Monday, June 25, 2007

My Three Shrinks Podcast 26: Black Box Reloaded

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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.


Anonymous said...

Perhaps Cheryl Fuller should stop calling herself a therapist and use the title "life coach".
G.P's also see the "worried well".Who isn't worried at some time or another? The G.P. will, hopefully, rule out any actual disease and tell the patient that they are well. Fuller could tell the folks shelling out for her services that they are fine and may wish to take up knitting to distract themselves.
A woman, or anyone for that matter, dealing with the legacy of an abusive or traumatic past may or may not qualify for an official heavy duty DSM dx. She/he may or not be "mentally ill", but it is doubtful that that person woke up one fine morning and just decided to try therapy. That person does not have the psychological equivalent of a stubbed toe.
Life can suck and most people do not require therapy as a result. They are somehow able to carry on. Not so for plenty of those carrying heavy baggage around. In Fuller's world, they might get treated if she can add them to her sliding fee schedule and still turn a profit off her other "people she sees". If not, then they would be out of luck but probably not for too long. When they have numbed themselves with drugs or alcohol long enough to qualify as addicts, when they do make a suicide attempt, when they do attack their kids or others around them and end up in jail, then they might get some help.
I never really saw the fact of having a diagnosis as a big plus in my life. I always focused on the stigma (read the Ethicist in yesterday's NYT and you will see what I mean). Post Fuller, I see how lucky I really am. I will not be denied the insurance coverage. I hate that black and white thinking.

With regard to short term hospital stays and therapy: in my experience these stays have been used to stabilize. The staff should try to ensure there will be treatment post discharge if possible and not already in place, but how useful is it really to have "therapy" with some stranger when you are in hospital for a brief time and then start again on the outside? The best ones inside are usually the nurses. Everyone else is too busy.
With regard to mentally ill therapists, looking forward to hearing your views. There are plenty of therapists with no dx who should not be in the field. As long as a therapist is being treated and is a good responder to that treatment, judgement not impaired.., what would make them any less of a therapist? ALL therapists should, ideally, have supports in place that would ensure any decompensation on their part was picked up. Since the world is not ideal, that is not the case in practice but I am unconvinced that a therapist with a dx poses any greater risk to the public than one without. Go ask K.R.J. for her views. Or maybe she just spends her time writing.

NeoNurseChic said...

OT but....American Idol is having an audition in Philly for the first time ever this year!! Is that a sign, or what?! My best friend just told me this morning. So - I've gotta find someone to work that weekend for me (since you get your wrist band on the weekend) so that I can go audition!!! pick a song!!

Just had to share.... :-P

Take care!
Carrie :)

Anonymous said...

carrie, You have my vote.
I tried to visit your blog and couldn't get in.

NeoNurseChic said...

Hmmm - I don't know why, Dinah. But the fact of the matter is that I don't write on it any longer. It's a dead stick now. Rather sad, actually! The last time I wrote anything on it was the day I got that phone call from Jordan. But I'll make sure you are on the list again - I know I put the Shrink Rap gmail address on there anyway! Do you have a separate google ID I can enter?

I was thinking about the song, "Broken Wing" by Martina McBride. Lindsay (my best friend) and I were discussing this morning how a lot of people sing that song, but it's still a good one. Hmmm..... This could be fun!

I mentioned one time to my psychiatrist about auditioning for that show (I was only mentioning it to share my mom's reaction every time I say I'm going to audition), and he said that a lot of the point of the show is tearing people down and humiliating them. This is true - BUT - I still want to audition!! Just have to free up that weekend!

Take care,
Carrie :)

Sarebear said...

Roy, I'm only a bit into this 'cast, but I must respectfully, but STRONGLY, disagree with your opinion that only major mental illnesses should be covered by insurance (well, actually, isn't that only what alot of insurances will cover?).

See, I KNOW. I. KNOW. WITH. ALL. MY. HEART AND MIND. that if I could have had access to therapy and other treatment much, much sooner in life, that my mental health would not have deteriorated anywhere NEAR this FAR.

Without knowing what was wrong, I could infer, as a child, young teen, etc., that there was SOMETHING DIFFERENT about me, that there was SOMETHING that needed addressed . . . but I didn't know what. See, I'm very intelligent; very bright. If it weren't for that, I'd have been gone a long time ago. I could infer that there was something going on, from seeing and analyzing the differences in my functioning or lack thereof, my interactions, and those and that of others . . . . anyway, but I THOUGHT IT WAS ME. Does that sound like an excuse, to say hey, I wanted a label, a diagnosis, so that I could/would find out that it WASN'T me? Well . . . hell, yeah! Lol. When you've put EVERYTHING THAT YOU HAVE INSIDE, AS A HUMAN BEING, A PERSON, A GIRL, A WOMAN . . . . . into trying to BE, trying to EXIST, trying to LIVE . . . and constantly being the square peg that can't interface correctly with a round peg world . . . when you have picked yourself up, time and time AGAIN, over and over, and faced the SHEER SHAME of EACH AND EVERY FAILURE (and there are MANY) . . . . and spent a lifetime doing this, AND STILL YOU FAIL . . . . YES, I want to know WHY. My soul CRIES with the desperation to KNOW WHY!!!!

