Saturday, January 30, 2016

Guest Blogger Dr. Mark Komrad on Evidence-Based Medicine and Clinician Experience

In my last post- Medications, Parrots, and Crazy Virginia Laws --, I talked about Robert Whitaker's post on Pete Earley's page.  I put a link to Pete Earley's blog, but not my Shrink Rap post, up on my personal Facebook page.  Now some of my Facebook friends are psychiatrists, so this turned my Facebook page into something of a blog post, with no cute animals.  You followed all that, right? (It's some weird version of social media hell, and yes, I tweeted it as well).  The commenters there gave me permission to put their responses as comments on Shrink Rap, but Dr. Mark Komrad's response exceeded the character count for a blog comment, so I'm giving him a guest post slot here.  Dr. Komrad is the author of You Need Help! an excellent book on how to get a loved one into treatment. His response is below:

Friday, January 29, 2016

Medications, Parrots, and Crazy Virginia Laws

For today's post, I'd like to send you around the web.

First, Pete Earley has a piece up by Robert Whitaker of Mad in America. Whitaker clarifies his position on antipsychotic medications and how their use should be avoided or minimized  in Robert Whitaker Explains his Research after being Pigeon-holed as Anti-Medication.  Let me add my bias: I didn't like Whitaker's book Anatomy of an Epidemic where he concluded that anti-psychotics cause psychiatric disability.  His point was correlational -- as anti-psychotic use went up, so did SSDI (government disability) claims. It's not that easy -- there are other factors that contribute to disability claims including financial & social incentives and the acceptability of being on SSDI.  After you read the post on Pete's blog, I'd like to make two points:

~I don't think that it's controversial that people should be on the lowest possible dose of medications --any medications.  Unfortunately, in psychiatry, we figure out the lowest dose by dropping the medications until someone gets sick.  It's not benign, with each small drop in dose there is some risk that a person will end up psychotic, in the hospital, or unable to function, and recovery can take months or more.  So when someone is doing well, working and involved in meaningful relationships, it's not a low risk issue to drop medications.  If they are having side effects, it's a lot easier to take this risk, because at least you're addressing a problem.  This stuff is not easy when you're talking about real people.

~I remember life before the second generation antipsychotics.  Patients hated taking Haldol and Prolixin and Mellaril and Stelazine.  They were very articulate about how miserable the side effects were, and I don't recall anyone saying that patients wouldn't take Haldol because they had "anosognosia" (ah, we didn't have that word then).  Psychiatrists were well aware that patients didn't take the medications because they made them feel like molasses had been poured into the crevices of their brains, or worse.  Second generation antipsychotics may be no more effective, but they are more acceptable to many patients.

Having said all that, Whitaker may be right that people do better with less medicine, either because those who aren't as sick don't need as much medicine and may be able to completely stop, or because the medications sensitize people and make them worse (I have no answers here.)  When someone is psychotic and suffering, this isn't all that helpful.  I wish we had better answers. Whitaker, and others point to Open Dialogue as a panacea, and it may be a better way with better results -- not much of it is controversial, just expensive and it requires resources for immediate response that we don't seem to have in this country.  There are 5.5 million people in Finland and 321 million people in the US, so the issues are different, and people in Finland get hospitalized and disabled, too. 

While I'm pointing you around, Alex Langford does a nice job of discussing Open Dialogue with all it's pros and cons on his blog Here.  Well worth the read. 

You've heard of Creigh Deeds? He's a Virginia state senator whose very ill and very dangerous son was released from an ER because of a quirk of Virginia state law that said if a bed could not be found within 6 hours, then a patient must be released.  Tragedy ensued -- Gus Deeds repeatedly stabbed his father and then died of suicide.   Over on Clinical Psychiatry News, I explain the idiosyncrasies of Virginia law that could allow such horrors to happen.  See Understanding the Deeds Family Tragedy.


And for the latest news in schizophrenia research, here's a study in Nature that's making headlines everywhere.  If I could understand it, I'd explain it to you.  Maybe Roy could drop by for this one? We haven't seen him for a bit.

Lastly, I'll include a link to an article about PTSD and parrots.  ClinkShrink likes birds, and she loves parrot jokes, so please do share yours.  What Does a Parrot Know About PTSD?


Thursday, January 21, 2016

No, You Don't Need Psychotherapy

Dr. Michael I. Bennett had a opinionator piece in the New York Times a few days ago that made my blood boil.  In You Are Stronger Than You (And Your Therapist) Think,  Bennett talks about a patient who has been in weekly psychotherapy for years until the insurance company decides that the patient does not need weekly sessions -- 12 sessions per year are approved.  But the patient is not Bennett's patient, and he writes from the perspective of someone who has worked for an insurance companies. 

