Tuesday, September 30, 2008

Borderline or Bipolar?

The Eternal Footman --see photo above-- commented on Mood Disorders 101; he (foot
man, so it's a he, right?) asks:

Okay, I'm going to add one more thought and then I'll shut up. Borderline Personality Disorder is a condition that includes "affective (=mood) instability" and the differentiation between a personality disorder and a mood disorder can be difficult even for experienced psychiatrists.

...raised another question which is: Is there any one or two key symptoms/behaviors that clearly differentiate Borderline Personality Disorder from any one of the mood disorders?

Great question. Easy Answer: No.

Okay, but you inspired a post, so I'll elaborate. How does a psychiatrist differentiate, sometimes unsuccessfully, the diagnostic quandary of mood disorder versus borderline personality disorder? They both entail mood instability and behavioral indiscretions, especially impulsive behaviors during manic and hypomanic episodes, and the results of these illnesses can both result in chaotic lives.

So in my shrinky mind, I'll start with the issue of chronicity and overall quality of life. Someone's trekking along just fine (it doesn't matter when or for how long).... they have a life pattern of being able to work and to love, and suddenly they get zapped with a depression and things start falling apart-- they don't want to socialize, they don't want to work. At some point, with or without treatment, the episode ends and they go back to their regular old life. This person doesn't have borderline personality disorder, they have had an episode of depression. Oh, but we've already said that there a people with chronic depressions which are less easily defined into distinct episodes, and it appears their may be people with bipolar disorder, especially bipolar disorder type II, who spend much of their time cycling into and out of depressions and hypomanias, and they all kind of blur together. The chaos of it all is rather disruptive, and during these not-quite discrete episodes of hypomania, they engage in all sorts of impulsive behaviors: promiscuity, drug use, indiscriminate spending, gambling, fighting.

Simply put, if life is a constant episode of chaotic behavior, if the patient is unable to maintain employment, is often the center of dramatic upheavals regarding interpersonal relationships ( or drama with everything else), if the patient can't maintain some semblance of romantic relationships or friendships and is always struggling with co-workers and employers, then a psychiatrist is going to label this a personality disorder. And to be totally blunt, if this same patient
repeatedly threatens suicide in a way that garners the troops, or cuts themselves because it relieves psychic pain, then a psychiatrist will label this Borderline Personality Disorder. If the patient is repeatedly painting pictures of people in black and white-- one moment someone is all good, the next they are all bad, or everyone is one color with no shades of gray, and if he manages to frequently pit the people in his life against one another, well, a psychiatrist is still going to label this Borderline Personality Disorder. Good or bad, right or wrong, that's currently how it goes. The label has a pejorative edge, as if the patient should just grab hold of themselves and stop doing this. These patients often are difficult to deal with, they ask a lot of their physicians and they often get angry at the docs who are trying hard to help them. They may push up against the shrink in such a way that the shrink gets uncomfortable, feels a need to set up clear boundaries, and these boundaries feel rejecting to the patient, who now has one more data point in seeing how everyone is mean to them. The patient may well not see that they had a role in inspiring the reaction. "I need you..." their behavior says, " and you shouldn't be pushing me away." There may be little insight that they are asking too much, that the shrink feels overwhelmed, over-wanted, pushed against the wall in uncomfortable ways.
And the other issue, not for today, is that sometimes psychiatrists label people they don't like with personality disorders rather than taking a careful look at their own roles in interactions that struggle. Diagnostically, the label is a vague one, and it means more than an isolated personality clash...again, for another day.

So the chronic, chaotic, interpersonal issues point more towards a personality disorder than a mood disorder. Self-mutilating behavior (as opposed to suicidality) is not a symptom of mood disorders. And while people with manias may wreak all sorts of havoc, it's an episode, not a lifestyle.

So here's the next question: Does it matter?

There are mood disorder experts out there who will say that if you take people with these chaotic stories, re-think them as having chronic and rapid-cycling mood disorders, and treat them with medications to stabilize their mood, they do better and sometimes the chaos calms down.

There are personality disorder experts out there who say they've never met anyone with borderline personality disorder who doesn't, at least episodically, have a co-morbid mood disorder.

So, I suppose if you're going to say it's Borderline Personality Disorder and the only treatment is long-term intensive psychotherapy and there's no role for even trying medications or considering the possibility of addressing issues of mood or anxiety, then perhaps the treatment options have been kept narrow and uncreative. If therapy alone isn't helping, the patient might consider another opinion. And if meds alone aren't working, then maybe some therapy is in order.

Friday, September 26, 2008

After the Data: More on the Phone Therapy Study.

Okay, if you read my last post, you know I ranted (who me, rant?) about Tara Parker-Pope's NYTimes Well blog post where she asserted that phone therapy is effective for Depression-- as effective as real life therapy with less attrition. People wrote in to talk about their feelings about phone therapy, but really my gripe was with the idea of presenting a conclusion without any details-- I had a lot of questions about how this conclusion was reached, and I thought perhaps there were only 12 patients in the study.