Anyway. So much damage that I've barely been able to touch in therapy because trying to rein in the symptoms and effects of unchecked for many years and thus grown into a wild and fierce beast of a horse issues/illnesses/etc, has been and still is the struggle at hand. But the damage caused by so many years of . . . . scraping my spirit and self-hood raw against the . . . requirements of being a person in this world and society of ours, and not having the capacity or the capability in some aspects of that, as if I was missing the proper enzymes to digest an essential food, or missing the proper antibodies to match up with and latch onto and defeat a terrible illness that, for everyone else, is a minor issue, if felt at all (perhaps something like the Europeans bringing a devastating illness to the Americas when they discovered it; one which barely affected them, but devastated native populations.)

Anyway, sorry to go on. Even though I DO have diagnosis(ses) of major mental illness, I know that there are other things that should have been addressed decades ago, to prevent much damage, and contributed to and made such illnesses worse, if not being perhaps one of the contributing causes.

So, I disagree because I KNOW.

Midwife with a Knife said...

Interesting podcast. I was thinking about the CISD (is that the right acronym?) thing. Our residency had something similar on sort of a scheduled basis.

The thing is, I always felt much worse afterwards. The best example is as follows. As obstetricians, we deliver a fair number of stillborn babies. Even worse than delivering them is giving patients the news that their (often and somehow saddest) term baby has died. All of the patients scream, everybody cries. It's horrible news to have to give someone. To this day, I hear that scream and know that it's the "dead baby scream". I still have nightmares that involve the dead baby scream. The worst thing is that it feels like you're doing something really bad to these moms by diagnosing their fetal demises.

Not surprisingly, these sorts of things come up fairly often in the debriefings.

As a second year resident, we were in charge of triage (kind of like an ER for pregnant women). Anyway, we were almost always the people to make the diagnosis of a fetal demise (dead baby). After a rotation particularly full of fetal demises (I don't know if I went more than a couple of days at work that month without diagnosing at least 1 fetal demise of a baby that otherwise would have been of a viable gestational age), I really felt very sort of numb towards the whole thing (for lack of a better word, really). It was kind of like it didn't bother me any more, or at least that's how I remember feeling at the time (except looking back on it, maybe it was bothering me more than I thought at the time).

Anyway, up comes our required and regularly scheduled debriefing, and everybody was talking about how sad they felt about all the dead babies. I didn't really say much, but all I could think at the time was that I didn't feel sad, I didn't really feel anything. And then after hearing how everybody else felt so sad, I figured I must have been some sort of terrible person, a cold hearted monster (I think I actually used that term for myself in my head for a while) to not really feel anything about having to tell all of those moms that their baby died. And I felt terribly guilty about not feeling how everybody else felt for weeks, maybe a couple of months.

So, I can imagine how those Critical Incident Debriefings may not be good for everybody. Not that I was seriously damaged by it, but it certainly didn't make me feel any better.

Apologies for the long comment!

Anonymous said...

I really enjoyed this podcast.

As to the question of whether insurance should pay for the treatment of someone experiencing uncomplicated grief, I don't see any waste of resources when you're talking about the first visit, where the assessment is done that concludes that what the person has is uncomplicated grief. We pay for preventative care in other health settings and that's accepted as good practice; even if a cancer screening turns up negative, the provider still gets reimbursed. My question for the shrinks is, is that true in your practice? Can you submit a claim with no diagnosis, and have it paid?

As to follow-up care for an individual without a serious mental illness, but who is troubled and would benefit from continued talk therapy, I think it would be reasonable for a payer (whether private HMO or government program) to pass them along to a less expensive provider, such as a social worker. I think that a psychiatrist's time is too valuable for public money (including HMO money) to be spend on treatment for those without a real mental illness. Of course, as I understand it, in practice most payers won't usually pay for talk therapy given by a psychiatrist in any case. And of course I don't oppose a self-pay patient getting any kind of care they're willing to buy and psychiatrist is willing to provide. I just think it would be nice if those without the resources (and who have a greater need) were able to access the same care, through better-funded public programs, or insurance plan's recognizing the value of the patient having the person who writes their scripts being the same person who does their talk therapy.