Monday, July 31, 2006

The Lost Chart

[posted by dinah]

I seem to have misplaced a patient's chart. My office is small-- a single room and a very important closet-- and I never took it home, so I know it's somewhere. I've searched every pile, I've gone through the file drawers twice, thumbing each and every file folder along the way. It will show up, I've misplaced charts before and they always show up, usually wedged into another chart or fallen through the hanging files, so I'm not actually worried, it's just the frustration of knowing it has to be there and it isn't.

There's nothing too crucial in this particular chart; if the patient shows up before the chart (and right now, that's a distinct possibility), it will be fine-- I remember her story, remember her meds, there are no irreplaceable consultants' notes, no labwork to be tracked down, it's just the idea: a medical record shouldn't be misplaced, though it happens all the time in clinics, but this is a single office, just me, it has to be there.

First, a little about the patient*. Ms. G first consulted me a couple of years ago. Her previous psychiatrist had moved away, she was down and wanted to resume the medication she'd found helpful, and her life was a mess. By the second appointment, she'd compiled a type-written list of what she wanted to change (oops, that list is in the missing chart). The list was four pages long. She came to a few sessions and then disappeared, calling once to ask for a refill, and then who knows? I wondered, I may have even called and left a message, or maybe I didn't (I probably didn't document "calling to ask how you are" so not in the missing chart). Time went by, well over a year, and she called to request an appointment.

"I want to resume therapy. I'm ready now." I asked what had transpired in the intervening seasons. Things had gotten much better. She'd left the dysfunctional relationship that was causing her so much discomfort. She is seeing a nice guy who treats her well. She stopped (well, almost) smoking pot. "I really didn't like that you thought I had a problem with it," she said. She'd quit (well, almost) to prove me wrong. I'll take it.

I listened.

"So," I said after enough listening (well, almost), "let me get this straight. You're smoking less, you've gotten out of that hellish relationship, you've met someone new and wonderful, you're feeling much better."


"And," I continued "you did this all on your own without psychotherapy, and now that everything is going well, you want psychotherapy?"

She laughed. We set a schedule, and other than a misplaced chart, the sessions are going well.

This afternoon, I scoured the office again. Maybe it's with my dead charts, I thought. I keep charts for patients whom I haven't seen in years, and don't expect to ever see again, in a separate drawer, but I keep them, because I've learned that no chart is really dead, people pop up when I least expect them. I'd been in that drawer recently to dust off the chart of a patient who showed up after a four-year absence.

There' s something hard about going through the dead chart drawer. I'm hit with names of people I don't recall, names that don't even sound familiar. I never pick them up to see, maybe this was someone I saw only once ten years ago, maybe it was someone I saw as coverage for another doctor. Or I see a name and it jogs my memory for a person or a story I'd long ago forgotten. What's the hardest though, is seeing the charts of those patients I'd seen for years, people I knew intimately, and wondering what became of their lives. Some of them disappeared from therapy without an explanation, or even if their was an explanation--maybe never clearly articulated but understandable, like a change in their health insurance or simply being tired of commuting an hour and a half each way to come to appointments-- I'm left wondering where they went, why, how they feel about the therapy they never ended, if they left angry, tired, or simply stale. Some of them, I know (ah, I've learned to call people who just disappear) simply tapered away when they felt better; they hadn't meant the last appointment to be the last, but simply felt the work was done. So there's the chart of the woman with really really bad OCD whose son died during her treatment and the horror of that night, of that phone call, rushes back at me. And there's the chart of the young man who was tormented by his inability to fall permanently in love (he was so young, the story hadn't yet been told), it's been years, he'd be in his early thirties by now: I wonder he'd ever married. Or the gentleman who got lost enroute to the first session at my new office, and after years of therapy had never come back. When I last called him, he sounded awful; he'd be in his late eighties by now, and I feel sad to think that he's possibly been dead a good long time. A book he gave me sits on my shelf. And there is the chart of man who left treatment to pursue something a bit fringy-- I'd heard his new psychiatrist lost his license, read in the paper that his wife had died and had, years after last seeing him, gotten a phone call one morning to hear his intoxicated and distressed voice, just calling to say hello. And finally, there's the chart of a patient who left angry, and of another who also left angry, and I'm left wondering how many others left with bad feelings.

Sometimes it's simply like the projector broke in the middle of the movie and I just want to know how the stories turned out. Other times, it's like looking at photos of my children when they were toddlers-- good things, good memories, but something about it is inexplicably painful.

The dead file drawer is hard. And Ms. G's file was not to be found.

(*Not her real name. Note the patient details are all obscured; I am mostly real.)

Psychiatry Board Exam Recertification

I take my Psychiatry Board recertification exam tomorrow. I was in the second year of people who had to recertify every 10 years, to prove that you keep up to date, rather than coasting on your laurels for the rest of your life.

The initial exam is a nerve-racking affair, consisting of two parts, about a year apart. Part I is a written (now computerized) exam, 6 hours of delightful multiple choice and K-questions, #2 pencils and monitored bathroom breaks (you know how a watched pot never boils? ... well... you know).

Part II is where at least a third of examinees fall down, succumbing to anxiety-stricken paralysis or fumbling mental status exams as you examine a real live patient in front of two real live psychiatrists for precisely 30 minutes, then spend another 30 minutes getting grilled and probed to determine if you know what you should know. A colleague of mine had a patient who peed in the corner of the room, then just stared, not uttering one word for half an hour. (He passed, with a measure of sympathy thrown in, no doubt.)

The recertification exam is a 5 or 6 hour computer-based test. I haven't studied one iota, lazily figuring that it should test me on real-world knowledge. At $2100, it's a bit of a gamble to not study... but as long as I don't pee in the corner of the room, I figure I should be okay.

Sunday, July 30, 2006

The Andrea Yates Case

[Dinah hates this
logo. What do you
I've seen a couple comments on the blog asking for a post about the Andrea Yates case. I know this would be an obvious topic for me, but I haven't touched it for a couple of reasons. First, I've been annoyed? pissed off? about the recent murder—the second one this year—of a correctional officer in our system that I figured it would be best to avoid the blog for a few days. I'm thinking there should be at least as much outrage over the premeditated killing of a law enforcement officer (see links in Officer Down), committed by two convicted murderers in a maximum security facility on lockdown, as there was over the deaths of the poor little kids in the Andrea Yates case. But enough about that. The legislative inquiry has begun and what must be done will be done.

The other reason I haven't blogged about it is because frankly, from a professional standpoint, it's not that interesting. If the jurisdiction had been any place other than Texas this would have been an uncontested insanity case, a legal walk-through. She had a documented psychotic disorder with an established treatment history. There was no question of drug or alcohol involvement, at least from what I've read in the media. This case became a media event because it was a death penalty case and because it presented political issues related to women—the burden of child-rearing and the role of men in childcare (especially for large families). Frankly, if the defendant had been a man I doubt this case would have gotten as much attention. Carrie made an interesting observation in a comment on my post Why I Hate Jason Burke:
One friend said that you'd have to be crazy to kill your own kids...well that should be proof enough right there that she wasn't in her right mind!
Not so. Most infanticide offenders are not psychotic, and most are male. Some infanticide (called neonaticide when the victim is a newborn) offenses are committed by young women who deny their pregnancy and are able to hide the pregnancy for months from friends and family. Women who kill older children also do so for non-psychotic reasons—remember Susan Smith? The killing of older children is sometimes prefaced with earlier incidents of child abuse and neglect. Full demographic and other background information about child offenders can be found here. As with most violent offenses, drug and alcohol abuse usually plays a role.

So there's my comment on Andrea Yates. I'm not going to comment on whether either of the two verdicts were 'right' or 'wrong'. I don't have access to any of the evidence and that's just not my call to make.

Happy Birthday, Vanuatu

My Dad was a ham radio operator. When I was a kid I sat on his lap and listened to him talk to people in exotic far away places like London and Germany and Iowa. He exchanged QSL cards with them, postcards that had radio call letters printed on them and short messages from the people my Dad talked to.

I think that's why I'm so fascinated by the range of people all around the world who stop by to read this blog. When I write something I get curious about how people from other cultures relate to what I'm saying and what they think about it. I want to ask questions and compare experiences. Today, in honor of all those readers from "somewhere else", I am going to dedicate this post to the smallest country ever to visit Shrink Rap: Vanuatu. Today is Vanuatu's Independence Day.

