Saturday, June 30, 2007

"Going Mental" for iPhone

Leander Kahney, the managing editor of Wired magazine, was quoted as saying, "They are going to go mental for it." He also predicted iPhone-inspired muggings and selling of first-borns. Folks have been waiting in lines all week just to get first dibs on Apple's new digital wunderkind. It is only a matter of time before i see an iPhone-inspired psychiatric problem in my E.R. And i know just the type of medication to use: an SSRi (or, iSSR?).

John Paczkowski from Digital Daily has dubbed the iPhone obsession iOCD -- and apparently this diagnosis is now in the DSM! Funny... the AMA stopped short of calling video game addiction a disorder, but there is clearly an overboard quality to the iPhone hype. Google "iPhone" and you get 118 million hits this evening, which is 50% more than yesterday. This is more than Paris Hilton and Britney Spears combined. And, it is certainly a few million more than "My Three Shrinks".

This video documents some of the iPhone hysteria...

And speaking of hype, how often do you think the iPhone is paired with some sort of psychiatric symptom? Let's see...

Clearly, the iPhone is one of the coolest tech toys on the planet today. Lack of interest is definitely NOT going to inspire many hits.

EDIT: But it may inspire a new religion (Xenu beware).

Other blogs and links worth checking out:

EDIT: Must-see YouTube Chris Pirillo here, with an iPod and a Zune going at it under the covers ... Zune doesn't satisfy like iPhone (Warning: Graphic Gadget Adult Situations).

Google Health: Where's a Psychiatrist When You Need One?

Google has established an Advisory Council for health-related googling. There are 20-something people on the Council, but no nurses and no psychiatrists (as far as I can tell... at least, no one is clearly representing these constituencies).

Of course, you cannot put together such a group without others complaining that they didn't get a seat at the table. Make the table too big, and it is hard to get things done.

But, given the fact that one of the main medical areas that folks do searches about is psychiatry and mental health, they need a web-savvy shrink (I'll volunteer ;-). And nurses are the infrastructure that supports today's health care system. The U.S. system does need fixing, but would completely collapse without nurses. They need a seat, too.

Thursday, June 28, 2007

Inspiring Grand Rounds at Wandering Visitor

Wandering Visitor has done a really great job with this week's Grand Rounds, with the theme of 'what inspires you', which in turn inspired us to write Fuel for our Fire.

And, now I know that those rainblow splashes you see, when the sun is high in the sky, are called "circumhorizon arcs". Now, I want to know the name of the other ones that occur around an hour or so before sundown (or after sunup), where you see two horizontal blips of color ( - - ), one on the left and one on the right. My recollection is that these occur when the sun is at an angle of 22 degrees, but I don't know the name or the physics behind it.

Wednesday, June 27, 2007

I Still Prescribe Seroquel But I Don't Get Paid To Do It.

Chapter 10 remains up at Double Billing. Thanks to those who've commented!

And don't forget to check out the ClinkShrink fiction venture at Double Celling!


How this money may be influencing psychiatrists and other doctors has
become one of the most contentious issues in health care. For instance, the more
psychiatrists have earned from drug makers, the more they have prescribed a new class of powerful medicines known as atypical antipsychotics to children, for
whom the drugs are especially risky and mostly unapproved.

Vermont officials disclosed Tuesday that drug company payments to psychiatrists in the state more than doubled last year, to an average of $45,692 each from $20,835 in 2005. Antipsychotic medicines are among the largest expenses for the state’s Medicaid program.

Wow! Or maybe Oy! That's a lot of money, they don't say How Many Vermont psychiatrists see that kind of moola. One, two, ninety percent of those maple-syrup, Birkenstock-wearing Shrinks, or all of them?

So, for the record, last year I earned $0.00 from pharmaceutical companies. Funny, it was the same amount that I earned the year before and the year before that and the year before that. What am I doing wrong? Where's my 45 grand?

Full disclosure: I work in two different settings that serve indigent, often uninsured, patients. Some of the people I see in private practice have no health insurance. Atypical antipsychotics cost a lot of money. If you don't have health insurance, they remain pretty much inaccessible to many many people. So I'm nice to the drug reps, I chat for a few minutes, I sign for samples, sometimes I even call and request samples, I use their pens, and if you show up needing an antipsychotic agent, you get the one that's in the closet. I used to run a clinic, and part of that work entailed educational programs for the staff and boosting morale: go straight for the stomach. Sometimes I asked the pharmaceutical reps to provide lunch and they'd bring a tray of sandwiches. This went over well with the staff.

Do the pens and sandwiches influence what I prescribe? I can't say no for sure, but it feels like they all come, so what's to say which I use more? Really, boils down to my anecdotal evidence more than anything else: if the first time I try a med, the patient returns saying it helped, I'm more likely to use it. If I have to slowly titrate up and it takes a lot of time and a lot of appointments, I'm less likely to use it. Sorry, Effexor. If the first patient who tries it comes back ranting it was horrible, I get a bit colored. I talk to my shrinky-friends: are they having the same experience? If not, I'll reassess and try again. Even if I don't use the drug myself, I still smile at the reps, sign on the dotted line, and throw the samples in the closet for whoever else wants it.

So why aren't they paying me? Really, that post I wrote on Why I Still Prescribe Seroquel, shouldn't that be worth a few bucks? Look, I'm cheap, never mind the 45 grand, I'd have done it for a mere $20,000.