Bennett writes:

I know what it’s like, as a psychiatrist, to feel that your patient’s safety depends on your availability to provide emotional support. However, I also know from experience that patients usually survive our vacations, unavoidable short-notice absences and cellphone failures without actually falling apart. Certain patients feel very vulnerable, needy and worried about abandonment, but they feel that way long before we start treatment and, usually, those feelings don’t change in response to treatment. Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be.

If weekly therapy does, indeed, have only a limited potential to heal and protect, then our patients must be stronger than they, and we, think they are. We know that depression and anxiety routinely distort our ability to think realistically by making us see nothing but our faults, failures and worst-case scenarios. When we’re sure that things will fall apart if weekly treatment isn’t readily available, we may well be accepting and stoking this distortion and, inadvertently, helping our patients believe that they are as weak and helpless as they feel.

Depression and anxiety, Bennett explains, can make some people feel like they can never be strong.  He goes on to advice:

My advice to my colleague was to make a list of the patient’s strengths and encourage her to review what she had learned from the tough experiences that she had endured and survived. It would be normal for her to fear the worst from the coming transition in treatment, but this was also an opportunity for her to see through the negative distortion caused by that fear, review her resources and prepare plans for managing whatever worst case scenarios she could imagine. My colleague could assure her, of course, that emergency care was available. But he could also express confidence in her ability to use what she had learned in their work together to survive and thrive, in spite of her doubts and fears — and of his.  

Where, oh where, to begin.  To contain my urge to rant and ramble, I'll hold my analysis to a few bullet points:

  • Obviously, Bennett may be right that therapy may foster dependence.  The therapist may be financially motivated to patients coming frequently, and there are patients who could be seen less often then they are.
  • So how do we determine how often a patient should come?  The therapist & patient in this case say weekly; the insurance company says monthly.  Why 12 appointments?  Why not 11 or 13? Or 17? Or 9?
  • What is the goal here? Is it to find that absolute minimum number of appointments that the patient can tolerate without another serious suicide attempt (as this patient had)?  Without hospitalization?  With medication? Without a recurrence of symptoms? (Which Symptoms?)
  • Is dependence bad?  What if one hour a week of "dependence" and any accidental psychotherapeutic work that happens to happen along with that dependence comes with the the trade-off is able to live life more fully and productively?  
  • "Objectively, there’s little evidence that the treatment relationship is as healing, powerful or anchoring as we and our patients wish it would be, or as we experience it to be."  Excuse me??? Oddly enough, it seems to me that the therapeutic relationship is often quite helpful.  
  • Might I add that very few patients continue for an extended period in weekly psychotherapy -- it's expensive (even with insurance there are deductibles and co-pays), and time consuming.  There is some automatic self-selection here that leaves the most vulnerable and distressed of people who even want this.
  • Okay, so what do we think about someone from an insurance company who has never met a patient, and generally hasn't reviewed their history and medical record,  should determine how much treatment they need?  Oh wait, managed care has been around for a while.  Now whose idea was that?
Your thoughts?

Tuesday, January 19, 2016

Drowning Bunnies

There was an interesting article in the Washington Post today about a new college president, brought in from the private sector to help a college flourish, who spoke on increasing retention/graduation rates.  In an article provocatively titled "University President Allegedly Say Struggling Freshman are Bunnies that Should be Drowned" (okay, it got my attention), Susan Svruiga writes:

Amid a conversation about student retention this fall, the president of Mount St. Mary’s University told some professors that they need to stop thinking of freshmen as “cuddly bunnies,” and said: “You just have to drown the bunnies … put a Glock to their heads.”

Simon Newman was quoted in the campus newspaper, The Mountain Echo, on Tuesday, in a special edition that reported the university’s president had pushed a plan to improve retention rates by dismissing 20 to 25 freshmen judged unlikely to succeed early in the academic year. Removing students who are more likely to drop out could hypothetically lead to an improvement in a school’s federal retention data; the deadline for submitting enrollment data is in late September.

Newman, a private-equity chief executive officer and entrepreneur who was appointed president of the private university in Emmitsburg, Md., in 2015, said Tuesday that there are some accurate facts in the Echo story, but “the overall tone of the thing is highly inaccurate.”

Oy.  I don't know what President Newman's issue is that he talks about drowning and shooting bunnies, but I since I don't know him --and would like to keep it that way-- I'm going to refrain from commenting on the judgment of the president of a religious educational institution who uses such harsh, violent, and vivid metaphors for talking about those he's entrusted to educate.  

So I'm not sure this is a psychiatric issue,  but I want to comment on the wisdom of weeding out freshmen who are doing poorly in their first month of college.  If one could tell within weeks of their arrival on campus who is definitely not going to make it to graduation, then I would agree with Dr. Newman's concept, but let me use my own language.  If you know for sure that someone is not going to be able to graduate from college, then you would do them the kindest service by not accepting them into your university to begin with.  If you did make a mistake and accept someone who obviously cannot succeed, then it may be best to help them exit early.  College is not for everyone, and if you're never going to graduate, then it may be better to forgo the expense, the debt, the years of struggle and discouragement, the lost income and lost opportunities to master other skills.  Of course, this could be wrong; someone who never graduates may learn incredibly useful things -- both in classes and in the struggle-- and may form invaluable friendships and networks.  Bill Gates didn't graduate from Harvard. Steve Jobs dropped out of Reed.  They did okay without the sheepskin.

