Thursday, February 26, 2009

Paxil, anyone?

I ran a poll, not long ago, after reading Peter Kramer's blog post on the relative efficacy of the different SSRI's. Here's what we found:

Which SSRI is the most Effective?

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Lexapro 19% (28 votes)
Cymbalta (SNRI) 13% (20 votes)

Total Votes: 150

Which Medicine Causes the Most Side Effects
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Total Votes: 134

Okay, so let's start by talking about how this 'poll' is meaningless. We don't know who took it-- patients, docs, random plumbers surfing through. We don't know what experience these people have had with antidepressants-- so the question has different meaning if it's asked to a doc who has only ever prescribed Prozac and Zoloft, then if it's asked to a patient who has been on a long trial of every medication. There's no real head-to-head here, no measures of efficacy, no controls. And I didn't even specify what the efficacy was for: Depression? Anxiety? OCD? Panic? Halitosis? Slipping behind your ear to hold your glasses in place?

Still, we had a clear loser, and I was surprised: Paxil. Few people voted for it's efficacy, many for it's side effects.

I don't start people on Paxil so much anymore: the lore is that it causes more weight gain then the others, and when I do prescribe it, I tell people to get weighed. It may cause weight gain, as an overall risk to populations, but all I care about is if it causes weight gain to my particular patient, and clearly, some people do not gain weight on it. The more concerning thing about Paxil has been the withdrawal syndrome that some people experience and so far I've found that it's manageable, especially if people come off very slowly. Still, all things being equal, these days I may start with something else.

So why was I surprised: I guess I haven't heard a lot of patients complain about side effects, and I have patients who've been on this medicine for some time. It seems to work particularly well, at least that's my impression, for Anxiety, and it seems to be well tolerated, the 'polls' would say otherwise. And for the uninsured, the generic is on Walmart's $4 list (as is Celexa).
Just my thoughts.

And to those who've read yesterday's post about does Facebook wreck your brain: If you read either the original article or the comments to our post, you'll note that the original piece is simply theories that all this computer time may re-wire people; there were no studies, no proof. And as some of our readers pointed out, On-line interactions may well be a segway into the world of Real Life encounters for people who might otherwise hesitate. I often wonder if my college experience would have been broadened by the world of the internet---

Tuesday, February 24, 2009

Does Facebook Destroy Your Brain?

Facebook founder and CEO Mark Zuckerberg

I have a Facebook page, I even have "friends" (even Fat Doctor!!), but I haven't really figured out what to do with it, so it doesn't eat my time. Something to check here and there. Roy has a Facebook page, but alas, few friends, and he's too busy twittering for it to really matter. ClinkShrink stays out of the fray, but I do write on her sister's wall here and there.

With the kids, it's another story. It consumes their worlds. Even my patients talk in terms of Facebook. Who's befriended you, who's UNfriended you, who's in a relationship with who, it's all there. I stuck my head in a video my own kid was making, only to run into some teens in the grocery store the next day and have them say, "I saw you on Facebook!"

So is this a good thing? (How could it be?).

From today's Mail Online, David Derbyshire writes "Social Websites Harm Children's Brains." I've clipped some parts of the article below:

Baroness Greenfield, an Oxford University neuroscientist and director of the Royal Institution, believes repeated exposure could effectively 'rewire' the brain.

Experts are concerned children's online social interactions can 'rewire' the brain....

'My fear is that these technologies are infantilising the brain into the state of small children who are attracted by buzzing noises and bright lights, who have a small attention span and who live for the moment.'....

Psychologists have also argued that digital technology is changing the way we think. They point out that students no longer need to plan essays before starting to write - thanks to word processors they can edit as they go along. Satellite navigation systems have negated the need to decipher maps....

Educational psychologist Jane Healy believes children should be kept away from computer games until they are seven. Most games only trigger the 'flight or fight' region of the brain, rather than the vital areas responsible for reasoning.