According to the CIA World Fact Book (does anyone else find it disturbing that the CIA keeps records on all this?), the natural resources of Vanuatu include manganese, hardwood forests and fish. It has active volcanoes and beautiful lagoons that inspired James Michener. It has typhoons, earthquakes and tsunamis. You can get some very nice real estate there too. I think we have much in common. We at Shrink Rap live near a beautiful harbor. We have natural resources like crabs and Old Bay Seasoning and the Orioles (American League champions in 1969 with 109 wins and 53 losses). We have natural disasters like tropical storms and floods and movies filmed here starring Meg Ryan and Kevin Spacey. And the Orioles (54 wins, 107 losses in 1988).

Tying all this in to Shrink Rap, I need to mention that Vanuatu also has at least one prison that houses all of 50 people. It looks like you all are working some new reforms over there, and that's exciting. I wish you the best of luck on your new Correctional Services.

And don't forget to stay in touch.

[Google Analytics Map of Shrink Rap hits for July 6-7, emphasizing Vanuatu]

Saturday, July 29, 2006

[Roy] Random searches

One of the things that bloggers get a kick out of (I know I do) is to look at the search terms people used that led them to the blog. I use Google Analytics to review our logs, which is one of the best log analyzers I've ever used. Here are interesting search phrases that led to Shrink Rap.

good breast
As if you were praising a pet or something. Stay.

breastfeeding campaign bronco riding
Now there's an interesting visual.

NFL player who still drinks breast milk
If he gets it from the above chick, it would be a milkshake.
51,000 hits on this search and Shrink Rap is #1. Good blog.

gleason xyrem
Poor guy. He's getting screwed. Probably cataplectic by now.

"put down the duck"
Step away from the duck and put your hands in the air.
#1 search here, too; not surprised.

myspace vs reality
Is it really one or the other?

they might be giants
Not really, but now there will be some.

Friday, July 28, 2006

Why I Hate Jason Burke

I'm posting this story as a warning to anyone who might be tempted to order medicine or other drugs through the Internet.

It all started about a year and a half ago. I got home from work and found one of those automated messages on my answering machine from Federal Express. The mechanical woman's voice (why are these telephone automatons always women?) telling me that there was a package for Jason Burke, and that it would be held for five days. I didn't think to much of it, except to hope that Jason Burke would think to call FedEx to find out what happened to his package. About a week later, I came home to find several “hang up” calls on my answering machine. Later that evening I got a phone call from a heavily accented Hispanic man asking for Jason Burke. I explained that he had the wrong number.

A month or so later, the same thing happened again---the automated FedEx message followed by the Hispanic caller, all looking for Jason Burke. By now I'm starting to think I've been the victim of identity theft. I did all the things you're supposed to do for that, checking my credit card statements etc, and nothing seemed to be amiss. Finally I called FedEx, after discovering that this company purposely does not list the local phone numbers of any of their offices---what a pain. The person on the 1-800 FedEx number assured me that they would change the number listed for Jason Burke's account.

A month later, same thing---FedEx call, followed by multiple Hispanic phone calls. This time I went to the local FedEx office myself. “I'm the person who is not Jason Burke,” I announced. The district manager pulled out the package in question: “You don't live at...(announcing the address, which I'm very tempted to post)? You didn't order something from the online pharmacy?”

“No,” I said. “Do I look like a Jason Burke?”

“We'll change the phone number on his account. He's a regular customer.”

That didn't surprise me. To make a long post longer, I got nowhere with FedEx, which never did change the number, or with the multiple Hispanics who called me from the Mexican online pharmacy asking me if I needed a refill on my Vicodin. Finally I called Jason Burke, whose number is publicly listed and FedEx could easily have looked up. Turns out that Jason Burke used my phone number to order his drugs. More than once. The first time I called him he sounded totally stoned. After he sobered up I to sue him again if he continued to use my number. He canceled his Mexican online pharmacy account.

The Mexican online pharmacy is still calling me regularly a year and a half later, sometimes as often as eight times a day. That's why I'm posting this story as a cautionary tale for anyone thinking about ordering medications through the Internet. If you do it once, they will haunt you forever. If someone uses your phone number to do it, they will haunt you forever.

In the meantime, Jason Burke's correct phone number is...

No, I can't do it. Besides, it's public information. Anyone can look it up.

Thursday, July 27, 2006

Ranting on Dr. A's Blog

I've been visiting Dr. A's blog and ranting there about the case where the courts have taken partial custody of a child when his parents have supported his decision not to continue with chemotherapy for Hodgkin's disease. Anyone want to rant with me?

[posted by dinah]

Wednesday, July 26, 2006

Officer Down

As of last night, here is the official body count for 2006:
  • Three murdered inmates
  • Two murdered officers
Enough said. It's time to rethink Project Restart:
Project RESTART as a whole has been criticized by the state prison workers' union, the American Federation of State, County and Municipal Employees (AFSCME), which accuses the administration of Gov. Robert L. Ehrlich Jr., a Republican, of emphasizing rehabilitation at the expense of safety by adding counselors and case managers while the number of correctional officers has declined at some institutions.

Disclaimer: The opinions expressed in this blog are my own, expressed while off-duty, and do not represent those of my employer or the state government. Please don't let an inmate kill me Governor Ehrlich.

Tuesday, July 25, 2006

[Roy] God as a natural phenomenon

Dan Dennett spoke in February at the TED Talks (Technology, Entertainment, & Design Conference) about he idea that the concept of God and spirituality is a byproduct of human evolution. It's about 20 minutes and is worth listening to.

It made me think more about the previous discussion about how one accepts or rejects responsibility over one's behavior based on knowledge of one's genetic code. This talk had me thinking about how some do "God's will" unquestioningly, as in "It's not my fault I blew up the abortion clinic" ... while others do good will while being atheists. Have a listen.

Also on the TED blog is a speech by Al Gore on global warming and a hilarious talk by Sir Ken Robinson on how children are taught to stop being creative early on. On University Professors: "They look upon the bodies as a means of transport for their heads... It's a way of getting their heads to meetings. "

Off Label; In Jail

[posted by Dinah > Blogspot ate it > spit half back up > whole post found by Roy, enabled by Safari's RSS feature]

And now for the re-posted post:

From last week's New York Times:
Indictment of Doctor Tests Drug Marketing Rules

At first, Dr. Peter Gleason thought his arrest was a joke.

Dr. Peter Gleason, 53, promoted Xyrem for purposes other than those approved by the federal government and now faces charges.

In the early afternoon of Monday, March 6, half a dozen men in suits surrounded Dr. Gleason, a Maryland psychiatrist, at a train station on Long Island and handcuffed him.

Dr. Gleason, 53, was taken aback because he was arrested, and later charged, for doing something that has become common among doctors: promoting a drug for purposes other than those approved by the federal government.

But prosecutors say that Dr. Gleason went too far. At hundreds of speeches and seminars where he was rewarded with generous fees, Dr. Gleason advised other physicians that a powerful drug for narcolepsy could be prescribed for depressionand pain relief. In doing so, he conspired with the drug's manufacturer to recommend it for potentially dangerous uses, the prosecutors claim.


The article goes on to discuss how Dr. Gleason prescribed Xyrem to 100 patients before the pharmaceutical company recruited him to promote the medication. He promoted the medication for off-label use and down-played (even lied?) about the risks, saying table-salt was more dangerous and that the medication was safe to use in children. These talks were given to physicians, the medication has a black-box warning, and the active ingredient is one found in date rape drugs, so it's possible his physician audience might not have believed his claims, or at least approached them with some skepticism (I can hope?). Did he tell his audience's he was being paid by the drug company to talk? No clue, but anywhere I've given a speech, disclosure of financial interests is mandatory.

I've actually heard of Xyrem only once, at APA when I talked to a drug rep about it-- when I heard the amount of paper work required to prescribe it, I figured I wasn't going to be using it anytime soon. I'm not the biggest fan of addictive medications anyway, as I worry that the problem I will create will be bigger than the one I've solved.

In psychiatry, we use medications "off-label" all the time. We see people who are suffering, and if they don't respond to the conventional stuff, we try something else. And we talk to each other, conveying anecdotal tales all the time--please don't put me in jail. And off-label stuff works, people get better. If I know I'm giving something off-label, I tell the patient. Sometimes I don't realize it. For example, a patient brought me an article the other day showing me that Wellbutrin XL is the first medication approved for Seasonal Affective Disorder. I've been treating people with anti-depressants for SAD for years, it never occurred to me that if their depression occured in winter then nothing was specifically approved for those depressions.

