Wednesday, December 30, 2009

Forwarding Address


I moved my office yesterday. As fate would have it, the final piece of mail I received at my old address was a notice from Medicare informing me that I needed to update them if there were any changes in my practice, for example, a change of address. It told me where to go (on the internet, that is).

Okay, so in case you're wondering, Medicare has 221 downloadable forms on their website.

If I understand the directions right (and do feel free to help me out here) CMS-8551 is the form for me:

Additional Information Physicians can apply for enrollment in the Medicare Program or make a change in their enrollment information using either: 1. Have a National Plan and Provider Enumeration System (NPPES) User ID and password to use Internet-based PECOS. • For security reasons, passwords should be changed periodically, at least once a year. • For information on how to change a password, go to the NPPES Application Help page and select the “Reset Password Page” on the NPPES Application Help page. 2. Go to PECOS to complete, review, and submit the electronic enrollment application via PECOS. 3. Print, sign, and date the two-page Certification Statement and mail it with all supporting paper documentation to the Medicare contractor within seven days of the electronic submission. NOTE: A Medicare contractor will not process an Internet enrollment application without the signed and dated two-page Certification Statement and the required supporting documentation. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed two-page Certification Statement that is associated with the Internet submission. Physicians who are enrolled in the Medicare Program, but have not submitted the CMS-855I since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS-855I) as an initial application when reporting a change for the first time. If a physician has any questions about reporting a change, the physician should contact his or her designated Medicare contractor in advance of submitting the CMS-855I.
(Note, I deleted the Medicare web addresses from the body of the text I copied)

Okay, so 221 downloadable forms, and the form for change of address is the CMS-8551. No prob, I'm on it. PECOS. What are PECOS? I know what pesos are, but PECOS? So form CMS-8551, downloaded for my change of address is 27 pages long. What would it take to get Medicare to have 222 downloadable forms, with the 222nd form being a one-page change of address form.

Tuesday, December 29, 2009

Shabby Chic is Perfect!


I moved today! My new office is wonderful. Roy made fun of me because I went to 4 paint stores and 'test drove' 8 different shades of tan, finally settling on Shabby Chic (tan). It's perfect and it goes nicely with the "mushroom" colored carpeting that was being installed at 4 pm yesterday.

So I'm excited. Same furniture. Same Dinah. Mostly the same pics on the wall. Somehow, though, I feel like I got something big out of the way.

Wednesday, December 23, 2009

Happy Holidays!


Happy Holidays from the Shrink Rappers.

It's that time of year when blogging gets a little lame.
I'm off to pack up my old office, feeling a bit sore after two days of trying to keep up with my high school athlete kid....I'm feeling a little out of shape these days, and so after a day on the ski slopes and an hour or so being yesterday's squash partner, well, I'm not moving so fast today! And my college kid has finally made it home after days of exams.... arrived for a month with a small suitcase containing his XBox and some dirty crumpled clothes, still refusing to be my Facebook friend.

Clink is off to the cold to ski and climb things. Roy....he was in the mall last night... who knows what he's up to? His new puppy seems to have a better designer wardrobe than I do.

So we'll blog or we won't, but if we don't, please know we're wishing you the best for a joyous holiday season and a safe, happy, and (mentally & physically) healthy new year!

Sunday, December 20, 2009

Facebook Undone


Today I was friended by psychiatrist friend I haven't seen in a while. She's in her 80's and has always been pretty technologically savvy. I told one of my teenagers, who has met this friend in real life, and she (the teenager) told me she didn't want to hear it! Huh, you aren't interested in my Facebook life?

"People don't talk about what happens on Facebook."

Huh? Neat stuff happens on Facebook, why can't I talk about it?

Well, I got an earful. You talk about what happens on FB, because then it's like you don't have a real life, and people will think you're pathetic, and this will push away the real people in your life who now think you're rather dismal and all you have to talk about is your virtual life because you have no real life to talk about, and then you'll have less people in your real life and you'll need Facebook even more, and it's a vicious cycle.

Mostly likely, I'm doomed.

Friday, December 18, 2009

Do Generics Work as Well as Name Brands?


It's my first night of vacation! I saw my last patient today and then started pulling the pictures off the walls in anticipation of my move. I ran over to see the new place, and it still needs insulation (it's on the floor), paint, and carpet. And doorknobs might be nice.

So we're expecting quite the snowstorm here. I'll let you know how it goes tomorrow, but the current forecast is for up to 20 inches. It didn't take me long to float from the weather to the health section of the New York Times, and here's an article by Leslie Alderman about generics versus name brands.

Are generics as good as name brands? I don't have any studies, I'm purely running on anecdotes, but this is my thinking: Usually. When I was resident, I learned that 15% of the time (and this isn't science, I don't think, I believe it's someone else's anecdote) generic nortryptiline doesn't work when name brand Pamelor does. So I've always asked patients to start with Pamelor....I don't use it much anymore....because who wants to spend 6-8 weeks on a medication trial and have someone not respond only to realize they were in that small group of patients who are sensitive to the brand.

Other meds: I've had a handful of people complain about generic Prozac-- fluoxetine. It's not as effective for them, or they have more side effects. Alderman's article talks about Wellbutrin XL and I didn't even realize that the XL form now has a generic. Sometimes people want the name brand.

So what do I do when a patient specifically requests the name brand? I give it to them: if they are right, then they are right. And if they simply believe that they won't respond to the generic, because there are people who say "Generics don't work on me," well, then there's power to such beliefs, and I just want my patients to get better.

What do you think?

Tuesday, December 15, 2009

Unemployment Is Not Good For Your Mental Health


From the NYTimes, "Poll Reveals Trauma of Joblessness in US" by MICHAEL LUO and MEGAN THEE-BRENAN

The article notes:

With unemployment driving foreclosures nationwide, a quarter of those polled said they had either lost their home or been threatened with foreclosure or eviction for not paying their mortgage or rent. About a quarter, like Ms. Newton, have received food stamps. More than half said they had cut back on both luxuries and necessities in their spending. Seven in 10 rated their family’s financial situation as fairly bad or very bad.

But the impact on their lives was not limited to the difficulty in paying bills. Almost half said unemployment had led to more conflicts or arguments with family members and friends; 55 percent have suffered from insomnia.

