Monday, December 30, 2013

Depression, the Secret we Share -- A TED Talk by Andrew Solomon

If you've ever been depressed, if you've ever known anyone who has been depressed, if you've ever wondered what it's like to be depressed, or if you just want to listen to a wonderful talk,  do listen to Andrew Solomon's TED talk.

Sunday, December 29, 2013

Psychiatry Articles on the Web

There have been a number of articles I've wanted to mention lately.

In the New York Times:
When the Right To Bear Arms Includes the Mentally Ill

In the Wall Street Journal, set in our own Maryland:
For the Mentally Ill, Finding Care Grows Harder


Representative Tim Murphy Instroduces Mental Health Legislation

From the StarTribune:

Minnesota Security Hospital: Staff in Crisis Spreads Turmoil

In Atlantic Monthly, a poignant story about one man's battle with anxiety:

Surviving Anxiety

And finally, on Salon, it's from nearly two years ago, but I ran across Linda Gray Sexton's account of being suicidal and found it to be moving:

In the shadow of my mother's suicide

Friday, December 27, 2013

Assisted Outpatient Treatment?

Happy Holidays, everyone.  Blogging has been a little slow here at Shrink Rap as the Shrink Rappers overdose on cookies and get caught up in all the usual holiday stresses that get to everyone.
I've heard rumors that in the coming 2014 Legislative Session in Maryland a bill may be proposed to make Assisted Outpatient Treatment (AOT) part of the landscape.  As it stands now, we are one of the few states that does not have AOT, or forced treatment, for outpatients, outside of the forensic system for those on conditional release after having committed a crime (often a violent crime).

Since Maryland doesn't have AOT, I have no experience with it.  Perhaps it's a good idea; I don't believe it's humane to leave people living in the filth and cold on the streets if they have a psychotic illness that could be treated.  But I'm also well aware that treatment has side effects for some, and limited efficacy for others, and I worry that forcing people to get care in an already strained system is not the same as forcing them to get thoughtful, individualized care, with a spectrum of treatments being offered.  

So I'm staying out of the discussion at this point, as all I can say is that I don't know what the right thing is to do. I do know that people have strong opinions.  

If you live in a state with Assisted Outpatient Treatment, and you've been a part of the program, then I"d love to hear your comments.  If you have a family member who gets AOT, or are a doctor involved with such treatment, then I'd love to hear your opinion as.  If you've never personally been involved with forced outpatient care, even if you've been involved with forced hospitalization, then I'd like to ask you to hold your opinions for now.  I really  would like to hear from the direct recipients of these treatments.

Thanks so much!

Saturday, December 21, 2013

Cymbalta Goes Generic

On December 11th, the FDA approved the use of generic Cymbalta.  The generic version, Duloxetine, delayed release,  became available in the USA four days ago.

Generics generally work just fine and they cost less.  Now and again, some people have side effects or feel the generic is not as effective effective, and for those individuals, it makes sense to remain on the name brand medication.  Generics cost less and the active ingredients are the same.  Oh, but there was a little issue with the efficacy of one pharmaceutical company's preparation of Wellbutrin, XL, 300mg.  See the In The Pipeline discussion of the problem in this blog post, "The Generic Wellbutrin: Whose Fault is It?"

So, generic Cymbalta -- is it okay to take this today?  I have some thoughts.

 I imagine it's probably fine and it's probably cheaper.  In fact, I called one pharmacy, and their out-of-pocket price  for a single 30mg tablet ss $11.73 for Cymbalta, and $8.44 for generic Duloxetine.  So the cost is less, but we're still talking about a very expensive medication, even in generic form.   It's also the holiday season: stress runs high and moods run low.  I imagine it's fine, but for any given person, there is the question with any medication switch as to whether that person might be the person to have side effects or experience less efficacy.

So just to consider :
  --What happens to this person during an episode of depression?  If prior episodes of depression required hospitalization, it might be worth waiting a little and seeing how others who have had milder episodes of depression respond to the generic.
 -- Physicians won't be consulted first, the pharmacy simply makes the substitution.
 -- If there is a problem, the psychiatrist may be away for the holidays and a covering doctor may have to be consulted.
-- It's a preparation of the medication that US physicians have no experience with.  The generic form has been available in other countries.

Medications change to generic all the time, including many antidepressants.  The cost drops and the medication becomes more accessible.  Generics work fine, and I personally have no qualms about taking them.  So I'll leave this as my take away message: just beware that this change has occurred and prescribers may not know about it.  If patients call with problems, it may be worth asking if their medication was changed to a generic, and patients who have problems may want to mention to their doctors that the medication was changed. 


Tuesday, December 10, 2013

Who are the Mentally Ill? Please take my Brief Survey!

