Thursday, January 31, 2008

In Treatment: Episode Number 3....the sub-blog

ClinkShrink has a GREAT Story about her day, you've got to scroll down to the Donut post.

Episode 3

It's about shrinks and parents, a theme close to my heart these days.

Paul's psychotherapy office, we discover, is in his home. A small boy, maybe 9 or 10, sits at his desk holding a thermometer to a light bulb while Paul and his wife argue in the background. The boy wants to stay home, but Paul doesn't buy the sick plea or the temp of 103. "We could rent a movie and watch it," the boy says, but Paul is stern. Boy must go to school, dad must go to work. The boy says, "You never believe me." The shrink dad cringes, we know there's more to it (damn it, there'd better be), we'll wait for another episode.

Patient Sophie is 16, an only child, an Olympic-hopeful gymnast. The handshake over first names reveals both her arms are in casts, and she's been referred by her lawyer. "I'm here for your professional opinion." Translates to, 'I'm not here for treatment.' Sophie was hit by a car while riding her bike, the question has been raised by the insurance company as to whether it was a suicide attempt, and in fact, Sophie had tried a friend's motorbike 2 years before and crashed into a car back then.

Paul asks about the accident. "I told you, I don't remember anything." She becomes uncomfortable. She's already seen a social worker and she didn't like the social worker because she thought she knew everything about Sophie.

"Can you help me with this professional opinion?"
"It's not like an XRay," Paul says, "It doesn't quite work like that." Sophie says she'll leave, but she doesn't. "I didn't come to talk about myself."

She gets angry. She wants Paul to ask her "shrink-like questions." She thinks Paul spoke to her mom, and she and mom clearly have issues. She came by bus, she'd never let mom drive her. Sophie's close to her dad, he's always there for her, but she finds him by calling "411" --Information-- because he moves so often. And, oh yeah, there's Cy the gymastics Coach who drew the topless mermaid on her casts and who's children she's babysat for.

Sophie is angry that Paul doesn't jump at the opportunity to read the insurance report she's brought him. He says they need to meet 3 or 4 times and he wants to read it alone. "Otherwise it wouldn't be professional." He echoes her words with such finesse.

Paul reads. Sophie wanders about his office. She comments on his collection of ships. He has asthma, she finds his inhaler. "Did you really read all those books or are you just trying to make an impression?" "They're your f***ing books, Buster." Oh my. And Paul is unflappable.

Sophie asks about Paul's daughter. How did she know? They are in the same grade, they once went to the same school, he was on the PTA.

They talk about a show that even I'm not old enough to know about "This is your Life" or something like that. Paul tells an angry Sophie that everyone thinks about death. "Suicidal tendencies, blah, blah, blah," she says.

"It's 10 of and you probably have to turn on your cell phone now," Sophie says to Paul. She asks Paul about his relationship with his daughter, she must call him at 10 of the hour. My real-life daughter and I laugh, I because I turn on my cell phone at 10 of the hour, my daughter because "I always call you on the hour because that's when you answer." Why aren't we on TV?

Paul gets water for Sophie at her request. He gently places a straw in it and asks if she needs help. For the guy who wouldn't watch a movie with his kid, he is the quintessential daddy to this patient who so desperately needs a parent. He gives them both an assignment-- they will both write an assessment of the insurance company's report.

Paul is good. He's really good. My daughter says he's old, wrinkly, gray. Nothing fazes him, he never says the wrong thing, he ties everything neatly together. His eyes light up when he smiles, sometimes even when he doesn't. He's a better shrink than I am any day, oh and that faint brogue to top it all off. When can I tell him my secrets?

You Eat Donuts Like A Psychiatrist

So I'm sitting in Dunkin Donuts having an apple fritter when this nice cleancut young guy walks up to me and says, "You should be eating a muffin."

I looked at him. He was nicely but casually dressed, in an Old Navy/Gap kind of way. I was sure I didn't know him. "Pardon?" I said.

"Dr. Ellen says you should be eating a muffin. She compared a bagel with cream cheese to an egg McMuffin, and said the muffin was better."

At this point I was rather intrigued. He engaged me in a long discussion of nutrition, exercise, the importance of balance in life. He was animated, gestured a bit, talked a lot but not too loud or fast.

"You're doctor, aren't you? You seem nice." he said.

OK, that spooked me a bit because I hadn't told him anything at all about myself. I admitted I was a doctor. Then he went on to tell me about his family (aging mother caring for father with Alzheimer's, multiple brothers and sisters overly involved in his life) and I began to catch the drift that he was having a bit of trouble breaking away from the conversation. I wasn't surprised when he mentioned he had bipolar disorder. By this time I was expecting it.

"You're a psychiatrist, aren't you?" he said.

OK, spooked again. I definitely didn't mention I was a psychiatrist. I know I've never seen this guy before.

"Uh, yeah," I said.

"I thought so. You seem nice."

He told me about his psychiatrist (someone I know, a non-Shrink Rap colleague of mine), his clinic (not too far away from my prison). He handed me a religious brochure, told me to "keep doing what you're doing, God bless you," and then left. He promised to say hi to his psychiatrist for me.

I still don't know how he pegged me as a psychiatrist. I guess I eat donuts like a psychiatrist.

Wednesday, January 30, 2008

In Treatment: Episode Number 2.....the sub-blog

Warning: PLOT SPOILER



Today's patient (well, yesterday's patient, I'm playing catchup) is Alex, I assume the therapist will still be Paul. And you know, Paul is kind of hot.


No denim today. Paul's in slacks, though Alex the patient wears jeans and a leather jacket.

It's Alex's first session, it starts at the door with a handshake and first names. Alex asks if there are ground rules. He looks around, touches some books. Paul jests, "In my profession we say that the customer is always wrong... it's a therapist joke."

Alex has done research: he knows Paul is the best. "So, do you recognize me?" Alex always goes to the best. Paul does not recognize him.

Alex explains that he flew a navel mission which accidentally resulted in the deaths of civilian schoolchildren while they studied the Koran, it was all over CNN. Alex is a wanted man by Islamic fundamentalists.

"You're dying to ask how I can sleep at night. Very well thank you. I hit my target, I sleep like a baby." Alex is smooth, cavalier, steeped in denial if you ask me. (You didn't ask, but hey, it's my blog).

Alex talks about how his father handled his mother's death, an event he deems the most traumatic thing in his life. He imitates his father: 'It never ends, Alex, your mother left such a mess.' His father soon remarried. "A whole life together and not a single tear."

Alex talks about running, his way of getting R&R. He runs with a gay friend named Danny, they go for miles. They run farther than ClinkShrink. Alex pushed Danny, who wanted to stop, to go for 26 miles, a marathon pace. At 22 miles, Alex had a heart attack and "died" but was revived from his 'total clinical death' defying all odds. He talks about the end, "the tunnel." Alex tells Paul, "All that time I tried to figure out if I had a hard on." And from there he talks about how his 92 year-old grandfather died with an erection. Danny, the gay runner, is a doctor who resuscitated Alex. Paul wonders if this links to Alex being fearful of being a homosexual. No way.

