Thursday, August 29, 2013

For the Rest of Your Life -- Or Perhaps Not

Over on 1 boring old man (who actually is not all that boring), Mickey is writing about a post of Thomas Insel's blog yesterday --  Insel writes about how some patients do better without long-term anti-psychotic treatment.  Dr. Insel is the Director of the National Institute of Mental Health.  

So perhaps you've heard that people with certain mental disorders need to stay on their medications forever.  Certainly, some do -- they stop their medicines and each time they try that experiment they end up sick --- in the hospital, in jail, on the street, or simply festering in the basement.  But some people stop their medicines and they don't get sick, so clearly, not everyone with a given diagnosis must stay on medicines for life, but we don't have a way of knowing who needs them and who doesn't.  We know risks for populations (maybe, to read Dr. Insel's blog, we don't know them as well as we thought), yet we know nothing about a given individual until a doc stops the meds or the patient goes off them on their own.  We also know that the medicines have risks.  How much risk?  Who knows.  Here, one figure sticks: of those who remain on an older generation antipsychotic (Haldol, thorazine, prolixin) for 25 years, 68% will get tardive dyskinesia.  And that figure doesn't say anything about dose.

So read Dr. Insel's post: Antipsychotics: Taking the Long View.
And read 1 boring old man's post: surprise...

And I'll copy a part of Dr. Insel's post here:

After six months of symptomatic remission following antipsychotic treatment, patients were randomly assigned to either maintenance antipsychotic treatment or a tapering-off and discontinuation of the drug. As expected, the group that stopped taking their medications experienced twice the relapse rates in the early phase of the follow-up. But these rates evened out after a few years, as some patients in the maintenance group also stopped taking their medication. Most important, by seven years, the discontinuation group had achieved twice the functional recovery rate: 40.4 percent vs. only 17.6 percent among the medication maintenance group. To be clear, this study started with patients in remission and only 17 of the 103 patients—21 percent of the discontinuation group and 11 percent of the maintenance group—were off medication entirely during the last two years of follow-up. An equal number were taking very low doses of medication—meaning that roughly one-third of all study patients were eventually taking little or no medication.
For me, there were three remarkable results in this study. First, the groups did not ultimately differ in their experience of symptoms: about two-thirds of each group reported significant improvement in symptoms at seven years. Second, 29 percent of the discontinuation group reported that they had also achieved a healthy outcome in work and family life—a number that should give hope to those struggling with serious mental illness. And finally, antipsychotic medication, which seemed so important in the early phase of psychosis, appeared to worsen prospects for recovery over the long-term. Or, as Patrick McGorry said in an accompanying editorial, “less is more.”2 At least for these patients, tapering off medication early seemed to be associated with better long-term outcomes.

Thursday, August 22, 2013

Facebook No More (At Least for Now)

It hasn't been the easiest of summers for me.  As I've mentioned before, my brother died unexpectedly. And then last week, a neighbor's house burned down in the most dramatic of ways.  Watch those candles, folks.  Who would think that a citronella candle outside could burn down an entire house in minutes?  The people all got out, and the firefighters were spectacular.  But it's all a reminder of how fragile life is, and how it takes but a moment for one's whole world to change.  I go through life feeling very blessed, and losing my brother put a kink in that whole concept.

Last month, in the middle of a sleepless night, I had a temper tantrum and said something I would not normally say on Facebook.  Then, I shut down my account.  I've been asked why I did that, and even to me, it doesn't really make sense.  I was momentarily annoyed and it wasn't well thought out.  

The truth is, I'm addicted to e-mail, and I was addicted to Facebook.  I'd checked it and then I'd check it again.  I like being connected with people, I like being in the know, I like looking at pictures of everyone's kids, and I like getting news from my favorite media sources and from news reporters I follow.  Since Facebook, I'm much aware of  current events.

Suddenly, I was Facebook-free.  Cold turkey, I surrendered.  I figured I would re-open the account at some point, and I'm sure I will, someday.  But what I discovered when I shut down the account was that life got different, in a better way.  I hadn't realized it, but every time one of my kids said something funny, or I went somewhere interesting, or something extraordinary happened or caught my attention, I was posting a status update, a link, a photo.  I was living my life for Facebook.  Now I can be in the moment without having to get the perfect picture, without wondering if I should post that quote or not.   Events don't have to be chronicled for others, they can be experienced for their own merit.  I'm not constantly assessing what picture to take and then to post.  Maybe it's because it's August and life always slows down in August, but I've felt my tension level drop and I think it's the relief of one less thing to attend to. 