From the Press Release from the Department of Justice:

As alleged in the indictment and a previously filed complaint, Xyrem’s manufacturer, Orphan Medical, Inc. (“Orphan”), relied on GLEASON to give lectures around the country promoting Xyrem to physicians for “off-label” indications and paid GLEASON tens of thousands of dollars for such speaking engagements. In 2004 alone, GLEASON spoke at over 100 events and was paid more than $70,000. GLEASON was allegedly in high demand by Orphan sales representatives because of his proven ability to generate “off-label” sales of Xyrem in their respective sales territories. The indictment charges that GLEASON engaged in deceptive and misleading behavior in promoting Xyrem by, among other things, suggesting to physicians that GHB was not a “date rape” drug, and that Xyrem was safe for very young children when, in fact, the drug’s labeling stated that Xyrem had not been proven safe and effective for people under the age of 16. The indictment also charges that GLEASON conspired with Orphan employees to defraud public and private health insurance plans by concealing, and advising prescribing physicians to conceal, evidence that Xyrem prescriptions were being filled for “off-label” indications that generally were not reimbursable.

For my own disclaimer: though Dr. Gleason is from Maryland, I don't know him and have never heard of him. And I don't think physicians should make money by promoting off-label medications for drug companies, effectively being their paid mouth-pieces to say what the company can't say. Interestingly, the drug company in this case is not being charged with anything. I don't know if Dr. Gleason is the only physician in the country paid to promote a medication off-label, though I'm assuming, maybe erroneously, that it's not known to be illegal to do so. I'm not sure why the number of speeches he gave or the amount of money he made is relevant.

So what's the purpose of this post? I suppose I read the article and was left thinking, even if he lied, is this a crime? Not, was the doctor right or would this be reason for an ethics query by a professional board, but is this reason for criminal prosecution? I figured I'd put it out to the blog.

Go Red For Women

This isn't strictly a psychiatric post, but it's not about inmates for a change so I guess it's OK. I just thought I'd drop a short note on the blog to remind people to watch their cholesterol, exercise regularly, control your blood pressure and stop smoking. In spite of what the blog says about Death and Hot Fudge Sundaes, do it anyway. I rather like our blog readers and I'd like them to be around for a while. I also thought I'd let people know that the American Heart Association has a program called Go Red For Women, designed to education women that heart disease is their biggest killer.

To bring this into the psychiatric realm, psychiatric disorders are associated with heart disease, particularly clinical depression. Untreated clinical depression is associated with an increased risk of cardiovascular disease as well as death following myocardial infarction. There is some evidence that treatment with SSRI's post-infarct can decrease mortality. It's not known whether there is a direct physiologic effect on the heart from depression, or whether it's due to other factors related to depression that can interfere with compliance with health care such as loss of energy and motivational impairment. So for those of you undergoing treatment for psychiatric disorders, there's another reason to take your meds.

I'm posting a link to an interview about women's cardiac issues, Leading a Heart-Healthy Lifestyle: A Mother and Daughter Perspective, because I think you don't hear enough about taking a family approach to health issues. Every once in a while at the gym I'll see a mother-daughter pair walking around the track or playing in the pool, and it makes me want to give them a pat on the back. What a great legacy to leave your kids. And yes, this counts for fathers too.

For more about heart healthy lifestyle, see the American Heart Association's web site.


And a word about the picture: it's an anatomically correct chocolate heart. I found it on a web site called Pushin Daisies, a self-described "mortuary novelty shop". Personally, I must have the anatomically correct chocolate brains. Brains, I must have brains.

Monday, July 24, 2006

You Can't Escape (or Maybe You Can?)

I'm still grieving the lost of my post, Off Label In Jail, inspired by an article in the 7/22 New York Times about a Maryland psychiatrist (no one I know) who was arrested for giving paid talks promoting the off-label use of Xyrem, a medication marketed only for narcolepsy, which contains GHB, the substance in the date rape drug. ClinkShrink, in kind form as she continues to address my constant quest for a viewable sidebar, shortened some lines I had drawn around a direct quote, but does not think that caused most of the entry to be eaten. I am left to blame the Support Duck as Max does not eat lines (he only eats meat).

You Can't Escape: or rather, I Can't Escape. I picked up a novel the other night, one I got from the library, chosen-- like I choose my wines--for the pretty cover. The first chapter was titled "Confinement" and the protagonist was having trouble getting up throughout the night, so I correctly assumed she was pregnant. By page two, her water had broken. By page three, it was apparent that she was a prison inmate about to deliver either a jail baby or a gummy bear. I wanted to scream and throw the book out the window. And if that wasn't enough, I was at the clinic today and I was approached by a drug rep who handed me an article about the wonders of treating criminals with Depakote. He let rip a line about how prisoners get no mental health care and I told him my co-blogger (ah, did he know we had a blog? he does now!) would be deeply offended. He went on about the jails, I excused myself to return to my patient (who had been a criminal). So this time it's someone other than Foofoo & Clink making it all about their prisoners.

Another New York Times piece well worth checking out:
He Who Cast the First Stone Probably Didn’t is an op-ed article by Harvard psychologist Daniel Gilbert as he looks at the psychology of fighting-- starting in his parents' station wagon, ending in the Mideast. Just a well-written, interesting piece.

I'm off to the beach for two days of sun. Escape. No kids. No Max. No patients. No prisoners (oops, but I'm going with a judge, hoping she won't bring her clientele).

Sock Puppets In Solitary

A recent New York Times article discussed the opening of an art exhibit for Donny Johnson, a Pelican Bay prison inmate who made paintings by leaching the color out of M&M's and painted using a brush made out of his own hair. My co-blogger Dinah wanted to know why I couldn't occasionally write a correctional post about something like that. I thought about it, then I read the article. I was struck by this part:
“He is serving three life terms in solitary confinement for murder and for slashing a prison guard’s throat.”
That's why. In this article, Johnson is the “artist” while the person responsible for keeping us safe from him, the correctional officer, is reduced to being a “guard”. (FYI to the New York Times, correctional officers are not “guards”. They are law enforcement professionals, like state troopers or your local police. “Guards” are civilians hired off the street and put into a uniform by a business or other organization. They have no particular training and no sanctioned law enforcement authority.) Johnson's work is featured in the Times while his victim remains nameless in the same article.

Nevertheless, the topic of prisoner art is an interesting one. I personally have some homemade artwork given to me by my patients, and I'm sure many of my colleagues also have an occupational therapy project or two lying around from their inpatient service years. In correctional facilities the main motivation for doing art---beyond simple relief from boredom---is that it can be a money-making venture. Inmates who are good at it can make up to $20 per day designing birthday cards, Mother's Day and other holiday cards. You can buy greeting cards from commissary, but frankly some of the inmate art is better and you can barter for it as opposed to having money taken out of your commissary account. Inmates who can draw sometimes also make money by doing tattoos, an occupation held by some of my patients when they're in free society. Tattooing in prison isn't really permitted due to the risk of HIV and hepatitis, but it's not high on the enforcement hit list.

It's rare for a prison artist to make money off their work from free society, as Donny Johnson did, although the article makes a point of explaining that the money his art earned went to a charitable prison fund. (I don't know why it didn't go to his victims' families.) I guess if acting is included then Charles Dutton certainly made it big after his stint in the Maryland penitentiary, but that's a unique case. For the most part, successful prison artists make their money more on notoriety than artistic merit. Most people have at least heard of serial killer art---John Wayne Gacy's clown paintings, Gary Gilmore's pencil drawings, etc. I've heard that Charles Manson fancies himself a musician and that he makes sock puppets in prison.

And for those of you who didn't know, part of our Federal tax money goes to support prison art. In 2006 the Washington DC Commission on the Arts and Humanities gave a grant to the Prisons Foundation to support and sell artwork made by prisoners. You can order it online and the proceeds from those sales do go to the inmate.

Blogger is driving me nuts... this from a psychiatrist

So I click on to Shrink Rap and I notice that my post, Off Label In Jail, is only half there. Mostly it's just the clipped and pasted paragraphs from the NY Times and it stops dead in the middle of the sentence. What happened? Did I inadvertantly delete most of it? Did Clink do something? Roy? So, not wanting half my thoughts up, I figured I'd save it as a draft and think about whether I wanted to redo it tomorrow. Only I did, and the half post remained up. So, I decided to delete the entire thing, only it's gone from the dashboard, but remains on the blog. I try again to delete it, but it doesn't exist to delete, but it's there! Okay, and by the time I've finished posting this, it will be gone and I'll have to wonder if it ever existed. Is it bad that I've passed these genes on to my offspring? In terms of diagnosis-- let's not go there.

