You Have to Fill This Form Out

Oh my, whose idea was it to mandate that psychiatrists need to fill out certain forms? I work in a clinic where people often walk in with disability forms. I don't know them, how do I know they're disabled? Maybe my great interventions will cure them and they can go back to work. "But I need the form tomorrow, doc, or I can't get my check." I filled one out the other day, feeling rather pressured-- it was on someone I was seeing for the second time, and the first time she'd sat there angry and hadn't spoken. So I put in my best guess at diagnosis, but you know, they all ask for the dates of disability, with a maximum of 12 months, and how would I know this??? That crystal ball, didn't I leave it in the top drawer? The patient became agitated, she needed the form for tomorrow or she'd lose her check. I had 4 patients who'd shown up simultaneously, and she'd also brought poetry to show me. She was getting agitated, I was telling her the therapist needed to do these forms, she was saying she'd lose her check if she didn't have it by tomorrow (now how can that be and why was that my problem? at 4 pm no less). I scrawled "unclear" for the dates of disability and she was livid. Oy. Maybe I should have just written a year, she was homeless in a shelter and hadn't worked in a zillion, and she had some mental illness where she was angry, irritable, sullen, and refusing to give information one day and effusive with poetry to share on another. I wish I just hadn't felt so cornered.

Oh, but then there's my favorite form the psychiatrist "HAS" to fill out. The payee form. My patient (a homeless woman with multiple medical problems and a fondness for crack cocaine and malt liquor) wants to be her own payee---she doesn't like that her daughter currently doles out the dough.

"You gotta fill the form out," she says.

"I don't do those forms, " I say.

"They say my psychiatrist has to fill the form out."

Whose bright Idea was that, I have no clue if people can manage their money. Plenty of folks I know with psychiatric disorders manage their finances fine. And plenty of folks I know without psychiatric disorders are financial disasters. I don't follow these people around to see how they manage, I see them for 20 minutes in a clinic to ask how their mood is and if they're having and hallucinations or side effects. I suppose if any ever had command auditory hallucinations to turn over their family trust funds to me personally, I might consider it.

"I don't know if you can manage your money I say." She stares at me. "Do you know if I can manage my money? I never said you need a payee in the first place. Go find who ever said you need a payee and have them say you don't."

"My psychiatrist has to fill it out," she insists.

No, your psychiatrist doesn't.

Oh here, read this: CLICK

My Other Life

Don't Forget To Take Our SideBar Poll.....

I work in two different clinics where I see patients just for medication management. Though I've ranted about the wonders of seeing a single psychiatrist for psychotherapy who also can evaluate for, monitor, and adjust medications, the financial reality of the world is that this is not the cheapest way to offer care, and in a setting where 30% of the patients don't keep appointments, it's not practical to schedule a psychiatrist with hour-long therapy sessions. Many patients in clinic populations need case management, help negotiating benefits, and liaison with rehabilitative and vocational services-- things psychiatrists aren't trained to do.

I've said I don't do med checks. I lied. Or rather, when I'm blogging, I tend to think about my private practice, not the clinics. I do med checks. Do I think I'm giving a lower standard of care to people who can't afford to pay me? Yup, sometimes I do. Mostly though, I've come to terms with it because of these issues:
-- The financial reality: given the No show issue and poor reimbursement rates for medicaid and uninsured patients, I am often paid than the clinics are reimbursed.
--Chronically mentally ill patients need a lot of care coordination with other specialists, care providers, supported employment, psychosocial rehab programs-- and they all have forms that need to be filled out. Charts are kept separately and have to be hunted for. Billing issues must be done as well. These things are done best by other mental health folks or secretarial people.
-- Coordination of care and continuity of treatment work best if patients are seen at an outpatient clinic that is affiliated with an inpatient unit and partial hospitalization program.
--Split therapy works best if the psychotherapist is readily available for consultation, and in one clinic where I work, the patients see the therapists and the docs together. Private patient split therapy can be a hassle with regard to communication and with regard to who does which pieces of the patient's care.
-- Many patients I see in the clinic have no interest in psychotherapy and little inclination to offer much information about their lives. I ask about any new things going on in their lives, their sleep, their appetite, their symptoms, do they hear voices, are they suicidal? Any side effects? Are the meds working? Any new medical problems or medications? The patients don't necessarily come with an agenda for introspection.

What I Read in The New York Times Magazine Today.

I thought Roy was going to write about the psychiatrist drug rep who wrote about his year of selling his soul in today's New York Times Magazine. Apparently Roy went shopping, and then he got eaten by a Leopard (is that the new Apple thing?)

In "Dr. Drug Rep," Daniel Carlat, a psychiatrist in Newburyport, Mass, talks about the year he worked for Wyeth pharmaceuticals. He visited the offices of primary care physicians and talked about the wonders of Effexor. He describes his ambivalence and conflicts-- the money he made was good. Oh, never mind, the money was great-- he was getting up to $750 an hour to talk to docs over lunch. But he felt like he was minimizing the risk of hypertension and withdrawal symptoms. Dr. Carlat writes:

I wrestled with how to handle this issue in my Effexor talks, since I believed it was a significant disadvantage of the drug. Psychiatrists frequently have to switch medications because of side effects or lack of effectiveness, and anticipating this potential need to change medications plays into our initial choice of a drug. Knowing that Effexor was hard to give up made me think twice about prescribing it in the first place.