So I emailed the author of the study, David C. Mohr, pH.D. at Northwestern, and within hours, I had a reprint of the study. It was a lot of data and I only did a quick read, but my questions were all answered, and here's the scoop:

This wasn't a research study: the journal article is a review of the literature of ALL phone therapy studies done, and 51 such studies were identified. All but 12 were excluded because they did not meet the authors' specific criteria to be included-- for example, some were surveys, not therapy trials, and any study that had ANY face-to-face contact was excluded. Mohr goes into detailed discussions of therapist training, treatment orientation, co-morbid illnesses, treatment format, and other variables. Mohr discusses how many of the patients and control subjects may have been on medications prescribed by primary care doctors or oncologists (--some of the studies looked at phone therapy in patients suffering from specific illnesses). I couldn't find any data from these studies that revealed that phone therapy worked as well as the traditional in-person stuff in a face off controlled trial.

The Well blog said: "The researchers also found that telephone therapy was just as effective at reducing depressive symptoms as face-to-face treatment."

Actually, the researchers wrote:
We also want to emphasize that it is premature to generalize
the results of this meta-analysis broadly. Individual studies suggest specific uses under specific circumstances; for example, telephone therapies may provide added benefit compared to care for depressive symptoms by a primarycare physician or to no care at all. However, because the depression symptom outcomes used in this meta-analysis were self-report instruments, the generalizability of these findings to clinically diagnosable depressive disorders is limited (Kendall & Flannery-Schroeder, 1995). Furthermore, the measures of depression used in this study had a wide range of specificity and sensitivity (Minami, Wampold, Serlin, Kircher, & Brown, 2007). Thus, the aggregated effect size estimates for depressive symptom severity should not be used as any sort of benchmark. In addition, the level of heterogeneity across studies suggests that we do not yet understand the characteristics of patients for whom such telephone interventions may be effective, and those for whom telephone intervention may not be appropriate. The heterogeneity in the severity of depressive symptoms and in medical comorbidities in the samples also limits generalizability.

AA noted in his/her comments that we here at Shrink Rap sometimes make statements without fully backing them up or giving a full assessment of the literature. I have to agree. We're rambling for fun, we try to be accurate, we look up and link, but psychiatry is sometimes vague, still a mix of art and science with more questions than answers and the it never ceases to amaze me that how differently individuals react to the same intervention-- be it a word muttered or a medication prescribed. We try to be careful, but we can't be exact and some of this is about ducks and chocolate and us just venting about our days. I promise, however, that the moment the New York Times wants to pay me a salary to do this, I'll become really really careful about the conclusions I draw!

Thanks to Dr. Mohr for providing the paper:
The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta-Analysis David C. Mohr, Northwestern University, Hines Veterans Administration Hospital Lea Vella, San Diego State University Stacey Hart, Ryerson University Timothy Heckman, Ohio University Gregory Simon, Group Health Cooperative

Tuesday, September 23, 2008

I Want To See Your Data

I've been resisting the urge to write about it, but Rach ( in her leg-warmers) has asked, so here are my comments about Tara Parker-Pope's New York Times Well blog called The Benefits of Therapy by Phone. It's a short piece, minus comments, so I'm simply going to paste the whole post. Ms. Parker Pope writes:

The Benefits of Therapy by Phone

INSERT DESCRIPTIONPhone-based therapy can be less hassle for patients. (Peter DaSilva for the New York Times)

Most therapists schedule face-to-face meetings with their patients. But new data suggest that therapy by phone may be a better option for some patients.

It has long been a concern among therapists that nearly half of their patients quit after only a few sessions. As a result, a number of health care providers and employee-assistance programs now offer therapy services by phone.

A new analysis of phone therapy research by Northwestern University shows that when patients receive psychotherapy for depression over the phone, more than 90 percent continue with it. The research showed that the average attrition rate in the telephone therapy was only 7.6 percent, compared to nearly 50 percent in face-to-face therapy. The researchers also found that telephone therapy was just as effective at reducing depressive symptoms as face-to-face treatment.

“The problem with face-to-face treatment has always been very few people who can benefit from it actually receive it because of emotional and structural barriers,” said David Mohr, professor of preventive medicine at the Feinberg School of Medicine and lead author of the study, published in the September issue of Clinical Psychology: Science and Practice. “The telephone is a tool that allows the therapists to reach out to patients, rather than requiring that patients reach out to therapists.”

Among patients who say they want psychotherapy, only 20 percent actually show up for a referral, and half later drop out of treatment.

Dr. Mohr said he began using phone therapy because he was working with patients who had multiple sclerosis who could not get to a therapist’s office. Some patients don’t have regular transportation to a therapist’s office or can’t take time off work or away from their families. In addition, a patient with depression may simply not be capable of getting themselves to the therapist’s office on a regular basis.

“One of the symptoms of depression is people lose motivation,” Dr. Mohr said. “It’s hard for them to do the things they are supposed to do. Showing up for appointments is one of those things.”

Where should I begin? I'll guess I'll start by saying I don't want to talk about the value of phone therapy. Certainly, phone contact between sessions can help alleviate a crisis and may provide some comfort to a patient, but this isn't about 'between-sessions' with a known live entity, it's about telephone contact in place of live sessions, and my understanding is that this is from the get go.