Finally, I need to say a few words about media sensationalism. Villainizing psychotropics seems to be the thing to do, and hell, get those docs who prescribe them while you're at it. I really wish that atypical antipsychotic medications didn't cause weight gain, diabetes, and metabolic problems. And now that I know this, I tell people. Many people don't develop these side effects-- I've become more diligent about checking labs and warning people of the risks. Though I really wish I could say that it's rare for people to develop diabetes either on or off these meds-- the truth is it's a really common illness and a lot of my patients have it before they see me, a lot get it during the course of treatment, and some get it during the course of treatment with atypical antipsychotic medications. If there was something else I could prescribe, I would and often I do. From my perspective of the doc-in-the-office, there sometimes is just no option but to use these medications, they're what we've got. This isn't to defend the drug companies, I believe their goal is simple: to make money. Kind of like your health insurer runs ads with soft music telling how they care, but really they just want to make money. What surprises me is that anyone expects anything else from them. No answers, sorry.

My last word about media sensationalism: It's hard to get Medicaid, you have to be sick. An episode of depression treated with Prozac doesn't do it. To get Medicaid, at least in Maryland, you have to be chronically ill (and even that isn't always enough), so a bad psychiatric illness, chronically, probably one that you need a chronic, expensive, antipsychotic medication to get. No wonder antipsychotics are a high percent of the Medicaid budget.

Okay, send the check, I'll be waiting

Tuesday, June 26, 2007

The Best of Intentions

First, the rest of Chapter 10 is up on Double Billing.

Really, in some ways, everyone is a little bit of a psychologist. People naturally look at their worlds and tell stories to explain what they see. Some people are more inclined to do so; they search for patterns, they find bits of evidence, they write the tale to make the pieces fit.

"Harvey is an introvert because he was bullied as a child."

Change the name, change the trait, change the cause, but we all do it. I can't tell you how many times a day I hear "I'm depressed because something bad (you fill in the event) is happening in my life." Or even, "I'm depressed because I've gained so much weight." Never mind that the depression came first, then the medicine to address the depression, and then the weight gain! Funny, but I don't generally hear, "I'm depressed because I have this illness." Okay, sometimes, but even in people with strong family histories, few precipitants, there is still a tendency to say "My brother is depressed because he sits in the house all day," rather than "My brother sits in the house all day because he's depressed."

Okay, so we're all out own psychologist, we all see cause and effect in others and ourselves. What strikes me most is that some people have a tendency to write their stories in terms of the untestable assumptions about the intentions of other people.

"He ignores me because he wants to make me angry." Or because he's jealous, or manipulative, or because people ignore me because they don't like me because I'm the wrong size, shape, color, religion.

How do you know? I often ask for evidence, and it pours in. Once someone has formed an idea about the intentions of others, the evidence supports the theory. A story is told that builds the hypothesis of meaness in the other person. I listen. Sometimes I say nothing (what's there to say?), other times I point out alternative reasons why someone could have done something so mean aside from their innate evilness. Bad hair day? Person was so wrapped up in their own stuff they didn't consider how it might impact someone else? Pure misinterpretation? Or simple inconsideration? When evil intentions are ascribed to total strangers who have no clear motive, I am particularly suspect of the stated intention. Maybe the guy in the car in front slammed on his brakes because his cell phone rang, or he realized he missed his exit, or there was something in the road, or he dropped the directions, and not because he wanted to make you swerve.

Am I right? Who knows. There are people out there who are purposely vengeful, and sometimes I can be a bit naive, unsuspecting, overly trusting. I want to believe that even if people are flawed, they are basically good, that their intentions were generally something other than to willfully cause pain. Funny thinking for someone who watches The Sopranos, Lost, and 24-- where evil is so central.

I think it helps people if they can clarify the intentions of others -- maybe even ask: Why did you do that hurtful thing?-- rather than create explanatory stories that may propagate painful myths. I'm fond of saying, "If he were sitting next to you, how would he tell the story?"

It's been a long day.
Oh, and I did the Double Billing link in green because Roy doesn't like the links in Red. It's because he has too many dopamine receptors in several areas of his brain.

Monday, June 25, 2007

My Three Shrinks Podcast 26: Black Box Reloaded

[25] . . . [26] . . . [27] . . . [All]
We again record this podcast in Dinah's backyard, with a guest cardinal who comments throughout the whole thing.

June 24, 2007: #26 Black Box Reloaded

Topics include:

  • Side Effects of Psychotherapy. Sharon Begley from Newsweek wrote an article entitled, "Get Shrunk at Your Own Risk." We discuss this particularly in reference to grief and bereavement, PTSD, and CISD.

  • Discussion at Cheryl Fuller's Jung at Heart about therapy as a treatment for an illness vs. as a tool to improve one's life. And here's an afterthought.

  • The Impact of the FDA's SSRI Black Box on the Decline in Depression Treatment in Kids. We discuss the June 2007 AJP article by Libby et al. showing that there was a 58% drop in expected number of antidepressant prescriptions for this population after the black boxes went up, and that the proportion of depressed children who remained untreated with antidepressants increased some three-fold. Other data has showed an increase in the suicide rate if this population afterwards. In the graph below, the black line represents the percentage of kids with major depression who were prescribed no antidepressant.
  • Q&A: "In my neck of the woods there is pretty much NO 'talk' therapy in short term inpatient settings. I know of many depressed individuals who have decompensated in these settings, and have had their depression actually increase on their departure. Any thoughts?"
The tune at the end is "Advice for the Young at Heart" from Tears for Fears, which you can get for less than a buck at iTunes.