Usually we think of computer games as being harmful in terms of exposure to violence, or in that they suck time away from important parts of life: contact with other people, exposure to new and interesting things. We don't usually think of these things in terms of the brain Hardwiring.

Shrink Rap: Grand Rounds is up at TBTAM

Shrinky links include: couples therapy for anorexia; working memory training; and how to apologize

Check out this week's Medical Grand Rounds on The Blog That Ate Manhattan.

Sunday, February 22, 2009

Go to iTunes U and Become a Psychiatrist

An interesting convergence of themes occurred today, from three separate threads. From this remarkable thematic convergence, I have come to the conclusion that one can become a psychiatrist just by sleeping.  Please, follow along.

I couldn't fall asleep last night and could no longer focus on writing a chapter for our book, and so was cruising iTunes U, looking to see what sort of interesting lectures they had there.  (Yes, it is ironic that, despite my above-stated conclusion, I was already a psychiatrist yet could not sleep.)

If you aren't familiar with iTunes U, they make audio and video podcasts of
 college lectures from MIT, Yale, Stanford, and other participating universities, available for free. No enrollment fee. No 8am lectures. No uncomfortable chairs. Alas, no credit, but you get to learn for free.

Believe it or not, I spent 45 minutes watching a Stanford engineering course on Fourier transforms -- and didn't fall asleep!  At 3:00 AM!!  Thank you, Brad Osgood (iTunes link HERE).  I did not take any notes, btw.

So, that was the first thread.  

After a fitful four hours of sleep, dreaming of wavelengths and lambda, I begin my Sunday morning with blueberry and ginger pancakes.  Since this is 2009 and all, I am reading -- not the Sunday paper -- but the Sunday blogs and news on the computer.  I come across a post by a fellow psychiatrist blogger in the Netherlands, DrShock, about a just-published article from Computers & Education, entitled "iTunes University and the Classroom: Can Podcasts Replace Professors?", and written by SUNY psychologist, Dani McKinney et al.  This was a very interesting second thread, which related to the first.  What Dr McKinney did was have two different groups of psychology students receive a lecture on "perception."  One group attended a traditional class lecture and the other received the lecture as a podcast.  They were later tested on their recall of information from the lecture.  Alas, there was no random group assignment, which is a relative weakness of the study design.  

But the findings suggest that a podcast lecture provided more opportunity to re-listen and take notes than the live lecture, as the podcast group scored significantly higher than the live lecture group.  Of those students who took an average amount of notes, the podcast students scored an average letter grade (10 points) higher than the classroom students.  (If you'd like a copy of the entire article, you may write Dr McKinney at mckinneyATfredoniaDOTedu.)

Most of the podcast students listened to the lecture more than once, so they had more opportunity to learn the material.  This is one of the benefits of having a recording of the lecture.

Here's what made me go "Hey, wait a minute, this is quite a coincidence!" -- I have had dinner with Dani McKinney before.  She is, in fact, a close friend of one of my close friends.

So, the third thread of this convergence of ideas hits me when I go to Shrink Rap and see that the Google ad on the right sidebar says,
"Be a Psychiatrist.  Advance your career - earn a degree in Psychiatry completely online."
Well, I can see the handwriting on the wall.  THIS is the 7th future trend in Psychiatry.  Online medical degrees.  You don't even need to go to class.  Just listen to the podcast (at least twice for better retention) and take notes while you listen, and you can advance your career in no time.  I suppose if you are really lazy, you could play the podcasts while you sleep.  I'm not sure if there would be adequate retention to pass the tests under this condition, but Dani assures me that she will be testing out this hypothesis with the next group of psychology students.  Wake me up when we get there.  In the meantime, I'm heading over to iTunes U to take some neurosurgery classes.  Reimbursement for procedures is much better than for cognitive services.

