Friday, June 20, 2014

Tired. Just Tired.



For years, I've absolutely loved having  Shrink Rap.  I've loved having a place to write, to vent, to share something cool I've learned, and I've learned so very much from readers who have really changed my life.  What a great experience from a thought at the kitchen table that started, "I want a blog.  What's a blog?"  Shrink Rap has inspired me to keep current with psychiatry and to learn about things to write about that I might otherwise just skip.  I love having a place to ask questions, especially when they're about things that make my brain start doing somersaults (--well, not really, I think it's anchored in there okay).   Someplace to talk about things that are really bothering me or to share a funny cartoon or to just be a bit ducky.  

Sometimes, over the years, I've gotten really annoyed.  As much as I like hearing about others peoples' experiences, I don't like when people generalize their interior world to everyone else. And when it's an incessant, it gets wearing.

Lately,  I'm totally consumed with writing our next book.  I'm meeting the most interesting of people, and it's fine with me that some of them are very much in favor of involuntary psychiatric care, for what seem to be caring and reasonable agendas, and some of them are very much against involuntary psychiatric care, for what seem to be caring and reasonable agendas.  But my brain is consumed with this.

And as much as I've loved Shrink Rap, the drum beat of negative comments and the inter-reader bickering, well, it's tiring.  For a short while, I moderated comments.  That's work, one more thing to do when I should probably be making pesto instead. Roy got tired long ago, and Clink chimes in when something really inspires her, so I've been most of the noise for a long time now.

I'm tired.  Just tired.   We'll see. I think I'm taking a little rest for now.

Monday, June 09, 2014

Is it Ok to Shrink your Sister in an Emergency?

I'd like to bend your ear with a hypothetical situation and see what you think.  This one is for the docs, and I'm going to start and end it with a simple question: is it okay to prescribe for a family member?  Is it okay to prescribe a psychotropic medication for oneself or a family member?  

Before you jump on me, let me tell you that to the best that I am aware, docs have always written prescriptions for themselves and for their family members.  An antibiotic, an allergy medication, I think this has been par for the course for straightforward things.  When I was an intern, one of the nurses asked me to write for an ulcer medication for her mother ---I said 'no' since I'd never so much as seen the mother, but it was uncomfortable for me.  I've heard older and wiser psychiatrists talk about prescribing Valium for themselves, Xanax for a friend afraid to fly, an antidepressant for a parent, and I've certainly had patients who've gotten medications from family members who are docs, including controlled substances.

Somewhere in there, it became taboo to prescribe for family members, particularly psychotropic medications or controlled substances.  In our state, the licensing board sanctions people if they learn about prescriptions written for anyone where there is no chart.  I think.  What's kosher and what's not kosher is a bit of a guessing game, and while obviously it's a problem to prescribe large quantities of Oxy for yourself, I'm not sure if or when it's a problem to refill a spouses' statin when their doc is out of town. 

So let me give you an invented scenario, and I'm curious as to what the docs out there think is the right thing to do.  If everyone else wants to chime in, that's fine, but please say who you are -- doctor, nurse, social worker, golf pro, whatever, no pure anonymous responders, please.

Lucy has a history of panic disorder and five years ago she was treated with medications: first with Xanax for a couple of weeks, and then with Zoloft.  Once the Zoloft kicked in, Lucy was able to stop the Xanax.  Lucy said the panic attacks were horrible, and the medications brought her tremendous relief, and she also had psychotherapy.  After about a year, Lucy tapered off the medications and she has been free from panic attacks ever since.  Until last week.  Out of the blue, Lucy was hit with a horrible attack.  She lives in another part of the country now, and Shrink Brother, visiting for a few days,  took her to the ER, where they ruled out a heart attack, gave her some Ativan, and sent her home with a prescription for ten pills and directions to see a psychiatrist.  

Lucy starts working the phone, but her new town is nothing like her old town.  She calls ten psychiatrists, most have a wait of 4 to 6 weeks.  Shrink Brother also calls around, but he lives in another state-- he's just visiting for the weekend -- and all the shrinks have secretaries that form pretty solid walls.  Weeks, if it's an emergency, she should go to the ER, but Lucy's already been to the ER.  Lucy wants to start back on Zoloft, because she remembers it took weeks to work.  Having moved to town 18 months ago, and being in very good health  until now, she never got a primary care doc or a gynecologist, and yes, she's well aware this is all her fault.  She makes the soonest appointment she can get with a psychiatrist -- 3 weeks, and is told that the shrink sees new patients for an hour, and after that it's a 4 patient/hour flow.  So, she'd like to start on Zoloft, she's still having panic attacks and is due to run out of Ativan, and she also needs to figure out how to get a therapist (plus a primary care doc and a gyn).  Brother shrink is worried about prescribing for her -- he's gone home to his own state and no one will be monitoring sister Lucy -- what if she gets suicidal or manic on the Prozac?  Does he really want to monitor sister Lucy for sexual side effects?  (TMI, he notes) Isn't it a problem for him to write for Ativan, an addictive, controlled substance, for a family member?  Lucy goes to an urgent care center, and is sent out with a script with a low starting dose of Zoloft -- enough to last for 10 days, and ten more Ativan tablets, not  enough to get her to the appointment.  Infuriating given that Lucy had made a point of telling them she couldn't find a psychiatrist to see her for weeks, but when she got to the pharmacy, she realized that the script was too low a dose and too few pills.