Even if it's not all about the diploma, the fact is that the first semester of college is a very stressful time.  Teenagers are leaving home for the first time, they have to wake up and get to class without alarm-clock Mom, perhaps after late nights up using their newfound freedom to discover substances or the opposite sex.  They may not have a sense of how much they need to study, and some may be up far too late pounding at the books, or simply worrying.  Others have to work to get all the bills paid, and figuring out the work/college/social aspects of school may be quite hard.  Some college freshmen get homesick.  Some become ill with serious psychiatric disorders.  But even the smartest, healthiest, and most driven of students may struggle that first semester in college.  Since college is about educating people, it does seem that some tolerance of these difficulties is needed.  From what I can tell,  the predictive value of that first semester is not terribly good.  I've heard stories of kids who've had any number of  issues and terrible grades, who have then gone on to do well.  It may not have been a smooth ride, but it was one that got finished.  

I vote for coddling the bunnies for a while, at least while they get through the transition of separating from their families and figuring out their new environments and its demands.   And you know, I don't think glocks are the answer to very much, and I'm all for a kinder, gentler world.    

Monday, January 11, 2016

Why Can't We Get Help?

On January 8th, Bloomberg Business ran an article on how law students are reluctant to get treatment for psychiatric problems and for addictions. It's not that law students don't suffer from these problems; in fact, surveys show they do in significant and increasing numbers.  Natalie Kitro writes:

People preferred to leave their illnesses untreated than risk not becoming a lawyer. More than 60 percent of students said they didn’t get help for their reliance on drugs or alcohol because they were worried it would affect their career prospects or their chances of getting admitted to the bar. Before they can practice law, students have to pass a “character and fitness” screening, in which officials look into their personal histories with the aim of rooting out people who are too morally compromised to serve clients. The American Bar Association says potential red flags include “drug or alcohol dependency” and “mental or emotional instability.”

Law schools have tried in recent years to convey that students will not be penalized for admitting that they’re suffering, but the report suggested that the efforts haven’t gone far enough. It is tough to counter what the study characterized as a deeply rooted culture of fear in legal education that discourages students from admitting weakness. 

So much for our legal colleagues.  Today,  Dr. Aaron Carroll has a compelling article in the New York Times about why doctors don't get help for psychiatric disorders. "In silence is the enemy for doctors who have depression," Carroll courageously starts by talking about his own episode of illness.  Carroll notes:

Last month, a study in the Journal of the American Medical Association reviewed all of the literature on depression and depressive symptoms in resident physicians — those are doctors still being trained. They found more than 50 studies on the subject. Research shows that almost 30 percent of resident physicians have either symptoms or a diagnosis of depression.

He goes on to postulate:

What makes this all worse is that medicine is a profession in which admitting a problem carries a stigma that can have more impact than in others. A study published in 2008 surveyed physicians in Michigan, asking them about their work experiences and if they had depressive symptoms. More than 11 percent reported moderate to severe depression. About a quarter of them reported knowing a doctor whose professional standing had been hurt by being depressed.
Credit Jody Barton
Physicians with moderate to severe depression had a decrease in work productivity and job satisfaction. They were also two to three times more likely to say that they were worried about, or had difficulty getting, mental health care. Although the Americans With Disabilities Act, passed in 1990, prohibits employers from asking broad questions about illnesses when people apply for jobs, state medical licensing boards still ask specific questions about mental health.
Because of this, physicians are much more likely to avoid treatment. They’re also more likely to self-medicate.

Sometimes that medication is appropriate, as with anti-depressants. Often, it is not. A 2012 study in JAMA Surgery found that more than 15 percent of the members of the American College of Surgeons had a score on a screening test consistent with alcohol abuse or dependence. Among female surgeons, the prevalence was more than 25 percent. Those who were depressed were significantly more likely to abuse or be dependent on alcohol.

And if that's not enough, two weeks ago, KevinMD ran an article called "Don't poop wher you eat: Mental Health Services for Young Physicians".  Amy Ho talked about insurance requirements that residents in training often must get health care --including mental health care -- at the institutions where they work.   Ho talks about the 29% of residents who are depressed, and the reality of seeking mental health care at an institution where you work:

While privacy protection acts like HIPAA are real, they are difficult to trust when you know every single one of your co-workers and ancillary staff (nurses, attendings, etc.) have a password into your private file. Further, unrelated medical care (for example, an ER visit during work hours from a needle-stick accident) allows completely HIPAA-compliant access by one of your coworkers into all of your records.