Saturday, July 22, 2006

Roy: Welcome to the Monkey House

Murky Thoughts brings up a good point in the discussion about nature vs nurture as factors in personal responsibility for behavior... that genes != nature... all that is nature is not necessarily hardwired in the genes. Well, yes and no.

The frontal lobe development that occurs in adolescence and early adulthood IS directed by genes, but is also influenced by environment, some of which is by choice (marijuana, stress of half-time job while attending college, headbutting soccer balls) and some of it is not (lead in the drinking water, malnutrition due to family's poverty, head injury from accidental fall down steps).

To complicate matters, just because you have the gene(s) for, say, alcoholism, doesn't mean you will become alcoholic. If you never pick up a drink, you won't become alcoholic. Ahh, but what if you knew you have the alcoholism gene, and you knowingly drank alcohol and placed yourself at higher risk of becoming alcoholic? How is that choice viewed by society, compared with the choice of taking that first drink while not knowing of the risk?

I think it comes down to intent and risk tolerance. Do you intend to become addicted to alcohol? If so, that's either stupid or pathetic. Perhaps you are a gambler. You may decide to take a 30% risk of becoming alcoholic by taking that first drink, while others may find that a 5% risk is too high to accept.

Here's where knowing more about our defining genes, and about how they interact with environment, should increase, not decrease, our responsibility. The dystopic geneticomedicolegal future may have been foreshadowed in The Minority Report, where people are arrested before they commit the crime. It is easy to imagine being fined or taxed a higher amount if we choose lifestyles which interact with our personal genetic knowledge in a manner which increases the costs to society. We see this now with increased insurance premiums for smokers. Why not drinkers? Or, more specifically, why not folks with alcoholism genes who drink anyway... but no tax for gene-free folks who drink. Scorn the guy who knows he has the Vioxx-causes-heart-attack gene but takes it anyway due to pain, while giving a heartfelt pat on the back to the guy who inexplicably suffers the same fate. Sounds like a Kurt Vonnegut story.

I'd like to imagine a world where we can choose to learn about our genes which define our propensity to develop alcoholism, to be creative, or to develop stomach cancer... and then use that information to help make more informed decisions about where to focus our resources, take risks, avoid genetic traps.

Mind you, this does not mean that people will choose to be limited by what their G, C, A, & T-leaves tell them. Some will choose to accept our current concept of what a collection of genes mean, while others with a more oppositional bent will choose to damn the torpedoes and full speed ahead into genetically uncharted territories, in the same way that some amputees will run a marathon.

Just some food for thought.

Friday, July 21, 2006


Everyone once in a while we get someone coming into the facility fresh off the streets who, as the correctional officers put it, "ain't looking too good". That's a correctional euphemism for "totally out of it". This can be a problem if the person is too psychotic to give his name or to cooperate with fingerprints. It can be very hard to book these guys, particularly if they're in a fighting mood. These are the folks I worry about---the inmate with no available record, who can't give a history, and whose mental status change is unexplained. These are the folks who end up having meningitis or neuroleptic malignant syndrome or delirium tremens or benzodiazepine withdrawal and who can end up DIC (Dead In Cell).

The challenge is to get the guy out of the facility and into an emergency room where the appropriate diagnostic workup can be done. Now you would think, since they're in custody already---in handcuffs---that this shouldn't be an issue, but it is. The physical transportation is the easy part---the bureaucratic nightmare is figuring out who should do the transportation. You see, the legal boundary line for jurisdiction between the local police and correctional staff is somewhat fluid, particularly for pretrial detainees who haven't been booked into the facility. Custody's view is that the arrestee belongs to the police up until the booking process is complete. The police believe that the arrestee becomes the property of the correctional facility as soon as they're dropped off and the officer has left. The police officer isn't going to want to come back, and the correctional command staff isn't going to want to give up an officer to stand watch at an emergency room. If you have someone with the appropriate licensure available you can do the paperwork for an emergency psychiatric evaluation, but then you have to deal with the hospital bureaucracy---not all hospitals accept emergency psych patients. If you don't do the emergency evaluation paperwork, they may refuse the patient completely---they "don't accept" psych patients from the jail. (Wow, where can I get away with saying we 'don't accept' someone at the jail?) Eventually I can get the inmate transported by pulling aside the duty lieutenant or the major and using the DIC issue. As in, "Look, I know this is a pain in the butt but this guy could end up being Dead In Cell if we don't do this." At that point the reaction I get is, "Oh, you mean he's not a psych patient?" and I go through an explanation of idiopathic versus non-idiopathic psychosis. Quickly summed up, I say: "I have to know what's wrong with his brain." Out they go.

So anyway, this is why I developed the CIC. Every correctional clinician with a fair amount of experience has one of these carried around in the back of his or her head. It's a short list of every well-known psychotic inmate who gets arrested in an "ain't looking too good" state. I call it my Comes In Crazy list. The CIC list does what the facility can't or doesn't do---it's an institutional memory of our sickest patients. The nursing staff turns over frequently enough that they won't know these guys, but give me a name and I can sometimes even remember the first time I met the person. Sometimes I can make an identification based on delusional content alone. And the inmates like that. They like being remembered. Like Cheers, they are coming to an institution where "every doc knows your name". Welcome to the CIC ICU.

Thursday, July 20, 2006

Medicare Claims: A Tale of Two Headaches (Maybe More)

[posted by dinah]

You know, it's the damnedest thing. A patient came in today and told me she'd called Medicare to ask why she hadn't been reimbursed for her care and they told her they'd never received a claim from the physician. I could swear I filed one. Actually, I could swear I filed the this exact same claim for this exact same patient three times, because that's how many times she's told me that Medicare hasn't received the claim. What I haven't figure out is why they get some of the claims, but not others, when I send them all in the same envelope. It's like the phenomena of the dryer and the missing single sock.

Okay, sometimes they get the claims, they just reject them. There are columns and rows and codes. The language of these things is a mystery to me: I was ranting at a patient recently (much as I love to rant, there are a limited number of things I can rant to patients about and I've decided that Medicare claims are one of them) about how I couldn't even understand the forms they send me and "I don't even know what coins is!" referring to the name of one of the columns. It was the patient who told me he imagined it stood for Co-Insurance. Wow, I thought, assuming he could be right, it was this Eureka moment where I got an answer after years of subconsciously wondering, only to have my bubble burst when it occurred to me that I didn't know what Co-insurance meant any more than I knew what Coins meant.

Some of the codes are subscripted with sentences that approach English. Some of my claims are returned with "PR-42", PR means "Patient Responsibility. Amount that maybe billed to a patient or another party." 42 means "Charges exceed our fee schedule or maximum allowable amount. Only the fee I charge is the fee determined by Medicare as the limiting fee for a non-participating physician in a non-facility; as a psychiatrist, I only bill for a few codes (mostly 50 minute psychotherapy session with medication management), so what is it sometimes deemed wrong and not other times? And then there's MA130: "Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocesssable. Please submit a new claim with the complete/correct information." It would be so nice if they told me What information is incomplete or invalid. And of course, there's MA28: "Receipt of this notice by a physician or supplier who did not accept assignment is for information only and does naot make he physician or supplier a party to the determination. No additional rights to appeal this decision, above those rights already provided for by regulation/instruction, are conferred by receipt of this notice." There's nothing like being succinct.

My favorite Medicare form story: a couple of years ago, Medicare announced that the physician's name, address, & phone number-- information which I have on a handy little rubber stamp designed to make it fit in the space-- needed to be placed in box #32. Before that, the information needed to be placed in box #33. They put this in a bulletin and somehow I didn't see it. A patient complained he couldn't get reimbursed, and since this pre-dated the time when a significant portion of my claims were 'not received,' I called for the patient. After sitting on hold for 25 minutes, I was told I hadn't placed my info in box #32. I pointed out that the exact same information was available to anyone who wanted to look in the immediately adjacent Box #33, but I suppose it's hard to shift one's eyes those few millimeters (please forgive my sarcasm here...). Funny, but not a single psychiatrist I asked had seen the bulletin, some had simply been wondering why they or their institution hadn't been paid in months.

Wednesday, July 19, 2006

What Max Wants

[posted by dinah and guest barker Max]

My husband keeps telling me that Max wants to be on the blog. Actually, he often tells me that Max thinks, feels, or wants many things. When I ask him how he knows, he responds with certainty, "You can tell."