Pharmakon: Fantasizing about family secrets

This fictional novel, Pharmakon, is written by Dirk Wittenborn, the son of a 1950's era psychiatrist. Sounds interesting, and a little uncomfortable to be reminded of the more primitive roots of modern psychiatry. We still have a ways to go. From The

"On Sunday, October 8 1950, my parents and their three young children were in the yard planting tulips when a stranger who seemed lost appeared in the street. My mother was just about to ask if he needed help when my father whispered urgently, "Don't look up and don't say a word." My mother thought he was kidding until he told her that the stranger was a deeply troubled former Yale student he had once treated. My father didn't know his former patient had a loaded revolver in his pocket, but he had good reason to be frightened -- the young man had recently composed a 'death list' of those he blamed for his unhappiness, and Dr JR Wittenborn was at the top.

For reasons that remain a mystery to this day, this mentally unbalanced angel of death passed my family by and walked up the road. Number two on his death list was a Yale psychiatrist who had also treated him, and lived in the neighbourhood. My father tried to warn his colleague, but in the pre-answering machine 50s there was no way to leave a message. A few hours later, gunshots rang out. The psychiatrist was murdered and his wife shot and severely beaten."

[Author on YouTube]
Have any of you read this?  What did you think?

Friday, February 20, 2009

Six Future Trends in Psychiatry

Henry Nasrallah in the Feb issue of Current Psychiatry describes 6 trends that will affect the practice of psychiatry.
  1. Earlier diagnosis and treatment.
  2. Genetic discoveries
  3. Targeting of neuroplasticity.
  4. Neurostimulation, as in VNS, TMS, DBS.
  5. Psychopharmacogenetics.
  6. Intertwining of physical and mental disorders.
What do you all think?

Tuesday, February 17, 2009

When Will I See You Again?

In the out patient mental health clinics in Maryland, regulations make it clear: any patient on medication must be seen by a psychiatrist every 90 days, patients who are not on medications are seen by the psychiatrist every six months. This assumes the patient is stable and all is going well, and certainly some docs in some clinics see the patients more often, but a minimum is regulated.

In the world of private practice, it's less clear. If patients are in psychotherapy, it's easy enough to deal with medications during a regularly scheduled appointment. But what about the patients who are done with therapy, who feel good, who want to continue on their medication? Some patients are fine with coming in monthly, others clearly don't want to, and if things are really stable, I'm happy to see folks every three months, the standard of the clinic. There are people though, who really don't want to come in that often, where it's a hassle for them to get off work. Sometimes their pharmacies start calling for refills (--with the mail order pharmacies, this can include twice daily phone calls and repeated faxes) and there is no contact from the patient. I've taken to ignoring these calls (especially the ones from the mail order pharmacies who want okay's for a 30 month supply) if I haven't seen the patient in a long time because returning them often involves a long time in voicemail hell to convey the message, "The patient needs to call me." Patients know to call me if they are having problems, I'll get them in soon. But for someone who doesn't want to come in, who says they are fine, I'm still not sure how often to insist on face-to-face contact. Here and there someone pops up who I've long ago assumed was gone--- If someone is to call me in 3-4 months, and they don't, I don't always remember to chase them down. And when I do, sometimes they've stopped their meds, or asked their internist for a prescription.

So is there an absolute answer? Is there an absolute minimum that a patient needs to be seen for a refill? Internists prescribe for a year a a time, and so do some psychiatrists (I think). What's your thoughts?

Monday, February 16, 2009

The SSRI Horse Race-- Take Our (Meaningless) Polls

This is not science, I'm just playing here, nothing random, nothing controlled, just questions for our readers.

