapacitated by disease to pose a threat to society. Of course, whenever you do that you run the risk of being wrong. Our most famous case of a wrongful lifespan estimate involved Deidre Farmer, a transgendered inmate with terminal AIDS. (Mr./Ms. Farmer was best known for his role in the landmark Supreme Court case Farmer v. Brennan, which established the mens rea (mental state) standard necessary for a facility to be found "deliberately indifferent".) Farmer was granted a medical parole and promptly went on to get better and commit new identity fraud offenses. He was ultimately apprehended after trying to forge his own death certificate.
So elderly folks with antisocial personalities can still be antisocial; they just do it slower.
Thursday, November 16, 2006
I thought I'd follow in Clink's footsteps and blog about things I've learned at the conference I am attending. This is the annual meeting for the Academy of Psychosomatic Medicine (APM), which is the organization for C-L (Consultation-Liaison) Psychiatry. (What is that? It essentially involves taking care of folks with other medical problems who also have something going on in the psychiatric area. If you look at this year's program, you get a sense of what we are about.)
Yesterday, I attended a 4-hour seminar on ECT. I don't do ECT, but it is done at my hospital. As Chairman of the department, I thought it was time for a refresher. Donald Malone and Leo Pozuelo presented (both from Cleveland Clinic). So here are some bullet points... (not to be used as medical advice...not warranted to be accurate)
[Ed: Most of us psychiatrists know that memory problems with ECT is a concern and that there is a need for better data, but these folks here focused more on the nuts & bolts of ECT, so I won't get into the memory issues here. There are a couple links in the comments, as well. The above Wikipedia link also has some discussion about this. Thanks, Alison.]
- Schizophrenia is the 2nd most common diagnostic indication for ECT in the US (Major Depression is #1)
- 86% response rate for initial treatment (50% after adequate med trials have failed)
- there are no absolute contraindications for ECT
- mortality risk ~1:10,000 (similar to that of any anesthesia)
- does not increase risk of spontaneous seizures
- common side effects: headache, muscle pain, nausea, same-day amnesia, same-day diminished cognition
- pre-tx with Toradol and 5HT-3 antagonist reduces SFX
- get separate consent for maintenance ECT, as reason is different (prevent relapse, not treatment)
- with maintenance, re-do consent every 6 months or so (some do it every time)
- monitor BP, pulse, O2 sat, ECG, EEG, nerve stimulator
- pre-oxygenate w/100% O2, esp w/morbid obesity, respiratory dz
- continue oxygen after stimulus for a bit
- BEWARE dental complications... most common adverse event... use bite block
- initial parasympathetic vagal discharge, with stimulus... can get asystole
- followed by increased sympathetic activity during clonic phase of sz
- then recovery phase, which can include both symp and parasymp
- can pre-tx with anticholinergic, like glycopyrolate or atropine
- check for dental issues
- H&P current
- assess by anesthesiologist & ECT provider
- routine brain and spine imaging not necessary
- CBC, CMP, EKG, HCG
- Post-MI: most do okay; 4-6 wks after MI generally okay; beta-blockade
- CHF: optimize cardiac status before ECT; give all rx in AM w/sips H2O; monitor for incr CHF between tx's; esmolol
- AFib: usually okay; may convert to sinus; ?incr risk if not on AC
- Pacemaker: no need to turn off; do turn off VNS
- Epilepsy: may use flumazenil to decrease sz threshold in pts on chronic benzodiazepines; keep AEDs on board; stack the deck by hyperventilation, etomidate, caffeine
- Parkinson's: ECT may improve motor fn; halve the antiparkinsonian dose (eg, Sinemet); might decr ECT to 2x/wk
- Dementia: 2/3 improved mood; 1/2 improved cognition; electrode placement; 2x/wk; ?hold Aricept vs keep and adjust succinylcholine; may reduce agitation... occ used to treat severe agitation in dementia
- NMS: last line
- MS: no problem
- Pulmonary: may need to intubate w/COPD; take inhalers in AM
- Osteoporosis: use good muscle relaxation; use neurostimulator to assure good relaxation; ?check spine XR
- DM: give half of usual insulin in AM, 2nd half after breakfast; check BS; hold AM insulin if prone to hypoglycemia; usually hold AM oral hypoglycemics
- GERD: pre-tx with H2-blockers
- Glaucoma: use drops in AM; ECT can briefly incr IOP
- Pregnancy: does not typically affect FHT/uterine tone; monitor fetus in high-risk preg; get OB consult
- increased ICP
- bad cardiac dz
- recent stroke
- severe pulmonary disease
Relapse after ECT: Sackeim (JAMA 2001)... relapse after ECT = 84% on placebo, 60% on nortriptyline, 39% on nortrip+lithium
* * *
Coming up ... Day 2 ... suicidality ... psychosomatic medicine ... alcohol withdrawal
Blogged with Flock
Wednesday, November 15, 2006
I contemplated putting up a post about the most embarrassing questions patients have ever asked, but honestly, I'm too embarrassed to repeat the worst one ( and no, I didn't answer). And I'm not someone who is easily mortified: I will readily admit that I did once show up in clinic wearing my dress inside out, and yes, it was obvious.