Alex and Paul tussle a bit. Paul points out that Alex has been testing him since he walked in the door. "You have no patience," Alex tells the therapist.

So now Alex tells Paul his chief complaint: He talks about being 'frozen' for 48 hours in a body suit during his time 'dead.' Paul tells Alex he has a strong will to live. He's come back from the dead, "and if you don't supply the goods...." Paul says, "this is a systems failure that wasn't supposed to happen to you."

Alex says his whole life was perfect, he was born to excel, he is the creme de la creme, "I'm a top gun grad and that training is not for pussies."

Alex wants advise. He continues with his cryptic style. Alex decided to go back to the site where he dropped the bomb on the school. "I don't have a guilty conscious." Paul worries that Alex will not be safe if he returns to the school. "This isn't for me." Alex says of therapy.

Paul talks about how Alex perhaps needs someone to be his commanding officer. Paul is scheduled to leave TONIGHT to go to Baghdad.

"Don't you think there's a strong desire there to atone for your actions?" Paul asks. Something finally hits Alex, he wants a cup of coffee, he doesn't want to leave even though his time is up.

My husband says it's not enough, it's just a plot summary, it needs a Dinah-spin. He wants me to predict where the therapy is headed. What does my husband think I do for a living? I'm a shrink, not a fortune teller!

So I liked this episode better than Laura. It was less predictable. Alex is a narcissist, I think, he's also difficult, constantly challenging and trying to out-smart the doc. He wants advice, but he isn't there to listen, he's there to hear he's right, to get permission in a sense, and to ignore whatever it is he doesn't want to hear. Maybe he's just there to out-best the best.

Monday, January 28, 2008

In Treatment: Episode Number 1.....the sub-blog


"In Treatment" begins on HBO tonight-- it's a series that will run nightly (and hey, I have no life, what else have I got to do?) . I'm going to try to post either during (can I do that?) or right after. I'll add the time as I write, and feel free to write comments as we go.
Warning: PLOT SPOILERS.

9:25 The excitement builds.

The patient cries. It isn't fun. She calls her doctor "Paul." She gets up and stumbles, he grabs her hand. Her nail polish is very red. Where did she leave her car? She sat outside for four hours in the dark before the session. He drapes her in a blanket. She talks about watching the minutes tick by on her cell phone. He is quite. She talks about her ambivalence about the session.
"What happened last night?"

She left Andrew. They drank.

The patient's name is Laura. "I did some terrible things last night."
Paul says it's okay if Laura vomits on his rug. Her phone rings in her very red purse. It's Andrew. Paul is wearing jeans. He doesn't let Laura take the call.
Andrew, it seems, has given her an ultimatum, they get married or he leaves, and she has 2 days to decide. Andrew cried. Laura was scared. Or she was angry. She feels manipulated. She smashed his laptop.

She went for a drink with a friend who dressed her in the little black dress she's worn to the session. Laura drank more and her friend left, and Laura met a guy-- probably a Republican--- he paid for her drinks. He followed her to a unisex bathroom. She had sex in the bathroom with the stranger. Way too many details. Suddenly thought of Andrew and he pees like a racehorse in the morning, sex aborted....more too many details...and then she thought about talking about this in therapy.

"And what did you imagine us saying?"

Patient worried that Therapist Paul would be disgusted. She confesses her behavior and leaves to vomit in his bathroom. Paul makes her tea.

Paul brings Laura back to talking about Andrew and points out to her that she was the one who delivered the ultimatum, "It sounds like you were the one who wanted to bring the relationship into crisis."

Laura gets angry. "I did no such thing." And suddenly Laura confesses to Paul that she's been unfaithful to Paul for a long time, "it's been here all along, you mean you've never noticed it." Oy. Obviously Laura is confessing her feelings for Paul and he doesn't get it. She wants Paul to hug her and confess his love. Paul looks only a little uneasy.

My daughter comments in real life: "These people are really messed up."

Laura is humiliated, Paul sits there like a Buddah. "You've become the center of my life."

"Laura, I'm your therapist, the parameters and limitations are established and ethically defined and not an option." Go for it Therapist Paul.

Laura talks about her fantasies about Paul. "I know it can never happen> I'm not going to boil your kids' rabbit." "The only thing that matters to me is you."

So far: it's not the Sopranos.

Sunday, January 27, 2008

My Three Shrinks Podcast 41: Chris Kraft on Conversion Therapy


[40] . . . [41] . . . [42] . . . [All]

You all may remember Dr. Chris Kraft from podcast #21 speaking about gender identity problems. He's back here today as a guest talking about some other sexuality issues, particularly the controversial notion of conversion therapy -- converting from homosexuality to heterosexuality.



January 27, 2008: #41

Topics include:
  • Top 10 Podcasts of 2007. Chris' first guest podcast, Chris Kraft on Gender Identity Issues (#21), was the 6th most downloaded podcast for 2007 (out of over 100,000 downloads for all podcasts for the year).

  • Conversion Therapy. Chris Kraft, Ph.D., talks with us for most of the podcast about the idea of using the therapy process to convert someone from being gay to being straight. References to Richard von Krafft-Ebbing (coined the term "homosexuality"), One Nation Under God, Exodus International, and Monday at the Charm (Dinah's book).

  • "Go to iTunes and Write a Review". Reviewer #21, St. Louis Doc, wrote on iTunes, "I am a psychiatrist and very much enjoy [the podcast]. ... About professional isolation: I've heard (and experienced) that psychiatrists/therapists are especially susceptible to becoming isolated and insulated in their own world. Because of confidentiality and because we don't tend to work in groups when we are doing therapy... So, your podcast, along with being educational and entertaining, is one partial antidote to this isolation. Through your podcasts, we psychiatrists can hear how other psychiatrists think in a way that is not censored or biased by the psychopharm industry. Please keep up the good work." St. Louis Doc, thank you for the kind words. I hadn't thought of this issue when it comes to podcasts, but isolation is indeed an occupational hazard.

  • Savage Love. Chris plugs Dan Savage's column and podcast on sexuality.

  • How Drugs Get Their Name. Roy talks about his recent post on the secret cabal of 5 people who grant all the generic names for new drugs.

  • Well: Tara Parker-Pope on Health. Dinah plugs this excellent column on health issues (while fantasizing that Tara gets her material from us).

The background music is from the mash-up I made for podcast #24, Dr. Phil on Skype.






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. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.
Thank you for listening.

Saturday, January 26, 2008

The Psychotic Dilemma


Mrs. Gersteweiner (not her real name) has been my patient at the clinic for many years. Mostly she's fine, she cares for her elderly mother, her grandchildren, and maybe even a few great-grands. For as long as I can remember, she's been diabetic. She's was hospitalized for episodes of psychosis long before I came into the picture and she sees me just briefly every few months for a review and refills of an anti-psychotic medication. Maybe she sees her social worker therapist (at the same clinic) monthly. Mostly, things have been fine.

