Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Thursday, May 31, 2007
Abilify Calling? Nobody home.
On May 19 I found this public pay phone advertising Abilify. I went today to pick up my General Tso Chicken, and I see the ad has been taken down. Maybe the purchased ad time ran out.
Or, maybe, Bristol-Meyers Squibb realized that they've gone too far by putting ads for their antipsychotic on pay phones.
What Kind of Psychiatrist Are You?
So I'm finishing up a session with a patient today and he suddenly asks, "What kind of psychiatrist are you?"
The question caught me off-guard as all sorts of things rushed through my head. Oh the usual kind of psychiatrist. The kind who writes a blog.
"What do you mean?" I asked. I wasn't sure what he was looking for.
"Like, oh you know, Freudian, Jungian...like that."
I rambled a bit inarticulately, still not sure what the question was. I told him where I did my residency-- if you're a local psychiatrist that means a lot and I could get plugged into a neat little stereotype. The patient is in car sales and doesn't know about ideological difference between the different programs in our fine city.
"I'm a general adult psychiatrist," I said. "I don't see kids." So there, something I'm not. I'm still left with wondering what I am. "I'm not a psychoanalyst, and I don't even know any Jungians."
Okay, I was babbling. It wasn't the first time. If you listen to our podcasts, you know that. Really, I was trying to guess at the question, what did the patient really want to know, what was the wish, the fear, the concern here? He'd only seen one other psychiatrist, and only for a few visits. I knew he didn't like her-- did he want reassurance that I was different? He knew that already, after the first appointment he'd commented about how different I was than Dr. EvilShrink. Figuring Dr. EvilShrink was his only frame of reference (and Woody Allan, of course), I babbled some more:
"Dr. EvilShrink sees patients for medications and sends them to see other professionals for therapy. I do both therapy and medication management."
Then I recalled how Patient was really not very interested in psychotherapy, or so he said. Talking was a chore and he just wanted to feel better. Not everyone has to talk, I take 'em as they come.
Patient made an appointment and left. I never did figure out what he was asking or what he wanted to know. Maybe he just wanted to hear me babble, so hopefully I obliged.
And Roy, you've inspired me to hit spellcheck. I just don't have proofreading in me. It's good I have you.
Wednesday, May 30, 2007
Serotonin Knockouts are a Pain in the SSRI
Okay, Dinah, here's something (though it doesn't really "shake things up").
Check out this article in the Journal of Neuroscience by ZQ Zhao et al., showing pretty good evidence (like we needed more) that the brain neurotransmitter, serotonin (or 5HT), is involved in pain regulation.
What they did was use knockout mice -- mice which have been genetically altered to remove or disable the gene which codes for a given protein -- which have had the codes for serotonin neurons in the brain removed. So, these mice do not have serotonin-producing brain cells. This permits the researchers to see the effect that selective serotonin reuptake inhibitors (SSRIs) and other antidepressants have (or don't have) on the mice.
They were interested in the anti-pain (also called nociceptive) effects of these antidepressants, and the role that serotonin plays. For example, we know that antidepressants which have BOTH serotonin and norepinephrine (NE) effects (SNRIs, like Cymbalta and Effexor) are better at reducing pain than those with solely serotonin effects (SSRIs, like Prozac and Paxil).
So, these particular mice have normal pain responses to hot things, reduced pain responses to mechanical pain (eg, pinch, squeeze, crush... in this study, they simply poked them with different sizes of fishing line), and elevated pain responses to inflammation (eg, an infection, arthritis, etc). The acute analgesic properties of antidepressants were simply nonexistent in these mice. Their acute pain responses were unaffected by antidepressants. However, SNRIs did reduce their responses to chronic pain, while SSRIs did not.
Although the noradrenergic system in Lmx1bf/f/p mice appears to be normal, the analgesic effect of the TCA amitriptyline on acute thermal pain behavior was strongly attenuated in Lmx1bf/f/p mice. Because a total absence of analgesic effect was observed in Lmx1bf/f/p mice treated with fluoxetine and duloxetine, the residual analgesic effect observed in Lmx1bf/f/p mice treated with amitriptyline is likely caused by mechanisms other than blockade of 5-HT and NE reuptake, such as channel modulation and NMDA receptor antagonism (Lawson, 2002; Wang et al., 2004). Together, our data indicate that although the NE component seems to be critical in the analgesic effect of antidepressants, endogenous 5-HT is also of fundamental importance for the analgesic effect of these drugs, especially in reducing thermal sensitivity.They conclude that "Together, our data indicate that although the NE component seems to be critical in the analgesic effect of antidepressants, endogenous 5-HT is also of fundamental importance for the analgesic effect of these drugs, especially in reducing thermal sensitivity."
The main reason I posted this is just to demonstrate the cool things one can do with genetics. You can knock out a gene; in this case, the one responsible for turning a developing neuron into a serotonin-producing neuron. You can then figure out what the consequences of that absent gene are. Finally, this also emphasizes how we can learn how to fine-tune our knowledge about pain control, so that more effective -- and less addictive -- treatments can be developed.
Shake, Rattle & Roll ?
Sunday, May 27, 2007
My Three Shrinks Podcast 22: Forced Treatment
Anyway, Welcome back! Dinah's friend, Victor, joins us again this week, providing his insights into salutations and valedictions. And, for our US listeners, don't forget to celebrate National Duckling Month this weekend (oh, and Memorial Day, too).
May 27, 2007: #22 Forced Treatment
- Physician-Assisted Executions. The American Medical News had a story by Kevin B. O'Reilly about how some states are trying to force physicians to participate in executions. The ethics of such activities are debated.
- Realizing the Promise of Pharmacogenomics. A draft federal report is available for public comment (by June 1) about the development of pharmacogenetics and the impact of genomic medicine on the future of health care. You can find the report and comment form here. "The report identifies a number of challenges for the development of pharmacogenomics and its effective integration into health care practice, including the need to improve the health-information infrastructure, to provide education and training for practitioners, and to maintain the confidence of all stakeholders by effectively addressing ethical, legal and social issues arising from pharmacogenomics."
