Friday, June 30, 2006

Roy: Psych Notes for Smilies

Inspired by Carrie's comments...
Carrie had wondered why her doc never put her on an antidepressant. She wrote: "God knows most days I wonder why not. LOL "
I replied: "It's because of the 'LOL'. If you couldn't LOL then maybe he would. Of course, if you were ROFLYAO, then he'd probably reach for the lithium."

This exchange got me thinking... hmm... how would a psychiatrist manage someone who could only communicate via emoticons? Below are the resulting progress notes...

:-)stable. cont prozac 40mg. f/u 3 mos.
:-))reduce prozac to 20mg. f/u 1mo.
:-))))d/c prozac. add lithium 300 tid. check TSH, creat. f/u 1wk.
:-Dadd depakote. check lithium level, LFTs, CBC. f/u 1wk.
:-|stable. cont prozac 40 mg. f/u 1mo.
:-(increase prozac to 60mg. f/u 2wk.
:'-(add wellbutrin SR 150mg. f/u 1wk.
X-(call 911. send to ER. check for OD.
:*}check breathalyzer. refer to AA.
%-}weekly tox screen. refer to AA/NA.
:-&@?add haldol 2mg bid.
|-0d/c ambien.
:-#d/c elavil. use hard candies.
;-Pd/c haldol. add clozapine. AIMS exam. vitamin E 800 iu bid.
:-)~reduce haldol. add cogentin to reduce sialorrhea.
8-~reduce dose of seroquel.
(:-)reduce depakote. add zinc, selenium.
;-)establish boundaries. do not schedule at end of day.
;-xsee with chaperone only.
=^..^=give Ativan 1mg IV to relieve catatonia. (thanks, ClinkShrink)
:-o(on seeing the bill for 1st appt.)
>:-O(on seeing the bill for missed appt.)

Roy @ Shrink Rap ( and

[thanks, SmiliesUnlimited, for the emoticons]

Flight of Ideas

The Red Sox are losing (bottom of the 7th inning) to the Marlins. They've been on a 12 game winning streak.

Question of the Day comes from my daughter: Why do old people wear ugly underwear?

Note to my son away-from-home: Feel free to speak to me in just one full sentence, though I do so love it when you grunt.

My husband wants to know why Fat Doctor says nice things about her husband and I never say nice things about him on my blog. Like Fat Doctor, I too have a wonderful husband. He's charming, smart, funny, handsome, and he doesn't overpay for his haircuts. Does it get any better than that?

My dog, Max, never complains.

Roy: the final post of the month is yours. Don't blow it.

Chomp, Chomp

No, this isn't another cannibal post. That's the sound of me eating my words. From a recent New York Times article, "Market Forces Pushing Doctors to Be More Available":

In Dr. Gerdes's office, the innovations include daily clinics at lunchtime called QuickSick, in which patients who have phoned up that morning can come in for routine problems requiring immediate attention, like an upper respiratory infection, and are guaranteed they will be examined, treated and on their way within a half-hour.

After a nurse checks the patient's temperature and blood pressure and types the symptoms into a computer, the doctor follows up with a brief exam. If medication is warranted, Dr. Gerdes can e-mail a prescription that will be ready when the patient arrives at the pharmacy.

"I can see three patients with acute needs every 15 minutes," she said.

The charge is $52 to $60, which is coverable by insurance and similar to prices at many of the new clinics springing up in places like CVS pharmacies and retail chains like Wal-Mart.

We have now entered the fast food age of medicine. QuickSick sounds like the Golden Arches of health care. Quick math check: one patient every five minutes at $60 a pop = $720 per hour of revenue. Guess I'd better take back everything I said about the spiritual gardening consultant. But do they charge for missed appointments?

Thursday, June 29, 2006

I Quit

I've been hearing these words quite a bit lately. To a certain extent it's a seasonal thing. Many of our facilities were built before air conditioning was invented. When the indoor temperature starts pushing 90 degrees, people rub on each others' nerves and tempers flair. The work is difficult enough, but dealing with these challenging patients gets even harder when you need to look after your co-workers' well-being. Battle fatigue can strike anyone, from the top administrator down to the scheduling clerk.

I try to remind people that the problems are temporary. I encourage them to take time off or think about ways of changing the job to make things more bearable. In a worst case scenario, I even suggest looking at other job options just to reassure yourself there are always alternatives available. Sometimes that's enough, but it doesn't always work. Sometimes people need to leave for their own mental health.

I don't want my colleagues to leave. The average length-of-stay for a new correctional doc seems to be six months to a year at the longest. "Lifers" are rare, at least among us non-inmates. I'm blessed to be working with a dedicated young doc now who is called to public psychiatry and is very, very competent. I've watched her grow in her correctional experience and learn, both with and without my help. She has reached the critical stay-or-go point that comes with the adaptation process. I'm keeping my fingers crossed.

Wednesday, June 28, 2006

Roy: Psychiatry declared a "religion"

I suppose some of you may find this story amusing; this Onion-like site has declared Psychiatry to be a religion, not a medical science.
"If you dressed up a parrot in a doctor’s smock and taught it some Latin phrases, it wouldn’t be a doctor. It’s the same with Psychiatrists."

If the God of Psychiatry for the last century was the Supreme Superego, it is now the Cosmic Chemical.
"The matter of faith in a deity was also a sticking point but a study of Psychiatric scriptures reveals that Psychiatrists believe in an invisible entity known as “chemical imbalance”. The existence of Chemical Imbalance is stated as fact in the texts though there is no proof of his existence, analogous to a Christian’s belief in God or a Muslim’s belief in Allah."

Now all they have to do is declare Scientology a real religion, and then I can truly deem The Spoof editors to be the Ra of Rhetoric.

I'm Still Thinking About Fat Doctor!

We started Shrink Rap in April. By early May, I'd become addicted, writing blogs, reading other peoples' blogs: blog, blog, blog. Even the word is ugly. In my post What's Happening To My Life, I mentioned that Roy had introduced me to Fat Doctor.

So, let me tell you about Fat Doctor. She is a family doctor, married to a minister. She works on the same unit as her mother, a nurse. She owns two dogs, one of whom has been treated with Elavil (can't remember if that was Big Dog, aka Spot, or Little Dog) and has a son, a toddler whose exact age I can't quite recall. Her sister recently had bladder surgery. Fat Doctor has been having a rough time of it lately-- this spring, while at a medical conference, she suffered multiple frontal lobe strokes and spent some time in the NICU being stented. She suffers from depression (she was on Prozac which she stopped when she was trying to get pregnant), restless leg syndrome, and sleep apnea. Following her strokes, she went back to work oh-so-soon, and has recently had neuropsych testing. Her pantyhose drooped in a rather horrifying way as she spoke at the end-of-year Residency dinner.

Oh my gosh, it's its own illness. I check in everyday, waiting to see what's happening next. It's like a Soap Opera, only I hate Soaps, and it's not a Soap Opera. Maybe it's like Tony and The Sopranos where I'm waiting to find out what happens next, but this is a real person's life. Except, this is a real person I don't know. Why do I care? It's not like I don't have enough people's lives to follow. I drop in, a session at a time, to my patients' lives and often I'm eager to hear what's happened with the same wonder and anticipation. Only, my patients are real people, and I have some small degree of control-- if something heated is going on ( for example, waiting for biopsy results) I'll ask a patient to call between sessions and let me know how it turned out.

I worry about Fat Doctor. Only weeks after her CVA, she was complaining about being tired, lethargic, lacking motivation. Her brain, I think, was telling her to rest, and yet she pushed herself and returned to work. She's getting better, in leaps & bounds, or so it seems and so I hope, but I do wonder if she should have taken it a bit more slowly.

