Saturday, November 29, 2008

Should Psychiatrists See Patients for Psychotherapy?

The trend is for psychiatrists to see patients for psychiatric evaluation, treatment with medications, and a medicalized version of psychiatric care, while parceling out psychotherapy to non-MD psychotherapists-- social workers, psychologists, licensed clinical counselors, nurse therapists, pastoral counselors (and anyone else who wants to listen...a bartender or two, perhaps the hair stylist).

Those readers who've been following Shrink Rap for a while know that I work in two types of outpatient settings: a community mental health center where I see people to treat their mental illnesses with medications, and a private psychotherapy practice where I use medications but I also provide psychotherapy to patients who want and need it. ClinkShrink sees patients in forensic settings (name your jail) and she sees a remarkably high volume of patients. She deals exclusively with medical issues-- patients may say or hear things that impact them positively, but the formal setting of therapy to talk, as a process over time, to resolve specific issues, to deal with past events, and to alter patterns of behavior, is not what she does. Roy has worked in many settings, but his current hat is as a Consultation-Liason psychiatrist in a large community hospital-- he mostly evaluates patients and makes treatment recommendations, but he doesn't see outpatients over long periods of time. He used to do that.

Psychiatrists (in the old days) used to see people for psychotherapy routinely, especially before medications were available. I think I was finished with medical school before I even knew that social workers saw clients for psychotherapy. I thought they met with families, worked for agencies, helped with disposition and obtaining benefits, and had a lot to do with foster children and protective services. I believed psychotherapy was the exclusive domain of psychiatrists and clinical psychologists. I simply didn't know.

I've talked here before about why I think, in a totally ideal world, that it's best for patients to see one person for psychotherapy and medications: one stop shopping is more convenient, psychiatric illnesses aren't 'explained' away without the offer of medications, the doc really gets to know the patient and learns to differentiate better what is, and what is not, a symptom of illness or medication side effects, and there isn't a set-up for patients who are prone to dividing their care-takers into good guys and bad guys.

The reality of the world is that psychiatrists are the most expensive mental health professionals, and in the shortest demand. They are more expensive to train, they often finish school heavily in debt, and there aren't enough to go around. And psychiatric residency programs, for the most part, don't emphasize psychotherapy training-- the resident has to pursue it. A psychiatry resident was recently telling me about a patient who wanted insight-oriented psychotherapy and the resident said, "We just don't have time in residency to do that." For those who know they want to pursue a career in research, spending a lot of time learning to do psychotherapy may not be a wise use of limited time. Some people might go as far to say that it's wrong to have psychiatrists doing psychotherapy, especially in shortage regions where there aren't enough shrinks to go around--- a lot more patients can be seen for quick med checks than for 4 times/week psychoanalysis (-- I'm not a psychoanalyst, by the way).

I believe that people should do what suits them, given the realistic constraints of their environment. I'm even okay with the psychiatrist beauty queen. With regard to psychiatrists doing psychotherapy: I like the work and there seems to be a demand for it. I also work in a clinic where the option does not exist to do this kind of work, but it does afford me the opportunity to see a different population of patients and to work as part of a team.

(Roy made me proof read this; my first draft was a disaster.)

Thursday, November 27, 2008

Engage with grace: End of Life Discussions

Does your family know if you want to be put on a ventilator if needed? 
Kept alive with i.v. fluids and nutrition? 
For how long?
So you have a living will or advance directive?
Can your family find it?

It's a tough discussion to have, but even tougher to discuss when you have a feeding tube in your nose, a breathing tube in your throat, and are unconscious. So, while everyone's enjoying turkey at the table this week, someone bring up the topic so that everyone knows how aggressive to be if you are facing death. The website, Engage with Grace, can help.

Happy Thanksgiving!

From the Shrink Rappers to you.

(And don't forget, Roy wants you to have a happy holiday discussion about your end of life issues!)

Wednesday, November 26, 2008

Can I Have a Word With You?

A while back, one of our commenters took issue with the fact that I referred to a patient's complaint. It got me thinking about the way doctors word things, sometimes in ways that may sound pejorative.

So the standard format of medical notes opens with the "Chief Complaint." If the patient comes in saying things are great, the medical note begins, "patient has no complaints." Often the patient's exact words are quoted. To a physician, this isn't whining, it doesn't have a pejorative edge. The patient's problem is what we are taught to focus on, though a complete medical evaluation includes a review of systems (that's the term) where patients are asked, in a systematic way, about symptoms that may be indicative of a health problem apart from those pertaining to the chief complaint.

