Tuesday, May 31, 2011

Daniel Carlat on Antipsychotic Medications for Agitation in Patients with Dementia



Lately, it seems like all the press about psychiatry in The New York Times is bad. We don't talk to our patients, we over-medicate them all from the children to the elderly, we all get bribes from drug companies. It's not that I don't think that these things don't happen, it's just that I don't like the sensational tones, and the one-sided nature of the presentation of psychiatrists as bad, the generalizations that it's "everyone," and the use of information taken out of context to make our practitioners look bad.

In a May 9th article Gardiner Harris writes:

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” Daniel R. Levinson, inspector general of the Department of Health and Human Services, wrote in announcing the audit results.

Mr. Levinson apparently feels the government should collect information on diagnoses so correct prescribing can be assessed.

On CNN today, Danny Carlat writes his own response in "In Defense of Antipsychotic Drugs for Dementia."

The story highlights include:
STORY HIGHLIGHTS
  • Daniel Carlat: Report implies evil doctors are giving deadly drugs to nursing home patients
  • But antipsychotics are most effective drug for calming agitation in dementia, he writes
  • Carlat: No drugs are FDA-approved for this agitation, a terrible condition
Carlat writes:

But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.
The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

Monday, May 30, 2011

Right About Now, We Need A Duck Break


I showed up at my community's organic vegetable garden to work yesterday morning. I was a little late and people had begun to disperse. A neighbor tossed some spinach my way. Another said, "Larry says we need ducks."

We need ducks? We have a patch of land by some athletic fields. No pond. Are we going to eat the ducks? No, they are going to eat the bugs off the vegetables. Interesting. I'd never heard of this. Larry's raised ducks before? Last week he was talking about chickens. It's all so confusing.
Apparently Larry wants us to research ducks, and so here is what I found:

http://www.grit.com/Livestock/Raising-Ducks-Helps-Your-Garden-Patch.aspx

The photo above, by the way is a picture of ClinkShrink and I together in Hawaii. I'm the duckier duck.

Saturday, May 28, 2011

Guest Blogger Dr. Jesse Hellman: More Thoughts On Rachel Aviv's Article on Involuntary Treatment


Jesse has wanted to do a guest blog post for a while now, and The New Yorker article finally got him blogging. I wrote a brief post yesterday, but he does a more thoughtful analysis of this complicated and provocative issue. Clink is off somewhere.. I am looking forward to hearing her thoughts after the holiday.
__________________________

In “God Knows Where I Am” Rachel Aviv sees the protagonist Linda’s
refusal of treatment as an expression of her illness. The moral
impasse she describes for our profession, though, is real: denial of
the need for treatment, or of one’s illness, can be an expression of
that illness; the refusal of treatment can also be a valid position
which we understand and support.

Mental functioning can be variable, at times better and at times
worse. At times the craziest thoughts are held in check, or do not
manifest themselves, while at others they hold total sway. The
underlying assumptions of our society are shared by us, and these
shape our reaction to the illness that Linda has. Other societies,
with different traditions and philosophical underpinnings, are
comfortable with very different stances.

Before Linda was discharged from the hospital the staff did everything
they could to dissuade her, and to provide for her safety. She
rejected every effort to provide housing and support. The hospital
argued that she was too sick to make decisions which even included not
allowing the staff to notify her sister and daughter. After her death
the family sued, stating that insufficient effort had been made to
protect her. The hospital then argued she was not sick enough to
justify stronger measures. What was true?

When we look at a complex issue, or event, we naturally can only see a
part, and our response is shaped both by what we see as well as the
assumptions we carry. What weight to we place on independence versus
the rights of others? What extrapolation can we make to an unusual
thought, in that do we see it as the harbinger of insanity or of
artistic creativity? Do we value religious musings or find them
suspect?

Aviv lets us see that while a part of Linda’s functioning might have
been creative, artistic, perceptive and so on, it was increasingly
shaped by an imagination which was not tempered by reality. It was as
if she was in a dream but could not awake, a dream which increasingly
dominated the most important parts of her ability to survive.

So what is the proper role of society when confronted by such illness?
What if her fantasies had shifted from thinking spies were all around
her to imagining the world could only be saved if she were to shoot
her congresswoman?