So recently, a colleague insisted I was in training with him. I wasn't, in fact, I finished 10 years after he did, and it occurred to me that he thinks I'm 10 years older then I am. Clink says it isn't so: Thank you, Clink. This still wouldn't make me as old as Meryl Streep, whom I look nothing like, but we don't have to go there today.
The day after my time warp with my previously-esteemed colleague, I saw a patient I hadn't seen in a few months. He has a persistent mental illness which limits his life in many respects. He is always pleasant, but always answers my questions with a simple Yes, No, Fine, Okay. He offers little else and I've been unable to learn much about him, though he's seen me in the clinic for many years now. So I asked my patient, as I often do, "Do you have any questions for me?" On this particular day, he asked, "How old are you?" Well, this was a rather sensitive topic given the weird insight the day before that I could be mistaken for someone 10 years older then I am. I responded, "How old do you think I am?" (Please don't tell my former supervisors this, they'll revoke my Boards certification.) Whew: he aged me a few years younger than I am. I answered his question (at this point, why not?) and then he asked, "Do you believe in God?" Okay, I didn't care if he knew how old I was, but enough is enough.
I told the story to Clink, and she responded with one of her own:
So in my clinic this afternoon my inmate patient said to me, "Oh, you're doing Lord of the Rings today.""Huh?" I said."Your dress," he said. "It's like what the elves wore in that movie.""Oh," not knowing what the heck I should say to that. Then I started thinking--yeah, yeah I could get confused with Liv Tyler. Sure, it could happen. At least he was commenting on the dress and not my ears.
And, Roy, what do your patients say about you?
P.S. I can't wait for Fat Doctor's stories.
Monday, November 13, 2006
Last week, I saw Martin Scorsese’s The Departed. It was in every respect an excellent, riveting movie where the action never paused and 150 minutes simply flew. Excellent in every respect, that is, but that I left the theatre unsettled by the film portrayal of yet another disturbed psychiatrist.
Vera Farmiga plays the smoldering Dr. Madolyn Madden (why aren’t psychiatrists ever named Dr. Sanity?) who works for the state of Massachusetts treating traumatized police officers. She quickly becomes involved with good-guy/really bad-guy Colin Sullivan (Matt Damon) after a chance elevator meeting where sparks instantly flew. She then sees Billy Costigan (Leonardo DiCaprio) the bad-guy/really good-guy as her patient in psychotherapy. In their discussions about truth and deception, Billy quickly turns the tables and manages to unnerve Madolyn, after which he demands Valium. She chases him down to give him a prescription, hands it to him saying she’s referring his case to another clinician, and moments thereafter ends up in bed with him which she deems fine because he isn’t her patient. Oy. Here we go again.
Why is it that the shrink is always either part of the problem—think of Dressed to Kill where the cross-dressed psychiatrist kills his patients or Silence of the Lambs where Dr. Lechter doesn’t just kill them, he sautés and eats them as well—or consumed with problems of her own? Even The Soprano’s Jennifer Melfi (Lorraine Bracco) who gets my vote for conducting the media’s most realistic portrayal of psychotherapy, is kind of screwed up. She does okay inside the consulting room, but after hours, her marriage has failed, her son is a mess, she confesses to her own psychiatrist that she drinks to deal with all the stress.
But, wait, you say, what about Judd Hirsch in Ordinary People? He played a good psychiatrist, he helped the kid. He was everyone’s ideal doctor, available at 3 AM for therapeutic breakthroughs, engaged and engaging, insightful, and even kind of normal—a role model for psychiatrists every where. Can I point out that Ordinary People, still sited and remembered for the Judd Hirsch portrayal, was released in 1980, nearly twenty-seven years ago?