“Everything gets touched,” said Colleen Klemm, 51, of North Lake, Wis., who lost her job as a manager at a landscaping company last November. “All your relationships are touched by it. You’re never your normal happy-go-lucky person. Your countenance, your self-esteem goes. You think, ‘I’m not employable.’ ”

A quarter of those who experienced anxiety or depression said they had gone to see a mental health professional. Women were significantly more likely than men to acknowledge emotional issues.

Monday, December 14, 2009

Electronic Hair Records!


Roy has Electronic Medical Records on his mind lately and if you'd like to hear him, oh, he'd love to tell you his thoughts. Or read his last post here. I'm still not sure how I feel about Electronic Records-- I worry about confidentiality and the propagation of incorrect information.

So why are medical records oh so important? What about making other important things into Electronic Records so that information can be shared and referred to? Never mind Electronic Medical Records, what I need are Electronic Hair Records!

Hair, you ask? Hair! Let me tell you about my hair. I am a user of hair chemicals and it's no picnic when I'm away and need an emergency procedure. What could electronic hair records do?
Well there was the two year period where I saw a very nice hair dresser and somehow my hair was always too light. I had her switch chemical brands, but to no avail. Finally, I switched salons, and my hair is darker. There was the time that I wanted to have a chemical procedure done with a gift certificate at another salon and was told that if I'd had a certain process done previously, my hair might break off or fall out. If there was an EHairR, my hair dresser could have checked this-- instead we had to call my home salon and determined that it wasn't safe....my hair, indeed, could have fallen out. Oh, and because of all the processes, I must use a sulphate-free shampoo. No EHairR: I have to be the one to remind the shampoo person of this issue each and every time. No one even asks.

So what could an Electronic Hair Record do?

  • Keep track of all chemical processes, brand names, colors, and dates of application.
  • Coordinate dates of chemical processes to prevent interactions.
  • Include panoramic photos of all haircuts so that patron could walk in and say, I liked the way it looked after the last cut and that cut could be reviewed.
  • Include standardization of lengths: bangs to a half inch above the eyebrows would be precise.
  • For those with thinning hair or balding, track hair loss.
  • Include computer generated growth photos to help schedule haircuts with important life events.
  • Download onto a iPhone app so the patron could, at last, own their own EHairR!
  • Compare costs and ratings for different salons and hairdressers.
I think I'm on to something here.

Sunday, December 13, 2009

Flower for Patients


A group of internet friends (what do you call people you know only via the net? peeps? tweeps? there have to be better words) have been talking over the last couple weeks (via Google Wave and also on Posterous and Skype about what we've been calling "Flower" or #hcflower on Twitter) about the changes that need to occur to reform health care.  One of the revolutionary -- and critical -- changes needed is the recognition that patients need access to their health data.  They not only have a right to access it, but should own it and be able to license access to it.  For a particular purpose.  For a particular period of time.  To particular individuals or organizations (my doctor, my hospital, my insurance company, my wife, my tweeps).

But that is not being much discussed in Washington.

One of these friends is Gilles Frydman, who also founded ACOR.  Click on his post on Open Streams and Fax Machines below.

-via Gilles Frydman on e-patients.net

"Close to $2.5 trillions have been spent on health care since President Obama announced his decision to reform the health care system. A year later, as expected,  all the talk in Washington remains about:






  • the end/restart/end-again of the public option
  • the expected final/interim/temporary definition of “meaningful use”
  • the amount of savings/taxes/additional expenses
  • move from FFS (I really mean Fee-For-Service) to PFP and
  • comparative effectiveness/death panels/healthcare rationing


Have you heard ANY politician talk about patient/individuals empowerment in relation to health care reform? I have not! Health care reform is still 100% about reimbursement reform and 0% about social innovation. No surprise when individuals so often experience dehumanizing events when they interact with the medical system."  [more]

[photo credit: bestrated1 via Flickr]

Tagging pictures by just looking at them


Reading your mind via EEG to label your snapshots. Very cool!

-via SciTe Daily:


"Assigning textual tags to an image is an important task because tags are needed for things like image search. When you search for an image of a “cat,” modern search engines can only identify an image as containing a cat if the tag “cat” is associated with it.
Having people tag images by hand is an onerous task. Shenoy and Tan of Microsoft Research developed a way to tag images automatically by reading people’s brain scans while they look at images. The people did not even have to specifically think about trying to tag the image; they merely had to passively observe it."  [more]

[photo credit: krischall via flickr

Wednesday, December 09, 2009

Displacement


Displacement is a defense mechanism that occurs when one refocuses an emotion, like anxiety or anger, onto a benign, less-threatening object than the object it is intended for. Kicking the dog is the classic example, with the assumption that it's safer to kick the dog than it is to kick the boss.

Moving is, for me, both an exciting event and a stressful one. Invariably, I deal with it by focusing my energies on worrying about something that is a bit ridiculous. When I finished med school and was leaving my life as a student to become an intern, I worried about finding enough boxes to pack in. When I finished my internship and was getting ready to move out of state and begin residency training in psychiatry, my husband pre-empted my obsession: he went out and bought boxes. (Who buys boxes?) I worried, instead, that there wouldn't be enough shelf space in my new kitchen-- I'd seen the apartment once on a whirlwind tour of apartments and couldn't remember the details. The funny part is that the kitchen we were leaving in New York City measured exactly two-feet by five-feet (yes, I measured it) and had only a single cabinet and no shelves. I'm not sure what I thought I owned that needed so much shelf space, but I arrived in town here to discover that both sides of a long kitchen were lined with shelves, cabinets, and drawers-- more than I would ever fill.

So I'm getting ready to relocate my practice. I'm moving 3 miles and I'm moving into a space that's being tailored to my needs. Oh, but I'm moving one of me into a space with 5 offices: I need some buddies. A couple of people have expressed interest in joining me, and this is exciting! Only I'm not showing any prospective sub-letters the space right now because it a construction zone, full of debris and equipment. Somehow, wandering around the space and muttering "put a door here, move a wall there, change these lights..." came pretty easily. Pick a color for the walls...well, that's where all my angst got displaced to.