Friday, May 27, 2011

The Unwilling Patient: New Yorker Article


In balancing rights against needs, though, psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish.
-- Rachel Aviv, God Knows Where I Am, The New Yorker, May 30, 2011

In the May 30th issue of the New Yorker, Rachel Aviv writes about the plight of a woman who does not believe she has bipolar disorder, or any psychiatric illness for that matter. It's a poignant and tragic article about a woman who is incarcerated for a crime, spends a year and a half in jail before she is found incompetent to stand trial, then goes to a psychiatric hospital where she remains until she is discharged with no plans for housing, money, follow-up, or notification of family--- it's not that the hospital wouldn't offer any help, it's that the patient wanted her freedom and would not allow interventions. Aviv gives examples of the woman's psychosis as a motive for her behaviors. Free, she finds a vacant farmhouse and breaks in. She is fearful of being re-captured, and remains hidden in the farmhouse, subsisting on 300 apples. She journals, she appreciates nature, and she reads books she finds in the attic. In mid-January, three months after her release from the hospital, and 39 days after she ate the last apple, she dies of starvation. Her body was not found until May.

Aviv's article focused on two aspects of the psychiatric system: the emphasis on the patient's insight as a focus, even requirement, of treatment, and the issues of involuntary treatment in patients who aren't posing an imminent threat of violence. I couldn't quite tell where Aviv stood on these issues--she seemed to waiver from condemning a system of forced care, to condemning a system that would let an ill patient leave untreated with no money and no notification to family members. She definitely does not like that the system would have provided for housing for this patient, but the patient wouldn't sign the requisite forms because they noted that she had a mental illness, a fact she did not agree with. Aviv mentions the concept of "thank you theory" --the idea that once patients get well they will agree that the treatment was in their best interest. She notes that only about half of patients who are involuntarily hospitalized later believe it was necessary. It's a difficult statistic to work with--because it means the other half did believe that treatment was necessary, so how, as a society, do we know what we should do? She talks about advance psychiatric directives.

I'd like to share parts of the article, but I had to buy the issue online to read it and it doesn't seem to let me copy and paste. You can listen to a podcast with the author on The New Yorker's website at:
http://www.newyorker.com/online/2011/05/30/110530on_audio_aviv



Read more here: http://www.newyorker.com/reporting/2011/05/30/110530fa_fact_aviv#ixzz1NbdWI6sM
So really, this is a ClinkShrink article. Maybe she can read it and post again?

To Shrink or Not To Shrink?


Here at Shrink Rap, we often talk about the stigma of having a psychiatric disorder. It's funny, but society has it almost ranked, so that certain illnesses are very stigmatized--schizophrenia and schizoaffective disorder, and borderline personality disorder, to name a few, and others are pretty much socially acceptable: Attention Deficit Disorder, for example, especially among the high school/college crowd where the patient often gets identified (or self-identifies) as the source for those late-night stimulants that so many kids cop.

It's not just the patients. Psychiatrists are also stigmatized, and that doesn't help much when our society talks about the shrink shortage.

Exalya writes:

I'm a first (almost second) year medical student with a strong passion for psychiatry. I love listening to your podcasts; you give me hope for my future when the drudgery of first year classes is getting me down, and I feel like I always learn something useful.

That aside, I am writing to you seeking some advice. At my school, we are required to follow doctors in family practice clinics periodically during years 1 and 2. Frequently I am asked, "What field are you interested in?" to which I reply, of course, "Psychiatry." It seems like every time an attending finds out that I'm into psych, I get eye rolls and flippant remarks. The most common ones are "Psychiatrists just push drugs," "Talk therapy is garbage," and "You'll talk to patients more in family practice." Do you have any advice on how to deal with attendings who do this? Is this the kind of attitude I'll be facing during 3rd year rotations outside psych?

Appreciate anything you have to offer!


----
From Dinah:

Dear Exalya,

I am so glad you enjoy our podcast! I also got the same nonsense, one of my preceptors told me that I would be more use to society as a plastic surgeon. Great.

The three of us wrote a post sometime back called Who Wants to be a Shrink?...please check it out.

Psychiatry has a lot of options: it is what you make it. You can have a low volume practice and focus on psychotherapy, you can have a high volume practice and madly write prescriptions, or you can mix it up. You can teach, do basic research and never see a patient, be a chairperson or administrator, focus on public health or private health. I do promise you, if you want to, you will talk so much more to your patients than in family practice. I also promise you won't make the money that you would in a surgical subspecialty. There is always the advise the financial aid adviser gave me when I graduated from medical school heavily in debt and insisting I was going in to psychiatry: "Marry rich."

What should you do? Ignore these turkeys. Do what you love and have a career where you enjoy your days. We took a survey recently: 90% of the shrinks in our state said they would do it again (at least of those who answered the survey).



