Saturday, July 30, 2011

Freedom of Information: Online Education and Open Access



I'm back and holding down the fort temporarily while Dinah's away. After five years of blogging it's a little difficult to find a new topic to get excited about, and no, I'm not going to write about the Norwegian spree killer.

Instead I'm going to put up this YouTube video by law professor James Duane giving a lecture about police interrogations and how anything you say---even when it's true and even when you're innocent---can and will be used against you. I'm posting this link for two reasons: I'm interested in why people confess to crimes they don't commit, and because I think it's incredibly generous of an academician to take the time and effort to give away knowledge to the world at large. I'm a firm believer in open access education. I like the idea of using social media to give anyone a chance to learn something new.

While many people complain about the influence of the pharmaceutical industry on medical research and clinical practice, you don't often hear people express concern about the stranglehold the publishing industry has on new medical knowledge. Think about it: if you're a doctor and you practice in an isolated part of the country, with no academic affiliation, how do you get your medical literature? Maybe through a hospital library (if the hospital has one), maybe through a limited number of journals published by a couple organizations you might belong to, but not to the global world of professional publications. And it's going to cost you hundreds of dollars. And pity the forensic professional who wants to get LexisNexis access---even for lawyers this costs thousands of dollars.

This is why I give extra props to organizations like the American Academy of Psychiatry and Law (disclosure: I'm a member, big surprise there!) which has chosen to keep it's journal free and available in full text to the world at large. I'm also a fan of the Public Library of Science and Open Courseware Consortium.

Information wants to be free.

Addendum: I forgot to mention the Google Books project, which is scanning books from various academic libraries. I found this book recently: The Mental Status of Charles Guiteau. Guiteau was the man who assassinated President James Garfield. Most potent quote so far: "Crazy, perhaps, but not so crazy he should not be hung."

Thursday, July 28, 2011

Google+ Button Added


Dinah asked me to add a Google Plus (G+) button to our posts. Done.
Does she use G+? Do our readers?

I will say that I've been using G+ now for about three weeks. If you've been hiding under a social media rock lately, G+ is Google's next attempt at a social media platform. It has some elements of Facebook, some of Twitter, some of Friendster, rolled up together to give users more control over whom they share with. A "tweet" or post can now be shared with just those Circles of people you choose. There is also a cool new feature called Hangouts that is like Skype on steroids. You can have a videochat with 9 other people simultaneously. Wouldn't be surprised to see a therapist using it for group therapy. It has better privacy control features than the leading social media tools, and is quickly gaining ground.

I'm thinking we could do our next podcast via Google+... if only Dinah would sign up.
At least she got her button. Reward her by giving her a +1 below.

Wednesday, July 27, 2011

Happy Shrinks!


Today's blog post can be found over on Shrink Rap News on our Clinical Psychiatry News site.

In it, I talk about why psychiatry is the best medical specialty   : ~ )   and I reveal the results of a question we asked to Maryland psychiatrists:  “Overall, are you satisfied with your career as a clinical psychiatrist?”  



So what percentage of respondents do you think said "Yes, I find my work rewarding and would chose this career again?"   Take a guess, then click over to Shrink Rap News and find out the answer!  The article is entitled "Would You Do It Again? Psychiatrists and Career Satisfaction." 


In case you missed it, Roy also has a post up from last week on Health Insurance Exchanges and Accurate Provider Directories.  If you've ever tried to find an In-Network doc, only to discover that everyone listed on the insurance company website is now 6 feet under, you may want to read this.
Ooooh...it's going to annoy Roy that I fooled with the color scheme.   [fixed it. ~Roy]

Sunday, July 24, 2011

Cocaine: Running all Around Their Brains

First, a quick shout out to Dr. Doug Perednia over on Road to Hellth (paved with mixed intentions) who wrote a glowing review of our Shrink Rap book!  


We think of addictions as conditions that destroy lives.  With some addictions-- like crack, or cocaine, or heroin-- it seems inevitable.  In the New York Times, there are two recent articles about addiction that are worth looking at.  Sherwin Nuland has a book review of

Sigmund Freud, William Halsted, and the Miracle Drug Cocaine
By Howard Markel
Illustrated. 314 pp. Pantheon. $28.95.

Dr. Nuland writes:

That song of praise was “Über Coca,” a monograph published in July 1884 in a highly regarded journal. In his perceptive new book, “An Anatomy of Addiction,” Howard Markel points out that this landmark essay — Freud’s first major scientific publication — was in fact a turning point for the young scientist. “The most striking feature of ‘Über Coca’ is how Sigmund incorporates his own feelings, sensations and experiences into his scientific observations,” Markel writes. “When comparing this study with his previous works, a reader cannot help but be struck by the vast transition he makes from recording reproducible, quantitatively measurable, controlled laboratory observations to exploring thoughts and feelings.
Nuland goes on to say:


“Most recovering addicts,” he writes, “insist that two touchstones of a successful recovery are daily routines and rigorous accountability.” Around 1896, Freud began to follow a constant pattern of awakening before 7 each morning and filling every moment until the very late evening hours with the demands of his ever enlarging practice (he was soon seeing 12 or more patients per day), writing, lecturing, meeting with colleagues and ruminating over the theories he enunciated in such articulate literary style. Markel concludes: “It appears unlikely that Sigmund used cocaine after 1896, during the years when he mapped out and composed his best-known and most influential works, significantly enriched and revised the techniques of psychoanalysis and . . . attempted to ‘explain some of the great riddles of human existence.’ ”

 We're a psychiatry blog, so I'll let you read the book review (or the book) yourself if you want to read about the Dr. Halstead, the famous surgeon, and his cocaine use.

In a separate opinion piece, "Addictive Personality?  You May be a Leader"  neuroscientist David Linden talks about how similarities between addictive personalities and leadership characteristics:

The risk-taking, novelty-seeking and obsessive personality traits often found in addicts can be harnessed to make them very effective in the workplace. For many leaders, it’s not the case that they succeed in spite of their addiction; rather, the same brain wiring and chemistry that make them addicts also confer on them behavioral traits that serve them well.
So, when searching for your organization’s next leader, look for someone with an attenuated dopamine function: someone who is never satisfied with the status quo, someone who wants the feeling of success more than others — but likes it less.