Mostly. A few years ago, she had an acute exacerbation of her psychotic illness. Oy. Relatives came ranting to me. Mrs. Gersteweiner was irritable, paranoid, and not herself at all-- and she absolutely didn't believe something was wrong with HER! (Ah, years later, she still doesn't think that episode was her illness). She was hospitalized, it was not nice, she may have been in seclusion for a while, she may have been released and needed readmission, I just remember that no one was happy and I'd rather not go there again.

Somewhere in the course of this, Mrs. Gersteweiner's anti-psychotic medication was changed from one atypical to another atypical, the dose was futzed with and with regard to the diabetes, well, I'm not sure which came first, the atypicals or the diabetes, it's been years for both, but people do get diabetes who are not on atypical anti-psychotic agents and she had both illnesses before the meds were linked to diabetes. Not that that particularly matters, but....

Mrs. Gersteweiner is mostly fine (now).

Her therapist, however, has been contacted by the patient's primary care doc-- her sugars are high, her cholesterol is high, can't we prescribe something other than Atypical X? I forgot to mention that while Mrs. Gersteweiner is in denial about her psychiatric illness, she also isn't so keen on having diabetes and diet/exercise/life style changes/fingersticks/ or even compliance with the primary care doc's meds aren't very high on her list....she doesn't quite buy that she really has diabetes.

Would it help to stop Atypical X in terms of diabetes and cardiac risk factors? Maybe.
Would another Atypical antipsychotic with a more favorable profile still work without worsening her diabetes? Maybe.

Remember, she's already failed one anti-psychotic, so I wonder if one med will work as well as another? Probably not. A little bit of a crap shoot here. The risk is that I change the anti-psychotic agent in the Hope that it helps her labwork, decreases her cardiac and diabetic risk, and the Hope that it works as well as Anti-psychotic X. The changeover could result in another episode of psychosis requiring hospitalization.

I try to present the risks and let it be the patient's choice. Except the patient doesn't believe she has a psychotic illness, and she simply says she doesn't want diabetes, and so far my conversations with her have ended with my saying, "Why don' t you just stay on this for now?"

You'll forgive the confabulated details, but I've had the same scenario happen enough times that I can't be the only one with this dilemma.

Friday, January 25, 2008

I'm On It


I got an e-mail from my husband today-- he sent along a review by Dorothy Rabinowitz of a soon-to-air HBO series called "In Treatment" and suggested I "sub-blog" as the show plays.

So Dorothy Rabinowitz writes:

It is odd that the network that has tried long, hard and haplessly to come up with anything remotely equal to the power and creativity of its blood-drenched "Sopranos" saga has finally succeeded in a series entirely shrouded in the quiet of a therapist's office, where the only threats come from words, revelations, the assaultive force of unwelcome truths. They are an arsenal of terrible power as deployed in the battles waged hour after hour in the intimacy of the consulting room -- the arsenal that drives so much of this series that is, in its invention and artistry (if not in its nonlavish production values), a worthy successor to "The Sopranos."



A show about psychotherapy that ranks with The Sopranos? I'm on it. Five nights a week, starting Monday, from 9:30 to 10. Five nights a week? I'll do my best, that's a lot of therapy to watch for someone coming home from the office.... it better be good. The psychotherapist is played by Gabriel Byrne (pictured above) and his therapist (of course) is played by Dianne Wiest. If I don't get to it in real time, there's always TiVo. ClinkShrink tells me she can't watch it, no Cable. Roy may be under the floorboards again, and I'm not sure what kind of reception he gets there
.

The 4H Club

When I took a medical history from one of my patients he told me, "I belong to the 4H club: hepatitis, HIV, herpes and hemorrhoids."

In medicine you see the term "comorbidity" used quite a bit. It basically just means that a patient has more than one medical problem happening all at once. It isn't specific to any particular combination of illnesses. In forensic psychiatry it usually means mental illness combined with substance abuse, combined with personality disorders. In the correctional world you can add a few extra layers of pathology by throwing in the medical diseases: hepatitis, HIV, head trauma, diabetes and other stuff, like the 4H list given to me today by one of my patients. (On the positive side, he had no history of closed head trauma.)

Practically speaking, what this means for treatment is that everything is going to be a little more complicated. You have to think about how the personality disorder will color the patient's reaction to your care, how the head trauma will affect his ability to understand what you say to him, and what the co-existing medical conditions will do to your choice of psychopharmacology. That can be a challenge. (OK, so the hemorrhoids in today's patient didn't really complicate the pharmacology. At least not until they invent rectal psychotropics.)

Working in a correctional environment actually helps when you're dealing with some of these multiply co-morbid cases. The structured environment gives some predictability and stability to their lives. It takes away some degree of stress in that they don't have to think about where their next meal is coming from. The clear rules and expectations set boundaries for containing the maladaptive behaviors. And while drugs and alcohol certainly do exist in jails and prisons, there's a lower likelihood that the patient will be using inside the walls than in free society. Finally, the patient has access to medical care that he might not otherwise have in the streets so the co-existing medical conditions are less likely to hinder treatment. My job would be much harder if I were treating these folks in free society.

Then again, in free society I'd have a desk and a telephone. And modern ventilation. And office supplies. And an office. Clerical support. A fax machine. Ample parking space. Unlocked restrooms. A vermin-free place to eat. And...

Oh, never mind.

Thursday, January 24, 2008

Meeting Under The Table


ClinkShrink is working on a post while I type, so if mine goes on top, please check out hers, too. It's something to do with the 4H Club, she must be making jam again.

So everyday now, I sit with patients and think "I wish I could blog about this." This confidentiality thing, from a blogging shrink's point of view: it's so unfair. Okay, if you told me a great story today, it's not going up on Shrink Rap. My friends and colleagues, however, don't have Hippocrates-protected confidentiality, so I'll blog about them instead.

Have you been to a big meeting lately, say 10 or 12 people around a conference table? I've been to a bunch, and ya gotta love technology. There's someone who chairs any given meeting, and being the overly compulsive crew that psychiatrists are, there's a meeting before the meeting to set the agenda, and the meet at the meeting with the typed-and-distributed hard copy script. But then, under the table, there's the rest of the meetings with their own agendas going on by way of blackberry and cell phone text messages. So perhaps the topic on is The Kelly Case and Forced Medication legislation, or changes to the state's medication formulary, or yet another form that needs to be signed or... you name the topic. My cell phone pings. Roy texts from across the room: "wimp." My cell phone pings again: commentary on what someone said (.... and, please, if you're getting text messages about all the things I say, I don't want to hear it). Camel is concerned that what she said might be taken out of context. Only no one noticed what she said because everyone present is dealing with their own Under The Table agendas, including the person chairing the meeting who's getting pinged about how he's spending too much or too little time on any given topic. I get bored and text my kid at home to ask about the latest with American Idol, or Gossip Girl or whatever the show of the moment is. Other kid pings to ask what's for dinner. ClinkShrink pings with a photo of a pigeon or a mushroom or something she sees on a walk.

Just don't ask what really happened, I have no clue.