So there things I miss.  I miss hearing how my sister-in-law is doing several times a day (we now resort to email), I miss knowing what's going on in the world (sort of, a little) and my account is linked to the Shrink Rap Facebook page, so I can't update that with relevant links.  Roy can still access it, but somehow it's always been my job.  I'm still tweeting; for some reason, that doesn't have the addiction issue, perhaps because I don't actually know any of my twitter followers.  I've always been a Facebook fan, and I've encouraged friends to join, but suddenly, I'm not such a fan.


On another note, I wrote about addressing the concerns of the Anti-Psychiatry crew over on Clinical Psychiatry News.  Here's the link

Tuesday, August 20, 2013

Why Are Inmates Dying?

In yesterday's New York Times there was a story by Erin Banco called Suicides Worry Experts at Big Jail in Capital. The story talks about four deaths at the DC jail this year and the general worrying trend of increasing correctional suicides nationally. The article speculates that the deaths may be attributed to lack of adequate mental health staffing or deficiencies in the jails' observation practices. Some of the people interviewed for the story linked the deaths to cutbacks in state mental health budgets.

Correctional suicide is an area that, as Dinah would put it, is a "Clink" thing---a topic I've been interested in for a number of years. I wrote about this three years ago in an article called Correctional Suicide: Has Progress Ended? In my article I pointed out that nationally we seemed to have hit a "floor" with regard to suicide prevention---rates had been declining consistently over the years until a recent plateau. I wrote about what I thought might be the cause of that plateau: the Prison Litigation Reform Act which limited prisoner access to the courts and circumscribed how far courts could intervene to improve prison and jail conditions,  as well as changes in the profile of the typical correctional suicide, and the increasing problem of gang violence and intimidation in corrections.

What was most striking for me then was the fact that correctional suicide studies are starting to show increasing numbers of inmates who die from suicide without any previous mental health history or history of suicide attempts. I coined the term for this phenomenon a "clean" suicide---one that could not have been picked up or prevented through currently accepted screening methods and referral protocols. The New York Times article didn't address this, but I couldn't help wondering if the deaths in the DC jail might fall into this category.

What I didn't mention in my earlier paper---because the numbers weren't out yet---was that the increase in jail and prison deaths may reflect a larger trend in rising national suicides. According to the CDC, the age-adjusted death rate for suicide has increased by 8.7 percent since 2000. The other new data comes from the recent Department of Justice report on inmate sexual victimization and abuse. According to this national survey, being a sex offender increases the by other inmates. The Washington Post has reported that three of the four DC jail deaths were by detainees who were charged with sex offenses.

The Times may be correct that cutbacks in state mental health budgets have had an effect, but this does not address the fact that for many states the funding for correctional health care comes out of the public safety budget rather than the health and mental hygiene budget. State cutbacks could still play a role, just not through the route the article suggests. States with privitized correctional health budgets would also have to be examined separately to look for contractual budget changes.

So those are my thoughts about the NYT correctional suicide story. I figured I'd better get this post up fast before Dinah nudges me to write about it. (Yeah I know, I'm supposed to be re-reading the book proposal but Dinah you know I had to blog about this.)

Monday, August 19, 2013

EMR's : Good or Bad

Over on GregSmithMD, Dr. Smith talks about the downside of Electronic Medical Records: Thing one: they distract the doctor, Thing Two: They take a lot of time and decrease free/casual/down/recharging time for docs, Thing Three: Some older wiser therapists opted out and retired, taking their talents and the institutional memory with them.  Dr. Smith also points out that it helps to have legible notes.

As I've mentioned, I left my job at the clinic where I've worked one morning a week for the past 15 years because I couldn't deal with learning the new EMR, see My Epic Meltdown

So never mind the fact that EMR's require that doctors collect all sorts of information with each visit which may or may not be relevant to the patient's care.  Treatment becomes a checkbox from a drop down list.  The screen sucks time and attention.  But I have a different concern.  When I go to a doctor, I ask for a copy of the consultation note.  I keep copies of my labs, copies of notes from any specialist I see, results of any test I have.  I've been struck by how these notes contain gross examples of inaccurate information.  So far, nothing I've seen has been scary, but there's the documentation that my liver and spleen are normal in size by the doctor who didn't check (maybe X-Ray vision was involved).  And I really like how I'm "currently married."  Does that imply that it's a temporary state?  I've been with the same guy since I was 18, at this point I'm thinking it may last for a bit. Okay, I'm nitpicking. None of this matters, and I avoid docs with electronic records, so mistakes hopefully don't get transmitted.