- Dopamine, Genetics, and Environmental Stressors in ADHD. As an example of the above, this month's Archives of General Psychiatry has an article by Manfred Laucht, et al., showing evidence of an interaction between a mutation in the Dopamine Transporter (DAT) gene and severe environmental stress (e.g., abuse) triggering symptoms of ADHD. Also mentioned in the podcast is data suggesting that certain Serotonin Transporter Promoter (5HTTP) mutations predict one's response to SSRI antidepressants, the development of side effects to these drugs, and the propensity to develop psychiatric symptoms.
- Forced Outpatient Treatment in PA. Liz Spikol, who writes the blog and newspaper column, Trouble with Spikol, for the Philadelphia Weekly, writes about Pennsylvania Senate Bill 226, which would make it easier to make people with severe mental illness who are "unlikely to survive safely in the community without supervision." A long debate on the podcast ensues (half the 'cast) about the ethics and practicality of such tactics.
- Don't miss Roy's telling of the official (according to psychologist, Richard Wiseman) funniest joke in the world (around the 25 minute mark). Just to be on the safe side, be sure you aren't driving when you listen to it.
|Find show notes with links at: http://mythreeshrinks.com/. The address to send us your Q&A's is there, as well.|
This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.
Thank you for listening.
So Camel and CamelMan went out to dinner the other night. They're sitting alone eating their dinner in peace because CamelChild is off at a national oratory competition where she's leaving the rest of those orating children behind in the dust. The waiter brings them drinks and declares they've been sent over as compliments of another couple in the restaurant. Camel looks around and sees one of her patients. How nice? How awkward. Camel called me from the restaurant....What should she do? It's not really a question, it's more of an I-need-to-tell-this-to-someone moment. CamelMan wants to buy the other couple drinks back (CamelMan is not a physician or mental health professional). Camel knows the sender of the drink, sitting there with his own, is an alcoholic, but even if he weren't, she still would feel uncomfortable reciprocating.
What to do? Thank the patient and move on? Sometimes this is the only thing to do. Tell the patient she can't accept this, and risk that the patient will feel rejected, or start a whole back-and-forth "I insist" scene? Quietly tell the waiter to transfer the charge to their bill, hope it happens as quietly as intended and the patient doesn't leave feeling insulted? Perhaps there is no perfect answer. Generally, though, shrinks hate it when this happens.
-- Happy Memorial Day weekend. ClinkShrink is playing scrabble with her family. This I know because she sent me a cellphone pic followed by an email asking for words with 3 u's. Roy is doing yardwork and thinking about ducks. And I will be cooking dinner tonight for Camel and CamelMan.
--It's not too late to observe National Duckling Month!
--Double Billing will continue on Tuesday.
--And Hi to Elise: I've just learned that my mother-in-law reads Shrink Rap.
May is National Duckling Month
Back in 1988, the Senator Jesse Helms introduced a bill making May National Duckling Month. The bill, which passed easily, listed the following reasons for this critical piece of legislation:
Unfortunately, as you can see here, this measure did not cut our national trade deficit.
Whereas the duckling industry in the United States is approximately one hundred years old, and with duck having historically been a delicacy for the Egyptians five thousand years ago and more lately in the Far East, especially for the Chinese in the preparation of the famous Peking duckling;
Whereas duckling is rising in popularity in the United States among all people, and not just ethnic groups;
Whereas demand for duckling has increased at restaurants by 300 to 400 per centum over the last four to five years;
Whereas there is a need to educate the consumer as to the nutritional value of duckling, which is an excellent source of protein as well as being low in sodium and saturated fats;
Whereas the duckling industry in this country produces over one hundred thirty million pounds of duckling annually, generating over $176,000,000 in revenue;
Whereas the duckling industry employs over one thousand United States citizens and contracts with over two hundred fifty family farms;
Whereas the duckling industry uses one hundred fifty thousand tons of feed produced by local farmers;
Whereas breeding has increased the lean meat portion and reduced the fat content of duckling; andWhereas the United States duckling industry exports thousands of tons of duckling products (including duckling meat, tongues, feathers and liver) to over forty countries--including those of the Far East--thus helping to reduce the national trade deficit.
Anyway, it was "Resolved by the Senate and House of Representatives of the United States of America in Congress assembled, That the month of May is designated as `National Duckling Month,' and that the President is requested to issue a proclamation calling upon the people of the United States to observe such month with appropriate ceremonies and activities."
Enjoy your celebratory ceremonies and activities during these last duckling-dedicated days. And, maybe, send some duckling tongues overseas. It's good for our economy.
Saturday, May 26, 2007
Depakote & Ammonia
This is a brief post about the underrecognized side effect of elevated serum ammonia (NH3) levels causing altered mental status, confusion, and delirium in people taking valproic acid or valproate (Depakene is US brand name... also applies to divalproex sodium, or Depakote).
A case of Depakote-induced hyperammonemic encephalopathy was presented at last week's Annual APA meeting. Here's another case (actually, this one is mostly valproic acid toxicity) on Erik Mattison's blog. This problem is often not recognized because ammonia levels are not standard blood tests to do (this test is also a bit of a pain, in that the blood has to be kept on ice immediately after drawing it).
In his presentation on May 21st, Dr. Rasimas discussed the case of a 36-year-old with treatment-resistant schizoaffective disorder and quiescent hepatitis C who returned to the emergency department in a state of lethargy and confusion less than 3 weeks after being hospitalised for lithium toxicity. Personnel in the ER started the man on sodium divalproex, which is chemically related to valproic acid, at a dosage of 1000 mg in the interim to treat hypomania. A nightly dosage ultimately resulted in a serum level of 114 mcg/mL...Typical symptoms for this type of metabolic encephalopathy include confusion, agitation, disorientation, insomnia, hallucinations, picking at bedclothes or in the air, twitching, and asterixis (also called "liver flap", where your hands twitch when holding your arms outstretched as if you were stopping traffic). If an EEG is performed, this usually demonstrates a diffuse encephalopathy.