Find show notes with links at: 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

Thank you for listening.

Sunday, June 24, 2007

Dr. Crippen, Blog Fodder

Oh he's done it now. He has truly done it. I have spent several years of my life working to become a doctor, only to have Dr. Crippen suggest that perhaps I and other women physicians don't have a right to certain specialties or job flexibility. He quotes a Dr. Sarah Blayney, who writes:

"The training jobs as they stand are all or nothing. You either do all the hours or don't get the post. I want to pursue a career in hospital medicine, which will mean me committing to a minimum of five years of fairly hefty on-calls. "

At the moment I am 24, single and am enjoying life. But in four or five years time my situation may have changed and I may not want to work those hours."

She said flexible working would be particularly relevant to female colleagues wanting to start a family, but said male colleagues were also interested in changing their hours. For example, some wanted to take time out to travel, she added."
Note that the need for flexible job hours is cited as a concern for both men and women. However, Dr. Crippen takes it upon himself to limit this issue to women:
"It is right and proper that women can pursue a career in medicine. But at what stage do we decide that the needs of medical training can no longer be subsumed by the needs of working mothers?"
Perhaps Dr. Crippen would do well to remember that not all women are, or are planning to be, mothers. Perhaps he would do well to remember that here are many other reasons for limiting on-call and extended working hours---like retaining one's sanity. But that's OK because he also suggests that: "Sarah lives in cloud-cuckoo land. She wants the job but she is not prepared to do the hours....You need to grow up a little.... Just because you are a girlie, you can’t expect medical training to be turned on its head."

Good God. I thought we had grown beyond that. I thought I had left thinking like that behind on my surgery rotation, along with the bra-snapping resident and the resident who once complained about me scrubbing in: "I found a medical student to help, but she's a girl." Given that over half of all medical students in training today are female, it's truly time for this discrimination to be over.

So please feel free to visit NHS Blog Doctor today and leave a comment. The only comment I have to say right now is: "Sic 'em!"

[From Clink: Sigh...she insists on modifying my post again...At least I can modify her awful color choice.]
Guess What? The first half of Chapter 10 is up on Double Billing.

FDA Drugs: March 2007

2007: Feb | Jan . . . 2006: Dec | Nov | Oct | Sep

FDA Drugs: March 2007

  • Zenvia for "Involuntary Emotional Expression Disorder". Avanir Pharm received an "approvable letter" last October for its Zenvia, which is a combination drug of dextromethorphan/quinidine (DM/Q) used to treat what is otherwise known as labile affect or pseudobulbar affect, a brain condition where one will have uncontrollable bursts of laughing or crying without truly being happy or sad. This typically occurs after a stroke or with pseudobulbar palsy or ALS. The FDA had required more data, which the company recently provided at a meeting. The DM is an NMDA antagonist, and quinidine is being used here as a P450 CYP2D6 enzyme inhibitor, which makes the drug stick around longer. The FDA asked Avanir to resubmit a new NDA for a lower, safer dose.[PubMed]

  • Cephalon gets yet another Warning Letter on Provigil. The FDA dinged Cephalon again in this Feb 27 letter about inappropriate marketing claims suggesting that Provigil is effective for certain conditions when these data have not been submitted or approved by the FDA.

  • Marijuana-based Drug Gathering Data. Sativex is an oral spray containing two active compounds from the cannabis sativa plant being developed for several conditions, including MS-related spasticity, AIDS-related anorexia, and neuropathic pain. Given the fact that it is directly derived from pot plants and the U.S. paranoia about marijuana, I'm sure this drug has a long, uphill battle to get approved here. [PubMed]

  • Prozac Labeling Change for Infants. The labeling information for Prozac/fluoxetine now has added info on the risk of Primary Pulmonary Hypotension (PPH) in drug-exposed newborns.
    PRECAUTIONS-PREGNANCY-NONTERATOGENIC EFFECTS. Infants exposed to SSRIs in late pregnancy may have an increased risk for persistent pulmonary hypertension of the newborn (PPHN). PPHN occurs in 1-2 per 1000 live births in the general population and is associated with substantial neonatal morbidity and mortality. In a retrospective case-control study of 377 women whose infants were born with PPHN and 836 women whose infants were born healthy, the risk for developing PPHN was approximately six-fold higher for infants exposed to SSRIs after the 20th week of gestation compared to infants who had not been exposed to antidepressants during pregnancy. There is currently no corroborative evidence regarding the risk for PPHN following exposure to SSRIs in pregnancy; this is the first study that has investigated the potential risk. The study did not include enough cases with exposure to individual SSRIs to determine if all SSRIs posed similar levels of PPHN risk.
    I don't know if all SSRIs will get this language. The link goes to the original NEJM article.

  • New FDA Info Sheets on:
  • Invega/paliperidone
  • Keppra/levetiracetam
  • Trileptal/oxcarbazepine
  • Permax Recalled. The FDA announced that the dopamine agonist, Permax (pergolide), has been voluntarily recalled due to concerns about damage to heart valves. Permax was used to treat Parkinson's disease and restless legs syndrome.

  • Phase III Trials Started on Flurizan for Alzheimer's. This looks like a promising drug from Myriad to keep track of.

  • Geodon Label Updated. The labeling info for Geodon (ziprasidone) was updated in the Patient Summary section, to include the black box warning about diabetes and also include the more recent indications for manic and mixed episodes of bipolar disorder.