There is a saying, “Don’t [poop] where you eat” — that is, to keep personal and professional separate. For many residents whose health care is limited only to their place of work, there are often no other options. Of depressed first-year residents, over half cited “perceived lack of confidentiality” as a barrier to treatment.

So I'd like to suggest that these issues of stigma have gotten worse, and not better.  When I was a medical student at an institution with a strong psychoanalytic bent, entering psychotherapy was considered part of what one did to get to know yourself better: essential if you were going to be a psychiatrist, but also not shameful if you believed the unexamined life was not worth living.  People talked openly about being in therapy.  The chief resident in psychiatry put his analysis schedule on the unit bulletin board (times not to disturb him).  A cardiologist told me he wanted to be a psychiatrist until he went into treatment and realized he only wanted to deal with his own issues.  People openly talked about going to therapy.   One of my classmates had a very serious suicide attempts -- it wasn't widely known, but I asked her roommate where she was headed one evening and the answer was to visit her in the ICU where she was on a ventilator.  I don't know what transpired from there, but I do know she wasn't kicked out of medical school--as she might have been today-- and she went on to graduate on time and to obtain a very competitive residency slot. It's not that it was such an ideal world -- many people at my undergraduate school died of suicide and I don't know if those people were in treatment or not. But in some circles, there was less concern with secrecy and stigma.

I believe that certain behaviors have always been, and always will be, stigmatized.  When your mental illness leaves you to suffer quietly, the problem is yours, and if we hadn't come to associate "mental illness" with mass murder, and the possibility of unpredictable, disruptive behaviors, if we didn't erode privacy with records in the cloud, and if we didn't make it so damn difficult and expensive to get good treatment,  then there should be no shame for seeking treatment for depression, anxiety, or even most substance abuse problems.  I'm not sure our society has ever been comfortable around florid psychosis, nor do I think it ever will be.

Okay, hold with me for one more article.  In yesterday's Washington Post there was the story of the Dallas District Attorney who's position was being threatened because she disappeared for a couple of months to get inpatient treatment for depression, and had been treated for substance abuse.  But this DA's illness was, per the media, not just about her own personal suffering.  In a paranoid state, she fired  colleagues, she was obviously intoxicated at work, and her illness left her impaired and made life difficult for others, until she got treatment and recovered.  A judge dismissed a lawsuit to oust her. I wish her all the best moving forward.  One might hope, however, that people in such powerful positions might feel it's safe to get help before their problems effect others. 

Tuesday, January 05, 2016

Is Everyone Mentally Ill?

We talk about mental illness based upon a standardized set of symptoms, where the symptoms co-occur in groups/clusters/syndromes in ways that enable us to cluster them together (i.e. make a diagnosis), treat the illness we've defined, and have some means of predicting outcome (i.e. 90% of people will have full remission of their symptoms within 6 months).  We talk about these clusters of symptoms as being illnesses or disorders, and we look for biological correlates -- changes in brain chemistry, anatomy, metabolism -- to divide those people who have the disorder from those who don't in the hopes that someday we will have tests to tell us who will respond to various treatments.  It would be very nice to get rid of all this trial and error medication cocktail stuff and just have a test that says "Meds won't work for you, you need TMS," or "no point in using an second generation antipsychotic, go straight to clozapine."  So far, no great breakthroughs in terms of either diagnosis or treatment predictability, but give it time. 

So there was an article in the New York Times on January 2nd titled "Is the Drive for Success Making Our Children Sick?" Vicki Abeles talks about how childhood stresses lead to illnesses, including ulcers, as well as more medical illnesses as children age into adults.

Abeles writes:
STUART SLAVIN, a pediatrician and professor at the St. Louis University School of Medicine, knows something about the impact of stress. After uncovering alarming rates of anxiety and depression among his medical students, Dr. Slavin and his colleagues remade the program: implementing pass/fail grading in introductory classes, instituting a half-day off every other week, and creating small learning groups to strengthen connections among students. Over the course of six years, the students’ rates of depression and anxiety dropped considerably.

But even Dr. Slavin seemed unprepared for the results of testing he did in cooperation with Irvington High School in Fremont, Calif., a once-working-class city that is increasingly in Silicon Valley’s orbit. He had anonymously surveyed two-thirds of Irvington’s 2,100 students last spring, using two standard measures, the Center for Epidemiologic Studies Depression Scale and the State-Trait Anxiety Inventory. The results were stunning: 54 percent of students showed moderate to severe symptoms of depression. More alarming, 80 percent suffered moderate to severe symptoms of anxiety.

“This is so far beyond what you would typically see in an adolescent population,” he told the school’s faculty at a meeting just before the fall semester began. “It’s unprecedented.” Worse, those alarming figures were probably an underestimation; some students had missed the survey while taking Advanced Placement exams.