I'll leave the rest to you.

Kindle versus Nook?








 Vs.





We bought our daughter a Kindle for her birthday and I'm using it while she finishes her hard copy books.  So far, it has two books on it: Shrink Rap (because my husband bought it for his iPad and it magically appeared on the Kindle, perhaps because they are all linked to my Amazon account) and Slaughterhouse 5-- her summer reading.  So, Billy Pilgrim, Kilgore Trout, Roland Weary and a bunch of Tralfamadorians are taking a walk down memory lane.  It's light, it's easy, it's portable, and I'm addicted to screens.  I'd kind of like to turn the pages with a touch screen, and how do I get the print a little larger for when the lighting is low (oy, I've hit that age)?  So, Kindle versus Nook: if you're done the comparison, do let me know....

Friday, July 22, 2011

Is Psychiatry Different From Other Specialties?



In the Clinical Encounters case featured here two days ago, I presented the story of a psychiatrist who goes for a urological procedure and discovers that one of his former patients is the nurse assisting.  People wrote in to suggest ways he should handle this awkward situation and I was struck by the idea that some suggested he tell the urologist that he knows the nurse in a social setting (because he can't tell the other doc that the nurse was his psychiatric patient) and the assumption that the urologist would be understanding, and that perhaps the urologist should have policies in place in case of such events.


Do surgeons think this way?  I assumed the urologist would be angry--his time had been allotted for the procedure, and it's a surgical procedure with professional staff, what's the big deal?  To a surgeon, I think you see the best, and if the best is your friend, then so be it, a body's a body.  It's not unusual for clergymen to be treated by their parishioners, for medical staff to be treated at their own hospital and by members of their own department, and for surgeons to operate on colleagues.  In small towns, there is often very little choice as to who delivers your baby or shrinks your head.


Traditionally, psychiatry is a bit different, and we maintain some distance.  In the program where I trained, this view was not felt to make sense: if you're sick, you go to the best, and we are the best.  Psychiatrists would have their family members come in for care, and there were times that people in the department were admitted to the inpatient unit (and yes, I mean psychiatrists as well as nurses, staff,  residents, and med students).  For those who insist that the stigma of a label or a treatment necessarily destroys you-- it ain't so. 


It all makes me, personally, a little uneasy-- I like my privacy, even for the most mundane of medical things, though I do think that if I had some unusual, or difficult-to-treat condition and the 'best' was someone close to home, I'd get over it very quickly.

Thursday, July 21, 2011

Guest Blogger Dr. Jesse Hellman on Mrs. Brown


Recently there have been a number of posts on Shrink Rap that touched on issues of what is normal, and do we today treat as illness the vicissitudes of normal human life. And occasionally there are films which also address these themes, if inadvertently.

In Mourning and Melancholia Freud discussed the question of the natural state of mourning and how it resembles, and differs from, melancholia, as depression was called then. I doubt that Freud’s work was on the minds of the producers of Mrs Brown, starring the great Judi Dench, but perhaps it was, as Queen Victoria was still deep in mourning three years after her husband Prince Albert’s death. She kept herself secluded from the public, allowed no happy sounds or colors around her, took no pleasure in anything, had an increasingly irritable nature, and was sad and morose.

Trying to cheer her, her chief-of-staff Sir Henry Ponsonby brought to Balmoral Castle one John Brown, an eccentric Scot who had served the Prince, and whose good report in that regard made her acceptable to the queen. He was to take her riding. John Brown, disregarding all protocol and tyrannizing the staff, gradually became very close to Victoria, so much so that it was virtually a scandal. The queen was called by her detractors, in derision, Mrs Brown. All Parliament was looking to how events in the queen’s life would affect them, and Benjamin Disraeli, the prime minister, visited her in Scotland. Eventually Victoria managed to regain her interests in life and returned to London to both vanquish the opposition that had emerged and retake her role in the center of the Empire.

Curiously, one week before seeing this film I had stumbled onto an estate sale in Georgetown. The house itself had just been sold and most of the furnishings were gone. Among books remaining in the library was a complete edition of the novels of Benjamin Disraeli. I had not realized that the great prime minister wrote novels. Anyway, I passed on it and now after seeing the film sorely regret it. If I had seen the film first...

Wednesday, July 20, 2011

Clinical Encounters: The Psychiatrist as Patient to the Patient


I've been thinking we should start a Clinical Encounters series where psychiatrists can write in with cases and other psychiatrists could give opinions-- all anonymous, of course.  Clink and Roy aren't so sure this is a good idea (or they are sure it's a bad idea!) but I thought I would try a preview with my own confabulated encounter and ask for your insights---this one is open to everyone.  It's an altered version of something that happened to a shrink friend of mine many years ago, so while the details are disguised, the uneasiness of the situation is not.  


Dr. Mind is a psychiatrist in private practice who is having an embarrassing little problem and he goes to see a urologist.  He needs a procedure, something quick that can be done in the office on an outpatient basis.  In comes the nurse to assist Dr. Phallus, the urologist, and the nurse greets Dr. Mind with a smile.  Ah, she is a former patient of Dr. Mind-- the now very vulnerable patient who does not want this nurse/ex-patient of his in the room to have any part of his procedure or rather sensitive body parts.  He's in quite the pickle here: He's the patient and he has his feelings to consider, but he can't exactly divulge to Dr. Phallus, "Your nurse was my patient and I don't want her here"-- complete with any incriminating things he might know: she's got a drug problem, she told me stories about her treatment of patients that made me cringe...or she's a wonderful person but he just doesn't want her here.  

Your thoughts on how Dr. Mind should handle this?

Monday, July 18, 2011

Book Review: Crazy by Rob Dobrenski (ShrinkTalk.net)

Rob Dobrenski, PhD. is a psychologist who blogs over on ShrinkTalk.net.  He's written a book about what it's like to be a psychology graduate student, a psychotherapy patient, and a psychologist.  Oh, we like the folks who go from Shrink blog to Shrink book -- it somehow feels familiar -- and so I agreed to read his book: Crazy: Tales on and Off the Couch.