  • Symmetrel Label Updated. Apparently, there have been some reports of agranulocytosis (dangerous drop in White Blood Cell WBC count) with Symmetrel (amantadine), which is used as an antiviral, for Parkinsons, for pain, and probably a few other things. The labeling info now reflects this.

  • FDA Adds Warnings on All Sleeping Pills. The FDA has asked that all makers of sedative-hypnotics, like Ambien, Sonata, and Lunesta, add warnings to their labels about (1) anaphylaxis (severe allergic reaction) and angioedema (severe facial swelling), which can occur as early as the first time the product is taken; and (2)
    complex sleep-related behaviors which may include sleep-driving, making phone calls, and preparing and eating food (while asleep). The warning affects the following 13 drugs and their manufacturers:
    Ambien/Ambien CR (Sanofi Aventis)
    Butisol Sodium (Medpointe Pharm HLC)
    Carbrital (Parke-Davis)
    Dalmane (Valeant Pharm)
    Doral (Questcor Pharms)
    Halcion (Pharmacia & Upjohn)
    Lunesta (Sepracor)
    Placidyl (Abbott)
    Prosom (Abbott)
    Restoril (Tyco Healthcare)
    Rozerem (Takeda)
    Seconal (Lilly)
    Sonata (King Pharmaceuticals)

Saturday, June 23, 2007

Fuel For Our Fire

Wandering Visitor, a very positive-thinking resident who is running Grand Rounds next week, is looking for posts on what inspires us (see also Why Do I Blog?). So we thought we'd have a go at this. We are three psychiatrists from three different perspectives (prison-based forensic psychiatry, outpatient psychiatry both private and clinic-based, and hospital-based consultation-liaison psychiatry) who blog and podcast about stuff that captures our interest.

At the risk of sounding oppositional (who, me?), I'm inspired by my co-bloggers particularly when I disagree with them. Fortunately they remain my friends in spite of this. Friendly disagreement is a wonderful source of intellectual growth and mental stimulation.

I'm also inspired by any topic that gives me a chance to talk about
what it's like to work in a correctional facility, care for inmates or generally care for those who aren't able to care for themselves. I think it's important to remind people that you can't "lock someone up and throw away the key" and forget they exist. I'm here to talk about what happens within the walls.

I like the unusual and the off-beat; I blog about
cannibals and insanity acquittees and human sacrifice and write travelogues about my favorite historical prisons. Occasionally I try to be relevant to my forensic training by reviewing topics like the Tarasoff duty and sex offender commitment laws.

Occasionally I ramble about ducks and that really floats my boat. My co-bloggers are very patient with me.

This "what inspires me" bit puts me at risk of getting sappy and melodramatic. To minimize this risk, I will switch into Outline mode...
Alright, that's enough of that.

Sadly, the first thing that came to my mind when I thought about What Inspires Me is: Good Food. Why? How? I don't know, it just does. I'm hoping that I don't miss out on too many
Hot Fudge Sundaes in the name of healthy living and the never-ending quest to be a size smaller.

Goals of any type inspire me. I'm slow and steady with good endurance, but I've never had any speed. ClinkShrink runs 9 minute miles, Roy's wife does half-marathons. I decided I should be able to run: just one 10 minute mile. Then 2 miles in 20 minutes. I've hated every second of it and I'm convinced that the longer, slower, uphill trek was better for me, but hey, I did it. Why? Why not. So
trying to get my latest novel published is a goal, and by all means, drop by Double Billing and comment on my fiction. I had to get that plug in.

My husband, my children, my dog Max, and the
wonderful friends I have in my life all inspire me often. ClinkShrink, Roy, and Camel are among the most inspiring. My patients are often inspiring and I wish I could write blog posts about some of the brave and amazing people I see.

Friday, June 22, 2007

L.A. E.R. Tragedy . . . Emergency Mental Health Care

Connect the dots between these two stories...

Dr. Cory Franklin has a Commentary in the Chicago Tribune about this tragic story of a lady who died in an L.A. E.R. waiting room with bystanders calling 911 to help her because she couldn't get help in the ER.
Shortly after another bystander made a second futile 911 call imploring paramedics to take Rodriguez to another hospital, she died of a perforated bowel. A security videotape, still unreleased to the public, is said to show her writhing on the hospital floor unattended for 45 minutes. At one point, the tape reportedly shows a janitor going about his business mopping the floor around her.
. . .
This should be the audio of the 911 call... [removed due to misbehavior... try this link to listen: Youtube]

Mary Beth Pfeiffer in yesterday's Huffington Post discusses our broken mental health system.
In the 1990s, Virginia built 18 new prisons and closed 1,400 mental hospital beds. Across America, state spending on prisons spending tripled in the last 25 years while spending on mental health care rose by about a fifth.

And if you thought the era of shuttered hospital beds was over, consider that America lost another 57,000 psychiatric beds from 1990 to 2000. As a result, from 1992 to 2003, American hospital emergency rooms saw a 56 percent increase in people experiencing psychiatric crisis. It's time to stop the bloodletting.

Where is our compassion, our humanity, our duty?

Wednesday, June 20, 2007

Mental Illness and the Right to Vote.

“I just think if you are declared insane you should not be allowed to
vote, period,” said Joseph DeLorenzo, chairman of the Cranston Board of
Canvassers. “Some people are taking these two clowns and calling them disabled
persons. Is insanity a disability? I have an answer to that: no. You’re insane;
you’re nuts.”