Wednesday, January 23, 2008

Poll Results: It's Hard to Talk About ......... in Psychotherapy


From our sidebar poll:
Sex
72 (31%)
Professional Fees/Payment
59 (25%)
The therapeutic relationship
90 (39%)
Medications
8 (3%)


Votes : 229


My vote went towards Professional Fees, in case you wanted to know. When people don't pay, it's still stressful, and I still feel awkward about asking to be paid. For a lot of people there's a discomfort about psychotherapy of "I have to pay someone to listen to me." If I have to ask to be paid....well.... it's a reminder that I'm here for reasons besides my total devotion to patient care (--I got bills, too)...and if I have to ask to be paid repeatedly, well, it can make everything feel pretty uncomfortable.

Okay, sometimes it's hard to talk about the therapeutic relationship. But as the shrink, it's never hard to talk about sex or meds.

Feel free to chime in....

Tuesday, January 22, 2008

Interactive Brains

Neuroanatomy was my favorite class in medical school. I loved tracing out the brain pathways, figuring out which part did what, connecting up clinical syndromes to what I knew about brain structure and the nervous system. I learned all this back in the dark ages, back in the paleontologic age when whales had legs, before comets struck the earth and caused the last ice age. The World Wide Web didn't exist then either. I had to learn this stuff by examining the actual brains of dead people, by looking at stained microscope slides of brains and by pouring over books (the things with pages, covers and ink) rather than web sites.

So now the modern age is here and students get all kinds of cool high tech stuff to learn with. Just out of curiosity I scoured the web and put together a quick and dirty list of some web sites that provide interactive imaging of the human brain. Dang, I wish I had that when I was a med student.

Michigan State Brain Bank

Harvard's Whole Brain Atlas

University of Florida (takes a while to load, Flash-based, no labels)

University of Washington

Wayne State University

University of Utah (This one was my favorite atlas. It shows actual photographs of gross brain anatomy. You can click on the name of the structure and an arrow points to it. No neuroimaging to interpret, just identification of gross structures.)

University of Michigan


Columbia Brain Atlas

Here's When You Need A Psychiatrist


Have we written this one yet? I seem to think that Roy, our Consultation-Liason Boy, may have done this.

This is just my opinion, it's written with the non-shrink doc in mind, and it assumes access to psychiatric care:

So when should a patient be referred to a psychiatrist for care?

  • When their distress due to psychiatric illness is such that they can't contain it and are driving the primary care doc nuts.
  • Any patient with the new onset of a psychotic illness should initially be stabilized by a psychiatrist (this is just my opinion) if they are willing to go. Psychotic illness: any illness accompanied by hallucinations and/or delusions. Psychosis is frequently seen in Schizophrenia and Bipolar Disorder, but can also be seen with depression, delirium, and a host of other non-psychiatric illnesses. If the patient's hallucinations are caused by a brain tumor and they resolve with removal of the brain tumor, then the psychiatrist may not be necessary. Maybe Roy can write us a "causes of psychosis" post.
  • For depression: my conservative rule would be to refer after the patient fails one antidepressant medication given at a therapeutic dose for long enough. What's a therapeutic dose: I go as high as a) the patient will tolerate or b) to the highest recommended dose (which ever comes first). If a patient can't tolerate more than 50mg of zoloft, well, this isn't a full trial. Switch to another med and try to get the patient up to a full dose. Wait AT LEAST four weeks (the mantra is 3 to 6 weeks) on a good dose. It's not uncommon to get a patient who has been on small doses of many anti-depressants, none for very long. And primary care docs aren't the best at augmentation strategies.
  • Any patient with Bipolar Disorder needs a psychiatrist to stabilize them, and a psychiatrist available for management of episodes. If someone has been stable on Lithium for the past 8 years, they don't need a psychiatrist to prescribe it.
  • When prescribing that first antidepressant, ask every patient with depression if they've had a manic episode: "Have ever had a time when your mood was too good, when you had excessive energy and needed less sleep, when you talked faster than usual, your thoughts raced, you were more impulsive than usual with regard to spending or sex?" Anyone who doesn't look at you like you're nuts for asking this needs to be questioned in more detail about manic episodes. If the patient has a history of even one manic episode, you're dealing with Bipolar Depression and prescribing antidepressants could be very risky-- not a bad time to refer.
  • Don't prescribe Xanax for a chronic anxiety disorder. It's hard to treat patients who get dependent on xanax and it's hard to refer them if they end up on high doses.
  • Any patient with a recent serious suicide attempt or recent psychiatric hospitalizations should be stabilized by a psychiatrist.
  • Any patient with any psychiatric disorder that is compromising their ability to function, who does not improve after two to three months of treatment, should be referred for psychiatric care-- so OCD or Panic Disorder that is not getting better quickly.
  • If a psychiatric disorder puts anyone's life at risk, it's probably more than a primary care doc wants to or should deal with.
  • Any patient who is being treated by a primary care doc for a psychiatric illness should be asked if they want to see a psychotherapist (a shrink or a psychologist or a social worker or a nurse therapist). The patient may say that the pills have cured their depression and they don't need to talk. In the absence of information, this should be respected. But the gentle offer of a psychotherapy referral should be made early.
Sorry, a little haphazard, maybe Roy can come in and add an addendum....

Monday, January 21, 2008

Everybody Doesn't Need Psychotherapy


There, I said it. And primary care docs do just fine at treating many cases of depression. Everybody doesn't need a psychiatrist. There, I said that, too.

So, with my years of experience with my psychotherapy practice, here is my bullet-point formula for who needs psychotherapy:


  • Oops, I don't have one.
I have no idea. Some people find that psychotherapy is essential to dealing with mental illness. Some people find it helps them sort out their maladaptive behavioral patterns and enables them to stop doing the same things over and over. Some people...oh I could go on and on. I touched on this in my post You're Supposed To Get Better, back in July, when I did go on and on (so what else is new?). The bottom line: there are people who come willing and readily to therapy, they talk openly about their problems, they do the work of therapy, and they don't get better, they don't change, but if they get comfort from it and it helps sustain them through their suffering, that's good. Only some people don't even find therapy comforting. Other people resist coming, "My primary care doc's been telling me to call you for two years now." They come in begrudgingly and filled with skepticism, talk about their problems, often for not all that long (a few weeks, a few months, maybe less) and they get a lot out of it. "I wish I'd come sooner."
Some people come, don't say much of anything, but still get better, feel comforted, or find that it's helped them to change.

My next post will be When To Refer. Maybe later? It's a holiday, so we'll see.

And finally, the Shrink Rappers met yesterday to do a couple of podcasts. They were both themed, though apparently Roy plans to post the second one first, so we had the pleasure of talking about the "last podcast" before it was done. So, if I have this right, Dr. Chris Kraft joined us for the "first" show and we talked about the Sexual Re-Orientation treatments. If ClinkShrink is our walking encyclopedia of Prison History, well Chris knows an awful lot about the history of Sex! The 'second' podcast is a discussion about the appropriate and inappropriate uses of Benzodiazepines. Essentially, the show consists of the three of us Screaming at each other. So I promised a series of posts on benzos, perhaps I do short ones as a prelude to the My Three Shrinks bloodiest podcast ever.