So does it matter? Do these media images of psychiatrists as disturbed, if not dangerous, individuals who sleep with, kill, and even eat their patients because of their own psychopathology influence the real man’s decision about whether to seek help when his distress gets to be too much? Does it add to the stigma that still permeates the world of mental illness? Or is it all simply entertainment, obviously distorted and exaggerated to meet the needs of the big screen?
Who knows? I believe it leaves both psychiatrists and psychiatric patients a bit ill at ease. I hope, however, that the benefits of psychiatric care speak for themselves. Psychiatric treatments change people’s lives, usually for the better, even when administered by morally conscious, ordinary psychiatrists. Unfortunately, that’s not entertainment.
Saturday, November 11, 2006
I forget where and when I've heard his name before, but when I got to the airport and picked up something to read on the plane, my thalamus filtered down onto Fast Company's cover article (What If You Never Forgot Anything? [use acces code FCNOVENG]) on Microsoft's Gordon Bell, ringing a bell in my head.
The bell ringing was attached to other dimly recalled bits -- Xanadu (or something like that... [ed:it's Memex]), a guy from the 1950's (what is his name [ed:Vannevar Bush]? I wish BWI had free internet access so I could google it), and past articles I've read about neurocomputer interfaces). The article is about this brilliant Microsoft researcher who has spent the last 7 years recording every single interaction he has. Conversations, phone calls, emails, faxes, paper documents... you name it. He accumulates an average or over a megabyte per hour, a gigabyte per month. He's obviously not keeping any video (but he does snap a photo every 60 seconds).
Why? It's an experiment in computer-assisted human memory, or maybe call it "memory augmentation". It's a log of your life, or a lifelog. Editor Mark Vamos would miss the ability to forget those memories which evoke embarrassment or regret, but the delete key (or hard drive failure) could take care of that.
Okay... it came back to me as I read the article. I've been to his website before -- MyLifeBits -- when I saw something about this a few years ago. I can see the utility of something like this.
Well, the challenge with this sort of thing (which, I must say, is pretty cool) is not in doing it. It lies in the ability to search the info... searching text (easy), audio (harder), and images (harder still) ... while also being about to easily access and efficiently use associated data and metadata.
If you want to start your own MyLifeBits experiment, writer Clive Thompson includes a 7-item shopping list [use acces code FCNOVENG]
So, I'm thinking about the impact this would have on Psychiatry. Now I'm putting myself in the patient's place. Recorders blaring, I could easily review my therapy session and get more bang for my emotional buck. If my therapist flogged too (flog=lifelog... I'm still on the plane so I cannot google "flog", but I'm sure that I can't be the first to coin this term), I could tap into her system and see my reactions from her perspective, maybe in a picture-in-picture sorta deal.
"Frank Nack: 'I'm a big fan of forgetting. I don't want to be reminded of everything I said.' Forgetting ... is key to cultural concepts like forgiveness and nostalgia."
"...knowing that everything is being logged might actually turn us into different people. We might be less flamboyant, less funny, less willing to say risky but potentially useful things..."
"If you lose your keys, you can scroll back and figure out where you put 'em."
"But the real goal is to 'discover things that even you didn't know that you knew.' "
"In spring 2004, Gemmel lost a chunk of his memory... [His] hard drive crashed, and he hadn't backed up in four months. When he got his MyLifeBits back up and running, the hole that had been punched in his memories was palpable, even painful."
The article also reviews experimental software which mines the data in Gordon's LifeBits. It associates unexpected ideas based on past memories, recalls long-forgotten bits at just the right time, and creates new information, connections, and ideas buried in your flogs.
Like a good therapist.
This could put quite a few therapists out of business. But it would also open up a whole new area of psychotherapy -- lifelog-assisted psychotherapy ("flog therapy"?). This could only develop after folks have flogged quite a bit of their life, I would think. So the therapist would become a sort of guide, teaching folks new, psychodynamically-informed methods of mining their flogs and tapping into their "unconscious."
Well, I guess I've gone out on a limb here. But probably not much further than I did in Reality Therapy Vlog.
The flight attendant is making us put our portable electronic devices away and place our tray tables in their upright, locked, position. If I had my flogging equipment, I'd show you all her picture (looks kinda like Bjork, very cute) and you could hear her admonish the guy in front of me who was refusing to turn off his iPod. Alas, it will all be a dim memory in a few weeks. Gotta go.