My husband wonders if Fat Doctor is real.

"What if someone's just making this stuff up?" he asks.

No, no, no. Fat Doctor is real, she has to be. She likes Diet Coke.

"And, so, how fat is she?" my husband wants to know. I think he, too, might get sucked in.

Roy: Healthcare Truth & Transparency Act

I've been a lax blogger (working too hard). SHP inspired these thoughts.

This from the APA today:
RE: New APA-backed U.S. House Bill Attacks Consumer Confusion about Physicians and Non-Physicians

We are pleased to let you know that today Representative John Sullivan (R-OK) and Representative Gene Green (D-TX) introduced bipartisan legislation to help safeguard patients from misleading claims by healthcare providers about qualifications and training. Representatives Sullivan and Green were joined by Representatives Michael Burgess (R-TX), Joe Schwarz (R-MI), Charles Bass (R-NH), Michael Bilirakis (R-FL), and Pete Sessions (R-TX) as original cosponsors.

The bill, the Healthcare Truth and Transparency Act, will promote patient safety and informed choice by better distinguishing between physicians and non-physician groups who create confusion by their apparent efforts to cloak themselves in the medical or physician label. As an example of the potential for consumer confusion, your DGR provided our congressional leaders with examples of the growth in the use of "medical psychologist" -- a misleading and frankly meaningless term that is the creation of those in organized psychology who seek prescriptive authority by state legislative fiat, not by virtue of medical education or training. The Sullivan bill says that:

‘It shall be unlawful for any person who is a licensed health care service provider but who is not a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine to make any deceptive or misleading statement, or engage in any deceptive or misleading act, that deceives or misleads the public or a prospective or current patient that such person is a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine or has the same or equivalent education, skills, or training. Such deceptive or misleading statements or acts shall include advertising in any medium, making false statements regarding the education, skills, training, or licensure of such person, or in any other way describing such person’s profession, skills, training, experience, education, or licensure in a fashion that causes the public, a potential patient, or current patient to believe that such person is a medical doctor, doctor of osteopathic medicine, doctor of dental surgery, or doctor of dental medicine.’

As part of our ongoing efforts to deal withnon-physician scope issues, the APA has also joined a coalition of medical specialties and the AMA in foundingthe Coalition for Health Care Accountability, Responsibility and Transparency (CHART), which is committed to promoting and supporting the Sullivan bill.

Both the Sullivan bill itself, and APA's membership in and support for the CHART organization, together with APA's founding role in the AMA scope of practice center, are concrete examples of our continuing efforts to proactively respond to the psychology prescribing struggle. We hope theapproach taken by the Sullivan bill willoffer our District Branches and State Associationsa template for relatedefforts in the states. At a minimum, enactment of the Sullivan bill will provide a means at the federal level of addressing efforts by non-physician groups to use tactics that may mislead and confuse the public. As part of our ongoing campaign to assist our District Branches and State Associations, APA is also working on other legislative "templates" that we hope will be of use in playing offense as well as defense in the states.

Trick-cycling's post about nurse practitioners and physicians, along with today's well-timed announcement, made me think of posting this. I do find still that many folks don't know their ologist from their iatrist. Now there's the urse actitioner. The legislation would require these non-MD providers to correct patients, when asked the question, "What's up, Doc?"

Tuesday, June 27, 2006

No Show

I hate it when patients don't show up for their scheduled appointments.

I have a solo private practice, it's just me-- no partners, no staff, no secretary. I run on time and I don't double book. Patients know that the time is theirs, I tell them this before the first appointment: The time is reserved for you, if for any reason you're not going to keep the appointment, please call and cancel. I tell patients on the first day that I bill for any appointment not cancelled at least 24 hours in advance, with the exception of weather emergencies or the sudden onset of an illness (in other words: I don't want to be infected or vomited on). Any appointment that is simply not kept is billed in full and the cost of a missed visit can't be passed on to an insurer. I've said it, and a few years ago I wrote it and handed it out on a sheet of Office Policies.

My first few years in practice, I was lax about enforcing the late cancellation/ no show policy. I hate charging people for a service they don't receive, especially since it seems that most of my patients struggle a bit financially. At some point, I realized my schedule was mayhem. People didn't show up, or they called asking for a different time-- I like to be accomodating and would shift when I could, but I started to feel like each day was a juggling routine, and the number of No Shows and Late Cancellations escalated, often for reasons such as conflicting Karate lessons, or I Forgot. I quickly figured out that if I value my time at Nothing, the patients do as well.

I still am a bit ambivalent about it and often debate with myself what to do. If I call and find the patient, we can develop a plan -- to reschedule or for him to come in for the remainder of the time-- and at least I can do something else with the time. If not, I am held hostage in my office, waiting to see if the patient is simply caught in traffic or enroute. I could rant about why is it that I have to repeatedly call patients on their mobile phones to ask if they're coming, only to be told at 15 minutes after the hour that they're almost there-- they couldn't phone first to let me know they're running late/? Another post for another day.

I still sometimes let the Late Cancellation folks slide, though my neighbor told me she still puts it on their statement with a notation "Fee forgiven due to..." and I've adopted this practice, even if it's just to write "Fee forgiven, one time only." The repeat offenders, I bill, even if I feel badly about it.

So yesterday, I left the clinic and went to my office. My first patient did not show up. He's done this before, several times, and I was unable to reach him on the phone and the bill is in the mail. The background is that in the past, I've spent the better part of a weekend worrying about him and ended up having someone go to his house when I could not reach him anywhere for days: he was busy and hadn't checked his messages in some time, but was alive and well. My next patient also didn't show up. This gentleman has been in treatment with me for years, and has only once or twice missed his weekly session. He always comes on time, and he called last night saying it was important that we meet and he came in today at a time that was convenient for me-- I let yesterday's missed visit slide with a One Time Only notation. Today, I had a late cancellation from someone who had switched work shifts to help a desperate colleague-- the catch: she'd switched shifts several days ago and had exhausted her One Time Only (which I believe was actually two or three times) pass several missed visits ago. Still, this patient works several jobs and struggles to keep up-- I feel badly charging for the missed visit.

In the public psychiatry clinics where I've worked, No Shows are always a problem. The clinics get the bulk of their revenues from Medicare and Medicaid and billing is not allowed if the service isn't rendered. In effect, the therapists' time is valued at Zero, there is little disincentive for patients to come, or even to call, if they can't come (or if they oversleep or if something better comes up or if they don't want to talk about the yucky things going on in their life). In some clinics, patients are discharged if they miss three appointments, but that's never been the case in the clinics I work in, and across the board, Community Mental Health Centers sport a 30% No Show rate (sorry, I should have a reference and a link, plus I think it was actually only 29%).

It comes up with Pro Bono patients as well, and when I've offered free care through Maryland's Pro Bono Counseling Project, I've taken to adopting a No Show fee-- if you show up, care is free, if you blow me off, there is a nominal fee meant to discourage people from abusing my time.

Do these measures work? Mostly, I think so-- it's much less of a problem than it used to be, though I did just write about 3 patients who didn't come in the last two days, and I didn't even mention one of the patients at the clinic who didn't show....

Teach Them A Lesson

According to the Bureau of Justice Statistics, as of mid-year 2005 over 6000 juveniles were incarcerated in adult detention centers* pending trial. This number has actually been declining after reaching an all-time high in 1999. While there is no constitutional right to public education, many states do have laws that mandate the provision of education to juveniles housed in adult jails, or prison policies that mandate participation in GED programs for juveniles serving time in adult prisons. About a quarter of all state prison inmates get a GED while incarcerated.