Rhode Island is among a growing number of states grappling with the
question of who is too mentally impaired to vote. The issue is drawing attention
for two major reasons: increasing efforts by the mentally ill and their
advocates to secure voting rights, and mounting concern by psychiatrists and
others who work with the elderly about the rights and risks of voting by people
with conditions like Alzheimer’s disease and dementia.

Can I cringe long and hard now? The mentally ill shouldn't vote? What's a mental illness? Anyone who's had an episode of depression or mania? Obsessive Compulsive Disorder? How about those panic attacks? And we can't figure out at what instant someone with dementia becomes unsafe to drive, how do figure out the instant at which they should stop voting? Anyone confined to a psychiatric facility? Anyone getting disability payments for a psychiatric disorder?

Dumb people can vote. Illiterate people can vote. Republicans can vote. Ugly people can vote. Why should the mentally ill have a standard different from anyone else's?

Tuesday, June 19, 2007

From The NYTimes: When is a Pain Doctor a Drug Pusher

Oh, no, I did it again, I posted over Roy! I swear, I didn't know. Scroll down for his post.

We like to talk about subjects where the lines get blurry. Who should get care? When is it an illness? Xanax? Seroquel? Which side of the fence and how far over might one lean?

So here's an interesting cover story in the Sunday New York Times Magazine: When is A Pain Doctor A Drug Pusher?

It's the story of a pain doctor who has been sentenced to 30 years in prison for his sloppy and questionable prescribing practices. The article's author, Tina Rosenberg, comes at it with the tone that it's outrageous that he was sent to jail, deemed a criminal, for his lax practice. Bad doctoring, she contends, is cause for civil malpractice litigation, not criminal prosecution. The docs who prescribe in exchange for sex or drugs, they are the criminals. The doctor in the story did none of those things. She makes the point that the standards for prescribing narcotics, especially to a chronic and drug-tolerant population of pain patients (who may be peppered with occasional abusers) are purposely not stated, and leave the doctor open to both scrutiny and criminal charges.

There are red flags that indicate possible abuse or diversion: patients
who drive long distances to see the doctor, or ask for specific drugs by name,
or claim to need more and more of them. But people with real pain also
occasionally do these things. The doctor’s dilemma is how to stop the diverters
without condemning other patients to suffer unnecessarily, since a drug diverter
and a legitimate patient can look very much alike. The dishonest prescriber and
the honest one can also look alike. Society has a parallel dilemma: how to stop
drug-dealing doctors without discouraging real ones and worsening America’s
undertreatment of pain.

* * *
But such guidelines are futile while there is one pain specialist for,
at the very least, every several thousand chronic-pain sufferers nationwide. And
even though pain is an exciting new specialty, doctors are not flocking to it.
The Federation of State Medical Boards calls “fear among physicians that they
will be investigated, or even arrested, for prescribing controlled substances
for pain” one of the two most important barriers to pain treatment, alongside
lack of understanding. Various surveys of physicians have shown that this fear
is widespread. “The bottom line is, doctors say they don’t need this,” said
Heit. “They’re in a health care system that wants them to see a patient every 10
to 15 minutes. They don’t have time to take a complete history about whether the
patient has been addicted. The fear is very real and palpable that if they
prescribe Schedule II opioids they will come under the scrutiny of the D.E.A.,
and they don’t need this aggravation.”

By the time I finished this article, I was glad I'm not a pain doc. I was even more glad I'm not a pain patient.

VA Mental Health Overhaul Sought

Congress and the White House are pushing for reforms in the Veteran's Administration and other military hospitals to overhaul the mental health care provided to people serving in the military -- particularly those coming back from Iraq and Afghanistan -- and those who have already served.

Today's Washington Post states:
Over the past two days, The Post has published stories detailing the bureaucratic and health difficulties of troops returning home with PTSD.
The Army is hiring 200 more psychiatrists, psychologists and social workers to help soldiers with mental-health problems, and next month it will launch an educational program on stress for all soldiers and commanders, said Maj. Gen. Gale S. Pollock, the acting surgeon general of the Army.

The Army is also expanding a pilot program at Fort Bragg to offer behavioral-health treatment at primary-care facilities to reduce the stigma for soldiers seeking care, Pollock said.

"The tragic cases of combat stress discussed in the Washington Post June 17-18 are powerful and concerning to the U.S. Army," Pollock said in a statement. She emphasized that the Army is continuing to address the problems of soldiers with PTSD, including placing hundreds of mental-health specialists on the battlefield in Iraq and Afghanistan to counsel soldiers with combat stress.

Pollock cited efforts such as post-deployment health assessments, begun in 1998. Based on a 2004 study by Walter Reed researchers, the Army added a second screening for soldiers a few months after their return to catch problems that are not quickly apparent, such as PTSD.
Cruz, who helped capture Saddam Hussein, has been plagued by anxiety and nightmarish images of dead Iraqi children since returning home. Yet VA has denied his claim for compensation, ruling that his psychological problems existed before he joined the Army and that he had not proved that he saw combat.
The Washington Post has set up a special online area for this topic, "Walter Reed and Beyond," here.

Monday, June 18, 2007

My Three Shrinks Podcast 25: Sibling Reveille

[24] . . . [25] . . . [26] . . . [All]
We were expecting to have Doctor Anonymous on as a guest (not one of those soundboard guests) today, but he couldn't make it and sends his regards. We'll try another time. Happy Father's Day.

June 17, 2007: #25 Sibling Reveille

Topics include:

Find show notes with links at: 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 (Note: beginning with this podcast, I am encoding the .mp3's as mono files to reduce bandwidth. Let me know if that's a problem for anyone.)

Thank you for listening.