During my talks, I found myself playing both sides of the issue, making sure to mention that withdrawal symptoms could be severe but assuring doctors that they could “usually” be avoided. Was I lying? Not really, since there were no solid published data, and indeed some patients had little problem coming off Effexor. But was I tweaking and pruning the truth in order to stay positive about the product? Definitely. And how did I rationalize this? I convinced myself that I had told “most” of the truth and that the potential negative consequences of this small truth “gap” were too trivial to worry about.

----

And on another note, ClinkShrink mentioned to me tonight that writing doesn't come easily to her-- huh?! Some words of encouragement anyone?

And Roy, quicker on the uptake here! Hope you enjoy the new purchases. I hope you don't mind that I stole your topic....

Wishing You and Yours A Happy Holiday Weekend

I'm full of turkey. I've seen ClinkShrink & Roy-- I know they are alive and well, and Roy mumbled something about putting up a podcast.

Pecan pie is good for the soul, even if it's not chocolate, of this I am sure.

Until the Sunday New York Times, my best to our Shrink Rap readers and may the holiday find you with lots to be thankful for!

Is This Forensic Psychiatry?

In my post Is This Psychiatry? janye made the following observation:

And, just how are mental health issues different in correctional institutions? Aren't the same medications being used? I'm just trying to understand how psychiatry in a criminal setting is different from the general population settings besides the obvious of the patients being locked up? It doesn't appear to be a speciality when you get down to it!

There are two parts to this question. The first part is, how are correctional and general psychiatry different (if at all)? And the second part is, is correctional psychiatry truly forensic psychiatry?

Both great questions.

Correctional and general psychiatry have similarities but also some huge differences. As janye noted, the medications are the same (yes, I have access to modern medications in prison). You still take a history, do a mental status examination, do lab work, gather outside history when indicated and provide treatment using the same general pharmacologic approach as in free society. I have access to an infirmary, seclusion rooms, and observation procedures when needed just like in free society.

But there are major differences. The patients may be the same if you work in a public mental health clinic, but if you are in a private hospital or private practice they will definitely not be the same. Correctional patients have loads of comorbidity including personality disorders, substance abuse, learned maladaptive behaviors, head trauma, chronic medical diseases etc. By the time they get to my clinic they have often been treated with the gamut of medications.

The other major difference is the environment. This is not a minor thing ("besides being locked up") and it has an effect on how you can practice. The inmates don't hold their own meds. They must report to a pharmacy window (see also my post Pill Line) or a nurse must bring medication to them. Certain medications are valuable in the institutional economy so you must be judicious about how much and what you prescribe. On the positive side, inmates are usually (not always, but a lot of the time) free of drugs and alcohol so you can use lower doses than what they get in free society. There are lots of other differences but these are a few.

Your own personal practice environment is radically different than what you would experience as a general practitioner in free society. You may or may not have an office, a desk or a telephone. You may or may not have heat and/or air conditioning. (My personal record: 100 plus heat index in a bare cell with no ventilation.)

Big differences. Differences that not everyone is cut out for. Fortunately, I like a challenge. Correctional psychiatrists tend to be laid back, not easily flustered and have a high tolerance for chaos. There is a difference between general psychiatry and correctional psychiatry.

And now the second question: is correctional work considered the practice of forensic psychiatry?

In a nutshell, yes. In the late 1990's the American Council for Graduate Medical Education (ACGME) officially recognized forensic psychiatry as a subspecialty of psychiatry. When fellowship accreditation standards were set up, they required fellowships to provide at least six months experience in a correctional facility. In order to become a forensic psychiatrist you have to spend time working with prisoners.

Now, most correctional psychiatrists currently are not forensic psychiatrists mainly because there just aren't that many forensic psychiatrists. And you don't have to have forensic training to work in a correctional facility. But it really does help. Forensic training exposes you to the correctional environment in a supervised fashion. It gives you an understanding of criminal procedure and mental health law. It gives you experience working with violent offenders and potentially dangerous seriously mentally ill patients. All of this comes in useful in prison. As in all psychiatric practice, patients want to be understood. If you understand their culture, their problems and predicaments, you will be better able to treat them. If you have no clue what the legal issues are that they're facing it would be hard for them to feel understood.

So there it is. This is forensic psychiatry.

Vote On The New Sidebar Poll!

What's your favorite anti-psychotic agent? I'm collecting more useless data.

Final Results of the Sidebar Poll on What's Your Favorite Sleep Medication

I posted the results of our sidebar poll and I meant to take it down and put up a new one: What's Your Favorite Anti-Psychotic? of course. But I never got around to it and people have just kept voting.

And it's Sunday: coffee and The New York Times. The Magazine's lead article is about is by Jon Mooallem and is called "The Sleep-Industrial Complex." It's a long piece that talks about mattresses (What's YOUR sleep number?), pills, the history of sleep, our expectations and perceptions of what goes on in those wee hours.

