Monday, October 29, 2012

What I Learned Part 4

This is a belated post about the AAPL conference, since yesterday was devoted to finding my way home around Sandy. It's rainy heavily here and the wind is starting to pick up a bit. Dinah's at home waiting for a tree to fall on her house but there's no word from Roy. I'm hoping all our readers are home safe and prepared.

The last day of the conference was worth waiting for. I regularly attend the presentations given by the Computers in Psychiatry committee, and this year was no exception. Two presenters had to leave early due to the storm, but the remaining members talked about how to do Google power searches (using conjunctive and disjunctive search terms and site-specific searches) and other non-Google search engines (there's something other than Bing?). There was also a presentation about a wide variety of health care related smart phone apps. As yet, the FDA does not regulate these as medical devices and there is no standard method for assessing accuracy, efficacy or reliability. For those docs "prescribing" or recommending apps, there was discussion about whether or not the use of apps is becoming a standard of care for medicine and at what point there may be liability for their use---not following up on an app "flag" for instance. I was pleasantly surprised to see that one of the first psychiatry apps mentioned was "What's My M3?", a project that Roy has been affiliated with. (Maybe Roy might want to right a post about the standard of care and liability issues I mentioned? I'm sure this has been discussed and I'm curious.)

The last session of the day was about assessment of stalkers. I learned that three-fourths of more than 400 Canadian politicians had experienced an overt threat. When assessing risk, the assessment considers both the stalker and the situation. The three main considerations are level of persistence, risk of injury to the target and the potential for recurrence if the stalking has stopped or interrupted. The most persistent stalkers are those with psychotic illnesses, specifically delusions. Grandiose or erotomanic stalkers are less likely to present a risk of danger since they are seeking intimate contact rather than violent contact. People with paranoid delusions who are also angry are more likely to present a risk of violence. There's a lot more to these assessments, but those were the highlights that I took away.

That was the last session of the conference. I confirmed my flight as I left the hotel, but by the time I got to the airport checkin desk it was cancelled. Such is the risk of the AAPL conference. Last year at this time in Boston we were facing an impending snowstorm.

If you're in need of more conference fixes, I'd recommend the Child Sexual Abuse Conference (hashtag #CSAC12 on Twitter) which is live-streaming some talks.

Saturday, October 27, 2012

What I Learned Part 3

Oh my...I still have one more day to go at the conference and my brain is already full.

The award for Weird Presentation of the Week (and that's saying a lot at a forensic conference!) goes to the poster on zoophilic interests in cases of Asperger's syndrome. I'll say no more about that. Just make sure you know who's petting your dog.

Another poster was an interesting case presentation about sleep apnea and anger and hostility. Apparently treatment with continuous positive airway pressure therapy has lead to significant improvement in irritability for sleep apnea sufferers. You might want to read a little bit about previous research on this here.

I enjoyed a panel discussion about ethical issues in forensic evaluations, particularly as it related to interviews of collateral informants. Although non-confidentiality warnings are routinely given, there is still the possibility that an informant may volunteer self-incriminating information or information that falls under a mandatory reporting duty.

Unfortunately, our luncheon speaker was held up in Tennessee and couldn't make his talk. I was looking forward to listening to Jon Ronson, author of The Psychopath Test. Instead we heard a talk by Dr. Phil Resnick about the relationship between paranoid delusions and violence. In addition to hearing a number of good anecdotes, we learned that delusions are more highly correlated with violence than command hallucinations.

The best session of the day was a panel presentation about false confessions. This has always been an interest of mine, but I've rarely had the opportunity to hear the people who have done the original research. I learned a lot about the Reid technique, including which techniques are commonly used and how the techniques are varied depending upon the presence of mental illness. I learned that of people exonerated by DNA, 16% had given detailed confessions. Overall, 80% of defendants waive their Miranda rights. In Canada, interrogations don't have to end when a defendant asks for a lawyer or when he claims his right to avoid self-incrimination. One panelist presented the results of a survey of 332 Baltimore County police officers regarding their understanding of juvenile development and their use of interrogation techniques. The survey showed that even though they understood the developmental differences between juveniles and adults, their actual interrogation practices were no different.

I listened to a presentation about the new diagnostic criteria for antisocial personality disorder coming out in DSM-5. In a word: ugh. Don't ask me how people are going to interpret the "self-identity" and "self-direction" criteria. The requirement for childhood conduct disorder will be dropped. I'm predicting even greater diagnostic discrepancies than what we have now.

Finally, a group from West Virginia presented some background information about an ongoing survey project regarding the use of social media in forensic evaluations. There wasn't a lot of data available yet because many of the forensic fellows had not received the survey (it was sent to all program directors and their students). Social media use by forensic psychiatrists was not directly correlated to age. Both early and late career forensic psychiatrists used it. There was a good overview of how social media content could be used in both civil and criminal cases. During the question session I added a comment about social media use in medical education as well.

Tomorrow is the last day, then I make my way back through the storm (or hopefully, ahead of the storm). Wish me luck.

Friday, October 26, 2012

What I Learned Part 2

Oh my, it's hard to keep my mind on professional things when I see a hurricane headed toward my home. The airline says they're not expecting it to affect my flight back, but I'll believe that when I see it.

But on to the conference...