The issue that brought this topic to mind was a recent CNN story commenting on restrictions to juvenile education in the Cook County jail. Specifically, this jail has banned hardbound textbooks and also regulates juvenile access to pencils. The article portrayed this as unreasonable or unnecessary, however this is pretty standard correctional stuff. Most facilities have restrictions on hardbound books because they can be used to store or transport contraband. And pencil-stabbing is certainly not unheard of. The fact of the matter is that when it comes to constitutional rights, there is an uncanny resemblance between the restrictions placed on students and the restrictions placed on inmates. In public schools the restrictions are justified by the fact that the school is acting in the place of the students' parents, meaning that the school has an obligation to supervise and safeguard their juveniles. Correctional facilities have the same obligation.

I actually had a different topic I was planning to blog about, but the recent reference to the gansta-wannabe son changed my mind. When he gets home you should greet him at the door wearing a sign saying "Geek Mom".


*A bit of explanation for our foreign readers and those not familiar with the American correctional system: detention centers, or jails, are run by local county governments and house pretrial detainees. Prisons are facilities run by the state or Federal government, and are used to house convicted and sentenced offenders.

Monday, June 26, 2006

To My Son...

50 Cent: The Massacre
My gansta-wannabe child has left home to try his brain at a college course this summer. Never a camper, this is the longest he's been away from home.

So far, life without you:
I've been thinking about you and wonder how you are. I liked talking to you last night, but a little more info would be okay. Say Hi to your roommate, John, from the unknown place. I hope he likes watching The World Cup and you find someone up there who isn't a Geek. I'm glad they found your luggage and you got to bring your clothes with you. I hope you wear it. If you send me your email address, I'll write to you.

Even your sister misses you. Dad tried to give her your seat at the dinner table (why? ask Dad...he thought she was too far away at the end of the table) but she wasn't interested.

I should have something more interesting--from a psychiatric perspective-- to say about my oldest child growing up, but it's too hard to think about the fact that soon he will be leaving for good.

Saturday, June 24, 2006

With A Nice Chianti

OK, I've behaved myself for almost an entire week while Dinah was gone. I blogged about topics that were relevant, serious and (hopefully) thought provoking. I haven't made a single reference to the Support Duck.

Now let's talk about cannibals.

After all, I'm a forensic psychiatrist. A friend of mine once described a forensic psychiatrist as "the person who is leaning forward in fascination while everyone else is leaning backward in disgust." I'll try not to be (too) disgusting.

What brought this topic to mind was a recent CNN story about a conditional release hearing for a New York insanity acquittee accused of killing and eating bits of his former student. I can't really blog about cannibals in general since I've only met one---he seemed like a nice enough fellow---so instead I'll write about the insanity defense.

The first step in an insanity defense is to determine whether or not any given psychiatric condition meets the legal definition of "mental disease or defect". This determination is made at trial by the "factfinder", in other words either the judge or the jury. The "mental disease or defect" does not have to exist in the DSM. For example, some novel "diseases" are urban stress syndrome, "road rage" and the infamous "Twinkie Defense". Similarly, a disease that is defined in the DSM may be barred as an insanity defense by law. The classic example of this is alcohol intoxication. Alcohol intoxication is a recognized clinical syndrome, but you can't use it to excuse criminal responsibility. Anyway, the first step in a successful insanity defense is a legal decision that the defendant suffer's from a mental disease. At the release hearing for Mr. Cannibal his doctor testified that he suffered from "sexual sadism and pedophilia". Both of these disorders are recognized psychiatric conditions defined in the DSM-IV.

The next step in an insanity defense is to see if the defendant meets the legal test for insanity. A legal "test" is a written definition or standard. In general, there are two insanity tests in common use: the ALI test and various derivations of the McNaughton test. The McNaughton test states that a defendant is insane if he is unable to understand the nature or quality of the act, or---if he did understand the nature of his actions---that he didn't understand that they were wrong. In 1955 the American Law Institute (A.L.I.) wrote the Model Penal Code in an effort to make criminal laws uniform across the country. The Model Penal Code's insanity test, also called the ALI test, states that a defendant is insane if he "lacks substantial capacity to appreciate the criminality of one's conduct or to conform one's conduct to the requirements of the law". It has two parts, a cognitive standard and a volitional or behavioral standard.

In the case of Mr. Cannibal, neither sexual sadism and pedophilia alone would be likely to impair one's appreciation of reality by either the ALI or McNaughton standard. The only remaining argument for our New York gentleman was that he was unable to control his behavior for some reason. The CNN article doesn't provide enough information, but I'd be willing to bet there's an additional diagnosis in there we haven't heard about, like psychosis or mania, that also affected his reasoning ability.

OK, so I really didn't talk about cannibals. To make up for this I'll post some relevant cannibal-themed music links:

Just a modest proposal for those with a taste for such music.

Friday, June 23, 2006

I agree with Shiny Happy Person and some other random thoughts

Shiny Happy Person of Trick-cycling for Beginners (will I ever understand that blog name?) writes about her frustration with Nurse Practitioners prescribing in Bonkers New World. Her post has 30 comments and going, so a topic with some heat to it. I'll take it a few degrees higher and say I think patients get the best care when they see a psychiatrist for both their psychotherapy and their medications. Just my opinion.

Roy, I just listened to your animated cartoon link re: NSA wiretapping. I can't decide how I feel about it. How was I supposed to feel?

Manny is having a good night, the Red Sox are winning 7-2 against the Phillies.

Congratulations, Clink!

Shocking news, hot off the press:
ClinkShrink passed the recertification boards!
We'll let her continue on in her roll as Blogger-extrordinaire with continued expertise in the field of both forensic psychiatry with a subspecialization in Support Ducks!

Wednesday, June 21, 2006

Welcome Back...

I woke up this morning in Lake Como. Hard to imagine: it's been a long day, including a delayed flight, a two-hour drive on this end, and my son's entire wardrobe is currently presumed to be somewhere in Europe, hopefully headed home soon. After ten days in Tuscany, Baltimore never looked more drab.

When I go on vacation, I always worry, even if just a little. I have patients (fortunately just a couple) who fret for weeks in advance about my absence-- the funny thing is that the patients who worry most about my vacation tend to be the ones I worry about the least. There is always at least one psychiatrist available for emergency coverage-- for this trip there were three doctors covering-- and I remain torn about whether to leave my contact information. These are competent, experienced psychiatrists who can manage any emergencies just fine without me, but what if??? Not to mention the fact that it's rare that anyone actually calls my coverage for anything other than prescription refill authorization, and even then, folks usually have checked their supplied before I've departed, or somehow they manage. So, if I leave contact information and I hear nothing, I can assume everything is fine. Or if I call and check my voicemail, and there is nothing earth-shattering, I can also figure everything is fine. But if something isn't fine, if I'm checking my messages, calling people back, getting aggravated about the non-urgent things people want (...Oh, despite the "I'm away and unavailable" message, repeated demands that I call back as soon as I return because there is going to be an issue with the patient's insurance next month...not my idea of what needs my immediate attention upon re-entry) then am I really even on vacation? I feel like one of Seligman's rats in a learned helplessness experiment--the light isn't on, it's safe, if the light is on, watch out here comes the shock.