Friday, June 15, 2007

Pot Calling the Kettle Black?

Lilly is complaining that all the lawyer ads about suing Lilly for diabetes is resulting in pts stopping their meds and relapsing.
Lilly on Wednesday released the results of a company-funded survey that asked 402 psychiatrists who treat patients with bipolar disorder or schizophrenia to complete an online questionnaire. More than half of the participating psychiatrists said they believed their patients who stopped medication or reduced the dosage did so after seeing lawyers' advertisements about anti-psychotic drugs.
Wonder how many people went on Zyprexa due to Lilly ads?

Time With A Patient

My good friend and once med school roommate had a letter published in today's New York Times. Quoted in full:

Re “A Stubborn Case of Spending on Cancer Care” (Business Day, June

Despite recognition of the problem, the fact remains that our current
system of health care reimbursement values procedures and volume over time spent with patients.

The time spent talking with patients and families is an
investment that pays for itself many times over. Carefully eliciting a history,
reviewing records and communicating with other health providers, assessing
patients’ values and weighing them into decisions regarding complex treatment
options cannot be done in 10 minutes, but it can provide better and more humane

Technologically advanced and costly treatments save lives, but
their allocation needs to be made sensibly and not to the detriment of
old-fashioned talking and listening between doctor and patient.

Patients want and deserve this time-intensive care, and although it
can often be ultimately cost-saving, it will not be the norm until the financial
incentives reverse themselves.

Susan C. Kalish, M.D. Boston, June 12, 2007

I have a nice friend, she is a warm and caring doctor with an enormous heart and wonderful values, even if she isn't a psychiatrist (she's a geriatrician). Sometimes I'm not sure exactly what medicine is about--we allocate our resources in idiosyncratic ways, some of which don't make sense in terms of cost-benefit but do in terms of emotion. We've come to see physicians as precious resources, whose time needs to be meted out in cost effective 10-minute doses while the humanity of medicine is doled out to less expensive professionals-- nurses, physician assistants, social worker therapists. Susan says, and I'll agree, it's a mistake.

$#!&*@$ You!

Someone said something rather nice to me the other day. He said, "You don't deserve to be cursed at." I thought that was rather sweet.

I have to say that after a couple decades in the profession I rather took it for granted that getting sworn at occasionally was part of the job. I could be blessed in my morning clinic and cursed in my afternoon clinic and it just goes with the territory. I don't really take it personally and it rather amuses me that people could see me so differently in a single day when I am really the same person all day. (I mean, not having a twin like the psychiatrist in Double Billing. Oh by the way, the next installment of Double Celling is up too.)

I'm not a therapist but I know in therapy the clinician expects that at various times in treatment people may become annoyed or upset or angry for reasons that may or may not be reality-based. Being a good psychiatrist means being able to handle a patient's strong emotions with them while remaining a stable figure in the patient's life. You just can't have thin skin about it.

So anyway, it was interesting hearing this from a non-mental health professional lay person. From the outside it does seem odd. On the inside it's just a way of life.

Wednesday, June 13, 2007

Making Strides (Props to Rodricks)

OK, here's something weird. I am writing a post with the hope that I will drive traffic away from our blog. The post I'm about to direct you to is a worthy cause and I enjoy calling attention to people who do common sense things for a good purpose. (And considering how often we bloggers parasitize the standard media it's only fitting that I should drive traffic back in that direction once in a while.)

In June 2005 one of the columnists for our local newspaper, Dan Rodricks, wrote an open letter to the drug dealers of our city. The point of the letter was to ask them to stop killing people.

Seriously. Really. That's exactly what he said. Read it here if you don't believe me.

Now the cool part.

He offered to help them get real jobs. And that's what he's been doing for the past two years. Any ex-offender looking for a job can call 410-332-6166 for information about companies that hire ex-offenders. He's had more than 5000 inquiries and mailed out loads of packets of information about job opportunities and substance abuse programs. He's even sent these packets to inmates in our prison system and I really like folks who help my patients.

And it's not even his job to do this.

I'd like to keep up the momentum, so if any you are willing and interested you can support this project by sending a check to:

Goodwill Industries


Strive is a national organization that provides job training and job-seeking skills for impoverished people, including ex-offenders. You can find a local chapter here.

I know it seems odd to ask a global readership to support a local effort. Well, if somebody can ask drug dealers to stop killing who am I to be less bold?

What Paris Hilton is reading in jail

You guessed it:
Chapter 9

And join us for next week's podcast where Hillary Clinton will be talking about how much she's enjoying Double Billing. Senator Clinton will be sitting right next to Dr. Phil.

Monday, June 11, 2007

What I Think About Paris Hilton

I'm really not one for celebrity gossip but this news (and I use the term loosely) item had some good correctional teaching points so I thought I'd address it. Besides, it's just a matter of time before somebody drops a question to My Three Shrinks asking my opinion about Paris Hilton and her jail status.

So here goes:

Looking at this from the Sheriff's viewpoint, I can imagine what was going through his mind. He's got a new inmate who is:

1. a high profile case
2. a previously upstanding citizen
3. crying, distressed and not eating
4. has a known mental disorder (in treatment at arrest)
5. has an active substance abuse problem
6. is in isolation in a single cell
7. is serving a relatively short sentence
8. is within 24 to 48 hours of incarceration

Egad. The next thing this Sheriff is going to imagine is Paris Hilton hanging dead in a jail cell. She has eight separate risk factors for a correctional suicide and it is not good to have a dead celebrity in your facility. Ideally, the proper intervention would be to get her referred for crisis intervention services as quickly as possible. Educate her about what to expect and how the incarceration will run. Get her referred for psychiatric evaluation and pharmacology, if indicated. If all else fails, use suicide observation to preserve safety. I don't know the LA jail or what resources they have; given her relatively short sentence the Sheriff may have felt the more efficient alternative was to release her to home detention.