The poster session was notable for a nice outcome study done in Georgia about the efficacy and cost impact of a jail-based competency restoration program. Another poster about assisted outpatient treatment in New York showed that there was considerable variation in willingness to seek outpatient commitment, possibly related to available outpatient services. There was a presentation about the use of restraints in pregnant psychiatric patients which was interesting. There was a national survey of mental health program directors which showed that up to 80% of responding systems had no established policy about this.

There was a panel presentation about the AAPL guidelines for sanity evaluations, which are being updated. Members were given the opportunity to comment upon the current guidelines and any issues that needed to be revised.

I was pleased to see ethics featured prominently at this conference, including a very informative panel presentation about the process by which AAPL and APA manage ethical complaints and the difficulties writing and enforcing professional guidelines. I learned that about 10 to 15% of ethical complaints to APA district branches are related to forensic issues.

The luncheon speaker was David Kaczynski, brother to the infamous Unabomber Theodore Kaczynski. He gave a very moving talk about his early life with his older brother, Kaczynski's gradual withdrawal from his family and society in general, and the slowly growing realization that his older brother was indeed a killer. He talked about his struggle to come to terms with his suspicions, the impact on his elderly mother and what it felt like to be caught between preventing future murders and potentially sending his brother to a death sentence. He talked about his work after the trial, reconciling with some of the victim's families. My most memorable quote: "Teddy's bombs destroyed lives, but healing is possible."

The early afternoon session was a smorgasboard of random topics. There was a survey of judges regarding their willingness to allow defendants to represent themselves at court (pro se defenses). Judge weight heavily the defendant's ability to understand the risk of a pro se defense and the defendant's willingness to accept standby counselor. Psychiatric input is considered, but mainly as it related to a description of symptoms and impairment rather than the ultimate opinion of competence. There was a description of a telepsychiatry program used in the New York prison system, where fourteen facilities used teleconferencing to provide over 12,000 patient contacts in one year.

Finally, the secondary them of this conference appears to be the use of psychological tests by psychiatrists. The last session of the day was entitled "Psychology vs Psychiatry in Risk Assessment". The panel presented individual cases and general principles related to the use of violence prediction instruments and how they are currently used in forensic work. The limitations of these instruments were also discussed, which was interesting because this is not something that often gets discussed by those who use them (at least in my experience). One example of this was the use of a violence risk instrument for conditional release. Since the risk of dangerousness must be due to a mental illness, and since the instrument did not rely upon illness-based dangerousness, the instrument was not relevant to the legal question at issue.

So that was the day. You can follow my live tweets from the conference at:

Thursday, October 25, 2012

What I Learned Part 1

Those of you who have been reading the blog for a while know that every year I blog and live-tweet from the American Academy of Psychiatry and Law conference. This year we are hosted in Montreal, the land of fine dining and the most beautiful language in the world. Thus, the foodie picture. When I fly back I will be carrying extra baggage and I don't mean my luggage.

The poster session this morning was quite crowded and I wasn't able to get near most of them, but I did see a lot about legal and clinical implications of synthetic marijuana. Forty-one states have laws criminalizing sale and use of these new chemicals which go by a variety of street names. Effects on mental state can be extreme, including disorganized and violent behavior and hallucinations. So far there are no known longterm clinical effects associated with its use, however. Intoxication has been used in criminal defenses to mitigate culpability (although not generally successful as the basis for an insanity defense) and in states where the substances are still legal courts are struggling to figure out how it should play into a mental state defense.

Dr. Charles Scott gave an outstanding presidential address entitled "Believing Doesn't Make It So: Forensic Education and the Search for Truth." He discussed the evolving---and higher---expectations for forensic evidence, including psychiatric testimony, and how this should inform forensic training and practice.

The next session was a very nice (if I do say so myself) panel presentation about civil commitment of mentally ill offenders following release from prison. California has a mandatory civil commitment law which requires transfer of certain violent offenders with serious mental disorders to a psychiatric hospital at the end of incarceration. Legal challenges to this law were discussed and compared to the New Jersey system, which uses a non-mandatory administrative procedure instead. Finally, these procedures were compared to the state of Maryland where there is no established transfer policy but a wide degree of consultation and collaboration between the correctional and mental health systems, which in many cases obviates a need for hospital transfer.

[At this point in the day I stepped out for lunch and came back four courses later. Oh my, the food was amazing.]

The afternoon session was a very practical panel presentation about who should get access to forensic reports and the implications of HIPAA on evaluee access to protected health information in the report. Historically forensic reports were considered legal work products rather than medical documents, and as such an evaluee did not necessarily have a right to get a copy of or read the report. Under HIPAA some types of reports---such as a disability evaluation or fitness for duty evaluation---might be considered to be protected health information which an evaluee has a right to access. This is an evolving area, however. And under HIPAA, evaluees do not have a right to reports generated for civil, criminal or administrative hearings. This isn't a settled issue and there was good audience discussion.

The evening session was a mock trial which presented the new DSM 5 proposed criteria for hebephilia. The limitations and implications of the new criteria were discussed, which appeared to rely heavily upon an assessment of the victim's Tanner stage. The issue was presented in the context of a fictional sex offender civil commitment hearing, with three mock experts: one for the state, one for the defense, and one independent court-appointed expert. A strong case was made against inclusion when the defense expert testified that the new criteria could result in an 80 percent increase in false positive diagnoses.