Tan. I want tan walls. It's a warm color, it's neutral, it'll look nice with my red chairs. I called a decorator, she couldn't come soon enough. I advertised on a listserv for an emergency decorator, I got a few suggestions and a friend with good taste came to my rescue. She picked a carpet and a paint. The paint went on kind of yellowy. The carpet wasn't available. She picked another carpet ("Mushroom"...do I want mushroom? No one involved was asking me any more). She picked paint. Taupe. Gorgeous. It went up purple. I've been to 4 paint stores and have bought 6 sample quarts. The back of my basement door looks like a an artist's palette. The office looks like...I don't what it looks like, with variations of pinky tans and purply tans and yellowy tans all up all over the place. The property manager has taken to yelling at me "I'll come pick you a color!"
So I've got it, finally: the walls will be Shabby Chic (thank you Benjamin Moore).

What next to worry about? Well the forms, of course!

Tuesday, December 08, 2009

Assessing Teenagers


Teenagers. They should be considered their own species (--note, no one asked me).

Perri Klass, M.D. has a nice piece in the New York Times about assessing teens for depression and suicide, "18 and Under--Asking the Hard Questions." It's mental health from the perspective of a pediatrician, and I like that she's thoughtful about the issues.

Here's an excerpt:

And before you get to the S’s, there is the E for emotion, which, Dr. Ginsburg said, should be much more than screening for depression. “If you start by asking boys if they’re depressed or sad, most boys will deny that,” he told me. “If you start by saying, ‘So, are you stressed out?’ — every boy, no matter how big and strong, every girl, no matter how much she wants to portray herself as being in control, will admit to stress.”

Markers for depression may help identify adults at risk for suicide, but they are not a reliable way to screen adolescents. “Only about half of kids who kill themselves are depressed in the way that we think about depression — sad, not taking care of themselves, not sleeping or sleeping too much, not eating or eating too much,” Dr. Ginsburg said. The other half may be impulsive, angry, disappointed, trying to get even.

Dr. Shain said adolescents often changed their ideas and their plans. So an assessment has to go beyond the feelings of the moment to include thoughts they have had, dangerous ways they have behaved and the important questions of intent and ambivalence.

“Sometimes you’ll get an ‘I don’t know’ answer,” he explained, “which might be ominous, might mean they don’t know or might mean they don’t want to tell you.”

If a teenager does acknowledge thinking about suicide, there are many more questions to be asked. Dr. Lydia A. Shrier, director of clinic-based research on adolescent and young-adult medicine at Children’s Hospital Boston, said some young people chronically struggled with these issues.

Monday, December 07, 2009

Please Print Legibly



I'm not much for paperwork. In fact, I hate it.

In my private practice, I give people directions on the phone: how to get to my office, where to park, what to bring, what to do about their health insurance, yadayadayada.... It's a lot of information. I don't have forms, except for an Authorization to Obtain/Release Psychiatric Information, and I give people a single sheet of Office Policies with my cancellation policy and how to reach me: cell phone, home phone.

No other forms, and a few times I've wished I had an emergency contact or some piece of information I didn't have at my fingertips. So I'm moving this month and I'm re-thinking my professional life. Mostly, I've funneled my anxiety into the decor--I'm now on my 5th and 6th quarts of sample paint. Why does
taupe look purple when you put it on the wall?

Oh yeah, I was talking about forms. So I'm going to try sending out a few sheets of information before the first appointment: directions, where to park, what to expect, what to bring, and a form requesting some basic contact info. I've been wondering what other people do, and so I've been surfing other shrinks' websites to see what they do: a lot of them have their forms up, some even have their fees listed. This is interesting.

So the forms thing also gets interesting. Some people have really extensive, all-inclusive, no-issue-left-unaddressed forms. One doc asks people to circle the name of any psychotropic they've ever been on, and he lists the name of every psychiatric medication. Here's the list:

Abilify diazepam metamphetamine Rozeram Adderall divalproex sodium Methylin Serax alprazolam doxepin methylphenidate Serentil Ambien Effexor mirtazapine Seroquel amitriptyline Elavil Moban sertraline amoxapine escitralopram Modafanil Serzone amphetamine Eskalith molindone Sinequan Anafranil fluoxetine Nardil Stelazine Antabuse fluphenazine Navane Strattera Asendin flurazepam nefazodone Surmontil atenolol fluvoxamine Neurontin Tegretol Ativan Focalin Norpramin temazepam atomoxetine gabapentin nortriptyline Tenormin Aventyl Geodon olanzapine thioridazine bupropion Halcion Orap thiothixene Buspar Haldol oxazepam Thorazine buspirone haloperidol Pamelor Tofranil carbamazepine imipramine Parnate Topamax Carbatrol Inderal paroxetine topiramate Celexa Klonopin Paxil Tranxene Centrax Lamictal pemoline tranylcypromine chlordiazepoxide lamotrigine perphenazine trazodone chlorpromazine Lexapro phenelzine triazolam citalopram Librium Pimozide trifluoperazine clomipramine lithium prazepam Trilafon clonazepam Lithobid Prolixin trimipramine clorazepate Lithonate Primidone Valium clozapine Lithotabs propranolol valproic acid Clozaril lorazepam protriptyline venlafaxine Concerta loxapine Provigil Vivactil Cylert Loxitane Prozac Wellbutrin Dalmane ludiomil quetiapine Xanax Depakene Lunesta Remeron ziprasidone Depakote Luvox Restoril Zoloft desipramine maprotiline Risperdal zopiclone Desyrel Mellaril risperidone Zydis Dexedrine mesoridazine Ritalin Zyprexa dextroamphetamine Metadate

Just in case you were interested.

Other shrinks have fewer forms, but still post some very interesting stuff. One has photos of herself in a red leather skirt on an analyst's couch (I thought it was an ad for a TV show about a psychiatrist!), another includes his resume and mentions he was an Eagle Scout.

Okay, so tell me if you have a shrinky website, I'd love to look at it. And since I've always just asked people questions and never asked them to fill out forms, tell me how you feel about forms, both from the doc's point of view, and also from the patient's perspective. Thank you!

Oy, the Ravens, they aren't doing so well. I think they got the wrong forms.

Friday, December 04, 2009

Memorial For A Brain


When I was in medical school I was fascinated by neuroanatomy and neuroscience. I enjoyed reading popular science books like Broca's Brain and The Three Pound Universe. I liked reading about the classic clinical cases studies that taught us a lot about how the brain works---cases like Phineas Gage, the Nineteenth Century railroad foreman whose brain injury revealed the purpose of frontal lobes, or the case of H.M., the man whose temporal lobectomy taught us about the how memory works.