In describing patient symptoms, doctors also will sometimes use the statement "patient denies" symptoms. It's sometimes felt that this implies the physician doesn't believe the patient-- patient denies hallucinations is a different statement than no hallucinations.

And then, of course, there are the subtleties of sorting out how people interpret our rather unusual questions in psychiatry. We ask if people hear voices, and when I started doing this I was surprised at how many people say Yes. I soon realized that it's not at all unusual for people to occasionally hear the voice of a dead relative calling their name--- this is, I believe, a cultural phenomena, and in the absence of other voices or symptoms of psychosis, it's not necessarily a psychiatric symptom or a marker of psychopathology. And we ask people if they ever have the sense that the TV is talking to directly to them-- a symptom we call Ideas of Reference from the media. People sometimes think I'm asking if something said on TV feels like something they can identify with strongly, which is a different phenomena (one that's not a psychiatric symptom) when what I literally mean is--- is someone on the TV speaking specifically and only to you? And assessing paranoia in a city with a mind-boggling crime rate is a task of it's own. The questions have to get pretty specific, and if you're not a little worried, well, that's a little odd.

Shrink Rap: Grand Rounds is up at Canadian Medicine

Grand Rounds us up at Canadian Medicine. 

Almost didn't link to them due to their flagrant {and fragrant} display of malpractice ads in their Google Ad section on the right (see that section in black). Maybe someone can let Stephanie in advertising know that they can tweak their GoogleAdsense settings to exclude certain words, such as "maIpractice", "v1agra", "", and "porn".  That's what we've done here.

Tuesday, November 25, 2008

I Am Not A Beauty Queen

I was doing productive work, I really was. I was doing some Internet research when I stumbled over this:

Yes, Mrs. United States has an 'M.D.' after her name. She's a psychiatrist. Now THERE was a blog post in the making. I couldn't resist.

According to the APA-sponsored web site Healthy Minds, Dr. Gariane Gunter (a third year psychiatry resident) ran for Mrs. South Carolina and later Mrs. United States on a platform (beauty pageant contestants have platforms??) of advocacy for people with mental illnesses. Now let me say right off the bat that I think it's very cool that she is publicly speaking out on behalf of our patients and doing what she can to call national attention to the problem of psychiatric stigma. She's also participating in a program to teach children and teenagers about psychiatric disorders, an important project given how many are afflicted with them and how cruel teenagers can sometimes be to anybody who's 'different'. Dr. Gunter wants to become a child and adolescent psychiatrist.

My other thoughts about this were two-fold. First, if I were a patient would I want my doctor to be a beauty queen? Ugh, I'd feel obliged to put on makeup for every appointment and I don't wear makeup. (What is it about makeup, anyway, that psychiatrists seem to equate this with mental well-being in women? You always see a mental status exam that notes whether or not someone is 'neatly made-up', as though the use of cosmetics actually meant something diagnostically.) The other thought I had was: 'Wow, and we obsess over revealing too much to our patients in a blog!' I wonder how her swimsuit competition photos went over on the ward, or how this will affect her future private practice. I already know how it would go over in a correctional clinic.

My third and final thought (OK, I had three-fold thoughts. I'm on a roll.) was about the irony of a psychiatrist participating in a beauty pageant while simultaneously educating the public about teen psychiatric disorders. I mean, aren't anorexia and bulemia going to be issues in this audience? Does it send the right message to equate success with physical beauty, while cautioning people about eating disorders? Am I stretching the issue way too far and need to chill out?

All thoughts welcome. I'm going back to work now.

Sunday, November 23, 2008

Because I Said So....

I recently linked to an article on the Well Blog about a child with Asperger's Syndrome in NYC. The boy's parents were at odds with their housing co-op about the boy's need for an emotional support dog in the no-pets-allowed complex.

Roy said that's what docs get to do: determine medical necessity.
Commenters on our blog and the Well blog were mixed, and I really don't have enough facts to feel comfortable commenting on the situation.