So bear with me while I tell you that the book rubbed me wrong at the outset.  Dr. Dobrenski begins by saying something to the effect that he describes things that all shrinks feel, and if they say they don't, they aren't being honest.  I really hate it when people tell me what I feel.  It's like saying that Prozac made your depression better and if it didn't, then you just didn't recognize it.  And then the book gets off on a provocative start -- Rob discovers that many people in his life, from a patient, to a colleague, to himself -- are "f***ing crazy." The asterisks are mine. Dr. Dobrenski had no trouble using the word -- I counted 19 times in the 39 pages, including in direct quotes of discussions he has with both a patient and one of his supervisors.  Not in a million years.  I wasn't sure what the point was.  To let people know he knows obscene words?  To be provocative, obviously.

Somewhere around page 50, the author begins to talk about his work with a teenage boy.  He loses some of his bravado, chills on the cool, dirty words, and when he talks about this socially awkward teen who keeps him jumping with his incessant questions, I turned a corner.  It suddenly felt genuine, and I could feel Rob's anxiety as he was in the room with this boy who would have made any therapist uncomfortable.  Oh, plus Rob's back goes in to spasm and he has to deal with this as he finesses conducting the session.  Somehow Rob has either willingly taken on, or been thrust into, the role of being the patient's sex educator.  A little unusual, but I do think many therapists can identify with being cornered into an uncomfortable role in therapy -- if not for many sessions, then at least for a few minutes.  
    "....but seeing a 14-year-old in a blue blazer with a crest on it, speaking like Dr. Ruth, made me feel beads of perspiration form on my forehead.    

   "Why are some people gay and some straight?"     

   I sensed that Jack's questions might be getting progressively more difficult.     

   "That's actually a question that no one truly knows the answer to...."     

   "And you, Robert? What do you think?"     

   Did I murder someone?  Am I on trial here?  Again, the rule: Do. Not. Lie. 

I ended up enjoying the rest of the book and I thought he did a nice job describing his work with sex offenders and their partners.  Worth the read for someone who wants a peek into therapy without actually going, but probably not for the practicing shrink.

Just a few minor details: There's no medication called Xypreza, it's Zyprexa, and Zoloft does not come in 10 mg doses. And finally, the peek is a peek, it's not an in-depth examination, and it is from a single perspective. 

And finally, to the guy who starts his book by saying, "Any shrink who tells you he can't relate to what is written here is incredibly private and guarded..."  I'd like to assert that eating photographs of your ex-girlfriend is really weird and is not a universal phenomena. There are some things you may be better off not announcing to the world. 
    

Friday, July 15, 2011

Zucchini Nut Loaf

Roy came over last week bearing gifts.  He brought me a large green baseball bat.  On closer inspection, I realized it was a club.  What would I do with a green club?  My imagination ran wild.

"From my garden," Roy said proudly.  He must be using the green club to beat away the squirrels.  Ah, but then I realized it was a Zucchini!  Roy had grown the world's largest green squash.  I'm set on vegetables for the next few months.  Zucchini on anabolic steroids!

For Clink & Roy, from page 58 of the Better Homes and Gardens Bread book I've had since college:

Zucchini Nut Loaf

1.5 C flour  (Clink: the "C" stands for 'cup")
1 teaspoon (t) cinnamon
0.5 t baking soda
0.5 t ground nutmeg
0.25 t baking powder
0.5 t salt
Mix the above together and set aside (dry ingredients)
1 C sugar
1 C finely shreeded unpeeled zucchini
1 egg
Beat together sugar, zucchini and egg, the add oil and lemon peel and mix well.  Stir in the above dry ingredients.  Fold in chopped nuts
1/4 C cooking oil
0.25 t finely shredded lemon peel
half C chopped walnuts

Good stuff.  And for the record, Roy hates when I exaggerate, but the zucchini is about as long as my dog, Kobe.

Turn batter into a greased 8X4X2 inhl loaf pan and bake for 60 minutes at 350 degrees or until wooden pick inserted near center comes out clean.  Cool in pan for 10 minutes.  Remove from pan, cool on rack.  Wrap and store loaf overnight before serving.  (Oh, my--- I never read that last sentence before.  I've always eaten it warm...perfect that way).

Shrink Blogs 2011

We used to have a blog roll on the sidebar.  Apparently, we don't anymore.  We have everything else on our sidebar, including a complete list of....  oh, nevermind.


It has occurred to me that we have been blogging for a very long time and during that time, many of our shrink blogging buds have come and gone.  I got attached to those people we knew when we were new and I spent more time reading 'other peoples' blogs'...oh where did Lily (drivingmissmolly) ever go?  And does Shiny Happy Person, the young shrink across the pond, still Shine?  I know Carrie and Fat Doctor are out there, and I was so pleased to get email from FooFoo5 when he heard us on NPR.  Nostalgia....it keeps things real.


So I thought I try to get a list of current Shrink Blogs together.
Here are the oldies (meaning they've been around since roughly 2005):
I believe The Last Psychiatrist is the one of the oldest out there. 
Dr. Michelle Tempest has also been out there longer than we have on 
A Psychiatrist Who Learned From Veterans belongs to a Texas psychiatrist.  
Novalis blogs on  Ars Psychiatrica.
Turbo, over on May Shrink or Fade--- I forgot he existed, but he's blogging about how he lost 25 pounds doing air squats and eating beans, if you're interested.


Newer on the list:
Moviedoc blogs over on Behavenet and has an impressive list of stuff there.

Steve B. blogs on Thought Broadcast, definitely worth visiting.
Shrink Unwrapped, used to be the Oracle at D--she's now releasing her name and photo.
Danny Carlat blogs on the Carlat Psychiatry Blog

The Alienist (I'm not so sure about this handle, feels too ET-ish)
1boringoldman is a retired psychiatrist in Georgia who writes about his "political ravings."
David Allen blogs over on the Dysfunctional Family blog---or something like that. Good stuff, check it out.
There's kiddy stuff on Child In Mind
The Sports Psychiatrist-- self-explanatory, I think
Dr. Shock is a Dutch psychiatrist who is rather stimulating.
Dr. Steven Reinbord also has a shrinky blog.
Sizing Up the Shrink is the new kid on the block and we welcome him!
Dr. Psychobabble is another resident in training.


