Thanks to the Sports Psychologist

Note to Rach: it's now 24 hours since the game began. And you're officially hearing from Dinah.

I walked into work this morning and one of the therapists I work with at the clinic congratulated me. I was clueless. What? He wouldn't say. Finally, "The Red Sox." Oh yeah, them. I'm a bit sleep deprived, I have a banner hanging on my house, I've carved a pumpkin. Still, it's not the excitement that 2004 was (I'm sorry, remember I'm really a sports fan by proxy, I like the idea, I haven't gotten all thrill of a Real fan) back in the day of the Curse of The Bambino. And also, we've got the angst of a teenager trying to meet a November 1st deadline for some college applications, so I'm a little distracted. Still, I heard from friends in Boston, the boys in my house are a bit brighter, my daughter spent her day discussing Mike Lowell, and The RED SOX won the World Series!

So I went to check Curt Schillings's Blog, 38 Pitches. Mr. Schilling, minus the bloody sock, is feeling very thankful today. Since this is a mental health blog, I thought I'd skip where he thanks God, his wife, coaches, friends, neighbors, coaches, etc, and skip right to his gratitude to the team psychologist:

Don Kalkstein. Sports Psychologist. Hmm, is there a team or market more in need of someone like that than this one? Given the length of our season, the grind of the schedule, the market we play in and the other things that come with playing in a ‘win it all, always’ environment there is no doubt a need for someone not coaching, to chat with. DK is the goods. His dedication to the Dallas Mavericks is his only real vice (though it’s a necessity since he works for them I guess, but my Suns are still better!). DK is, after all is said and done, someone I would call a friend before anything else. He’s one of those rare people that makes you drop any and all pretenses about 8 seconds after you meet him and chat, about anything. He’s also Tito’s Fantasy Football bench coach and an incredibly horrid NFL talent evaluator……

So what does a sports psychologist do and can I have this job?

Is It Worth It?

In a number of posts lately, commenters have been talking about a trade-off: is the potential to get better worth the risk of possible side effects? And if the treatment actually does effect improvement, is that improvement worth it when side effects do happen. As our commenters have pointed out, that's often something that only the patient can decide....though we psychiatrists will add that in certain conditions (mania, disorders with a delusional component, disorders where violence is a symptom) that insight can be impaired and sometimes it's good if the patient gets a little input from others. Mostly, though, especially when the issue is one of subjective distress, the patient is uniquely able to make the "Is It Worth It?" determination.

Okay, so Judith Warner has a neat post on the New York Times Domestic Disturbances blog where she talks about The Migraine Diet, food, meds, and lifestyle issues pertaining to the treatment of her migraines. She talks about the recommendations of David Bucholz, the Hopkins migraine Guru (and my neighbor...) -- avoidance of medications that can lead to rebound headaches and a diet devoid of...food (--I'm kidding of course, but apparently caffeine, pizza, beer, and chocolate--the foods Shrink Rappers love-- are out). Ms. Warner writes:

Some people do manage, through diet and exercise, or by protecting themselves from their worst “triggers,” to free themselves from their drugs. But many can’t do it. Many find they can’t accept living in the compromised condition that drug-free existence requires.

A smart high school girl I know switched a few years ago from a mainstream school, where she was struggling with dyslexia and ADHD, to a school that specializes in teaching kids with severe learning disabilities. Being there has permitted her to function without her ADHD meds. But now she’s bored. She’s dispirited by the lack of academic challenge and she wants out, because she’s afraid that, without academic challenges, she won’t be able to get into a mainstream college.

That’s the tradeoff: taking daily drugs, or living a life that feels not quite worth living.

The story ends with a prescription for Topamax and a snickers bar, result pending.

-------------

If you haven't been following Foo Foo's blog, Turn Your Head and Scoff, by all means, visit. He tells a moving story about a young woman's death from colon cancer-- I started to comment, but just didn't know what to say. He tells about life in San Diego with the fires burning, and of course, there are those lovely pics he posts of the interior of his own GI tract.

-------------

I think the Red Sox will clinch it tonight.

Perchance to Dream

I've been having trouble sleeping sometimes lately. Oh, who am I kidding? I've always had intermittent insomnia, lately it's bothering me more for some reason. I'm lucky: if I don't sleep well, I don't feel it the next day, and so I've learned not to worry so much about it. If I go a few days with restless nights, I start getting irritable, and then I usually sleep well for a bit until the cycle repeats. A friend insists I'd sleep better if I turned off the computer and TV by 10 or 11 pm. I'm usually IN bed by 11:30, and I'm not much of a TV watcher, so I don't think that's it-- I sometimes get on the computer after that if I can't sleep, but I've tried first. Then she said it's the Diet Coke I have with dinner. Fine, I've given up caffeine after 9 am. I've had no Diet Coke in almost two weeks. I don't miss it, but it's not making much difference. Some nights I sleep well, others I don't. Last night, by the way, Roy was in my dreams....

So with that as a prelude, the New York Times has an interesting piece on sleep medications. I prescribe sleep medications sometimes, and I really don't think they're a problem for short term issues-- someone who sleeps poorly because of an acute stressor. And SSRI's often disrupt sleep, for some people the combination of an SSRI with trazodone seems to be helpful for both sleep and depression. Getting back to the New York Times article, "Sleep drugs found mildly effective but wildly popular"-- Stephanie Saul writes,

But if the unusual pitch makes you want to try Rozerem, consider that it costs about $3.50 a pill; gets you to sleep 7 to 16 minutes faster than a placebo, or fake pill; and increases total sleep time 11 to 19 minutes, according to an analysis last year. If those numbers send you out to buy another brand, consider this, as well: Sleeping pills in general do not greatly improve sleep for the average person.

The article goes on to say that while total time asleep is increased by 25 minutes or so, that sleep satisfaction amongst insomniacs is greatly increased. The article goes on to theorize why that is, to talk about some specific problems with certain hypnotics, and to say that the perfect sleep agent hasn't been found.

And with this thought, I've changed the sidebar poll-- Please vote for your favorite sleep medication. In Roy's honor, I've tried to be a bit more complete. And once again, in my pursuit of useless data, I don't care who you are, if you take or prescribe it, or if you merely like the idea, just tell us your favorite.

Oh, and finally, I should have put this on my last post about the Red Sox, but if you didn't know it, Red Sox pitcher Curt Schilling is a blogger-- do check out 38pitches.com . Funny, but his posts get more comments than our Shrink Rap posts get. I wonder why.