Patient H.M. had parts of both his temporal lobes removed in order to treat a seizure disorder. After the surgery he was unable to form new memories at all, and he became one of the most-studied subjects in the field of neuropsychology. From H.M. we learned that there are two types of memory, declarative and procedural memory. Declarative memory is the what we use when we learned facts. Procedural memory is what we use when we learn how to do things, like brush our teeth or ride a bike. H.M's temporal lobectomy destroyed his declarative memory, but his procedural memory was left intact.

I'm bringing this up now because of an article in Wednesday's New York Times, "Dissection Begins on Famous Brain". Patient H.M., whose name we now know is Henry Molaison, died last year and donated his brain to a neuroscience project at M.I.T. They are in the process of sectioning his brain to learn more about what went wrong with it. There is even a web site, the Brain Observatory, where you can watch the sectioning as it happens.

I read the story and checked out the sectioning web site, but my reactions are mixed. As a psychiatrist it's fascinating to see that we can study a lesion from an individual patient all the way down to the microscopic level, but as a human being it leaves me feeling rather sad for this guy. It was noble of him to donate his brain, and years of his life, to science but on the other hand I can't help wondering if he ever just wished people would leave him alone.

Thursday, December 03, 2009

Are They Animals?

Here's a story about a supermax facility in Illinois. Apparently efforts are being made to improve mental health services to these control unit inmates, some of whom have been in
solitary confinement for up to ten years.

They're getting a lot of service: group and individual counselling, psychiatric treatment and recreational activities. And they've had some serious behavior problems---109 of the 247 inmates are there because they committed new criminal offenses while in prison, including
stabbing correctional officers and murder.

To me the story isn't interesting because of the mental health care issues or because of the nature of the inmates----that's pretty much old stuff to me. What I always think is fascinating are the comments left by the readers. Some people think the inmates are so mentally ill
that they shouldn't be locked up in spite of their repeated violent offenses. Others call them "animals" or worse, and want them all to be killed. Stories like this reveal more about the readers, and about society in general, than about the patients I treat or the system I
work in. As long as there is this level of hysteria and extremism we as a society have trouble addressing the needs of our offenders realistically.

Wednesday, December 02, 2009

Living Life Backwards


It used to be, in the good old days, that people lived life sequentially. You moved forwards. Not completely-- we take pictures so we can look back and remember, and save a bit of the present for the future when it will then be the past. We go to class reunions, save mementos of special occasions, hold on to love letters, treasure bits and pieces of the past, and here and there, we reconnect with someone from another time and place. It grounds us, forms some connection, gives us a sense of history and meaning.

And then was the Internet and we all Googled and Oogled and found lost lives and reconnected via Email.

And there was Facebook and the past and the present are now one and the same. We live stuck in time and I'm never sure which direction I'm going. Reconnection is the rule-- I have Facebook friends from kindergarten. A few years back, I got an email from my prom date-- "Remember me, the guy in the tux 25 years ago?" Okay, it was fun. Last night we chatted on Facebook. He landed where I thought he would land (sequencing DNA, if you must know). I then found a page for my elementary school. The school name was spelled wrong and the street name was also off, but the photo...no doubt it was my elementary school. The FB members were talking about the teachers, trying to remember them all. I'd forgotten about Mr. Firestone, the 4-6th grade gym teacher. But they forgot a lot of other teachers-- I was tempted to join so that Mr. Trogler wouldn't be lost-- but did I really want to? Shouldn't I be spending time on things that move me forward? There's that book to write (oy)...dogs to walk...laundry to fold...endless paint swatches to try for my new office. Instead, here I am chatting with my prom date, thinking about Mr. Shannon --my 5th grade teacher who had us write about an invention. My invention: a machine that would type what you said-- he told me it could never be done. That and growing hair on a bald head...oh for Mr. Shannon to have met Rogaine. The things I remember. I know what's happening in the lives of my friends far and wide (Laurie's mom read to her son last night, photo on Facebook; Joan's foot hurts; my second cousin unwittingly set her alarm an hour early and didn't realize this until she was outside waiting for her ride at 6 AM...). Connection is good, but when does it become too much?

Have I Told You This?


I've been told that I have a tendency to repeat stories. I've been told that several times, usually with the implication that I'm starting to "lose it". Finally, in today's New York Times there's an article that proves I'm normal.

According to "Story? Unforgettable. The Audience? Often Not.", researchers have demonstrated that there's a difference between "source memory" (a memory of where you learned certain facts) and "destination memory" (the memory of the person you told a fact to). The story talks about a study done by two Ontario psychologists. They took a group of college students and gave them a list of 50 facts. Half of the students were told to read the list quietly to themselves and were shown a picture of a celebrity immediately afterward. The other test subjects were told to pretend that they were "telling" the facts to a picture of a celebrity. All of the subjects were then tested to see if they could remember which celebrity-fact pairs they were given. Students had significantly worse memories for the celebrities they were "talking" to than for the celebrity they were "learning" from.

The psychologists say this is normal, because when someone tells a personal story they are self-involved in the process and less able to attend to the person they are speaking to---making the audience forgettable, in a sense. This also serves an adaptive function:

"The tendency to blank on who-I-told-what may in fact reflect the workings of a healthy memory. Psychologists have found evidence that when people reset a password or a new phone number for an old friend, their brain actively suppresses the out-of-date digits. The old numbers are a competing memory, and potentially confounding."

In other words, if you spend a lot of memory power keeping track of what you've told and to whom, you're going to forget more things overall.

So there. I'm going to pass this little item along to the person who teases me about my repetitive personal anecdotes. Or maybe I've sent this to him already, I don't remember.

Tuesday, December 01, 2009

Things We'll Never Know

I've been following the story of Maurice Clemmons, the suspect wanted for the killing of four police officers in Seattle. I don't have any connection to the case, but his story is familiar to me from thousands of inmates like him I've met over the years.

In addition to the media reports, I reviewed the parole and clemency documentation published here.

Here's what strikes me about the case:

Clemmons was a repeat offender who committed new crimes every few months until he turned eighteen. The longest break in his criminal activity was the eleven years that he was in the Arkansas prison system. We don't know what he was involved in before that because juvenile records are generally sealed.