It's a blog post, not a rigorous scientific article, but I'm going to start by saying I thought the post is irresponsible. That feels strong, and I'm an avid Well reader, but it's full of all these blanket statements, given as facts, with nothing that backs them up. There's a link to an abstract, and an email to request the full article, but I'm going to note that the abstract also gives very little information about the methods used and the conclusions reached. I didn't write for a copy of the full article (I will) -- maybe it was great science that warrants the conclusion that phone therapy for depression is as good as live therapy, but it's hard to get there from either the blog post or the abstract. Stay tuned: we'll use the full article for a future My Three Shrinks podcast.

Okay: The article starts by saying that therapists are concerned about patients leaving after only a few sessions. Is this true? Maybe people feel helped and leave. Maybe the therapist is horrible and they leave. And actually, insurance companies judge the best shrinks as those whose patients come the fewest times (presumably the quickest cured, but certainly the cheapest for the insurance company).

The next interesting assertion is that only 20% of people who want psychotherapy come for treatment? How do we know this? I suppose there could be a number for those who initiate treatment, but for those who Want?

Moving along, the issue is one for treatment of Depression, nothing is said about any other disorder, and I was left to wonder how the diagnosis was made: presumably over the phone? Is it just patients who self-diagnosed as Depressed? If a patient phone screened for another illness, were these results omitted so the finding could be positive for Depression? And is medication an option or perhaps these patients were identified by primary care docs who had already made the diagnosis and prescribed the medications? We have no idea what the pool of patients was, if medication has a role, or whether the patient or therapist initiated the calls. We do know that few dropped out of treatment: I do agree it's easier to call in than to deal with the hassles of getting to an appointment, but perhaps it's even easier if the therapist is doing the calling and the at-home patient (or on the cell out-and-about) just needs to answer the phone. How long did the patient need to remain engaged for the session to be called "therapy?"

And the patients got better, compared to controls, but even the abstract doesn't tell us if the control group is a face-to-face therapy cohort or a no-treatment group. There are no rating scales, no average score changes, not even a mention of how many patients were involved. The abstract says '12 trials of psychotherapy' so I'm thinking this means 12 patients. If so, that's hardly a number that has any real meaning as a measure to influence standards of care and attract the attention of the New York Times and I'll return to the word irresponsible. What happens when the person at the other end of the phone is acutely suicidal?
What happens when a patient lodges a complaint against a phone therapist who isn't licensed in their state? And might I wonder if insurance companies could use such articles as rationale for out-sourcing psychotherapy to phone sessions with therapists in other regions where care might be cheaper? I'll leave that one to your imagination.

Sunday, September 21, 2008

You Know You've Been Blogging Too Long When

So here at Shrink Rap, we've been at it for a while. Since April of 2006, to be exact, and we have 839 posts now. I think that's a lot of posts.

On my post (was it today or yesterday, or what day is it, anyway?) titled What's In a Name, TigerMom commented, " From the title of the post, I thought you would address what doctors and their patients call one another."

I've written about that, right? I'm sure I have, early on, I don't know what I said, but I'm sure it's been done. If I haven't written it, well one of us has. So I searched. I finally went into our posts, all 839, and went to the oldest page. There's was a post called What's In A Name.

So I have two thoughts:
1) Oy, I reused a post title without even remembering this. If the blog isn't getting old, then maybe I am.
2) Perhaps I'm mellowing, but in the years since, I'm not sure I quite care so much what anyone calls me anymore.

To TigerMom, with regards.

Saturday, September 20, 2008

What's In A Name?

My favorite commenter, Anonymous, asks:
Once a person is diagnosed as, say Bipolar II, do they keep that designation for the rest of their lives?

Oh, gosh, I think we all wished we knew more about the exact course these illnesses would take and that we could tell each individual what to expect. We don't. I like the part of the question that asks if one keeps a diagnosis for life.

It left me thinking about what a diagnosis actually is. I know what a piece of chocolate cake is, and I could give a pretty good guess as to the fate of that cake if it's put near me. I know what a diamond is and that it is likely to last for a very long time.

Unlike a piece of chocolate cake or a diamond ring, a diagnosis is a hypothetical construct. It isn't a real thing, it isn't tangible, and the only meaning it has is the meaning we give it. Diagnosis isn't even an illness, which is slightly more concrete for certain diseases (say broken bones or the presence of a tumor) because one can have an illness without ever having a diagnosis simply by avoiding contact with physicians. While mostly we agree that certain symptoms (for example, having hallucinations or delusions) are likely the cause of a yet-to-be-fully-elucidated pathological process, some diagnoses are a matter of spectrum-- the somewhat random designation of when sadness or grief is "depression," when personality is disordered, or the precise reading at which we deem blood pressure to be "hypertensive."

The meaning of diagnosis is left to each person. Some people advertise their diagnoses, others live in fear of stigma. Sometimes, diagnosis is used to protect a member of society from suffering from the consequences of their behavior ("not criminally responsible") or to justify financial support from the government ("disabled"). In the negative, diagnosis alone seems to be held in the greatest regard by insurance companies. The implications for a diagnosis of AIDS are profound when one wants insurance. The same person, undiagnosed and
undesignated, might find it easier to get insurance. There's a blood test for AIDS, there isn't one for Schizophrenia.