When the patient was admitted to the hospital, his AST and ALT were normal at levels of 17 U/L and 44 U/L, respectively, while ammonia was elevated at 66 mcg N/dL. Serum lithium was 1.2 mmol/L.
Dr. Rasimas said he was asked to consult on the case, at which time he determined that the patient's dose of sodium divalproex should be immediately discontinued, suspecting a case of hepatotoxicity. The patient's other psychotropic medications, including lithium, were then resumed. Lactulose and supportive care were given. Ammonia peaked at 111 mcg N/dl within 36 hours of presentation while AST and ALT never exceeded 38 U/L and 81 U/L, respectively.
The symptoms of delirium resolved slowly during the 96 hours following the discontinuation of divalproex sodium.
I've seen several cases of this, and it is gratifying to recognize it, stop the Depakote, add lactulose (helps to reduce the ammonia), and see improvement. I've seen it with even lower ammonia levels (40's) when GI docs say that they doubt that is the problem. But when it improves, it is hard to think that it is anything else.
Friday, May 25, 2007
The Rest Of Chapter 5 is Up on Double Billing
Where is Hillary on Insurance Discrimination for Mentally Ill?
- a "prevention initiative" to reduce preventable diseases such as diabetes;
- modernizing health-care records through computerization;
- overhauling care for the chronically ill, whose costs account for approximately two-thirds of all health-care expenditures;
- "ending insurance discrimination" by providing care to people with pre-existing conditions, who are currently shut out;
- creating a "best practices institute," with both government and private participants, to determine standards of care;
- legalizing prescription-drug importation and requiring Medicare to negotiate lower drug prices; and
- implementing "common sense" changes to the medical malpractice system.
I was surprised to see her mention "ending insurance discrimination" without mentioning -- in the same breath -- ending the long-standing practice of carving mental health treatment out of the rest of the medical system, while applying different payment mechanisms (higher co-pays, for example) which have resulted in fractured care systems and higher costs. Even Medicare continues to charge beneficiaries a 50% co-pay for outpatient mental health care rather than the 20% for all other organ system disease.
This "carve-out" system is the ultimate in insurance discrimination. This lack of parity between brain illness and body illness should have ended in the 1990s, during the Decade of the Brain.
So, I went to the source at hillaryclinton.com. I found yesterday's speech about her health care plans. Skimming it, I saw no mention of mental health care. Ctrl-F brought up the Search bar... I typed "m-e-n-t-a-l" ... no hits.
I'm sure she supports this concept (who wouldn't, other than maybe insurance companies?), but c'mon lady, give it a bullet point. Make it a campaign issue. At LEAST pay lip service to it in your speech. Millions of Americans get shafted on this issue every single day.
What will you do about it, Madam Senator?
Darth Vader had Borderline Personality Disorder?
WebMD reports that Anakin Skywalker (you know, from Star Wars), who, of course, became Darth Vader, showed "clearly" symptoms of Borderline Personality Disorder, as determined by psychiatrists at the French Toulouse Hospital. [5 commas!]
The French psychiatrists — who included Laurent Schmitt, M.D. — based their diagnosis on original Star Wars film scripts. Schmitt's team describes Skywalker's symptoms, including problems with controlling anger and impulsivity, temporary stress-related paranoia, "frantic efforts to avoid real or imagined abandonment (when trying to save his wife at all costs), and a pattern of unstable and intense personal relationships," including his relationships with his Jedi masters. Changing his name and turning into "Darth Vader" is a red flag of Skywalker's disturbed identity, note Schmitt and colleagues.Huh? BPD is not the first diagnosis I would come up with. I would've thought Narcissistic PD before BPD. Needs at least 5 of these [from Wikipedia]:
- has a grandiose sense of self-importance
- is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
- believes that he or she is "special" and unique and can only be understood by other special people
- requires excessive admiration
- strong sense of entitlement
- takes advantage of others to achieve his or her own ends
- lacks empathy
- is often envious or believes others are envious of him or her
- arrogant affect.
Thursday, May 24, 2007
The Pushy Patient
Wednesday, May 23, 2007
The beginning of Chapter 5 is up
Tuesday, May 22, 2007
Viagra, East of Java
No, they didn't put the hamsters on Hooters Airlines... they just woke them up early:
The team observed how easily the hamsters adjusted by noting how soon the nocturnal animals began running on their exercise wheels when the lights went out.
They found that sildenafil boosted the ability of hamsters to recover 25 to 50 per cent quicker than untreated animals. Sunlight is thought to be a key influence on the body clock by its involvement in a neurochemical pathway in which cGMP is involved, and in this way the drug is thought to make the brain more sensitive to the effects of light, Dr Golombek said.
However, the drug only worked when applied before an advance in the light/dark cycle, equivalent to an eastbound flight.
Encouragingly, Viagra worked at doses low enough not to trigger erections, though Dr Golombek stressed that human tests would be needed to confirm that this was also true for people.How did they measure hamster hard-ons, I wonder.
The scientists believe that frequent fliers and shift workers may well benefit from moderate doses of sildenafil, with passengers probably taking it during flights.
"Shift work and chronic jet lag reduce mental acuity and increase the risk of a number of medical problems," Dr Golombek said.
"A potential jet-lag treatment for advancing cycles could also be important for the safety of counter-clockwise rotating shift work and the potential long-term health consequences for airline crews regularly crossing time zones."
So now there may be a whole 'nother mile-high club... just for jet-lagged shift-workers traveling eastward. (Maybe one would use depo-provera for westward jet lag, huh?)