Okay, so wait, at least half of a group of students surveyed were moderately to severely depressed (?what about mildly depressed), and 80% were moderately to severely anxious?  And the symtptoms abated when the stress disappeared?  This doesn't make sense -- are our disorders illnesses --- brain diseases (as some like to call them)-- or are they part of the spectrum of normal reactions to stress, pressure, and likely lack of sleep? 

In a clinical setting, I'll tell you that sometimes it feels really clear cut: there are people who get sick and they get severely psychotic, or they markedly change from their usual personality. They shut down and lose their usual vitality and ability to function; they aren't showing up for those AP exams.  They become so symptomatic that they become someone totally different, and there is no 'hiding' their illness.  In other cases, it's not so clear cut -- people come in complaining of symptoms of depression, loss of interest, sleep changes, libido changes, suicidal thoughts, and any mix of symptoms that meet criteria for a disorder, and they attribute their distress to a given set of life circumstances.  But they're functioning in their usual roles,  and they are able to mask their symptoms: the rest of the world may not know how badly they feel.  If they are coming to see me as a psychiatrist, they often want medications, and medications often help.  Would they need medications if we could remove the stress?  Often they say 'yes' but we can't make that happen.  Maybe you're thinking about school stress and pressure to achieve, but there are other stresses -- illnesses, financial burdens, divorce, family chaos -- which don't go away by dropping a class or giving up tuba. 

If the studies cited above are accurate -- and I didn't look at them -- and the symptoms are persistent, then this doesn't fit with our idea of mental illness.  It comes to be about a normal reaction to stress, a need -- as noted above-- to change our environment, and a question as to what gives resilience to those few who don't have symptoms. 

Tuesday, December 29, 2015

Happy New Year: What are Your Hopes for Mental Health Policy in 2016?

Happy New Year!
So the end of the year has me reflecting on the things that have..well...annoyed me a bit this past year, and about the things I'd hope could be different.  It gave me a chance to take stock and come up with my wish list, which is up on our Clinical Psychiatry News website Here.
Do surf over and let me know what you think.
What did I miss?  What would you like to see change?

Monday, December 28, 2015

I Owe You What?

The question of agency in psychiatry is an interesting one.  To me, it's clear: I'm the agent of my patient, it's his best interest that I care about.  But the odd thing is that society periodically asks me to assess patients for their interests. 

 Is my patient able to serve on jury duty?  He tells me he's very anxious, in fact he's taking medications for anxiety, and he has some health issues, and everything about jury duty is hard here in the grand city of Baltimore.  There's a daily stipend; it doesn't cover the parking fee.  You have to negotiate downtown traffic, park in a garage, walk to the courthouse, and if you're put on a criminal trial, there is the fear (albeit the risk is perhaps quite small) that you or your family could be in danger if you vote to convict a gang member.  The seats in the waiting room are uncomfortable, the temperature is always wrong --either way too hot or way too cold. Serving doesn't mean you'll ever be called to a court room, I've spent 8 hours in a freezing waiting room to then be dismissed at the end of the day.  Okay, but here it's not the court asking, it's the patient asking -- but the point is that if I say someone can't serve, they get a free pass. 

What about driving? Periodically, someone gives me a form to fill out for DMV regarding their safety to drive because they carry a psychiatric diagnosis .  I'm not aware of any purely psychiatric diagnosis --with the exception of dementia --which leaves one unable to drive, and invariably the patients does wish to continue driving. Driving helps get to appointments and to obtain medications and food, among other things. Usually it's people with schizophrenia or bipolar disorder who show up with the forms.     I have never witnessed any of my patients drive; if I did, I still wouldn't know how to judge; driver safety assessment is not taught in medical school.  And many patients talk about having multiple accidents, unrelated to any diagnosis or substance issue (they're just lousy drivers) and they never show up with forms. 

A difficult one is the people who show up with forms for clearance  for a new job.  If they are bringing me a form, it means they've told the employer or the human resource folks that they have a diagnosis.  Often, it's my opinion that it would be in their best interest to at least try working --- work adds structure and meaning to a life, it often adds health insurance (a very good thing), and it adds money which allows for food, housing, medications, entertainment, and opportunities for fun, all of which improve mental health! 

 Sometimes, however, I'm not sure if my patient will be able to do the job --- like driving, I was not trained to assess the ability to work.  Sometimes I can see there might be problems -- the patient misses appointments because they get too depressed to get up, or they have executive functioning issues where they simply don't organize their lives well ("Oops, I forgot I scheduled 3 appointments at the same time!").  But still, if they want to work, and if they can, it would be in their best interest.  Now, obviously, there are some exceptions here where it's not in my patient's best interest to take a job -- for example if there's been a history of repeated suicide attempts or violent behaviors, then perhaps it doesn't make sense for me to clear a patient for a job if it requires that he carry a firearm.  But mostly, it's more benign stuff and I've seen people who can't get to an appointment reliably, but can manage a job -- either they prioritize getting to work, or they have jobs that value performance more than punctuality.  And many people negotiate successful work lives around substance abuse problems, especially if they can limit the substances to after-hours.   And there, too, there is a check on the system that doesn't fall on me; jobs where sobriety is crucial usually include drug screening.