From Roy:
I agree with Dinah. You will have lots of flexibility in what you can do. And you do not need to marry Rich or any other guy. As for the flip remarks, you Will get them. Shrug them off as uninformed comments, or as just trash talk to get you to go to their specialty. Just smile and tell them that you hear all the smart people go into psychiatry ;-)

__________________________________________________________________

From Clink:
Yes, I heard comments like that when I was a medical student too: if you become a psychiatrist you'll lose your medical skills, why bother being a doctor if you're just going into psychiatry, psychiatric disorders mean there's nothing "really" wrong with the patient, etc. Twenty years later, I still occasionally hear comments like that---even from friends and family. It's a hazard of the biz. You'll eventually have the last laugh though, the first time you get called to consult on a delirious patient and you can lecture the "real" doctors about forgetting their basic psychiatry skills. You'll also see how the karma plays out during residency: all the surgery and internal medicine docs will be miserable while the psych residents love their work and their patients. And really, psychiatry IS a lot more fun than any other specialty. Don't be too hard on the docs making ignorant comments. They're jealous.

Thursday, May 26, 2011

Transfering Care and Do You Have to Meet All Criteria for a Disorder to get Meds?


A college student wrote in and asked the following questions:
1. Do you ever transfer care and how do you decide when to transfer care? If a patient is stable do you transfer care and prescribing over to a general/family/primary care doc? I know that most depression, anxiety, adhd, etc is diagnosed and treated in primary care these days anyways, under what situation is diagnosis and treatment management by a psychiatrist recommended over a
general practitioner or conversely when is treatment management by a general practitioner recommended over a psychiatrist? Do you ever feel like your patient's level of need/functioning/distress doesn’t warrant your care, such as when they are improving with treatment, if so do ever you suggest that they should reduce their visits or seek care elsewhere?

2. Does a patient have to be diagnosed with a disorder in order to be prescribed medications? For example, do they have to fit the clinical criteria in the DSM for depression before you will feel comfortable prescribing antidepressants to them, or is just complaining of feeling sad and hopeless enough? Is complaining of being inattentive and failing classes enough to warrant adhd medications? I know it gets dicey with
controlled substances and insurance coverage/reimbursement, but in general I am curious regarding the indications for medication prescriptions? If a patient doesn’t fit the exact DSM criteria for a disorder but they feel they will benefit from medications, do you give it to them?
-------------
Wow, that is a lot! The student began by telling us she sees a psychiatrist for 7 minutes every three months to get stimulants.

Do I transfer care? Not usually. Maybe the better answer is really rarely. I get patients from primary care docs who feel the patient needed more. I figure people come to me because they want a psychiatrist, they like having someone to talk to (I do Not do 7 minute sessions, but I certainly do see people a few times a year), and they like knowing they have a psychiatrist if something should go wrong. If someone who is stable for a while on a set dose of medicines were to ask, "Can I just get this from my primary care doctor?" I would say "Sure." I really have only been the one to suggest it when the patient makes it clear that scheduling with me is a burden, and I don't think I'm adding to the mix in any meaningful way. When this has happened, I've said, why not just have your primary care doc prescribe it and if you have any problems, I'm happy to see you again. This hasn't happened much. What happens more often is that people drift out of treatment, and I imagine they either stop their medicines, or get them from their internist. Sometimes they come back when they have a problem, and that's fine with me.

Regarding questions about whether meeting DSM criteria is a necessity for medications, that really depends on the doctor. I don't keep a DSM in my office and I never sit there with a check list of symptoms to say "Yup, you got it," "Nope, you don't." Why is that? Because the book was written by consensus-- a bunch of guys in a room agreed these are the symptoms you need to have Panic Disorder, not by a blood test or some thing that clearly correlates with prognosis. Precise diagnoses are really good for insuring that everyone in a research protocol has the same condition, and I don't do research. So maybe the patient doesn't quiet have enough symptoms for a diagnosis of depression, or perhaps they haven't gone on quite long enough, but perhaps the symptoms that are there are intense, incapacitating, or dangerous, and the patient is requesting medications. I'm not likely to send them out saying "You need one more symptom and 2 more days before your suicidal misery meets criteria, so come back when you have another symptom."

ADD may be it's own issue because of the controlled substance/addictive substance question, and the fact that some clinicians feel the diagnosis is over-made. People can be inattentive for many reasons: depression, pretty girl outside the room, boring instructor, cell phone texts keep coming in, worried about not being invited to big party tonight, upset about cat's cancer diagnosis...and the list marches on. Failing tests may be due to lower than needed IQ, partying too much, misunderstanding about what would be on the test, instructor with lower than needed IQ, girl in next seat vomiting, poor preparation, bad night's sleep, substitution of decaf for caffeinated coffee (Clink's version of Hell). Lots of people with ADD do just fine without meds. Being smart helps in the way of compensation. Lots of people with ADD seem to have disabilities beyond what one might expect with some distraction. I don't treat a lot of ADD, and my guess is that it depends on who you go to for this: the people who have large practices and do a lot of this work seem to have somewhat lower thresholds for aggressive prescribing, and a greater comfort level with the problem and the cure.

I hope I answered the questions okay.