Makes me think of the B-52's song, Lava:
My body's burnin' like a lava from a Mauna Loa
My heart's crackin' like a Krakatoa
Krakatoa, east of Java, molten bodies, fiery lava
Fire, fire, burnin' bright
Turn on your love lava
Turn on your lava light
Fire, oh volcano, over you
Don't let your lava love turn to stone
Keep it burnin'
Keep it burnin' here at home
Sunday, May 20, 2007
Writing Bad Prescriptions
OnthePharm has a good post about doctors with such bad handwriting that it is hard to make out their prescriptions.
Unfortunately, these are my "prescriptions" they are making fun of. But they weren't really prescriptions, they were notes from my Poetry Class, where I had to write haikus.
Here's the first haiku (above)... I hope you like it. To see the others, go here (comment #12 I think).
Scrooge 1 IQ say Lassie.
Yo, smile, Poog Pro.
And FIFO mail.
Saturday, May 19, 2007
Shrinks On Segs
The tour was followed by a nice lunch overlooking the harbor, then a delightful afternoon of podcasting attended by another special guest and podcaster. (How's that for a teaser?) Roy took the picture here, as well as some video that will get linked as soon as he has a chance to put it up. Now we are truly multi-media.
...and theres [Note: Fix this obvious typo. And you need more commas. --your editor Clink] are new questions to consider on Double Billing: The Interactive Novel Project. Click here
I can't believe how far this Direct-to-Consumer (DTC) pharmaceutical marketing has gone.
I went to the Chinese take-out place ("take-away" for you Brits) tonight to pick up some General Tso chicken, and outside the place I see the phone above. Sealed onto the outside casing of the phone, and obviously part of a marketing scheme that Verizon is making money on, is this huge ad for Abilify (aripiprazole), an atypical antipsychotic drug for schizophrenia and bipolar disorder.
That's just going too far.
And the rest of Chapter 2 is now up on Double Billing: The Interactive Novel Project.
Friday, May 18, 2007
Is THIS SSRI Withdrawal Syndrome???
This is a clinical case, but it's not my patient-- it's a little more personal than that, but still, no distinguishing characteristics, the names have been changed to protect my friends. You might ask why I'm rendering a clinical opinion on someone who is not my patient, who I haven't really examined but for pieces of a brief phone conversation, and that would be a good question. That can be it's own post, maybe one day when Roy is let out?
So I get a call from a dear friend from another state. Her father died last year shortly after being diagnosed with a terminal illness. Her mother happened to see her own GI doc and mentioned that her husband was dying. The story goes, "He told me it would be a rough time for me and prescribed paxil, it helped a lot." I personally don't prescribe medications simply for Hard Times or uncomplicated grief, and I didn't ask for a retroactive history, symptom list or mental status exam. She took paxil, it helped, time passed, she was doing better. So my friend's mother...let's call her Sally... spoke with her primary care doc who had her taper down off paxil cr 12.5 mg by taking one every other day then stopping.
The day after stopping she began to feel sick. Roughly 4-5 days later she was brought to the emergency room: she felt awful. Sally had a bad cold. She had a bad headache. She was confused, she began hallucinating. "Hallucinating? --She saw people moving, she woke someone in the middle of the night asking what a non-existent noise was, she insisted something wasn't written on a paper that was, repeatedly, until it was pointed at for her. Everyone was worried. I should mention that Sally is in her 80's, but she lives alone, drives, takes part in a number of organizations, and is the proud user of some of my favorite hair chemicals. She's not usually confused and she looks years younger than she is. She also suffers from a chronic GI problem, I don't know the rest of the medical history other than Hypertension and that med had been changed recently, too. And I don't know about past psychiatric history, but there's no psychiatrist in the story.
In the ER many tests were run, a brain CT was done. Nothing. The psychiatrist came and proclaimed "Paxil withdrawal." Relatives looked it up on the internet, all these symptoms have been described. She went home to wait it out, but she was feeling worse and worse and now developed a cough. Her primary care doctor said she could go back on Paxil but would then need to remain on it for life, and she didn't want to do this. Friend read on the internet that she could take a single dose of Prozac, which has a longer half-life than paxil, leaves the body more slowly, also increases serotonin levels, and this would help. Primary care doc agreed to call in a few prozac pills.
What did I think? Would this prozac thing work? He only called in 10 mg, was that enough?
Given that I didn't see the patient, I thought a lot, and I'll tell you my thoughts, as I told them.
1) This could be paxil withdrawal, though I personally have never seen anyone hallucinate and the hallucinations sounded a bit too close to delirium for me (Sally sounded fine on the phone). I was much more worried that something else was wrong, that an infectious process might be missed, that this could be related to her GI disease. This was my number one concern, though I was repeatedly told the ER did lots, all tests were fine, that 3 doctors had confirmed this was Paxil withdrawal.
2) Okay, so take a dose of paxil-- if it's withdrawal the symptoms should go away, soon and dramatically. Sally didn't want to do this because then she'd have to stay on paxil forever. No no no no no, I said, it would just be helpful to be sure that's what it was. She could take one dose, be sure she was okay, than happily withdraw. Or she could taper more slowly using 10mg and then 5 mg dosages.
3) Sally took the Paxil. She didn't know if she felt better-- not a good sign. The next day she took it again, she still had URI symptoms, now she had a low-grade temp. Confusion occasionally. The headache was better.
4) Friend wanted to give Sally the dose of Prozac. I said not to-- her symptoms had not resolved, I didn't think this was paxil withdrawal, adding Prozac would not help and she would be subjected to any side effects or adverse effects of the new medication.
The days went by, Sally did better, but hasn't returned to baseline. She's stayed on Paxil. She's staying alone most nights, still gets confused, and honestly, I haven't had an update in days.
The answer? I don't really know. I doubt that it was SSRI withdrawal given that some of the symptoms were not the usual and that she didn't get noticeably better after taking the Paxil. Though I do imagine this could explain part of the picture. Bronchitis (or pneumonia-- I don't know if a CXR was done)? Exacerbation of GI illness wouldn't explain headache, cold symptoms, but might explain some GI symptoms that developed after the Paxil challenge, the low grade fever, the likely delirium. Hopefully they're all doing better.