We hear about "the mentally ill" all of the time.  They shouldn't have guns.  They die an average of eight years younger than those without mental illness.  We don't have enough hospital beds for them.  They're filling our prisons and some of them are homeless... oh, the list goes on.

Defining the term is important because we single this group out for all types of discriminatory practices related to employment, driving, gun ownership, and even the ability to enter the United States for a vacation (at least on a few occasions).  We also single this group out for special benefits such as being allowed to take their dogs on airplanes or to receive benefits from the government in the form of disability payments,  health insurance in the form of Medicare, and entry into specialized day programs and vocational rehabilitation programs.  But there is no agreed upon definition of who is mentally ill, and the Diagnostic and Statistical Manual ( DSM) lists hundreds of disorders, limiting its utility as the determinant of who is mentally ill and therefore eligible for discrimination, stigmatization, or special benefits.

I'm a psychiatrist, and I confess, I have no idea who these "mentally ill" are.  I think if you asked many people in treatment about being mentally ill, they might think you are talking about someone else.  People may not think the term applies to them because they don't have the insight to realize they are sick.  Or, they may not think of themselves as mentally ill because with treatment, they've gotten better.  Finally, many people who get treatment don't identify themselves as mentally ill because they are too busy identifying themselves as being Mary's husband, Tom's mother, a doctor or a lawyer or a barber, master gardener, avid Raven's fan, or any other aspect of identity that consumes time, generates income, and adds value to society.   It might not occur to a patient to identify themselves as "the mentally ill" even if they take medicine and go to therapy. 

So I'm going to ask you.  Who are the mentally ill?  Please take my quiz only once, and please ask your social media followers to take the survey-- it should only take a few minutes.   It's am important question, one that guides all types of legislation and policies and I'd love to know what you think.  And thank you!  Comments on the post are welcome.


Sunday, December 08, 2013

Andrew Solomon on Shameful Profiling of the Mentally Ill by Immigration Officials

In Today's New York Times, Andrew Solomon, author of The Noonday Demon and Far From the Tree, has an opinion piece on "Shameful Profiling of the Mentally Ill."  It's on a topic that ClinkShrink has been very interested in: the disturbing issues that arise when the immigration department  ("ICE") decides the fate of psychiatric patients. 

I'll leave you to read Mr. Solomon's article about tourists who were not allowed to enter the United States because they had been hospitalized for depression in Canada.  One woman was simply traveling through the US to get to her cruise ship, stringed lights in hand to make her cabin festive.

Solomon concludes:

Stigmatizing the condition is bad; stigmatizing the treatment is even worse. People who have received help are much more likely to be in control of their demons than those who have not. Yet this incident will serve only to warn people against seeking treatment for mental illness. If we scare others off therapy lest it later be held against them, we are encouraging denial, medical noncompliance and subterfuge, thereby building not a healthier society but a sicker one.

Well put.  And have I mentioned that I loved Far From the Tree?  It's a wonderful look at issues of identity in those who are  different, but more than that, Solomon exposes the complexity of calling these conditions "disorders" requiring treatment, versus viewing them as a natural part of human diversity to be accepted rather than fixed.  The topics addressed include mental health disorders, but it's so much broader as he looks at topics including deafness, dwarfism, musical genius, autism, schizophrenia, transgender children, and children conceived in rape, to name just a few.  Ten years of writing, three hundred interviews, and well worth the read.   

Friday, December 06, 2013

Guest Blogger Dr. Erik Roskes with an Update on Gun Legislation and the Mentally Ill