So that was the first day. More to come so stay tuned. Live-tweets can be followed at: [For those concerned about speakers' informed consent for social media coverage, all presenters are advised at abstract submission that sessions are recorded and they know that sessions may be covered by the media.]

Wednesday, October 24, 2012

Guest Blogger Dr. Meg Chisolm on Systematic Psychiatric Evaluation

Over on our Clinical Psychiatric News blog, I've written a review of a new book, just published by Johns Hopkins University Press, Systematic Psychiatric Evaluation,  A Step-by-Step Guide in Applying The Perspectives of Psychiatry, by Margaret S. Chisolm, M.D. and Constantine G. Lyketsos, M.D., M.H.S.  Do check out my review over on CPN (it should be up later today), along with ClinkShrink's article on "Debunking The Mad Artistic Genius Myth" and Roy's piece on World Mental Health Day which lists some great resources. 

Dr. Chisolm was kind enough to write a Shrink guest post for us on her inspiration for writing the book, with just a little about French cooking.  Sorry no recipes here.  Meg writes:

I did my psychiatry residency training at Johns Hopkins University in the late 1980s, under department chair Paul McHugh and residency director Phillip Slavney.  These leaders also are the authors of the textbook The Perspectives of Psychiatry, whose principles informed the way I and a generation of Hopkins psychiatrists since have been trained.  The basic idea of The Perspectives is that by conducting an evaluation that considers a patient’s psychiatric presentation from each of four perspectives, the clinician can better understand the nature(s) and origin(s) of the patient’s problems, and develop a more comprehensive and personalized formulation and treatment.  (The four perspectives are: disease, dimensional, behavior, and life-story.) 

The most frequent question raised about the Perspectives model by trainees and clinicians unfamiliar with the approach is “How are the Perspectives any different from Engel’s biopsychosocial model?”  In response, McHugh and Slavney are fond of saying that the biopsychosocial model provides the ingredients (atoms to biosphere) for understanding patients with psychiatric illness, but the Perspectives provides the recipe.  I like this analogy (or is it a metaphor?) because, in addition to enjoying my work as a psychiatrist, I like to cook.  But, more about that later. 

As a Hopkins-trained psychiatrist, I had probably read The Perspectives of Psychiatry about five times, beginning with my stint as a medical student during my sub-internship at Hopkins.  Let me tell you, The Perspectives is a good, but hard read.  As a student, I don’t think I understood much of it.  Reading it again as a psychiatry intern, having seen many more patients with psychiatric conditions, it started to make some sense.  As a junior resident, I began to understand it a little better, which was a good thing since – by then – I was expected to be teaching the book to medical students.  By the time I was a chief resident teaching junior psychiatry residents how to apply the Perspectives approach to patients, I thought I had it down.  Well, I was wrong.  It wasn’t until I began writing a casebook companion to The Perspectives of Psychiatry that I finally figured it out.  So, if the biopsychosocial method provides the ingredients and The Perspectives of Psychiatry the recipe, that’s one highfalutin’ cookbook!  And that’s where our new book Systematic Psychiatric Evaluation: A Step-by-Guide to Applying ‘The Perspectives of Psychiatry’ (Chisolm & Lyketsos) comes in.

So, back to French cooking.  If any of you are into cooking, reading cookbooks, or just watching the Food Network, you may have heard of Auguste Escoffier’s 1903 Guide Culinaire.  Escoffier wrote his book for professionally trained and experienced European chefs (working in restaurants, hotels, ocean liners, private estates, etc).  Escoffier’s book outlined recipes and discussed methods of professional food preparation and kitchen management.  Escoffier did not offer his reader detailed recipes with instruction on basic cooking techniques, as he assumed the reader would already have this set of knowledge and skills.  His book’s target reader was not the average home cook looking for advice on how to keep a soufflé from falling.  Enter Julia Child and friends.  In Mastering the Art of French Cooking Julia Child et al translated a selection of Guide Culinaire recipes into simple steps and added detailed instruction on the basic techniques (How do you keep a soufflé from falling?  Ask Julia).  Julia Child’s goal was to start someone off in French cooking with the hope that someday they would be ready to go deeper and perhaps read the master himself. 

And so it is with Systematic Psychiatric Evaluation.  If you’re a clinician who already conducts a systematic psychiatric evaluation and are adept with applying the Perspectives approach to patients, there’s no need to read our book.  But, if you are new to the Perspectives and/or want to familiarize yourself with the model, we’ve got you covered.  Systematic Psychiatric Evaluation walks the reader through the basic concepts of The Perspective of Psychiatry and shows, step-by-step, how to apply these concepts to evaluate, formulate and develop individualized treatment plans for patients with psychiatric conditions.

Bon appétit!

Tuesday, October 23, 2012

How Has Psychiatry Changed: On National Public Radio


Our blogger friend, Steve who writes on Thought Broadcast, was on Talk of the Nation yesterday to discuss trends in psychiatric treatment.  If you didn't get a chance to listen, I'm taking the liberty of embedding the interview here.  Steve did a great job!

Okay, Steve, time to get off Facebook and write another blog post, it's been a while!

Monday, October 22, 2012

Podcast #69 : Partnering WITH Patients

Here are the topics we discuss on this fine evening at Roy's house:

  • What does "Shrink Rap" mean (reader request)?
  • Roy talks about an "amazing" conference he went to called Partnership with Patients.  This conference was started by Regina Holliday, patient-advocate-extraordinaire. Here are some links for things that caught his attention:
  •  Clink talks about a Massachusetts legal case regarding gender reassignment of prisoners
  • And finally, we talk about a reader's question about how and why patients test their therapists/psychiatrists.