The Red Sox Are Ahead

So we live in Baltimore, but my family roots for the Red Sox (it's a by-marriage sort of thing). Fortunately, the Orioles don't make this very hard.

In theory, I'm all into it. I like being aligned with a cause--something more fun than all the medical policy stuff I get to be indignant over. I bought a Red Sox flag and hung it on the house. I sort of know what's going on, I know the names of the players, sometimes even their numbers, I know who Dice-K, Youk, and Big Papi are. I know what it means (I think) to say "It's Manny being Manny." I know most of the rules and how the game is played, which is much more than I can say for football, even though that's the other non-stop event in my house.

I like the idea but as a true sports fan, I just don't cut it. The guys in my house can recite every play, every at bat, every caught and almost-caught ball. I can sit in front of the TV staring at it, get bored and faze out. Then I suddenly realize there are two men on base and I never noticed them getting there. Pitchers duel are the worst. I do tend to remember Grand Slams, and I usually know who won.

When I met ClinkShrink, she was a Twins fan. Now, she never talks baseball. And Roy, as a sports guy, he's a failure.

So what's this got to do with psychiatry?

My Three Shrinks on BlogTalkRadio

[Previous] . . . [DrA on BTR] . . . [38] . . . [All]

---

This is a recording, also available on Blog Talk Radio, from Dr Anonymous' LIVE, call-in, internet radio show, which is broadcast every Thursday night from 10-11pm ET.

---

October 24, 2007: #36a MTS on The Doctor Anonymous Show on BlogTalkRadio

Topics include:

• This is pretty cool technology, folks. All three of us called in to chat with Dr A and to answer questions from the listening audience. Most of the questions had to do with Halloween, such as:
• why do we like to get scared?
  
• what was your favorite Halloween candy to get?

To listen to more of Dr A's shows, go to his section on BTR to listen.

---

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.

Neuroscience Funding Gets A Boost

Just a couple weeks ago the Justine and Catherine MacArthur Foundation awarded a $10 million dollar grant to twelve universities to study neuroimaging and the law. The purpose of the grant is to get a better understanding of the relationship between functional neuroimaging studies and forensic issues such as competence to make decisions, criminal responsibiity and disabiity. This grant has the potential to really change the nature of psychiatric expert testimony.

The grant has three components: brain abnormalities, substance abuse and decision-making. There will be some overlap between these areas, but the general idea is to start bridging the gap between what is seen on a functional MRI and the ultimate legal questions of criminal culpability and competence. This can be a life or death question---in Roper v Simmons neuroimaging was used as evidence that juveniles should not be given the death penalty. Hopefully the MacArthur grant will shed some light on whether the degree of brain myelination in juveniles is, in fact, relevant at all to criminal responsibility. Right now the legal opinions based on neuroimaging have tended to leap a bit beyond what science has shown in my opinion.

And Now a Word or Two about Mood Stabilizers

I came to talk about mood stabilizers and figured I'd start by summarizing our sidebar poll "What is Your Favorite Mood Stabilizer?" Only every time I come on, the poll has gotten more votes, so I guess I'm waiting for the mood stabilizer poll to stabilize.

Here's where we're at so far:

What's Your Favorite Mood Stabilizer?

Lithium	32 (22%)
Depakote (Valproate)	27 (19%)
Zyprexa (Olanzapine)/ other atypical anti-psychotics	29 (20%)
Carbamazepine (Tegretol)	1 (0%)
Gabapentin (Neurontin)	9 (6%)
Lamotrigine (Lamictal)	44 (30%)

143 votes, Lamictal has been consistently in the lead since the beginning. Both surprising and not surprising.

I talked about How A Shrink Chooses an Antidepressant. I have less to say about how a Shrink Chooses a Mood Stabilizer. In fact, I'm not really sure. I'll tell you how This shrink chooses a mood stabilizer. It's not that much different, so click on the that post for more details.

• History of Past Response.
• Family History of Response
• Patient Preference. This is a big one with mood stabilizers. The gold standard is Lithium and some patients just won't hear of it. They think taking lithium means they're really far gone, that it's heavy duty stuff, that it means they're crazy.
• Medical issues: lots of them with mood stabilizers.... lithium can effect the thyroid and kidneys, it interacts with lots of other meds, depakote can effect the liver, so can tegretol, lots to think about, lots to monitor.
• How strongly I'm convinced that the patient has had a full blown manic episode. Plenty of people say "I'm Bipolar" but the history doesn't reveal a story for episodic, syndromic co-occurance of the hallmark symptoms of mania: elevation in mood or irritability, increased energy/ decreased need for sleep, quickening of thoughts or speech, impulsivity with regard to spending, sexuality, religion, hallucinations, grandiose delusions, inflated sense of worth or well-being. None of these symptoms alone are enough to diagnose mania, ya gotta have a few and they have to occur at the same time as the other symptoms. Lots of people shop impulsively to cheer themselves up, lots of people have periods where they feel more energetic and productive, lots of people get happy when they win the lottery. It's sometimes hard to get a history for a syndromic diversion from a baseline (or pre-morbid) personality.
• If I think someone definitely has bipolar disorder, and there isn't a reason not to use it, I start with Lithium. It's a good mood stabilizer. It's cheap. I'm familiar with how to use it. It's also a good anti-depressant augmenter. Despite all the hype about the awful side effects (weight gain, nausea, tremor, cognitive slowing, renal and thyroid impairment), I've seen lots of people have good responses and not have any side effects, so I start with that assumption and I use low doses. If the patient gets better, I don't push the level, even if it's really low. If the patient has intolerable side effects, I try another preparation of lithium (eskalith, lithobid), and if that doesn't work, I stop it and try another med. Why do I like lithium? I think because I've heard enough people put up resistance, then try it and come in saying "I feel normal for the first time." The down side is that you have to do bloodwork every 3-4 months even if the patient is well and has no symptoms.
• If I'm not so sure about the manic component as a real, syndromic entity, and the primary complaint is depression, I start with Lamictal. The upside-- it's well tolerated, people like it, there's no routine labwork and there's no stigma. The down side-- slow going to build up from a dose of 25mg to the therapeutic range of around 400mg. Another down side-- that fatal rash risk. And the final down side-- I've heard a couple of anecdotes of patients who have ended up in the ICU with rashes, liver zorkout, life-threatening problems. Not a lot, but it only takes one such story to make you hold your breath when you write a prescription and I have a friend who says "I'll never be able to prescribe Lamictal again." It's not science. I actually tell patients this story-from-hell when I prescribe it, and they'll still take it over lithium. Mostly, it's a good medication, it's well tolerated, and it helps.
• If a patient doesn't want Lithium, I prescribe depakote. It's associates with it's own issues, including weight gain, needs lab monitoring, and if the patient doesn't have insurance, it's expensive and hard to get samples of.
• I haven't prescribed tegretol in ages and I wondered if the reason it's so unpopular on our sidebar is because it isn't used so much.
• I prescribe anti-psychotic medications to people who are agitated, acutely suffering, not sleeping, in need of something quicker than lithium/depakote/ or lamictal. These medications work, they're well-tolerated, patients like them. And I worry about the metabolic effects and wish there was some free ride.
  