And just in case you thought I forgot my Novel obsession, here what people are saying about Double Billing over on The Interactive Novel Project:
Parked : "Now, you have my attention! Kudos! The first chapter just didn't hit me like the second one did. "
ClinkShrink: Wow, is that an improvement over the first chapter! The first chapter was just too short and sketchy and I felt no pull for the character. This is totally different. Very cool.
emy I. nosti: Love it. I'm hooked.
Tomorrow, I promise, SSRI withdrawal syndrome. Really!
[From Clink: This is your fourth blog post about Double Billing this week, but who's counting? I've decided I really must write a serialized short story about a writer who ends up in prison.]
Thursday, May 17, 2007
Feelings and Stuff
First, I want to share my feelings of the moment with you:
Sad: That Fat Doctor has closed her blog. I actually discuss her life with my husband as though she's a friend or family member.
Annoyed: That an insurance company can't process the claims for one of my patients until I fax them a copy of my medical license. No insurance company has ever wanted this before, Why exactly are they the only one that can't process claims without it. Not quite true: a few weeks ago, an insurance company mailed me a Letter to my office: they couldn't process claims without my address (!--where did they think they were mailing the letter?), a copy of my Tax ID number-- I don't believe I've ever had such a document-- and my license, however I believe this is the same insurance company that called today. How many hoops can they insist I jump through. Okay, okay, I faxed it, time to move on.
Tired: Long day of being mom and doc and still more to do. Currently, I'm procrastinating.
Thank you all for your votes and comments on the first chapter of Double Billing. It's still not too late to vote, I was hoping for 50 million responses and so far have gotten....ummm a little over 50.
Did you want the story of that chapter? When I wrote the book, I liked the first chapter a lot. I showed the book to an agent who said "No thanks," and I got a bit paralyzed. I decided to take a grad school course in the hopes of learning something about fiction writing and getting some constructive feedback. I had to apply to grad school, got accepted, took the course, got a huge amount out of it, reworked the beginning of the novel, and incorporated a bunch of the instructor's ideas, one of which was to have the intro chapter look like it was in third person but then have the narrator introduce herself into the story in this way that some of you described as "jarring." I liked it, he liked it. What's wrong with Jarring, anyway? If someone walks into a restaurant to unexpectedly find an identical twin, it might be, well, jarring. But okay, like it, don't like it, let me think about the commas, I am so fond of them.
So now I put up the original version of Chapter One on a new blog, Double Billing: The Interactive Novel. I'd love your vote. So far it's 6 unopposed votes for the original chapter.
As soon as I can get some traffic there, I'm going to stop hogging Shrink Rap for this (though I will post when the other blog is updated), and I'm going to put up the novel chapter by chapter for as long as anyone can stand it.
And ClinkShrink, thanks for your repeated concern, but I'm happy to have the feedback and my feelings just don't get hurt over this stuff. Carrie, that's for you, too!
Wednesday, May 16, 2007
The Interactive Novel Project Is Up And Running
Things I've Never Done
Preamble inserted by Dinah: It's ClinkShrink's birthday! She's turning....oops...old enough to be a prison nun. Old enough to have her own duck and her own blog and to come to my house for crabcakes, hon. Old enough to ride a segway (so at least 14). This is not her cake, it's the cake we ate when Shrink Rap turned 1. Yes, really, how nuts is that? And what does Clink want for her birthday, besides the biggest crabcake that I should be making now? She wants you to
on my novel chapter!!! And she wants to tell you that I'm setting up an separate blog arm called Double Billing: The Interactive Novel, to be up and running soon with more chapters so you can find out why both characters are named Emily. But for now, she might want to ride an elephant. I'm not sure why.
HAPPY BIRTHDAY, CLINKSHRINK FROM YOUR CO-BLOGGERS AT SHRINK RAP.
You can talk now.
I don't typically write personal or sentimental posts but I'm feeling a bit reflective today. Today I am 210 years old, in dog years and hex code. Actually that really just applies to my knees. The rest of me is somewhat younger. On the event of my 210th birthday I thought I'd write about all the things I haven't done.
I think the most adventure I've had so far in my life was at the age of ten when I road both a camel and an elephant at a state fair. From an adventure standpoint it's been rather a downhill slide since then. I've never been much of a traveler so I've never seen Reykevik, Icelandic ponies or puffins (I learned recently that people eat puffins which makes me inexplicably sad). I haven't hiked to Machu Picchu or canoed down the Amazon. I haven't climbed a mountain (or talked Dinah into climbing lessons). I haven't cured a disease or authored a novel or founded a nonprofit organization. I've put a few cartoon doodles up on the blog but it's not exactly what you'd call being an artist.
I've spent much of my professional life in prison. That by itself would be enough adventure for most people and I certainly do hear some interesting stories. People wonder why I don't get out more. The answer to that question is an ethical dilemma on the order of the trolley car crash variety. Here's the dilemma:
If you're the only doctor in town, do you leave town?
Even though we are one of the top ten states in the country with regard to the number of psychiatrists per capita the fact remains that if I leave prison then my patients will have no one. Who will make sure my little old man in segregation gets his Risperdal? How will my sometimes-suicidal sometimes-violent young alcoholic get his depression treated? Who will round on the infirmary patients and do competency assessments on the treatment-refusing medical inpatients?
If there's any question about the effect of a missing doctor on patients, you can see what happens in the comments on this story.
Nevertheless I do plan to celebrate my birthday. I haven't found any rideable camels or elephants in Charm City yet, but I do know where you can get a nice Segway ride.
Tuesday, May 15, 2007
What Do You Think: The Interactive Novel
Sunday's New York Times had an article on the unpredictability of the publishing industry: The Greatest Mystery: Making A Bestseller. The jist of the article is that publishers aren't good at guessing in advance what will sell, and the industry has surprisingly little feedback and interactive responses from its market.