We talk about "carrying a diagnosis." Whatever that means. I think, if one suffered from episodes of an illness many years ago, and one has remained symptom-free for a long time with no treatment, the issue of designation (-- for purposes of a medical history, or perhaps for government security clearance when applying for the Vice-Presidency in any party)... is best left to an honest recount of history. If it were cancer, one might say they were diagnosed with cancer 20 years ago, treated for a period of time, and have been disease-free since.... I'm not sure
psychiatric illnesses are any different.

Thursday, September 18, 2008

Mood Disorders 101

In yesterday's post, I talked about how Ron Pies questioned the difference between depression and "proper sorrows of the soul"-- ah, Dr. Pies was quoting some dead monk-- and Lily mentioned that she was just diagnosed with Bipolar II. It got me thinking that we should say something about how a psychiatrist thinks about mood disorders. If you're a psychiatrist, you can go home now, today's blog post is not for you.

I'm going to start by saying that I'm typing this off the top of my head, I'm purposely not pulling out the DSM (Diagnostic Statistical Manual), I'm just rambling. I'm very good at rambling. So this is how I think about mood disorders and how I go about reaching a diagnosis.

In the course of the day, a person without a mood disorder generally feels "fine." People go through life with a fairly steady mood, not too good, not too bad. Sure, stuff effects mood, and it may vary some-- people feel transiently ecstatic about wonderful things happening, people feel sad about distressing things happen, and there's the unexplained 'bad hair day' also known as 'waking up on the wrong side of the bed.' Let's take it as a given that people have moods, they vary some, sometimes the reason is obvious, and they aren't generally extreme.

Mood itself is a good place to start. Mood variation alone is not enough to make a diagnosis of a mood disorder (weird, huh?) and someone who feels very sad, even a lot, who has no other symptoms of depression, isn't called depressed. So someone is trekking along just fine and then suddenly they start feeling down/sad/miserable and at the same time other symptoms emerge. These symptoms may include: changes in sleep, appetite, a decrease in the ability to feel pleasure, loss of energy, loss of interest, decreased sex drive, irritability, guilt, a feeling of being physically unwell, hopelessness, helplessness, thoughts that death might be welcome, or thoughts of suicide. People who have pain syndromes will have worse pain, people with Parkinson's Disease may have worsening of their movement disorder, people with dementia may have more trouble with their memories, food may seem tasteless, colors may look less bright. People's thoughts change-- these are the cognitive symptoms of depression-- with a tendency to see oneself in negative ways, to take on blame, to block or discount all positive feedback the world might give. You can't have just one symptom to be diagnosed with
Major Depression, you have to have a few symptoms and they have to occur together, because mood disorders are 'syndromic' illnesses: they are defined by the co-occurring constellation of symptoms. The same person may have different symptoms during different episodes of depression, but generally episodes are discrete, and with or without treatment, they usually abate eventually.

There are some people who don't see their depressions as discrete episodes but feel they've been depressed for a very long time. Maybe they have Major Depression, but there is also a condition known as
Dysthymia which is a chronic, low grade depression which lasts for years (--at least part of the day, most days, for at least 2 years, I think). This version of depression is not as striking as an episode of Major Depression-- the symptoms aren't as severe, abrupt, or debilitating and other people are often not as tuned in to the sufferer's distress.

That's the down side of mood.

Then there's the Up side of mood. Mania is the extreme up state, and the associated mood state is either elated/ecstatic or extremely irritable. Again, a simple shift in mood is not enough to diagnose an illness, there need to be some associated symptoms which occur at the same time as the mood elevation/extreme irritability.
Manias include an increase in energy and a decrease in the need for sleep. The issue of Need for Sleep is important here: it's not normal to be awake and active for days at a time and not feel tired, this is much different than insomnia. People may have more ideas, they may have completely irrational ideas, judgment becomes impaired, thoughts may flow much faster, sometimes racing so fast that the patient can't keep up with them. Activity increases, speech may become fast and pressured. The person may feel very very good about themselves, very optimistic and positive, or believe they have special powers. There may be an increased interest in sex or religion, and people may spend lots of money on things they wouldn't normally spend on. Behavior may become impulsive and insight is often very impaired. The manic patient often resists the idea that they have an illness, and doesn't see how outrageous their behavior has become. They may hallucinate (see or hear or feel things that aren't there) or have delusions, particularly of grandeur, but sometimes of paranoia. Full blown mania is not subtle and often results in psychiatric hospitalization.

Anyone who has had even a single episode of
Mania, ever, is diagnosed as having Bipolar Disorder, Type I, what used to be called Manic Depressive disorder. Do note that a person can be diagnoses as having Bipolar Disorder even if they've never (or Not Yet) had an episode of Major Depression. The fact is that it's extremely rare for someone to suffer an episode of mania and then live out life without ever having an episode of depression, that manias tend to recur (sometime after decades) and that it's not unusual for a person to have an episode of mania and then 'crash' into an episode of depression. Anti-depressants and steroids can precipitate an episode of mania and we still don't know if those manias have the same implication for lifelong diagnosis.

