Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen. All patient vignettes are confabulated; the psychiatrists, however, are mostly real. --Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)
I went to a really fascinating event tonight: a screening for Paul Dalio's film Touched With Fire. The film was named for Kay Redfield Jamison's book, and in fact, Dr. Jamison made an appearance in the film! She's a woman of many talents, and now she can add movie star to the list! After the film, which was introduced by Ray DePaulo, the Psychiatrist-in-Chief at Johns Hopkins Hospital, there were some comments and a Q & A session with both director Paul Dalio and psychologist/writer/researcher/film star Kay Jamison. I mean really, the only thing missing from this memorable evening was wine & cheese and the opportunity for selfies.
So first, let me give you the advertisement for the event, then I want to talk about the film. Here's how it was sold:
Okay, so before I start talking about the film, I want to warn you: plot spoilers follow. If that's a problem for you, stop reading now. I do apologize, but their is no way I can talk about this incredible movie without discussing the plot.
Touched with Fire, Paul Dalio’s feature film debut starring Katie Holmes and Luke Kirby, revolves around two bipolar poets whose art is fueled by their emotional extremes. Katie Holmes stars as Carla, a talented writer who struggles with the disorder and its management. After a particularly intense manic episode, she ends up in a psychiatric hospital where she meets Marco (Luke Kirby), another talented writer who refuses to stay on his medication because it fuels his intense creativity. When they meet, their romance brings out all the beauty as well as the darkness of their condition, and its impact on their lives, families, careers and future.
Drawing inspiration from his own life experience with bipolar disorder, Dalio wrote and directed the film which includes strong performances by Griffin Dunne, Christine Lahti and Bruce Altman. Kay Jamison, author of the book "Touched with Fire," the definitive work on creativity and madness, makes a cameo. It was produced by Jeremy Alter and Kristina Nikolova, who also served as the film’s co-cinematographer. Spike Lee, Dalio’s professor at NYU Film School, is executive producer. The film will be released theatrically in February 2016. Touched with Fire takes the audience on an authentic journey through the highs and lows of bipolar disorder and how it impacts not only individuals but their friends, families and work life. It is an outstanding film that offers a holistic portrayal of mental health and provides audiences with an inside look into one of the nations’ most discussed and least understood mental health conditions.
Paul Dalio sees this film as a catalyst to change the way bipolar disorder is discussed and we are using this event as one of many ways to start changing conversations.
Have you tried to find a psychiatrist lately? It can be hard. Of course, there are your insurance panels, if the docs listed aren't dead or listed in error and are taking patients. And sometimes, people just get lucky and make a call to happen upon a psychiatrist they like a lot.
It can also be a hassle, and to someone who contacted me recently, "If I didn't have an anxiety disorder when I started looking for a psychiatrists, I'd have one now!"
I can push an icon on my phone (Open Table) and find out in a matter of minutes exactly which restaurants in Baltimore can take a party of 6 at 7:45 tonight, or another icon (Uber) to get a driver to take me to that dinner me in minutes, but there's not an easy way to figure out who can see a patient quickly -- it's hit or miss and often a matter of luck or who you know, even when there may be doctors with time, or perhaps someone who had a bunch of unexpected cancellations one day.
I thought I would try to rectify this situation in Maryland and in less than an hour (~I've had a little practice with these website things), I was able to set up an Access to Care website in Maryland, located at MarylandPsychiatrists.net. Do check it out, and each week, more and more psychiatrists have registered with openings. I'm trying to get the word out that the website exists, so if you're a doctor in Maryland, do let folks know.
My co-blogger, ClinkShrink, has very strong opinions on Physician Assisted Suicide. My personal opinions are less strong, though with 40,000 suicides in the US every year, I'm not sure why it's necessary to involve physicians as the agents of death; we went into this field to help people, not to kill them. But I don't believe that every suicide is necessarily either the result of mental illness or a tragedy. We all die, and for myself, if all that remains of my life is suffering, I'd like to go quickly. Clink and I say that she's worried they'll knock her off too soon and I'm worried they'll keep me around too long.
But what about psychic suffering, which by anyone's measure, is just as bad, if not worse than physical pain. I've had a patient tell me that his cancer treatments with all their complications, didn't compare to the pain of his depression. And certainly, many people do decide that their psychic pain is unbearable, or believe they've become a burden to others, and so end their own lives. But should doctors have a role in this? Should we kill people because they have treatment-refractory depression? I'm thinking that's not a good idea and please don't show up at my office looking for your lethal prescription.
In Belgium, psychic torment is an acceptable reason for euthanasia. And they even have a menu: you can drink a potion, or a doctor will administer a lethal injection. That's right, in the land of beer and chocolate, the doctor will actually murder you in the name of medicine.