It did get me thinking about the concept of Medical Necessity and before I start rambling, let me say that I didn't see the term "medical necessity" on anything associated with the kid and dog case. What I read simply said that doctors thought a dog would help the boy, that the co-op agreed to let him have a small dog with many stipulations attached, and the feds, specifically HUD, took on the cause and felt the co-op discriminated against the family. You can read Here.
Medical Necessity is a funny concept, one I'm not always 100% comfortable with. I think the issue here is that when we as physicians deem something Medically Necessary, it implies some imposition, usually financial, but in the case of the service dog--furry-- on someone else. Usually we use the term to mean that it's something someone's health insurance should pay for that they don't (or may not want to) pay for. If there's not a cost (financial or otherwise), then one can leave it at "My doctor said to do ...." and there's not a reason to deem it "medically necessary." That's a term that goes in writing and means someone, somewhere will find it inconvenient.

I don't usually declare that things are Medically Necessary from a psychiatric viewpoint, except for specific medications-- sometimes Name Brands (as opposed to generics) and then because the patient has tried the generic and found that either they don't work as well or they cause side effects. The other Medically Necessary things I recommend are sessions (ie, treatment is medically necessary) or Hospitalization...ah, the joys of managed care. Sometimes I tell people to stay home from work, especially if I feel their behavior during an episode of illness puts them in jeopardy, and I'll write a note saying they need time off, or that they were at a doctors' appointment, but this usually doesn't require a statement of medical necessity, per se, it falls under sick leave. My stationery doesn't even say I'm a shrink, and unless I'm specifically asked, I don't volunteer that in "doctor's excuse" notes.

In the case of the dog and the kid, the term "medically necessary" wasn't used-- it was simply said that the dog might be helpful to the boy. What about another occupant who might require a animal-free environment? How do we determine whose rights trump whose? Maybe this is a bad example, because one can envision that one condo owner could live with a dog in such a way that the other people in the condo aren't disturbed by it and the presentation by the press left the reader feeling that the complex owners are unsympathetic child and dog hating meanies who were being unnecessarily arbitrary. I got curious and did a little googling-- it seems the dog would be going through a training process with the boy. The other issue was concern by the building about the area around the entrance to doctors' offices in the building.

So this is my concern with extending the definition of what is a disabilty and what we should do as a society to accommodate the needs of the disabled: if the issues get too diffuse, then ultimately the laws to protect the disabled hurt them. Don't want any autistic kids here because then we'll have to allow their dogs. Okay, maybe that's silly, but the issue isn't just what one group needs, it's also the fear of being sued because of the perception of injustice, or the fear of having to accomodate. The issue of medical necessity feeds into this unless we hold to a fairly strict notion of what is medically necessary, and as doctors.

If you want to read more about the kid with the battle for the dog:
Try this or this.

And just to be clear, this is a rambling post. Most often, 'medical necessity' is a term that has to do with Medicare reimbursement...somehow I've gone off about service dogs and co-ops and broader implications to society.

Thursday, November 20, 2008

The Kreativ Blogger Award

Our thanks to Healthskills who passed along the Kreativ Blogger Award to us!

I've been reading your blog for a while - this is a great post, as is the previous one on DSM v.

I've passed on the Kreative Blogging award to you, as I love to read your site.

Head to to see what I wrote - basically you list 6 things you love, then nominate six blogs for the award. It's fun, and creates some great links you might never have made before!

Six things I love? Can I do this for my co-bloggers?
And six blogs? How do I choose? I read Fat Doctor faithfully, sometimes I check on FooFoo5, and often I see what KevinMD is blogging about. I sometime check The Last Psychiatrist but he often annoys me. There's the Well blog over at the NYTimes, but I don't think Tara Parker Pope is looking for awards from me. And I often check out the blogs of some of our commenters, by all means keep leaving links-- I hate to mention one without mentioning them all....

ClinkShrink and Roy, by all means chime in.

Wednesday, November 19, 2008

Is This It? Are We Talking Yet?

So a new patient presents with the usual chief complaint of: "I'd like to enter psychotherapy so I can better understand myself, my motivations, my patterns of behavior, and resolve any unconscious conflicts that may be hampering my ability to live life fully." Patent after patient, all day long.

In case you didn't catch my sarcasm, no one has EVER presented (to me) with such a request, perhaps because I'm not a psychoanalyst? People come because:

They are having psychiatric symptoms such as sustained sadness, irritability, panic attacks, anxiety... fill in the blank ....

Bad things are happening in their lives and they are having trouble coping.