So I thought, what if I try to see if I can get some feedback on Double Billing, my novel-of-the-moment, either use the feedback, or let prospective agents know that 50 million people read the first few pages and now want more? So here goes, the first chapter, the set up for the rest of the novel. If you want to make suggestions on how it would be better, please feel free to comment. If you're not a regular commenter, just click on "post a comment" at the end of the piece. If you're not a blogger, sign in under "other" so you can give yourself a name, real or fictional. If you must be anonymous, please end your post with a distinguishing signature (i.e. "Anon-1") I will also stick a Poll below. Please, please, vote on the poll. If it helps the cause, the protagonist is a psychiatrist.
After this, I'll be back with a case of SSRI withdrawl, after I find out the answer, and get permission.
Double Billing: Chapter 1 (it's only 2 pages):
She emerged from the subway to an assault on all her senses. Cars, buses and taxicabs honked their horns, black exhaust puffed in her face, pedestrians rushed by with to-go coffee cups still steaming, the wind blew cold, and she had no idea which way to go. She studied the streets signs, glanced at a map and unable to get her bearings, finally just picked a direction and started walking.
Emily Mason came to New York City that day, in part, to see The Gates in Central Park—the display by Christo and Jeanne-Claude of monuments lining the footpaths of the park. Each one was a huge metal portal topped with an orange curtain flap that billowed in the wind, looking a bit like a giant puppet theatre. There were thousands of them, literally 7,503 Gates, each standing 16 feet tall, lining 23 miles of walkways.
Emily made her way to Central Park and once there, she walked for hours, stopping only once to buy sugar-coated nuts from a vendor. The Gates were the oddest of sights, magical and magnificent, and Emily felt compelled to follow their trail. Was it art, she asked? What did it mean? Here and there, in the northern, quieter parts of the park, Emily would leave the paths, climb a boulder to look out over the landscape, and find herself giggling out loud at the bewildering sight of the orange fluttering canvases.
Eventually, the sun set and the temperature dropped; after all, it was February. It was suddenly quite dark and a stranger to New York City, Emily found herself a bit disoriented and unsure of how to get where she wanted to be. Chilled, tired, and no longer able to appreciate anything but her own discomfort, she left Central Park on the East Side by the Metropolitan Museum of Art and walked over to Third Avenue. She wanted hot soup or coffee, or both, and ducked into a diner.
“Emily,” A man said. She glanced at the stranger reflexively; she didn’t know him and Emily is such a common name-- obviously he was talking to some other Emily. He was sitting alone, though his table remained set for two and he’d been careful not to let his belongings— his black leather gloves, house keys, an unopened envelope-- spill onto the other half.
There was no hostess and Emily searched for a clean table—the ones closest to the door had dirty dishes on them.
“Emily!” The man’s voice was more insistent. She spotted a table for four; the restaurant was nearly empty and she was certain it would be okay to sit there alone. She’d have room to give her bag its own seat and spread out with a street map. Emily settled her coat onto the chair beside her though, still chilled, she left her scarf draped around her shoulders.
The man was suddenly there, having gotten up from his own seat to approach her. She could have been frightened but he had a gentle face, a cultured presence, and nothing about him was threatening.
“What are you doing?” he asked. “I got us a table over there. I ordered a drink for you.” She was confused. I’m sorry, sir, she wanted to say, but you have the wrong Emily. Before she could speak, his expression changed. His eyes grew wide, maybe his skin blanched a shade.
“Emily, what did you do to your hair? And where did you get those clothes?”
And so my identical twin met Jules, my husband-- her brother-in-law-- just moments before I, also an Emily, arrived.
End of Chapter One.
Please Vote Below-- you may need to scroll down a bit to the poll.
If you'd like to keep reading, I'll be posting in segments at:
Double Billing: The Interactive Novel Project
Come visit. Read another version of Chapter One. Comment! Vote!
Thank You all for your input, I love reading everyone's opinions.
Sunday, May 13, 2007
My Three Shrinks Podcast 20: Mother Talkshoe
We had to do something a little different this week. We three shrinks were all busy ... Mother's Day weekend, yard work, Longwood Gardens, and luaus kept us too busy to get together to do a podcast. I insisted that we find a way to do it online, so I FINALLY convinced Dinah that even she could do it ;-)
Ten o'clock last night, it all came together, and we were able to do a podcast, thanks to Talkshoe. (If you haven't checked out Talkshoe, do it. It lets you podcast by phone!) As luck would have it, a storm came through and turned the transformer down the street into a Fourth of July celebration. Despite being without power, we still managed to get it done. Is that dedication, or what?
So, here ya go. It is a little rough, as we weren't sure what we were doing (what else is new?), and recording it via cell phone caused occasional lags and silent periods... hmm, just like psychotherapy.
May 13, 2007: #20 Mother Talkshoe
- Happy Mother's Day!
- Turkewicz law blog a hit with Clinkshrink. Her recommendations? Malpractice Primer and Economics.
- Q&A: Zoe Brain asks "Is there a Standard of Care for GIDNOS in the case where the patient is intersexed? And does the degree of intersex affect the therapeutic regime, and if so, how? I'm familiar with the WPATH (Formerly HBIGDA) v6 SOC for GID. But once a diagnosis of GIDNOS is established, the SOC does not appear to apply."
Answer: Huh? (We did the best we could.) Also, see Farmer v. Brennan.
- APA says people with Medicare Part D having trouble getting their psychiatric medications. Also, discussion of the "donut hole."
- Medical Truth in Advertising bill: Is your "doctor" really a doctor?
- Ethical conundrums: trains and Tarasoffs and guns (oh my!). Also, Maryland's problematic law requiring reporting of childhood abuse, even if you are now 90 or you don't know who the perpetrator is. And, what do you do with a dead astronaut on the way to Mars?
- If Dinah had Lost It in Space, she Wishes she would have a Crystal Ball.
- A shrink like me?
Find show notes with links at: http://mythreeshrinks.com.
This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.
Thank you for listening.
Saturday, May 12, 2007
Does Anybody Out There Know a Good Literary Agent?