The best part was going out for Indian food after. I am the type of person who always enjoys eating a good meal with friends.

Friday, January 18, 2008

Fluoxoperidonacaine: How drugs get their name



Ladyk73 (aka LadyAK47) asked a while back about how drugs get their names.

Hello there! I have a question!!!!!!
(I can imagine Roy crawling into the dungeons of some long-lost medical library somewhere to find the answer to this)

Anyways, this is really bothering me.

When I was a C-/D+ pharmacy student, one of the few things I learned was that there was some sort of nomenclature that was used to name drugs. The generic/chemical name, not those fancy drug pushers name....

Why does Trazodone have an -one suffix? As in a whole lot of corticosteriods end in -one.
What does the -one in trazadone stand for? Or does any of the name can be explained by nomenclature ways?
Great question!  Glad you asked...

The drug names are all decided by Tony, Bill, David, Peter, and Darin.

These are the most recent members of the USAN, the United States Adopted Name Council.  This is a 5-member organization consisting of representatives from the AMA, APhA, USP, FDA, and a member-at-large.  USAN works with the World Health Organization to come up with rules for naming drugs, and agrees on new drug names after the manufacturer applies for a new name (usually after submitting the drug to the FDA as an IND (Investigational New Drug).

There is a list of rules for naming drugs, typically based on their chemical structure, their therapeutic indication, or their mechanism of action.  Examples:

a.  The name for the active moiety of a drug should be a single word, preferably with no more than four syllables.
b.  The name for the active moiety may be modified by a single term, preferably with no more than four syllables, to show a chemical modification, such as salt or ester formation.  Examples can include cortisone acetate from cortisone, cefamandole sodium from cefamandole or erythromycin acistrate from erythromycin.
c.  Only under compelling circumstances is a name with more than one modifying term acceptable.  Compelling circumstances may pertain to such examples as pharmaceuticals containing radioactive isotopes or the different classes of interferons.
d.  Acronyms, initials and condensed words may be acceptable in otherwise appropriate terminology.


To see the entire list of rules, go to this .pdf, the USAN Stem List.  Examples:

CHEMICAL SUFFIX TYPE OF MEDICATION EXAMPLES
-anserin

serotonin 5-HT2 receptor antagonists altanserin, tropanserin, adatanserin 
-azepamantianxiety agents (diazepam type) lorazepam 

-peridol antipsychotics (haloperidol type) haloperidol 
-peridone antipsychotics (risperidone type) risperidone, iloperidone 
-perone antianxiety agents/neuroleptics duoperone  
-pezil acetylcholinesterase inhibitors used in the treatment of Alzheimer’s disease donepezil , icopezil
-pidem hypnotics/sedatives (zolpidem type) zolpidem alpidem 
-pirdine cognition enhancers linopirdine, besipirdine, sibopirdine

Rx for Podcastopenia

As our podcast pallor slowly waxes, we plan to record another one on Sunday... this one with our colleague, Chris Kraft PhD.  You may recall Chris from Podcast #21, Chris Kraft on Gender Issues (okay, it originally had a more sensational title, but Dinah's cooler head prevailed...listen to the podcast to get it), where he talked about intersex disorders.


He's back this weekend to talk about, well, we'll decide when we get there (you think we actually plan this stuff?).  Actually, if there are some topics you'd like to hear about, Post a Comment to this post to let us know, and we might actually pick it up (no complaints if we don't, please).

Sanitized For Your Protection

When I was in medical school they taught us that epidemics of infectious diseases were particularly likely to break out in public institutions like schools, colleges, correctional facilities, dormitories and military barracks. When you consider all the infectious illnesses a person could catch in prison---methicillin-resistant staph or drug resistant tuberculosis or hepatitis or HIV---I guess the common cold is pretty benign. Nevertheless, I take precautions to keep from getting sick and to keep it from spreading to others.

This actually isn't as easy as it sounds. Alcohol-based hand sanitizers are contraband and I have to provide my own kleenexes (Puffs only, thank you, with lotion). There is soap in the bathroom, if you have a key to get into the bathroom. I keep a can of Lysol by my desk. When I see an inmate who has a partcularly nasty cold I run down the hallway spraying doorknobs and swabbing them down with tissues in the hopes that even if I don't prevent the cold completely maybe I can at least minimize the viral load a bit. I make look a bit paranoid doing it, but it seems to work. I can't remember the last time I had a cold (although my pneumonia last January was particularly nasty).

I wish all infectious agents were that easy to control within the institution. Demoralization is the most infectious agent of all, and the toughest to treat once an outbreak starts. I wish Lysol would work for that.

Thursday, January 17, 2008

A Plug for My Three Shrinks



Anne is a Man. That's the name of a blog that reviews and recommends podcasts. It looks like he's done over 360 podcasts, categorized into topics, with a leaning towards politics and history. Wow! I didn't know this resource was out there. Anne the Man likes ShrinkRapRadio (no relation, but now I have to check it out).

Wanna guess what podcast is featured today??


For a review of our podcast, My Three Shrinks, CLICK HERE

Thanks, Anne the Man!

Wednesday, January 16, 2008

This is Why You Need A Psychiatrist


From today's Wall Street Journal, an article on how antidepressants aren't all they were cracked up to be: Antidepressants Under Scrutiny Over Efficacy. David Armstrong and Keith Winstein write,

"Since the overwhelming amount of published data on the drugs show they are effective, doctors unaware of the unpublished data are making inappropriate prescribing decisions that aren't in the best interest of their patients, according to researchers led by Erick Turner, a psychiatrist at Oregon Health & Science University. Sales of antidepressants total about $21 billion a year, according to IMS Health."


Actually, the issue at hand is that the pharmaceutical companies don't publish or make public the studies that don't show the results that will sell their meds. It's not a news release that we've suddenly realized that antidepressants don't always work. These are two separate issues. The WSJ article is based on a report in the New England Journal of Medicine, Selective Publication of Antidepressant and Its Influence on Apparent Efficacy, and it uses data on antidepressant studies to make this point. Okay, it's also about how antidepressants aren't as effective as the drug companies say they are, but this just doesn't surprise me. The WSJ article goes on to say,

"There is a view that these drugs are effective all the time," he (Dr. Turner) said. "I would say they only work 40% to 50% of the time," based on his reviews of the research at the FDA, "and they would say, 'What are you talking about? I have never seen a negative study.'" Dr. Turner, said he knew from his time with the agency that there were negative studies that hadn't been published.


There's someone out there who thought antidepressants work all the time? This is why people need psychiatrists, not primary care docs, managing their psych meds:

1) Even at high enough doses given for long enough (6 weeks), any given antidepressant may not work on any given patient. Or it may help with some symptoms and not others.

2) If one antidepressant doesn't work, another might.

3) If one antidepressant doesn't work, augmenting with a second medication may work.

4) As a patient suffering from Bipolar Disorder, depressed, moderate in severity, recurrent, said to me recently, "I think the therapy helps as much as the medicine."