Here's my question about Electronic Records:
~ Don't they risk that misinformation will be perpetuated?  Isn't this dangerous?  Shouldn't patients review the records to be sure they are correct?  Why aren't we more worried about this?
~Don't they increase the physician liability?  If a doctor writes something in the record, even a note from a phone call, and this contains important information, and these charts quickly get full of information because every phone call, every visit with every healthcare professional (including phone calls requesting refills taken by a nurse) is a separate note, isn't each physician responsible for knowing what's in all these now-legible notes, and if something gets buried in one of many notes and the physician misses something important, isn't it now an issue?  Patient calls and notes they developed a rash with a medicine.  Doctor puts it in a phone note, but doesn't record it in the allergy section and forgets at the next visit.  Patient later has a bad reaction when given that same medication a few years later.  

Okay, so what have your experiences been to date with EMRs?  Good, bad, happy, sad?

Friday, August 16, 2013

Is the Government Getting in the Way of Treating Those With Severe Mental Illness?

So Twitter led me to Pete Earley's blog this morning, and that led me to The National Review for an article by E. Fuller Torrey and D. J. Jaffe -- see : After Newtown; The existing federal mental-health agency actually opposes efforts to treat mental illness.

To quote part of the article (surf over there for the whole thing), and note that SAMHSA is the government's Substance Abuse and Mental Health Service Administration:
What is severe mental illness? According to the National Advisory Mental Health Council, in response to an inquiry from Congress, severe mental illness includes schizophrenia, schizoaffective disorder, bipolar disorder, autism, and severe forms of depression, panic disorder, and obsessive-compulsive disorder. One measure of SAMHSA’s lack of interest in these disorders is its current three-year planning document, “Leading Change: A Plan for SAMHSA’s Roles and Actions 2011–2014.” Despite being 41,804 words in length and acknowledging that 9.8 million Americans are afflicted with what it refers to as “serious mental illness,” the SAMHSA plan includes not a single mention of schizophrenia, schizoaffective disorder, bipolar disorder, autism, or obsessive-compulsive disorder.
So, when it was asked to provide direction for the Biden Task Force, SAMHSA had nothing relevant to offer. It invited Daniel Fisher to provide testimony as a psychiatric expert. Fisher, director of the National Empowerment Center in Massachusetts, to which SAMHSA has given $330,000 a year for many years, has publicly stated that what is called severe mental illness is really just “severe emotional distress” and “a spiritual experience.” He also believes that “the covert mission of the mental health system . . . is social control.” Fisher’s former deputy similarly asserted that “mental illness is a coping mechanism, not a disease.”
Such views are consistent with views expressed by many invitees at SAMHSA’s annual conference. In 1995, for example, one speaker claimed that “schizophrenia is a healthy, valid, desirable condition — not a disorder . . . what is called schizophrenia in young people appears to be a healthy transformational process that should be facilitated instead of treated.” Similarly, in 2010, another speaker extolled mental illnesses as “extreme states of consciousness that are mad gifts to be nurtured and cultivated,” and he advised people with mental illnesses to stop taking their medication.
That the federal agency charged with reducing the impact of mental illness on America’s communities is sponsoring forums at which severe mental illness is extolled as a good thing has overtones of Lewis Carroll. But the situation is even more bizarre than that. SAMHSA’s only recommended “treatment” for all mental illnesses is the “recovery model” — in other words, everyone should simply recover. This is similar to the Caucus race in Alice in Wonderland in which the Dodo declares that “everybody has won, and all must have prizes.” The “recovery model” was officially defined by SAMHSA in 2004 as including ten “fundamental components,” the most important being that it is “self-directed by the individual, who defines his or her own life goals and designs a unique path towards those goals.” The “recovery model” includes no mention of the need for medication or other specific treatments. It makes no allowance for the fact that many individuals with severe mental illness are unaware of their own illness. This is an ideology, not a treatment. Under the “recovery model,” John Hinckley was defining his own life goal — the attention of Jodie Foster — when he shot President Reagan. Similarly, Cho, Loughner, Holmes, and Lanza were presumably attempting to define and achieve their life goals, too. Their actions would meet SAMHSA’s definition of “recovery.”