From my perspective, it seems that Max wants a limited number of things:
  • Max wants meat, as evidenced by his position under the dinner table and by his eagerness to ingest meat, but no other food groups.
  • Max frequently wants to go outside, which becomes apparent when he stands at the door scratching the paint off, then eagerly races out when the door is held open for him.
  • Max, often only moments later, frequently wants to come inside, which he shows by performing the same behavior, only the paint gets scratched off the outside of the same door.
  • Max wants to bark hysterically at any passing dog, cat or rabbit. He is indifferent to squirrels.
  • Max wants his friend Tex to come over in the mornings, as is evidenced by the fact that he waits at attention for him then goes wild and greets him at the gate. Either he wants Tex to come over of he wants Tex's owner who feeds them both treats to come over, I can't tell who he is happier to see.
  • Max wants his butt scratched, as evidenced by the fact that he presents his hindquarters to everyone who enters our home (this can be embarrassing).
  • Max wants to go for a walk. Always, just touch his leash and even I can tell.

That's it for what I know that Max wants. He's never mentioned any interest in the blog to me. I'm hoping this will be some sort of dream come true for the dog, or if not, then perhaps for my husband.

Judging by the amount of chasing and bribing it took, I don't think Max wanted his picture taken today.

Sunday, July 16, 2006

Who Wants A Diagnosis?

[posted by dinah]

It started back on Out of The Office when TheTundraPa commented that she didn't socialize with her depressed patients--too needy and I suppose they aren't good company. This didn't sit so well with Neonursechic who responded, "Just made me feel like because I have depression, then nobody wants to be friends with me -" Sarebear, too, feels her mental illness interferes with her ability to make friends. Please forgive me if I misinterpreted anyone, and hey, that's what the comment section is for.

Then we move along to the posts on Whining, and my esteemed co-blogger Roy confesses that his wife thinks he has ADD because he leaves household projects unfinished, he denies the diagnosis, and like a good friend, I pipe in with the unsolicited opinion, based on nearly a decade of observation in a variety of settings, but no formal psychiatric evaluation, that Roy does not have ADD, that his office is a mess because he is a Slob. Off blog, he told me he'd rather have ADD than be a slob, and back on blog, he's now commenting about whether Slob will be in DSM-5 and can it be labeled Messiness, NOS.

So, who wants a diagnosis and what does it mean?

For Roy, I'm left perplexed that he would want a psychiatric diagnosis, a damaged brain that would impair his ability to function. He wants to opt out of responsibility for his behavior, be able to drop those dirty sock anywhere and have an excuse. If a diagnosis doesn't exist, damn it, he'll make one. Might I suggest that as long as I don't have to live with Roy, that it's fine if he's a Slob? A certain degree of neatness is expected in the little box, and if one chooses to be sloppy, perhaps that's fine. He's rationalized it all away (too busy to be bothered), so why does he need a now socially-sanctioned diagnosis to relieve him of responsibility for a behavior he admits he's chosen?

It is estimated that over 26% of people suffer from a psychiatric disorder in any given year, the
lifetime prevalence is much higher. If TheTundraPa is able to avoid friendships with people with depression, or any other mental illness, my best guess is that this may be a function of under-diagnosis and treatment out there on the Alaskan tundra, it seems to me that all one has to do to find people with mental illnesses is to look-- or to mention at a party that you're a psychiatrist. While people with Axis I diagnoses may have periods where they are less interested in friendships or less available to participate in friendships, the mere existence of a psychiatric diagnosis doesn't chase people away-- in fact, when people advertise their diagnosis they often serve as magnets for others who are suffering from the same problems and are thrilled to find someone who understands. I'll requote Shiny Happy Person (see the whining post for her link): "Having a mental illness deprives you of the right to be a weirdo." I'll add to that magnificent thought: Perhaps having a mental illness deprives you of the right to be a slob, or to be an unlikeable person, but I don't think so.

Clinical Judgement And Judicial Clinicians

We've had some discussions on this blog about split-therapy versus single-provider therapy, and over at Trick-Cycling there was a vigorous discussion about the role of nurse-practitioners in mental health care. In the correctional world we have one more practitioner to deal with: the judge.

In most cases the role of the judge is limited to sending the patient to our facility or getting him or her out. We do get referrals for treatment from the court, and for the most part these are appropriate. It can never hurt to have an extra pair of external eyes watching out for my patients. The problem happens when the role of the judge extends beyond identification and referral and into the realm of imposing treatment. I don't mean ordering that the patient participate in treatment, I mean ordering the treatment itself.

The usual way this comes up is at the bail review hearing. Inmate X appears in court and says to the judge, "I'm not getting my (insert sedating psychiatric medication here)." Inmate X does not mention that he was not participating in treatment at the time of arrest, or that the only time he takes medication is when he's locked up. Nevertheless, an order gets written that Inmate X must be evaluated for medication. Well and good, this is appropriate although not totally necessary. Provided that Inmate X was honest with the intake nurse and gave a history of mental health treatment, he would have been referred to see the psychiatrist anyway. We now have two duplicate referrals, one from the court and one from the intake nurse. Subtract one point for inefficiency.

But back to the court-ordered treatment. Occasionally Inmate X will tell the judge that he wants to be on the mental health tier. We do provide some special housing for inmates with chronic mental illnesses who have trouble in general population. No problem. But if the inmate gets into trouble or starts fights or otherwise acts up on this tier, he might not be accepted back there. Thus, the court-ordered jail hospitalization. Not because he needs to be in the hospital, but because the judge wants him out of general population. Subtract one point for losing an inpatient bed.

Some judges order that the inmate "be provided with medication"; usually the implicit understanding is that the medication is provided if clinically indicated. Rarely, you'll get a judge who orders that an inmate should get medication, even if the inmate has already been seen and found to have no Axis I disorder. I've also seen orders specifying the name, dose and frequency of medication to be given. This creates an interesting situation when the patient then tells me he has a history of an adverse reaction to that same medication. Subtract one point for creating a legal conundrum.

So far I haven't heard of any correctional physician who has been found in contempt of court for using sound clinical judgement, or who can document the reasoning behind a clinical decision and can explain it coherently to the court if asked. The real downside is that doing this takes time which could be spent providing clinical care. That's where I see a need for sound judgement.


Disclaimer: The opinions expressed in this blog are my own, expressed while off-duty, and do not represent those of my employer or the state government. Please don't make me listen to Barry Manilow.

Saturday, July 15, 2006

Ethics, Shmethics

Someone asked me an interesting question last night. He asked, "So, do you think it's appropriate to work in an environment that you think is so inadequate that you can't give even minimally adequate care?"

It wasn't the first time that someone suggested to me that correctional work was unethical. Many years ago when I first started working in prison a colleague of mine said to me, "Surely, you're not working there." He was implying that to work inside a correctional facility was equivalent to participating in punishment. Fortunately, times have changed.

In 1988 the American Psychiatric Association published a position statement on psychiatric services in jails and prisons, and this is what it said:
"Psychiatrists should take a leadership role administratively as well as clinically...the APA calls on its members to participate in the care and treatment of the mentally ill in jails and prisons, for without an increased commitment and involvement of its membership in providing services to the mentally ill in jails and prisons, position statements such as this will be meaningless. The breadth and depth of these problems demand much more."
Correctional experience is now mandatory in some situations. In the 1990's forensic psychiatry was recognized as an official medical subspecialty. The American Council for Graduate Medical Education (ACGME), the organization which accredits forensic psychiatry training programs, requires that all forensic psychiatry fellows have a minimum of six months experience working with inmates in a correctional facility. Child psychiatry fellowships also require forensic experience, which in some programs may involve work in juvenile correctional facilities.

Correctional psychiatry bears similarities to the newly developed field of disaster psychiatry. Disaster psychiatry developed as a result of the September 11th terrorist attack and other subsequent tragedies. It is based on the idea that when the health care need is urgent you treat the patient where you find them. The correctional environment may not be optimal or ideal, but it is no worse than caring for victims at the scene of a car accident or treating wounded soldiers on the battlefield. Or, for that matter, treating hurricane victims. In the latest issue of BrainWise, the newsletter put out by the Johns Hopkins Department of Psychiatry, Dr. Michael Kaminsky vividly described his experience providing mental health care in central Louisiana following Katrina:
"In one way, Katrina was paradise. No billing, no medical forms. We became super efficient. We just did what was needed. And we loved it."
They treated 45 patients in two days, many of them suffering from complicated major mental illnesses. And talk about an inadequate work environment---their clinic was an elementary school cafeteria with sheets draped over the windows for privacy. Surely this was not an environment that was adequate for providing mental health care. Surely, he didn't work there.