Let me give a plug to some local Maryland shrinks with blogs, folks we know:
Gordon Livingston is a psychiatrist and author who blogs on Psychology Today on Lifelines: Do check out his writing.
Roger Lewin is a psychiatrist, poet, and author.
Dean McKinnon is another Psychology Today blogger and author of  Trouble in Mind.
Meg Chisolm just started a blog on social media and medical education.


How'd I'd do?  If I missed you or someone you love, please let me know and I will update this post.
Podcast Number 60 went up yesterday.
Please vote on our sidebar poll.  Please just pick an identity and don't lose any sleep over it.
 

Thursday, July 14, 2011

Podcast #60: On the Verge


Please take our sidebar poll and tell us who you are.
  If you don't know who you are, please guess.  
In Podcast Number 60, we discuss the following:

Questions from readers--

  • Sarebear asks: What is a Nervous Breakdown?
  • Mary and Max, an award-winning claymation movie about an 8-yo girl and a middle-aged man with Asperger's. Very educational about Asperger's, and extremely entertaining.
  • Another reader asks: How are psychiatrists prepared to manage psychiatric disorders in patients with autism?
  • The New York Time review of a movie, Beautiful Boy, which led us in to a discussion of guilt and blame and our desire as human beings to believe we have control over what happens to us.  Too bad none of us saw the movie.
  • Finally, we talk (or perhaps "ramble" is a better word) about the psychology of podcasting.
Thank you for joining us!


****************************

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com


Thank you for listening.
Send your questions and comments to: mythreeshrinksATgmailDOTcom, or comment on this post

To review our podcast, please go to iTunes.
To review our book, please go to Amazon.

Tuesday, July 12, 2011

Psychotherapy and Psychiatry: Keeping it Alive


This is part of a simultaneous 3 site post.



On Shrink Rap Today over on the Psychology Today website, I talk about how high-volume, rapid-care psychiatry shows us at our absolute worst, and I report on survey results about how psychiatrists in Maryland are practicing--- please be forewarned, this was from an emailed poll and the data was not validated or verified, but it is interesting! 



On Shrink Rap News over on the Clinical Psychiatry News website, I make a case for why psychiatry residents should be required to learn how to do psychotherapy even if they don't plan to practice it when they finish training.  


We really don't even have a precise definition of what "psychotherapy" is, and CPT coding has defined it in terms of time spent in a session and reimbursements.  A 50-minute session gets coded as 90807 which stands for "45-50 minute psychotherapy session with medication management on an outpatient basis in a physician's office."   The frequency doesn't matter, nor does the content of what transpires-- at least not for the CPT codes.  But certainly, not everyone who comes for a 50 minute sessions is actually in a formal insight-oriented psychotherapy.  Good care involves listening to the patient before making decisions about medications, and seeing 4 patients an hour, lined up on a conveyor belt, hour after hour, regardless of the patient's need to talk or the complexity of the case-- is no way practice psychiatry (and I personally wouldn't have the stamina).  Those who do it have bought in to an insurer's idea of how the world should work.    In fact, very few psychiatrists in Maryland reported that they practice this way, even if the media would have you believe that this is the norm in psychiatry.


I like to think of psychotherapy as a process over time where the talking itself is part of what heals.  Certainly there is something about talking openly about things which may be troubling, embarrassing, or leave one feeling vulnerable, which is helpful, particularly in a setting deemed to be safe and free from negative judgment.  From the psychiatrist's point of view, psychotherapy is about looking for patterns in thoughts, feelings, behaviors, or reactions, and bringing these patterns to the patient's awareness in a way that may allow him to change.  

Obviously, I think psychotherapy is important to psychiatry.  
Please do check out the other posts on Shrink Rap News and Shrink Rap Today.

You are invited  to comment on any, or all, of the websites.  
While you're here, please take our sidebar poll ----->
And  please do let us know if you have an active psychiatry blog or know of any for our list.


Thank you for participating in today's 3-ring psychotherapy post!

Monday, July 11, 2011

Shrinky Blogs? And Please Take Our Sidebar Poll

Who reads Shrink Rap?  We have a vague idea (we think) who comments.  But who reads it?

We took a survey years ago [Roy: 2007], I thought we should repeat it.
Please choose a single identity--whichever best describes you.

Also, I'd like to put together a list of current psychiatry blogs.  If you're a psychiatrist with a Blog, please leave us your URL in the comment section and please please give a few-word description of your blog and how long you've been posting for.

If you're not a shrink, but you know of other Shrink Blogs, please let us know that as well.
I'm only interested in active, ongoing blogs. 
Thank you!

Self-Disclosure: To Patients Versus To the World

Dr. Maureen Goldman talks about self-disclosure for psychiatrists and brings the topic up in the context of Marsha Linehan's recent announcement that she was treated for a psychiatric disorder as a teenager.

In Clinical Psychiatry News, Dr. Goldman notes:
Psychiatric care and psychotherapy are different from the Alcoholics Anonymous fellowship, where the mutual sharing of personal experience is an integral part of helping people maintain sobriety. I believe that there is middle ground between disclosing personal information and presenting myself as a blank slate. In my practice, I show myself to be a real person. I make mistakes and admit them. I joke about my poor bookkeeping skills and inferior technological skills. I look things up during sessions if necessary, and I tell patients when I need to do research or consult with a colleague. I treat them as real people, too, not just as patients. 

I do not, however, share my own story. Mostly, I think that I can help people feel heard, understood, and known, and create a therapeutic plan without personal disclosure. I communicate that "I get it" without being clear that "I really get it." 

I cannot speculate about the motivation behind Dr. Linehan’s decision to allow her mental health history to be chronicled in the New York Times. The story was a very public disclosure, and in that way quite different from a disclosure made in the context of a one-on-one, doctor-patient therapeutic relationship. 

We've talked in detail about self-disclosure before, and specifically about whether psychiatrists should tell their patients if they've suffered from a psychiatric disorder.  See our post on Self Disclosure and Being Genuine.

I thought it was interesting that Dr. Goldman used this particular example to discuss why psychiatrists should not self-disclose.  Mostly, I thought it was interesting because I disagree-- otherwise this would not have made it to a Shrink Rap post.