I just read Peter Kramer's
Psychology Today blog post called Lexapro and Zoloft in a Cloud of Dust. Dr. Kramer talks about the relative efficacy of SSRI's, their market share, and if the drug company's influence docs to prescribe in a way that isn't in sync with research. Lexapro, the most expensive SSRI, apparently has the biggest market with 13% of the market share. He writes:
Now comes news of a large-scale analysis of research on antidepressant efficacy. Published in The Lancet, it finds a hierarchy, with Remeron, Zoloft, Effexor, and, yes, Lexapro, leading the pack, Cymbalta and Prozac in the middle, and Luvox, Paxil, and (especially) reboxetine, which is marketed outside the US, bringing up the rear. Celexa and Wellbutrin gave statistically fuzzy efficacy results; the two drugs appeared to be about average for the group. In terms of tolerability, Zoloft, Lexapro, Celexa, and Wellbutrin led the pack. So the results give a special place to Zoloft and Lexapro.

Do read the original post.

So I thought I'd put up two polls, and again, this isn't science, it's just curiosity. Pretend you didn't read the paragraph above, and I'd like you to answer two questions: What do you think is the most Effective SSRI, and Which SSRI do you think causes the most side effects. I don't care if you're the patient or the doctor, or a non-MD therapist who's simply just heard patients talk about the meds. It's a question of perception, with the awareness that maybe you haven't seen all the horses race. Efficacy: Which med works the best (If you've only been on Prozac and that worked great, it's fine to answer that!). Side Effects: Which med makes people feel the yuckiest (now there's a scientific term).

Sunday, February 15, 2009

Escape To New York

OK, I'm out of prison. After a few months of listening to guys talk about stabbing people, firebombing houses and other general nasty things, I've escaped to New York. I walked through Central Park, saw a couple art galleries and went to a Broadway play (Speed The Plow, it was great). Oh yeah, and had some delicious food.

So now I'm blogging from the Mac-users mecca, the Fifth Avenue Apple store. The one that looks like a big glass cube. I've just bought my new 16 gigabyte iPod touch and am happy as a clam. Yes, I'm out of prison...and mildly out of control in this store. I've got pictures to send my co-bloggers.

And now a request---soon there is a play opening here called Zombie. It's about a serial killer. They're giving discount tickets to folks interested in forensic psychiatry. I'm going to be gone before it opens. I need somebody to see this thing and post a review. Thanks

Friday, February 13, 2009

Twitter Twitter Tweet Tweet

What has my life come to? It's 10:30 on a Friday night and I have an uncontrollable urge to blog. Please someone, get me a life. And the energy to move on a Friday night.

So here goes: a tech post by Dinah. Wish me luck.

I'm reading the NYTimes on line and there's a piece by David Pogue: Twitter? It's What You Make It.

I read and I read and I could swear this David Pogue guy is ROY! It sounds like Roy, it smells like Roy, it talks like Roy, it Twitters like Roy. Roy wants me to Twitter me (is that nasty??) but I've said no, I'm married. Now it seems he wants to Twitter you, if you look at our sidebar. I totally don't get it, nor do I understand why the top of our side bar has a link to Shrink Rap with Bacon (I'm not linking it). Next he'll want to be my BFF. Oy.

And the cartoon above is so ClinkShrink won't feel left out.

I'm off to eat twinkies now. Those I understand.

Thursday, February 12, 2009

The Silent Psychiatrist

This morning, I woke up and got ready for work. Time to go and I called to the kid to come. Only nothing came out. Nothing. I felt fine, but I'd lost my voice. Completely, barely a whisper emerged.

It was just before 8. Kid announced she felt sick and went back to bed. I fetched the carpool kids (--the issues of what to do about carpoolers when one's own child is sick could be its own entire blog). My first patient was for 9:00 and it seemed like too short notice to cancel. I did croak out cancellation calls to the next couple of patients with the thought that they might have a hard time conducting the session without my input; some people don't come in and just talk spontaneously, they look to me for direction, a little more than I sometime wish and a lot more than my voice could tolerate today.

As shrinks go, I talk a lot. As people go, I talk a whole lot. I think I'm probably in the top ten percent for talkativeness in the general population, though I quiet down when ClinkShrink tries to monopolize the podcast.