In case you haven't heard enough from the Shrink Rappers on mental illness and gun legislation, I'm stealing a synopsis of the recent legislative changes from The Crime Report, a blog by forensic psychiatrist Dr. Erik Roskes.  Taken verbatim, with permission of course:
On October 1, 2013, Maryland’s modified firearms safety law took effect.  Passed in the aftermath of the Newtown massacre, this law expanded the group restricted from owning certain firearms.  This blog will focus only on the mental health aspects of the law, as I have no claim to expertise outside the mental health arena. 
 Editor's Note: See an official report from Connecticut State's Attorney on The Crime Report here.
Until September 30, 2013, two classes of people were restricted from possessing regulated firearms:
(1) a person who “suffers from a mental disorder… and has a history of violent behavior against the person or another,” and
(2) a person who “has been confined for more than 30 consecutive days to a [psychiatric] facility.” 
Effective October 1, 2013, a new law took effect, expanding and modifying the classes of people restricted from possessing weapons for reasons related to mental illness.  Now, the groups include:
(1) a person who “suffers from a mental disorder… and has a history of violent behavior against the person or another;”
(2) a person who “has been found incompetent to stand trial” (IST);
(3) a person who “has been found not criminally responsible” (NCR – this is Maryland’s version of the insanity defense);
(4) a person who “has been voluntarily admitted for more than 30 consecutive days to a [psychiatric] facility;”
(5) a person who “has been involuntarily committed to a facility” for any period of time; and
(6) a person who “is under the protection of a guardian appointed by a court…, except for cases in which the appointment of a guardian is solely a result of a physical disability.”
It is important to note the following:
Importantly, criminals without mental illness are only restricted if they have been convicted of specific “disqualifying crimes” or if they have received a 2 or more year term of imprisonment for a common law crime.  This disparity regarding removal of weapons from offenders with mental illness whose weapons would not be removed based on the crime alone raises potential disability rights questions.  
Thus, for example, category 1 requires no causal nexus between the individual’s mental illness and his or her history of violent behavior.  Thus, a person with, say, an eating disorder and a history of fighting during his or her adolescence would be subject to the restriction on firearm possession.  Conversely, the person with a history of multiple fights, no mental illness, and no other disqualifying events (such as a conviction for a violent crime) would be permitted to retain his (or, less commonly, her) weapons.  Where exactly is the logic here?
Categories 2 and 3 involve numerous defendants whose crimes themselves might not be dangerous.  In the hospital in which I work, the modal crime for which people are committed as IST is trespassing. 
While few people are found NCR for crimes that are not violent in some way, there are some whose underlying offenses are non-violent. 
Category 4 is especially concerning to those of us treating people with mental illness, in that it targets patients who seek treatment willingly, and who do not meet any of the other criteria for removal.  Thus, this restriction is imposed on people without any history of violence or criminal behavior, and who have sought treatment of their own accord.  Essentially the restriction punishes the very behavior we would wish to reinforce. 
Category 6 is interesting in its leading to bizarre rules, such as the recent report in Iowa regarding the ownership of guns by blind people.  From where I sit, this is simply a head-scratcher, making me wonder who is making decisions on our behalf. 
But most concerning for me is category 5, which was modified in the section of the code regulating involuntary commitment to require the hearing officer to determine if “the individual cannot safely possess a firearm based on credible evidence of dangerousness to others;” if the hearing officer so finds, he or she is to order the individual to surrender any firearms to law enforcement.  Note that no such finding is to be made for individuals civilly committed only due to self-directed dangerousness or suicidality.
According to the US Centers for Disease Control and Prevention, indicate there are over 19.000 firearm suicides per year in the US.  By comparison, there are about 11,000 firearm homicides each year. 
Based on research from the NIMH, at least 90% of those who commit suicide (approx. 17,000) have the sorts of mental illness that could lead to civil commitment.  Research varies with regard to homicide, but for discussion purposes, assume that as many as 10% (approx. 1100) of people who commit homicide by firearm have mental illness.  Simply put, for every gun-related homicide committed by a person with mental illness, there are approximately 17 gun-related suicides. 
If the new Maryland law were to be applied nationally, we would be potentially preventing a small number of people with mental illness from committing homicide by firearm, while doing nothing to protect the vastly larger number of people who might kill themselves with that same weapon. 
As I have already written, reactive gun laws do little more than assuage the public’s anxiety about mental illness, without doing much of anything to actually protect the public.  It makes us believe that our elected officials and appointed policy makers are doing something – anything – to make our communities safer, without regard for whether the things that they do actually will lead to positive results.  From where I sit, the changes in Maryland will do little to make our communities safer.  With apologies to a recent New York mayoral candidate, there are just too damn many guns. 

--Erik Roskes, M.D.

Wednesday, December 04, 2013

Guest Blogger Dr. Ronald Chase on Historical Misuses of Psychiatry

Dr. Ronald Chase is the author of  Schizophrenia: A Brother Finds Answers in Biological Science.   Today, he joins us as a guest blogger to talk about his recent trip to Heidelberg and the atrocities committed by the Nazis under the guise of psychiatry and a reminder for all of the things psychiatry should not be.  Dr. Chase is a biologist who taught neurobiology at McGill and now writes about mental illness.  As per the title of his book, the topic can be very personal.  

A Memorial is a Reminder

To research a book I am writing about the 19th century origins of modern psychiatry, I recently traveled to Heidelberg, Germany. I wanted to see the clinic where Emil Kraepelin and other influential psychiatrists had worked. I met up with Dr. Maike Rotzoll, a psychiatrist and historian who had been a psychiatric resident at the same clinic. She kindly agreed to show me around. As we approached the stately old clinic building, she suddenly turned from the beckoning entry and led me to a small enclosure just opposite. There, surrounded by a ring of small trees, stood a monument. “I want you to see this,” said Dr. Rotzoll.