In the course of a patient's treatment, the decision to disclose information is a personal one and it needs to be made in the context of what is best for the patient.  With the exception of inevitable life events on the part of the psychiatrist (I'm sorry, I won't be here next week because I'll be delivering twins and I may be out for a while taking care of them....) the patient's interest is always what matters.  I agree that if the doctor is not sure how the patient will receive information, it is safest not to disclose personal information.

The dynamic that goes on is a complicated and unpredictable one.  The patient may feel burdened by any adversity in the doctor's life.   They may feel disappointed that their doctor is flawed.  They may feel special, in a good way or bad, that their psychiatrist let them in on secrets.  Or they may simply feel that it's nice to share a world with someone who has been in a similar circumstance.  The issue remains one to be handled between the individual psychiatrist and the individual patient and what is in their best interest.

The dynamic that goes on between the psychiatrist and the world is a different story.  It's not about what's best for the patient, it's about the doctor and their right to freedom of speech and self expression.  The problem with saying that Dr. Linehan should not have made such an announcement is that it's too much burden to place on psychiatrists to say they must live their lives in ways that won't upset their patients.  Is it okay to be seen in public entering a synagogue, church, or mosque?  To have a political bumper sticker or sign on one's house (I would contend that it's problematic to have political material in the office)?  To wear a Yankees hat?  To have tattoos? To post ducks on a blog?  To participate in an undignified hobby?  To be gay?  Certainly, patients have feelings about all these things and may have negative feelings which interfere with their treatment.  But psychiatrists are people and they have the right to inhabit the world in a way that is comfortable, just as patients have the right to find another psychiatrist.

Personally, I thought Dr. Linehan's statement took courage and I thought it was a wonderful proclamation of hope for those who struggle with chaotic feelings and behaviors as teenagers.  They don't all drop off the face of the map---some recoup to live full and productive lives and contribute a great deal to society.  I didn't see a problem with this announcement and I applaud her for coming forward.

Sunday, July 10, 2011

No Better Than a Sugar Pill?


We're only a few minutes in to "today" but here's a link to an article in the New York Times by Peter Kramer-- In Defense of Antidepressants.  Kramer writes:


Could this be true? Could drugs that are ingested by one in 10 Americans each year, drugs that have changed the way that mental illness is treated, really be a hoax, a mistake or a concept gone wrong?
This supposition is worrisome. Antidepressants work — ordinarily well, on a par with other medications doctors prescribe. Yes, certain researchers have questioned their efficacy in particular areas — sometimes, I believe, on the basis of shaky data. And yet, the notion that they aren’t effective in general is influencing treatment. 

Kramer goes on to discuss issues in the research that may have biased studies that deem anti-depressants to be no better than placebo.  Do read it if you get the chance.

Saturday, July 09, 2011

Guest Blogger Jesse: Philosophy Follows Funding


The “Chapter that Wasn’t Written” in Shrink Rap should have been on the changes in psychiatry due to insurers. Recent posts have underlined the effect of pharmaceutical companies and the ways in which they have distorted data and biased the attempts to have an evidence-based practice. While these comments have a lot of validity, I think the  influence of Big Pharma on the field has been exaggerated. There is another culprit which has had a more pernicious and less easy to combat effect on psychiatry.

When insurance companies started to severely limit psychotherapy and reduced reimbursements drastically, the entire field of psychiatry changed. They made practicing purely a med management model much more profitable than talking to patients. Worse, they created an atmosphere in which a doctor who saw his patients frequently was considered to be doing something unnecessary. Just a short time ago there was no need in Maryland to explain to one of the “reviewers of medical necessity” even twice-a-week psychotherapy. Such treatment rapidly became impossible to get approved.

The training programs changed to reflect the economic reality. Psychiatric residents once had extensive training in psychotherapy. Many residents were in psychoanalysis. No more. Becoming expert on how the mind, as opposed to the brain, works has been abandoned to psychologists and social workers. As always, Philosophy Follows Funding.

Friday, July 08, 2011

Committed!

There's all this 'stuff' I need to work on, but when it comes down to it,  I'd rather post on Shrink Rap then do any of the writing I need to get done for real work.  Why is that?

One of our readers has commented that she's been involuntarily hospitalized for 'suicidal ideation,' presumably in the absence on a plan or any intention.  Why is that?  We hospitalize people involuntarily when we believe they may be dangerous, but the truth is, many people who feel depressed have suicidal thoughts, this is not at all uncommon, 'dark thoughts' are frequently mentioned during treatment, and the truth is that if we hospitalized every patient who thinks about suicide, umm...there would be no where to put them and no one to pay for it.  Insurers put a huge amount of pressure on hospitals to keep people out and get people out.  I remember the ER patient who was suicidal with a plan to shoot himself.  The ER shrink called the insurance company to authorize the admission (it may have been voluntary) and the insurance company wanted to know if the gun was actually loaded! 

It got me thinking, how does a patient get involuntarily hospitalized for thoughts, with no intention to act on them?  I came up with a few ideas:

  • The psychiatrist doesn't believe that the patient has no intention of acting on them.  Why would that be?  Somethings that might lead a psychiatrist to question a patient's word: A past history of a serious suicide attempt, especially a recent one.  A friend or relative in the docs face saying they are lying.  Another source of information that would indicate a lack of clarity about intent: a Facebook post saying "Goodbye, cruel world" a text message, something that makes the doc anxious.  Indications that there is a plan: the patient has been giving away valuable possessions, has written a note, has mail ordered a noose. 
  • There is a mis-communication and the psychiatrist thinks the patient is having more active suicidal plans then the patient is actually having.  This might be sorted out if more time is spent evaluating the patient or discussing options with the patient, but there are all sorts of other issues which may be playing out unrelated to the patient: the psych ER has 8 people waiting to be seen and there are too many things happening for the psychiatrist/ER staff to give them each enough attention.
  • There are other risk factors which leave the psychiatrist feeling worried: substance abuse, for example, a history of repeated ER visits, a history of violence.
  • The patient has a severe mood disorder and there is concern that the patient won't follow up with out-patient care and the psychiatrist makes a paternalistic decision that it would be in the patient's best interest to get intensive, aggressive treatment in the hospital.  
  • The psychiatrist has his or her reasons for being predisposed to being overly cautious:  a patient is thinking of shooting up a school with no intent, but there was a high profile case similar to that all over the news yesterday.
  • The psychiatrist has his own baggage: a lawsuit for a suicide has left him feeling it's best to 'play it safe and admit for observation,'-- the patient looks like his mother who died of suicide, another patient who swore they had no intent then suicided outside the ER door.  All sorts of factors influence how a shrink thinks.
  • A family member says, "He needs to be in the hospital, if you don't admit him and he kills himself, I'll sue your ass off."
  • The patient refuses to commit to a safety plan.
  • The psychiatrist is evil and loves power.  (I had to throw that in here)
This is our 1,500th post.  Thank you for helping me procrastinate.