• Sometimes I use one of the older anti-psychotic-- navane may be my favorite
  
• If there is no history of substance abuse (---hmmm, that's rare in people with bipolar disorder), I may prescribe some ativan or klonopin for the short term.
• I haven't used Trileptal, I don't know why. I have a patient or two on Neurontin, I stopped prescribing it when studies showed it didn't help with mood stabilization. Perhaps I was wrong. And I haven't seen very many people tolerate Topamax, though I have seen it work wonders for migraines.
  
• Lithium is my favorite.

Okay-- I know there are lots of people out there who've had bad experiences with lithium. I'm not advocating that anyone re-try a medication they didn't tolerate. I'm just suggesting that everyone responds differently and before the medication is prescribed, your doc doesn't have any way of knowing if you will have problems or be one of those people who has a wonderful response and no side effects.

And to one of our anonymous commenters who wrote in:

Anonymous said...

I hope you have a really great reason for purposely for gathering useless data.

Yes, anonymous, I had a really great reason: I was curious, wondered if I'd learn something (and I did) and I thought I'd use the information for a blog post. Rest assured, I have indeed gathered completely useless and out of context data. It still makes me happy when my useless information is quoted by the Wall Street Journal.

What I Learned Part 3

The final installment in my conference series. Tomorrow I come home to my fellow bloggers! I miss them.

• In France they are doing an interesting project to look at the effects of incarceration. They are asking prisoners to spontaneously describe their incarceration experience and how they think it has affected them, then they are using computerized lexicographical analysis to define common domains of concern.

• There was a poster looking at the neuroanatomical basis of empathy, sympathy and moral reasoning. Highly theoretical and completely lacking in data, unfortunately.

• In 1895 Bridget Cleary was burned to death by her husband, who believed that she had been kidnapped by fairies and a changeling left in her place. It is possible that Michael Cleary suffered from a form of Capgras delusion.

• Someone tried to do a study looking at treatment compliance and motivation for change in sex offenders, but there weren't enough sex offenders motivated to participate in the research.

• Very few states have laws requiring mandatory reporting of impaired drivers to the MVA.

• One Russian psychiatrist proposed that the term "dependent behavior disorder" be used as a diagnosis for a broad range of compulsive behaviors.

• The first documented use of telepsychiatry was in 1959. In the U.K. a criminal justice statute required the installation of teleconferencing equipment throughout the courts and correctional facilities in the country. This is now being used to perform clinical and court-ordered psychiatric assessments. Free society studies have shown patient satisfaction to be similar between telepsychiatry evaluations and face-to-face interviews. In the U.S. there are a number of undefined legal issues with regard to telepsychiatry and computer-assisted treatment. These including licensing issues for practice across state lines, informed consent for remote clients/patients and malpractice coverage across state lines.

• Directors of forensic fellowship training are working to create measurement tools and procedures to meet the core competency requirements of the American Council for Graduate Medical Education (ACGME). There was a very nice workshop that presented a "toolbox" of techniques for documenting residents' competency as well as a discussion regarding how to prepare for an accreditation visit. The workshop also discussed the challenges of funding a forensic fellowship program.

THE END

Thank you for reading

What I Learned Part 2

Here's the second installment in my conference ramblings:

• The Supreme Court decided in Sutton vs. United Airlines that for the purposes of the Americans with Disabilites Act the disability must be assessed only after attempts have been made to correct the impairment.
  

• Liability in medication-related tort claims is best reduced by well-documented informed consent (Duh. But that came up a lot this year so I mention it.)

• In states that allow for outpatient commitment, only 20% of pretrial detainees who are referred for commitment actually end up getting commitment orders. This is because most of them are either sent to prison prior to a commitment hearing or because they are committed to a hospital for restoration to competence prior to an outpatient commitment hearing.

• Death Penalty

In 2006 there were 53 people executed, 32 were white and 21 were black. In 2005 there were 1805 whites and 1372 blacks on death row. One out of 12 death row inmates had committed previous homicides. Death penalty aggravating and mitigating factors are set by state statute. Aggravating factors include victim characteristics (law enforcement or firefighting personnel, children, pregnant women), defendant characteristics (previous violent offenses), and offense characteristics (murder committed during the course of a felony, contract killings). By law all possible mitigating evidence is allowed to be heard during the sentencing phase of a death penalty proceeding. Although mental health issues are statutory mitigating factors, sentencing juries actually consider them as aggravators and they are more likely to result in a death sentence. The main purpose of expert mental health testimony in a death penalty hearing is to humanize the defendant and to change the focus of the hearing from the crime to the defendant. It also serves to give the defendant an opportunity to communicate to the jury through the expert. Surveyed death penalty defense attorneys usually prefer psychiatrist rather than psychologist expert testimony. They prefer forensically trained experts with an area of expertise that is relevant to the case, with good testifying skills.

• Risk Assessment in the U.K.

The U.K. has a relatively new law that allows for the indefinite detention and/or community supervision of violent offenders. This led to the creation of the Risk Management Authority, an administrative body that trains, supervises and regulates official risk management assessors. The assessments are quite exhaustive and includes a minimum 6 hour interview over three days. It is primarily a clinical assessment although it does require the use of at least one "official" approved actuarial tool. There were only 7 orders for assessments filed in 2006. Some offenders refuse to cooperate since they know it could result in a lifetime of supervision and mandatory treatment.