So suddenly, I couldn't talk. I figured it would be a good experiment, or at least a good blog post. I listened and I let the sessions flow a little more organically. There were places I'd normally interrupt to ask questions-- I didn't. At the end of the session, I asked how it went. The first patient said it was fine once he realized I felt okay (I felt fine). With that, I called the rest of my patients and left the choice to them-- a couple came, a couple didn't. There was one session I'd wondered about, and I did end up having to do a fair amount of talking/croaking.

I wondered if I would be a better therapist-- I sometimes think I talk TOO much. I don't think it was better. I don't think it was particularly worse, either. I'll be happy when I can just talk again. Camel says to rest my voice, Roy says to gargle with salt water. Off to hot tea with honey now. Thank you for letting me croak here.

Tuesday, February 10, 2009

Shrink Rap: Grand Rounds is up at THCB!

Notable links: more Wellsphere woes & FAQ; anti-clotting support goats.

Just A Little More Time

Okay, so I'm going to post a scenario and I want your opinion. There's no 'right' answer, I don't think, or you'll tell me if there is. I'm particularly interested in opinions from other mental health professionals, so please note in your comments if you're one of those, but as always, I'm interested in feedback from all our readers.

A patient and doctor have a long-standing relationship, they always meet for a 50 minute session, and if often goes closer to 60 minutes. Perhaps a few times they've even gone longer. It's been years, and now the sessions are scheduled erratically, so it's not a given that things can be finished up 'same time next week.' On this particular session, the patient brings up something towards the end that unexpectedly takes a long time-- maybe she wants the doc to write a new script (maybe it's even Xanax ! and the doc is uncomfortable). Some disagreement follows, and the session goes until a quarter after the hour. The doctor never formally states there will be a charge for the session that has run over and there has never been a charge for an over-time session before, though this session may be longer than any other. Is the doc justified in sending out a bill for the extra time? And if so, by how much? An extra quarter of a session, or an extra 50% given that the session technically ran 75 minutes and not 50 minutes. Does it matter if it was the last patient of the day and there's not an all-day back up for everyone else because of the extra time? Let's say it was the patient's final session and so please don't answer with "examine it in the next session" or "send a bill and see what the patient says." And don't worry about the Xanax, new script, whatever issue, it doesn't really matter Why the session ran over, the scenario is about the time and the unexpected charge.

I often run my 50 minute sessions closer to an hour, and sometime I run a few minutes over that. There have been a handful of sessions that have run quite a bit over, and it's never occurred to me to charge for something that wasn't agreed upon in advance, but I'm not saying it isn't the right thing to do-- boundaries, income, time-is-money and the doc has bills to pay, too.

Just wanted your thoughts.

Monday, February 09, 2009

GotGigs? How many gigs are in YOUR pocket?

It occurred to me recently that most of us carry a fair about of memory devices around in our pockets, purses, and belts.  I pointed out to Dinah at dinner recently my new 16GB thumb drive (, $25).  After making some sort of dirty crack, I realized that I typically carry around over 40GB of memory on my person (new 16gig thumb drive, old 8gig thumb drive, 1GB thumb drive on keychain, 16GB iPhone 3G, and my Treo has a 500MB flash memory card in it).

So, I want to know... How many gigs are in YOUR pocket?
Let us know below.  Then post a picture of your gigs to Flickr, using the tag "gotgigs".  I'll put the pics here (as soon as I figure out how to do a flickr gadget).

Just As I Was Thinking About You

I think I have ESP. Last week, I was thinking about a patient I hadn't seen in a couple of months, and he called, just as I was thinking about him. It's happened before with this patient. Today, I was walking to my car (where I'd left my cell phone, unsubmergered), and I started to think about a patient I haven't seen or thought about in some time. I've been treating her for over ten years, and issues of age and health have made it hard for her to get in to see me. It's been a year, maybe more, but every once in a while, she surfaces. So I'm thinking about her, wondering how she is, and I get to my car and there's a voicemail from her. Sort of eerie. I have ESP.