Thursday, July 07, 2011

Last Chance for Your Input On Personality Disorders

DSM-5 Revisions for Personality Disorders Reflect Major Change
Public Comment Period for Proposed Diagnostic Criteria Extended Through July 15
 
ARLINGTON, Va. (July 7, 2011) – The American Psychiatric Association’s diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) propose a significant reformulation in how personality disorders are identified and assessed. The change integrates disorder types with pathological personality traits and, most importantly, levels of impairment in what is known as “personality functioning.” 
 
With its multidimensional framework, this hybrid model is very different from the way personality disorders are presented as rigid behavioral categories in the current manual. The goal of the new criteria is to maximize their utility to clinicians and benefit to patients.
 
DSM is the standard classification used by mental health and other health professionals for diagnostic and research purposes. The manual’s next edition, representing the latest scientific understanding of the etiology, characteristics and relationships of mental disorders, will be published in 2013. Release of DSM-5 will culminate more than a decade of rigorous work involving hundreds of experts from the United States and abroad.
 
The new draft criteria for personality disorders are currently being evaluated through field trials in real-world clinical settings across the country. Public comment also is invited on the proposed revisions to these and other diagnostic criteria. Submissions will now be accepted through July 15. All criteria are available for review on www.dsm5.org.
 
As recommended by the DSM-5 Personality and Personality Disorders Work Group, 10 categories will be reduced to six specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal). But for a diagnosis within these descriptive classifications, several conditions must be met.
 
Critically, a person must have significant impairment in the two areas of personality functioning – self and interpersonal. Self is defined as how patients view themselves as well as how they identify and pursue goals in life. Interpersonal is defined as whether an individual is able to understand other people’s perspectives and form close relationships. The scale by which these will be judged ranges from mild to extreme.
 
In addition, the work group determined that pathological personality traits must be present in at least one of five broad areas – such as whether a person is antagonistic versus able to get along with others, or impulsive versus able to think through possible consequences of action.
“The importance of personality functioning and personality traits is the major innovation here,” said Andrew Skodol, M.D., the work group’s chair and a research professor of psychiatry at the University of Arizona College of Medicine. “In the past, we viewed personality disorders as binary. You either had one or you didn’t. But we now understand that personality pathology is a matter of degree.”
 
Noted Robert Krueger, Ph.D., a member of the work group and a professor of psychology at the University of Minnesota, “Our proposed criteria get away from the idea that personality pathology is just a group of disorders. We’re instead defining it as a much broader characteristic.”
 
Underlying the work group’s recommendations are longitudinal studies and other clinical research since the early 1990s that have revealed the shortcomings of the current behavior-based criteria. Because behavior can be intermittent and changeable over time, the criteria can hinder an accurate diagnosis and even impede treatment.
 
By contrast, impairments in personality functioning and pathological personality traits tend to be more stable over time and consistent regardless of the situation. Both stability and consistency would be required under the revisions to the diagnostic criteria.
 
Over the next year, the DSM-5 Task Force and its work groups will continue refining the categories and specifics of all disorders to be included in the next edition. The current public comment period will play into their deliberations. As with the first public review last year, when the APA received more than 8,000 written responses from clinicians, researchers and family and patient advocates, every comment will be considered. As of mid-June, nearly 1,800 additional responses had been submitted.
 
In the meantime, the first round of field trials continues at nearly a dozen larger academic and clinical centers; almost 3,900 mental health professionals in individual practice and smaller settings also will participate before the trials conclude. Another public comment period on the criteria will then follow.
 
The DSM-5 diagnostic criteria will be determined by 2012 and submitted to the APA’s Board of Trustees for review and approval.
 
The American Psychiatric Association is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psych.org and www.healthyminds.org

Goings On About Town



For today's blog post, I'm going to send you over to Thought Broadcast to read Steve's discussion on
I Just Don't Know What to Believe Anymore. 

Two new blogs I thought I'd put in a plug for:

Shrink2B is writing about his residency training experience (now on day #6) over at 
Sizing Up the Shrink.


There's a patient blog worth looking at over on
Lithium and Lamictal.


Tuesday, July 05, 2011

In Electronic Health Information, Who Decides Which Info is "Sensitive"?


I participate in a committee that establishes policies for our state's health information exchange (HIE). The HIE is the electronic infrastructure that permits hospitals, physician groups, labs, imaging companies, pharmacies, and others to share information about patients. The idea behind the sharing is to make it easier for your primary care doctor to share your health data (ideally, with your permission) with your cardiologist and your dermatologist. The potential benefits to this sharing include:
  • quicker exchange of information than with faxing or mailing
  • less likely for papers to get misfiled or lost (eg, think Hurricane Katrina)
  • better tracking of who accessed what information
  • less duplication of tests ("I know you had a CAT scan at the other hospital last week but I can't wait for the results to be sent to me so I'm getting another one.")
  • improved coordination of care
  • fewer medical errors due to more information available
  • decreased liability due to sharing of important information with other providers
The potential risks include:
  • decreased privacy due to potential for data breach, identity theft
  • loss of data due to technical problems (viruses, hardware failure, etc)
  • failure to secure data due to inadequate authentication, authorization, encryption, etc
  • more errors in health record due to automated data collection processes
  • increased liability due to sharing of sensitive information with other providers
I wanted to talk briefly about this notion of "sensitive health information." Our committee has spent many hours discussing what this might mean and how to define it. One view is that all health information should be treated as "sensitive," while another is that only certain categories of health information, such as mental illness, substance abuse, HIV status, domestic violence, abortion history, and genetic data, should be treated with additional safeguards against inadvertent access or disclosure. This latter viewpoint promotes the stigma about mental illness that we have been trying to erase.  It wasn't so long ago that epilepsy and cancer might have been on this list. My viewpoint is that patients should be the one to decide which elements of their health information should be treated with extra precautions and which should be considered routine.