Blogged with Flock
Friday, November 10, 2006
Buttercup was dressed in tiny costumes and humiliated as a piglet and so he has anger issues. He has been treated with Seroquel, Risperidal, Ritalin, Cylert, Strattera, Paxil, Prozac, Wellbutrin, lithium, valproic acid, Tegretol and clonidine. He has had individual and family counselling, anger management therapy, cognitive behavioral therapy and a structured behavior plan. His family has mortgaged the house to pay for his medication, therapy, Level 5 schooling, residential treatment, private attorney, victim restitution and the costs of his juvenile probation. He will be coming to my prison next week. I know the first thing he is going to say:
"I keep begging for help, but all they ever do is lock me up!"
The most recent Journal of Clinical Psychiatry has an article about using the active ingredient in psilocybin mushrooms (which is a potent specific serotonin receptor agonist) to treat OCD. I wonder if anyone knows of folks with OCD who have tried LSD or other hallucinogens. The study suggests that, whereas traditional medications for OCD may take 3 months to work, this drug worked same day, and its effects lasted beyond 24 hours.
I have to start with a disclaimer: I am not a child psychiatrist.
Also ClinkShrink posted below while I was typing this. Make sure you check it out, and by all means, comment on her post, it makes her day!
So this month's American Journal of Psychiatry arrived in the mail today. I read for a bit about how the suicide rate in children ages 5-14 has was lower in areas where the number of SSRI prescriptions were higher. It's a complex issue, I'm not sure I followed it all (--okay, I read it really quickly and I skipped to the Results and Conclusions sections) but the point was that the Black Box warning on anti-depressants may be inaccurate, or may discourage use of a medication that lowers, rather than raises, suicide rates.
So I came home and ran through my blogroll. Shiny Happy Person and FooFoo are still missing in action. Fat Doctor and Dr. A are both tired and have photos of trains on their blogs. Dr. Crippen across the way on the NHS Blog has a post about children and depression. Poor Dr. Crippen is frustrated; he has a long post--- a really long post-- on how mentally ill children in the UK no longer have access to child psychiatrists, that the system has been dummied down with non-physician, under-qualified mental health care workers.
Over here, at least in major metropolitan areas, mental health centers which treat children all have child psychiatrists on staff. At least on good days. I've already written my thoughts about why psychiatrists should see patients for psychotherapy. As important as that is, it's even more important for child and adolescent psychiatrists to see their patients for psychotherapy, and it's hard to find docs who do both, who do both well, who have time to accept new patients, and it's expensive and really an option only in the private sector.
So why do I think this is so important? And remember, I'm not a child psychiatrist.
Suppose we assume that the FDA is right and that SSRI's cause some children to have suicidal tendencies (-- note that none of the children in the studies of these medications died of suicide). The current thinking is that this may well be right, that a small percentage of children, say 1 to 2 per cent, start thinking about suicide after beginning these medications, and that the thoughts are the result of the medications, not simply a pre-existing symptom as a result of the depression. It seems that the highest risk is in the first few weeks, perhaps even the first few days, of treatment, and as such it is now suggested that children be seen weekly during the initiation of pharmacotherapy. At any rate, warranted or not, the Black Box warning has given parents reason to pause before allowing their children to be medicated, and has given pediatricians reason to refer to specialists.
So a child is seen for depression. Perhaps he sees a psychiatrist who does only medication evaluations, and not psychotherapy. In this setting, the psychiatrist generally does a comprehensive evaluation with the patient and the parents. Based on his/her exam and the reported symptoms, a medication may be started. The problem with "medication evaluations" is that there is some pressure to make a decision about medications fairly quickly. Generally, patients walk away from these first-time visits with a prescription, maybe an appointment to come back in a few weeks for a "med check." It takes the medicines weeks to work, so this makes pharmacologic sense, it just doesn't make patient sense when dealing with a distraught human being. With kids, though, the stakes are higher now, we have that wonderful Black Box warning discouraging the use of anti-depressants. Oh yeah, and there's this other thing with kids: they go through "phases." It can be hard to figure out what's a reaction to circumstances -- think things like parental divorce, moves, new schools, broken hearts-- or what's a normal developmental stage-- think teenage angst, moodiness, irritability, some of which is psychopathology warranting medication and some of which is not. So, if the psychiatrist sees a child for psychotherapy, there isn't a rush a to determine if a medication is needed immediately, he's able to try psychotherapy as a first-line treatment in less severe cases, and he's able to more closely monitor the child's progress, response, and adverse reactions.