From the Washington Post-- on Shrink Rap

Mind matters: What your shrink really thinks

Shrink Rap: Three Psychiatrists Explain Their Work,” (Johns Hopkins University Press, $19.95)

The HBO series “In Treatment” is between seasons, leaving a void for therapy voyeurs. Luckily, there’s “Shrink Rap,” in which three area psychiatrists dish about their field. The book is a spinoff of a blog that Dinah Miller, Annette Hanson and Steven Roy Daviss created five years ago; it later became the podcast “My Three Shrinks.” The doctors, who are affiliated with such local institutions as Johns Hopkins Hospital and the University of Maryland, discuss psychiatric medications, involuntary hospitalizations and the business of psychiatry, among other topics, with compelling patient vignettes. Though the writing is more formal than their breezy, witty banter on the blog and podcast (bound to happen), it’s a fascinating peek into the minds of those who study minds.

— Rachel Saslow

Here's the Link.

Wednesday, May 25, 2011

Florida Don't-Ask-Don't-Tell Gun Law Modified

Here's a follow-up to my March post about the Florida bill to outlaw physicians from asking their patients about access to firearms. Dinah later posted about the effects of the bill on pediatricians. The bill passed, though it was amended to remove the jail time and the potential $5M fine (a bit excessive?).

The Florida Medical Association originally opposed the bill, but now has expressed satisfaction with the compromise language. In March, Asher Gorelik, M.D., president of the Florida Psychiatric Society (FPS), expressed to Psychiatric News his membership's opposition to the bill, particularly “a great deal of concern about how this law would interfere with the ability of the psychiatrist to properly assess a patient.” But in a recent follow-up interview, Gorelik stated that the new language in the bill “no longer interferes with the ability of a psychiatrist to perform a risk assessment.
~Psychiatric Times

Tuesday, May 24, 2011

Tell Me Why I Don't Like... Tuesdays?


You know that 1979 Boomtown Rats song, "I Don't Like Mondays." (This Youtube music video features a very young-looking Bob Geldof.)  The song is about the 1979 shooting spree on a Monday morning at a San Diego elementary school. The shooter's only state reason for doing it was that she didn't like Mondays.

The silicon chip inside her head
Gets switched to overload
And nobody’s gonna go to school today
She’s gonna make them stay at home

It turns out that -- contrary to popular impression that Mondays are the worst day of the week -- Tuesdays are the worst day of the week.  According to a piece by Chris Hall (@hallicious) on HealthCentral, Tuesdays are the worst day of the week (moodwise) while Sundays are the best. This is based on mood rating scores from 500 users of the Mood 24/7 service, which HealthCentral licenses from Johns Hopkins University. After you sign up for the free service, the software sends you a text message at random times, and you text back your mood rating for that day.

So, you'd think that the latest date of the coming apocalypse, October 21, might be on a Tuesday. But it's not -- it's on a Friday.  Maybe it will get moved again.

Friday, May 20, 2011

Sponsor Shrink Rap for NAMI Walkathon


The National Alliance on Mental Illness is dedicated to improving the lives of individuals and families affected by mental illness, by grassroots advocacy for public health policy and funding that supports awareness, education, and advocacy for mental illness.

So I just realized that the annual NAMI Walks fundraising event in Baltimore is tomorrow morning. While the other shrinkrappers are still having fun and sun in Hawaii, I'll be leading the Shrink Rap team here at home tomorrow morning. Please support NAMI by sponsoring my walk. You'll be supporting a good cause, will feel great after doing it, and maybe even lose weight vicariously! (It's also tax-deductible.) NOTE: you can donate even after the event is over.

Click on the logo above to sponsor, or go to http://www.nami.org/namiwalks11/BAL/drdaviss. I'll be happy to mention your name and/or link if you like in a follow-up thank you post next week (just include your info in the Message To Me window after making your donation). Even $5 will be greatly appreciated!

Thank you,
~Roy

Please Go To Amazon and Write a Review!

Aloha! Clink and I are still in Hawaii on opposite ends of the same island. Gorgeous here, and oh,how I love vacation! I am having some technical difficulties posting from an iPad, and maybe Roy could add a photo for me.

You're used to hearing us say on our podcast, "Please go to iTunes and write a review!"

Now, I'd like to ask, if you've read our new book, Shrink Rap: Three Psychiatrists Explain Their Work,
Please go to Amazon and write a review!

Thank you so much, and I am going back to my vacation now. See you next week. Roy, hold down the blog-- you're doing a great job.

Wednesday, May 18, 2011

Results from Our Survey on Attitudes Towards Psychiatry

Aloha from the American Psychiatric Association's Annual Meeting in Honolulu! The weather is gorgeous here and it's been a great meeting. Yesterday, I heard Archbishop Desmond Tutu speak, and today, I listened to "Conversations" with Lorraine Bracco--also known as Dr. Melfi from The Sopranos. The beach is nice, too, and Clink has been scuba diving. Should I tell you she just learned to swim this past winter? She is amazing!