  • 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

    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.

Saturday, October 20, 2012

Kids and Mental Illness

I try to stay out of the whole Kiddy Bipolar Debate debate: none of the Shrink Rappers see children, so my knowledge of childhood psychiatric disorders is limited to what I saw during a 3 month inpatient rotation 20 years ago, what I read, and what I see of children in my personal life.  It's a messy topic.  

I brought it up today because the Wall Street Journal has an article that summarizes nicely all the issues, the issues with regard to diagnosis, the fear of over-treating, the problem with under-treating, the question of whether mood dysregulation in children should be a separate disorder.  Please see Shirley Wang's article The Long Battle to Rethink Mental Illness in Children

I'm glad they're leaning towards renaming bipolar disorder in children.  When you hear Bipolar Disorder, you think about a lifelong condition that requires medication forever.  Children have phases, behaviors occur in some arenas and not others.  Perhaps if a child's emotional life is intolerable to them, or their behaviors make it impossible to function in their worlds, it's worth the risks to administer medications.  But a kid throwing horrible tantrums, fighting, running around the room, does not necessarily evolve into the same category as an adult who has 3 episodes of depression, and 2 episodes of psychotic mania, during their lifetime.  Oh, and I'm the one who thinks we should Rethink all of the Bipolar Diagnosis, not just for kids. 

So Wang writes: 

At one of his group's first in-person meetings, the NIMH's Dr. Leibenluft, an expert on bipolar disorder in children, gave a 20-minute PowerPoint presentation with evidence for a potential new disease. She called it Severe Mood Dysregulation.
She described a decade of studying children with severe mood problems that don't fit neatly into current illnesses. Thus began a cerebral process to decide what these kids might be suffering from.
The two main options: Create a new disease, or create a variant to an existing disorder. The discussions ran for years.

Friday, October 19, 2012

How Would You Fix the World?

Ah, our candidates have been debating, and everyone has a fix for society's woes.  Romney has an easy plan: cut taxes, this will let businesses keep their money so they can hire more employees, create more jobs (he has the precise number, even) and help the economy grow and everything will fall into place.  If we cut funds to Medicaid, Medicare, undo ObamaCare, and fire Big Bird, then we'll be able to pay off the trillions of dollars of National Debt, all while growing the military, and all will be well.  I know, I'm exaggerating, and it really isn't clear that cutting government funds to public television would mean the demise of Ernie & Bert.  Obama -- I'm not sure what his plan is to save the nation, but whatever it is (? more of the same), it's probably not going to lower the national debt.  It seems we live in a place where our expenses exceed our income.

I don't want to use this as a soapbox to express my political views or to influence your vote, instead I want to tell you that sometimes I have fantasies about how I would fix the world.  Actually, I have a lot of them.  I thought I would tell you my main thought, and ask you to tell me yours.  I'm a doctor, I've never taken a single econ or poly sci course in my life, so please be gentle with me.  It's just a fantasy.  And I won't make fun of yours.

So here's my thought, and unfortunately, it would entail more spending by the government.  I would like to see public schools mandated to have class size limits, preferably to 10-12 students, for certain grades, in any area where poverty levels are high, crime and drug use is a problem, and graduation rates are low .  I'd like to see the class size brought down for either first or second grade so that each student could get intensive, individualized education so that as many children as possible would get a good start with being able to read, because once they fall behind here, they're lost forever.  I'd like to see school days be longer and include some time on the weekend. It doesn't need to be all grind and work: wouldn't it be great to include an hour a day of sports and exercise for children in poverty regions where obesity rates are highest?  And games (Scrabble, anyone?), music, and ideally a bit of immersion in a second language?  It would be very expensive: more teachers (oh, and more jobs for teachers...), more classrooms (oh, and more construction jobs to build the classrooms), more resources all around.  And longer days would give children a chance to do their homework in school, provide child care so that their parents could work and have more disposable income, and keep the children out of drug-ridden, dysfunctional environments.  (I'd be fine with having the extended day segment be optional).  Oh, and Head Start has tried such things and the children make gains, but they only last for 3 years.  Okay, so look at the school curriculum and figure which years are the most crucial in maintaining a student's success, and shrink the class size for a few other years.  Maybe we make sure everyone is able to read and do basic arithmetic by the end of 2nd grade, and make sure everyone can write book reports and simple research papers, manage money and measurements, know a little about science,  how to read a newspaper, keyboard, use technology,  and start to think critically in 5th grade.   Too expensive, you say?  And I would counter with Really?  It would entail putting much more money into education, and making sure it goes to direct child-centered resources, like teachers and books, and not towards more administrators, or more standardized tests.

  So how does this fix the world?  Well, perhaps if we can impact these children early, they will be in a better position to succeed later, they will have feel more self-confident and won't view selling drugs as the only way out of poverty.  They will be more employable, and more likely to contribute, rather than drain, resources.  And perhaps if just a few less children from every class end up in jail, that could pay for my plan.  We hear outcries about public spending, and certainly, in wealthier areas where children do fine in classes of 30, there would be an outcry that their children should have smaller classes, especially since they are paying more taxes, but those same people don't object to spending $25-50,000 a year of their taxpayer's money to house those same children in jail when they grow up to be criminals.  