Really, though, Doctor, it started in my professional childhood. A newbie to private practice, I was off for just a few days, and having not yet figured out that they could live without me, I gave my contact information to the covering doc, also a newbie. I left worrying about a patient who had uncharacteristically missed an appointment with me the morning before my departure. As my husband packed the car, I made one more call to his house and left yet another message on his machine. His mother, upon hearing my messages, called the covering doc (who then called me) to say he'd been killed in a car accident. There was nothing I could do, but I spent my short vacation second guessing myself-- was it really an accident? Could I have, should I have, done something different-- the accident was his fault, was there something I could have foreseen about his mental state that predisposed him to being in the wrong place at the wrong time? I also spent my trip grieving the tragic loss of a promising young life, I was very fond of this gentleman. If I had it to do over, would I have simply not wanted to know for a few more days? Even asking feels selfish.

I haven't found the right answer, nor am I really looking. I don't let myself check my voicemail, it tends to aggravate me. It is, however, the first thing I do when the plane lands, while I'm waiting for the baggage to arrive (or not), and I always feel a bit of relief when nothing too bad has happened. No one I was worried about called; there was however a message from a new referral asking that I call her back right away as she wanted to be seen within 24 hours (hmmm... ClinkShrink, do you see 'em that fast in prison??).

And for this time, the answer was that the morning I left, I emailed the covering docs with a phone number for my international cell phone. Jet lagged, feeling like it's 4AM, on my twelfth (or so it feels like it) load of laundry, wishing for my Tuscan hilltop, but mostly glad to be home.

And can you believe that neither Clink nor Roy posted any pics or cartoons while I was gone???

Tuesday, June 20, 2006

The New Asylums

This is just a brief post to recommend a documentary for those who haven't seen it yet. It's a Frontline episode called The New Asylums. This is a vivid but balanced story about correctional mental health care and the needs of mentally ill inmates. You can watch it in streaming video at the Frontline web site. I will warn you that Part 2 has a scene of a very ill, out-of-control patient that could be shocking.

Here is an observation from the documentary that I could relate to:

"We release people with two weeks' worth of medication. Yet it appears that it's taking three months for people to actually get an appointment in the community to continue their services … and if they don't have the energy and/or the insight to do that, they're going to fall through the cracks and end up back in some kind of criminal activity," warns Debbie Nixon-Hughes, chief of the mental health bureau of the Ohio Department of Corrections.

Nothing will make you feel so helpless as a former patient who calls from free society to ask how he can pay for his medication. Or who says the clinic won't take him because he has no insurance. The part of the quote I disagree with is the part that says the patient is destined to fall back into criminal activity. I cringe a bit when I hear mental illness and criminality being inextricably linked and inevitable. There's nothing like worsening the stigma of our own patients.

Monday, June 19, 2006

Car Momma

I have a terrific auto mechanic. Every three or four thousand miles, religiously, I take my vehicle in to see his Car Momma. Car Momma changes his oil, changes his filters, checks his fluid levels, rotates his tires and generally reminds me of any maintenance that needs to be done. We have been through a lot together: snapped timing belts, bent pistons, leaky head gaskets, thinning brake pads, funky air conditioning problems as well as a few bad parts that I didn't even know existed, much less what they did. Car Momma is good at explaining things, but even so I don't have any problems admitting my stupidity when necessary to ask questions. At other times she'll notice that I'm looking at her with the expression of a stunned labrador retriever, and then she'll slow down and go over things again. She gives me advice about which problems are big enough to worry about and which problems we can just wait and watch. I like her for that. If my car were a patient, I'd say its age-related problems were in stable remission. I know that Car Momma can't fix everything---like the body damage done by the omnipresent tailgaters in this city---but it was nice of her to say hi while I was waiting in the body shop. A good psychiatrist is a Car Momma for people.

Saturday, June 17, 2006

Noted In Passing

I went out to lunch today at a restaurant that specializes in organic, fair-trade, allergen-free, dolphin-safe food. While I was waiting I browsed the brochures, business flyers and cards that people left in the lobby. I found pretty much what I expected to see in a place with organic, fair-trade, allergen-free, dolphin-safe food: business cards for accupuncturists, Chinese herbalists, shiatsu, yoga and feng-shui. Then I came across one that stopped me in my tracks. It was an advertisement for...are you ready...Angel Adjustment. The flyer made a point of noting that Angel Adjustment was trademarked intellectual property, and that it was designed to promote general wellbeing. It was offered in collaboration with "Dr. X, PhD". Didn't mention what the field PhD was in. And the cost? Only $50 for a half hour, or $110 for an hour. And I didn't even know that angels needed adjusting, which just goes to show what they teach you in medical school and maybe I should demand my money back. In medical school they should teach you about the etiology, diagnosis, treatment and prognosis of maladjusted angels. After all, they make you memorize the Krebs cycle and as far as I'm aware that's got nothing to do whatsoever with my spiritual well-being.

Then there was the brochure for the "spiritual garden consultant", only $65 per half-hour. Now, if the state of your garden reflects your spiritual wellbeing then I am in seriously deep do-do. If that's the case I don't need a lawn-care guy, I need an exorcist. When I go into any kind of home and garden store, I get an inverse humane society reaction. At the humane society the lonely lost and abandoned puppies and kittens run up to you and cry and whimper for attention. At the home and garden store budding rose bushes scream and plead for their lives like I'm the next coming of Saddam Hussein. Now there's a guy with seriously maladjusted angels. Then again, I'm not really trained to diagnose that.

Thursday, June 15, 2006

Thank You For Sharing?

In the most recent issue of Psychiatric News it was announced that the Substance Abuse and Mental Health Services Administration is giving out $7.2 million in grants to develop or expand six jail diversion programs in various jurisdictions throughout the country. Some of the funds will be used to target repeat offenders, people with mental illness who get arrested as often as once a month. This is good news for both the correctional system and for those suffering with mental illness.

However, consider this part of the article which refers to the sharing of information between systems:

The next step will be linking the databases of all the elements in the system to better track offenders. Each has its own information system, but the systems are not tied together, said Alvarez.

"Someone being seen by a mental health team can be arrested, but the team won't know [the person is] in jail."

With the SAMHSA grant, the mental health center would be notified immediately and contacted again for follow-up before the person leaves jail. In between, the judge at the initial hearing will also have better information to direct disposition of the case. (italics inserted by me)

As a clinician, I'm in favor of anything that helps me provide care to my patient. If I can quickly get clinical and treatment information from a mental health center this is a good thing. I am more concerned when that information slips out of the realm of the therapeutic intervention and into non-clinical realms. Consider this hypothetical situation:

You are a successful small business owner who happens to have bipolar disorder. For years you have been responsible for seeing your doctor regularly, taking your medicine, and generally staying well because you like being well. No one has ever needed to tell you to do this. One day, after George W. announces his intention of invading Lichtenstein for harboring international tax fugitives, you decide to drive to Washington to take part in a peace demonstration. You are arrested, along with six of your Blue State terrorist-hugging friends, and taken to the D.C. jail. You know it's not a good idea to go without your lithium for a few days, so you mention this to the nurse doing your intake assessment. Three days later, at your bail review hearing, the judge decides to release you on bail. The judge announces, in open court, that due to your bipolar disorder you will be required to attend regular appointments with your doctor and take your medication. If you fail to do this, you will immediately be picked up and returned to jail. Your first thought is: "How the (insert expletive) did this judge know this and WHO gave him/her the right to announce it??"

Nevertheless, you bail out and return to your doctor. Upon arrival to your first appointment after arrest, the first words out of your doctor's mouth are: "So, what's this I hear about you getting arrested for being a Blue State terrorist-hugger?"

This hypothetical speaks for itself. Now, that being said the work-around for this problem is quite simple. Ask for the patient's/defendant's/consumer's permission. I usually don't hear this mentioned when people discuss information-sharing between systems. Some mental health clinics have another way of addressing this, by talking to the patient in advance about disclosures in the case of arrest. I think advance directives are a good way to solve this problem.