Another development was the creation of a Dangerous and Severe Personality Disorder Service, which essentially is a tool for civil commitment of psychopaths. This has led to 150 referrals a month and an increased number of non-mentally ill sociopaths in forensic hospitals. (One presenter's quote: "The system is swamped.") They are treated with cognitive-behavioral therapy at a cost of $500,000 per inmate per year. Remarkably, there have only been three minor inpatient assaults involving these patients over five years.

• Liability and risk management in forensic practice

Case law is still defining areas of liability for forensic clinicians. Most liability seems to arise as a result of independent medical evaluations (IME's). The 2006 case Harris v. Kreutzer determined that there was a limited physician-patient relationship created during the IME. The three duties created as a result of this are: 1) to cause no injury during the evaluation (read the Harris case), 2) disclose significant findings to the evaluee (eg. an orthopedic surgeon doing an IME who incidentally discovers a tumor), 3) maintain confidentiality (eg HIPAA compliance)

Most states have limited civil immunity for expert testimony but this is not absolute & varies with jurisdiction. Experts appointed by medical boards for peer review have been sued with varying degrees of success by their evaluees. A forensic expert could face discipline from the AMA, the state medical board, or a specialty organization. In general psychiatric practice most liability comes from suicide or from medication-related injuries.

• Ethics of Forensic Psychiatry

In 1982 Harvard professor Dr. Alan Stone gave an address in which he suggested that it was unethical for psychiatrists to be involved in expert testimony. The last panel today was an update by Dr. Stone on his position and a response from a number of illustrious colleagues. I can only give this topic pitiful recapitulation here. Stone argued that psychiatry has no absolute truths to offer and that professional consensus is dangerously misleading. Panelists Ezra Griffith, Stephen Morse and Paul Appelbaum responded that it is ethical for professionals to aid the court's search for truth and to promote justice. While acknowledging potential ethical pitfalls, there was a consensus that evolving standards of science provide something to offer.

(Incidentally, in Podcast #14 (No April Fool) I talked about the New York Times article, Brain On The Stand, which quotes Dr. Morse's views on the use of neuroimaging in forensics. Now that I've had a chance to listen to this guy speak it is clear that he is someone to keep an eye on. Interesting things are going to be coming out of U. Penn, particularly with his involvement in the recent $10 million MacArthur grant for neuroscience and the law. This is probably worth a blog post all on its own, when I get the chance. Right now I'm off to dinner.)

What I Learned Part 1

This is my second annual blog post that summarizes my experiences at the forensic conference I attend every year. Last year I put up a three part "What I Learned" series, which I occasionally go back to when questions come up and I know I heard something about it once but can't remember the details.

So here goes:

• The Atlantic ocean is surprisingly warm for October.
• There are approximately 5000 women murdered every year in honor killings. Syria and Jordan still have laws on the books for men to kill their wives without consequences if they are caught in the act of adultery.
• There is evidence that the Slater method may be effective for restoring developmentally disabled defendants to competence to stand trial.
• Only two states in the country (Connecticut and Indiana) have laws that allow police to seize legally owned weapons from dangerous individuals.
• Violence predictions instruments, even the PCL-R, has not been validated for use with women and it is not recommended to use them as a predictive tool for female defendants or prisoners.
• Vaginal plethysmography exists but has not been validated for use in evaluating female sex offenders.
• In recent years the number of women found Not Guilty By Reason of Insanity (NGBRI) has increased. This may be due to increased awareness of post-partum psychiatric illness.
• Culture-bound syndromes can be seen in immigrant populations and it is necessary to understand these phenomena in order to distinguish them from delusions. Ashanti witchcraft, "root workers" and others may lead to commonly held cultural beliefs.
• A woman named Marti Ripoli was an infamous serial killer in the nineteenth century. She was thought to be responsible for the deaths of 25 children, whose blood she used to make magical remedies that she sold on the streets. Belle Gunness had nothing on this lady.
• Alan Felthous gave an amazing Presidential Address in which he reviewed the religious and philosophical underpinnings of free will from Aristotle up to the neuroanatomy of decision-making as shown by functional MRI's. All in less than an hour. Wow.
• There was a great panel presentation about cults. They discussed the difference between a religion, a sect and a cult. They described characteristics of cult leaders and followers and cult dynamics including recruitment, retention and deprogramming. They presented case law regarding deprogramming practices and risk management issues for psychiatrists. Finally, they presented the satanic cult abuse issues of the 1980's and the lessons learned from this. (I enjoyed the tutorial about the Church of Satan and what to ask your Goth patients. Also the Church of Satan tattoos. Personally, if I saw a 'Satan Rules' tattoo I don't think I'd need to ask too many more questions.)
• In Germany forensic experts are always the agents of the court rather than agents of an adversarial attorney. The goal is a neutral and impartial evaluation. (We could learn something from that here in the States. I bet their malpractice costs are significantly lower.)
• The concealed information test is the most commonly used experimental deception paradigm. It has been used in functional MRI lie detection studies, the first one of which was published in 2001. The number of fMRI lie detection studies has increased quickly since then, but a number of the authors are partners in two companies that do commercial fMRI lie detection, Cephos and No Lie MRI. (We discussed this topic in Podcast 5: Sex, Lies and Neuroeconomics.) Functional MRI's cost about $1800.
  
• SPECT scans are very sensitive but completely nonspecific. They are abnormal in a broad variety of conditions but there is a lot of overlap between conditions. When using SPECT to evaluate mild traumatic brain injury, it is important to first rule out the confounding variable of clinical depression.
• Problematic Internet use covers a broad range of behaviors: cyberstalking, cyberbullying, excessive surfing, excessive online gaming and inappropriate work behavior.
• When evaluating a building for Sick Building Syndrome it is important to do a visual inspection first, then take samples if necessary. Sampling includes measurements of wall and room humidity, temperature, carbon monoxide and carbon dioxide levels and surface swabs. A normal carbon dioxide level is 1000 parts per million. Normal building temperature is from 68-72 degrees in the wintertime with less than 60% humidity. Some plaintiffs alleging sick building syndrome are actually suffering from somatization disorder so it may be necessary to involve forensic psychiatrists in these evaluations.

PHEW. And that's only the first day. Here's the other thing that I learned:

I love eating lobster while watching the ocean. Beats the heck out of working in prison.