Thanks for indulging my fantasy.  I would love to hear your plan for fixing some of our problems. 

Tuesday, October 16, 2012

One Dad's Perspective

Okay, while our presidential candidates are debating, I thought I would link to an article by a former state legislator.  In "How I Helped Create a Flawed Mental Health System That Failed Millions -- and My Son," Paul Gianfriddo talks about his decades-long attempts to help his ill son, a young man who sounds to have mental health and educational needs that couldn't be met by a system with limitations.

Gianfriddo writes:

The 1980s was the decade when many of the state’s large psychiatric hospitals were emptied. We had the right idea. After years of neglect, the hospitals’ programs and buildings were in decay. But we didn’t always understand what we were doing. In my new legislative role, I jumped at the opportunity to move people out of “those places.” Through my subcommittee, I initiated funding for community mental health and substance abuse treatment programs for adults, returned young people from institution-based “special school districts” to schools in their hometowns, and provided for care coordinators to help manage the transition of people back into the community. 

But we legislators in Connecticut and many other states made a series of critical misjudgments that have haunted us all ever since. 

First, we didn’t understand how poorly prepared the public school systems were to educate children with serious mental illnesses in regular schools and classrooms. Second, we didn’t adequately fund community agencies to meet the new demand for community mental health services—ultimately forcing our county jails to fill the void. And third, we didn’t realize how important it would be to create collaborations among educators, primary care clinicians, mental health professionals, social services providers, and even members of the criminal justice system, if people with serious mental illnesses were to have a reasonable chance of living successfully in the community. 

During the twenty-five years since, I’ve experienced firsthand the devastating consequences of these mistakes.

The story about his son is heart-breaking and there is no happy ending.  I'll leave you to read the whole article and see what you think.  And if you'd like to check it out, Mr. Gianfriddo blogs, often about mental health issues, at Our Health Policy Matters.

Sunday, October 14, 2012

What Doesn't Kill You Makes You Stronger

I wanted to share this with you -- I thought you might find Act 3 interesting.  It's about a woman with life-threatening OCD.  Act 3 starts just after the 36 minute point and lasts for about 15 minutes.

Wednesday, October 10, 2012

Falling: Faces of Depression and Anxiety (by Clara Lieu)

Clara Lieu is an artist at Rhode Island School of Design.

She has this amazing gift of observation. For example, she has this series on her website ( called Waiting. Here is how she describes it.

I am interested in the contradictions found in waiting figures: even though these figures stand in very close physical proximity to each other, it seems apparent that there is a significant emotional distance between them. Each figure seems locked within their own existence, unaware and unresponsive to the other figures surrounding them. Yet simultaneously, waiting in a line creates a situation where the gesture of one figure leads directly to the next, creating a fluidity between all of the figures. I am engaged by the individual and group anxiety that seems to permeate such silent and still scenes.
So true. My first iPhone line was like that.

She also completed a very impressive series of drawings and sculptures called Falling. This series, unlike her others, are very personal, based on her own experience with depression.

She emailed My Three Shrinks to let us know about her work. I was so impressed that I asked her more about herself and the motivation to show such an intimate view of her anguish.
I developed depression and anxiety at a young age, and lived with the condition for most of my life before being diagnosed and treated just a few years ago. It was startling to see myself clearly for the first time, free from the disease. Only at that point did I have the emotional distance that allowed me to to be in position to address this subject artistically. I knew at that point that I felt an uncontrollable drive and compulsion to make the work.
"Falling" was an unusual project me for in that it was told from a very personal, intimate perspective unlike my previous projects, which approached the subject matter with an emotional distance. Depression is something that happens privately, behind closed doors; it's a secret that most people keep hidden and never talk about in public. Unfortunately here's still a social stigma associated with depression that causes people with depression to conceal their true emotions from others. On a broader level, I'm looking to open a dialogue about a topic that is rarely discussed openly by exposing my own personal experience. 

She goes on to describe this body of work:
"Falling" is a visualization of personal experience with depression and anxiety. The condition brought on frequent episodes where I felt emotionally and physically out of control. Unable to “release” myself from these episodes, I waited for the physical limitations of my body to end them. Recounting the affected years, I realize how accustomed I became to depression’s influence; many emotions and feelings belonged to it and not my own personality. After an extended, untreated struggle, a diagnosis brought relief, and the process of unearthing myself from the disease began. 

Her work can be found at

Note: October 11 is National Depression Screening Day.       Get screened.

Tuesday, October 09, 2012

Dinah is Mad

A few days ago, I posted a link to what I thought was a nice article in the New York Times about a special team of NYC police officers who talk people out of jumping off bridges and buildings, and even jump into the waters to fish them out.  The responses to the post and to my comments left me a bit distraught.  It's been a while since Shrink Rap has been this contentious, and it left me feeling rather defensive.  I tried to put up a response in the comment section, but my comment was too long, so I'm posting it as it's own post.

First, Sarebear, thank you.  She wrote:

"The range of human behavior, motivations, reactions to illnesses is huge. Just because it's not YOUR experience, doesn't mean it isn't valid as someone else's. Just because your experience isn't THEIR experience, doesn't make yours invalid either."

Brilliant.  Thank you.