Wednesday, June 14, 2006

Roy: Quotes seen around the blogs

girl MD: "i've already had one cup this morning, but there's no such thing as too much coffee."

* * *

shrinkette: "I've made a rule here: 'No medical advice is given on this site.' But suppose that a commenter says: 'To taper a med, do A, B, and C.' Does that violate my rule? Should I delete the comment?"

* * *

bioethics: "Truth is an important component of the fiduciary responsibility of the physician to his or her patient. But as with the physician's prescription of a medication for treatment of a patient's illness, the maximum dose is not often the appropriate dose to prescribe, should the dose of truth administered to a patient be titrated too? "

* * *

blogborygmi: "If I were a fat pediatrician, I might be a little reluctant to counsel a fat child, myself, because, you know, little kids can't abstract like adults can."

* * *

mind hacks: "Transcranial magnetic stimulation (TMS) is a technique whereby magnetic fields are used to temporarily alter the function of the brain by inducing an electrical current in the brain tissue. ... Much weaker magnetic fields (about the strength of a loudspeaker) ... have also been used to induce unusual experiences by stimulating the temporal lobes ... A new project called Open-rTMS aims to develop this latter type of system (actually, generally not referred to as TMS in the neuroscience literature) and publish the plans and software online. They're currently looking for people to sign up to the mailing list and kick the project off, so if you're looking for a way to alter your state of consciousness with magnets, this might be your chance."

* * *

rebel doctor: "On-line poker is a dangerous and seductive mistress. I fight her allure (usually unsuccessfully) every night."

* * *

john grohol: "I have not been able to see either of these [reality TV] shows since I don’t have access to that channel, but the premise of both is disturbing. I’m also troubled by the idea that there are likely psychologists working as consultants in designing the shows and the experiments."

Quick Links

Here's a couple items for the curious:

If you've never been inside a prison cell (here's hoping that's most of you), I'm giving you a link to a virtual tour of the Minnesota Department of Corrections. Specifically, a single cell inside the control unit prison.

And for readers who would like to send a "goodie package" to their favorite lifer in New York, here's a link to the Prison Store. And before you comment, I can tell you right now that they don't carry shanks, sedatives, tattoo kits or a "lock in a sock". If you thought profiteering in mental health was bad, take a look at this.

If you can't find your favorite lifer, you can try the inmate lost-and-found for state inmates, or the Federal Bureau of Prison inmate locator. (Yes, you can find the Unabomber. If you can spell his name.)

Tuesday, June 13, 2006

Roy: Random stuff

Cute animated cartoon about NSA wiretaps. [Gelwan]

* * *

Sokoto evacuates lunatics from streets: It's interesting to see that, while some in the US and other developed countries debate whether folks with mental illnesses should be called patients or consumers or clients, there are other countries which use more quaint terms.

* * *

Botox smiles on depression: "A small-scale pilot trial, published in the May 15 journal Dermatologic Surgery, found that Botox injected into frown lines around the mouth or in forehead furrows of 10 women eliminated depression symptoms in nine of them and reduced symptoms in the 10th." And in a related story, researchers report successful treatment of epileptic seizures using botox injected into every muscle of the body.

* * *

Wellbutrin approved for Seasonal Depression: I expect now to see tons of Wellbutrin commercials every Thanksgiving... " 'Tis the season to be jolly..."

* * *

Monday, June 12, 2006

Investigate Your Doc

In keeping with my recent theme of entrepreneurship in medicine, I'm posting about another money-raising venture related to mental health: web sites designed to provide information about physicians. Let me say first that I think patients do have a right to know the qualifications and experience of their doctors. That's really not the issue. The issue I have is that there are businesses out there profiting from patient fear. For example: HealthGrades. This is a company that offers to provide reports about the physician of your choice, including information about internship and residency, hospital affiliations, disciplinary actions and malpractice claims. This is all pertinent information that patients might want to know about their doctors. What this web site doesn't mention is the fact that all this information is already available to you, for free, through your state's medical board. Or you can go to the reference section of your local public library and use the American Board of Medical Specialties to look up information. (Or buy your own copy! Only $649 through Amazon.)

Sunday, June 11, 2006

This Post Is Unrated

While cruising around the blogosphere and generally surfing the net, I came across a web page that advertised testing for just about everything: IQ, personality, depression, anxiety, psychosis (do many people with psychotic disorders search for online tests for it?) as well as a few for medical issues such as obesity (see last post) and heart disease. That got me thinking: What do you get if you invent a rating scale? Aaron Beck has his famous scale as well as the Beck Institute for Cognitive Therapy and Research. Robert Hare has the ubiquitous Hare Psychopathy Checklist with its national training circuit as well as books and manuals. It seems to me that mental health has become something akin to the Tai Bo of medicine. Invent the right angle, sell it and you're pretty much set for life. The pharmaceutical industry gets a lot of heat for its profit margins and marketing efforts, and as a result drug companies have limited patents for their products. After twenty years, drugs go off-patent and generic forms are introduced. Perhaps therapeutic monitoring tools like psychological tests should also have time-limited copyrights.

Saturday, June 10, 2006

Exercise Your Imagination

Alright, since certain people have objected to my frequent posts on correctional topics, here is an entirely non-corrections related psychiatry post.

Given the recent post on atypical antipsychotics in children, I started thinking about our national epidemic of obesity. According to the CDC, here are the top ten states with the highest obesity rates, expressed in percent:

West Virginia24.6

Presently 16% of children and adolescents in the United States are overweight. In addition to the commonly known medical complications of obesity, overweight children have significant psychiatric sequelae: peer and teacher stigmatization, depression, and social withdrawal. If the condition persists to adolescence, weight problems can precipitate eating disorders such as anorexia nervosa or bulimia. While treatment stategies exist, the prognosis is worsened if the condition begins in childhood and the child has at least one obese parent.

So far the evaluation of obesity in children has centered on identification of endogenous (medical) or genetic causes. Given that some atypical antipsychotics have been associated with substantial weight gain in children, drug-induced causes must also be considered.

Of course, all of these risks must be weighed (pardon the pun) against the morbidity and mortality associated with untreated bipolar disorder.

...ironically, in prisoners weight gain is considered a good thing---a healthy sign of returning nutrition after months of drug and alcohol abuse, or an indication that weight-training is paying off.

DOH...almost made it.

Friday, June 09, 2006

AGP: Antipsychotic use in kids increases

The New York Times highlights this week's article in the Archives of General Psychiatry
suggesting that the use of atypical antipsychotics in children continues to climb. At the top, you can see the relative rates at which folks enter 5 commonly-prescribed antipsychotics in Google's search engine. I would have thought that Zyprexa would have been #1 search, as it is the #1 cost drug for many state Medicaid formularies.

Nearly one-fifth of visits to psychiatrists included prescriptions for antipsychotics. This is quite disturbing, especially because nearly 40% of the kids are taking these for "disruptive behavior disorders". The drugs are approved for schizophrenia and bipolar disorders.

National trends in office-based visits by children and adolescents that included antipsychotic treatment, 1993–2002. Annualized visit rates per 100 000 population aged 0 to 20 years were calculated using National Ambulatory Medical Care Survey and US Census Bureau data:

from the NYT:
Dr. DelBello said that the field "desperately needs more research" to clarify the effects of the antipsychotic drugs, but that many children struggling with bipolar disorder get more symptom relief on these drugs than on others, allowing psychiatrists to cut down on the overall number of medications a child is taking.

HR 4157: Electronic Health Records Debate

[Cartoon by Steve Greenberg, posted with artist's permission.]