What I don't understand is the whole ShrinkRap with Bacon thing on our sidebar. I guess Roy did this. Why does anyone want bacon with our blog? It's just sort of weird. He couldn't have put ducks up?

And for a final thought: my husband is leaving on a jet plane. He texted to say there is a comfort dog in the next row. I can't wait to hear how the flight goes.

Thanks to everyone who's commented on our pre-draft of a chapter. I like the diversity of opinions. And to anyone who thinks their middle schooler might get something out of it, that would be wonderful!

I'll get a photo in later: let me know if you have any special requests....

Wednesday, February 04, 2009

Chapter Two, Section One: The Psych Eval

We've mentioned that the Shrink Rappers have a book proposal out there. It's gone through two review processes, with one more to go before we'll know if it's a go. Still no final name, our editor and Roy are both unhappy with Off the Couch...

Okay, so I thought I'd try to write a piece of a chapter here and see what our Shrink Rap readers think.... this is rough, I'm typing as I go, so the pre-draft, if such a thing exists. Here goes:

Tell Me About Yourself: The Psychiatric Evaluation

Josh Ford has never been so tired in all his life. He was the starting quarterback on his high school football team, and a pretty decent shortstop as well, even though he suffers from asthma. He was always a good student and he didn't have any trouble making friends in the dorm when he went to college. It's the Spring semester of his sophomore year, and Josh is just not feeling well. Josh has lost interest in hanging out with his friends, he's virtually stopped going to class, he sleeps long hours-- even for a college kid-- and when he went home for Spring Break, his parents were shocked to see he'd lost twenty pounds. His primary care doctor could find nothing wrong, and Josh admitted to him that he's feeling pretty down and hopeless, suicidal even. Josh was told he's suffering from depression and a psychiatric evaluation was recommended.

So Josh is not real, he's a figment of the Shrink Rap imagination. We'll borrow him to walk us through different aspects of this Chapter, called All in A Day's Work.

The purpose of a psychiatric evaluation depends, in part, on the setting in which it is conducted. In an outpatient setting where the patient will go for on-going treatment, the psychiatric evaluation is used to make a diagnosis and formulate a treatment plan. It offers the psychiatrist a chance to hear the patient's history and gather information necessary to do those things, and it gives the patient a chance to see if he's comfortable working with the psychiatrist. In an Emergency Department, the purpose is much different. The mental health professionals in the ED will not be offering on-going care and their goal is to determine if the patient requires hospitalization, and if not, then to provide an outpatient referral. The issues in an emergency setting are often focused around determining safety. In an outpatient setting, the psychiatrist may be interested in hearing many details about the patient's life, in other settings, the focus may be more on the acute symptoms that have brought the patient to care now.

So Josh goes to see a psychiatrist. This particular psychiatrist schedules the evaluation as a two hour session. Some psychiatrists allow one hour, some allow two, and some designate the first few sessions as a time to diagnose and make a plan. In clinics, the psychiatric evaluation is usually done in one hour, and the evaluating psychiatrist may or may not be the treating psychiatrist, depending on how the clinic is set up.

The questions the psychiatrist asks Josh may depend on the particular orientation of the psychiatrist. Some psychoanalysts leave the patient the space to tell their own story and ask very few questions. Most psychiatrists do a very structured interview to collect very specific information.

Like Josh's fictional psychiatrist, I usually allow two hours to see a patient on the first visit. I start by asking about what brings the patient to treatment: what doctors call the Chief Complaint. I then ask ask when the problem started and ask questions about what may have precipitated the problem-- did something upset Josh? How long has he been depressed? Did it come on suddenly or gradually? What symptoms is he having and how much are they interfering with his life? This is called the History of Present Illness. Psychiatrists have different styles of doing interviews, and I actually like to take a history backwards. Once I've heard about the current problem, I ask the patient if I can ask about their past and come back to the current problem later. I then ask questions about the family: Who is in it? What are their occupations? Are they healthy? What are the patient's relationships with other like? I then specifically ask about any history of psychiatric illness in family members, specifically blood relatives, and I ask the question in several different ways because genetics are so important in psychiatry. Josh's mother, we learn, has bipolar disorder, and a sister has been treated for panic attacks.