I've lost count, not just of the rejections (oh my gosh, I lost count of those years ago), but maybe even of how many novels I've written. Maybe it's time to throw in the metaphoric towel, to devote myself to other pursuits, become a relentless blogger, see more patients, spend more time cooking for my kids, do their laundry even. Gee, when did those kids last have their sheets changed? Travel the world, exercise more, go to all those meetings I tell people I don't have time for ( Roy, you can skip that sentence). Longer walks for Max, perhaps.
It started with Monday at The Charm (see the sidebar). Maybe I queried a million agents? I finally found one, the agent submitted the novel to some publishers, no luck, and I later learned this agent is on every list of evil, avoid-like-the-plague agents. It's okay, no one else was jumping. So then I surrendered on the commercial route and started sending direct queries to small independent publishers--- one called Erica House, fairly local, was interested and offered a contract. I was thrilled-- at least my book could be shared with my friends and family, and this has been a good thing. I went to the bookstore and found some diet book by the same publisher, it looked legit. Somehow, in the course of the year (or was it two?) it took to get published, Erica House vanished and was replaced by an imprint called AmErica House, then PublishAmerica, which has since published a zillion books in something called Print On Demand which somehow likens it to vanity or self-publishing, even though I didn't pay them to publish the book. In literary terms, the book isn't taken seriously. PublishAmerica does no direct marketing, I hired a publicist, there was a little press on the book which came out in August of 2001, not the best timing for a novel, and on the day America invaded Afghanistan, the Baltimore Sun ran a pretty nice review and I was thrilled to be called "a gifted writer" in print. It doesn't get any better than that, though mostly I was beside myself about the state of the world, even I didn't care about some novel.
Next there was Home Inspection. A handful of the many queried agents looked at it, all rejected it. It's about two patients who see the same psychiatrist and their love story plays out in their sessions, perhaps the one who changes the most is the shrink. Okay, so this time I found an agent right away, she had at least one author I'd heard of, a long list of successes, and 50 years in the business (literally) and didn't know how to use a computer ("the machine is broken"). No online mentions at all, and 13 publishers rejected Home Inspection. It's a tough market for fiction I'm told. I tried the small publisher route, found someone local, but whose books had won some awards, and he said, "I'll meet you for coffee and tell you what's wrong with your book." I met him and his assistant for lunch and they gave me a blow-by-blow of what needed to be done. Make it first person, not third person, increase the emphasis on the psychiatrist. I did this, his company went on a publishing freeze. I found all sorts of garbage about him on the internet, lost count of how many lawsuits he'd been involved with, and stayed away. I renamed the characters, changed the title to Patient Pursuits, tried again to find an agent, no one seemed to notice they'd seen the book before, and they all sent the same "sorry this isn't right for us" rejection slip. Even the few I had some more personal contact with didn't notice they'd read the book before. I gave up, figured if something else made me famous, then Patient Pursuits or Home Inspection would gain a life.
Then there was Mitch & Wendy, a children's book written for my kids. One reputable publisher sat on it for months, said maybe, then no. One agent lost it in a pile, when I called over the summer I was told "they're in the Hamptons." I want to be in the Hamptons. Finally, feeling apologetic about the lost manuscript, she sent a 3 page critique (in a cascade of "dear author f* off" slips, this is noteworthy). Mitch & Wendy have now aged and entered a nursing home. Oh, and the book ends with the Red Sox miraculously winning the World Series, long before it actually happened, so if that one gets dusted off, I'll need to rethink this.
Then, there was By Reason of Insanity, 290 pages of odd dribble about a woman who kills her sister's psychiatrist. Even I can't read it. It took a year and a half to write, and I've dismissed it as a project that got me through a hard time. My husband and sweet cousin were subjected to reading it, but I passed on the whole find-an-agent routine, and probably just as well.
In there, I've searched in funny ways-- I organized a symposium for APA called Telling Stories: The Psychiatrist as Novelist and I met some pretty neat guys, and yes, I've contacted their agents. I could only find one other female psychiatrist novelist, with the same iffy publisher that I have, and she couldn't make the symposium. I went to Robert McKee's Story course-- this was the 3 day screen writing course featured in the Nicholas Cage movie Adaptation-- it was an amazing experience. Robert McKee stands in front of an audience of hundreds and lectures, single-handedly for 10 hours a day for 3 days. I learned a lot about plot construction, movies, all sorts of stuff, and met a couple of interesting people, including a high school teacher who had written a screen play once over a weekend that became a mainstream film, and yes, I went home and rented it. Last year, I took became a grad student and now I know more about constructing fiction, I got some great feedback on my novel of the moment, life goes on.
So the novel of the moment is called Double Billing, named by ClinkShrink after she and Roy were given a one sentence synopsis. Psychiatrist walks into NYC diner to bump into her unknown identical twin. Lots of twists and turns. Several agents have agreed to look at the novel, they've all said "not for me." What is for them? I've read all the books, taken all the advice, wished someone would just tell me "You have no talent, give this up." The blog has helped, it's diverted some of my writing energies and I've been happier being an unpublished novelist since. Yesterday's mail brought a rejection from the agent who represents my favorite book, The Kite Runner, who had agreed to look at a synopsis and three chapters.
I guess it's all part of the journey. Thanks for listening. I'll be back as a Shrink Rapper soon.
Thursday, May 10, 2007
I Wish I had a Crystal Ball
Wednesday, May 09, 2007
What Happened With the Gun Guy
Moral and Ethical Choices
The following 2 vignettes are sometimes used to illustrate that thereDiscuss.
are universal moral standards that transcend religion, culture, and
ethnicity, because everyone, regardless of background or belief system,
always gives the same answers. See what you think.
Suppose there is a runaway trolley car that is about to mow down and
kill 5 people. Now suppose that there is one observer standing next to
the track watching this, and he realizes that, by throwing a switch, he
can divert the car onto a different track so that it will kill only one
person, but spare the other 5. Virtually everyone says that the morally
correct thing to do is to throw the switch and sacrifice one person to
save 5; most even go so far as to say that it would be morally
reprehensible for him just to stand there and do nothing, once he
realizes that throwing the switch is an option.