Home detention is a good tool used to reduce institutional crowding but it is limited to people with relatively short times left on their sentences and to non-violent offenders. Given that she only had less than a month to serve, keeping her in jail was a waste of space. In Charm City she probably would not have been incarcerated for a first probation violation; I think she probably was treated more harshly than the average defendant. Maybe this was because of her celebrity status or maybe she didn't present herself well in court. In our prison system the decision to put someone in home detention is made without judicial input; it's the institution's perogative to assign someone there.

She was being kept in a single cell because of her celebrity status, but she was seen crying and not eating there. Most completed correctional suicides are done by inmates in single cell status. The facility would have had a reasonable concern about maintaining her safety under these circumstances. One option would have been to put her on suicide watch involuntarily, but again this involves a fair amount of embarrassment and discomfort to the person you're doing this to. I understand she is now housed in a special needs unit where she is being monitored, another reasonable alternative. The term "special needs unit" refers to a specific tier or placement within a facility for vulnerable inmates who require therapeutic monitoring. It is not the same as protective custody in that a special needs unit is controlled and regulated by mental health staff. People with chronic serous mental illnesses or developmental disabilities may be housed on a special needs unit. Every facility does not have a special needs unit; they usually just exist in larger (over 500 beds) facilities so your average small local county jail may not have one.

So that's what I think. I'm sure she'd be welcome back at the Charm City zoo or the local television station anytime. As long as she doesn't drink.

Sunday, June 10, 2007

The Ultimate Disappointment

And now what was that all about? So boring, I could barely stay awake. My husband is now watching the end of The Sopranos for the third time, convinced we missed something. Meadow is now trying to parallel park for the twenty-third time. Onion rings get ingested over and over again. A neighbor called, frantic, twice, concerned that her TV had gone dead.

Nothing happened.

My husband keeps muttering, "It's coming back, they're going to make more episodes. It's a set up for a movie." He just can't face the fact that this was it: the final episode of The Sopranos was the lamest ever.

Nothing happened.

I'm off to grieve, I don't have it in me to find a picture to upload. Our podcast was better.

My Three Shrinks Podcast 24: Dr Phil on Skype

[23] . . . [24] . . . [25] . . . [All]

Okay, folks, this one's a bit on the long side, but well worth it. Around the 28-minute mark is an "interview" with talk-show psychologist Dr. Phil. See below for my notes about it, but let's just say that Dinah has vowed to get even with Clink and me. Or, click here to listen to just the prank and the mash-up song.

Also, listen in to us next week in Podcast #32 as Doctor Anonymous joins us as a guest blogger (this one's for real).

June 10, 2007: #24 Dr. Phil on Skype

Topics include:

  • Genetics of Cocaine-Induced Paranoia. Roy talks about a recent article in Biological Psychiatry by Kalayasiri which suggests that a particular mutation (C1021T) in the dopamine beta-hydroxylase (DBH) gene was associated with significantly increased paranoia in a small group of cocaine abusers. Genetics is playing an increasing role in understanding how we respond to drugs AND to our environment.
  • Dinah wins an award for her writing.
  • Expectation Vs. Evidence-based Medicine. We get into a detailed discussion about how patients' perceptions and expectations get in the way of evidence-based medicine (with examples from Flea's post on admitting children and direct-to-consumer advertising). "Doc, my friend got better with DrugX so I want to try it." "It goes back to 'who deserves care'."
  • Dr. Phil visits My Three Shrinks. THIS IS A MUST-LISTEN SEGMENT! Clink and I play a trick on Dinah by "calling" Dr. Phil on Skype and he "interviews" us. This is a riot!! Dinah is such a good sport. [link to DrPhil Soundboard]
  • Dark Tourism. After reading a NYT piece on touring prisons, Clink discusses the concept of dark tourism, where people seek out notorious sites to see (like cemeteries and prisons). She sent us a humongous scholarly piece on the subject (see Clink's Travelogue for more fun). Dinah talked about visiting catacombs in Paris where the walls are made of human bones, and here's a pic of those. (Note from Dinah, I wanted to put the picture and the link in, but I didn't listen to the podcast to hear if I was editted out. They do those things, you know).

  • Special DrPhil/MTS mashup treat at the end. Credit KLF (aka The Timelords aka The JAMs) for the song, Doctorin' the Tardis, which you can find on emusic for 25 cents, or on iTunes for 99 cents.

Find show notes with links at: 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

Thank you for listening.