To the assortment of anons who felt inspired to write in with:

"Yet again, I wonder if this is how you interact with your patients. How do you maintain a practice? Or do you perhaps see only the very mildly mentally ill, the slightly neurotic."  and " It's also surprising that both of you claim enough knowledge of suicide to present at a conference."

I think you should find other another psychiatry blog.  This is far beyond the realm of what one would say to someone in their living room, and the readiness with which you insult us is as though we are not human beings with feelings!  I showed this to my husband whose response was "I don't know why you do this and why you would interact with people this way." 

My comment on the damage suicide leaves in it's wake is a statement of fact.  One friend told me that she started to feel just a little better five years after her son's suicide.
A reader responded that my comment was "demeaning and insulting." " Of course every suicidal person has considered carefully, long and hard, the effect his or her suicide will have on his loved ones. The implication that they have never thought such a thing is really offensive." 
To the anon who wrote:
"Dinah, it sounds like you've never treated suicidal people. If true, it is surprising.
I have never treated a patient who has successfully committed suicide.  I have treated two patients who have had serious attempts while under my care, and many who have had serious attempt before they were my patient.  In general, a serious suicide attempt is reason change doctors -- it is a sign that the treatment is not working, and it destroys trust.

And while I have not treated many seriously suicidal patients, most people with depression have suicidal thoughts and feelings, different from what it takes to complete the actual act. On the rare days when the thoughts seem like anything more than thoughts, I have no qualms about telling my distressed patient that I would be devastated if they committed suicide.   

I can't count the number of people I have treated who have had relatives commit suicide, but it's a lot.  Should we start with the woman whose husband waited until she was coming up the walk to shoot himself in front of her? That began her long and involved time as a psychiatric patient.

No, it's not always thought out enough to be "selfish," (I never used that word) sometimes it's from psychosis, sometimes it's a teenager who can think of no other way to deal with heartbreak, sometimes it's an escape, other times it is the by-product of overwhelming depression.  It's still leaves generations of pain.

  Over 38,354 died by suicide in 2010, despite the best efforts of psychiatry, the NYPD jumper team, and the lack of mental health euthanasia teams.  That number doesn't count the suicides done in ways that medical examiner might have deemed accidental.

Jane, we don't believe that people with intractable psychiatric problems should kill themselves, much less have an institution promoting euthanasia for the mentally ill (what's next?).  We believe they should change doctors, try different or unconventional therapies, seek other opinions from experts,  and we see psychiatric conditions as treatable.

Re: The suicide prevention conference: they invited us to present, we had never heard about the conference before.

I am sorry to be so defensive.  The comments from this post left me very angry. 

I will leave you with a quote from the comment section of the NYTimes article on their Special Teams:

  Casey from Denver wrote:
This work is profoundly important because many people thinking of suicide change their mind. A study by Dr. Richard Seiden of people prevented from jumping from the Golden Gate Bridge found that after an average of 26 years, 94% were still alive or died of natural causes. One of the rare jumpers who survived said later:
“The last thing I saw leave the bridge was my hands. It was at that time that I realized what a stupid thing I was doing . . . It was incredible how quickly I had decided that I wanted to live.” So keep up the good work, you brave men and women of the Emergency Service Unit!

Monday, October 08, 2012

Reading While Depressed

I have to get off that suicide topic. Here's something a little more helpful:

In the current issue of the Paris Review, a reader writes in asking what she should read while depressed. Review writer Sadie Stein answers with a number of interesting suggestions, followed by 67 reader comments with additional ideas.

If you need to clean your head out from our last post and discussion, read this:

Life-Affirming Reads

Murder of the Self

Darn you, Blogger. I'm trying to get two presentations done along with lots of other work and there you go, distracting me.

So we have the issue of suicide and criminal law and a discussion of whether it's a crime to kill yourself. Dinah and I just did a presentation about social media and suicide at a local conference on suicide, so the topic is fresh in my mind.

To my knowledge there are no states that still have laws against someone who attempts suicide. In some states, suicide is a common-law crime that could bar recovery in civil cases (and insurance companies don't pay out for the survivors of people who kill themselves).

The complications come up when the suicide attempt puts others at risk. When someone shoots himself and lives, but puts others in danger during the act he could be charged with reckless endangerment or criminal negligence (as well as the associated handgun offenses if applicable). Yes, people have gone to prison for this. Possession of a controlled substance without a prescription, even if possessed for the purpose of suicide, is a crime.

A lay person who forms a suicide pact with someone could be guilty of conspiracy to commit murder (at worst) or aiding and abetting a suicide. Euthanasia, the killing of a terminally ill person, is less of an issue now that we have living wills and advance directives. There is no constitutional right to assisted suicide, by a physician or anyone else, according to two cases decided in the 1990's by the U.S. Supreme Court. Few states allowed physician-assisted suicide, and many have recently passed laws banning it.

Suicide is similar to drug addiction in that both could be considered "status offenses"---it's not a crime to be who you are (someone with suicidal ideation or someone with an addition to drugs), but it could be a crime to possess the materials to express who you are (drugs, a gun, etc) or to carry out some aspects of the behavior (buying the drugs, firing the weapon, etc).

No time to put up specifics about which states and how many of them do what, just an outline of the issues FWIW.