So Roy has been talking about CPT coding-- the codes psychiatrists submit to insurance companies that explain what we do to get reimbursed-- and about new Diagnostic Criteria in the making. We talked about CPT coding on our soon-to-be released My Three Shrinks Podcast, and it got me thinking:

What makes it Psychotherapy? Roy pointed out that there is felt to be a problem with the CPT code 90862-- Medication Management, a code unique to psychiatry. The reimbursement is the same if you spend 5 minutes or 500 minutes with the patient managing their medications, there are no gradations, and clearly the slant is to pay docs more to see more patients for less time each. You can call it psychotherapy, and then time figures in-- there are codes for 25 minute therapy sessions and 50 minutes therapy sessions, but it all got me thinking.

So like what does make it psychotherapy? If a patient walks in the door for a session that is scheduled as a medication management session and the doctor asks, "How are you?" and the patient starts talking about a stressful circumstance they are dealing with in their lives and feels helped by the brief session: is that psychotherapy? How long does the session have to last? How regularly does it have to occur? Many people want sessions every other week or once a month because they can't afford weekly, or twice weekly, sessions or they can't logistically make the time in their lives. Other people don't even want to schedule that regularly, they call when they want to come in and the frequency of sessions varies with how they are doing. Even with irregular sessions, many people do really good work and make really substantial changes in how they deal with the world or how they let the world deal with them, and they find the sessions helpful, but it may not be an on-going process.

So what does make it therapy? The Psychiatric Times front page article this week is called The Decline of Psychotherapy-- it takes info from
National Trends in Psychotherapy by Office-Based Psychiatrists
Mojtabai and Olfson
Arch Gen Psychiatry.2008; 65: 962-970.
and it goes into statistics on how many (or how few) psychiatrists do therapy with all or some of their patients, all or some of the time, now versus way back when.

Psychotherapy is a treatment where the talking is part of the cure. From the best I can figure, if the psychiatrist calls it therapy, and the patient calls it therapy, then whatever transpires between the two is therapy, and hopefully someone finds it helpful.

Monday, November 17, 2008

The DSM-5 Debate

Christopher Lane over at the LA Times has an Opinion published in yesterday's issue exposing the debate within the APA (now spilling out) about how transparent to make the process for developing the upcoming DSM-V.
...The bone of contention: whether the next revision of America's psychiatric bible, the "Diagnostic and Statistical Manual of Mental Disorders," should be done openly and transparently so mental health professionals and the public could follow along, or whether the debates should be held in secret.

One of the psychiatrists (former editor Robert Spitzer) wanted transparency; several others, including the president of the American Psychiatric Assn. and the man charged with overseeing the revisions (Darrel Regier), held out for secrecy. Hanging in the balance is whether, four years from now, a set of questionable behaviors with names such as "Apathy Disorder," "Parental Alienation Syndrome," "Premenstrual Dysphoric Disorder," "Compulsive Buying Disorder," "Internet Addiction" and "Relational Disorder" will be considered full-fledged psychiatric illnesses.
Perhaps some think that this is another thing, like making sausage or legislation, that one doesn't want to know how it is made or what goes into it.  Let's hope not.  In fact, Robert Spitzer, who chaired the group which created the third edition of the DSM (the so-called Diagnostic & Statistical Manual contains the gold standard definitions of various mental illnesses and other conditions), sent out an open letter a few months ago calling on the APA to open up the process.  In response, the APA is now publishing Work Group reports and is planning to publish the minutes from the meetings, as well.

The DSMV is expected in 2012.

Sunday, November 16, 2008

A Podcast is Coming! A Podcast is Coming!

It's been months, literally.
We've done two that haven't been posted yet-- fortunately it's psychiatry and not the Dow Jones Industrial average, or gas prices, so they're not terribly time-sensitive. But Roy didn't want to put them up as if we'd just done them, so we made a new one this evening.
Clink had come from climbing.
Roy and I had been battling it out at Risk.
Stay tuned.....
[Edit: So it took a year :-(   Anyway, check out #48: Genital Retraction Syndrome. -Roy]

Friday, November 14, 2008

Over at the Well blog....

You know I like all the Service Animal stuff the New York Times writes about. In fact, the Emotional Support Duck started off our duck obsession here at Shrink Rap.

From the NYTimes Well blog, Dogs and Autism:

A legal battle in New York City highlights the healing power of dogs for children with autism and Asperger’s syndrome.

Manhattan federal prosecutors have accused the owners of an Upper East Side residence of discriminating against 11-year-old Aaron S by preventing him from having a dog, The New York Daily News reports.
The report goes on to explain:

According to the newspaper, a lawsuit claims the building owners violated the Fair Housing Act by imposing unreasonable demands on Aaron’s parents before allowing a dog. Among the restrictions reportedly imposed by the building: the dog couldn’t be left alone for more than two hours, it would have to be taken in and out of the building on a service elevator, monitoring of dog walkers who might take it for a stroll, and $1 million in liability insurance for any injury or property damage caused by the dog. A company-hired doctor reportedly agreed the dog was medically necessary.