He was already under court supervision when he was convicted of the robbery and theft that sent him to prison in 1990. Even though he was only about eighteen, the judge slammed him: over a hundred consecutive years for what (in Baltimore at least) would have been a ten year sentence, max. When he was first considered for parole, the board would have granted him parole only under one condition (a "firm" condition, as handwritten onto the parole document): that he leave the state. This was not your average offender.

He asked to have his sentence reconsidered, and was granted a reduction by a new judge who noted that she didn't understand why he had been given so much time. (There was no discussion of the reasoning behind this decision other than that the sentence seemed excessive. No discussion of his previous offenses or the nature of the index crimes.) The state's attorney's office opposed his parole each time it came up (then again, that's their job).

When he petitioned Governor Huckabee for a commutation he admitted that he had some initial adjustment problems (he didn't mention what they were, but I could make an educated guess) but added that since his mother died he was determined to turn his life around. He denied any history of alcohol or drug abuse or any history of psychiatric illness or treatment. According the Examiner.com web site, he never required mental health care during the eleven years in prison. When he got out and moved to Washington he was able to run his own landscaping business and get married. A pretty good start, even without therapy.

Prior to killing the police, Clemmons exhibited unusual behavior: claiming to be Jesus, to be able to fly, and forcing his family to undress. To put it modestly, this was a bit of a change for him. He might have been violent and antisocial in the past, but he was never known to be "crazy".

The general public will never know the full story behind the change in his mental state since he was killed by police. Had he survived, he likely would have received a thorough and detailed pretrial psychiatric evaluation for an insanity defense. Only then would we have found out if he really had a psychotic disorder or if he was psychotic due to PCP, Ecstacy or crack cocaine use.


Could any of this have been prevented? I don't know. Maybe, if his sentence hadn't been reduced, both he and the four police officers might be alive today. Then again, maybe he could have been killed (or murdered someone else) in prison. We'll never know.

Friday, November 27, 2009

Surgery for OCD?


Benedict Carey writes about surgical treatments for obsessive compulsive disorder in yesterday's New York Times in "Surgery for Mental Ills Offers both Hope and Risks,"

In one procedure, called a cingulotomy, doctors drill into the skull and thread wires into an area called the anterior cingulate. There they pinpoint and destroy pinches of tissue that lie along a circuit in each hemisphere that connects deeper, emotional centers of the brain to areas of the frontal cortex, where conscious planning is centered.

This circuit appears to be hyperactive in people with severe O.C.D., and imaging studies suggest that the surgery quiets that activity. In another operation, called a capsulotomy, surgeons go deeper, into an area called the internal capsule, and burn out spots in a circuit also thought to be overactive.

An altogether different approach is called deep brain stimulation, or D.B.S., in which surgeons sink wires into the brain but leave them in place. A pacemaker-like device sends a current to the electrodes, apparently interfering with circuits thought to be hyperactive in people with obsessive-compulsive disorder (and also those with severe depression). The current can be turned up, down or off, so deep brain stimulation is adjustable and, to some extent, reversible.

In yet another technique, doctors place the patient in an M.R.I.-like machine that sends beams of radiation into the skull. The beams pass through the brain without causing damage, except at the point where they converge. There they burn out spots of tissue from O.C.D.-related circuits, with similar effects as the other operations.

Carey goes on to talk about the rigorous screening, the risks of surgery, and tells stories of both good and bad outcomes.

Thursday, November 26, 2009

My Three Shrinks Podcast 47: Genital Retraction Syndrome


[46] . . . [47] . . . [48] . . . [All]


Happy Thanksgiving!!!


As a big thank you to our readers (and listeners), we three shrinks got our act together and edited one of our most recently recorded podcasts and got it out there, finally. I did the editing and posting this time instead of Roy, which means that it will be less polished, more crackle-and-pop filled and less balanced volumetrically (if that's a word) than usual. So be it. After leaping over a high Garage Band learning curve I figured that was enough of a time investment to begin with and I'd figure out the more polished aspects later. But enough about the process. On to the podcast.


For podcast 47 we started out with a discussion of gender bias in civil commitment when we discussed the book (which none of us have read) entitled Mad, Bad and Sad: Women and the Mind Doctors. Clink talked about the history of civil commitment law (with a brief diversion into the "Beauty and the Beast". Don't ask.).


Then we talked about cholesterol in relationship to suicide (yes, there is one---how weird is that?). Dinah mentioned an article from the March 2008 issue of Psychiatry Cholesterol Quandaries: Relationship to Depression and the Suicidal Experience. Low cholesterol levels were associated with increased rates of suicidal ideation. Unfortunately, the article didn't mention actually what was considered a "low" cholesterol level. A number of PubMed studies supported a relationship between increased rates of low mood and hospitalization for depression in people with low cholesterol levels.


Finally, we talked about disappearing genitals. At the time the podcast was taped there was a rash of alleged "penis thefts" in the Congo; several people were accused of being sorcerers who cast spells to shrink or steal men's penises. We talked about the koro delusion (believing one's penis is disappearing) versus a cultural belief or mass hysterical phenomena of sorcerer accusations (believing that others are causing many men's penises to disappear).


After that last topic I even have the nerve to add: Please, go to iTunes and write a review.


[Roy was here, adding usual podcast footer links...]





Find show notes with links at: http://mythreeshrinks.com. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom).

This podcast is available on iTunes (feel free to post a review) or as an RSS feed or Feedburner feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.
Thank you for listening.

Monday, November 23, 2009

Don't Smile (...at least not on Facebook)



A Canadian woman lost her disability benefits because her insurer found her smiling, and vacationing, face up on her Facebook page. See details Here.

The article notes
:

"In the moment I'm happy, but before and after I have the same problems" as before, she said.

B--- said that on her doctor's advice, she tried to have fun, including nights out at her local bar with friends and short getaways to sun destinations, as a way to forget her problems.

She also doesn’t understand how Manulife accessed her photos because her Facebook profile is locked and only people she approves can look at what she posts.

It kind of reminds me of Roy's post: Wipe that smile off your face. Thanks to Meg for the link!

Sunday, November 22, 2009

Shrink Rap Barbecue

The three Shrink Rappers and their friends got together tonight for a Korean barbecue. I volunteered to write the blog post for it. After I spilled dipping sauce on my jeans I figured that was the best way to ensure the incident would be reported most accurately. It was purely an accident and their was no alcohol involved. I did spend the remainder of the evening smelling "nasty, putrid and fishy" in the words of one diner, even after a thorough cleansing in the restaurant bathroom. (I'm much more coordinated climbing than doing anything else, including walking.)