This was ultimately agreed upon by the other committee members, but it still didn't help us much because the technology for patients to review their health information and mark which bits should be tagged as sensitive is not yet built into nearly any of the electronic health record products or the HIE systems. There is no standard for doing so nor is there even any agreement about how or whether it should be done. Groups like healthdatarights.org and speakflower.org have promoted these ideals, but we are not much closer to achieving them.

Anyway, I discussed this topic in my Shrink Rap News blog post this week over on Clinical Psychiatry News. Read more about it over there. If you are a psychiatrist, log in or register on CPN and join the discussion (my mistake -- other professionals and also consumers are allowed to register over there).

Does Ed Want his Personal Health Information on A Centralized Network

What do you think?  I can't tell what Ed wants. 

-- You have to admit, though, Roy has one cute pooch.

Monday, July 04, 2011

Podcast 59: A Brief Chat


This is the first My Three Shrinks podcast since the publication of our book, Shrink Rap: Three Psychiatrists Explain Their Work.   We had a little production glitch and the podcast is a bit slow for the first two minutes, and it's a bit shorter than our usual.

  • We talk about the process of writing the book and the issues that physicians fact when writing about their patients and whether this is different for psychiatrists versus other physicians.  Clink talks about her post Doctors Who Write and discuss the dilemma doctors face when writing about their patients.
  • We talked about how we chose names for our characters in the vignettes.
  • Roy talked about AADPRT (he likes acronyms) which obviously stands for American Association of Directors of Psychiatric Training and their link on how to use social media.  Roy notes that he is growing old (the rest of us aren't) because he began a Schizophrenia researcher Listserv twenty years ago on Gopher.
  • In the next podcast, we answer reader questions: Sarebear wants to know what a "nervous breakdown" is and we respond to a question about how it may be harder to make psychiatric diagnoses in people with co-existing autism. But we didn't talk about those things in this podcast. 

****************************

This podcast is available on iTunes or as an RSS feed or Feedburner feed. You can
also listen to or download the mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening. Send your questions and comments to: mythreeshrinks@gmail.com.


We invite you to review our podcast on iTunes and to review our book on Amazon.

Thank you for listening.

Why Isn't There an Anti-Oncology Movement?

Happy Fourth of July to all of our readers!


We will be posting a podcast later today--we kept this one short and sweet at just over 15 minutes.


We've talked quite a bit here about Anti-Psychiatry sentiment, and I keep wondering why psychiatry alone gets such controversy.  Oh, I think people are frustrated with other areas of medicine, and doctor bashing has become a popular past time, but I'm not aware that any other sub-specialty has an organized "anti" movement.  


Here's why I think that oncology might be a good candidate:


Like psychiatry, the treatments are not guaranteed: they may work, they may not.  

The treatments have horrible side effects: vomiting, hair loss, nerve damage, chemo brain, organ damage, cardiotoxicity, loss of body parts from surgery, infertility, and the list goes on.


They are never given involuntarily, you say, but I assure you there are patients who are cajoled and guilted into some pretty toxic treatments even when their chances of meaningful recovery may be quite low.  And a patient in a hospital who tries to refuse care and check out may well end up having a psychiatry consult called to assess their competence to make decisions.

Treatment is extremely expensive.   If you thought Abilify costs a lot, try Avastin at $88,000 a year, or Provenge which prolongs life by an average of 4 months and costs $93,000.


My best guess?  I think we're so conditioned to think of Cancer as deadly and terrifying that those who survive the illness and the treatment are 'programmed' to believe they must be thankful, and those who don't are too dead to complain.  Leslie will tell us it's because there is no formalized mechanism for involuntary treatment, and Rob will tell us that it's because there are known pathological mechanisms which dictate that cancer is real.  Is that totally true?  Don't we think that there are people who have early-stage breast and prostate cancers that likely won't progress to fatal diseases who are still subjected to disfiguring and toxic treatments in a mass sweep to decrease mortality rates?


Oh, my, not a very holiday-esque post!  And I don't have it in for the oncologists at all, I was just wondering. 










 

Sunday, July 03, 2011

Beards & Bow Ties




I stole this from Dr. Shock. It was written, directed, and narrated by Kamran Ahmed (no, not the Bollywood star -- the UK psychiatrist).
Seems like as good a time as any to turn on comment moderation.  Pretend you're in our living room.


And do join Clink in a discussion of tonight's CNN piece on St. Elizabeth's Hospital and the insanity defense.

Voices From Within



Tonight CNN will be airing a documentary shot inside the old St. Elizabeth's Hospital, made by patients, about insanity acquittees. This is a very rare opportunity to see the realities of daily life for those found insane and learn more about the insanity defense. For more see the CNN story here.

Saturday, July 02, 2011

Is it Time for Comment Moderation? Please Vote on Our Sidebar Poll

One complaint about psychiatry is that psychiatrists won't entertain ideas that counter what 'established' psychiatry believes.  We actually don't think that's true--psychiatry has made a lot of changes.  At Shrink Rap, we pride ourselves on taking all comers and letting people rant about whatever they want (no obscenities, please).  For years, we've put up posts and people have come on to tell us about their experiences, both good and bad.  Lately, we've had a lot of contention in our comments, and some repetitive links to sites that counter what we feel is good medicine.  We haven't removed them-- it's not that we oppose the idea that there are people out there who think our treatments aren't helpful, and we certainly believe that they aren't helpful to everyone-- but at times, the comments are incessant, repetitive, angry, mean, it feels like we're being harassed, and that we're being used as a site to place advertisements to other blogs/information which we feel are incorrect, and I worry that these anti-psych messages may insult our readers who a) practice psychiatry, b) feel helped by psychiatry, or c) feel frustrated with psychiatry but have found Shrink Rap to be a somewhere they can respectfully vent.  While I don't want to shut down dialogue, this is a Psychiatry blog, and those who don't like us are welcome to start their own blogs!  Funny, some of our ardent 'haters' (I use that term kind of affectionately) don't have blogs, don't have sites that allow comments, or moderate their comments, all while accusing us of being closed minded.