So the final results of our Sleep Med survey--please SCROLL DOWN (there's a technical glitch here and I can't seem to get rid of "error loading data" but it's loaded!):

	Answer Text	Votes	%
	ambien	36	19%
	trazodone	33	17%
	dalmane/restoril/klonopin/ativan/valium/serax (benzodiazepines)	26	14%
	benedryl/tylenol PM/ visteril (antihistamines)	21	11%
	Other...	20	11%
	seroquel or zyprexa (off label)	18	10%
	lunesta	6	3%
	sonata	6	3%
	rozerem	3	2%
		189

	Other
		hot Chocolate
		Prefer not to take them
		remeron
		resterol
		Klonopin
		medical marujana
		clonidine
		A good workout at the gym
		melatonin
		Remeron
		amitriptyline
		zopiclone
		Melatonin
		Prefer not to take them
		zopiclone
		bourbon
		I watch mindless TV until I fall asleep. Sometimes it works, sometimes it doesn
		no caffeine after 6 p.m.
		zopiclone
		ethanol

Let Me Tell You About My Office

I told you how Roy dropped by for an unexpected visit. In the comment section of that post, talk started about how a psychiatrist's office is set up. I was thinking, in response to the notes, no no no, I didn't think about it that hard, you all are reading meaning into places where there is no meaning! The lack of a clock isn't purposeful, there is no desk because I didn't need one, not because of any great thought about barriers-- though I would never practice psychotherapy across a desk, I do sometimes think it would make life easier when I eat soup for lunch. Finally, there were some comments about Feng Shui.

So let me tell you about my office, there are some things I thought about long and hard.

I moved from a group setting when things got very crowded and I didn't want the process to be prolonged. I also hate traffic and long commutes, like to be able to go home during down times, so I looked close to home and for something that would take forever to move into . I'll spare you all the details, but I moved into an office that was already occupied by a psychiatrist, and had been occupied by a psychiatrist before that, so nothing in the layout was designed by me. The furniture was what I could get fastest: so what was in stock at a local furniture store, a couch and chair from IKEA that took 6 weeks (rather than 3 months in a regular furniture store) and some odds and ends from a consignment shop, shelves and a file cabinet from Staples.

The waiting room is small. I hate fluorescent lighting for psychotherapy, so there are lamps, 2 chairs, a coffee table with magazines spread out, a replica of an old radio which I set to NPR or something soft, another end table. There is a folding chair in case someone brings two people with them but no one has ever unfolded it. It's a subdued, but slightly claustrophobic room. It used to be totally stark without the lamps and the end table (a pretty piece from pier one with musical notes on it) until I wandered into the office of the guy across the hall and saw his rugs and antiques and that inspired the Pier One visit. There are some pictures on the wall, and a patient gave me a cute book of animal photos called The Blue Day Book which sits on one of the tables. The magazines are mostly Baltimore Magazine and a few random things--sometimes I bring in the New York Times Magazine or Book Review, there is a copy of Feng Shui (yes, I'm not kidding.). The radio adds to the soundproofing. The waiting room has a door and is connected to the office by a short dark hallway.

There are double doors to the main office. This is weird and Roy commented on it: you open a door and there is a door. I was told it is for soundproofing. It works.

The main office is bigger than I need. There is a couch for the patients to sit on, a chair for me. I bought them together and made sure they were the same height, this was important to me. Farther away, there's a desk chair on wheels-- gives someone the option of sitting farther away, of not sitting on the couch, of rolling around a little. There's an area rug, 6' by 9' maybe, between them, no coffee table. I have a small wooden end table with drawers with an ornamental vase and fake flowery things (the real plants I tried all died), pens and a prescription pad. A long sofa table holds a lamp and some decorative thingys. (I think it was from Hold Everything or Pottery Barn). A large file cabinet sits next to the couch in a corner. It's draped with a piece of fabric to make it look less like cold steel metal. A plant sits on top. There are some plants on the two windowsills and by the windows the ceiling does this weird uppy thing. I keep the blinds are kept mostly drawn, the walls and carpet are light, the office is a bit under-furnished and a friend described it as cavernous. It's also gotten a lot of compliments. There is a table next to the couch that holds a tissue box. A large double bookshelf holds mostly magazines, some books, random objects, and one shelf essentially serves as a "desk". An ottoman sits next to my chair to collect stuff-- mail, forms, a clipboard, whatever, and it has a lid that opens to throw clutter in. Aside from the pile next to the chair and some mess on the desk shelf, there is no clutter, I'm a pretty neat person. A closet with double doors holds a dorm-sized fridge, microwave shelf with samples, paper goods, supplies, motrin for the occasional headache, a hammer, screwdriver, light bulbs. The walls hold some random pictures and the obligate diplomas.

And when I first started, I asked a talented, creative, decorator friend to come help me with colors. She pulled the place apart and put it back together in its current state. The carpet got lighter and the walls got darker. My friend is a Feng Shui expert, so the place has been infused a little, though no running water, no hanging crystals. A water thing would nice.

A little about my office decorating consultant
:

Shelly Daly

A Stone's Throw

tel: (410) 664-4370

Shelly is a professional interior designer with more than twenty years experience and a certified Feng Shui practitioner. Her work in both residential and commercial 'environmental therapy' bring together her eye for design with the far reaching principles of Feng Shui. In addition to personal Feng Shui, Shelly works with architects and realtors on existing and unbuilt projects to determine advantageous orientations,layouts and design. She also offers holistically based interior design services including 'Done in a Day', a unique hands on design process that involves rearranging a client's existing furniture and accessories to create a stunning new environment. 'Done in a Day' works well for; selling your home, jumpstarting the redecorating process or simply for the design challenged wanting to uncover their personal style.