My Three Shrinks LIVE on Blog Talk Radio Tonight at 10pm ET

[38] . . . [39] . . . [40] . . . [All]

---

Doctor Anonymous started an internet talk radio show last month on Blog Talk Radio. I have listened in, and he runs a great show with terrific guests. Tonight, however, I'll be on the show... but perhaps you will tune in anyway, just to see how it goes. (Listen to the Dr. A podcast we did Sep 2 on Depression Overdiagnosis.)

Actually, I've been pestering Clinkshrink (who is currently in a warm southern state eating chocolate-covered lobster) and Dinah to join in, so maybe we'll be surprised and have all of us on. [They did call in (Dinah in the last few minutes).]

The show allows live calls (from like a real phone... no computer needed). Click here or the Blog Talk Radio logo above to tune in. 10pm ET Thursday, Oct 18, 2007. I'll see if he'll let me put it on a podcast, too.

The show was fine...you can listen to it on the site, or even download it to your computer or MP3 player. DrVal and ladyk47 and others were there.

Please Vote On Our Sidebar Poll

What's your favorite mood stabilizer? I set up the sidebar poll a couple of weeks ago, right on the heels of the What's Your Favorite SSRI? poll. The Shrink Rap poll was actually mentioned on The Wall Street Journal Health Blog. Yup, we've arrived in blogger nirvana, move over Fat Doctor!

These are funny questions, they're asked without context, kind of purposely so. What's your favorite? But we don't ask who you are, the doctor or the patient, or perhaps the relative of someone who never actually prescribed or swallowed the pill. And we don't ask your experience...is this the only mood stabilizer you've taken? Are you a family practice resident who has only written 4 prescriptions ever for mood stabilizers? Or are you an experienced Bipolar Expert who has written many many scripts and really knows your stuff?

Roy didn't like the poll to begin with. I went for the cheesy blogger poll, too lazy to import a bigger one from polldaddy, and it limits the number of choices. Roy wanted Klonopin added. He wanted Trileptal. He wanted Topamax. He scoffed. What can I say? And apparently either no one likes or uses Tegretol (carbamazapine) so that was a waste of a choice.

I had more to say about SSRI choices. I'll think of something to say about Mood Stabilizers. Just not tonight. For now, please vote. Thank you.

TMBG Mesopotamians

And now, for this musical interlude from They Might Be Giants (click picture).
(note the emotional support goat at the end)
[iTunes]

We've been driving around
From one end of this town to the other and back
But no one's ever seen us (No one's ever seen us)
Driving our Econoline van (And no one's ever heard of our band)
And no one's ever heard of our band

We're the Mesopotamians
Sargon, Hammurabi, Ashurbanipal, and Gilgamesh

Then they wouldn't understand a word we say
So we'll scratch it all down into the clay
Half believing there will sometime come a day
Someone gives a damn
Maybe when the concrete has crumbled to sand

We're the Mesopotamians
Sargon, Hammurabi, Ashurbanipal, and Gilgamesh

The Mesopotamish sun is beating down
And making cracks in the ground
But there's nowhere else to stand
In Mesopotamia (No one's ever seen us)
The kingdom where we secretly reign (And no one's ever heard of our band)
The land where we invisibly rule

As the Mesopotamians
Sargon, Hammurabi, Ashurbanipal, and Gilgamesh

This is my last stick of gum
I'm going to cut it up so everybody else gets some
Except for Ashurbanipal, who says my haircut makes me look like a Mohenjo-Daren

Hey, Ashurbanipal
I'm a Mesopotamian
Sargon, Hammurabi, Ashurbanipal, and Gilgamesh

We're the Mesopotamians
Sargon, Hammurabi, Ashurbanipal, and Gilgamesh

"Hey, man, I thought that you were dead
I thought you crashed your car"
"No, man, I've been right here this whole time playing bass guitar
For the Mesopotamians"

We're the Mesopotamians
Sargon, Hammurabi, Ashurbanipal
Sargon, Hammurabi, Ashurbanipal, and Gilgamesh

We're the Mesopotamians
Sargon, Hammurabi, Ashurbanipal, and Gilgamesh

Congress Wants More Money Spent on Research for Postpartum Depression

The US House of Representatives passed a bill (H.R.20) that encourages NIH to spend more money on PPD, recognizing it as an underfunded area of research.

Rep. Bobby Rush (D-IL) has been pushing this bill for 5 years or so (in honor of Melanie Stokes). (He needs to work on his blog.)

This is a really great effort. The bill goes to the Senate now. Let both of your Senators know how you feel about this bill.

The Bloody Bride

Roy pointed out recently that I haven't posted in nearly a month. Oops. I like hanging out with Roy and Dinah and I do like the blog, but sometimes you just have to think about something other than psychiatry.

Like opera, for instance. This weekend I saw Donizetti's Lucia di Lammermoor. It was great. The storyline is that Lucia, the heroine, is betrothed to a total stranger in order to restore the fortunes of her family. In order to guarantee the betrothal her brother forges a letter from Lucia's true love (who is off somewhere in a foreign country) telling her that he has found someone else. Lucia marries against her will, then on the wedding night she stabs her husband to death and wanders around in a bloody wedding dress singing a seventeen minute aria about her hallucinations.

This opera was first shown in 1835. Many sopranos have sung the role since then and they all developed their own particular way of portraying insanity. In this particular version of the mad scene, singer Natalie Dessay wanders the stage while waving a knife, looking dazed, screaming, laughing for no reason, thowing herself down and rolling down the stairs. At one point she tears up her veil and cradles the pieces like a baby. Eventually a doctor comes on stage and gives her an injection.

Color me cynical but most psychotic folks I've known don't do a lot of that. It was good drama, but not real. I thought that considering our reason podcast talking about the portrayal of psychiatrists in the media it might be good to mention the portrayal of insanity.

The ironic thing about this opera is that while Donizetti was writing it he was becoming ill with bipolar disorder himself. He ended up institutionalized. Sadly, he died about a hundred years before there were any injections or pills to help him.

SAMHSA Report: 7% of Fulltime Workers Had Depression

SAMHSA reports [pdf] on Major Depression rates for various occupations, finding that 7% of full-time workers have had a Major Depressive Episode over the past year.

People in the personal care (childcare, eldercare) and food and beverage service (waitstaff, bartenders, food prep, etc) had the highest rates, at 10% (women in this group had the highest of all rates, at nearly 15%).

Engineers, architects, and surveyors had the lowest rates.