I don't think it's news that a) anyone can write a prescription for Prozac and the patient may not get better, or b) this is complicated stuff.

The issue of the pharmaceutical agencies hiding their negative data is also not news. Personally, I think the legal penalties for withholding this information should be stiff enough to stand as a deterrent. You just don't hear of drug company CEO's in the cell next to Martha Stewart.

Tuesday, January 15, 2008

Violent Mood Swings


"My mood is swinging."

When I see this as a chief complaint in a progress note I know what I'm going to read next: a diagnosis of bipolar disorder, not otherwise specified, and an order for the mood stabilizer du jour. What I will not (usually) see is a description of what mood states the patient is "swinging" between, the duration of those mood states or a list of associated symptoms. This isn't specific to correctional work in that I've also seen documentation like this in discharge summaries I've received from hospitals.

I'm familiar with the various "flavors" or subtypes of bipolar disorder that have been hypothesized, but the guys I treat don't fall into a clearcut diagnostic category (unless you count personality disorders) and sometimes there are cases that really push the boundaries between an Axis I and an Axis II problem. I see this a lot when I'm dealing with inmates with a history of institutional violence.

People who do research on violence struggle over how to define or characterize violent acts. You'll see references to predatory violence versus instrumental violence versus opportunistic violence versus impulsive aggression. The nuances elude me, other than to say that the one consistent thing seems to be the degree of planning (or lack thereof) involved in the act.

Before deciding to throw meds at the problem, I'll usually do an assessment to clarify whether or not violence really is an issue. You'd be surprised the number of guys who self-identify temper as an issue, but when you take their histories they've actually held it together quite well. Someone who only has one ticket (infraction) for fighting in a year of incarceration really can't be considered to have too much of a problem with violence. In cases like that I'll ask more questions to figure out exactly why the patient thinks it's a problem; more often than not, they're troubled by the fact that they merely have violent thoughts. In that case the inmate has unrealistic expectations of what a medication can do for their problem.

Other questions I ask are:

* who are you fighting with, inmates or officers or both?
The choice or level of discrimination reflects the degree of control over the violence.

* have you gotten into fights that you haven't had tickets for?
If the answer is yes, this usually means that the patient and his/her opponent plans the fight to avoid detection by custody, another situation where medication is unlikely to be of benefit.

* do you fight when you're sober and clean?
By far the most common precipitant for violence is substance abuse, either in the facility or in free society.

* do you have a bad temper even when you're not depressed?
Clinical depression can decrease frustration tolerance for prisoners. This is often the factor that causes them to seek treatment when they wouldn't even think of seeing a shrink on the outside. Treating the underlying depression fixes the temper problem.

* tell me about some of the situations you've gotten mad in recently
Often there's a good reason for it. Medication is unlikely to help you keep from getting mad when you've got people cursing at you or threatening you. Normal anger exists for a reason and medication will not keep someone from ever getting angry over things that would anger anyone.

So once I've done all this I'll decide whether or not the violence issue is one that might benefit from medication. I'll make it clear in my note that violence is the target symptom and I won't try to stretch a diagnosis to justify a treatment plan.

I think all classes of pharmacologic agents have been used to treat violence at one time or another, but most recently mood stabilizers have shown the most utility for aggression associated with personality disorders. Lithium has been used for this since the original studies in the 1970's, when it was found to cut the violent infraction rate in prisoners by about half. (Interestingly, some of this subjects also discontinued the medication on their own because they didn't "feel" it working, even when it was.) Valproic acid, carbamazepine and now the atypical antipsychotics have all been used for this. SSRI's can have an interesting pro-apathy (if that's a word) effect in some people, giving them the ability to "shrug off" experiences that they normally would have gotten upset about. Regardless, the goal is to lengthen the patient's fuse and give them time to think before they act.

As one patient of mine put it: "The medication doesn't lengthen my fuse. It gives me a fuse."

Monday, January 14, 2008

Fill In The Blanks



This is kind of a How-To post, if that's okay. It's about "How To" start off a therapeutic relationship in such a way that the patient's ability to feel hopeful is optimized, and the patient feels confident about the Shrink's skills. We've talked about people getting to Shrink Rap when they Google "how to manipulate your psychiatrist." This post is going to have a tinge of "how to manipulate your patient." Sort of, not really. This technique works well for psychiatric evaluations and the beginning of psychotherapeutic relationships, but it works just fine for other medical specialties, and probably in any field where a client comes to a professional seeking help solving a problem. There's no science here, just my own observations of patients, and my own feelings when I've seen a doc.

I'll call the technique Fill in the Blanks, but I'm not sure that's quite right. It could also be You're the Type of Person Who....

Quite simply, people feel a degree of confidence in a doctor who understands them, who helps them rephrase their feelings with new words that resonate, who knows things about them before being told. If the doctor can predict the future, well that's helpful, too.

So I'm struggling a little to really explain this and I don't have a great example. Often it boils down to saying to people, "You're the type of person who...." Here's an easy one that I often resort to: I can usually get a quick handle on whether someone is an introvert or an extrovert, and from there it's easy to make some quick assumptions about them. To an extrovert: You live in the moment, you sometimes forget that things will get better soon. To an introvert: Sunday nights are hard for you, you tend to get anxious about the upcoming week.

There are some basic Fill-in-the-Blank rules:

  • In the course of telling a stranger about themselves, it's important to eat your words quickly if the patient tells you it's not true. If the patient says "actually I'm not that kind of person at all," the doc should ask, "What kind of person are you?" No one wants the blanks filled in wrong (even if the doc is right!), it leaves the patient feeling unheard, misunderstood, and rapport and confidence are killed. If someone is a touchy type of person who is easily offended, they may read too much into such statements and Fill-in-the-Blanks is risky.

  • It's good to Fill in the Blanks with positive things about people. "You're the type of person who would sell your children as sex slaves to get your next drug fix" doesn't work. "You're the type of person who does a great job taking care of other people but doesn't always take the best care of yourself" is a better risk-- it paints the patient as selfless. ClinkShrink is the type of person who is always polite to everyone. Roy is the type of person who is always up for a new challenge. Dinah is the type of person who is always happy to eat a good meal with a friend.

  • Perception is more important than fact. If the patient feels understood, it doesn't matter if the interpretation is perfect. "You have a strong moral code and sometimes this causes you to be angry at people who cheat the system." If it works for the patient, don't worry about the fact that they plagiarized a term paper or shoplifted a few times.

  • Watch their face: expression says it all. People nod and light up when they feel understood. Some people are compliant and will say "Yes, doc" to everything. If they get grit their teeth and eye the vase to throw it at you, you've got it wrong. If you're fumbling, just say so. "I have the sense I've got you pegged wrong. Can you help me here?"

  • It's okay to lie a little, but not a lot. Well, not really lie, but I tend to be reassuring in a way that may be more powerful than I can know for absolute sure. From your story, you've had a few episodes of depression before and they've always resolved, this one will resolve too." People feel buoyed by hopefulness, they don't tend to come back and say "You promised I'd get better and I didn't." So far (should I even say this?) no one has demanded a refund. But don't lie a lot-- if the patient has two weeks to live, it's poor form to assure them that their terminal condition will resolve.
--------------
Coming soon: a series on benzodiazepine use.