Just my thoughts.
Thursday, November 09, 2006
- Zacarias Moussaoui was really nuts. He was also really a member of Al-Qaeda.
- Forty people have requested physician-assisted suicide in Oregon where it's legal. (After our discussion with The Ethicist I call physician-assisted suicide the Probate Attorney Employment Act. I wonder how you defend a will for someone who's been euthansized.)
- Psychotic death row inmates in South Carolina are more likely to select electrocution over lethal injection.
- Serum cortisol levels correlate with performance on simulated emergencies faced by police officers. Police performance varies inversely with the officers' own opinions about their performance.
- Suicide screening instruments do not predict suicide deaths in corrections (yeah, we pretty much all new that).
- In 1970, 90% of all FDA Phase I trials were conducted on prisoners.
- For the CSI fans among our readers, there was a terrific panel presentation on the forensic investigation of motor vehicle accidents. This is what I took away from it:
Here is a partial list of injuries found at autopsy during motor vehicle death investigations:
1. transverse skull fractures and a ring fracture of the foramen magnum.
2. petecchial hemorrages in the eyes and the skin of the upper thorax from traumatic asphyxiation
3. aortic transection, liver laceration and rib fractures from thorax trauma
4. fractures of the wrists and forearms (from gripping the steering wheel)
5. fractures of the ankles (from stomping on brakes)
6. "dicing" or cube-shaped lacerations of the lateral arms due to side window glass (indicates body position at time of impact)
Forensic biomedical engineers have a fascinating job. One admitted: "Crash testing is really fun."
The bottom line on the crash investigation panel: Presentations featuring autopsy photos should never be scheduled immediately before lunch.
Wednesday, November 08, 2006
I'm not sure what to say. I've never gotten anything quite like this.
In honor of the upcoming holidays, one of our blog readers has donated a flock of ducks to a family in need. Wow! Look how happy that kid looks with all his ducks in a row.
Heifer International is a nonprofit that alleviates hunger, poverty, and environmental degradation through gifts of food and income producing farm animals and training. These animals provide a source of protein, such as eggs and milk, for children and generate income for families through the sale of animal products. Since 1944 Heifer has helped over 4 million families in 125 countries become self-reliant. Each family "passes on the gift" by giving one or more of its animal's offspring to another family in need.
This is very exciting. Clink will be making sauce for all the ducks , family members will have a choice of bing cherry sauce or l'orange. Roy is relieved, these meals will spare a few fish and with those failing fisheries, every poultry meal helps.
So to DrivingMissMolly: Thank You from the Shrink Rappers.
Please note that Fat Doctor has also posted about holiday gifts to the doc. I'm not sure what to send in her honor. Perhaps we could send Midwife with a Knife baby pics of the little ducks?
Tuesday, November 07, 2006
This is all a lead in to my dislike of my husband's favorite TV show: Curb Your Enthusiasm. In case the show isn't bad enough, he TiVo's all the episodes (this allows him to re-run segments over and over) and sometimes rents old seasons.
For anyone who hasn't seen it, this HBO show is about Larry David, the creator of Seinfeld, and features him as a misanthopic nebish, who dissects life in a way that makes me cringe. In case your Yiddish is rusty, from YiddishDictionaryOnline.com: Nebish: nebish (American Jewish), a person who is inept, ineffective, shy, dull, a nerd.; a loser .
Okay, so Larry David plays his own character and the character bears his real name, but one has to assume this is a fictionalized version, kind of a Seinfeld-ized view of life. He isn't shy or even dull, but he is inept, a definate social loser. The storyline is about how he continually manages, through an amazing talent for social ineptitude to get himself into one bind after another. His world view is characterized by a cynical spirit tinged with paranoia. His talent for inappropriateness reminds me of someone who floats around the autistic spectrum, and in the middle of conversations, he suddenly focuses on the most inane of details. I don't just dislike the show, I get uncomfortable and even annoyed watching it.