Shelly is also available for workshops, lectures & small group discussions as well clutter and organizational assistance. References from happy clients and a brochure further explaining services and fees are available for the asking. Her work extends throughout the Mid Atlantic region. Please e mail or call for further information.

Dropping By

My office is in a building with lots of other offices and some stores. It's not uncommon that friends will mention they've been in the building for a reason, or they might say they're going to be there and might drop by. I generally suggest that they not do that-- I see patients back-to-back most days, it's more than a bit awkward to have my personal life intrude on my professional life, though I don't want my friends to think I don't love seeing them, just not during the work day.

Yesterday, between sessions, I got this text message from a friend, "I'm in the building. U there?"

I called and said, "I have to see a patient quickly, come up in a little bit."

It felt like a funny, meant-to-be sort of thing set up by the cosmos. I didn't tell the friend all the details, but I did have a patient scheduled that hour only the night before she'd called and said she forgot what time the appointment was. I told her (same time as friend showing up), but as an afterthought I added that I had another time available later if that was more convenient. It was, she took it, thereby freeing the cosmic time slot. And you know I don't do "med checks" but the patient I'd scheduled into that time is the only patient in my entire practice that I see for brief med checks-- a patient who came to me completely stable with no symptoms or side effects, no desire for psychotherapy, who could easily be managed by an internist (and has been told that) but he wants a psychiatrist to write his prescription.

Friend came up and we chatted. He sat where the patients sat, I sat where I sit. I'm not the quietest of therapists, but when I'm doing psychotherapy, it's all about the patient. I got to talk about me. He looked around, asked about the position of the clocks. Why doesn't the patient get to see a clock? Why don't I have a desk? We talked about some other stuff. I didn't ask if he needed more meds. He left when the hour was up. I wondered if he felt funny that the patient in the waiting room must have thought he was a patient.

It was nice to see you, Roy.

Is This Psychiatry?

In her post Why Shrinks Don't Take Your Insurance Dinah talked about insurance reimbursement for psychiatrists and the effect of patient volume on revenue. She speculated that someone who ran purely a medication management practice could make a fair amount of money, but then she added this caveat: "I'm not sure I'd call it psychiatry, and I'm not sure how long I'd survive or how much better the patients would get, but hey."

I think I'm pretty qualified to answer those questions because I have the kind of practice Dinah is talking about. My clinical practice is entirely a medication management clinic within a prison. I have a high volume practice---two months ago I had the most patient contacts of any correctional psychiatrist in the state. I don't do high patient volumes for the money. I get paid the same hourly wage whether I see one patient in an hour or four. On the average, I see about three patients an hour. I see a large number of patients because there are a lot of people who need care and the majority of them have at least three risk factors for suicide. I see large numbers of patients for medication management because any one of them could die if I don't. And I don't do therapy sessions.

So is this psychiatry? Absolutely. I didn't become a psychiatrist because I wanted to be a therapist. I had no interest in psychotherapy and I honestly still don't. I became a psychiatrist because I enjoyed neuroanatomy and was really good at it and because I was fascinated by the functioning of the human brain. I wanted to be a 'real' doctor who treated people with serious brain diseases.

Do my patients get better? Some of them do, some of them don't, just like in private practice or any other branch of medicine. I can say that it's easier to tell if my medication management patients get better because I know what I'm treating and I have specific symptoms I can monitor. I think it's a little tougher to say that for psychotherapy; how do you know the therapy is working---because the patient says it helps and they say they like it? Because they keep coming back for more? Hard to tell.

Most psychiatrists practice in a range of settings, with a variety of patients, using a combination of therapeutic interventions. I don't have therapy sessions but I do provide crisis intervention and brief supportive counselling because sometimes the patient needs it right then, and you can't just cut them off and walk them into a counsellor's office. Psychiatrists in private practice usually have some patients who come only for medication management, and there are some patients who don't want psychotherapy. Some people might feel that advocating a med management-only practice exemplifies all that's wrong with the profession today, the death of the patient as an individual and the constriction of the profession. I counter that to cling to a private practice therapy model at the expense of public service med management is to abandon the most functionally impaired, at-risk patients whom only we are qualified to treat.

Why Shrinks Don't Take Your Insurance

Many psychiatrists in private practice don't take insurance, or don't 'accept assignment.' They require the to patient pay them and then the patient can submit to his health insurance company and reimbursement is made directly to the patient. This often means that the patient, having gone Out-Of-Network, has a higher co-pay &/or a higher deductible, and the hassle of paperwork. Generally, if a patient sees an In-Network psychiatrist, they make a copay and the hassle of getting the rest of the money falls on the doctor.