At this point, Brother Shrink is totally frustrated.  His sister has now been in an ER and an urgent care center, she has an appointment with a psychiatrist, chosen for the soonest appointment, no clue if he's any good.  Nothing horrible will happen if Lucy goes without medications, she'll simply suffer longer and it's feeling a bit unnecessary when he could phone in some Zoloft and a few more tablets of Ativan to hold her over.  The only other option that either of them can think of is for Lucy to continue to make regular visits to the urgent care center where a doc with no expertise in psychiatry can continue to prescribe, if he feels so inclined.  At the same time, Brother Shrink worries that if there is a bad outcome, now or ever with any of his other cases, it will come out that Brother Shrink inappropriately prescribed to sister.  

What should he do?  Jesse?  PsychPractice? Dr. Reidbord?

Saturday, June 07, 2014

In the Works, "Committed: The Battle Over Forced Psychiatric Care."



Good morning, I've missed you.  Blogging has not been the same lately and I've let some great topics go by. 

 Let me tell you what I've been up to.

There have been so many things to write about lately, and I will tell you that my brain is just bursting with all the work Clink and I are doing on our new book: Committed: The Battle Over Forced Psychiatric Care.  ClinkShrink is doing some of the background stuff, she's being (as always) the forensic expert, she's sweeping up after my grammatical carelessness, and correcting the forensically idiotic things I say.  She's focusing on legal cases and a chapter on restraint and seclusion.  I'm taking the lead on writing some of the other chapters, and her description of this is that it's like trying to keep up with a hamster in an exercise wheel.  That hamster would be me, and I'm having no more luck keeping up with my own thoughts then Clink is, but every now and again, I jump off and take stock.  I started with this very funny idea that I would work on one chapter at a time, and that each chapter might take a month.  Okay, so some chapters are taking a very long time to get the parties lined up for, and I'm working on 5-7 chapters at once.  These days, I'm as much journalist as shrink.

Would you like to hear about the book?  Don't hold your breath on being able to read it anytime soon, but it's making progress and some days the progress is much faster than I expected.

The first two chapters are from the perspectives of patients -- wonderful, intelligent, articulate, people -- one of whom found that involuntary hospitalization was traumatizing to her and left feeling her injured, another  of whom found it help keep her life from disintegrating.  I purposely chose people who had good insight and believable stories -- I didn't want the person who felt her care was unkind to be dismissed; I thought her complaints were valid and warranted a critical look.  Both patients allowed me to access their medical records, and to interview their doctors and family members, so I felt like I got a good sense of what went on.

Since the book is "The Battle Over Forced Psychiatric Care,"  the third chapter is called The Battleground.  This is the most difficult chapter to write to date, just because it's taking time to get together with everyone.  So far, I've interviewed  E. Fuller Torrey of the Treatment Advocacy Center, Ron Honberg of National NAMI, Ira Burnim of The David L. Bazelon Center for Mental Health Law, and an anonymous gentleman from the Church of Scientology in New York City.  I have times set up later this month with Paul Summergrad, the President of the American Psychiatric Association, and Daniel Fisher of the National Empowerment Center (a Recovery Group), and I have been working hard with MindFreedom (a survivor organization) to find a time for a conference call.  Some other great people have chimed in as well: Xavier Amador, Solomon Snyder, and Paul Appelbaum has been helpful every step of the way.  

Chapter 4 is currently on Civil Rights, and it's taken from a news story our readers pointed me to about a woman in Vermont who was held in a hospital for 5 and a half weeks with no hearing.  The case is the springboard for discussion, so I've talked with a wonderful legal aide attorney in Vermont as well as the president of the Vermont Psychiatric Society.  As in many of our chapters, the laws there are changing as we write and the hamster keeps trying to run faster.

Chapter 5 is on law enforcement and how people enter the mental health system through police interventions.  I focused here on Crisis Intervention Teams, and Officer Scott Davis has been a gem to let me ride along with him and share his world with me, and Judge Steve Leifman in Florida has given some wonderful insights and statistics.

Chapter 6 is on the inpatient unit, and the chairman of psychiatry, Dr. Ray DePaulo was truly my hero for allowing me to shadow him on the unit.  Steve Sharfstein, a former APA president and CEO of Sheppard Pratt Hospital talked with me about how his institution works, Dr. Bruce Hershfield a former a superintendent of Springfield State Hospital, shared his insights with me, and I had a present-day tour of the state hospital, which now houses 230 people, down from a high over 3,000. 

In short, lots of lunches, and lots of insights from really brilliant people.  

Clink is working on Chapter 6: restraint and seclusion, and the plan down the line is to look at the legal system through the public defender's office,  outpatient commitment, violence and mental illness, guns and mental illness, maybe forced ECT, maybe indefinite confinement of sex offenders (we'll see), and a little more focus on both families and legislation.  Jeff Swanson at Duke has provided invaluable guidance, and I've grown very fond of these folks at Penn from The Scattergood Program for the Applied Ethics of Behavioral Healthcare -- and I'm looking forward to spending more time with Candice Player, and John Monahan, once I finish the current chapters and more forward.  For my brief blog post, there are many many people missing, but I wanted to give some quick shout outs and just an update on the quite nature of Shrink Rap these days.

What do you think?  Obviously our blog readers have been instrumental in shaping in our writing.  But if you're looking for a book to either extoll the virtues of forced care or to completely vilify it, you may need to hold back.  These are complicated issues and our goal is to talk a close look at involuntary treatment, figure out when it can be made kinder and gentler, and figure out if or where it fits in with psychiatry and/or the prevention of violence.

Friday, June 06, 2014

Help! My Patient Got Arrested. What Do I Do?

Today over on Clinical Psychiatry News I give advice to mental health practitioners about what to do when you need to make sure your patient is taken care of when he ends up in jail. This is never the kind of stuff they teach you in residency, so I end up fielding phone calls from friends and colleagues about it sometimes.


Hopefully you'll never have to deal with this, but if you do you'll know where to begin. Read the column here.