So what's my obligation here?  The patient the wants the job.  No one's life will be in danger if she fails, though with some people, job failure can be a huge emotional setback.  The structure, purpose, and money will all be be good if the patient can manage to  work.  But there are these forms that I've been handed with a long check list of  questions regarding the ability to perform tasks where I have no idea, or I suspect that, based on history, the patient may not be able to do --like show up, attend to detail, demonstrate organized thinking-- but I could be wrong, because I have been before, and a work setting is different from a psychiatric office.  If I say I don't think the patient can perform, they don't get the job and they lose the chance to try. 

In my head, it's a dilemma.  There is no question that I am the agent of the patient and that I owe nothing to a patient's potential employer with whom I have no relationship just because they send a packet of papers.  I want what's best for my patient, but as human being, if I have reason to believe the patient can't perform a task and I say they can, then I'm basically lying.  None of it feels right.  

Psychiatrists (and perhaps doctors as a whole) have ended up in these strange places.  We often don't know if our patients can work, serve on a jury, drive, own a firearm safely, go to summer camp, or manage the stress of any given situation.  New settings can be stabilizing or destabilizing.  I'm not sure how we got to be the gatekeepers on such things.

Your thoughts?
So when I'm 

Monday, December 14, 2015

Film Preview: Touched With Fire

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:

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.
 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.

Carla and Marco are two poets who meet in a psychiatric hospital.  Group therapy feels a bit like a college seminar with a little psychosis thrown in, and the facility looks more like a middle school. There is wonderful collection of books with painting by Van Gogh,  photos of brain scans, and astronomical maps. There are art supplies galore.  Carla and Marco are bright, attractive, creative people, and what a relief to have people with mental illness portrayed as normal looking people who don't have strange mannerisms or dress in plastic bags.  They aren't pushing grocery carts, but they aren't doing well, either. They are human and likable, and Marco in particular comes off as being educated, brilliant, and in possession of this wonderful passion for life -- if you can overlook his constant pain and alienation.

So both patients have insomnia, and every night at 3 AM they meet in the activity room.  Van Gogh's Starry Night is projected onto the wall, and they connect with an intimacy that is, well, the stuff that movie love is made of.  And besides that, they build a sculpture out of the plastic chairs by piling them up, putting Play Doh on them, and sticking forks in the Play Doh, and they talk about going away (metaphorically, that is), to another place or planet. If they get lost, meeting back in the pages of the Van Gogh book.  All goes well until the psychiatrist decides they should be sleeping, not connecting, and they drug the night aide with their sleeping pills to continue with their rendezvous.  Ah, that doesn't end well, and when the well-meaning doctor tries to separate them, Marco throws some books, pushes a chair, they cling to each other, only to be separated by guards -- they end up sedated and restrained in their separate seclusion rooms.  Really?  And now it looks like an old psychiatric hospital. This was the first point where I felt some angst for the characters.  It seems like there should have been some kinder, gentler way to deal with this.

After discharge, the couple find each other -- they meet up in front of the genuine Starry Starry Night -- and their romance begins.  Their parents don't approve: two bipolar patients have to be bad for each other.  Again, I had another Really? moment.  Okay, maybe it isn't meant to be: people often connect in the hospital and when they leave, the connection ceases to be, but is a preconceived stereotype that two people with bipolar disorder are bad for each other.  Honestly, I wanted the parents to rejoice in their relationship -- if it didn't work out, then so be it, relationships often don't.  

Marco really struggles.  The medicines make him numb and lifeless, he simply can't feel.  And his well-meaning doctor doesn't offer to work with him to find something better; instead he tells Marco that his moods have been extreme and unregulated for so long that he doesn't understand what 'normal' feels like -- a stance Marco rejects.  In a world presented as either/or, Marco chooses mania, and he and Carla both end up off their meds after ceremoniously dumping them into a park fountain.  When they drop off the radar for a bit ---enjoying nature, each other, and love propped up by mania -- Carla's mother cajole's her into a get together, under the guise that she will accept Marco.  But oops, all the parents show up with Marco's doctor and the men in the white coats.  My third moment of Really?  They weren't bothering anyone. 

So Marco and Carla run off and have these wonderful moments bathing in lakes and driving through gorgeous mountains.  It's all good until the police try to pull them over and Marco's answer is to drive into a river.  Back in the hospital, it's revealed to all that Carla is pregnant -- something the couple wanted.  They promise to stay on their medications, be responsible, and everyone prepares for the birth of this baby, whose job it will be to make them whole, and to be comfortable on this planet.  