Oh, I'll let you all do the commenting.

my pet!

NOTE from Clink: Now the duck works.

Thursday, November 13, 2008

It Could Happen To You, Too

ClinkShrink and Roy would like me to shut up already. One more thought, and then I will, I promise. I know, I'm getting everyone stirred up about the question of whether docs respect when patients say they have side effects from meds. It's an issue that's come up over and over on Shrink Rap.

So Anonymous (one of the many) wrote as a comment:

Maybe if psychiatrists put themselves on meds as this doctor did with Wellbutrin, your perspective would change. After she suffered horrific side effects and withdrawal symptoms, she is a lot more empathetic when her patients complain about side effects.

Thank you, Anonymous, for the comment-- it's a topic I've been wanting to write about for a long time and you've provided a spring board.

So when people have a problem or a solution, it's normal to think that other people might have the same reactions. Many of the anti-anti-depressant (or anti-AnyDrug) comments on the internet have the overtone that these medicines hurt me, they should be banned, or no one should take them. I'm an offender: if you tell me you have back pain, I'll be the first to ramble about how my back spasms have been totally cured by swimming (sub-text: swimming might fix you, too).

Psych meds: They work for some people. They don't work for some people. Some people have side effects. Some people don't. It's quite clear that many people simply don't tolerate them. And I do believe that some docs don't 'believe' their patients when they describe unusual side effects or reactions or that they may believe the patient but respond in a way that feels dismissive to the patient. I also know that I sometimes wonder if a side effect is from a medication or from something else (another illness, another medication, something else going on at the same time) . I see a fair number of people who return and say "I didn't like how I felt and I stopped taking that stuff" and usually that means that trial of that particular medication is over. I also see a fair number of people who say medication helps and they've had no side effects from it, at all. Or medication doesn't help and they have no side effects from it-- it's feels like they are taking a sugar pill.

So the idea that shrinks should try taking an antidepressant so they can empathize with the patient's response -- there is one important assumption here: That the shrink would have side effects! What if the doc, any given doc, goes on Wellbutrin like the doc in the article and unlike that doc, doesn't have any side effects? By this logic, wouldn't that make them less empathic? Huh, that stuff is hell on you, can't be, I tried it myself and I was fine. By the same token, if the doc pops a pill and has awful side effects, might the doc never be willing to give it to anyone? After all, it caused awful things to happen, and might the doc therefore deny a certain treatment to his patients who might benefit from it? I think such things happen all the time: doctors are human, it's hard to ignore your own experiences, especially the extreme ones.

I'll shut up now.

Monday, November 10, 2008

Quote of the Day

I've had a long day and it felt like every one was pretty troubled. I'm trying to decide who to give credit to for the 'quote of the day.' I started by thinking it might go to the person who informed me that I looked good (always nice to hear) and then added that usually I look sick and I've gained some weight. Okay, I'm not sure what to do with that one.

I've decided, instead, that I liked the remark posted by blogging psychiatrist Doug Bremmer in the comment section of my post Tell Your Doctor if You Experience Any of the Following....

He writes:
Doug Bremner (MD) said...

As a "blogging doctor" I am struck by how much anger there is out there about side effects of antidepressant medications, and how much psychiatrists are felt to be to blame for that. Perhaps there has been over-promotion of prescription medications. But there are side effects that we don't know about and only learn about with longer experience. We are not magicians or mind readers.

I do often feel when I read our comments from readers who've had bad experiences with medications or hospitalizations or psychiatrists who say insensitive things, that people feel there is something purposeful about it. It's hard when someone comes in and describes something as a side effect of the medication and I recall that the symptom was there before the medication was even started. With time, we've learned that this can be the case-- if a patient starting an SSRI now says "this medication is making me feel more suicidal," Docs listen. It's still hard when someone says a medicine causes a side effect never described and I don't know what to do with it. Sometimes I try to talk people into staying on their medication if, for example, they complain that a newly added anti-depressant is making them more depressed-- the medicines take time to work, weeks in fact. If a patient continues to complain, eventually I'm left to conclude that this medication either doesn't work or isn't tolerated in this person. Sometimes people complain bitterly about side effects while at the same time they say they feel the medication helps, and then I say: It's up to you. It gets trying when this means that every visit consists of stopping a medication that hasn't been given a fair chance only to begin another medication-- the arsenal of medications available can be run through pretty quickly with this strategy and it doesn't make sense. Okay, I'm rambling.