The report is based on interviews of over 107,000 people, and uses a DSM4-based questionnaire to determine past-year depressive episodes. One of their main points is that employers lose $30-44 billion annually due to employee depression.

Sunday Brain Soup

I looked through Google News today to see what is happening in the world of "brains." Here's some of what I found . . .

* * *

A study came out recently in the journal Emotion reportedly showing that people identify fearful faces much more quickly than other faces. Makes sense. Apparently, the wide-eyed stare has a lot to do with it.

'The team found people became aware of fearful expressions much faster than neutral or happy faces. "We were seeing it pretty much universally," [David] Zald said.
He thinks it has something to do with the eyes.

"If you compare the amounts of the whites showing with a fearful face versus a neutral face, the difference is really quite striking," he said.'

So it's the whites of the eyes that do it. That explains the popularity of the runaway bride story a few years ago.

* * *

Of course, women are probably even quicker at this than men, because, as everyone knows, women have a much bigger crockus than men. What? You don't know your crockus from a hole in the ground? Maybe you missed that class. Or maybe you are just feeling empty-headed today (then maybe this belongs to you).

* * *

"First Successful Treatment For Chronic Traumatic Brain Injury In Rats"
This is great. We can't get funding to help find better treatments for people with traumatic brain injuries, but we now have a good treatment for rats who have had too many encounters with a broom handle.

* * *

Tech.Blorge is reporting that it is now possible to directly control your Second Life avatar with a brain-computer interface.

"Sometimes you look at a friend and could swear they're directly connected to the computer. New technology could soon make that the case. Professor Ushiba of Keio University has unveiled a brain-computer interface (BCI) that allows users steer characters with their thoughts, reports pinktentacle."

* * *

Finally, from Thailand's The King & I: "The reign in Chiang falls mainly in the brain."

Let Me Tell You About My Illness

So I'm standing at an event, drink in my hand. It's a work thing. I ask the gentleman next to me, "What's new?" I don't know what I expected, but there was another man next to us, someone I didn't know, and the answer I got wasn't quite what I was expecting.

"My psychoanalyst released me." Okay, I didn't know you had a psychoanalyst and I didn't know it was up for discussion, but fine, we talked about his therapy for a few moments and moved on.

It happened years ago, but I brought it up because in the comment section of some of our posts, people have brought up the issue of feeling stigmatized and discriminated against when they've talked about their mental illnesses.

I'm never sure what to make of this. I know many people who are so very successful and who suffer either quietly or rather openly from psychiatric disorders. People seem to have their own valence for privacy needs. As a med student, a professor I barely knew told me about his anti-depressant use-- he was very matter-of-fact about it. And perhaps it's because I'm a psychiatrist, but in my personal life people mention all the time that they're taking such-and-such a med or seeing so-and-so for therapy. Okay, you say, it's because I'm a shrink, but I'll tell you that they aren't always quiet about it. One friend, a well-respected physician, told me the details of his entire family's psychiatric issues while we watched an event at our kids' school. He had a rather large audience for his story and I don't think he cared. In case you missed it, Dr. X takes Celexa and is in both individual and couples' therapy. I could fill a blog with these stories.

Okay, so what about my patients? Some of them are pretty quiet about their illnesses or issues, though most tell their family members. Others are rather vocal about their issues. Does it hurt them? Do people run the other way, do jobs get lost, are they treated poorly? From what I can tell, if someone has friends when they are well, if they have a job when they're well, people are understanding.

I don't give advice on this issue: do what you're comfortable with. If someone thinks the information might be used against them, they should keep quiet about their psychiatric disorders and treatment. Obviously, there are venues in which privacy isn't a legal option-- you can't omit your treatment with medications if you're a pilot or astronaut, and the list goes on....

Here are a few factors that I think play a part in how the fact of mental illness is received by another party.

-- The other person's own experiences with psychiatric disorder. Some of my patients seem to be magnets for people with their disorders. When they tell others about their diagnosis, they aren't shunned, instead they are embraced by people who are relieved to have found someone to unload their secrets on, someone who has been there themselves. If the other person's only experience with mental illness, however, is the psychotic person who shot their mother, well.....

-- The delivery. If the person with the problem is nonchalant about it, it's a less of an issue than if they're confiding their deepest darkest secret. Of course, confiding one's deepest, darkest secret has its place, too.

--The bizarreness of the symptoms. Most people have some understanding of sadness or anxiety and can extrapolate this to a severity worthy of a diagnosis. Symptoms which are difficult for most people to relate to are more likely to get raised eyebrows. I'll hold off on examples here, but feel free to let your imagination run wild. Which leads us to....

--How much the patient's symptoms interfere with other people's lives. And for how long. So a declaration that "I have panic attacks" might be met differently by one's boss than, "I had a manic episode last week during which time I stole $40,000 from the till and spent it on a non-returnable artist's rendition of a bird's nest. " Some people suffer silently, others have symptoms that effect others profoundly.

-- Who the patient is when they're well . If a person with a psychiatric disorder is liked and respected when they're well, people are more likely to be sympathetic to diversions from their usual state, especially if they return to wellness and being that likable person.

--Any way you dice it, people are more sympathetic about Axis I disorders than they are about personality disorders.

-------
Bottom of the fifth, Red Sox are losing 5-3.

Virginia Report: Not Enough Psychiatrists, Beds

The Washington Post reports today on a 230-page state report that finds Virginia "lacks experienced psychiatrists to evaluate the mentally ill, there aren't enough beds for those seeking emergency treatment in many areas and hospitals are losing money on mentally ill patients, according to a state government report."

Last year, NAMI released a Report Card for each state, grading them on things like access to care, services, and infrastructure. Virginia received a grade of D. Today's report suggests increasing funding to meet the state's need.

"Additional psychiatric beds cannot be opened unless there are psychiatrists available and willing to staff them," the report says. It adds: "On the outpatient side . . . a lack of psychiatrists affects licensed hospitals because individuals in need of psychiatric service cannot find them in the community and . . . turn to emergency departments. . .

To address these shortfalls, the report suggests that the state "examine its potential role in . . . assuring an adequate supply of beds . . . [by] increasing financial support for uninsured psychiatric patients."

NAMI's report noted the lack of culturally competent treatment, and rights abuses in some of the state hospitals.