But fortunately, he did. Ethics, shmethics.

Thursday, July 13, 2006

Put Down the Duckie: A Psychotherapeutic Study


[posted by dinah, not clinkshrink]

Oh, I do so wish I could play the video on the blog....this loses so much.

Put Down The Duckie

Case Presentation, please see lyrics below.

Ernie is a 37 year old single male (?) muppet with borderline intellectual functioning (vs. ADD?) who presents with a chief complaint of a "silly squeek" when he plays the saxophone.

The patient is self-referred to Mr. Hoots, a wise psychotherapist & jazz musician, with a full practice (a "busy bird") who is experienced in a number of psychotherapeutic modalities.

After a brief period of observation, Mr. Hoots identifies the source of the squeek: Ernie is holding his support rubber duck while trying to play the saxophone. Mr. Hoots points out this maladaptive behavior pattern to Ernie and identifies corrective measure for him ("put down the duckie"). Despite repeated behavioral directives, Ernie is not able to follow through with Mr. Hoots' treatment recommendations and the issue of compliance is raised. Frustrated, Mr. Hoots uses self-disclosure as a psychotherapeutic maneuver, telling Ernie, "I've learned a thing or two, through years of playing in a band, it's hard to play a saxophone with something in your hand!"

Ernie remains resistant to Mr. Hoots' interventions. In the video rendition of the psychotherapy, during the Put Down The Duckie refrains, Ernie is shown to be participating in group psychotherapy with a number of celebrities (Madeline Kahn, Danny DeVito, Paul Simon, Wynton Marsalis, & Jeremy Irons) who all instruct and encourage Ernie to Put Down The Duckie while modeling the appropriate behavior of playing their instruments without a squeeky support animal.

Acknowledging the failure of these behavioral interventions, Mr. Hoots turns to a more psychodynamic understanding of Ernie's persistant dysfunctional behavior. Addressing the separation anxiety which prevents Ernie from parting with his duckie, Mr. Hoots reassures Ernie that he does not need to permanently part from his duckie, and adding a cognitive component, he takes Ernie through stages of imagining progressively more difficult forms of seperation ranging from putting the duckie in his pocket, to sending him off on a train, and finally to flying duckie off on a rocket! With his internal conflicts identified, his fears exposed, rehearsed, and allayed, Ernie is at last able to Put Down the Duckie in what is truly a successful psychotherapy.

Wednesday, July 12, 2006

The Burden of Proof

I was entertained this past weekend and now I feel guilty. It took a couple days for this to hit me, probably because most movies I rent end up being so bad I live to regret them even at Blockbuster prices. The movie I saw this past weekend, Proof, was not one of these movies.

For those of you who haven't seen it, Proof is the story of a promising young mathematics graduate student named Catherine (Gwyneth Paltrow) who drops out of college to care for her equally brilliant but mentally ill father, a mathematics professor named Robert played by Anthony Hopkins. Following his death Catherine's older sister arrives from New York to help wrap up family affairs. Older sister is well-meaning but domineering, and her persistent doubts about Catherine's mathematical abilities leads Catherine to question her own sanity.

That's the basic plotline. Trust me, it's better than I describe it.

I have trouble watching medical or forensic movies. I usually don't gravitate toward movies about serial rapists, homicide detectives or other psychotic killer types. Even watching this movie I couldn't help thinking that perhaps Catherine had done her father an injustice by keeping him at home, out of the hospital. According to the storyline, Robert developed mental illness near the end of his life after a long and successful career. I couldn't help wondering if Robert really did belong in a hospital initially, at least for a good diagnostic workup. I had to remind myself that this was fiction, and fiction with a lot of precedent: One Flew Over the Cuckoo's Nest, Fisher King, Prince of Tides, All About Eve. Movies about mental illness are no different than dramas based on physical diseases. Where would Love Story be without cancer?

So why the guilt?

I've been having flashbacks to Dinah's post That's Entertainment. In that post Dinah talked about a reality show that featured people with real psychological problems being placed in a house together. I realize that reality shows are different from fictional movies, but I couldn't help thinking that crippling brain diseases should not be entertaining. But Proof was. It made me think about the sacrifices that have to be made to care for elderly or disabled relatives, and the compromises that siblings make to maintain their own relationships in these situations. It was about love and devotion, and more than a little guilt.

I guess that's the burden of Proof.

So What's Wrong With Whining??

[posted by dinah, in response to Peter's Guest post: "A Culture of Whiners?"]

So, I liked the article in Harvard Magazine, and I loved Peter's metaphors comparing taking aspirin for headaches and seeing a doc for a sprained ankle to taking psychotropics for human distress, and I love thinking about this stuff which is why we have this blog.

I think, in my personal, non-affiliated opinion, that we've grown into a society that expects people to fit into a very small box: if you don't think and feel and function in a very limited and circumscribed way, then something is wrong with you. Worse than that, people become very distressed that they aren't living up to their expections of themselves (or other's expectations of them) and become demoralized and consumed by their sense of failure; sometimes it's very hard to get people to look at the idea that maybe they weren't meant to live the life that was prescribed or self-imposed, and the fallout becomes it's own problem.

Having said that, let me limit my discussion to two specific disorders: ADHD and Social Anxiety Disorder, and I may throw in a mention of medicating Grief. Let me also say that I don't know a whole lot about ADHD (I don't treat kids) or even Social Anxiety Disorder, but hey, I've read the DSM, I prescribe the meds, and I even watch the Paxil commercials--I just meant that I haven't read the research in depth and while these problems surface in the course of my routine general adult psychiatry practice, I don't label myself as an "expert" and if my sense on the phone is that someone is calling for nothing more than a prescription for an amphetamine, I send them to someone else.

So part of the box we've created: kids are supposed to sit still and concentrate in school. Let me give you a funny example from my personal life. When my son was 10 and entering middle school, he was accepted into a math/science magnet program in the public school system. The program had an excellent reputation and my son spent a day shadowing another child. The school day went from roughly 8 to 3 with 25 minutes for lunch (it took him that long to get through the line, he ate cookies). No recess, no gym, and the kids were assigned 2 to 3 hours of homework a night. Now whose idea was that to come up with this sort of curriculum for sixth graders? The school he ended up at gives middle schoolers a 20 minute break after 2nd period, a 45 minute lunch, gym 3 days a week, and an extensive after-school sports program. An all boys school we looked at included 2 recesses a day in addition to the other stuff.

So, the ADHD diagnosis is a complicated one, because it entails sometimes unreasonable expectations of children (and some restless adults), it often doesn't take into account that people just don't concentrate well on things they aren't interested in, and with the diagnosis comes the expectation of treatment with an addictive, even dangerous medication that has often unpleasant side effects, so it's not a benign designation. The Last Psychiatrist tells us that little research has been done on the carcinogenic effects of Ritalin, and psychiatrists are uneducated about the few studies that are out there. For the psychiatrist, it's a hassle: all this press about physicians being monitored, prosecuted even for over-prescribing controlled substances (ok, pain meds, but just wait...), and amphetamines in particular can't be phoned in or re-filled in Maryland, so getting the hard copy to the patient is always an issue. And the other consideration is that amphetamines help everyone, even folks without ADHD, perform better, faster... so maybe they belong in the water supply? And I suppose there's this funny little question that no one dares ask adults with ADHD: What if it's not that you're not living up to your potential, what if you're just dumb? (and no, I don't ask my patients that!) When does someone fall far enough off the curve that we question if the problem is disorganization such that it's a Disease, versus a varient of the norm, simply a character trait?

But here's the thing: there are children who just can't function, hyperactive kids who prevent other children from learning, who can't hold still long enough to get educated, and there's no issue here: they need medication and it's preferrable to putting them in special environments (--if you choose to homeschool your ADHD kid rather than give them ritalin, more power to you). And there are people who take stimulants and function much better, hold on to jobs they wouldn't otherwise be able to keep, stop having those funny little episodes of disorganization (hmm, locked the keys in the car while it was running again...) and who feel life is much better on medications.