Nevertheless, the company was wonderful and we enjoyed talking about our plans for the blog, the book and our Twitter feeds. I did manage to edit one of our recorded podcasts and I'm just waiting for Roy to give me our theme song and directions for how to put it up on iTunes and the My Three Shrinks web site. Besides that we talked about emotional support dogs on planes, impaired (but not smelly) physicians, licensing laws and hummus. We seem to be fixated on hummus these days.

Roy and I talked about the iPhone apps we'd like to design someday. Dinah showed us her new phone, a lovely shade of green.

We need to do this more often.


Hummus Links.


Rach got me worried about rancid tahini. I asked Victor, he says it can stay in the fridge for six months. I checked Chowhound and here is what I found:

How Long For Tahini?

I also found a Chowhound site with tips for making homemade hummus:

Why is restaurant hummus better?

Happy dipping?

Saturday, November 21, 2009

Getting Help When Money is Tight and When It's Not


Moving on from the Hummus debate...

Today's NYTimes has an article called Getting Mental Health Care When Money is Tight.
Leslie Alderman writes:

According to a recent survey by the federal Substance Abuse and Mental Health Services Administration (Samhsa, pronounced SAM-suh) , the leading reason that people with mental health issues don’t seek treatment is cost. They fear the fees.


The article goes on to list websites, support groups, self-help ideas (yes, exercise was in there!), pastoral counselors and an assortment of options for people who want help but are uncomfortable with the cost. The author even suggests:

If you have a good relationship with your primary care physician, you could see him or her. Your doctor may be able to refer you to a local mental health center for therapy, and maybe consider medication to help you out of your immediate funk. Doctors may also know of psychologists who see patients on a sliding fee scale.

Hmmm, sounds like psychiatrists aren't a very generous crew-- there's no mention of the idea that one of those might discount their fees.

In Maryland, there have traditionally been a few options:
1) Community Mental Health Centers have treated uninsured, indigent patients, specifically those with major mental illnesses. These patients are deemed "gray zone" and have been cared for in the clinics....not sure that continues with all the governmental budget cuts. Often these patients end up being eligible for Medicaid, and sometimes SSDI (Social Security Disability) and eventually Medicare.
2) Homeless patients (and homeless is defined pretty loosely, and not limited to 'street' people--) can be seen at Health Care for the Homeless-- they're sliding fee scale allows for
very low fees.
3) The Pro Bono Counseling Project coordinates care for those with limited resources through a network of volunteers in the community. The list includes therapist of every ilk-- but I will say the social worker volunteers greatly outnumbers the psychiatrists.
4) Teaching programs (and this was an option in the NYTimes article) offer treatments of all types--- including psychoanalytic training programs where discounted analysis is available.

Do you know of other resources? By all means, write in!

So my other thought was this. I think health insurance is a good thing, and actually, I hope some reasonable level of health care should be accessible to all, but given that it's not, have we become complacent in a way that's not helpful? The article starts out talking about a person with what may be a major depression and the person is afraid that the cost of treatment will add to the stress:

IMAGINE this situation. You fall into a deep
malaise. Friends say you need help, but you don’t have insurance (or the insurance you do have has very limited mental health benefits), and you worry that extra bills will only add to your malaise. So you do nothing.

The article goes on to describe discount means of getting care, and you know I think these are all reasonable options. But we all know there are people who worry about money with a variety of thresholds-- one could worry that extra bills will add to the stress even if there's money in the bank. And no where does the article suggest that if there is some means of paying for care, that the cost of NOT getting treatment may well exceed the cost of getting care. Maybe the person above has a depressive episode-- maybe he'll go for an evaluation, a few weekly visits, then a year's worth of monthly visits, and get meds from Walmart or free doc samples. Let's pretend he responds well to the first medication, that he gets a lot out of a few therapy sessions, and ...hmm....maybe $600 later he feels a lot better. Let's say he doesn't spend that money and he's miserable. Let's say he loses his job, he loses opportunities...he lives life less fully.

I've watched people who pay $20K year for their child's kindergarten not be willing to go outside their HMO to get appropriate medical care for the same child.

I liked Alderman's article, she offers good suggestions. I guess I just wished that she'd made the suggestion that, if possible, psychiatric treatment might be worth paying for. I know I'm going to get comments from people who really do stretch to pay for their treatment. I'd love to hear from the folks who have a few resources but still elect not to get treatment they might like to have.


Friday, November 20, 2009

In The Hood

One of my Twitter followers recently asked me to blog about what's been happening in the prison neighborhood recently. Basically what's happening is that there is a serial rapist running around central Baltimore. This past week a woman's body was found three blocks from the prison. The police suspect the killing took place during a sexual assault, and they sent police cadets out to scour the public housing complex nearby to look for evidence. (I have to admit, when I saw them my first thought was: "Oh, they'll find lots of evidence. Some of it may even be related to the killing!") Today the local newspaper said that DNA evidence has revealed that the rapes are being committed by two different suspects. One suspect is targeting women who are waiting at bus stops while the other is committing home invasions.

So why am I blogging about this? (I mean, other than because somebody asked me to.) Because periodically somebody asks me if I feel safe working in prison. Well....compared to the streets of Baltimore....need I say more?

Thursday, November 19, 2009

What Should I Do?


A reader asks if we give advice. I hope it's okay if I copy and paste the question from the comment section of another post, I'll leave the commenter's handle out:

I went to a psychologist 7 or 8 years ago and all she did was tell me what I should do. “Go there, do this, etc.” She didn’t listen to me at all. If she had, she would have known that the things she was telling me to do were things that I would never ever do. I quit after 2 or 3 sessions. I decided to try therapy again about a year and a half ago and my psychiatrist is the complete opposite. She has never given me a single word of advice and even when I directly ask her opinion, she will only occasionally give me a straight answer. I appreciate the fact that she isn’t trying to force off-the-wall ideas on me, but sometimes I wish she’d put in her 2 cents. Where do you guys stand on this? I’m just curious as to what’s the “norm” since my 2 experiences have been so drastically different. Thanks.