Sunday, October 07, 2012

Capitated care, Young Brains, & Suicide Prevention Police

Thank you to everyone has been participating in our multi-post discussions of Capitated Care versus Fee-for-Service.  Based on the input of our readers,  I've come to the conclusion that in systems with capitated care (i.e., a national health system): 1) Our readers are pleased with that, feel it provides better blanket coverage to a large population and the emphasis is more on medicine and less on money.  2) Capitated care is less about service with a smile.  3) Capitated care does a better job with treating populations but may not be the best care for the individual with an outlier problem.  We've heard about systems in Canada, the UK, and Hong Kong, and of course, the USA.  I can't recall whether our Australian readers chimed in.

In today's New York Times, I wanted to give a shout out to a couple of articles about psychiatry. 

Robert Cantu and Mark Hyman have a book out called Concussions and Our Kids, and Dr. Cantu has an op-ed piece in today's paper, "Preventing Sports Concussions Among Children,"  talking about measures we should take to prevent brain injury during routine team sports for children under age 14.  The bottom line: children should not play tackle football, head the ball during soccer, body-check in hockey,  add chin-straps to batting helmets and eliminate head-first slides in baseball, and require helmets for field hockey and lacrosse players.  As psychiatrists, we're rather fond of intact brains.  The authors challenge us to re-think our approach to children's sports.  

The New York Times also has a nice article on the NYPD's Emergency Service Unit, an elite squad of 300 police heroes who talk people off bridges and rooftops.   So far this year, the NYPD has gotten 519 calls for people who are about to jump.   See Wendy Ruderman's, "The Jumper Squad."

Saturday, October 06, 2012

The Bestest Cheapest Care Possible

If you've been hanging out here on Shrink Rap for the past few days, you know we've been talking about how the healthcare dollar gets spent.  Do capitated systems (coverage for all with a single pot of moo-la) make it harder to get services?  Our readers say "No."  Do fee-for-service systems inspire doctors to order more and more services so they make more and more money at the mercy of the helpless patient and the poor insurance company?  Are psychiatrists who do psychotherapy a total waste of money when cheaper professionals could do the same job?  

Some of the questions that have come up in our comments section imply that there are precise answers to these questions.  There aren't.  In situations where there are protocols, there is no issue, in any system, the protocol is followed for any patient who enters the arena.  It's where stuff gets foggy that the questions get raised.  Let me walk you through some examples.

Jim is eating breakfast with his wife.  She is a Democrat and he is a Republican.  Sesame Street comes on and Jim's wife starts to cry, Romney will obliterate Big Bird if he is elected.  Jim wants to put in his two cents, but suddenly, he can't get the words to form.  He tries to speak, and nothing makes sense.  One of his arms isn't working, and one of his legs isn't working.  Cookie Monster comes on, Jim's wife refocuses her attention to the conversation they were having over bacon and eggs, and she realizes that something is horribly wrong.  She calls an ambulance and Jim is brought to the hospital.  There is no question that Jim will be seen by a doctor, probably fairly quickly, and sent for a brain scan.  No one will ask if the scan is necessary, his insurance company will not deny it, and even if he is poor and uninsured, he will have the brain scan.  Who will get the bill is another story, but this will happen no matter where he is.  Beyond that, I don't know what the options are.  It doesn't matter if the system is capitated or fee-for-service, and the ED doctor is paid a salary and he makes no more or no less for ordering a brain scan.

Bill is having awful headaches.  His doctor doesn't know why.  He does a neuro exam and it is normal.  He asks Bill lots of questions.  There is nothing that indicates that these headaches are any thing other than tension headaches, and they don't occur in the early morning or with have any nausea or vomiting with them, there are no scotoma, there is nothing to indicate that something awful is going on.  Still, Bill is 43 and he's never had headaches before and his doctor feels uneasy.  He'd like to order a brain scan, but with a negative neurologic exam and no indicators of a mass or trauma, there is not a clear indication to order an expensive scan.  In a system where his doctor must either justify his decision for the scan (fee-for-service managed care), or have money taken out of the big pot that serves everyone,  Bill won't get the scan.  Does it matter, does Bill need the scan?  Well, if an operable lesion is found (a tumor, an circulatory malformation, increased pressure) then it was needed.  If nothing is found, then the scan was reassuring but unnecessary.  Do note, that obtaining the scan does not put any money in the doctor's pocket unless he has some interest in the radiology center (this is not likely).  

So would it change your opinion of whether he needs the scan if I told you that I know someone with headaches and no other symptoms who had a malignant brain tumor -- discovered because his doc got the scan that wasn't indicated?  If Bill's doc knew someone with that story, he'd really want to get the test done.  Would it change your mind if I told you I know a man who told his doctor for years "There's something in my head."  Years.  There was a large, benign,  slow-growing meningioma finally discovered.  So does everyone need scans?  Does it matter?  The man who had "something in my head" for 7 years had his tumor removed and did fine.  The woman who's doctor jumped on ordering the scan for the headache told the patient it wasn't urgent and she got the scan a few weeks later.  That end of that story is rather tragic. 

Finally, John is absolutely tortured, he can't sleep and he's hearing voices and he's acting really strangely.  John's psychiatrist diagnoses the psychotic disorder of your choice and wants to start a medication.  Which medication?  Let's be real, there are no good choices.  We could try one of the old medicines.  Haldol works well and it's cheap.  Oh, did anyone mention that patients hate taking haldol, that back in the day when the old neuroleptics were all we had to offer, that people had to be coerced into taking them and they used to say it felt like molasses had been poured into their brains. They walked stiffly, their eyes rolled up into their head during dystonic reactions and they drooled.  And in 25 years, 68% of them got tardive dyskinesia.  