Sunday, November 09, 2008

Roy Conquers The World!

Roy taught me how to play Risk today. As you can tell from the title of the post, he won. By a lot. No mercy at all. His little gold men ruled and they ganged up on my little red guys and he plucked them off, one by one, methodically and brutally. I thought I owned America, but it didn't matter. He took my home base of Indonesia, held his own Madagascar ever so dear, and trounced the rest of us with competitive zeal.

So you know a little about us from reading Shrink Rap and playing Risk proved to be as a good a way as any to study personality. Roy has wondered if he has ADD. He doesn't. I'm a bit obsessive: I spent the game lining up the little soldiers who weren't in play. First they were arranged in rows, then in a straight line, finally, with a bit of agitation, they stood in a disheartened clump. Roy was cautious and concerned with a big picture, but his little soldier guys were lying around everywhere. I let his ones in waiting just lie there-- the ones in play I had to stand up and arrange within the borders of their territories. Roy was meticulous with his planning and strategy. I just wanted to attack any where I could. My real life demands some attention to detail, I wasn't investing any of it in a board game. Here was my chance to let loose. Our third player, like Roy, took the game pretty seriously and really wanted to understand it (I just wanted to play, who cares about the rules?) and spent a fair amount of time contemplating the next move. "Processing information" was what I was told when I asked how spending all this time helped anything. And then I wondered why I got laid out in the dust with those little soldiers. And to think, I thought I could expand into Canada.

Tell Your Doctor If You Experience Any Of The Following...

A reader writes in:

I might suggest that in some cases, the more outre side effects of SSRIs are not reported because the person taking the drug is afraid of being thought insane. I had unbelievable rage while I was taking Effexor, and never told anyone about it because I was afraid of not being believed, and also afraid that there was something else seriously wrong with me.

I am a highly intelligent and naturally moral person, and never hurt anyone despite my desire to do so, though I did put my fist through a wall at one point. But I had extremely disturbing violent impulses while on the drug, including a desire to maim or kill my beloved cats, and a strong desire to physically assault the woman I was dating at the time.
All of this vanished completely when I decided to voluntarily go off the drugs, which I had been told I would need for the rest of my life. As it happened, the psycho-emotional disorder I had was consistently missed by therapists and clinicians, and SSRI drugs were not an appropriate treatment.

This may or may not account for the peculiar side effects, but at any rate -- my thought is that possibly these things go unreported due to shame and fear on the part of the patient.

So we don't give medical advise here on Shrink Rap. I borrowed this comment, however, because I'm struck with how often patients withhold critical information. If a patient tells me that since we started a medication, he's had a new symptom, if that symptom is intolerable to him, or in any way worrisome, I don't sit there thinking they are crazy. I stop the medicine. If the side effect sounds like it's a little uncomfortable but the overall quality of someone's life is better with the medication, I simply restate the facts and my thoughts about whether the good outweighs the bad, I let the patient chime in with their thoughts (I'm not in their body), and I consider the circumstances before the medication was started as well as the response to the medicine. If someone was suicidally depressed and unable to function , then maybe it's worth tolerating a dry mouth in exchange for the ability to return to work and not be sad or suicidal?

It's not just medications-- it's anything major going on in someone's life. If something huge is going on in a patient's life, the doctor needs to know. "I'm more depressed lately," has one meaning in the context of a medication change and another meaning in the setting of a recent loss.

What psychiatrists can't do is know what someone is experiencing without being told. We don't have crystal balls, we don't have ESP, we aren't mind readers, we don't "know" what you're thinking, feeling, worrying about, distressed by, unless a patient tells us in fairly precise terms.

Thursday, November 06, 2008

The Snake Trail Test

Psychiatrists have a way of assessing judgment during the mental status examination. Typically they'll ask a question like, "If you found an envelope lying on the sidewalk and it was addressed and stamped, what would you do with it?" The typical answer, the one that will get you a 'good' rating on the judgment line, is: "I'd mail it." Duh. There are other possible responses, some of them more interesting or creative than others, but that's the response you get most of the time.