So let's take one episode, or just a fragment of that episode. Larry is trying to get a friend to find him tickets for synagogue for the High Holy days. Normally, he's not religious, but this year he wants to go because he nearly drowned and he decides he was meant to go. Mid-conversation, he starts up a discussion about how the handle on his teacup is too small. Then he decides to leave the party, even though he's brought another couple and they don't want to leave yet. That night in the throes of marital relations, he insists on answering the phone. And finally, upon being honored at Leo's Deli by having a sandwich named after him, he lets Leo know he's displeased because he doesn't like his sandwich: can't Leo give him someone else's sandwich? And when an insulted Leo won't trade his sandwich, Larry says he'll find someone to trade, all while his father is sitting at the table, please with his Larry David sandwich, but in the midst of either choking or having a stroke.
Never mind, you decide: Click here to watch Curb Your Enthusiasm
So what's this doing on our Shrink Rap blog? I watch the show and feel like I'm watching a patient, not a comedian. I'm still trying to figure out why it makes me so uneasy. What do you think?
Saturday, November 04, 2006
According to yesterday's Science Magazine, we may lose the availability of sustainable fisheries by 2048 (see Scientific American: Overfishing Could Take Seafood Off the Menu by 2048). The article predicts total collapse of all world fisheries by 2048. "Total collapse" is defined as 90% depletion since the 1950s.
[prepare for non sequitur]
We have also been rapidly losing the availability of psychiatric beds for folks in need of acute inpatient hospitalization for mental health problems like major depression, bipolar disorder, and schizophrenia. In Where have all the psych beds gone?, I deplored the massive loss of inpatient psychiatric beds over the past 40 years or so. We used to have 20.4 beds per 10,000 population, and it is now down to 3.6. The numbers are now at about 18% of what they were previously. Another 8% to go before the U.S. hits "total collapse." Of course, there has been an opposite trend in forensic psychiatric beds, but I'll leave that for Clink to blog about (also see Hot Potato).
"Holy mackerel!" is right. People are boarding for days at a time in Emergency Rooms all over the country, waiting for a bed to become available. So, what's the current state of affairs? Check it out...
Pennsylvania State Hospitals Cutting Beds: NAMI President, Dr. Suzanne Vogel-Scibilia, as well as other citizens, petitioned the governor to halt bed closures. "'We ask this because of current inadequacies in community resources and the lack of a statewide comprehensive plan for closure and placement,' the petition reads."
Florida Community Loses 16 Beds: Citrus County now has no psychiatry beds. Hospital officials say the beds were not needed. "But mental health advocates say Florida faces a shortage of inpatient psychiatric beds. The state received the lowest score possible in terms of access to inpatient services, according to a recent study by the National Alliance on Mental Illness. 'There are about 3,000 more beds needed in the state,' said Sue Homant, executive director for NAMI Florida. 'My personal guess is the number is even higher than that.'" ... According to NAMI's Report Card, Florida scored an F in Infrastructure, 48 out of 50 in per capita spending on mental health (a whopping $37.99 per person), and was number 15 in suicide rank. Florida is floundering.
Ohio Gaining Beds: "Mental health professionals say more beds are needed since a number of hospitals with psychiatric services closed or cut beds in the past decade."
Connecticut ERs Filled to the Gills: 2-weeks in ER awaiting a bed is common [treating them in a unit takes less time than this].
Let us know what is happening in your state (or country).
[posted by dinah]
One commenter (was it Sarebear?) mentioned some time ago that she didn't know what to get her psychiatrist for the holidays. I thought about this and decided the answer is easy:
Give your psychiatrist a holiday card and write something meaningful and kind in it. Say, "Thanks for helping me." Or "I'm glad you're in my life." "You're the best psychiatrist in the world" works nicely, too. If you hate your psychiatrist and for inexplicable reasons feel compelled to get them something anyway, then skip the note and just give a generic Seasons Greetings card.
Don't get your psychiatrist an expensive gift. And don't, not even as a joke, give your psychiatrist money or make comments about a holiday "tip."
So gifts and shrinks are often an unsettling combination. As psychiatrists, we're taught that treatment is offered for a fee. End of discussion and anything more represents a violation of boundaries. Psychiatrists in training are told not to accept gifts, and psychotherapists as a whole are taught to try to understand behaviors that skim the usual boundaries. So, theoretically, the psychiatrist should refuse the gift and explore with the patient what meaning the gift, the refusal, the whole exchange, has to the patient.