Now, a different scenario: there is a hospital with 5 patients who will
die very soon if they do not receive organ transplants, and there are no
donors immediately available. (They all need different organs.) Now,
suppose someone is brought into the emergency department of that
hospital after having suffered a life-threatening, but easily
repairable, injury -- and he has and organ donor card in his wallet.
Would it be ethical for the ER staff to deliberately withhold treatment
and let him die so that his organs can be used to save the other 5
patients? Everyone says "no" to this question. Why? How is it different
from the trolley car scenario? Aren't they both cases of sacrificing one
to save 5? Why is it right to do so in the first case, but wrong in the
second? And why does everyone, regardless of background, give the same
answers to these two illustrations?
Just for fun, I'd like to throw a few qualifiers into the second
scenario. Would your answer change if the potential organ donor who can
be easily saved, but will die without treatment, had been driving drunk?
Would it change if he were a paroled murderer? What about if he had been
speeding at the time of his accident and had killed a family in another
Tuesday, May 08, 2007
Tarasoff Overview & Inservice
Dinah's post Johnny Get Your Gun generated a lot of interest in and comments about public safety and the mental health professional's duty to warn or protect. Some readers commented and cited the Tarasoff case, which made me think a quick inservice was in order. Many of our readers aren't mental health professionals or aren't American, so it's not really fair to leave them without any context for the discussion. Also, many American mental health professionals have heard of Tarasoff but may not really be aware of the limitations or extent of this decision.
First some background:
In 1969 a Berkeley college student, Prosenjit Poddar, became enamored of co-ed Tatiana Tarasoff. He pursued her to the extent that police got involved. They detained Poddar and referred him to the college counselling center where he was seen by a psychologist. The psychologist consulted with his superior at the center, and both decided that Poddar did not need to be hospitalized. Poddar later shot and killed Tarasoff.
Tarasoff's family sued the university, the police, and the mental health professionals for failing to hospitalize Poddar. The suit was originally dismissed by the California Supreme Court (in a case now known as Tarasoff I) because all of the defendants were government employees who were acting within their discretion regarding the hospitalization decision. Thus, they were covered by government immunity. Also, at the time no mental health professional had any duty to a third party---the clinician's only duty was to the patient. The suit was dismissed without prejudice, meaning that the plaintiffs were free to refile the suit on other grounds. The California Supreme Court hinted in their opinion that if the suit had been filed on the grounds of failure to warn or protect the defendants would not be immune from suit. The plaintiffs took the hint and refiled on these grounds.
This led to the case known as Tarasoff II, in which the California Supreme Court found for the first time that mental health professionals had a duty to protect (not just warn) third parties of danger from their patients.
Now the thing to remember about case law is that opinions are only binding on the regions that the appellate court has jurisdiction over. The Tarasoff cases were decided by the California Supreme Court and were binding only in California. Only the U.S. Supreme Court can issue opinions that apply to the entire country. So how did this idea spread across the country?
If I were a complete cynic I'd answer: Blame it on the lawyers. Being only a partial cynic, my answer is that the creation of this new duty created a new fertile ground for recovery in case of injury. A flurry of cases in other states followed the reasoning in Tarasoff and laid the groundwork for mandatory warnings in other jurisdictions. A nice overview of the current state of national Tarasoff laws can be found here.
Fortunately, the Shrink Rappers live in Maryland. Our professional organization took a proactive approach to this impending issue and crafted a Tarasoff duty by statute rather than waiting for it to be created through a lawsuit. It was designed thoughtfully and narrowly so the duty for our clinicians is not as broad as that which is implied in the California cases. It can be found in Courts and Judicial Proceedings (granting immunity for certain actions) and it states:
§ 5-609. Mental health care providers or administrators.
(1) In this section the following words have the meanings indicated.
(2) "Mental health care provider" means:
(i) A mental health care provider licensed under the Health Occupations Article; and
(ii) Any facility, corporation, partnership, association, or other entity that provides treatment or services to individuals who have mental disorders.
(3) "Administrator" means an administrator of a facility as defined in § 10-101 of the Health - General Article.
(b) In general.- A cause of action or disciplinary action may not arise against any mental health care provider or administrator for failing to predict, warn of, or take precautions to provide protection from a patient's violent behavior unless the mental health care provider or administrator knew of the patient's propensity for violence and the patient indicated to the mental health care provider or administrator, by speech, conduct, or writing, of the patient's intention to inflict imminent physical injury upon a specified victim or group of victims.
(1) The duty to take the actions under paragraph (2) of this subsection arises only under the limited circumstances described under subsection (b) of this section.
(2) The duty described under this section is deemed to have been discharged if the mental health care provider or administrator makes reasonable and timely efforts to:
(i) Seek civil commitment of the patient;
(ii) Formulate a diagnostic impression and establish and undertake a documented treatment plan calculated to eliminate the possibility that the patient will carry out the threat; or
(iii) Inform the appropriate law enforcement agency and, if feasible, the specified victim or victims of:
1. The nature of the threat;
2. The identity of the patient making the threat; and
3. The identity of the specified victim or victims.
(d) Patient confidentiality.- No cause of action or disciplinary action may arise under any patient confidentiality act against a mental health care provider or administrator for confidences disclosed or not disclosed in good faith to third parties in an effort to discharge a duty arising under this section according to the provisions of subsection (c) of this section.
[1989, ch. 634; 1997, ch. 14, § 9; 1999, ch. 44.]
The key points compared to the Tarasoff cases are that the statute requires imminent danger to an identifiable victim. Clinicians are not required to foresee danger to the general public, nor are they required to predict dangerousness into the indefinite future. Clinicians are given the discretion either to warn the victim or to carry out a protective plan; hospitalization is not mandatory. Regardless, a decision to break confidentiality is shielded from liability if the clinician is acting in good faith.