I had a chance to come up with a new "judging judgment" type question this week. I call it the Snake Trail Test. Here's how I came up with it:

As coincidence would have it, one of the best local climbing spots near here also happens to be a repository for copperhead snakes. Since I've taken up climbing I've now seen more copperheads in the wild than I've ever seen in any zoo. Whenever I see a snake, I warn any hikers I happen to see in the area. Many hikers are parents with small children. It's been interesting to see the wide variety of responses.

One parent immediately grabbed the kid and said, "No no honey, don't go down that way. We'll go on this trail instead." Another parent still went down the trail, but cautioned the kids and made sure they stayed on the far side of the path, away from where the snake was spotted. The most interesting reaction came yesterday, from a young tattooed woman hiking with four kids under the age of ten. After I gave her the warning she shrugged, pointed back over her shoulder at the trail she had just come down, and said, "Yeah there's another one back there." Not a word to the kids and they all scrambled on without a care.

The psychiatrist within me thought: "Checkmark for 'poor' judgment." Then I thought again: "Maybe she's an herpetologist. Maybe she comes from a charismatic poisonous snake-handling cult. Maybe she's been hiking here for 20 years, has seen lots of snakes and never had a bad outcome." There were a lot of reasons why someone might not be freaked out by the idea of a poisonous snake in the trail.

My new Snake Trail Test has got me thinking about how we interpret judgment.

Judgment is formed through learning, experience, culture and a multitude of other personal idiosyncratic factors that a psychiatrist might or might not be aware of. The best way to sort out 'normal' and 'impaired' judgment is to ask followup questions. "Why would you do that?" is a good one. "Why not do this?" is another good followup question.

I didn't have a chance to ask the tattooed lady more questions, but I bet if I did she might have given me a good education about snakes.
Note from Dinah: Here's a post from Edwin Leap about what Not to bring to the ER with you, and it includes the snake that bit you.

Wednesday, November 05, 2008

Great Minds, Great Music

Richard Kogan is a psychiatrist who is also a Julliard-trained concert pianist. He does a series of captivating biographical presentations on the lives of composers, and punctuates his talks by stopping to play music by the composer that illustrates a given point. The presentations take a great deal of research, and they have a psychiatric bent-- all the composers Dr. Kogan chooses had colorful lives filled with tragedy, drama, complicated relationships and yes, psychiatric disorders. He notes, "It's hard enough to make a psychiatric diagnosis in my office with a live patient..." He's produced five such psychological perspectives on Schumann, Beethoven, Gershwin, Tchaikovsky, and most recently, Leonard Bernstein. I've heard four of them in the last six years (with my tone deaf ears); I think this makes me a groupie.

"I have a passion for the interface between my two professions of psychiatry and music, and I'm intrigued by the mysteries of the mind and the nature of the creative process." Kogan says.

Wanna listen?

So I'd like to throw Richard Kogan in a room with Oliver Sacks , the neurologist/author of
Musicophilia, Tales of Music and the Brain, and just sit and listen for a while.

The Session That Never Ends....

I saw a patient where the session seemed to drag. He was ready to go, but the session was little more than half over; I commented that we still had some time and I asked a few more questions. It felt like time was going slowly, really slowly. At some point, I finally realized that time had literally stopped-- the clock had not moved for some time. I glanced at my cell phone, only to realize that it was now 5 after the hour: our 50 minute session had gone on for 65 minutes. My clock battery had died, the clock had stopped, and I'm still wondering how it took me 25 minutes to figure this out. Hoping my patient didn't think I was holding him hostage.

Somehow seems appropriate for Election Day for the never-ending campaign. I am so glad it's finally over.

Tuesday, November 04, 2008

A Brief History of Shock Treatment

Dinah's post about the new movie, The Changeling, generated some discussion about ECT in the comments (Angelina Jolie's character got electroconvulsive therapy in 1928, nine years before the first published description), started by Romeo Vitelli who asked, "Did they have ECT in 1928? I was under the impression that it was first developed in Europe in the 1930s."

Anonymous wrote:
Electroconvulsive shock therapy was discovered by Ugo Cerletti and Lucio Bini in Rome, in 1937.

The History of Shock Therapy in Psychiatry

Apparently insulin-induced coma was all the rage in the late 20s.

And didn't Francis Farmer (and a whole bunch of other people) get an ice-pick lobotomy from a psychiatrist in the 1950s?

Psychiatrists of yore performed some pretty barbaric treatments on their patients.

It seems the movie took some liberties with "the truth," though. No surprise there.

Anon is right about 1937 being the first description, though it must have occurred earlier for them to write about it.  But other types of "shock" treatments were used before electricity (as in "a shock to the system").