When residents ask me what to do when patients want to give them gifts, I say "Tell them the program has rules that say you're not allowed to accept gifts." This is the truth and the resident risks getting in trouble if they do accept gifts. If you can't take a pen from a drug rep anymore, why should you be allowed to take a timeshare from a patient? (Okay, I made that up, I've never heard of a patient gifting a resident with a timeshare, but we can all have fantasies, right?)
I'm in private practice, there's no program director, I make the rules. When a patient gives me a gift, I accept it and say, "Thank you." Why? Because it seems intentionally hurtful to do otherwise-- I assume it has meaning to the patient, that their feelings will be hurt if I refuse the gift, that the patient has taken the time, effort, and money to pick out a gift and this represents something meaningful to him and that it might be painful to have this refused. While the act of giving a gift might have a multitude of meanings, depending on the gift, depending on the patient's illness, depending on the circumstances, I just can't find a way to say No that would feel anything other than rejecting. So I accept the gift and thank the patient, and if the gift is edible, I eat it. This is the thing though: while I've decided that this is the way to go, at least so far for me within the realm of my own practice, I always feel like I'm doing something wrong by accepting a gift, training issues remain in the back of my head, and I'd really rather just have a card that says I'm the best psychiatrist in the world.
Disclaimer in honor of Dr. A, Fat Doctor, Flea, Midwife with a Knife and other non-shrink physicians: Doctors in other specialties have no such concerns with accepting gifts. They probably don't want anything that taxes your budget. Food is usually good, a bottle of wine, a plant, candles, all will do nicely. Fat Doctor, I hear, is in need of some good toe nail polish remover.
Friday, November 03, 2006
Just a quick list of relevant FDA and related notices...
Europe approves Chantix: FDA approved this drug in May, but I have yet to see ONE patient on it. This is a unique, anti-smoking drug, so I figure it would be going like gang-busters by now. What's up with that?
Generic Zyprexa: Generic-maker Roxane has received "tentative approval" to make generic olanzapine. This Lilly drug is usually one of the top 3 most costly line-items in each state Medicaid pharmacy budget. The problem with "tentative" approvals is that there remain many hoops for Roxane to jump through, including patent battles, before they can get this to market. Lilly's patent expires in 2011, so it may be a long battle.
Johnson&Johnson has received an approvable letter for their new schizophrenia drug, paliperidone. Unfortunately, it's not much of a new drug. Risperdal (risperidone) get converted to paliperidone in the liver, so the new drug is pretty much the same as the old one. But since Risperdal comes off patent soon, this new drug provides more shelf-life on this product. I figure most will stick with the older, cheaper drug. For more on this, and a great blog I just discovered, go to David E. Williams' Health Business Blog.
First Autism Drug: Janssen (a J&J subsidiary) received a new indication for "irritability associated with autistic disorder" for Risperdal (there are some concerns). That's two firsts. First drug for autism. First drug for "irritability". This really opens up a whole new horizon. It will now be a race to get a drug approved for "agitation associated with dementia". This would be a block-buster!
Severe Alzheimer's Dementia indication approved for Eisai's Aricept (donepezil). It used to be just mild to moderate dementia.
Seroquel for Bipolar Depression: AstraZeneca has received a new indication for "treatment of major depressive episodes associated with bipolar disorder." I think Lamictal is the only other one with this indication (correct me if not).
Thursday, November 02, 2006
I know it's a crazy (woops) idea, but I have to get it out of my system. What do readers think of a podcast from Dinah, Clink and me? I'm thinking of kinda of a free-wheeling (with some structure, I guess) discussion about, well, some of the same types of things we blog about?
Would anyone listen (I know, why listen to our blather?). What do you all think?
Wednesday, November 01, 2006
Everyone needs a camel, but only Dinah needs a giraffe.
She inspired me tonight. I knew I had one, somewhere, buried deep in the thirty plus years of memorabilia scattered everywhere in my house. I tore my second floor apart tonight looking for this. I searched everywhere---closets, drawers, my filing cabinet. At last, there it was along with a number of other things I doodled in my high school, undergrad and medical school days. Somewhere there are also caricatures of our department chair and residency director, but they may be trapped on the hard drive of my 21 year old Mac Plus.
Over the next few weeks I'm going to put them up on the blog with my posts. On the average they are 25 years old. Most of them are done in pencil on legal paper, overdrawn with black felt tip pen. And I can honestly say I didn't see anything like this last week at the Chicago Museum of Contemporary Art.