In a few hours, we will be giving our workshop, The Accessible Psychiatry Project: The Public Face of Psychiatry in New Media. We are telling the audience that the survey we did was not validated, was not statistically analyzed, and is not real science. Mostly, it was about how cool it is that we can even do this at all (ask questions, interact with readers, have an impact). I thought I'd share the survey results with everyone here. If you took the survey, thank you, again.



702 responses
Summary 




Who are you?
A professional who treats psychiatric disorders (for example, a mental health professional, a primary care physician/ nurse practioner, or pediatrician)
12919%
Someone who works in a field connected to psychiatry, for example a researcher, health writer, clergyman, patient advocate, support staff in a mental health facility
10015%
Someone who is or has been in treatment for a mental illness
41060%
The family member or close friend of someone with a psychiatric disorder
25638%
The family member or close friend of a mental health professional
9614%
An innocent bystander with no direct relationship to the mental health profession
639%
Other
7912%
People may select more than one checkbox, so percentages may add up to more than 100%.




My age group - Choose one
Under 20
203%
21-35
25136%
36-50
22532%
51-65
16323%
Over 65
203%




My perception of psychiatry has been primarily shaped by . . .
My personal experiences as either a professional in the field or as a patient
55081%
The experiences of those close to me
29143%
The portrayals I see in the media
11717%
Information I have read about psychiatry
33749%
I don't have any preconceived ideas about psychiatry
172%
Other
325%
People may select more than one checkbox, so percentages may add up to more than 100%.




I believe that psychiatry . . .
more often than not helps people with mental health problems
44866%
more often than not harms people with mental health problems
7711%
encourages people to use diagnostic labels to explain their bad behavior or laziness
11918%
provides explanations for behavior in a way that is ultimately helpful
33850%
is a field that is about controlling others and is basically evil
365%
is a field that is about helping those with mental disorders to live better lives
46769%
Other
18127%
People may select more than one checkbox, so percentages may add up to more than 100%.




Psychiatric patients, in general, ...
are just regular people
52478%
are more creative and/or interesting than the average person.
12519%
are uncomfortable to be around
7912%
are often dangerous or scary
325%
are unreliable
558%
should not be permitted to work in certain professions, such as medicine, child care, or law enforcement
335%
live better lives if they hide the fact that they suffer from mental illness
15122%
live better lives if they are open with the fact that they suffer from mental illness
22133%
Other
15723%
People may select more than one checkbox, so percentages may add up to more than 100%.




Psychiatrists are . . .
interesting people
28443%
weird people
14622%
intimidating because they may analyze me in public settings or know what I'm thinking
497%
on the whole, no different than any other group of professionals
31747%
pawns of the pharmaceutical industry
15924%
interested in knowing and understanding their patients as complete human beings
28042%
just interested in symptoms and medications
21532%
troubled people looking to cure themselves
6410%
I have no opinion about psychiatrists
264%
Other
16625%
People may select more than one checkbox, so percentages may add up to more than 100%.




Have you ever been evaluated or treated by a psychiatrist? -
Yes
44764%
No
21531%




Psychotherapy . . .
more often than not helps people recover from or manage mental illness
41762%
more often than not helps people to better understand themselves and negotiate their lives
45768%
encourages a detrimental, self-centered perspective
507%
more often than not makes people feel or behave worse than they did before they entered treatment
233%
is for people who don't have friends to talk to
568%
is more often than not inferior to medication as a treatment for mental disorders
548%
is more often than not superior to medication as a treatment for mental disorders
17626%
does nothing
294%
I have no significant opinion about psychotherapy
457%
Other
15423%
People may select more than one checkbox, so percentages may add up to more than 100%.




Have you ever been in psychotherapy? -
Yes
48669%
No
17625%




Psychiatric medications . . .
more often than not help people recover from, or cope with, their difficulties
36855%
more often than not cause problems that are worse than the ones they treat
14021%
have saved lives and helped people to function better
49073%
are a quick fix for people who don't have the inner strength to deal with adversity
639%
treat illnesses that can strike anyone
38858%
are the creation of a greedy pharmaceutical industry that has deceived the public
13821%
I have no opinion about psychiatric medications
152%
Other
22333%
People may select more than one checkbox, so percentages may add up to more than 100%.