Insulin shock treatment was first described in 1934 by Manfred Sakel, according to my 1948 third edition of Samuel Kraines' The Therapy of the Neuroses and Psychoses.  Insulin was used to induce a "therapeutic coma," usually daily for 15-30 days and lasting 30-60 minutes. Occasionally, the coma resulted in a convulsion, and it was found that these convulsions resulted in improvement, spawning many different "treatment" pathways to achieve these therapeutic convulsions.

Kraines (p487): "There may be convulsions present during the coma; but contrary to Sakel's fears, these convulsions are usually found to be beneficial to the patient. Indeed, some authors give metrazol or use electric shock for patients who are in insulin coma." (p493): "... [other] agents include ... picrotoxin, coriamytrin, azoman, ammonium chloride, camphor, methylguanidine and others."

Metrazol was first introduced by von Meduna in 1935 for schizophrenia, the same year that Moniz and Lima from Portugal described prefrontal lobotomies.

As for the therapeutic use of electricity, well, speculations started almost as soon as electricity was discovered to affect tissue in the late 1700's.  

From "Electricity and Life", a translation of three French articles by Fernand Papillon in the Journal of Insanity from 1873: "It is for this reason that the diseases which have their seat in the encephalon are particularly easy to treat by electricity. The latter, wisely applied, is a sovereign remedy for cerebral crises, delirious conceptions, headache, sleeplessness, etc. The first physicians who made use of the electric current understood perfectly the happy influence of the galvanic fluid on the disturbances of the brain; they even thought to use it for the treatment of insanity. Researches have not been continued in this direction, but the facts published by Hiffelsheim authorize the opinion that they would not be unprofitable. These facts show how much service the electric currents, but the constant currents only, will some day be able to render in cerebral affections. This is a point to which it is important to call the attention of alienist physicians." [alienist=psychiatrist]

I haven't seen the movie yet, but I guess they must have wanted it to be in 1928 (because of stock market crash?), so they took artistic license on when ECT began.

Sunday, November 02, 2008

Psychiatry, Hollywood Style

Warning: early plot spoilers...I don't discuss the end at all.

I went to the movies last night and saw The Changeling. It was an intense, riveting movie. Based on a true story: the year is 1928, the town is Los Angeles, and 9-year-old boy is missing, his single mother is terribly distraught, and 5 months later the boy is returned to the mother except, oops, wrong child. There is a side plot about the corrupt police department, and they are using the mother-child reunion as an example of how things sometimes go right, so no one is happy when the child who claims to be the missing Walter Collins steps off the train and mom is not over-joyed. Pictures are taken, and the police chief convinces mom that the boy has changed with time. Take him home on a 'trial basis,' really, this shorter kid is yours. The dentist and teacher confirm that it's not the right kid, but the police have their own doctors in hand, and oh no, they all manage to paint mom as being paranoid when she wants the police to re-open the case and find her the right kid. In the meantime, she's got this other kid hanging around who calls her Mommy.

Mrs. Collins gets agitated while talking to the police chief who simply insists, we got you the right kid. He has her taken away to the psychopathic ward. The staff are emotionless, the place is bleak, the rooms are cells with bars and the room doors have windows with hatches. The patients are all unwashed (though Angelino Jolie's makeup never comes off) and they are dressed in hospital johnnies to make certain they look all the crazier. Medication is forced, and if you smack the shrink, you're hauled off for immediate and un-anaesthetised ECT where the button gets pushed by blank-faced nurses who have no thoughts of their own. And if you refuse to sign a paper saying the police were right, they did nothing wrong, and the kiddy they gave you is yours, same thing-- more ECT, especially if you say to the shrink who asks for the signature, "F** you and the horse you rode in on." To help matters, the psychiatric ward is full of women who've questioned the police (--this could be a setting in Communist Russia) where it's so much easier to call whistle-blowers psychotic and lock them away forever. My favorite was the prostitute, played by Amy Ryan, who was locked up for claiming one of her clients had brutalized her, and oops he was a policeman. She tells the protagonist, ""You gotta do everything you can to look normal. If you smile too much, you're delusional; if you don't smile, you're depressed." Oh, there was something brilliant about if you don't do either, but I can't remember or find the whole line. The message was a simple one of you can't win and no matter who you are, the psychiatrist finds a way of contorting into something being horribly wrong with you.

It's a pretty bleak view of psychiatry all done Hollywood style.