Only Marco can't do it.  Carla arranges for Marco to meet Kay Jamison -- a writer he idolizes-- who assures him he can stay on medication and still feel passion and be creative.  Marco, however, doesn't buy it -- Jamison, he decides, is a fake.  She writes about great artists because she can't be one!  He stays off his medications and becomes exuberant, magical, and then insistent -- while painting Starry Night onto the baby's nursery wall, he loses it and pushes pregnant Carla to the ground.  

Carla reappears to a 'baby shower' Marco has thrown with their parents gathered around the crib -- there are balloons and champagne, and Marco presents Carla with a gift-- The Little Prince -- a book in which the prince comes from another planet.  He announces the unthinkable: Carla has had an abortion.  Untreated mental illness has driven this relationship has come to its inevitable end.  Ugh.  I wanted it to work.

Time passes, and in the closing moments of the film we get our "happy ending."  Carla and Marco come together for a book store reading of a book of poems they wrote together when they were pregnant and manic.  Marco is on his medication, and Carla is doing well ---her father is proud of her and she has a new boyfriend.

In the discussion after, we learn that filmmaker Paul Dalio struggled with much of what Marco struggled with: how to manage his bipolar disorder without crushing his creativity. Dalio, too, met with the real life Kay Jamison who served as an inspiration to him.  

Dalio and Jamison talked about bipolar disorder as a "gift," a subject that came up in the movie.  I wondered, is bipolar disorder the gift, or are these two tremendously talented people who happen to have bipolar disorder? They talked about all they could do after bipolar disorder that they couldn't before, and I wondered -- is it the illness, the experience of the illness, or do people just find more talents as they age and mature.  After all, bipolar disorder often strikes young and we all grow into ourselves, with or without an illness.

Finally, I want to reiterate that I really wanted this couple to work out.  I wanted them to continue to rejoice in their love, to manage their lives,  and to have their baby with the happily-ever-after coming before the last few minutes.

The movies was the absolute best ever film portrayal of bipolar disorder; the people were real and they were so much more than their illnesses as they moved through each stage -- manic, desperately depressed, suicidal, and finally, well.  

So I'm going to end with one final thought.  The film was presented as a realistic portrayal to destigmatize mental illness, and while everything about this film was rich on so many levels, I didn't think it destigmatized bipolar disorder. I didn't leave the theater thinking it would be fine if I or my children got this disorder. I didn't want my patients or their parents to see it if they were early on in the illness.  These characters were very sick; not everyone with bipolar disorder end up in and out of the hospital, not everyone destroys their careers, their love, and their unborn child.  I want my patients to feel more hopeful.   Kay Jamison and Paul Dalio are much more inspirational, hopeful examples of people living full and creative lives with bipolar disorder.  

If your goal is to understand bipolar disorder -- with all it's passion and pain-- then, hands down, this is the film to see. 

Thursday, December 10, 2015

Over-the-Counter Antidepressants?

Today's post is over on Clinical Psychiatry News, "Should SSRI's be Sold Over-the-Counter?"  
It's a question I'm asking just so people will flip the idea around in their heads a bit; it's not one I'm trying to sell.  

Please check it out Here, and do let me know your thoughts.

Thursday, November 26, 2015

Black Friday Shopping: Free Novels from Shrink Rap!

Happy Thanksgiving!

I realized that it's been a long time since I had a free promotion for my novels, and with Black Friday looming, I thought it would be nice to have Shrink Rap jump on the bandwagon with Black Friday shopping you can do from your living room, and with a great price, too: free novels.  The promotion goes for 4 days: Now through Monday 11/30/15.  If it goes well, I will set up another promotion for one day in December.

Double Billing is the story of a woman whose life changes when she discovers she has an identical twin she never knew existed. It's a quick read with a little  psychiatry sprinkled in.
 The book was a page-turner because of elegant structure and pacing.  I really cared about the author’s take on things –because she is a psychiatrist? because I’ve followed  her blog for a while?– which meant that I was interested in the protagonist’s thoughts, feelings and actions.  At times I ached for the mess her life was in, at others I wanted to shake her into action, and then she’d find her backbone again, just in the nick.  

Home Inspection is a story told through psychotherapy sessions in a format that is similar to the HBO series In Treatment.
Dr. Julius Strand is a psychiatrist who plods along in his already-lived life until two of his patients inspire him through their own struggles to find love.  
  I like to read all sorts of books, but books where there's something in it that reflects a part of me, a part of my life, a part of my experiences, are something I go out of my way to find. I have not found any fiction book that does nearly as much to show what psychotherapy is like.

If you don't own a Kindle reader, you can install a free Kindle app on your computer, tablet, or cell phone by going
here and then you can read any Kindle book. You don't need to buy a Kindle to read on your computer, tablet, or smartphone.

There is is a single link to my Amazon page with all my books here.
The price for Double Billing, Home Inspection, and a children's novel: Mitch and Wendy, are all $0 and can be downloaded instantly.