Have you ever taken psychiatric medication? -
Yes
45865%
No
21030%




Sometimes, patients are seen for brief visits by a psychiatrist for management of their medications and if they need psychotherapy, they see a social worker, psychologist, nurse therapist, or counselor (so-called "split treatment"). What do you think of this practice?
Brief visits with a psychiatrist for medication management typically work well
15423%
Psychiatrists should spend more time than this with their patients to manage medications
34852%
When possible, psychiatrists should provide both psychotherapy and medication management to their patients
37756%
Patients should not see psychiatrists at all: medications should be managed by other professionals such as primary care physicians, nurse practitioners, or specially-trained psychologists
386%
I have no significant opinion on this topic
528%
Other
16124%
People may select more than one checkbox, so percentages may add up to more than 100%.




Electronic Health Records (EHRs or EMRs) . . .
should not contain any records of psychiatric illnesses and treatments (including medications) even though that means my primary care doc or ER doc wouldn't know about my meds or condition unless I tell them
8913%
should have separate and higher protections for mental illness than for other health problems
21832%
should exist for psychiatry exactly as all other medical records do, with the same protections as for other health condition, because adding special protections increases stigma against mental illness
27541%
should allow patients to control which information they wish to be shared and with whom for all medical specialties
29043%
facilitate better communication and improve psychiatric care
26139%
negatively affect communication and detract from psychiatric care
497%
I have no significant opinion about electronic health records in psychiatry
7411%
Other
9414%
People may select more than one checkbox, so percentages may add up to more than 100%.




Direct-to-Consumer (DTC) advertising (commercials/magazine ads) of medications . . .
decreases the stigma associated with taking psychiatric medications and is therefore good for psychiatry
14221%
scares prospective patients too much with the lists of side effects
10916%
provides incomplete medical information and the suggestion that patients should demand specific treatments without individual consideration of the patient and their problems
49774%
provides useful information to patients and increases awareness about treatment options
12819%
should be allowed to continue
9013%
should be no longer be allowed
30445%
I have no opinion about direct-to-consumer advertising
436%
Other
10916%
People may select more than one checkbox, so percentages may add up to more than 100%.




Psychiatric blogs by mental health professionals . . .
more often than not are useful sources of information
30045%
more often than not are biased and unhelpful
365%
are entertaining or interesting to me
40160%
I have no opinion on psychiatry blogs by mental health professionals
17626%
Other
538%
People may select more than one checkbox, so percentages may add up to more than 100%.




Blogs about psychiatry in general -- including those by patients and those who may be disenchanted with psychiatry -- have . . .
provided encouragement for me to get treatment or to recommend treatment to others
11017%
discouraged me from getting treatment or recommending psychiatric treatment to others
284%
had no influence on my attitudes towards psychiatric treatment
21633%
had a positive influence on how I view psychiatry
13320%
had a negative influence on how I view psychiatry
558%
I have no opinion on psychiatry blogs in general
21132%
Other
9715%
People may select more than one checkbox, so percentages may add up to more than 100%.




Do you feel this survey is balanced and fair? -
Pretty much
43161%
In the middle
19828%
Not really
406%




Comment box for additional comments or suggestions . . .
You're missing the large portion of the population who doesn't read blogs like this. My close friend has very different attitudes toward psychiatry (they are wierd, controlling, just want to push meds, etc.) and she may be more the typical person.You surely didn't think this was a balanced or fair survey. did you? Was that part of your plan?You have to find a way for members of the same family (spouse/parent) who are on the same insurance policy not to see each other's medication/psychiatric treatment records.Lawyers take the name of a medication and then create an attack on the person for ...


Number of daily responses

Monday, May 16, 2011

Guest Post from Eric Stevenson: Caring for a chronic illness patient: A difficulty on its own



This Guest Post is from Eric Stevenson, a health and safety advocate who resides in the South Eastern US.


Having a chronic illness can be extremely tough, not only for the patient themselves but also for those who care for them. The process of loving and supporting someone with a chronic illness can be very difficult and challenging. Many times caregivers don’t want to speak up about their own stress because they may feel guilty or that it doesn’t matter as much than the patient’s problems. Luckily, there are a few ways to be prepared and help in the difficult situation of caring for a person with a chronic illness. 

There’s a great amount of social factors and possible coping strategies involved with care giving, as some things can influence stress levels in a positive or negative direction. Financial instability can cause major stress and mental issues for caregivers. In many times a chronic illness can lead to major financial problems as hospital bills continue to stack up. Financial factors can influence the mental state of caregivers in either direction. With more financial support, caregivers are often able to delegate some of their responsibilities, thus lowering stress and improving mental health. 

Social support also plays a huge role in the process of caring for a chronic illness patient. The help of family, friends, or even neighbors can play both a positive and negative part in the mental state. Not allowing for any support for the patient can often cause problems, but so can minimal support for yourself or a care giver. The stress and difficulty of taking care of someone with a chronic illness can be a major burden. Not having anyone to talk to or vent is often a major cursor to stress. 