This means that access to psychiatric care is limited to those who have the money to pay up front, the wherewithal to stick their statements into an envelope and send them to the insurance company-- after they've called a separate managed care company, gotten pre-authorization, had Dr. Shrink submit a treatment plan, yada yada yada, as Mr. Seinfeld would say-- and the willingness to take on the financial risk that the insurance company might find some reason not to reimburse. By not accepting assignment, the doctor has greater control about little things like getting paid, but the patient supply becomes limited in a way that restricts access to care. Patients who want the financial and logistical benefit of remaining in their network are often surprised to find that it's difficult to find an in-network psychiatrist (even though the insurance company has this large list of providers) or that those psychiatrists aren't taking patients, or that they see patients for brief med checks but not for psychotherapy, or that it's hard to find a psychiatrist who feels warm and fuzzy enough. From the patient's point of view, it's not fair. There's a reason for this: it's not fair.

So why don't all shrinks accept assignment, why aren't they lining up to be members of insurance networks who would funnel lots of patients their way?

Let me tell the story from the psychiatrist's point of view. If a psychiatrist doesn't accept assignment, s/he sets his own fee-- generally what the market will bear-- perhaps decides when and if and for whom to slide or even forgo his fee, and he gets paid by the patient. This one is easy.

If the psychiatrist accepts assignment, he agrees to practice according to the terms of the insurance company. He sees the patient and collects the copay. Maybe it's a flat $30 co-pay. Maybe it's 80% for the first 5 visits and 70% for the next 5 visits and 60% for all the visits after that oh but the patient is only covered for 25 visits a year and the psychiatrist has agreed not to balance-bill as part of the deal. I don't know what happens if the patient needs a 26th appointment, I believe the doc eats the fee or simply doesn't offer the extra sessions. At any rate, the doctor now needs to figure out how much the patient has to pay and it's his responsibility to collect this. Oh, but it's not 80%/70%/60% of HIS fee that the insurance company will pay, it's 80% of what the insurance company has decided is Usual & Customary. And if they decide that Usual & Customary Rate (UCR) is $10/session or $25/session or $50/session less than anyone in town charges, then that's what they pay on. And while it might be a piece of cake to calculate if the the UCR was say $100/session and the patient paid $20 and the insurance company paid $80, well it's a pain in the neck if the UCR is $97.84/ session and you have to keep count of the sessions and figure out the percentages. Should I mention that different insurance policies by the same company can have different payment rates so someone has to call for each patient, verify the insurance, find out the terms, co-pays, deductibles, and this involves sitting on hold and dealing with assorted prompting menus. And if the insurance company finds a reason Not to pay, the doc is stuck--he can't bill the patient, he's just out the money. For a psychiatrist who does psychotherapy and sees maybe 8 patients/day at an insurance company discounted fee, well, it can be a big deal to have the insurance issues. And if the patient has two insurance policies and they each have different terms and they each decide not to pay because the other is the primary insurer-- oy! So not only is the psychiatrist taking his chances on getting paid, but he now has to have a secretary, an overhead expense his I-don't-accept-assignment compatriot may or may not want or need. And he now has to have an office big enough to accommodate secretarial space. I'll also tell you that while the secretary is paid an hourly fee, his ability to get paid is only as good as her motivation to follow through on dealing with the insurance companies, refiling denied claims, clarifying primary versus secondary insurance and getting the amount of the co-pays correct.

So how and why does any psychiatrist accept insurance? Basically, the insurance companies pay okay for short appointments with a psychiatrist. While there are time standards for coding psychotherapy appointments (25 minutes, 45-50 minutes), nearly everyone charges more per hour for a 25 minute appointment than for a 50 minute appointment, even many of the out-of-network docs. So a psychiatrist who sees two patients in an hour makes more than a psychiatrist who sees one patient in an hour, and often the insurance companies-- perhaps eager to encourage their policy holders to seek psychotherapy with a cheaper provider-- will pay a reasonable amount for a shorter session-- perhaps they make this worth doing. And "Med Management" 90862 for those of you who like CPT codes-- has no time restrictions on it. If a psychiatrist can squeeze four or five patients into an hour, he can do okay by the insurance companies.

Okay, I googled it and this is what I found: for Medicare, based on 2004 rates, irrespective of geography (so I guess a national average as each state has a different fee), the allowable fee for a 45-50 min psychotherapy session with medication management is $103.80. Half an hour is allowed at $71.31, and a 90862 med management with no time stipulation goes for $51.15 (here is my source)-- if you can see a patient in 10 minutes, you're doing as well as some lawyers. I'm not sure I'd call it psychiatry, and I'm not sure how long I'd survive or how much better the patients would get, but hey.

The Shrink Next Door

This is our 600th Post!
Lately my neighbors have been apologizing to me, which feels a little bit weird. We'll have brief (OK, sometimes not so brief) conversations and they end them by saying something to the effect of, "I'm sorry to chew your ear off," or "I know you're off duty, so I'm sorry about that," or words to that effect. They know I'm a psychiatrist so I guess they think they're burdening me when they do the normal problem-sharing thing that goes along with being a friendly neighbor. Now, it's possible that I get more than the usual share of mental-health related problem sharing because they know what I do for a living. And it's true I know lots of stuff about who in the neighborhood is on which medication, or who would never in their life take that particular medication, or who is looking for a psych referral (I give them names but they rarely follow through), just because of what I do for a living. But it doesn't feel like they're burdening me. I like my neighbors. I've never had a bad one, and that's pretty unusual considering how long I've lived here.