Social Anxiety Disorder I have less to say about. Mostly, I see this in people who are otherwise anxious, and I don't have a hard time giving someone who is suffering a non-addictive medicine. People have been taking a little inderal (an anti-hypertensive) for stagefright for a long time, and this doesn't seem to bother anyone. If someone is my version of Shy and wants a medication so they can function better in crowds, and I can't convince them that it's okay to be shy or cure them with my great psychotherapy skills, then I'm not adverse to giving someone who is suffering an SSRI, or even a little benzodiazepine for specific events (I write lots of people for a few pills of ativan for flying since 9/11-- I don't think I'm altering the makeup of the world, but maybe I should suggest non-addictive Support Ducks instead?) I tell people the risks of Paxil (since the commercials, that's what they want): I tell people the risks: sexual dysfunction, possible weight gain, a possible discontinuation syndrome upon stopping, and the fact that we don't know the long term side effects, and that it may not work (meds often don't for these milder spectrum problems), I'm willing to prescribe it. Sometimes people I don't think need meds feel much better, their lives improve, and they're very grateful. And if they have side effects or don't work, they can always be stopped.

Grief: just briefly. Most people don't go to a psychiatrist for grief, if they're coming to me they are usually quite symptomatic. Meds don't do much for uncomplicated grief anyway. This view that SSRI's just numbs people isn't usually so--though everyone is different.

The diagnoses themselves, without a demand for medication, can be extremely helpful. It often comes as a tremendous relief to people to have a name for their difficulties, to know someone else somewhere has felt this way before. And there are non-pharmacologic ways of dealing with ADD or social anxiety, or whatever problem you have, things one can do to compensate if one is aware, in which case I don't see a downside to the label. Now if only I could have gotten extra time on those SAT's....

And you can take medicines and get talk therapy, too, I'm all for it, see The Psychiatrist as Therapist post. Of course the insurance companies want whatever is cheapest, and of course they are molding how psychiatry is practiced. It sucks. And do I think psychotropic medications are altering the fabric of society? Yup, but maybe in a good way. Artists don't paint, composers don't compose, and writers don't write if they're dead or so depressed they can't crawl out of bed. A little existential angst does fuel creativity (or worse, the need to have a blog) but I haven't seen anyone rush to the psychiatrist because of their creative juices, they come because they are suffering, and until you've walked in their shoes, try not to judge. Of Course, Tom Cruise knows what's best, but as Brooke Shield put it to him in her New York Times Op Ed reply to his criticism of her taking medications, "I'm going to take a wild guess and say that Mr. Cruise has never suffered from post-partum depression.'

On the issue of illness versus character trait, I think Shiny Happy Person said it best with this thought: "Mental illness robs you of your right to be a weirdo." The designation as such robs you of the right to be many other things as well.

And so the giraffe: He was photogaphed by ClinkShrink's sister and he has a number of issues. For one, he is too small, and growth hormone shots will be starting next week with the hope of giving him a few more inches. He's fond of rainbows, cut out of the pack to shine beneath one, and we're wondering if he's schizoid, avoidant, seclusive, or anxious, or if he doesn't play well with others; perhaps he's just thinking his own, possibly brilliant, thoughts.

Tuesday, July 11, 2006

A Culture of Whiners?

Please welcome Guest Blogger Peter Owens, Professor at UMass Dartmouth and author of Rips, Oil and Chemical Spills, and Teens: Health and Obesity; while Peter's not a psychiatrist, he is Dinah's friend.

First, some excepts from the article Peter wants to talk about.
In "Prescription by Psychiatry" (link below), Ashley Pettus writes:

“By medicalizing ordinary unhappiness,” says professor of psychiatry and medical anthropology Arthur Kleinman, who is also Rabb professor of anthropology, “we risk doing a disservice to those people who have severe mental illnesses.” Kleinman fears that including mild forms of anxiety and depression under an ever-widening umbrella of mental disorders will divert attention and resources from diseases like schizophrenia and major depression, which remain undertreated and stigmatized across much of the world. In his view, “We may turn off the public, who are a huge source of support for mental-health research, by telling them that half of them are mad.”

Kleinman believes the weaknesses of psychiatric measurement are detrimental not only to the severely mentally ill, but also to the rest of us. The expansion of illness categories, he says, risks turning the most profound human experiences into medical problems. Grief over the loss of a loved one, or sadness in the face of death, for example, can look like depressive disorder, according to a checklist of DSM criteria. Doctors now routinely prescribe antidepressants to terminal patients on cancer wards and to bereaved family members whose grief symptoms persist beyond the DSM’s “normal” two-month period. By making the emotions that accompany loss and dying into disease, Kleinman says, we are in danger as a society of flattening out our moral life. “The intent may be: why should anyone have to feel any degree of suffering?” he says. “And the result may be: if you make it difficult for people to engage suffering, you may actually change the nature of the world we live in.”

Peter writes:

I was thinking about posing a question to your blog. The most recent Harvard Magazine has an article, Psychiatry by Prescription, about the moral/ethical tension between using designer drugs to treat the growing number of psychological disorders (social anxiety, mood disorders, impulse disorders, ADHD etc.) versus paying greater attention to the most serious and intractable diseases such as schizophrenia and bipolar disorder that tend to go untreated far more often.

I think the article underplays the consequences of these seeming "life problem" conditions, but it raises interesting questions. I also think the article fails to equate survivable disorders with useful correlaries in physical medicine. Most of us could survive a sprained ankle without medical treatment, but few of us would doubt the wisdom of seeking medical care. Most of us can survive headaches but think nothing of the moral implications of taking an aspirin. But someone taking an SSRI for persistent anxiety and chronic depression is considered morally suspect. There's a stern Puritanical subtext to these critiques that border on evangelicalism.

Ok, so what do you shrinks think about the whole designer drug, disorder de jour, chemical treatment of life's little problems critiques bouncing around the profession and FOX News? Have we become a culture of whiners, and are shrinks the enablers? Are you prescribing drugs that replace the moral grit and confrontation with personal honesty that used to be the hallmarks of psychoanalysis and talk therapy?

Monday, July 10, 2006

Roy: Hearing voices

When I was in medical school I recall seeing an unkempt-looking fellow standing on the sidewalk, talking to himself and spinning round and round. People walking past were giving him a wide berth. I stood near him and said, "Excuse me." At that utterance, he immediately stopped spinning and began walking down the street as if he were a skipping record and I just nudged the needle (hmm... do people even get this analogy in the CD-era... I'm feeling old).

As an aside, this symptom of spinning is an interesting phenomenon that has often been mentioned in older schizophrenia literature [PubMed]. What I find interesting is that the spinning is usually in the same direction (counter-clockwise), often attributed to asymmetrical changes in dopamine physiology. Hmm... wonder if it is clockwise in the Southern hemisphere.

So anyway, it was one of those brief, random interactions that you don't forget... never having an explanation to fully understand it so that it can be neatly categorized and put away.

I was at the ocean this past week and had several experiences of seeing folks standing or walking on the boardwalk, talking to themselves. At times, they seemed to be gazing in my direction, prompting an "Excuse me?" as I wondered what they were asking of me. After getting no response, I realized they were plugged in to a Bluetooth headset, chatting away on their phones, oblivious to the world around them.

It's funny (funny strange, not funny ha-ha, as Gilligan would say). If I saw the headset, then I did not get confused... I immediately realized they were chatting to someone else and didn't give it a second thought. But when the headset was in the ear I could not see, it caused an ambiguous moment, not knowing if they were talking to an unknown person, maybe hallucinating. It's funny how our (not just psychiatrists, but all of us) brains are wired to notice odd or unexplained behavior, while instinctively filtering out things which fit neatly into our "normal" or "expected" categories of behavior.

As the world becomes more wired (weird?), I wonder that our expectations about human behavior will change. Having a one-sided conversation no longer seems so clearly psychotic. The idea of a transmitter implanted into one's tooth no longer seems so clearly delusional. I still see people with schizophrenia having paranoid delusions, but I note that I more often discount their concerns that there are cameras watching them (there are) or that their email is being monitored (it is). The technology reshaping the world will turn us all on its ear.

Sunday, July 09, 2006

Emotional Support Animals, Revisited

ClinkShrink is having Duck issues. She is, I believe, fixated in the duck stage of psychosocial development: aside from the posts, the animated duckies, the living and re-living of the emotional support duck issue, ClinkShrink has shown up at my home with a stuffed duck (honest) and now she's having Ideas of Reference-- perhaps even Paranoia (the Duckie followed me to jail one day??)-- with regard to the Aflac Duck.

Rumination? Obsession? Over-valued idea? Delusion? Time will help define the problem, but in the meantime, let me re-assure you, ClinkShrink is not suffering, she is enjoying, even lingering over the object of her perseveration.