Wednesday, August 14, 2013

Are Too Many Anti-Depressants Being Prescribed?

Look, our friend Dr. Mojtabai and his study on the use of antidepressants is on the Well Blog in the New York Times!  See a Glut of Antidepressants by Roni Caryn Rabin.  Oh, and do read all 405 comments.  

The study looks at patients diagnosed with depression in primary care setting, and many given that diagnosis do not meet criteria for the disorder, but still get prescribed anti-depressants.  I wondered if some didn't meet criteria for depression because the anti-depressants were doing a good job of treating the symptoms.  Unfortunately, I could find the abstract for the original article, so I will refrain from commenting on it further.  

Ms. Rabin writes: 

The vast majority of individuals diagnosed with depression, rightly or wrongly, were given medication, said the paper’s lead author, Dr. Ramin Mojtabai, an associate professor at the Johns Hopkins Bloomberg School of Public Health.
Most people stay on the drugs, which can have a variety of side effects, for at least two years. Some take them for a decade or more.
“It’s not only that physicians are prescribing more, the population is demanding more,” Dr. Mojtabai said. “Feelings of sadness, the stresses of daily life and relationship problems can all cause feelings of upset or sadness that may be passing and not last long. But Americans have become more and more willing to use medication to address them.”
So let me ask you: is this a bad thing?  We're not talking about forced medication here, or prescribing addictive medications, so if a patient comes and says they feel depressed and they want medication, and they don't "meet criteria" for the disorder, but they insist they are suffering and depressed and are willing to accept the risk of side effects, it's it awful if a doctor gives them a prescription for the medication?  "I'm sorry Mrs. Jones, but your extreme sadness and suicidal ideation are only two symptoms and you need more, are you really sure you're sleeping okay?  You don't have major depression so no prescription and you'll be fine after some yoga."  Or maybe the patient tells the primary care doctor that they're depressed, but they don't have enough symptoms to meet criteria, but in fact they do meet criteria for a diagnosis of dysthymia (chronic, low grade depression), or for an anxiety disorder which might also be helped by an anti-depressant.  On the other hand, should we really have the expectation that everyone's mood will be good/fine/okay all the time?  Yes, the drug companies make money off this, but generic Prozac and Paxil cost about $40/year to be on, and one might hope that if they weren't helping, they'd be discontinued. 

And remember, Dr. Mojtabai's study was done with data from primary care settings, it's not about psychiatrists who are more accurate with psychiatric diagnosis than primary care docs.

Saturday, August 10, 2013

Back from Vacation: Roundup of Psychiatry in the New York Times

It's August, and  I've been away.  Now I'm back.  While I was gone, there were a number of articles in the New York Times that were Shrink Rap material.  Here is a list, with thanks to Jesse for keeping me informed:

Mark Epstein on The Trauma of Being Alive.  It's a nice piece about how people deal with loss, and it's feeling a little to relevant these days. 

Here are the response letters to the article. 

 I didn't see Epstein's article as a deterrent to getting care, as one trauma therapist who responded did, but rather as a suggestion that we take grief as it comes, however it comes, with no comment on what more to do about besides accept and "lean into" the emotions (whatever that may mean).  I figured that if one's response to the distress of a loss was to want to seek help, then the author,  a psychiatrist, probably wouldn't be blocking the door.   

Pam Bellack wrote on the successes of forced outpatient care in Programs Compelling Outpatient Treatment for Mental illness is Working, Study Says.

In a response letter, three professors wrote about Forced Drug Treatment.

Don't hold your breath waiting for the Shrink Rapper book on this -- it will be years in the coming.

In Lawyers of Sound Mind, Melody Moezzi writes about the hassles newly minted lawyers have to go through in some states to enter the Bar if they've been treated for psychiatric disorders. 

In When Doctors Discriminate, Juliann Garey writes about her experiences with doctors who've dismissed her health problems after learning she takes psychotropic medications.

And in New Sign of Stimulants' Toll on the Young, Sabrina Tavernese discusses the increased rate of ER visits for stimulant-related problems, especially for those who obtain them without a prescription and for those who combine stimulants with alcohol. 

And over on Clinical Psychiatry News, ClinkShrink chides the president of APA for irresponsible tweeting.