That being said, I can't say that I've ever gone to my mechanic neighbor for car advice or to my hair stylist neighbor for coloring advice (although Dinah probably thinks I should) but that's not because I don't think they'd help me if I asked for it. It just never occurs to me to ask. It is nice to know though that any one of those folks who apologized to me for "problem dumping" would be just as quick to listen to me if the tables were turned. That's just being a good neighbor.

My Three Shrinks Podcast 38: New & Improved!

[37] . . . [38] . . . [39] . . . [All]

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Okay, this podcast is a milestone for us. Dinah bought several hundred dollars worth of sound equipment (Alesis MultiMix8 w/Firewire, Behringer C-1 mics), which took us several hours to properly set up to record so that each of us comes into the MacBook as a separate track, thus letting us have more equal sound volumes (before we all shared the same mic, so our voices were at different levels).

I've set it up so that if you listen to the .m4a version (that's what gets downloaded from iTunes), Clink's more on the left channel, Dinah's more on the right, and I'm in the middle. Let us know how you like it. I'm still figuring out how to use it all to achieve the best sound quality, but I think #38 is the best one we've ever done so far.

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November 11, 2007: #38 New & Improved!


Topics include:

• MacArthur Foundation Grant. Decision-making, substance abuse, and brain abnormalities. Developing guidelines for judges about neuroimaging and brain function.
  
  
• On our Shrink Rap blog, Clink blogs about What She Learned (Part 1, Part 2, and Part 3) at her AAPL conference.
  
  
• Delirium. Roy discusses delirium, or encephalopathy, what it is and recent findings about longer term damage. This was on the front page of a recent WSJ.
  
  
• Shrink-proof containers. Clink brings back a hotel bottle of mouthwash that she could not open.
  
  
• Q&A: Gerbil brings up recent study on chocolate lovers.
  
  
• Online CBT for Depression. Study finds it helpful for mild-moderate depression. Eliza.
  
  
• Telepsychiatry. We just chat about some of the issues.
  

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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.

Psychiatry's Identity Crisis

Today, the Sunday New York Times has not been inspirational. I suppose I could blog about the pictures they have of the brains of the political candidates, but I just don't want to.

So I surfed around and from KevinMD, I landed on The Medfriendly Blog where neuropsychologist Dominic Carone is talking about how some physicians claim that others-- particularly psychiatrists and physiatrists-- aren't REAL doctors. Dr. Carone goes through the definition of doctor, and his theories on why some docs dis other docs. I added my thoughts to his comment section, specific to psychiatrists, that we may be seen as "less than" because we are less-hands on, our version of an exam is a of mental phenomena and not necessarily of the body, and that part of our treatment is the act of listening/interpreting. Also, many shrinks don't wear a white coat (I'm one of those). Plus we have the Woody Allen view of shrink as psychoanalyst, and pure psychoanalysis can be done by people with several different degrees.

You know, it's a complicated issue because even the term "shrink" is sometimes shared with psychologists, and I generally address anyone with a PhD (even if it's in history, social work, nursing) as "Doctor" and I'm completely comfortable with that, but really, is someone with a PhD in English a "doctor"? No, they have a doctorate degree, but the professional designation is reserved, I think, for those who've graduated from medical and osteopathic schools. Dentists, podiatrists, and vets (and others, for example, neuropsychologists) do the same stuff as "doctors" -- they diagnose and treat illnesses, they have training that's at least as extensive as a people doc, the same prerequisite education, they've dissected those cadavers, they write prescriptions and perform surgery -- in my brain they are certainly doctors, but I bet if you ask them what they do at a party, they say 'I'm a vet/dentist' not I'm a doctor (the podiatrist probably says 'I'm a foot doctor' but hey).

Even without a white coat and a complete physical exam (...ah, I do sometimes check vital signs, ask a patient to walk, hold out their hands to evaluate a tremor, check for cogwheeling, order labs, request that medication vials be brought to the session) ...here's my view of why shrinks ARE docs.

Psychiatrists must attend medical school. To even get into medical school, certain pre-med requirements must be met and back-in-the-day these included: 2 semesters each of calculus, chemistry, organic chemistry, biology (one semester was biochemisty), physics, and all the sciences included lab courses as well. I believe a year of English is now required, my university back then required it for graduation as well as 2 years of a foreign language and some history/social sciences as well.

Medical School entails a two year pre-clinical course of study. I'm not sure I can remember all the courses I took, but here's a smattering: gross anatomy with cadaver dissection, histology (the study of cells), physiology, pathology, pharmacology, biochemistry, neuroanatomy, embryology, microbiology, immunology. With all the talk around about psychologist prescribing legislation which allows psychologists to prescribe psychotropics after taking a 10-week pharmacology course, I want to point out that pharmacology for medical students is a second year course, begun only after years of science prerequisites are met. That's another rant for another day. In the second year, medical students begin learning to perform physical exams and take medical histories.

The two final clinical years of medical school include for everyone (even shrinks): 12 weeks of internal medicine, 12 weeks of surgery, rotations in pediatrics, OB-GYN, psychiatry, neurology, and I maybe missing some other stuff. Surgery for me included a few weeks of cardiothoracic surgery, and electives in neurosurgery and plastic surgery. The fourth year has lots of elective time and time to interview for internships/residencies. I spent some time doing psych research in California, primary care on a Navajo reservation, psych rotations in hospitals I thought I might want to go to, cardiology, a pain service month, and I can't recall what else.