So mania isn't subtle, but there are people who have episodes of elevated mood states without the extreme symptoms. Maybe they have periods of time where their mood is better than the norm of fine/okay/good, and their energy is increased, and they are more productive or impulsive, and revved up than the usual even-keel. They may look good, feel good, live life a little more grandly. This may be subtle, and it's this state of elevation that is called
Hypomania. This mood state may be hard to differentiate from a high-energy person, an anxious person, someone with Attention Deficit Disorder, or just the way that everyone wishes they could feel all the time. Hypomanias do not result in psychiatric hospitalizations and are not accompanied by extremes in behavior, hallucinations, or flagrant delusions. Hypomanias alone do not generally result in someone coming to psychiatric attention and patients present during episodes of Depression. This is Bipolar Disorder, Type II.

People with Bipolar Disorder, type II, generally spend much more time depressed than hypomanic, their depressions may be harder to stablize, and they often do better if a mood stabilizer is added to the treatment regimen.

If this isn't all confusing enough, there is a diagnosis called
Cyclothymia, which means that a person's moods vary from hypomanic to mildly depressed, but none of the episodes of depression is severe enough to warrant a diagnosis of Major Depression. Psychiatrists don't use this diagnosis very much.

Okay, I'm going to add one more thought and then I'll shut up. Borderline Personality Disorder is a condition that includes "affective (=mood) instability" and the differentiation between a personality disorder and a mood disorder can be difficult even for experienced psychiatrists.

Wednesday, September 17, 2008

Psychiatry Stuff in the New York Times.

Has anyone seen my co-bloggers? I think they've vanished.

I'm still here. Life feels a little weird lately-- my oldest teen, the one who makes all the noise-- went away to college a few weeks ago, and younger teen started at a new school. Things feel a little off-kilter, like there's an odd void. It's more peaceful, and college kid sounds very happy. It's all good, just a little unsettling, and I feel like I need to figure myself out all over again.

With that as an aside, two interesting articles in the New York Times:

In The Bipolar Kid, Jennifer Egan explores the increase in the number of children diagnosed with bipolar disorder, the struggles their families face, the maze of treatments and medications these families explore, and how little we know about this disorder. As a parent, I found it a sad read. As a psychiatrist, well, there's this awareness that some people have stories of really horrendous childhood behaviors and grow up to be just fine. Egan writes:

Most clinicians say they believe that there will eventually be clear “biological markers” of bipolar disorder: ways to see and measure the disease as we can seizures, cancer or hypertension. Scientists are working to identify the genes (there appear to be many) involved in creating a predisposition for bipolar disorder. Brain imaging, still in its infancy, can already detect broad differences of size, shape and function among different brains. The hope is to know early on who is at risk so their condition can be diagnosed and treated as early as possible. Mental illness wreaks brutal damage on a life, crippling decision-making, competence and self-esteem to the point where digging out from under years of it can be next to impossible. And there is also a biological theory for why going untreated might worsen a bipolar person’s long-term prognosis. Epilepsy researchers have found that by electrically triggering seizures in the brains of animals, they can prompt spontaneous seizures, a phenomenon known as “kindling.” Simply having seizures — even artificially generated ones — seems to alter the brain in such a way that it develops an organic seizure disorder. Some scientists say that a kindling process may happen with mania, too — that simply experiencing a manic episode could make it more likely that a particular brain will continue to do so. They say this explains why, once a person has had a manic episode, there is a 90 percent chance that he will have another.

And our former guest blogger, Dr. Ronald Pies, had a short piece in Tuesday's NYTimes: Redefining Depression as Sadness. Dr. Pies talks about the difficulties psychiatrists face in differentiating bereavement from normal sadness, the risks of under-diagnosis and the implications of over-diagnosis. He writes:

Let’s say a patient walks into my office and says he’s been feeling down for the past three weeks. A month ago, his fiancée left him for another man, and he feels there’s no point in going on. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.

Should I give him a diagnosis of clinical
depression? Or is my patient merely experiencing what the 14th-century monk Thomas à Kempis called “the proper sorrows of the soul”? The answer is more complicated than some critics of psychiatric diagnosis think.

My quicky take on his partial vignette, without my usual 2hour psychiatric evaluation, is that it's unusual for someone to seek psychiatric treatment for the first time because of a recent loss-- people generally cry on the shoulders of their friends, talk to their religious leaders, grieve and don't consider this unusual. The subset of people who present to a psychiatrist maybe having a more severe response, or another concern. With the little we know, it sounds to me like this patient has an Adjustment Disorder with Depressed Mood (is it okay if venture a guess based on on a few sentences?) and the patient should be seen often for psychotherapy. I'd give him medications if: 1) he has a history of depression and this looks like a recurrence 2) he's suicidal or unable to function/work 3) he's really insists that he needs a medication and he's intolerably miserable 4) he got no relief after a few weeks of therapy. Oh, and actually, if any of those things were going on, I'd call it Major Depression and not Adjustment Disorder. I just thought I'd stick in my unrequested opinion here, sort of silly given how little we know, but the issue of understandable reactions versus psychiatric illness is one we like talking about here at Shrink Rap.

Tuesday, September 16, 2008

Accountable To Whom?