Okay, we'll skip the Haldol, because everyone does.  Let's try a newer medicine.  Zyprexa works really well for psychosis and it's well tolerated.  It's an older medication and it only costs $1000/month to be on the generic (I kid you not).  Oh, and of all the atypicals, Zyprexa is the most likely to be associated with weight gain and metabolic changes and John is already overweight and his cholesterol is a bit high, and his father had a heart attack at a young age and has diabetes.  Let's avoid Zyprexa for now.   Risperdal might be a good choice, and it only runs about $50 a month for a low dose if you shop around.  Oh, but John is really worried about this weight gain and diabetes risk, and he says he wants the medication with the lowest risk of weight gain and diabetes.  That would be Abilify, which comes in at roughly $500/month.  John wants that, and he says he has a $25 dollar co-pay and he wants the minimal risk of weight gain and diabetes.  But really, his psychosis is bad, Zyprexa probably works best, and not everyone gains weight and gets metabolic abnormalities on it: the issue is one of risk.  If he does get diabetes, the cost of his care increases dramatically.  So does a patient have the right to request the safest medication, even if it will cost the taxpayer $450/month more (Abilify versus Risperdal)?  What's the easy answer here?  And if he takes a less effective antipsychotic and ends up in the hospital it will run roughly $1700/day, so it might be most cost effective to avoid that.  Just so you know, if the patient has Medicaid in Maryland, the government does not allow the first trial to be with Zyprexa (costs too much with the metabolic risk) or Abilify (too expensive).  John may want the least risk, but Uncle Sam (or Uncle Martin?) just says no.

Friday, October 05, 2012

I Chose the Wrong Profession

Oh, actually, I love my work.  I love seeing patients for therapy and I've seen over and over how helpful medications can be, so I'm glad I can prescribe them, and I love that most people feel better (or they quietly move on and I don't know).  

So far, I chose the right profession.  Hoping that holds for a while.

I entered college with plans to become a psychologist.  I didn't really get the differences between a research psychologist and a clinical psychologist.  My university also offered a major called The Biological Basis of Behavior, and there was a strong graduate program in experimental psychology but not clinical psychology.  I thought I wanted to be a researcher, and I majored in both Psychology and "BBB" (as it was called).  At the end of my second year, I had the thought that I would like to do research but I'd like to see patients as well.  There was no one to tell me that Clinical Psychologists can do both, and so I figured that going to medical school and becoming a psychiatrist would give me more options down the road.  So I went to medical school -- in New York City, where psychiatrists back then were often psychoanalysts and I'd never even heard the terms "med management" or "split treatment" -- and I became a doctor, then moved to Maryland and became a psychiatrist.  I liked that there were so many options, and I realized I really liked seeing patients and that research was more about writing grants (and praying you got them) and concerns with data in a way that I'm not primed for.  

Back then, I had no idea that social workers did psychotherapy.  As a medical student, and even as a psychiatry resident, I saw social workers do family therapy on the inpatient unit and arrange for discharge planning, help patients obtain benefits, and arrange for aftercare programs.  I was well into residency training before I realized that psychotherapy was mostly done by social workers.  

I had no idea that there would ever be any expectation that I would see 3-4 patients an hour and confine my work to asking about symptoms and side effects, much less the time consumption that filling out paperwork (soon to be computer work) would become in clinic settings.  

I brought this up because we've been talking about capitated care versus fee-for-service care on an earlier post.  I think the capitated care folks are winning so far, they seem to like their system.  But in 2012, in capitated care systems, psychiatrists do management, they don't do psychotherapy.  Where would that leave me?  Am I worried?  No, there seems to be a demand for what I do, and neither presidential candidate has come knocking at my door for suggestions, so I'm just hanging out to wait and see.  I am feeling a bit obsolete and like somehow, I ended up on the wrong train. What do you think?

Tuesday, October 02, 2012

What Makes for Better Care: Capitation or Fee-For-Service?

In the United States, most medical is rendered on a fee-for-service basis.  The more often you come in, the more money I make (at least from you).  In theory, it motivates doctors to recommend more services, and it motivates insurance companies to bargain for very low payments and to deny services.  Another form of payment is what the HMO's do -- a population is defined and a medical system is given a certain amount of money is divided to provide treatment for those patients.  This form of reimbursement gives doctors the ability to divide the money pot in such a way that the neediest get the most, but it also encourages doctors to offer less care to any given patient.  In such a system, doctors are generally rewarded if there is money left over and penalized if they go over the budget.  Incentives may be put in place to encourage good outcomes.

Mental health treatments are often different from other forms of care in that the medications can be very expensive (okay, there are other expensive medicines that run circles around us, but as frequently-used meds go, Cymbalta and Abilify are money drains) and psychotherapy is a time intensive treatment where there are no absolute standards that determine who comes twice a week versus who comes twice a year.  Capitated systems don't typically (?ever) pay for psychotherapy by a psychiatrist  -- the kind of work I do -- and they don't typically allow for on-going weekly psychotherapy sessions, unless it's felt this is absolutely necessary to prevent a more costly hospitalization.

What system are you covered under?  What do you think works best and why?  Obviously, I interested in hearing from our readers outside the United States.