Nick Meyers, the APA Director of Government Relations, sent the following memo out yesterday, alerting psychiatric physician members about pending national legislation on electronic medical records and their impact on privacy and confidentiality of personal health information. I'll try to post more on this later, but in meantime, contact your Senators and Delegates to let them know that privacy is important to you, and that you want to be notified if there is a breach in the confidentiality of your records (see latest VA fiasco here or here or here).

This afternoon, the House Energy and Commerce Health Subcommittee approved its version of legislation to facilitate the development of a national health information technology infrastructure (H.R. 4157). The Subcommittee action follows approval of a different version of the bill by the House Ways and Means Health Subcommittee, whose Chairman, Nancy Johnson (R-CT), is the lead sponsor of the bill.

As approved by the two Subcommittees, both bills codify the Office of the National Coordinator for Health Information Technology (ONCHIT), lay out broad policy goals for the establishment of a nationwide interoperable health information technology infrastructure, and include important “safe harbors” to the Stark II anti-kickback law as the HIT system is developed. The goals of the national HIT system include the promoting of health care quality, reducing medical errors, improving efficiency, facilitating portability of patient information by patients, and promoting health care research. The Ways and Means bill includes as a goal that the national HIT system “ensures that the confidentiality of individually identifiable health information is secure and protected.” The Energy and Commerce bill requires that the system is “consistent with legally applicable requirements with respect to securing and protecting the confidentiality” of patient records.

The Ways and Means bill as introduced included a study of privacy that opened the door to possible weakening of current privacy protections, and would have allowed the Secretary of HHS broad latitude in acting by regulation to “harmonize” privacy laws in a way that could have undercut existing HIPAA rules protecting state privacy laws that were stronger than HIPAA’s basic requirements. APA, both individually and in conjunction with the American Medical Association and mental health groups including the American Psychological Association and the American Psychoanalytic Association, has always sought to include the strongest possible privacy protections as one of the essential elements of any national HIT system. We met personally with Chairman Johnson and her key health staff to outline our concerns and to offer constructive suggestions about how the bill’s privacy language could be improved. With her support, our efforts resulted in an extensive reworking of the bill as approved by the Subcommittee. While not perfect, the changes are a very substantial improvement, and Chairman Johnson certainly deserves thanks for her efforts. A more detailed analysis of the changes is forthcoming.

The bill approved by the Energy and Commerce Health Subcommittee explicitly protects the current HIPAA “non-preemption” language that ensures that stronger state privacy laws will remain in force. While this is an important acknowledgment, additional work is needed to protect patient medical records, as evidenced by recent revelations of data and record loss in the VA system and DOD, among others. During Subcommittee debate, Democrats proposed an amendment that sought to strengthen the enforcement of existing privacy protections and require a privacy breach notification. The amendment failed by a vote of 10 to 12.

What’s next? Next Tuesday, the full Energy and Commerce Committee will consider its amendment to H.R. 4157. We also expect the full Ways and Means Committee to consider the bill as soon as next week. If the two bills continue to have major differences, they will have to be reconciled presumably in the House Rules Committee. Since the House GOP leadership has designated the week of June 18 as “Health Week” it seems very likely that HR 4157 – however amended – will be a centerpiece of the week’s activities.

Wednesday, June 07, 2006


[posted by dinah]

Tony Soprano with his emotional support duck

Season Six has ended, and for the first time, I am disappointed.

Last summer, The Sopranos gave my life meaning. Why? I don't know.... It's a dramatic thing to say, but it somehow did. I'd never watched the show, though several people suggested I should... It's set in Elizabeth, NJ, the land of my childhood, and it opened with a mob boss seeing a psychiatrist. What more could I want? Still, for years, I resisted. I don't like TV (too busy blogging, I suppose) and I don't care about the mob. Until, one day my husband arrived home with the first half of the first season on VHS tapes, on sale for $5. Instantly, I was hooked. We watched one episode a night, sometimes two. I thought we were nearly done, when I discovered another tape; I was disappointed.

"I thought we were making progress," I said.

"I don't want to make progress," he said. "I want to watch TV."

We finished the VHS tapes, and I started to rent the sequential episodes at Blockbuster. Only, I had to watch them in order, so there were days I would call four different Blockbuster stores searching for the right volume of the right season, and then run around town fetching and returning the DVDs. Maybe it didn't give me meaning, but it did give me focus and purpose, and it kept me busy (actually, I didn't have a blog back then). It wasn't as good as talking to prisoners while sitting on an upside-down bucket, but I was able to negotiate these transactions without the aid of a support goat.

The summer ended and we'd made progress; we'd seen every episode. At some point we even caught up enough to watch The Sopranos with the rest of the world on TV as it was aired.

My favorite plotline will always be the insatiable priest who was fixated on Carmela's home cooking with this odd sexual twist to his appetite. "I've got the only priest who's straight," she lamented. And didn't you love (and squirm a bit) when Tony had Dr. Melfi's car stolen to repair it? Finally, there was something rich about his dilemma of how to present his career to his own children-- his sense of wanting AJ to be like him, but to be protected from his world as the central conflict he brought to psychotherapy. Oh, I could go on and on....

There were some frustrating moments in the earlier seasons as well. Dr. Melfi was developed in the second season (I think it was the second season) as being torn about treating Tony...she is stressed by the issues that arise in his therapy, and we get insights into her quandary through her sessions with her own psychiatrist, Eliot. At one point, she confesses to Eliot that she is drinking too much, and agrees to go to an AA meeting-- the plot line drops here and we never hear about this again. I didn't forget, however, and waited an entire season for it to resume before I finally faced the sad truth that this had been brought into the script for no apparent reason. And I wasn't sure what to make of Dr. Melfi's rape-- I wondered, as I suppose the script writers would like, if Tony had something to do with this, though apparently not. Again, a couple of episodes and the fact of the rape was as though it had never happened.

So, this season: I thought the whole suspense of whether Tony would die (of course he wouldn't, he's the protagonist!) was too drawn out, the hospital scenes became tedious, the issue of his changed identity in the fantasy scenes from the coma...They did nothing for me. Vito, the not-so-closet homosexual was destined to die, and it felt so unfair, but that was perhaps the one plot line seen to completion. Christopher's back using drugs, Carmela remains hung up on what happened to Adrianna...I suppose there's another season, but it was a bit frustrating to have this season end on Christmas shot, shown in my living room in June.

I did get one answer, though. A number of posts back, I talked about my criminal patient and referred to Tony Soprano and how I didn't know what he was working on in treatment any more. In this season's final episode, he said to Dr. Melfi, "I come to hang out with you; the therapy's not going nowhere anymore." (or something like that) He adds the insight that the women he's attracted to for his extra-marital affairs are all like her.

Okay, there are more episodes to come. I hope they're worth the wait.

Tuesday, June 06, 2006

Side Effects: Possible Death

This recent post about involuntary medication & the potential to leave patients in limbo in the hospital reminded me of the recent dilemma involving Russell Weston, the Capital Hill shooter. Eight years ago this chronically mentally ill man walked into the Capitol and killed two people, wounding a third. Although suffering a chest wound, he received treatment at the scene and survived. He was hospitalized and taken to court for involuntary medication. The medication order was initially granted but the order was stayed to allow his public defenders time to appeal. The issue: if restored to competence, Weston could face the death penalty. Thus, he was kept untreated for years while the issue was litigated. Finally, in 2002, the Supreme Court turned down his final appeal and he was treated involuntarily. A four year hospitalization without treatment.

Dangerous on the Outside

[posted by dinah, not ClinkShrink]

The Maryland Psychiatric Society Council Chairman writes:

A case currently working its way through the Maryland legal system may jeopardize our ability to treat involuntary patients who are refusing medications.