In psychiatry, we talk a lot about the treatment of mental illness. Sometimes we talk about the treatment of disordered behavior, but often that discussion falls into the realm of other specialists such as psychologists, social workers, or lay support people (is that what I should call them?)-- members of self-help groups, personal coaches, and others.

Just to be clear, I'm talking about addictions and motivated behaviors-- people who can't stop doing what they're doing and seem to be driven by something other than logic. So the alcoholic who keeps drinking despite horrible repercussions, the smoker, the drug addict who keeps using when he's lost so much, the over-eating overweight person who grabs the next chocolate cupcake, the bulimic, the gambler, the internet sex addict, the pedophile, oh, name your "addiction." Illness or choice? The owners of such problems struggle, and often unsuccessfully.

This is what's frustrating about treating disordered behavior: we're not very good at it. It's really hard to get people to "Just say No." Actually, almost no one just says no. Sometimes people seem to have their own epiphanies-- something clicks-- and they change. Sometimes they "hit bottom" and they turn around. Some people just live in their ditches.

So how hard is it to change behavior? I think it depends on the person and on the addiction. Many people stop smoking-- for some it's harder than for others. The stats are that something like 95% of people regain lost weight within 2 years. I don't quite believe that, seems like I know people who've lost weight and kept it off, though not most. In the course of taking many psychiatric histories, I've heard of many people who've gained better control over a variety of behaviors. The most desperate often seek help, sometimes more than once, sometimes in a variety of places.

Here's my caveat:
I'm not very good at getting people to change behaviors they don't want to change. I've made some observations, I've tried to change some of my own behaviors (-have you seen the chocolate?), I've watched lots of people struggle with big things and small things.

Support helps. A lot. And accountability helps--perhaps it's essential. 90 meetings in 90 days, the mantra of starting in a 12-step program. And having a sponsor, or a therapist, or a coach--someone to be accountable to, helps. Are there things about a sponsor or therapist or doctor that increase the success of the person trying to change? I believe at some level, the "coach" (I just need a term here, let's go for this one) has to be someone the patient respects. It helps if the coach is not judgmental, is optimistic, encouraging, and believes in the patient's ability to meet their goal. It helps if the patient wants to please the coach, but isn't so worried about a negative reaction that he (the patient) lies and says he's meeting goals when he isn't. If the coach is a forbidding character, the patient may simply never return. Frequency of accountability helps: whether by checking in or by face-to-face. Having reasonable goals helps.

Oh, I'm rambling. You tell me what helps a patient change...

Saturday, September 13, 2008

I Have A Friend....

ClinkShrink is looking for something to climb. Roy is collecting links to Mental Health Blogs: Thanks for all your contributions and if you'd like to add another mental health blog to the list, please visit Roy's post and comment.

I titled this post "I have a friend..." because it's not an unusual way for someone to start a conversation with a psychiatrist about a mental health problem in a social setting-- maybe it's about a friend, maybe it's about themselves, I never ask, I take it at face value. Sometimes I later hear, "actually it's my problem."

So I have a friend (--really) ....

We're together in a public place, there are people around that we know, probably not within earshot, but who knows? The friend is, well, more of an acquaintance-- we don't know each other so well.

"I know you don't like Xanax, but it's the only thing that helps when my thoughts race."

I'm caught off guard. It was a statement, not a question, and I should have listened.
I mumble something. Whatever it was, it was probably the wrong thing to say.

"Why don't you like Xanax?" Friend asks.

Oy: if you haven't read Roy's post on Why Docs Don't Like Xanax (some of us), then by all means,

Issues with addiction, I say.

"I don't take it every day, just when I can't sleep and my thoughts are racing. What else could I take?"

Okay, at this point I retrospectively cringe at my response. What was I thinking? Roy and ClinkShrink would crawl under a rock and pretend they don't know me. I mumble something about Ativan and Valium being less addictive. I mumbled something about perhaps the Xanax wasn't a problem. Oh, I recommend these medications rarely, really rarely, and only to patients I've carefully evaluated. What was I thinking to suggest the names of other meds? Or what
wasn't I thinking?

The subject changed, we didn't discuss it any farther, but I was left obsessing about the weirdness of my response, the irresponsibility of it, the cavalierness of even hinting that certain medications (addictive ones at that) might be better than something already prescribed for a condition I didn't explore, by another physician, for a person I didn't know terribly well.

So this post will now have two themes:
1) When personal friends asks a psychiatrist (this psychiatrist in particular) for advice.
2) What I did wrong, which is basically everything.

Friends ask me for suggestions from time to time. ClinkShrink and Roy might (I'm not sure, I'm surmising this) say one shouldn't give any suggestions and that by listening, engaging, offering advice, that one essentially establishes a doctor-patient relationship and becomes responsible for them and becomes open to all the obligations inherent in any doctor-patient relationship, including the right to be sued for malpractice. Again, I'm putting words in their mouths, so Clink and Roy: do feel free to add to the bottom of this post.