Sunday, January 13, 2008

Sunday Morning, a Little Late



Just to share an interesting piece from this morning's New York Times Magazine.

In "The Moral Instinct," Steven Pinker writes about the factors that influence our thoughts and feelings about what we find admirable, despicable, acceptable, and moral in the context of our society. He asks some tantalizing questions, though it's a long piece and near the end he lost me for a bit before he found me again. Always fun, Pinker talks about a college professor I did a work-study project with about a zillion years ago. Dr. Paul Rozin studies cultural influences in food tastes and he was quoted in the article in a discussion about moral issues related to vegetarianism. Given ClinkShrink's recent post about prison food and cannibals, I wondered why she wasn't interviewed.

Just a couple paragraphs that I found interesting:


Dozens of things that past generations treated as practical matters are now ethical battlegrounds, including disposable diapers, I.Q. tests, poultry farms, Barbie dolls and research on breast cancer. Food alone has become a minefield, with critics sermonizing about the size of sodas, the chemistry of fat, the freedom of chickens, the price of coffee beans, the species of fish and now the distance the food has traveled from farm to plate.

Many of these moralizations, like the assault on smoking, may be understood as practical tactics to reduce some recently identified harm. But whether an activity flips our mental switches to the “moral” setting isn’t just a matter of how much harm it does. We don’t show contempt to the man who fails to change the batteries in his smoke alarms or takes his family on a driving vacation, both of which multiply the risk they will die in an accident. Driving a gas-guzzling Hummer is reprehensible, but driving a gas-guzzling old Volvo is not; eating a Big Mac is unconscionable, but not imported cheese or crème brûlée. The reason for these double standards is obvious: people tend to align their moralization with their own lifestyles.

I will say, though, when Pinker talks about research on ethical behavior in monkeys--"The impulse to avoid harm, which gives trolley ponderers the willies when they consider throwing a man off a bridge, can also be found in rhesus monkeys, who go hungry rather than pull a chain that delivers food to them and a shock to another monkey"-- I had to wonder about the morals of a scientist who could even design such a study.

Saturday, January 12, 2008

Soylent Brown



Dinah wanted me to talk about the alleged Texas cannibal that PETA is using to promote vegetarianism.

I have to say, cannibalism is not nearly as interesting as what's being served on the prison menu these days.

I've eaten in the officer's dining room, and it's an experience. Most of the bugs stay on the walls but occasionally you see a little baby bug crawling along the edge of the salad bar. The inmate workers who serve the food all wear gloves and hair nets. I really don't notice the tattoos anymore. They're friendly and polite. They ask if you want the soggy vegetables or the dry white bread or they'll ladle a few scoops of thick sludgy soup into a styrofoam cup for you. On fried chicken days the line is always long, but they still ask if you want extra fries with that. There's always enough little ketchup packets to go with the fries. On non-chicken days, they have a brown square of some meat-type thingie. I'm still working on that one, trying to figure out if it's from the land, from the sea or from the air. At this point I just call it Soylent Brown.

One of the kitchen cadre workers told me that Soylent Brown is a staple of the inmate diet. It's from the food contractor, who I guess buys it by the truckload. For inmates who want a vegetarian diet I guess they can be reassured---my cadre worker tells me Soylent Brown is 90% soy and ten percent meat flavoring, according to what's listed on the box.

Several years ago there was a science fiction movie called Soylent Green. Like all great science fiction movies it starred Charlton Heston. It was set in the future when human overpopulation and global warming had killed off all the world's resources, and the entire human race was dependent on a type of food called Soylent Green. To make a very long story short, Heston played a detective who eventually discovered that Soylent Green was made out of recycled humans. I've included a UTube link to the crucial scene at the top of this post.

(Incidentally, when people talk about physician-assisted suicide I always free associate to the euthanasia scene from Soylent Green.)

So anyway, most of the civilian staff bring their lunches to work rather than risk the food in the officer's dining room. That worked fine until some unspecified employees (whether civilian or custody staff, I don't know) started smuggling contraband in inside their lunch bags. So then all the employees were required to bring their lunches in using clear plastic containers to make it easier to inspect the food on entry. So fine, everybody gets a clear plastic container.

Then more stuff gets smuggled in. Security rules change. There is a proposal to ban all outside food from coming in to the institution. The civilians are horrified that they might have to choose between starvation (only having a half hour for lunch means you can't really go out to eat) and eating Soylent Brown. We're talking Survivor-type reality show here. We're talking 'I may be forced to eat my co-worker' decisions. Fortunately, the no-outside-food rule gets voted down. Somehow the warden's office still gets to bring in catered food for special events; don't ask.

The bottom line is that news stories about cannibalism aren't nearly as interesting to me as the ever-changing security rules related to prison food. It's one of the things about my job that makes the work consistently challenging.

Thursday, January 10, 2008

Dose Dependent

Sometimes I wonder how much free society doctors know about what their patients are doing. Without going into detail about specific patients, I can tell you I see guys coming in to prison on Valium, Xanax, Klonopin and other medications (or claiming to be on them) from their family doctor or their neurologist or their surgeon. They get the meds for chronic pain, back spasms, anxiety, PTSD, sleeplessness and now (the latest trend) restless leg syndrome. Occasionally the meds get prescribed for panic disorder, but I'm amazed that these folks also seem to be able to tolerate daily amounts of cocaine while suffering from panic disorder.

I don't doubt each of these doctors is acting in good faith, with reasonable care and consideration, in the best interest of the patient. I'm sure each doctor has their own particular 'red flags' to watch for which would trigger concern about addiction or abuse. I would be surprised if they all knew about each other.

Good doctors can be deceived and manipulated just like any other human being. Manipulation and deception go hand-in-hand with addiction. (Just look at the number of times people find Shrink Rap by googling 'how to manipulate my psychiatrist' and 'how to get a shrink to prescribe Xanax'!) Sometimes the doctor only finds out about the substance abuse problem after the arrest. I imagine the hard part then is not getting really pissed off at the patient when you find out you've been deceived. Sometimes when I hear free society docs talk about their cases I suspect substance abuse and suggest that perhaps the patient may not be telling the entire story. Those docs get offended. "You just say that because you work with criminals," they say, "My patient isn't a criminal." Well, a lot of addicts have problems without getting caught.

So what can I do about substance abuse in prison? The key element is education. When I have a patient lobbying for benzodiazepines (Xanax, Valium, Klonopin or something like that), I teach them about the effects of substance abuse on mood or other psychiatric disorders. I teach them about the physical effects of controlled substances, the potential for dependence and addiction, and the legal consequences of using illicit drugs. Finally, I encourage abstinence.

To which the patient usually replies: "I know all that, doc. Stop bullshitting me. The only thing that works is Xanax."

At least I try.