To go before a Medication Review Panel, a patient must have already been deemed psychiatrically ill and dangerous outside the hospital by an Administrative Law Judge. A lower court decision in Kelly v. DHMH changes the interpretation of the Medication Review Panel law to require dangerousness inside the hospital in order to justify forced medication. This creates a situation where a patient, committed to the hospital by an Administrative Judge because they are dangerous if discharged, cannot be treated because they are not dangerous inside the hospital. The patient would therefore have to remain in the hospital indefinitely without proper treatment and with little chance of safe discharge.

--bolding mine, letter excerpted with permission.

I'm not an inpatient psychiatrist, and I'm sure ClinkShrink will have volumes to add-- ah, the case in point is one of an inpatient at Patuxent, a forensic facility-- but I'm wondering how this works.

Let me try for a scenario. Patient is delusional about a neighbor, thinks the neighbor is implanting electrodes in his body while he sleeps, might need to kill neighbor (remember, I'm inventing this, please feel free to add a better fictional case). He's hospitalized, where he's free from delusional intervention, says he still might need to kill the neighbor, but is not violent on the inpatient unit, refuses meds, can't be forced to take them-- he's not dangerous in the hospital-- and can't be discharged because he remains delusional about neighbor and potentially is homicidal. For the sake of completeness in my fictional scenario, the neighbor exists and is not implanting any electrodes in anyone.

I would contend that since the patient's premise is delusional, his reality testing impaired, there is no guarantee that he is not dangerous in the hospital (actually, there is no guarantee that anyone is safe anywhere, but....). What is to say he won't suddenly become delusional about a nurse, or believe that the neighbor has entered his hospital room (delusions do tend to follow people) and what is to say he won't elope from a locked unit? I have worked in three different psychiatric hospitals where inpatients have committed suicide on the units-- if people are hospitalized to prevent suicide, it's not totally fool-proof.

Somewhere in here there is the assumption that psychiatrists and/or judges can predict violence and be certain of who is safe and in what setting. If only that were true. The Last Psychiatrist contends, "We spend a lot, a lot, of money and time hospitalizing people who are not going to die."*

So, eventually our fictional patient gets tired of years on the inpatient unit (I could make jokes here about withholding cigarettes, but I'll resist the urge), takes his meds, is quickly cured, and goes home. A few weeks go by, during which time he and the neighbor share herbs and tomatoes from their respective gardens, and finally, our fictional patient decides he doesn't need treatment and stops his meds, only to become delusional all over again. My point being that while we may want to involuntarily medicate dangerous, mentally ill patients for the safety of society, once they are back in "free society" they are free to stop their meds. Treating mental illness in people with dangerous behaviors continues to represent a delicate balance between the rights of the individual and the safety of others. I've nothing brilliant to add.

Quick closer-to-real life scenario and a link to a forced-medication tale:

When I was a newbie resident on an inpatient unit, I briefly had a patient who was mentally retarded with a psychotic disorder. He would stop his medications, have a few beers, and the voices would order him to kill children. He had no history of violence, no one knew if he really would kill children, but the family repeatedly got a bit anxious when he sat on the front steps with a machete. This was his tenth hospitalization for the same chief complaint. He'd come in, restart meds (including a shot of prolixin decanoate), and be discharged within a couple of days, only to repeat the pattern. So, if I'm thinking about Kelly v. DHMH, then I'll wonder if the rest of our laws make sense.

And finally, Tuboglacier, the psychiatrist who blogs at May Shrink or Fade, writes a story on a similar theme in Substituted Decision Making, with Clam Juice.

*(-- I might suggest that perhaps hospitalizing them worked and that's why they don't die, but that's another post for another day)

Monday, June 05, 2006

There Are No Atheists In Foxholes. Or Solitary.

When it comes to reading correctional litigation, some of my all-time favorite cases come from the First Amendment issues.

When it came time to figure out if inmates had the freedom of religion, the first thing the courts had to decide was how to define a religion. The line of cases that lead up to this involved a prisoner by the name of Harry William Theriault. Harry Theriault was a Federal prisoner incarcerated for various offenses who founded his own prison-based religious order, the Church of the New Song---conveniently acronymed CONS---but which he also called the “Eclatarian” faith. He claimed that while housed in the lockdown facility in Marion, Illinois he experienced visions of a force known as “Eclat” who instructed him to found the new religious order. He acquired a Doctor of Divinity certificate through mail order, and appointed a friend and fellow inmate as the First Revelation Minister. Theriault appointed himself the "Bishop of Tellus." He and his First Minister proceeded to file a series of First Amendment actions against the Bureau of Prisons and the chaplaincy service for failing to provide them with the means and opportunity to practice their faith---a faith which coincidentally required a substantially improved diet, free access to open meeting facilities for all believers and the freedom to conduct seminars designed to "destroy the prison system, the people in the prison system, the people in the parole system, the people in government in general, the judiciary," et. cetera. As word of the new faith spread through the Federal prison system, new believers were added to the suit. This process was facilitated by Theriault’s own travels through the prison system; at various times he was held in at least three different states due to his threats of mass violence and murder, destruction of prison property and assaults against correctional officials. In spite of Theriault’s own testimony that the Eclatarian faith began as a "game", the U.S. District Court in Georgia ordered the Bureau to allow him to have access to a chapel or auditorium to hold services. Before this could be accomplished Theriault was soon back in solitary confinement for destroying his cell and assaulting a correctional supervisor. Prison officials were held in contempt for failing to provide services, and the District Court ordered Theriault’s release from disciplinary segregation. He was transferred to a Federal penitentiary in Texas. Once there, he filed again in Texas Federal court for access to the prison chapel. The petition, now expanded to include 166 prisoners, was quickly dismissed by the U.S. Court of Appeals but Theriault had nine others pending at various stages of litigation. Eventually the Church of the New Song was excluded from First Amendment protection on the grounds that this amendment was not intended to protect "so-called religions which...are obviously shams and absurdities and whose members are patently devoid of religious sincerity." This eventually became known as the "sincerity of belief" standard.


  • Theriault v. Carlson, 495 F.2d 390 (1974)
  • Theriault v. Silber, 391 F.Supp. 578 (1975)

Sunday, June 04, 2006

How Jung?

In today's New York Times Magazine, The Soprano's Lorraine Bracco is interviewed in The Doctor Is In :

Why, on "The Sopranos," did you choose to play a psychiatrist of the Jungian school in particular?
It's what I wanted to be. I like that psychiatry better. I identify with it better.
What's wrong with Freud?
You know, I don't really know enough about it to discuss it on a bigger level, but I went the Jungian way in the show.

Maybe someone can help me here: what, exactly, is Jungian about Tony Soprano's psychotherapy with Dr. Melfi?

Double Poppycock

Dr. Eliot Gelwan blogs about British psychiatrist Dalrymple's musings ("Poppycock") that the dramatic and gut-wrenching symptoms which accompany narcotic withdrawal are induced by the presence of a sympathetic (and script-wielding) individual, and that the nature of addiction is essentially based on one's character defects (now there's an original thought).

Says Dalrymple:
I have witnessed thousands of addicts withdraw; and, notwithstanding the histrionic displays of suffering, provoked by the presence of someone in a position to prescribe substitute opiates, and which cease when that person is no longer present, I have never had any reason to fear for their safety from the effects of withdrawal.

Gelwan wisely concludes:
I largely agree that withdrawal from opiates is highly overrated, and that addicts have a hard time being honest with those of us to whom they come for assistance. However, ... the fact that Dalrymple works in the penal system ... is probably what stops him from being more compassionate toward these unfortunate individuals who have so little in the way of coping mechanisms... .