Many people deal with side effects of coping strategies. Some may take to avoidance, but in many cases that will lead to further health problems. Avoidance as a coping strategy has been known to bring on many cases of depression. Many caregivers with low self esteem will use emotionally charged coping strategies, while those with high self esteem may turn to task centered coping methods. In the end, research has shown a large connection in self esteem and depression within caregivers. 

Factors such as the type of illness and location will also play a large part in the process. Some diseases like mesothelioma (a cancer forming from asbestos exposure) will have a severely low life expectancy. When compared to a patient that may be expected to live many years longer, the care giving situation will be extremely different. 

In the end, there are certainly a few factors that will play a large part in the role of a caregiver for those with chronic illnesses. The value of a support system and being educated on the disease will remain important. Caring can end up being extremely difficult and stressful, thus caregivers should also be looked out for in the future.

Sunday, May 15, 2011

We Got Our Duck!



Jackie, our wonder editor, told me there was a duck surprise. Oh, good. I like surprises. And Shrink Rap likes ducks. And then I forgot.

So this morning I went to check out the Johns Hopkins University Press booth at the Exhibit Hall here in Honolulu at the APA. Lots of books, lots of people, and they have a poster up for Shrink Rap in a corner. And a big screen with images that change. Then I noticed it: the Shrink Rap stuff all has ducks on it! This, after they denied us a duck on our cover and said it made us look like quacks.

Ok, so it's beautiful here in Oahu and I'm off to soak up some sun.
I woke up at 5:20 this morning and have been learning about psychiatry all day!

Just a quick note to myself and a to-blog-about list. We've been so busy lately that time has been short for blogging and podcasting, but I still have ideas, so coming posts will (some day!) be:

--Response to the med student who wanted to know how to deal with negativity when she says she wants to be a psychiatrist.
--What is anti-psychiatry and why does it bother me. (Please pray for me if I go there).
--The chapter I wish I'd written, inspired by Jesse's comments.
--We got a request to talk about how autism may mimic psychiatric symptoms on our next podcast. Maybe we'll respond to the medical student on a podcast instead.

Ever feel like life gets just too busy? Okay, having fun at APA, gotta catch some rays now.
--

Friday, May 13, 2011

Come Visit Us at APA In Honolulu!


So glad Blogger is back. I was starting to go into withdrawal despite Roy's reassurance that it would be okay!


Aloha! Do come meet us at APA. I've never been to Hawaii before, I'm looking very forward to this.

On Monday, Morning, May 16th at 11 AM, we will be doing a book signing in the Exhibition Hall at the Johns Hopkins University Press at Booth 1424. The Press will be discounting our book to a mere $12, cheaper than you will find it anywhere! Let me further remind you that this may be a tax deductible business expense. Oh, come visit even if you don't want a book! ClinkShrink will be wearing a duck necklace.

On Wednesday morning at 7 AM, we will be giving our workshop called
The Accessible Psychiatry Project: The Public Face of Psychiatry in New Media in Room 326B in the Hawaii Convention Center. If all goes well with the technology, we promise an entertaining multi-media event. It's an early hour, but do bring popcorn anyway.



NOTE FROM CLINK:
Ignore what it says on the APA iPhone app about our presentation (they have it listed as 'withdrawn'). We ARE giving it!! I talked to the APA people and they're supposed to fix this.

ANOTHER NOTE FROM CLINK IN HAWAII:
Dinah just texted me that our presentation info was left out of the conference program! Augh, are we cursed?? We ARE giving the Accessible Psychiatry Project presentation on Weds morning at 7:00 am in room 326b.

On the positive side, the iPhone app is fixed and our presentation is listed correctly there.

Wednesday, May 11, 2011

Today's Shrink Rapper News



1) Our book is now out on Kindle. Apparently, you can get it in a minute for $10.

2) One of my old posts is up on KevinMD, Predicting How Much Impact Mental Illness has in a Person's Life.

3) In June, we hope to have another component blog up and running---Shrink Rap News-- we will be doing weekly posts on the Clinical Psychiatry News website. Those posts will target an audience of psychiatrists. Oh, we started with that idea here at Shrink Rap, but the readers we found, both shrinks and non-shrinks, have proven to be so much fun!

4) Aloha! We're getting ready to go to Hawaii for APA-- Roy will give you details about where to find us shortly.

5) Frazzled and frizzled, I did what I've never before done today: I blew off my hair stylist! Not on purpose, but I thought my appointment was 3 hours after she thought it was. Ah, you ask, did she charge me? Do hair stylists charge for No Shows? (They should). No, she had time for me later in the day, and Yes, if I can reschedule a patient who has forgotten an appointment on the same day, I don't charge for the 'missed' session. Someone would have asked that, right?

Monday, May 09, 2011

Those Privacy-Invading Pediatricians, Silenced!