The YouTube above is haunting. Emily has struggled with depression for a dozen years, and she's been approved for euthanasia. I'm going to tell you that Emily changes her mind at the end because if you don't know that this lovely 24 year old young woman lives, it's unbearable to watch. I find it hard to imagine that there is ever nothing that can be done to alleviate at least some of the pain ...even if it's ECT or ketamine, or TMS, or a few cocktails to temporarily numb the pain (~if you try that one, please don't drive afterwards) and no hope of a new treatment that might make it better. In this case, the events of the two weeks prior to her death date -- time spent meeting with friends to connect and say goodbye, getting ready -- were a period where the pain eased up. Emily felt better knowing there was a way out, she found hope in the prospect of death.
I know, I know, the conference was over more than a week ago. I'm writing these posts more for myself, as a way to review what I learned and stabilize it in my head. Thanks for bearing with me.
I'm back in Maryland, but I am still thinking about all that I learned at the MGH course. Let me see what else I can add of interest. Let me put in a plug for the course: It was an excellent catch-up class on practical aspects of psychopharm. Highly recommended, and I'll go again in a couple of years.
I'm soliciting wisdom from our readers on how to fill out a HCFA claim form. I'll start by telling you that my NPI number on the submitted form was in block 33A. My legacy number was not on the form. This is the third such notice I've gotten, and clearly, I'm doing something wrong. Perhaps you can help?
Greetings from Boston!
I am here, with 750 or so psychiatrists, at the Massachusetts General Hospital's 39th annual psychopharmacology conference. I wanted to update my medication knowledge, and the meeting runs through the weekend. The day has been stuffed with useful information, and really good lectures -- much too much to blog about and there are still 2 hours left tonight. Let me just give you a sample from each lecture:
Dr. Nierenberg on Bipolar Depression:
He suggested checking out MoodNetwork.org
"Bipolar depression is really hard to treat; so many people don't get all the way better."
~People can be depressed, manic, anxious and irritable all at the same time.
~Antipsychotics and a mood stabilizer aren't much better than antipsychotics alone.
~There are 4 FDA approved treatments for bipolar depression: olanzapine/fluoxetine combo, quietipine (Seroquel), Lurasidone (Latuda), and Lamotrigine (Lamictal)
~Seroquel's response rate is the same for 300mg as for 600mg
~Latuda's response rate is the same for 20-60mg as for 80-120mg
~Lamotrigine is not approved for the acute treatment of bipolar depression, but for prevention. It is well tolerated.
~Lithium + Lamictal are more effective to prevent depression than mania.
~Some people use antidepressants alway, some never : the experts can't agree.
~Low dose Abilify has been disappointing in bipolar depression.
~Single dosing at night may prevent renal complications.
Dr. Perlis on Long-term management of Bipolar Disorder
You only know if someone has bipolar depression after they've had an episode of mania; family history or early age of onset don't make the diagnosis if the patient is depressed.
~Effective antimanic agents: lithium, valproate, carbamazepine, any antipsychotic.
~Lamictal, gabapentin, and toprimate have not been shown to be effective for mania
~Lithium decreases the risk of suicide.
~Aim for a level of at least 0.6, but risk of renal damage increases with time (decades) and levels (>0.8)
~Lithium and valproate are better than valproate alone
~This guy likes lithium.
Dr. Fava on Treatment-resistant depression
Strategies: increase dose, change medications, augment, combine.
~Buspirone is a safe agent to use for augmentation
~Mirapex (pramippexole) --can go gradually up to 1.5mg bid
~There is some way to get a compounding pharmacy to make intranasal ketamine, but this needs to be monitored.
~Lots of stuff has been tried.
More later --
Now, results of a landmark government-funded study call that approach into question. The findings, from by far the most rigorous trial to date conducted in the United States, concluded that schizophrenia patients who received smaller doses of antipsychotic medication and a bigger emphasis on one-on-one talk therapy and family support made greater strides in recovery over the first two years of treatment than patients who got the usual drug-focused care.And I thought: This is news? Obviously, anti-psychotics have side effects, adverse effects and risks, so using using the lowest effective dose is good. If it takes a high dose of medication to quickly control an acute episode, it's often possible to back down on the dose after the condition has been stabilized. Talk therapy is often helpful, and of course family support makes all the difference in the world to anyone with a chronic illness or disability.
- Participants assigned to NAVIGATE remained in treatment longer than community care patients (a median of 23 months compared with a median of 17 months, and were more likely to have received mental health outpatient services each month than community care subjects (a mean of 4.53 services, compared with a mean of 3.67 services);
- NAVIGATE participants experienced significantly greater improvement during the 2-year assessment period than those in community care ; .