Both psychiatrists correctly point out that narcotic withdrawal generally won't kill you, but alcohol or sedative withdrawal may. However, to contradict Dr. Dalrymple (I love how that sounds), I am certain there are a number of lab animals which would clearly demonstrate withdrawal symptoms, whether or not in the presence of a nice scientist with a syringe full of relief.
Clink: He's got your (support) goat!

ClinkShrink Update

Psychiatry Shortage Grows 50%

Merritt Hawkins & Associates, one of the country's biggest physician search companies, reports that in 2005 there was a 48% increase in requests for psychiatrist searches. They attributed this to a "growing demand for behavioral health services and a diminishing supply of psychiatrists." (Duh.) But here's the interesting part:

"A growing number of facilities, many of them state funded mental health facilities or correctional facilities, are unable to recruit the psychiatrists they need and are reliant on temporary (i.e., locum tenens) practitioners to fill gaps in their staffs. We project that psychiatrists will become increasingly difficult to recruit and that the need for additional psychiatrists will become acute in the next five to 10 years."

Apparently when it comes to "fill order", public institutions are the last places to get physicians.

Free Society Sees Longer Waiting Times

According to a story in today's Los Angelos Times, the waiting time to see a physician has grown. Here are the delays they report:

  • dermatologist: 24 days
  • gynecologist: 23 days
  • cardiologist: 19 days
  • orthopedic surgeon: 17 days

I think this is interesting because some correctional systems require that inmates with positive intake medical screens see a physician within seven days---at least twice as fast as the waiting time in free society. And these are systems with the highest patient loads and the most difficult recruitment issues. Why are correctional facilities held to higher standards than free society?

Saturday, June 03, 2006

Public Psychiatry and Free Speech

For those of you working in public institutions in this country, the United States Supreme Court ruled three days ago that you have no First Amendment right to job-related free speech.

In Garcetti v. Ceballos the majority opinion stated:

"When public employees make statements pursuant to their official duties, they are not speaking as citizens for First Amendment purposes, and the Constitution does not insulate their communications from employer discipline."

In this case an employee of the California district attorney's office, Richard Ceballos, came to believe that a sheriff had presented false information in order to obtain a search warrant. Ceballos prepared a memo and presented it to his supervisors, who decided to procede with the prosecution. Ceballos was later demoted and transferred in retaliation. He filed suit against the district attorney's office (one of the defendants was Gil Garcetti, supervisor of the O.J. Simpson prosecution).

Eventually the case wound its way up through the 9th Circuit Court, which ruled that his speech was protected under the First Amendment. The state appealed, and the Supremes argued the case twice, once on October 12, 2005 and again on March 21, 2006 after Samuel Alito was appointed. The opinion was split along the lines of the usual suspects: Kennedy, Roberts, Scalia, Thomas and Alito ruled against the employee protection while Souter, Stephens, Ginsburg and Breyer dissented. In his dissent, Justice Breyer recognized that certain professions have ethical standards which compel them to speak out under certain circumstances. For example, prosecutors have an obligation to disclose exculpatory evidence. He also cited a case familiar to correctional psychiatrists:

"So, for example, might a prison doctor have a similar constitutionally related professional obligation to communicate with superiors about seriously unsafe or unsanitary conditions in the cellblock. Cf. Farmer v. Brennan, 511 U. S. 825, 832 (1994). There may well be other examples."

Breyer favored constitutional protection for government workers under specific circumstances:
"Where professional and special constitutional obligations are both present, the need to protect the employee's speech is augmented, the need for broad government authority to control that speech is likely diminished, and administrable standards are quite likely available. Hence, I would find that the Constitution mandates special protection of employee speech in such circumstances."

The majority of justices ruled against this. They felt that constitutional protection was unnecessary given the existance of Federal and State whistle-blower laws, various labor laws and professional standards that mandate certain speech.

Friday, June 02, 2006

My Favorite Contraband

If you ever get a chance to visit Vancouver, I encourage anyone with an interest in forensics to visit the Vancouver Police Museum. They've got a great array of exhibits---historical information about the Vancouver police, recreations of various crime scenes (including the axe used by a sixteen year old to kill his parents back in the 1950's), and a forensic medical display (not for children). One of my favorite displays was the collection of contraband confiscated from arrestees. Several times my first thought was: "How the heck would they hide something like that? And wouldn't it hurt??"

Of note, one picture I saw there was of the top police sharpshooters on the police force back in the 1920's or 1930's. The top five shooters were all women. Ironically, regulations then did not allow female officers to carry guns in the field.

Salt Mines

[posted by dinah]

I'm stealing a thought from Shiny Happy Person (and I do hope she is), the psychiatrist who blogs at Trick-cycling for Beginners.

SHP wrote:
Why, when so many of my patients are adamant that they do not have an illness, are they so keen to demand Disability Living Allowance, Incapacity Benefit, and free bus passes for those with a disability?

I've been perplexed for years about the relationship between mental illness and the ability to work. It's not that I don't think people with disabling mental illness shouldn't get benefits: I do. What I don't get is how we know when people can't work versus when they won't work, and I haven't observed a great correlation between severity of symptoms and ability to work. So, I see patients who are on disability for Depression or Bipolar Disorder who, on mental status exam, report that their mood is euthymic, their sleep and appetite normal, there are no psychotic symptoms, the medicines are working, and they are busy with a number of activities. Now, granted, these are chronic and intermittent illnesses; some of these patients have been hospitalized, all have had episodes of severe illness, but they also have periods of stability. This is not to be a comment that they should be working, just an observation.

On the flip side, some of the absolute sickest patients I have seen have worked despite their illnesses. One woman's anxiety clamped down her life such that she could tolerate no social events outside her home at all. She couldn't go to a movie or a restaurant (funny, she did have a pet but this was years ago, in the era before Emotional Support Animals, but she also had a family so if they couldn't get her out in public, would a Duck have helped??? Okay, I'm straying here, forgive me). Still, she got to work every day. And the happy ending to that story is that when SSRI's came out, her social life resumed.

The most depressed patient I have ever seen lived with constant misery, non-stop suicidal ideation, extreme guilt, constant self-criticism, and the only symptom that really responded to medication was her extreme irritability and sleeplessness. Still, this was a medical professional who repeatedly won awards and raised a family.

The most psychotic patient I have ever treated spent years in a state hospital. She is plagued by delusions and hallucinations, her symptoms dictate her every move. The symptoms here are so extreme and so unique that confidentiality concerns limit my ability to fully discuss this case, or even to distort it. In the years I've treated her, she has always had a job....well, almost, there was one brief period where she was too ill to get to work and she's left a job or two for reasons that probably haven't related to reality. A trained professional, she's at times taken positions well-beneath her abilities just to pay the bills. I would recommend she apply for disability in a flash, but it's never come up.

And finally, I once treated a man who had never worked. He'd been receiving psychiatric care since he was 10, lived with his father, never finished school despite a documented IQ in the 150 range. He struggled after the father's death, living in his dilapidated childhood home, intermittently doing chores or running errands for neighbors. He told me he didn't believe he could maintain a job at Burger King, that it might fly for a while, but he had periods where he just couldn't do anything. With decades of failures behind him, no stories of success, I believed him. The Disability folks did not, and his final appeal was denied. And so, when I see a patient who left work a few years ago, whose symptoms are now controlled with medication, who says they can't work and gets regular payments, I'm often left wondering.

Just my thoughts, no answers here, and I'm sure some of you will have great references to post, I won't steal your thunder.