I don't tend to worry about being sued. And when a friend wants to talk about a problem, knowing I am a psychiatrist, I listen and I don't usually immediately say, "Ask your Doctor" --because, well, it feels dismissive and I feel like the voice-over in one of the pharmaceutical commercials. I usually listen, answer what's asked to the extent that I can, and if the situation warrants, I gently suggest it might be worthwhile to have at least a one-time psychiatric evaluation. I never, ever, tell my friends they need long-term intensive psychotherapy or specific meds: that would be the job of the evaluating psychiatrist and I like having friends! I will refer friends to shrinks I think they'd like, if they want, though, hey, it's my best guess as to interpersonal/professional chemistry. I try to figure out an appropriate boundary -- somewhere that's caring but not opening myself up to to hearing all sorts of overly personal details-- and I try not to upset my friends or leave them feeling uncomfortable. Finally, I try to be of help.

Here's what I did wrong with my Xanax-for-racing-thoughts friend:
  • I didn't listen to the issue. Was there even a question or was it just a request that I hear that Xanax is helpful to this particular person? I never found that out.
  • If there was a question as to the appropriateness of this particular medication for this particular person, I really was in no position to comment or second-guess the doc who prescribed the med.
  • I jumped to a conclusion that, in the moment, I didn't even realize I was jumping to: The friend mentioned that Xanax helped with racing thoughts. I know this friend has trouble sleeping when there is a lot going on. "Racing thoughts" are a symptom of Bipolar Disorder-- it's a term used to describe the symptom of having one's thoughts go so fast that the patient can't keep up with them. They don't generally happen with conditions other than mania, and I assumed the friend wasn't really having "racing thoughts" but anxious ruminations associated with insomnia-- in other words, dwelling on daytime events and worrying which were interfering with sleep. I don't know any details, it was a quick assumption. It wouldn't have been appropriate ( nor would I have wanted) to ask all that I'd need to ask to figure out the precise phenomena, diagnosis, or if Xanax or something else was the appropriate treatment. I also assumed this friend doesn't have a substance abuse history and I'd have no way of knowing that....perhaps any addictive drug, be it Xanax, Valium, Ativan...might be the wrong choice. I should have kept quiet.

The subject changed, it took me a little bit to process what I'd said and what I hadn't said, and somewhere in there, we followed it up with a second, briefer conversation in which I said much of what I've said here.

Hoping my friend is now sleeping bette

Wednesday, September 10, 2008

Top Mental Health Blogs?

I have an upcoming talk to give on blogging as a form of advocacy and education in the mental health field. I'd like to know which psychiatry and mental health blogs (aside from ours, which we know you love the best ;-) you all find the most valuable. Please leave us a comment with your choices and what it is, in particular, that makes them valuable to you. I'll make a list later for everyone and find some way to organize the results.

Monday, September 08, 2008

What Didn't I Tell You?

It's not specific to psychiatry, but this caught my eye, first in the Wall Street Journal, and then through their link in the Boston Globe.

So a woman in her 70's is getting chemotherapy. She is also on painkillers and complains to her doc that she's dizzy. Fourteen times. She then has a car accident and kills two people. The relative of one of the people who was killed sues the doctor who prescribed her medications for failing to tell her not to drive. The claim is that if the doctor had specifically told her not to drive, she wouldn't have. A similar case went to court last year.

I don't know the details of the case, it's just what I read in the on-line articles, and we all know the press sometimes presents things in interesting ways. The question gets to be, however, what exactly is the doctor responsible for when a medication is prescribed? Side effects may or may not happen: bottles are labeled by the pharmacy, should everyone be pre-emptively told not to drive? And once some does have a side effect, and knows they have it, is it still the physician's responsibility to state the obvious: you're sick, you're on a sedating medication, it's making you dizzy, don't drive or operate heavy equipment? Is it the physician's responsibility to even ask if the patient drives, or to absolutely ascertain that he doesn't? Is saying "don't drive" enough? Should the family be brought in and the keys be taken away? What about the not as obvious: the doctor never said to give up gymnastics on the balance beam. Or not to rock climb (...ClinkShrink!) which may be hazardous, meds or not.

So the striking thing about this story is that the suit wasn't filed by the patient, but by the survivor of the victim's behavior. So, like, if an engineer takes a medication and has an accident, can the family members of every one injured on the train sue the doctor who prescribed the medication that the engineer took? And what about the pharmacy? It's all kind of confusing.

Sunday, September 07, 2008

Another Thing to Ponder

Thanks for the lively discussion in the post below. If you missed it, Click Here.

So Gerbil tells us she never refers patients to therapists she doesn't know personally.

This got me thinking: How much responsibility does a referring doctor bear for the treatment of his patient by another doctor, one he's referred the patient to?

Okay, so in this wide world of psychiatry, when a patient asks me for a referral (gay/straight/Republican/dog-owner, whatever), I often give names of psychiatrists I know personally whom I trust. In this realm, I'm pro-Gerbil. If someone wants a referral for someone in their insurance network, I tell them to call the insurance company: I have no idea who is in what networks. And sometimes I can even give people the name of a good primary care doctor (one I know and think highly of). If they go, and if the doc does wrong by them, how much am I held responsible for this? Most readers seem to feel it's not cool to "out" a gay doc, but am I obligated to tell a patient that someone I'm referring him to has been the subject of a malpractice suit? Or 5 malpractice suits? Or that decades ago he's been sanctioned by a professional board or banned from a hospital? Or that I happen to know he's cheated on his wife? If I don't just happen to know it (via the grapevine or whatever), am I obligated to research the past of another physician before I give out a name? Am I more obligated to do the Googling than the patient is?