- More improvement was also found on the subscales “interpersonal relations,” “intrapsychic foundations” (i.e., sense of purpose, motivation, curiosity, and emotional engagement), and engagement with “common objects and activities.” Service Use and Resource Form data showed significantly greater gains for NAVIGATE regarding the proportion of participants who were either working or going to school at any time during each month.
- The average rate of hospitalization was 3.2% per month for NAVIGATE participants and 3.7% per month for community care participants. Over the 2 years, 34% of the NAVIGATE group and 37% of the community care group (adjusted for length of exposure) had been hospitalized for psychiatric indications (n.s.).
- Finally: Median duration of untreated psychosis was a significant moderator of the treatment effect on total Quality of Life Scale and PANSS scores over time . There was a substantial difference in effect sizes comparing the change between treatments for participants with a duration of untreated psychosis of ≤74 weeks and those with a duration of untreated psychosis of >74 weeks.
The observation that patients with shorter duration of untreated psychosis derived substantially more benefit from NAVIGATE is important. Prolonged duration of untreated psychosis is an issue of national importance; reducing duration of untreated psychosis from current level of greater than 1 year to the recommended standard of less than 3 months should be a major focus of applied research efforts.
I received an email from the APA the other day noting the following:
Really? The codes look totally different, Medicare can't figure out if the codes are DSM-IV-TR codes or ICD-10 codes? Especially since it might be safe to assume that codes filed after October 1st are ICD-1O codes if they look like ICD-10 codes? I generate the forms with a computer program, and I went to add the "0" to the template so it would automatically populate every form, but the program doesn't even have a box 21.APA learned today that Medicare providers who file 1500 Health Insurance Claim Forms are having a large number of their claims returned due to a change in the reporting requirements that went into effect on October 1, 2015.
Medicare contractors are returning claims for correction or resubmission to mental health professionals who fail to indicate in line item 21 of the 1500 claim form whether ICD-9 or ICD-10 codes are used.
For services that were provided prior to October 1, 2015, ICD-9 codes should be used even if the claim is filed after that date; for services on or after October 1, 2015, ICD-10 codes should be used. ICD-9 codes are indicated by using a 9 in item #21; ICD-10 codes are noted with a 0.
|Graham Glancy |
Witness Protection Program: A Matter of Training
The New APA Guidelines on Correctional Psychiatry
The Psychiatrist in Peril: Current Topics in Malpractice
|Tobias Wasser |
Novel Approach to Teaching Residents About Violence & Safety
|Drew Kingston PhD |
The Relationship Between Mental Illness and Violence
|Caitlin Costello |
Adolescents and Social Medica: Privacy, Brain Development and Law
|Robert Forrest |
Treatment of Transgender Inmates
|Rosa Negron Munoz |
Educational Factors Contributing to Juvenile Delinquency
|Madelon Baranoski |
Role of Forensic Psychiatry in Veteran Evaluations
|Anna Glezer |
Myths and Realities of Women in Prison
|Jennifer Piel |
What Gets Judges in Trouble?
|Keith Stowell |
Forensic Issues in Emergency Psychiatry
|Hal Wortzel |
TBI Update: International Collaboration on mTBI and DSM-5
|Stephen Simring |
Forensic Psychiatry and the Death Penalty
|Lynn Maskel |
Rock and a Hard Place: Debating Sexual Sadism Diagnosis
“Today, patients suffering from severe mental illnesses struggle with adhering to or communicating with their healthcare teams about their medication regimen, which can greatly impact outcomes and disease progression,” said William H. Carson, M.D., president and CEO of Otsuka Pharmaceutical Development & Commercialization, Inc. “We believe this new Digital Medicine could revolutionize the way adherence is measured and fulfill a serious unmet medical need in this population. We look forward to continuing working with the FDA throughout the NDA review.”
“The technology can provide important advances in addressing highly prevalent problems in patients adhering to medications,” Kane told Psychiatric News. However, Kane pointed out, major concerns regarding the use of this technology are likely to arise, such as how the information obtained by the device will be protected.
William Carpenter, M.D., a professor of psychiatry and pharmacology at the University of Maryland School of Medicine, agreed.
In addition to issues of privacy, Carpenter told Psychiatric News that convincing people who are already vulnerable to paranoia to take a medication that may be viewed as highly intrusive as well as the potential high cost of the medicine could present additional challenges.
Carpenter described several other questions about the therapy, including how best to determine candidates for the ingestible-sensor medications. Additionally, he said psychiatrists may need to consider questions such as, “Is this an acceptable privacy compromise in an involuntary commitment?” or “Will the device lead to fewer in-person visits with clinicians and reduce the chances for integrative treatment and early detection of relapse?”
Carpenter concluded, “Some [psychiatrists] will be ready for this innovative approach of treating mental illness, and if this device is successful—with little compromise to the patient—the field will embrace it.”At this point, it's just too much Big Brother for me.