Before psychiatry training formally begins as a specific residency, a year of internship, hands on, being-a-doc is done-- a transitional year may include 6 months of psychiatry, I did a year of pure medicine and did the whole CCU/ICU/renal transplant unit/AIDS units stuff, no psychiatry.

Okay, then there were 3 years of psychiatry: inpatient, outpatient, electives, mostly just psychiatry except for when inpatients got physically sick and needed work-ups begun before the medicine folks arrived.

Many days, I feel like I've forgotten everything that doesn't have anything to do with psychiatry. Actually, I'm pretty sure I have. I haven't heard of half the meds people are on anymore, I forget the details of how lots of stuff works. My father-in-law asked if you pee less if you have one kidney...? does the second kidney double it's filtration rate? And I need to go look up what a mild decrease in T3-uptake means if the TSH and T4 are both normal.

I titled this Psychiatry's Identity Crisis, and if some surgeon or radiologist wants to fight... but really, amongst ourselves, we don't have a "crisis".
--Dr. Dinah

Trapped!

"I can't get Dr. ClinkShrink out!"

That is probably the number one item on my list of phrases I don't want to hear in prison. I heard it yesterday as I was on the wrong side of a locked door, at the end of the day, trying to go home.

It was a bad day. It started out bad, it stayed bad. I was 45 minutes late getting to work because of firetrucks blocking the highway. I saw a boatload of patients in the morning and as I was leaving a nurse ran behind me trying to get me to stay and see more. I miraculously finished my afternoon clinic on time, having seen all but two scheduled patients. A miracle, given how late I started.

Then the key jammed. I stood on one side of the door, the officer stood on the other side of the door twisting a key in the lock, stripping the cylinder, bending the key, yelling, "I can't get Dr. ClinkShrink out!"

I was stuck on the floor with three other civilians while they tried to find the keys to the back stairway. They found the keys. They directed us to the door leading to the stairway. They discovered there was no keyhole on the side of the door that the officer was standing on---with the key. I vaguely wondered what would happen if a fire broke out just then. I put the thought out of my head. I spent my time feeling grateful I wasn't stuck in the elevator like the last group of trapped civilians---fifteen in all caught somewhere between floors---when all the elevators broke down at once. No one could find the stairwell keys then either.

Then it occurred to me that standing behind a locked door at the end of the day was the most peace I had had all day. Next week I bring a support donkey.

Guest Blogger Dr. Peter Rabins on Deep Brain Stimulation

A while back we were talking about treatments for depression and some of our commenters asked about the newer, non-pharmacologic treatments out there. It was on my list, or maybe I was hoping Roy would jump in with some answers-- he likes gadgets and gizmos. We'd moved on and I forgot about this, but then we got an emailed request from JCAT in South Africa, asking for our thoughts on surgical treatments for depression, specifically Deep Brain Stimulation and Vagal Nerve Stimulation. I can't say I've ever recommended these treatments for any of my patients, I've never met anyone who has had them, and I don't have an opinion. I did, however, hear Dr. Peter Rabins talk about DBS as a treatment for depression last year, and so I thought I'd ask his opinion.

Dr. Rabins is a Professor of Psychiatry at Johns Hopkins Hospital where he is co-director of the division of Geriatric Psychiatry and Neuropsychiatry. He is the author of The 36-Hour Day, and more recently of Getting Old Without Getting Anxious.





Dr. Rabins writes:

There has been an amazing amount written in the popular
press about the potential for Deep Brain Stimulation
(DBS) to be usedto treat certain psychiatric syndromes.
Right now, there are preliminary and promising results
for severe, treatment-resistant major depression and
OCD but very little information has been published in
the peer-reviewed literature.

In Europe, DBS has also been used to treat anorexia 
nervosa,various substance abuse disorders, and even
aggressive behavior. Given what happened with
'lobotomy' surgery 60 years ago, I believe it is
incumbent upon the mental health community and
especially psychiatry to publicly and persistently
urge that the topic be approached from a scientific
point of view, that carefully designed studies with
long-term follow up data bemade publicly available,
and that very ill and vulnerable individuals be
protected from the harm and abuse that can result
from inappropriate claims, unnecessary and
non-beneficial surgery, and being taken advantage
of financially.

Many ethical and careful researchers have begun to
study DBS for psychiatric illness but it will take
time before results can tell us whether it is helpful
and worthwhile. In the meantime, it is best to keep
expectations down, to remind people that this is a
very expensive treatment that will likely only be
used for severe disease that has not responded to other
less invasive and less expensive approaches, and
that the treatments we have now for major depression,
including ECT,help the majority of very ill individuals.

How This Shrink Picks A Sleep Medication

I have more to say about sleep medications. But I have a lot less to say about choosing a sleep medication than I do about choosing an anti-depressant, and my thinking on this is a lot less structured.

Everyone who wants medication to help them sleep gets a talk about the obvious sleep hygiene issues. Here are the basics:
-- Choose a 7 hour period during which you'd like to sleep. Keep it the same everyday, for example, midnight to 7 am, but the exact hours aren't important. The regularity is. Set an alarm.
--Don't nap.
--Don't watch TV or do anything else interesting in bed (sleep and sex, that's it)
--No caffeine after 2 pm. And not much before that. That includes caffeinated soda and iced tea and sadly, chocolate.
--Exercise regularly, preferably 3 hours before you go to bed, but absolutely no closer to bedtime.
--Limit alcohol, and don't drink it near bedtime, it screws up your sleep architecture.
--If you have sleep apnea, use your CPAP machine. Really.