A while back, Roy blogged about proposed legislation in Florida that would make it illegal for physicians to ask patients if they own guns. What the??? Since when do we legislate what people can ask each other, outside of discrimination issues for jobs? And is there any precedent for legislating the conversation that occurs between a doctor and patient? So apparently this is going to pass, and Greg Allen writes in "Florida Bill Could Muzzle Doctors on Gun Safety,"

Florida Gov. Rick Scott is expected to sign a bill that will make the state the first in the nation to prohibit doctors from asking patients if they own guns. The bill is aimed particularly at pediatricians, who routinely ask new parents if they have guns at home and if they're stored safely.

Pediatricians say it's about preventing accidental injuries. Gun rights advocates say the doctors have a political agenda.

Ah, it's not about us shrinks, it's okay to ask if there is a question of danger. It's about the pediatricians. Personally, I think the pediatricians should fight back: if they can't ask who owns a gun and target their gun safety remarks, they should give extensive gun safety instructions and literature to every parent at every visit. Perhaps as a statement of unity, all pediatricians in all states should discuss gun safety with every patient, no questions asked.

Sunday, May 08, 2011

Happy Mother's Day to All

Saturday, May 07, 2011

A Cry for Help


When Roy and I were on Talk of the Nation this past week, a called phoned in to ask about her sister. The question was about care in the Emergency Room/Department, so it was a perfect Roy question and he fielded it. I've been playing with it since, and wanted to talk more about this particular scenario, because the scenario was very common, and the question was more complicated than it seems.

From the transcript of the show:

ANN (Caller): Hi, thank you very much. I would like to ask Dr. Roy (oh, I gave him his blog name here) a question: My sister was admitted to emergency when she cut her wrists, and the doctor on call pulled me aside and said, do you think she was trying to kill herself?

And I said - because my sister is very intelligent - I said, if my sister really wanted to kill herself, she would have done it. I think she's asking for help.

And so he said - and so he had her see the psychiatrist who was on call, or on duty. And she spoke with him for a while. And he sent her home, saying: Well, if you need me, I'm here.

What I would like to ask Dr. Roy is, what protocol was going on there? Why did they allow that to happen? And what would you change, if you could?

----
Roy did a great job touching on issues of voluntary versus involuntary hospitalization and the importance of hooking someone who is looking for help in to outpatient care.

If this were more of a two-way conversation, I'd want to ask more questions. What did the caller think should have happened? Was the sister given a referral for outpatient care? Was she asked if she wanted one? Was she already in treatment? My sense --and I could easily be wrong-- was that the caller thought the patient should be admitted to the hospital. She was desperate and ready now for help. The doctor asked the sister if she thought the patient wanted to commit suicide; hopefully the patient was asked that as well.

So if the caller thought her sister should have been hospitalized, there are things about the 'system' she isn't aware of. Hospital inpatient units are a place that people go to be kept safe. In many ways, they are a holding place and the goals there do not include treatment back to wellness, but treatment back to safety. It's a very low bar, and it ends up that only those who are imminently dangerous, or so disorganized as to be at risk, get admitted from an ER. There are some exceptions: if the ER doc doesn't believe a patient who says he's not suicidal/homicidal, he may err on the side of safety and admit the patient, or if the patient's behavior seems unpredictable, he may get admitted. At a community hospital, a typical length of stay is only a few days, very little actual psychotherapy occurs in the hospital, and while medications may be started, people are generally discharged before those medications can take effect or even be brought to steady-state levels. Gone are the days of long-term hospitalizations. And because of the acuity of illness in those people who are admitted to the hospital, psychiatric inpatient units are often not very restful places. If you want peace and quiet, you're better off in a hotel where you can order room service, have a massage, sleep peacefully, and it costs a whole lot less.

Sometimes people are admitted to specialty units where more intensive treatment does take place which may take longer and may have a goal that goes beyond imminent safety. There are special mood disorder units, eating disorder services, pain units, trauma disorder services, or inpatient stays for ECT...but one doesn't typically get admitted to these from the Emergency Room and often issues of payment limit who can be admitted and for how long. Of course, there is Clink's favorite place, The Retreat, where you can get help in a very pleasant environment, and I imagine they would be happy to have the sister of the caller from the radio, but that is self-pay.

"Getting help" usually means going to an outpatient therapist/psychiatrist and it's not something that necessarily gets started while the moment is ripe. If there is a clinic associated with the hospital, they may have emergency slots for the ER to offer fast appointments, but other times, it can take many weeks to get a first appointment. Private practice varies a good deal-- I know shrinks who can get you in within the week, and others with a 6 week wait, and many who are simply too booked to take new patients.

I didn't write these rules, I'm just letting you know what they are. How do you think it should all work?