 Both are also available as as paperbacks from Amazon, but not for free.

I'm more than happy to have people download my novels at no cost -- I'll be keeping the doctor day gig -- so please tell/tweet/blog/share the free promotions to anyone you think might be interested.

Finally, If you do read any of the books, please consider putting a review on Amazon.   


The promotion starts Friday, so it's off to turkey and family for today.  Wishing you all a gentle holiday.

Monday, November 16, 2015

Do You Need a Psychiatrist? In Maryland? Now?

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  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.

Friday, November 13, 2015

If You Don't Get Better, We Can Always Kill You

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.   

Tuesday, November 10, 2015

Who oversees medication pre-authorization?

Have you ever tried to get a medication preauthorized for your patient, only to be told "no" the insurance company won't pay for your patient to have the medication you say they need?  I've been trying to get a medication authorized, and I decided to see this through.  In some cases it seems there is no end to the hoops the insurance company can set, and no time frame for when they must answer.  Read my account here on the Clinical Psychiatry News website.

Sunday, November 08, 2015

10 Steps to Change the Stigma of Psychiatric Disorders for Better or for Worse with some Surprises

It's someone's mantra: the number one barrier to getting mental health treatment is stigma.  Maybe it's true and I'm not looking at the research, I'm writing from my own impressions (It's my blog...)

I'm going to suggest that the barriers to getting mental health treatment are
~1) Access.  Half of all counties in the US don't have a mental health professional (I saw that on Twitter, so it must be.)  That's any mental health professional, not just psychiatrists.
~2) Access.  If there's somewhere to go there may be many weeks to wait.  People don't like to wait and some of those people just won't make appointments far off; some will feel better before they actually get in and won't show up.
~3) Cost.  Over half of psychiatrists don't participate with insurance, the upfront cost of care is very expensive, and insurance companies vary in how well they reimburse out-of-network care and won't tell you what they reimburse before you file the claim which they may or may not lose or reject.
~4) Shame or embarrassment,  so stigma.
~5) The urgings of others who disapprove of the use of medications, don't believe in psychiatrists, don't want to foot the bill for relatives, don't want to take off work to drive a relative to appointments.
~6) Distrust of psychiatrists and the pharmaceutical industry

Somehow, we've become a culture that believes that if you say "End Stigma" you're doing something to end stigma.  Or that if you come out and announced all the awful things your mental illness has led you to do, that this ends stigma.  Bill boards are big.  Or that if you're a politician who says "We need to end stigma" while passing stigmatizing laws, that you're ending stigma.

So what decreases stigma.
1) When successful celebrities announce that they've struggled with mental illness, particularly if they have not made a spectacle of themselves and if they haven't led chaotic lives.  When Andrew Solomon talks about his struggles with depression, as he rakes in his many writing awards and gives his incredible TED talks, that's destigmatizing.  Brittany Spears -- not so much.

2) When regular people talk about their struggles with mental illness: especially if they are employed, married, and living productive lives.

3) This won't be popular but: Television commercials for pharmaceutical agents and direct-to-consumer advertising.  It's everywhere -- someone must be taking those medications and the ads normalize it.  It may be bad for all sorts of other reasons, but in terms of decreasing stigma, they help.

4) Parity for insurance so that mental health treatments aren't different/less than 'real' medical conditions.

What Increases stigma:
1) Anything that alters civil rights based upon the existence of a mental health diagnosis in the absence of a troublesome behavior.  So laws that restrict the purchase of guns by people with a mental health diagnosis, even if they've never done anything dangerous or threatening.  Or proposed laws that want to say that people with a diagnosis of a psychiatric disorder should be the only people who can't forbid their treatment team from releasing their diagnostic and treatment information to their family/caretaker.

2) Comments about keeping guns out of the hands of crazies.  ('nuff said).

3) Linking mental illness with mass murder.  I think.  I actually have never had a patient who has expressed any sense that being in psychiatric treatment in any way associates them with someone who does heinous things.  But it can't be a good association.

4) Fears of being made/coerced into to take medications when you don't want to take them and the concern that one's autonomy and individual decisions won't be respected.  Who wants to sign on for that?

5) The side effects of our medicines.  There's nothing desirable about being overweight, having metabolic syndrome, being sedated, having a tremor, or having other movement disorders.  

6) The devastation associated with untreated mental illness -- unmet potential, sometimes unemployability, homelessness (or being stuck in a parent's basement), incarceration, poor hygiene, odd behaviors.

So what did I miss?  I'm skeptical about the idea that Modern Family's Halloween episode with scary 'mental patients.' actually increases stigma -- it's a historical stereotype and it's too outrageous to feel like anything accurate -- but I certainly do understand that this is very offensive (I'm just not sure that all that is offensive is  stigmatizing).  By all means, feel free to correct me here.  And feel free to add to the list.