No one follows these recommendations, at least not when I make them.
Linda, the self-proclaimed sleep Nazi, would add: No Screens of any kind after 11 pm for adults and 10 pm for kids-- no computers, TV, video games. Even I'm glad I don't live at her house.

I prescribe sleep medications frequently, insomnia's a common complaint. Sometimes I feel strongly that someone should take a sleep medication-- disturbed sleep goes hand-in-hand with affective (mood) disorders and in patients subject to manic episodes, sleep is really important and I worry that poor sleep habits might either announce or precipitate an episode. Often, though, I feel like it's not the end of the world if every night's sleep is not perfect (great blogging gets done in those wee hours), and that some people are too quick to look to pills to fix problems. I'm probably going to get blasted for that one.

Sleep issues take on a life of their own. People get anxious about not sleeping and it builds on itself. They have all sorts of expectations about how much sleep they need or should have-- one patient was beside herself because she was only sleeping 6 hours a night and felt she needed 8 to 9 hours. Maybe she was right, but when I suggested that maybe she only needed 6 hours and that's why she was waking up, she felt I was dismissive and she found another doc. Another patient said he was greatly relieved when I told him his body was getting rest by just lying there quietly, he stopped worrying so much, and his sleep improved (plus, he turned on his CPAP machine).

All medications have the potential for side effects and adverse effects. Sleep medications are no exception. And many sleep medications are addictive and many patients insist they won't become addicted. And even folks who don't become addicted in an up-the-dose, abuse-the-med kind of way, they get habit-forming, whatever that means, and there are people who will end up taking a pill to sleep every night of their lives and won't hear of even trying to stop the medicine.

So my non-scientific, mostly random method of picking a sleep medication:

If the patient presents with depression, I hope that as the depression resolves, the sleep disturbance will resolve. Some anti-depressants are so sedating (TCAs, Remeron, Serzone, Trazodone) that they are effectively sleeping pills. Other times the anti-depressant, especially SSRIs, cause the sleep disturbance.

Trazodone. It works well in combination with SSRI's. It's cheap. It's not addictive. It's easy to stop. The down side: the fear of priapism and there have been case reports of patients who need surgical intervention. Ouch. The other downside: it doesn't always work, even in escalating doses. Or, it works but patients complain of feeling drugged for hours after waking up. When it's good, it's good.


If trazodone doesn't work or isn't tolerated, and there is no history of substance abuse (particularly of issues with alcohol/benzos), then I try Ambien. This usually works, and it doesn't have a hangover. At least it works for a while, some people get tolerant to it's effects. And some people never want to stop taking it. It's theoretically not very addictive, but it does hit those same benzodiazepine receptors.

If there's a history of substance abuse, I may try visteril. This works only rarely. Once someone has had extended exposure to alcohol or benzodiazepines, it's hard to knock them out.

If visteril doesn't work, I try Rozerem, even though I hate the Abe Lincoln/Beaver advertising campaign, and even though it costs a small fortune, and even though it did terribly on our survey. It does seem to work.

Sometimes I use seroquel or zyprexa. These work, though they have that same effect of leaving some people feeling groggy in the A.M. With all the concern about how these medications are linked with diabetes and lipid disorders, I use low-doses, as needed only for the short-term, and I don't prescribe it as quickly as I used to. Unlike many sleep medications, these are fairly easy to stop.

If there's no history of substance abuse, if the patient is a light social drinker with no history of abuse, then I may try ativan or valium for a short term issue. Restoril works well, though with it's long half-life, it's always a bit surprising that people don't feel groggy on this the next day.

I've never prescribed Sonata, and the first and only patient I gave Lunesta to complained of a horrible taste in her mouth.

With those thoughts, Good Night, Sleep Tight, Don't let the Bed Bugs bite.

Catching Zzz's : Survey Results

Okay, so we've had 121 votes, our sidebar polls are getting more votes quicker. I'm still having fun. Here are the results... if you scroll down, you'll see something called Zopiclone got a bunch of votes-- I believe this is Lunesta in some other land. Restoril and klonopin can get thrown in with benzodiazepines.
	What is your favorite Sleep Medication? benedryl/tylenol PM/ visteril (antihistamines) 9% (11 votes) trazodone 21% (25 votes) ambien 22% (27 votes) lunesta 3% (4 votes) dalmane/restoril/klonopin/ativan/valium/serax (benzodiazepines) 16% (19 votes) sonata 5% (6 votes) seroquel or zyprexa (off label) 9% (11 votes) rozerem 1% (1 votes) Other 14% (17 votes)

• resterol
• Klonopin
• medical marujana
• clonidine
• A good workout at the gym
• melatonin
• Remeron
• amitriptyline
• zopiclone
• Melatonin
• Prefer not to take them
• zopiclone
• bourbon
• I watch mindless TV until I fall asleep. Sometimes it works, sometimes it doesn
• no caffeine after 6 p.m.
• zopiclone
• ethanol