So you say Why Would I Refer anyone to someone with an unseemly background? And actually, I wouldn't if I knew the doctor had these issues and if there were other choices. But what if one lives in a small town and the patient needs a specialist, and there is only one such specialist (...oh, say a retinal surgeon or a hand specialist... or a cosmetic surgeon who specializes in...name your body part) and that specialist is known to be competent despite his unsavory past.

I know, I know...therapists are different.

Chime in:

Friday, September 05, 2008

Other People's Lives

Or maybe just this shrink.

I've figured out something about myself: I'm a voyeur, I love having an outside view into the window of other people's lives without participating. In a way, it's sort of what being a psychiatrist is about: we spend all day listening to the things other people have done, the relationships they've been part of, the trips they've taken, the dreams they dream, even the movies they've seen and the books they've read. I spend far more time listening than doing myself and sometimes I feel I'm the master of the vicarious life. Oh, not really.

Running a blog, for example, Shrink Rap, has elements of this. We throw out stories, or ideas, and people write in their thoughts in the comment section. Sometimes they answer each other and sometimes they use the original idea as a springboard to go someplace totally new (Warning: Roy forbids this). I read the comments, I watch it unfold. Sometimes something riles me enough to comment, sometimes a comment inspires a new post, sometimes I feel a need to address a comment or say thanks for a compliment. Mostly I just watch as the next chapter comes in. It's part of why I love reading Fat Doctor, I like sitting back and reading the next chapter of the very colorful life of some person I've never met, never will meet, and still feel some connection to.

Last week, I joined my neighborhood's list-serve. I'm getting maybe 20 emails a day, from people I know or don't, on and on about the most random of things. Our neighborhood has an Obama group. Oops, now we have a McCain group, too. Sarah Palin shoots moose. What to do about incessantly barking dogs, someone found a dead pigeon the other day, Bonnie needs a new microwave, Joan has a large plant to give away, and many people know exactly what you should do with unwanted clothes. And if no one wants that old freezer, Roberto says to donate it to the Goodwill. I wasn't there for it, but I hear people got really inflamed over issues of deer control. I could use a new carpool, and oh, I saw a rat in the alley the other day, but so far, I'm just hanging out watching. I'm not sure I was meant to participate.

Wednesday, September 03, 2008

Should Doctors Scold?

Okay, first I was scrolling through KevinMD's blog, and this caught my attention:
In Whoa! an Er Doc talks about psychiatric, pain, and obese patients in his ER. Regarding the obese patient in the ER, he writes:

However, many, many people are obese because they simply eat too much unhealthy food and do not exercise enough. Many of these people live in subcultures within America where obesity is not only tolerated (mostly in women), but is praised, despite the well known health hazards. Obese patients are treated with respect in my ER - however, if they are disrespectful to the staff, demanding, and make a nuisance in my shop, they will get rebuked,just like any one else. Additionally, just like with smoking, I feel it is a doctor’s duty to reprimand patients for unhealthy behaviour - and this includes unhealthy eating and subsequent obesity.

I'll refrain from rambling about people who blame overweight folks for their condition. Another post, another day. What grabbed my attention was this doctor's use of the word Reprimand. It's not just that he reprimands, oh my gosh, no, he feels a duty to reprimand. I think I missed that part of medical school.

Perhaps it's just the harsh terminology. He's talking about behaviors here: over-eating, under-exercising, smoking. Can I add drinking alcohol and using illicit drugs to the list? I do, however, sometimes feel a need to remind people that smoking is bad for your health (it seems to be one of the few behavioral issues we're fairly certain of) and it may well be that using illicit drugs makes it harder to stabilize one's mood. So far, very few people have changed their behavior simply because I've suggested it would be healthier. And fortunately, so far, very few people have left treatment when I've repeatedly suggested they change their behavior. Sometimes I add that if they don't do so, I may be limited in my ability to help them.

I do feel kind of obligated to state the obvious from time to time. I don't think I scold, and sometimes I wonder if I was firmer, more insistent, or more threatening, might I be more successful in getting people to change their behavior? The fact is, I don't have that in me, I don't really believe it would make a difference in anyone's motivation to give up their addictions, and I believe a physician's role is to treat illness and be compassionate, not to reprimand.

ClinkShrink, of course, just puts them in Lock Down.

Tuesday, September 02, 2008

This is a Projective Test

So what, exactly, does the term "lock down" mean to you?

From time to time, dear ClinkShrink tells me the prison or the hospital or her kitchen is on "lock down." She says this so matter-of-factly that I've never pressed for details. Hmmmm, did the garlic try to escape? Can you leave if you want? What if someone has to go to the bathroom? Where is your cell phone during this process? What if your meter runs out? How long is the longest a lock down can last? Is everyone locked down? To what?

I have visions. This doesn't sound good. If ClinkShrink weren't so matter of fact, I'd worry, but she never does.

What images does Lockdown conjure up for you?