Should we begin to moderate our comments?  
Oy, one more thing on the "To Do List." 
One more thing for the 'haters' to kvetch at us about.  We would continue to allow opposing views, but we would moderate out obscenities, pure hostility without a clear message, rudeness to us or other commenters, repetition, and comments that are placed merely to direct readers to other websites with the idea that those hold "The Truth" while our views are simply "wrong."


What do you think?  We'd love to hear your comments and please do vote on the sidebar poll, and only vote once.  We'd love to hear your comments even if you think psychiatry might be helpful to some people!


Someone suggested putting pro-psychiatry comments (and a plug for the Shrink Rap book!) on these other websites.  I've surfed over to some of them--- and you know, it is amazing to me how much more vocal people who don't like medications are, it's almost like it's not socially cool to say "meds helped me."


Your comments are welcome, and if you'd like to put Shrink Rap plugs on other sites, go for it!

Guest Blogger Dr. Andrew Angelino on AIDS, Russia, and Collaboration in Medicine

Every month, the president of our state psychiatric society writes a column for the newsletter.  This month, I read it and thought the column, directed only at psychiatrists, would make a good Shrink Rap post.  Dr. Angelino has graciously allowed us to reprint his article:



“I’d like to talk to you about this patient….”
Some presidents follow a format for these columns.  I have nothing against formats except that I hate them for their…well, “formatness.”  The way I see it, I get to write to you all about 10 times this year and they’ll print what I write pretty much for free and without question, as long as I make some degree of sense and don’t embarrass myself or the profession too much.  So, what I’m really trying to say here is, I hope you enjoy what I have to say. I hope it makes you think a little, and more importantly, I hope it makes you want to talk to another psychiatrist a little, because that’s my goal as your president – to get you involved in the conversation.
I just got back from Russia.  I spend about a week or two a year teaching AIDS Psychiatry in various cities in Russia.  Nowhere glamorous.  Usually, I get to go deep into Siberia in the middle of winter and freeze off body parts.  Although, there is something to be said for opening a conversation with “The last time I was in a Siberian prison….” 
AIDS Psychiatry is an interesting little niche.  Basically, I see patients with HIV infection who have mental health problems.  For the most part, people think that the role of the psychiatrist in this area is mostly dealing with grief or other adjustment issues – basically talking to folks about their concerns over having a life-threatening infection.  Slightly more sophisticated, some recognize that the action of HIV in the brain causes mental problems – dementia and major depression are examples.  But what many don’t think about is that HIV infection is an outcome of mental illness.  That the reason we have such a high concentration of individuals with mental illnesses in HIV clinics is that their mental illnesses render them vulnerable to behaviors that lead to outcomes like HIV, hepatitis, imprisonment, homelessness and other disenfranchisements.  And once they’re infected with HIV, we have complex mentally ill patients that now have to try to manage a life threatening infection along with their mental illnesses.  Basically, that’s my job: help the most vulnerable manage an incredibly difficult task, for the rest of their lives.
Now I’m not telling you this to toot my own horn.  I’m telling you because I learned, from a whole lot of firsthand experience, that all this integrated healthcare, medical home, accountable care mumbo-jumbo really works.
In my clinic, the psychiatrists work in rooms next to the medical doctors.  Today in clinic, I spoke to Mark Sulkowski, infectious diseases doc specializing in HIV-hepatitis C coinfection.  We have several patients together.  I know I can knock on his door anytime he’s not with a patient to discuss a patient or the latest new drug for hepatitis C (we have two new protease inhibitors that will likely increase cure rates).  We also have social workers and pharmacists and case managers and primary care docs and OB/GYNs and dermatologists and ophthalmologists and neurologists.  And we all write in the same charts and manage the same patients together.
In Russia, no such system exists.   Last week, we were discussing the tricky problem of managing patients with HIV infection, active tuberculosis, and active injection drug use.  The biggest problem is there is no system.  TB is treated in the TB clinic, HIV in the HIV clinic, and drugs in the “narcology” clinic (which is independent of both psychiatry and general medicine).  And nobody talks to anybody else.  The Russians are fascinated by the stories of how my clinic, and other HIV clinics in the US with some of the same services, manage complex patient issues.  They are in awe of the resources we can bring to bear to overcome a problem like adherence to medications.  And they are also in awe of our commitment to the public health that permits us to take a stand like mandatory TB treatment using directly observed therapy.
At the MPS annual meeting, I made a short speech.  I said I wasn’t going to stand up to say we have a broken health care system because I didn’t believe it, and I still don’t.  I think we have great health care in the US – it’s just not universally very focused.  We’ve let freedom to choose (a really good thing) gum up a system that can, and sometimes does, work wonders. 
And our profession has taken that a step farther.   We’ve lost ourselves a little in psychiatry and forgotten what makes us most useful to our medical family – our ability to influence attitudes and behavior.  We’ve occasionally let our patients excuse behaviors with mental symptoms and allowed them to fail because we sometimes overvalue their free will to choose to ruin themselves. 
We face issues in the approaching health care “reform.”  The same kinds of issues Russia is facing.  Do we remain in silos and let patients fail because they don’t integrate for us, or do we step into each other’s spaces and learn to co-manage difficult cases?  Do we let payors divide us and limit our work together, or do we strive to demonstrate how effectiveness in one compartment can have benefits in another, thus balancing out for the “whole patient?”  Do we become so specialized in our area that others with no medical training threaten to replace us because they are willing to work cheaper, or do we demonstrate the enhancement medical training has on our ability to integrate with our medical colleagues?
Every time we pick up the phone to talk to the patient’s primary care physician, we integrate health care a little more.  Every time we fax over a note, or send a short (encrypted) email, we integrate a little more.  Shared access to an electronic medical record between Emergency Department doc and psychiatrist?  You bet that’s integration.  And you’re already doing it all the time, I know.  So this “reform” should be a breeze, right?    I guess that’s why I can spend some of my time working on the Russian problem.