Wednesday, January 09, 2008

The Kelly Case and Forced Psychiatric Medications


Oops, I started this and had to run. I thought it was saved to "draft" but it actually posted before it even got started! This time for real:

This is a ClinkShrink issue: pure forensics, but it has my attention for the moment, and it has broad implications for the treatment of psychiatric patients in Maryland who are violent when they are mentally ill.

If you want to read about the Kelly Case in the
Baltimore Daily Record, CLICK HERE.

Okay, so in Maryland, a psychiatric inpatient can be forcibly restrained and forcibly medicated (by injection) if they are actively violent or threatening in a way that the facility staff and docs deem someone's imminent safety to be in peril. Such events are disturbing for everyone involved-- the patient is agitated, has often already struck or bitten someone, thrown an object or broken something, emotions are high, decisions are made quickly, things get intense. The medications administered are generally sedating and are short-acting. This is how it works for very acute situations.

Sometimes psychiatric inpatients are dangerous as a result of their psychiatric symptoms, but not imminently, and safety is a longer-term issue. These aren't people who are necessarily agitated or belligerent. If a dangerous patient is refusing to take medications, there is a legal mechanism to force them to take medicine-- in Maryland we call this a Medication Review Panel and it's a legal proceeding in which the patient gets to make his case and the psychiatrist gets to say why he thinks the patient needs to be medicated against their will. This is a more deliberate process, a legal proceeding.

I will tell you that the term "dangerous" is less narrowly defined. So someone who is hospitalized for depression who is not taking care of themselves such that a medical condition threatens their life (-- we're not talking about a sad diabetic who reaches for a piece of cake here, just to be clear on this). Most of the patients who come to Medication Review Panels have psychotic illnesses-- they are having hallucinations and/or are delusional, and they don't have the insight that they have an illness. Legally, someone can be as psychotic as they'd like and refuse treatment, the issue here is one of
dangerousness for someone who is already committed to an inpatient unit. Other examples might include someone who is so psychotic they are too disorganized to care for themselves and leave lighted cigarettes lying around, or they believe that the devil has instructed them to kill people, or use your imagination. Roy and ClinkShrink might be better at generating examples. Let me also clarify that the dangerousness must be a result of mental illness, otherwise we're simply talking about criminals.

No one has thought too hard about the exact location as Where someone might be dangerous. Until the Kelly Case, that is.

I've never met Anthony Kelly, I don't know his diagnosis or his symptoms. He is a dangerous man and he has been confined to a hospital for the criminally insane (okay, Clink, a maximum security forensic facility) since 2002. Mr. Kelly was deemed too sick to stand trial for his crimes and he refused to take medication. At a hearing in 2005, an administrative law judge said Mr. Kelly could be forced to take medications, but the ruling was reversed on appeal by Baltimore City Circuit Court Judge Lynne A. Battaglia. Judge Battaglia said that since Mr. Kelly is dangerous only when he's outside the hospital, but not while he's in the confines of a maximally secure facility, so he can't be made to take medications.

To the surprise of Maryland psychiatrists, the Court of Appeals upheld this decision:

"Because there was no finding that Kelly is a danger to himself or others during his confinement in Perkins Hospital, a prerequisite to forcible administration of medication pursuant to Section 10- 708(g) [of the Health-General Article], we shall affirm the judgment of the Circuit Court of Baltimore City."

This means that a person who is mentally ill and dangerous can only be forced to take medication if they are dangerous WHILE they are in the hospital --even if they would be dangerous if they were not in the hospital.

Many psychiatrists who work on inpatient units are not happy about this because it means that if someone is mentally ill and dangerous outside the hospital, but not dangerous inside the hospital, they can't be treated and and they can't be released. Because they are dangerous, they must be kept in the hospital, perhaps indefinitely.

I don't work in an inpatient unit, but what I don't like about this ruling is the assumption that someone has a crystal ball that accurately says When and Where and Under What Circumstances someone with a severe psychiatric disorder that renders them dangerous will act. People elope from psychiatric units, they commit suicide on inpatient units, they assault other patients and staff members.

Anthony Kelly remains in Clifton T. Perkins hospital, unmedicated, or so I understand. Outside the hospital, his illness presumably contributed to his actions such that he is in a hospital and not a prison for his crimes-- the rape of the women and the murder of two people including a child. He has presumably been a safe and non-violent patient on his unit, and he doesn't want medications. Psychotic patients have difficulty with reality testing, they can be unpredictable and some patients can be dangerous. I'm not sure how in the face of such heinous past actions that anyone can absolutely guarantee that a patient such as this might not suddenly attack another patient or a staff member even in the hospital.

While the Kelly Case has been a topic of discussion among psychiatrists in the state, all factual information for this blog post was taken from the article in the Baltimore Daily Record that I linked to above. Okay Clink, let's hear it.....

Sorry, no pic. I couldn't find one of Clifton T. Perkins Hospital and anything else seemed tacky for such a serious and disturbing topic.

Tuesday, January 08, 2008

Long Day for The Wimpiest of the Co-Bloggers


ClinkShrink cures 42 patients an hour.
Roy often is still in the hospital at midnight.
Midwife With A Knife catches 10 babies an hour, or extracts them with interesting devices.
Fat Doctor admits 30 patients a night (sadly, she doesn't dictate them).
Dr. Crippen, I hope is okay despite his mysterious disappearance.
Kevin MD blogs for more time than I can imagine.
NeoNurseChic works 12 hour shifts with an assortment of headaches and ailments, and doesn't complain.

Dinah works part-time. I am a wimp. This morning, I have a meeting from 8 to 11 AM about lots of things I either don't care about or things I do care about but can't do anything to change. From 1-8, I'm scheduled to see 8 reliable patients, most of whom will show up right on time, and there's no break in there. At 8 Pm, I'm due back at another meeting which may well go to 11 PM, a follow-up on this morning's meeting about things I don't care about or things I do care about but will be unable to change. Today, and today only I hope, I will not be a wimp.

Tomorrow, I will be a wimp.

Monday, January 07, 2008

Top 10 Podcasts from My Three Shrinks for 2007

Okay, this is my last Top 10 list. We served up over half a terabyte (!) of podcasts last year, producing just under 40 podcasts on My Three Shrinks. We had over 30,000 unique visitors, nearly 200,000 visits, and served up over 100,000 podcast downloads!

Here are the Top 10 downloaded podcasts in 2007:











RANK DOWN-
LOADS
PODCAST
110466#24: Short version of Dr Phil prank on Dinah [Listen now]
27252#1: Podcasting Makes You Potty [Listen now]
33572
#5: Sex, Lies, & Neuroeconomics [Listen now]
43534
#6: Advice on Manipulating Your Psychiatrist [Listen now]
53368
#13: Lost It In Space [Listen now]
63348
#21: Chris Kraft on Gender Issues [Listen now]
73343
#8: Positively Lost [Listen now]
83304
#10: Be Mine [Listen now]
93300
#17: Happy Anniversary! [Listen now]
103299
#12: Bilingual [Listen now]


Incidentally, none of the above generated the most comments. The two podcasts that stirred up the most comments (37 each) were #15: POTUS Reading and #18: Grand Rounds.