Once I've learned about the patient's family, I ask about their personal history from gestation forward. Were there problems in childhood with health, behavior, or development. I want to know details about education, occupation, encounters with the law, and romance. If there are children, I want to hear about them. I then ask about drug and alcohol use, medical and surgical issues, a list of current medications, drug allergies. At this point, I feel like I've gotten some lay of who my patient is as a person, who is important in their lives, and what has transpired. I then ask about their past psychiatric encounters, though most psychiatrists do this much sooner in the interview. What's important? Past diagnoses, hospitalizations, episodes of suicidality or violence towards others, and what treatments have been tried. I want to know the response to every treatment: were the outcomes good or bad. If medications have been used, then ideally I want to know each medication, the maximum dose that was taken, if the response was good or bad, and why the medication was stopped. In the course of taking the history, Josh's new psychiatrist learned that Josh had fairly severe asthma and he'd been to the Emergency Department a couple of time a year as a child for acute episodes of bronchospasm. He'd never seen a mental health professional before, but in high school he'd had a pretty rough period after a girlfriend broke up with him and he felt now a bit like he'd felt back then. He had not been as depressed during that episode, though his grades did drop during that marking period. Josh has never had any symptoms of mania, a condition which in which mood, energy, and activity are elevated, rather than depressed.

The final part of the psychiatric evaluation is called the mental status exam. This is the psychiatrist's version of a physical exam, only it's not physical! The patient is assessed and described, much as a novelist might write a character analysis, but in a formulaic way. The psychiatrist will observe and record anything notable about the patient's appearance. In Josh's case, he presents as a neatly groomed, casually dressed young man who appears his stated age. The doctor will note any abnormal movements (meaning neurologic problems, such as tics). The patient's speech will me noted if something is unusual. In Josh's case, he moves rather slowly, and it takes him a long time to get his thoughts organized. He talks quietly and slowly, but his thoughts are expressed logically. Mood is assessed in several ways: the patient is often simply asked about his mood, his energy, his participation in his usual activities. Is his libido the same, and are there changes in his sleep and appetite. He may be asked specifically about feelings of hopelessness or suicidal thoughts. Josh reports that he is sad all the time, that he often cries, and that he is feeling guilty and hopeless. He has had thoughts about suicide and has entertained ideas about how he might do it, but he feels these are just thoughts and is certain he won't act on them. The patient is then asked if he's having any usual perceptions: is he hearing voices or seeing things that are not there? False perceptions are called hallucinations. Does the patient have an accurate assessment of reality, or is he suffering from delusions? Sometimes it's difficult to tell what is a delusion and what is real, and this is where it helps to have an outside informant. The patient is asked about obsessive and compulsive phenomena. Josh is not having any hallucinations or delusions, and he's not suffering from any obsessive or compulsive phenomena. Finally, the patient's cognitive state is assessed. If it's not obvious that the patient is fully aware of his surroundings, then he may be asked questions about where he is, the date, current events, and a brief test called a Mini-mental status exam may be administered. Finally, the psychiatrist makes an estimate as to the patient's intelligence, insight, and judgment, based on what he has heard.

After the mental status exam, any relevant laboratory or radiologic tests are listed. The data collection is now complete, and the psychiatrist writes an impression, where he lists the important findings and may discuss his thoughts about what might be going on. A formal diagnosis is given which may include provisional diagnoses, as well as diagnoses to be ruled out. It is here, in the five axis diagnosis, that the psychiatrist lists Josh's diagnosis: he believes Josh has Major Depression, moderate to severe in intensity, possibly recurrent, without any psychotic phenomena. He notes that Josh has asthma, he lists any major current stressors, and he makes an assessment as to Josh's overall level of functioning. A course of treatment is outlined, and in Josh's case, it includes starting a medication and psychotherapy. If you stick with us through the rest of the chapter, you'll find there are some surprises, and Josh does not have either a simple or uneventful recovery.