Saturday, June 09, 2007

Shrink Mania: Post & Podcast Contents for the Past Few Days

Roy comes out from under floor boards on the weekend. He's out, in case you haven't noticed. I posted. Roy posted. He got up last week's podcast. He's getting up this week's podcast (Done -R). He posted. He posted. Clink stopped over to visit and pick up a helmet last night. She ran out saying she was going to blog about....oh I'll leave you guessing. It hasn't shown up yet, but I'm sure it will. I posted. At this point, we need a table of contents, so here goes:

DBH gene in cocaine-induced paranoia: Roy tells us why some mice might be more prone to cocaine addiction. CLICK HERE

Chinese Psychiatry and Internet Traffic for Blogs and Podcasts: Roy ponders why our My Three Shrinks podcasts gets hundreds of views from China while Shrink Rap gets NonE: CLICK HERE

Podcast #23: It's here, it's shrinky, we ramble about random stuff. Click Here

Someone Knows the Trouble I've Seen: Dinah relates to a NYTimes article about a mom who Facebooks (it's now a verb). CLICK HERE

Boundaries! Boundaries! Boundaries! : Dinah discusses the termination of Tony Soprano's long-term psychotherapy. CLICK HERE

ClinkShrink writes prison fiction: a new endeavor, a new blog. CLICK HERE
All of Chapter 8 is up on Double Billing, Chapter 9 coming soon. Dinah's novel in progress and I'd love your feedback. Insults are fine. I like compliments too. CLICK HERE

I think I've got it all, at least the last few days worth. Roy, where's YOUR fiction?

DBH Gene in Cocaine-Induced Paranoia

So I thought I'd make another post about how more is being learned about our genetic makeup and how that may relate to medication side effects. In this instance, the "medication" is cocaine, which causes a huge release of dopamine. Some folks get really paranoid after using cocaine. This study asked the question "Is reduced breakdown of dopamine associated with paranoia symptoms in cocaine users?"

First some background. The above graphic shows that the neurotransmitter dopamine (or DA) is converted into norepinephrine (or NE, sometimes also called noradrenaline, or NA) by the enzyme dopamine beta-hydroxylase (DBH). You can see that all this enzyme does is add the little -OH (or hydroxy) part to the dopamine molecule to make norepinephrine.

Kalayasiri 2007 showed that a particular mutation (C1021T) in the dopamine beta-hydroxylase (DBH) gene was associated with significantly increased paranoia in a small group of cocaine abusers (see top graph). Cocaine users were blindly provided with different doses of cocaine (bet it was easy to find subjects) and their level of paranoia was rated every few minutes using a Visual Analog Scale (VAS). Users with the TT variant of the gene rated their paranoia level consistently higher than those with the CC or CT gene variant. It has elsewhere been shown that the TT form of the DBH gene is broken, and so is much weaker at converting DA to NE. The resulting higher levels of dopamine in the TT people may be why they get more paranoia.

[Genetics 101 Note: when you see this type of notation, "C1021T", all it means is that at position 1021 along the double-stranded DNA for that particular gene, there is either a C or a T nucleotide at this single point on either DNA strand... if each of your two DNA strands (one from Mom, one from Dad) contain one or the other, then you are homozygous for either one (CC or TT)... if Mom gave you a C and Dad gave you a T, then you are a CT (called heterozygous). Thus there are 3 genetic variants (in this case, CC, CT, or TT) which can exist at this single nucleotide position. These single nucleotide variants, or "polymorphisms", are referred to as SNPs, or Single Nucleotide Polymorphisms. Different SNPs can result in that particular gene's product or function to be enhanced or diminished, resulting in functional variations which may contribute to individual variations in one's response to disease, drugs, or the environment.]

Because this paranoia and related symptoms are uncomfortable to most people, it may serve as a deterrent to using cocaine. In fact, folks with the TT genotype might be at reduced risk of becoming addicted to cocaine because their DBH gene does not work as well. In fact, the alcohol deterrent drug, disulfiram (Antabuse), also happens to block the DBH enzyme (remember, the DBH gene contains the instructions to make the DBH enzyme). This would result in someone with a normally functioning enzyme (from a CC or a CT SNP) to have an enzyme that works like someone with a TT SNP. Antabuse has been shown to be helpful in treating cocaine addiction.

As further evidence of this connection, Schank 2006 used DBH knockout mice to demonstrate hypersensitivity to cocaine in these animals, suggesting that low DBH activity in some cocaine abusers may increase the drug-related dysphoria and aversion, making them less likely to become addicted to the drug.

We hypothesize that the ratio of dopamine (DA) to norepinephrine within noradrenergic vesicles is elevated in TT [homozygous] subjects, so that during cocaine intoxication, DA-mediated neurotransmission is relatively elevated in regions richly innervated by noradrenergic and dopaminergic fibers (e.g., prefrontal cortex). Alternatively, given observations of up-regulated high affinity DA receptor binding sites in DBH knockout mice, TT homozygotes may be hypersensitive to DA, and thereby [may] be more vulnerable to cocaine-induced paranoia.

Pretty cool.

Chinese Psychiatry and Internet Traffic for Blogs and Podcasts

I've been noticing lately that we get a lot of traffic from China. I guess that makes sense... it is only the most populous country on the planet. But, it is now clear that the internet has hit China in a big way. And opened its borders.

Above is a list of our podcast traffic for the first week in June. China is our #1 international source of hits. Most of these hits are image files (our logo) but there are quite a few podcast hits (though most are not completely downloaded). Most of the traffic comes from Baidu, which is China's version of Google. Baidu is, in fact, a competitor to Google, and is now China's Number One Son, accounting for 62% of all searchs in China.

While our podcast gets 500 hits per week from China, our blog gets no traffic from China. Zero. Not one single hit.

This suggests to me that China censors all Blogspot sites (or at least all the ones which might use the word psychiatry or mental), but they have no mechanism for blocking our audio content.

Of course, Psychiatry has had a difficult past in China. It has been used as a government tool for social and political control (I'm sure there are some in the anti-psychiatry movement who feel this way about American psychiatry). This 2005 article points out that raw capitalism may now be the dominant force in Chinese psychiatry now.