Traditionally psychotherapists don't give advice--- perhaps this differentiates "therapy" from "counseling" which does imply that one person knows what's best. Psychodynamic psychotherapy is about delving and understanding unconscious conflicts, and it's done by looking at the process of the material a patient brings to the session. Rather than go for the superficial and concrete, perhaps there is something to be gained in understanding why a patient wants the therapist to give them advice. It's about understanding the mechanisms that guide the patient, not the specifics.

So I'm not an analyst, I'm particularly quiet, I tend to say what I think, and I'm a physician who treats conditions that I believe have some biological input. To some extent, I have to give advice: Take this medicine at this time. Don't take that medicine with this one, it'll kill you. Don't drink alcohol when you're taking Xanax, that'll kill you, too. I believe that when someone is suffering from a problem in a way that up-ends them, they should make it their job to do what they have to get well. What helps depression: medicine, exercise, sleeping enough, not sleeping too much, structure, being empowered. There was a study recently that suggested a link between Mediterranean diets and lower rates of depression--- so I tell people to eat hummus (if they like it!). I even suggest a brand because I've personally taste tested them all and have a strong preference. (Is it awful to admit this?)
Do I give advice otherwise? Yeah, sure. Sometimes I tell people who need more structure that they should get a dog. Dogs are good--- ya gotta get up and walk them, they're interactive, they're entertaining, you have to feed them, they pull people outside of themselves just a little, and they are object of passion-- passion, I think, is good.

What have I discovered? People come to their appointments, mostly. They take their medicines, mostly. No one really does much more of what I suggest. No one has bought a dog because I've told them to. And people who don't want to exercise rarely do so because a psychiatrist tells them the research says this will help. I'll let you know how it goes with the hummus. I don't think Freud would have liked me.

So I tell my patients what to do sometimes. The more salient question would be: Do you tell Roy what to do?

Tuesday, November 17, 2009

Do the Kids Do it Differently?

We've been talking about stigma and whether someone should tell people they suffer from a mental illness. I've said that some people advertise their illnesses and it draws people in, while other do it and find they are shunned. Commenters have had a variety of responses, but most votes go against telling people one has a mental disorder.

Does it matter what you have? Or how much it's disabled you? Or how it's framed? I talked about the chemistry teacher on antidepressants (and yes, the demographics were changed)--- she framed it as she was having a hard time after a major loss, not that she was suffering from a major mental illness that might effect her current behavior or reliability.

So is it different for the kids? They've grown up on Cymbalta, Zoloft, and Viagra commercials. They've posted their lives on MySpace and Facebook. When I think about my kids' friends, I have to say they are all pretty open about psychiatric illnesses-- I've had kids spend the night who take psychiatric meds, I've had little peeps point out a window and say, "That's where my psychiatrist is." I've heard that Sal and Hal both see the same therapist, that Bobby's been in treatment for anger issues, that Tom, Dick, and Harry are all on ADD meds. I've had a physician tell me about his depression and his family's therapy while we watched our kids' compete (and the whole teams' parents listened on). Back in the day when big pharma distributed pens, my kids would take them to school and other kids would volunteer, Hey I take that! When I think about it, I know a lot of kids who've had a lot of treatment.


ugh...blogger won't let me add a pic...

Monday, November 16, 2009

To Tell or Not to Tell? That is the Question.


Should patients with psychiatric disorders discuss them openly? Is it better to let it be known like it's no big deal, or to hold on tight to those secrets? We've talked about this a lot when we've talked about the meaning, the stigma, and the consequences of psychiatric labels. It seems to me that some people advertise their problems and are no more worse for the wear: they start talking at a party about how they have bipolar disorder and suddenly they are the magnet for everyone else's bipolar stories. It's refreshing, in a way, how free they feel to be open. Perhaps some of it is career-dependent: certainly it's more permissible among artists and musicians to have suffered, and some problems with mood or substances can be so much a part of landscape as to defy stigma.

Why now am I bringing this up? Carpool today: "We talked about therapy and antidepressants in chemistry." Hmmm, that's not chemistry, shouldn't they be balancing acid-base problems? "And what does your teacher have to say about it?" Apparently the teacher was on antidepressants for years during a difficult time, but she suggested the whole class probably had issues and things to talk about in therapy. Why not?

What do I think? This is a young, well-loved and respected teacher. If she's comfortable telling the kids that treatment has helped her, more power to her. Maybe someday some troubled person will figure Ms. Chemistry was cool with it and will get help. As long as they get to the acid-base stuff eventually.

Sunday, November 15, 2009

Life Without Parole, But With Health Care

The rising cost of prison health care is due mainly to the aging inmate population according to an article I saw on CNN recently. To me this really wasn't news; is it any surprise that older people have more medical problems? Or that the prison population as a whole is older due to longer sentences? Not really.


This story interested me because the Supreme Court is now considering the issue of life without parole for juveniles.  The idea is that juveniles can be rehabilitated and should be given a second chance, eventually.  

I can't help wondering if this issue is coming up now in part because prison officials, and inmate advocacy organizations, are starting to realize the full cost of a system filled with "lifers".  They need more than just medical care.  They need physical accomodation (and security accomodation) for wheelchairs, quad canes, braces, pumps and other medical devicies.  They need nursing care for feeding, dressing and bathing.  They need psychiatric care for dementia and other age-related psychiatric problems.  Eventually, they need hospice care.

Medical parole, also sometimes called "compassionate parole", is available in some systems. But this is sometimes dependent upon a terminal illness with a six month life expectancy. And it's not always granted if the inmate's offense was particularly notorious or horrific.

It's good to periodically examine our sentencing policies, but I get wary of any mandatory sentence that's based on a class of offenders rather than on the offense itself. Singling out people with mental disorders, juveniles, the developmentally disabled (and yes, women automatically get classified as 'vulnerable' and less culpable too) makes me uncomfortable. Banning life without parole for a juvenile, simply because he is a juvenile, negates a host of sentencing factors that a judge should be allowed to consider. These cases are challenging and difficult, and sentencing decisions are best left to an experienced judge who has access to all the information in a given case.

If life without parole is banned for juveniles, the next step logically would be to reconsider long sentences for older inmates.  Should someone who is fifty years old be given a 30 year sentence? Given that the average life expectancy for an American is 77 years, that's an automatic life sentence.  What about someone with cancer or HIV, someone with a potentially fatal illness who is not immediately dying? Should we base a sentence on five year survival rates? Otherwise, we are giving a life sentence, without parole. If you ban mandatory life for juveniles, you need to reconsider sentences that are the functional equivalent to mandatory life.