Tuesday, February 03, 2009

To Sleep, Perchance To Dream...

Patients frequently tell me their dreams. Part of the royal road to the unconscious, Freud tells us. I'm never quite sure what to do with them. I listen, I comment on how the dream contents relate to the events in the patient's life-- a phenomena known as Day Residue. Simply said, I don't know that much about how dreams are helpful, or why they've come to be.

That said, ClinkShrink had an interesting dream last night, one that she shared with me. She says I can blog about it, so why not?

Clink is climbing a mountain with my dog, Max. Max gets cold. He's shivering, in fact. Concerned, Clink checks Max in to a resort hotel where they offer to give him (my dog!) sherry twice a day. The dream, I'm told, was vivid and in color.

So what does this mean, doctor? I asked Clink if she'd watch Max overnight while I'm away at a party. I will be staying in a hotel, though not a resort. I won't be drinking sherry, at least I don't think so, as I've never before been inspired to drink sherry. There may be some in the cabinet, Clink, but it's cooking sherry, please don't give it to Max and I can't imagine it's much fun to drink. Why is Max cold? He has never complained about the temperature, ever. He does like to eat meat and he likes Mighty Dog, but really, Max is a mutt, and sherry seems way too sophisticated for the pooch. He's never been to a resort. Has ClinkShrink? And Clink does climb mountains these days and Max would probably be happy to go along. He's quite athletic, but he might get freaked by the steep edges. He's not much for vacuum cleaners.

And what did you dream last night?


Shrink Rap: Grand Rounds is up at Not Totally Rad!

Samurai Radiologist hosts this week's Grand Rounds at Not Totally Rad, with the focus on something cool or important that you've learned in the past year.

Leading off is a link to Val Jones' take on the Wellsphere fiasco, which I mentioned last week.  Other shrinky notables include incurable pain, wrestling with psychosis, Dr Shock (he's always worth reading), waiting-roomology, and dignity.

Sunday, February 01, 2009

Stolen from The New York Times

Today's post is a cop out. I'm stealing, verbatim, from the Social Q's column in the NY Times.
I've somehow missed the social Dear Abby column, but today's is shrinky, so why not?

Social Q’s

My Shrink (Gasp!) Has Shrunk

Published: January 30, 2009

After not seeing my therapist for several months, I returned to find her a wisp of her former self. She was never fat before, but she looks like a marathon runner now. It seems strange not to comment on such a significant change. But even my most innocuous questions — like “How are you?” — are either ignored or turned back on me. Should I be quiet, or can I mention the weight loss?

Christoph Niemann
Elizabeth, Berkeley, Calif. "

And the Social Q person responded:

"Oh, how I envy you! My therapist hasn’t changed so much as his shoes in all the years that I’ve been seeing him. And there’s only so much hay you can make with a scuffed-up pair of Bass Weejuns.

So speak up. Successful therapy requires you to share your thoughts. It may be the one office on earth where unedited candor is a good idea.

There will be consequences, though. If you compliment her on her weight loss, you will spend the balance of your session dissecting your body image. And if you sound a note of alarm for her health, the subject will turn to mortality — either fear of yours, or how the prospect of hers triggers your abandonment issues."


So I think I practice another brand of psychiatry. When patients comment on my appearance, I usually just mutter "Thank you" (or whatever might be my version of socially appropriate) and move on. I'm not sure I've ever cured anyone by insisting they fully understand their motivations behind noticing that I've lost weight, had my hair blow-dryed to a different style, or am wearing a new outfit. I'm not saying there is nothing to be gained from exploring these issues, I'm just not sure that it's worth the trade-off of taking the time away from talking about things going on in their lives.