It is a circular structure made of local sandstone and measuring about 10 feet in diameter. On its topside is an inscription which reads (in translation), “In memory of the victims — for us an admonition. We lament these 21 children, patients of the Psychiatric Clinic of the University of Heidelberg, killed in the name of criminal medical research in 1944.” All around the sides of the memorial are written the names of the murdered children. 

            Dr. Rotzoll explained that the children were killed by Nazis acting under the infamous Aktion T4 program of eugenics and euthanasia. Carl Schneider, then Director of the Psychiatric Clinic, was an active participant. Some contemporaries described Schneider as empathetic and enthusiastic about psychiatric rehabilitation, but he ordered these children killed to further the cause of what he called “National Therapy”. He collected their brains for histopathological research. Altogether, the Nazi euthanasia programs killed an estimated 200,000 persons with mental or physical handicaps, of whom 70,000 were psychiatric patients and 5,000 children.

            Although I learned a lot about late 19th century psychiatry while in Heidelberg, and I found the city beautiful, the thought of those 21 children weighs heavily on my memory. On the one hand, it is reassuring to know that post-war Germans are driven to express their horror and regret about what was done. On the other hand, it leads me to reflect on the dangers lurking even now for all of us. How was it that an institution that had hosted such distinguished psychiatrists as Franz Nissl, Emil Kraepelin, Alois Alzheimer, Karl Jaspers, and Hans Prinzhorn could have become involved in such terrible acts? Clearly, many medical professionals, among whom Carl Schneider, failed to see ethical implications in the prevailing social-political agenda, or their vision was blunted. It’s something to bear in mind as we read of American doctors assisting in the interrogation of prisoners detained as part of the war against terrorism. Especially worrisome is the recent report written by two psychiatrists detailing cases of complicity in the torture of prisoners at Guantanamo and other centers.

            I thank Maike Rotzoll for her contributions to this post.

Ronald Chase is an emeritus professor of biology at McGill University. His book combines, in alternating chapters, a 50-year memoir of his intellectually gifted older brother and an accessible explanation of the science related to schizophrenia.

Sunday, December 01, 2013

Quantifiable Goals

A local hospital was recently reviewed by one of those hospital accreditation agencies.  It did well-- passed with bells and whistles -- but for a few citations for psychiatry.

Individual Treatment Plans (ITP)s:
"Surveyors cited us for not having measurable goals in the ITPs. So, changes were made to [the electronic records system] to  clarify the requirement for objective and measurable patient goals as well as the patient’s progress toward those goals."

Okay, so help me with this.  Two decades of trying to come up with acceptable, measurable goals and I'm left with the idea that therapy has a limited number of goals and they aren't that measurable:
~Patient wants to feel better / Less psychic pain.
~To work and to love.
~No psychosis (and we measure that how?)
~To remain out of the hospital. (While measurable, I'm not sure that is acceptable to the bean counters).
~To remain out of jail/prison.
~Patient will resist urges to drink alcohol/shoot heroin/snort cocaine.
~Fewer self-injurious behaviors.
~Living up to potential.
~Acceptance of self as is, including the reality that patient may never be as beautiful/rich/smart or accomplished as he once believed he should  be.

What's measurable?  

Patient will have a Beck Depression Inventory score of less than 10 at every visit?
Patient will report spending less than 1 hour a day on compulsive checking?
Patient will lacerate himself fewer than 4 times per week and all lacerations will be less than 2 cm long and none will penetrate arteries?
Patient will report having suicidal thoughts less than 23% of waking hours?  

I remain clueless.  And of course, the treatment plan is about naming the goals, there are no citations for achieving them or not, or even for having them make sense in the context of the patient's life.

Paperwork chaos is not new.  I remember being an intern and being paged in the middle of the night to put a cause of death on a death certificate.  It was 3AM and I wrote down "pneumonia," because the patient had died of pneumonia.  I was paged again soon after.  "Pneumonia" is not an acceptable cause of death.  But that was what the patient died from.  I needed to know what organism caused the pneumonia, and that could only be known if a culture was done and that would take days to know.  The requirements said that a cause of death needed to be given now.  "Sepsis," I said (overwhelming infection).  Nope, I would still need to know the infectious agent, something I still didn't have access to at 3AM with a newly admitted patient.  I tried again: cardiopulmonary arrest.  That worked, sort of.  What was the cardiopulmonary arrest due to, I was asked?  Pneumonia, I said.  That's still not acceptable, unless I knew the organism.  I finally asked what is an acceptable cause of death.  I was given a few options, none of which pertained to the patient, but I picked one because there was nothing else to do.  

Okay, so what are acceptable, measurable goals in psychiatry?  And does measuring something make it more meaningful?