It gets complicated but hopefully these are the issues that the Supremes are going to be thinking about.

Friday, November 13, 2009

FDA & Social Media Hearing: #FDASM Word Cloud


Twitter was awash with thousands of tweets (click link to left to read them) the past few days regarding the FDA's hearing today and yesterday about regulation of pharmaceutical marketing on the internet and using social media. Above is the word cloud for the tweetstream on the topic (minus all the references to fdasm, fda, RT, bit.ly, http, etc).


If you want to dive deeper, check out the links on tr.im/hitlinks and on fdasm.com. A list of links to many of the presentations are available here. Public comments to the FDA are being accepted through Feb 28, so go to one of the above links to find the public comments page if you have something to say about this area. The controversies involve things like providing fair balance in 140 characters, making it easier to find plain English info on adverse effects, and whether the FDA rules about drug companies hunting down every mention of adverse effects should be revised based on the preponderance of user-generated content out there.

Wednesday, November 11, 2009

Shrink Rap: Grand Rounds is up at CRZEGRL (Veteran's Day theme)



The theme for crzegrl's Grand Rounds this week is Veteran's Day.

The shrinky links:

Tuesday, November 10, 2009

Sliding Fees



A lot of psychiatrists and other mental health professionals tell me they slide their fees, giving reduced rates to patients who can't otherwise afford to come. I want to ask: How do docs decide to do this? At clinics, scales are based on income (perhaps by family size), and just income, with a pre-set structure. But in private practice, this isn't usually the case (I don't think), and I wondered what other people do. In general, I've hesitated to slide my fees very much and this gets hard. Some of the patients I see live life without many luxuries-- rented homes, used cars, rare vacations. Sometimes it's a choice-- they choose not to work (when they could), and sometimes they are struggling quite hard to make ends meet, and yet they don't utter a word of concern about my fees. If anyone brings it up, it's me. Other times, patients are very verbal about their financial issues, how much they plan and calculate exactly what they can afford, and are very concerned about my fees and exactly what they can or can't afford. What's hard is that some of these same people are "strapped" because their life styles include many luxuries--boats, luxury cars, nice trips, a fine bottle of wine here or there, expensive tuitions, and maybe unexpected expenses. They come less then they should, or would like, because my fee is high. Maybe they've bitten off more then they should have (especially in the current economy) and are going through bankruptcy proceedings, or are simply worried about what the future might bring. Being tight on funds and the perception of what one can afford is based on many things, and so I'm putting this out not to get my own answers, but to ask how other people deal with this? Years ago I had a friend who was seeing a patient at a greatly reduced fee, only to discover that he lived in a much nicer house then she could afford-- it put some tension into the therapeutic relationship, I'm sure.

Monday, November 09, 2009

I Am Not 'One Of Them'

Since the Fort Hood shooting I've been hearing and reading a lot in the media about 'compassion fatigue' and 'vicarious trauma'. I feel compelled to blog after reading yesterday's New York Times article on the topic, which I'm sure won't be the last.

The idea is that any mental health professional who spends their days listening to patients tell their stories of traumatic events will eventually end up having emotional difficulties from it as well. The other term for this is 'compassion fatigue', in other words losing the ability to empathize with others or becoming numb to trauma due to exposure to patients' traumatic stories. The Times article is careful to point out that vicarious trauma and compassion fatigue will not automatically lead one to become a killer.

Well, I'm relieved to hear that.

Over the years as both a forensic and correctional psychiatrist I've heard plenty of trauma-related stories. I've reviewed autopsy photos and crime scene photos and read police reports of violent offenses and watched videotapes of violent offenses. I've heard people talk about
their crimes and talked to victims of violent crimes (if they survived). People who have read my "What I Learned" posts know that the annual conference of the American Academy of Psychiatry and Law regularly features presentations about serial murderers, psychotic killers, crime scene investigation techniques and other topics that can be a bit gruesome.

If all 1700 forensic psychiatrists in this country are exposed to this regularly that's a whole lot of vicarious trauma. It's good to know I won't automatically become a spree killer.

Frankly, I wasn't worried.

Sunday, November 08, 2009

Ch-Ch-Ch-Changes!


The times they are a-changing....

Next year, the new parity laws for mental health will go into effect: health insurance must cover mental disorders the same when it covers other medical illnesses, without limits on visits, or higher co-pays. It remains to be seen how this will play out-- my fear has been that the response might be to simply eliminate mental health benefits from insurance policies. From the American Psychological Association (sorry, it was a pdf file so there is not a direct link) on the Wellstone-Domenici Parity Act of 2008 :

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (The “Wellstone-Domenici Parity Act”) will end health insurance benefits inequity between mental health/substance use disorders and medical/surgical benefits for group health plans with more than 50 employees. Under this new law a group health plan of 50 or more employees that provides both physical and mental health/ substance use benefits must ensure that all financial requirements and treatment limitations applicable to mental health/substance use disorder benefits are no more restrictive than those requirements and limitations placed on physical benefits. This means that equity in coverage will apply to all financial requirements, including lifetime and annual dollar limits, deductibles, copayments, coinsurance, and out-of-pocket expenses, and to all treatment limitations, including frequency of treatment, number of visits, days of coverage and other similar limits.

We don't know yet how this will play out...I hate that little clause "...that provides both physical and mental health/substance use benefits..." because it's left as an option. Would we tolerate a health insurance plan that excluded pneumonia or cancer? And it would be so nice if one could see a psychiatrist without pre-authorization (do you need pre-authorization to go to the doctor for your back pain or headaches or fever?) but my guess is that won't play out, since surgeries require pre-approval in many plans.

The New York Times has an optimistic piece on upcoming parity. Leslie Alderman writes in "In Anxious Times: Help for the Mind as Well as the Body:" Alderman writes:

The law’s changes can be good and not so good. Good, because you might have access to more care. Not so good if there are new requirements, like getting precertification for coverage, that place additional barriers to getting treatment, says Kaye Pestaina, vice president of health care compliance for the Segal Company, a benefits consulting firm.

“Employees should make sure their employer provides information to them about any new medical management rules,” Ms. Pestaina said.

Okay, so the House just passed the President's Health Care Reform bill (all 1,990 pages of it). What might this mean for psychiatry and how will parity play out in a newly-insured American?