For those who've joined us late, I'm Re-Publishing the original post about Emotional Support Animals inspired by a May, 2006 New York Times article, written a bit less tongue-in-cheek than one might thought. Our lives have not been the same since, now get that Duck into the oven:

[posted by dinah]

In today's New York Times, Beth Landman writes:

The increasing appearance of pets whose owners say they are needed for emotional support in restaurants — as well as on airplanes, in offices and even in health spas — goes back, according to those who train such animals, to a 2003 ruling by the Department of Transportation. It clarified policies regarding disabled passengers on airplanes, stating for the first time that animals used to aid people with emotional ailments like depression or anxiety should be given the same access and privileges as animals helping people with physical disabilities like blindness or deafness.

These days people rely on a veritable Noah's Ark of support animals. Tami McLallen, a spokeswoman for American Airlines, said that although dogs are the most common service animals taken onto planes, the airline has had to accommodate monkeys, miniature horses, cats and even an emotional support duck. "Its owner dressed it up in clothes," she recalled.
There have also been at least two instances (on American and Delta) in which airlines have been presented with emotional support goats.

Wagging the Dog, and a Finger

I'd be indignant, but I can't stop laughing long enough.

Thursday, July 06, 2006

Out of the Office

[posted by dinah]

This post was inspired by Dr. A's account of his patient Jen in his post Bride of Hyperthyroidism and by Carrie's (NeoNurseChic, whom I always find inspiring) response to it.

"Hey, Doc," she said, "Don't forget to come to my wedding next month. It's going to be a good time." She then proceeded to tell me the entire plan for the day, which made her face light up and bring a smile to her face. "I'm sure it will be," I said, "I wouldn't miss it for anything."

And Carrie commented:
... doctors are a part of my life and hear all the negative things that happen all the time - it's nice to be able to give back and show I'm a normal human, too, and share the positives, too! Hope "Jen" gets her hyperthyroidism controlled and has a beautiful wedding!

This is the thing about being a psychiatrist-- it's this funny little world inside the office where intimacy reigns and boundaries become oh-so important. Psychotherapy mandates a number of important boundaries, sometimes they feel rigid, but mostly they serve as a protective barrier. I could ramble about the obvious-- defined meeting times and pre-determined session lengths, very restricted physical contact (I'm good with a handshake at the initial evaluation, and sometimes patients will hug me at the termination of therapy, a gesture that is beyond me to refuse), payment in exchange for the services (this, in addition to being a boundary issue helps me pay my bills), and perhaps most important, limiting meetings to the therapeutic sessions which take place in my office. In all honesty, I'd rather not see my patients anywhere else; given a choice, I don't even want to ride the elevator with them.

Mostly, I think my patients would rather not be with me outside the office, too. Of course, it's a bit inevitable. I ran into a patient one day when I was out for a walk. I introduced her to Max, my dog, and she said, "I didn't know you had a dog." I do. When I bump into patients and I'm with my kids, invariably they ask, "Who's that?" and I'm left to mutter something I hope won't lead to more questions.

People tell me about the events in their lives; usually they don't invite me, they seem to instinctively know the rule. Sometimes they'll say, "I wish you could be there."

Recently, a patient asked me to come to his art opening. He mentioned it several times, he gave me an invitation, he asked me to invite all my friends. It was important to him that people come, and he made it clear he wanted me to come.

"What would I tell people if they asked who I was?"

This is always an issue for outside the office stuff. "I'm the artist's psychiatrist"-- that just doesn't fly. It's a problem Dr. A doesn't have; he can go to a patient's wedding and just be Dr. A.

"Everyone knows I see you," he said. So I guess I could have said I was the artist's psychiatrist, I just wouldn't.

I went alone. The room was packed, my patient was holding court and doing a wonderful job, though I knew he was extremely anxious. I walked around, loved his artwork, tried to guess who was who from the puzzle of his life that I'd heard so much about inside the office. He was, for that moment, a normal human (actually, a rather talented human) with a normal life. A woman approached me and introduced herself as the artist's mother. I introduced myself by my first name only, shook her hand and simply said her son had invited me. Mostly I stayed lost in the crowd and enjoyed the artwork.

"The opening was great," the artist announced a few days later. "I wish you could have come."

"I did," I said. He looked surprised, then delighted. I told him which were my favorite pieces, told him how well I thought he did. Somehow I was pleased to have both been there and yet been just a little invisible.

Separated At Birth?

Coincidence? I think not.

I came in to work one day this week and the first thing I saw in the lobby was a four foot tall, plush, stuffed duck. My first thought was, "Omigosh they've been reading the blog." I thought it was very nice for a prison to have an emotional support animal. Then I saw the correctional officers standing at a table talking to salesmen about disability insurance.

I had been taken in by the Aflac duck.

Wednesday, July 05, 2006

Gummy Bears and Jail Babies

At any point in time about ten percent of all jail and prison inmates are women. The number of incarcerated women has risen in proportion to the total number of prisoners in the United States. What this means is that in a relatively large jail, in other words a jail holding over a thousand inmates, chances are good that there will be ten or fifteen pregnant prisoners. Some jails actually have maternity wards. All female correctional facilities now have provisions for pre- and post-natal care, as well as security procedures for delivery.

In Riker's Island:
"When a 5-day-old child
stopped breathing
and turned blue
in the jail's nursery,
doctors rushing
to resuscitate the child were
left banging at
the various security gates."
Some facilities have programs that allow newborns to stay with their mothers for some duration of time after birth. Both the Cook County jail and the Washington Division of Correction do this. These kinds of programs include parenting skills classes and education about birth control and the effects of drug abuse on neonates. In New York, Article 22 Section 611 of the state code allows infants born to incarcernated mothers to stay with them in the correctional facility up until eighteen months of age. If the woman has a nursing child under the age of one at the time of arrest, that child can be allowed to stay with her at the discretion of the warden. So yes, breastfeeding is allowed in jail (sorry, Dinah). This program is not an absolute right, however. If the mother is deemed to be physically or otherwise unfit, or if the father requests custody, the child can be removed from the facility under New York's statute.

I don't think anyone would disagree that it's a good idea to give inmates information about birth control, sexually transmitted diseases, the effects of substance abuse on fetuses, or parenting skills. I think men in prison need this information too. Male inmates want to be good fathers to their children---particularly when they had no fathers themselves. Unfortunately, if men a get therapeutic program it's usually an anger management class (although I suppose half of being a good parent is to keep your cool when the little buggers drive you crazy). Male jail inmates aren't typically given the chance to bond with their newborn, even when they are held in the same facility as the mother.

None of these educational objectives actually requires

What's bad for the goose
is bad for the gosling.
the presence of a child. In theory, having the child onsite gives the health care provider time to directly observe parental interactions and give immediate feedback when the situation arises. I suspect though that given the usual staff-to-inmate ratio there is probably little direct observation that takes place outside of actual class time. The more disturbing thought is that there is an implicit suggestion that the child is an integral part of the offender's reformation. While having a child certainly can be a reality check for any adult, I don't think an institution should be suggesting this is the purpose of the program. The purpose of the program is to decrease the risk to the child, not to reform the offender. An infant is not a rehabilitation tool.

The other thing I am curious about, and which typically doesn't get addressed in the average newspaper story, is what provision the facility makes for the medical care of the child. I'm not talking about the routine post-natal followup and well-baby checks. I'm talking about the emergencies. I ask this question because I know the confusion and problems that can surround adult medical emergencies in correctional facilities. Do the crash carts in these places carry infant endotracheal tubes? What about pediatrically dosed resuscitation meds? In one example of a worst case scenario, at Riker's Island in 1994 when a 5-day-old child stopped breathing and turned blue in the jail's nursery, doctors rushing to resuscitate the child were left banging at the various security gates.

I guess the bottom line I wonder about is whether the conditions of confinement at these facilities are truly fit for children. My opinion is that in situations where an institutional environment, either whole or in part, has been found to be unconstitutional then these programs should not take place. What's bad for the goose is bad for the gosling.


I have to explain the title of the post. I was just going to call it "Jail Babies" but my first instinctive thought was: "Wow, that sounds like the name of a candy." Thus, gummy bears. I've provided an explanatory link for our foreign readers.

Disclaimer: The opinions expressed in this blog are my own, expressed while off-duty, and do not represent those of my employer or the state government. Please don't pour honey on me and tie me to a fire ant hill.