"Additionally, Virginia's ability to serve its growing population of ethnic and racial minorities has suffered because the state has shown no initiative on the issueof cultural competency. Virginia has not conducted a cultural competency assessment or developed a plan to meet the needs of minorities, who comprise nearly 30 percent of the state's total population.

Lack of short-term acute care beds for individuals in crisis is another major problem. In Northern Virginia, the commonwealth's most populous area, approximately 24 percent of the region's private bed capacity vanished in 2005 alone, due mostly to the closure of psychiatric wards at four different hospitals. Individuals in need of beds are transported downstate, resulting in trauma for the individual and diversion of local police officers, who must spend hours transporting people to areas as far away as Hampton Roads.

State hospitals have posed a different set of issues. In the 1990s, four out of 10 were under investigation by the U.S, Department of Justice (DOJ) for egregious violations of the rights of patients."

To view the actual report, the 230-page pdf report is here, and the briefing, consisting of 60 slides, is here.

Generic Trileptal (Oxcarbazepine) Approved

The FDA just approved a generic Trileptal, an anticonvulsant related to the mood stabilizer, Tegretol (carbamazepine), and sometimes used to treat bipolar disorder. It is thought to have fewer problems with liver toxicity than Tegretol.

See the FDA announcement for more details. Three companies were approved to make the new generic.

More On Everyone's Favorite Medication: Xanax

First, check out Roy's post below from earlier today; he tells us how to cure alcoholism! Click Here.
[I do nothing of the kind, don't listen to her.]

So the New York Times has a health blog, and if you ask me, today it's trying to be Shrink Rap. In today's Post, For Some Bereaved, Pain Pills Without End,
the unnamed author talks about the ease with which physicians ( primary care docs) prescribe benzodiazepines for acute grief, the ease with which they refill these scripts-- often for years at a time--, the ease with which these patients become addicted and suffer from side effects:

Powerful benzodiazepines such as Xanax, Valium and Ativan are widely overused in older patients, many experts fear, leading to serious health worries, including sleep troubles, cognitive difficulties, car crashes and falls. Yet doctors in the survey seemed willing to offer unlimited amounts of these addictive drugs to help patients cope with death.

The study is small-- it consists of 33 primary care docs in Philadelphia, and interviews with 50 older patients who've taken benzodiazepines for years: 20% said they began taking benzodiazepines during a period of grieving. Want details? Read the original article HERE.

As always, the reader comments are as enlightening as the blog post itself (ah, that's true here at Shrink Rap as well).

Interesting stuff, but I guess I think the sample here is so small as to be useless. Half the docs said they'd prescribed benzos for grief (so at least 16.5 primary care docs) and 10 patients started chronic benzodiapine use after a death. I'm not surprised, I'm not commenting on anyone's practice, I guess I just don't like the tone of the blog post which somehow paints the docs as ignorant, perhaps lazy, may be even negligent or sinister.

Finally, please note that I stole my "grief" graphic from a Red Sox blog: http://redsoxdiary.blogspot.com/

Topamax Effective in Reducing Heavy Alcohol Drinking

JAMA has an article this week by Bankole Johnson, et al., showing the anticonvulsant Topamax (topiramate) to be effective in reducing percentage of heavy drinking days, from 82% in the placebo group to 44% in the Topamax group.

This was a double-blind, placebo-controlled, 14-week study, using 371 study participants. Dose range was 50-300 mg daily. Side effects included tingling sensations, changes in taste, loss of appetite, and impairments in concentration. Mean daily dose was 171 mg/day. They started with 25 mg/d for Week 1, then 50 mg/day for week 2, and increasing by 50 mg weekly (in divided morning and night doses) to the maximum of 300 mg/d.

This may be a good approach to helping some people reduce drinking, especially folks who might also have bipolar disorder, which is sometimes also treated with Topamax.

"Our study had 3 limitations. First, while the pattern of adverse events was similar to that found in our previous study,3 the more rapid titration was associated with decreased study adherence with taking the medication. Previously, when topiramate was titrated over an additional 2 weeks (ie, over 8 weeks rather than 6 weeks), retention rates were similar between the topiramate and placebo groups. Clinical sites least familiar with topiramate experienced more difficulties with retention, whereas completion rates among some experienced groups approached 90% (data not shown). We advise clinicians to use the slower titration schedule and to provide participants with focused education on managing emergent adverse events to maximize adherence with taking the medication. Second, as with most clinical trials in the alcohol dependence field, enrolled participants have to meet criteria enabling the conduct of a safe study. Because this cohort is often relatively healthier and perhaps more homogeneous than the general population of all those seeking treatment for alcohol dependence, our ability to generalize without restriction from this trial to clinical practice is limited. Third, this study did not have a follow-up period, so we could not determine whether, how many, and at what interval participants would have relapsed following medication withdrawal. Nevertheless, with respect to how people fare, on average, following treatment for alcoholism in a clinical trial, a meta-analysis of recent studies has shown that, even after a single treatment event, most can show substantial reductions in drinking up to 1 year afterward.

Our finding in this study that topiramate is a safe and consistently efficacious medication for treating alcohol dependence is scientifically and clinically important. Alcoholism ranks third and fifth on the US and global burdens of disease, respectively. Discovering pharmacological agents such as topiramate that improve drinking outcomes can make a major contribution to global health. Because topiramate pharmacotherapy can be paired with a brief intervention deliverable by nonspecialist health practitioners, a next step would be to examine its efficacy in community practice settings."

Play This For Your Children

I love this UTube video of a mom recounting her day to the William Tell Overture. I don't know who this lady is, but she's great. You'll forgive yet another of my diversions from psychiatry....




And yes, Roy, I posted a UTube video (not just a link) all by myself!

CANVAS (The Movie): This is Mental Illness Awareness Week

(from NAMI): Help CANVAS Fight Stigma This Week
Movie about a boy whose mother has schizophrenia — Spread the word about the movie, no matter where you live.

View the Trailer

Just in time for Mental Illness Awareness Week (October 7-13), the movie CANVAS is being released in Chicago and New York on Friday, to be followed by three other cities next week. If Friday and Saturday ticket sales run high in these five cities, the release may expand to 200 cities nationwide.

Starring Emmy Award-winner Joe Pantoliano and Academy Award-winner Marcia Gay Harden, CANVAS is the story of a family's struggle with schizophrenia. It educates as well as entertains. It will build awareness about mental illness and strike a blow against stigma--but only if enough people see it. In order for the movie to reach a nationwide audience, please take action to help:

• Spread the word! Please spread the word now with a personal message to family and friends in the cities below—and friends elsewhere.
• Buy tickets on-line early each week. You don't even have to live in the opening cities. Tickets make great gifts or donations. Use the links below to purchase tickets online.
• If you live in one of the five cities, go see the movie on a Friday or Saturday. Take a friend. Go in a group. Hold a discussion afterwards.

Starting October 12...
• In Chicago, AMC Loews 600 North Michigan 9, 600 N. Michigan Ave. 60611
• In New York, Regal Union Square Stadium 14, 850 Broadway, 10003

Starting October 19...
• In Los Angeles, Laemmie Sunset 5, 8000 Sunset Boulevard, 90046
• In Phoenix, Harkins Shea 14, 7354 E. Shea Blvd, (Scottsdale) 85260
• In Fort Lauderdale, check local listings as the date approaches.

Carbonated Panic Attacks

Don't forget to read Dinah's post below: Click Here.

Panic attacks are an acute, dramatic form of anxiety, including symptoms of shortness of breath, lightheadedness, tingling sensation, and fear of impending doom. One of the theories about the biological basis of panic attacks is the false suffocation alarm theory proposed by Klein, which suggests that the brain's sensor that detects elevated carbon dioxide levels is overly sensitive in some people, triggering panic attacks for no clear reason.

Eric Griez, a psychiatrist from the Netherlands, has published an article in the open source, online journal PLOS One, demonstrating further evidence of this connection (see also review in Science Mag). He exposed volunteers without an anxiety disorder to high levels of carbon dioxide, thus triggering the suffocation alarm at appropriate levels of CO2.

"Sixty-four healthy subjects underwent a double inhalation of four mixtures containing respectively 0, 9, 17.5 and 35% CO₂ in compressed air, following a double blind, cross-over, randomized design. Affective responses were assessed according to DSM IV criteria for panic, using an Electronic Visual Analogue Scale and the Panic Symptom List. It was demonstrated that carbon dioxide challenges induced a dose dependent negative affect (p<0.0001).>

The top graph shows a dose-dependent increase in panic symptoms, while the bottom part shows that younger people (solid line) developed panic symptoms more easily than older people (dashed line), suggesting that perhaps the triggering mechanism becomes less sensitive over time.

This falls under the what's-old-becomes-new-again category, as I recall this area of research 15 years ago. Still, it may be worth stirring up again, especially if it leads to more effective and safer treatments. In fact, Klein and Preter just published an amplification of the original theory, including evidence of involvement of opioid receptors in the response to the alarm being triggered.

Are You A Threat To National Security?

Periodically I get these calls. My patient, or someone who was once my patient, or someone I can't recall ever having heard of, has identified me as their psychiatrist and this is the government calling as part of a security clearance for a job with the government.

Assuming I can recall the patient, the questions are short and sweet. Usually something along the lines of Might This Person Represent a Risk to National Security?

Without exception, these patients have not been disabled by their psychiatric disabilities, at least not recently. And without exception, they are already functioning in their job --- I've never been called for a security clearance before a patient assumes a sensitive position with a federal agency. None of these patients have been suicidal or homicidal. Only one has previously been hospitalized, and that was many years before I'd seen the patient.

So here's the thing: I have no idea.

There is an element of unpredictability to psychiatric disorder. Some people have Bipolar Disorder and go years between episodes. Their symptoms vary. If someone's never had an episode of mania where they've done something dangerously impulsive, do I know that they won't any time in the future? Some people are absolutely tormented by their anxiety, but keep it well-hidden from the rest of the world and they function just fine. Other people are so overwhelmed with anxious ruminations that they can't get out the door, can't make a decision. Because a patient did nothing dangerous during their last episode of psychosis, am I sure they won't the next time?

The investigator doesn't want details. He doesn't want to know about past history, psychosocial history, substance abuse issues, or details of past episodes. He doesn't care if the to-be-cleared has been hospitalized. He simply wants to know if they are reliable, trust-worthy and if their psychiatric illness or the medications they take for it, might impair their ability to handle sensitive information in such a way that national security could be compromised.

I'm left to rely on past history. I tell the investigator anything that might be relevant , and I mutter a disclaimer about how the patient has an illness and so far they've not been compromised by it, but I can't predict the future.

My Three Shrinks Podcast 36: Just Do It

[35] . . . [36] . . . [37] . . . [All]

---

Folks, we have heard your requests for us to upgrade our sound quality. That is coming up, probably in Podcast #38. Yes, the Google Ads have paid only about 5% of the cost of the upgrade, but we may keep them on the site until they've hit $100, as I believe that is the minimum for a pay-out ($19.05 for September).

---

October 8, 2007: #36 Just Do It


Topics include:

• Crisis in the Treatment of Incompetence to Proceed to Trial. In the recent Online AAPL Journal, an article by Wortzel about problems with assessing defendants who are not competent to stand trial and restoring them to competence. [hmm, wonder whose topic this one is] At any given time, these people occupy about 10% of our nation's state psychiatric hospital beds. A complicated discussion ensues about who pays for forensic mental health care and how the system results in decreasing access to care for uninsured non-forensic patients.
  
  
• We respond to a question to the NYT Ethicist column, by Randy Cohen, which you can read here (as well as his answer). [Note: we last saw Randy when he stopped by to respond to a discussion about a previous column of his about suicidal people making wills.] The question involves whether it is okay for a physician, who is a psychiatrist, to prescribe a stimulant (Adderall) to his college kid for the purpose of improving test-taking performance. (We discussed the practice of treating family members in a prior post, My Patient, Myself.) A secondary question involves that kid sharing the medication with a friend. We also discuss the issue of using performance-enhancing amphetamines for non-illnesses, in addition to the potential for a performance-reducing effect due to side effects (which is also taken on my Gawker's Unethicist). (We also ask for help from any DEA agent listeners.)
  
  
• Clink celebrates her 25th Running Anniversary. She's been just doing it for a quarter century.
  
  
• Price Transparency for Psychotropic Drugs. Dinah discusses her post about the list of prices for antidepressants. Roy unsuccessfully looks for the prices of these drugs on the Maryland Medicaid website.
  

Coming up in Podcast #37... SSRI Poop-out (aka tachyphylaxis) and other good stuff. Oh, and here's a pic from my Vegas conference trip. Yummy!

---

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.