What I Learned Part 3

Psychiatric evaluations were done on all homicide defendants over five
years in one Pennsylvania county. Forty-three percent of defendants
had no Axis I disorder.

One 300 mg pill of Wellbutrin sold in the underground economy of the
South Dakota state prison system is worth the equivalent of one week
of inmate wages.

Male and female homicide offenders are exposed to physical abuse and
traumatic events at equal rates in childhood, but women are less
likely to exhibit antisocial and aggressive behavior in childhood.

In California, the law allows jails to be considered "treatment
facilities" for the purposes of involuntary medication.

Reed Elsevier owns Lexis Nexis and ChoicePoint, the two biggest
information databases in the country. In Australia lawyers are able to
serve subpoenas through Facebook.

Twenty-two states have laws allowing for psychiatric advanced
directives.

A one year followup study of offenders under community supervision
showed that about half were on prescribed medication. A quarter of the
prescriptions were for controlled substances, generally Xanax or
Klonopin prescribed by a family physician or an ER. Intravenous drug
use was rare. This study was done on 336 offenders in Iowa, where 98%
of citizens have a high school diploma. Their offenders are more
educated than the average Baltimore citizen. The average offender IQ
was 108.

Univ of Conn did a study of psychiatry residents rotating at a prison
outpatient clinic and compared their ratings of the rotation to
rotations at free society sites. The prison clinic had higher ratings
on all measures---patient diversity, case load, safety and other
factors. Half of the students went on to work in the public sector.

(The pumpkin was added by Dinah, but it was carved by ClinkShrink...
Happy Halloween from the Shrink Rappers!)

What I Learned Part 2

Notes from the second day of the American Academy of Psychiatry and Law.

The only psychiatric diagnosis not related to an increased risk of
suicide is mental retardation. Poor David Carradine got a mention
during the lecture on autoerotic asphyxia. Menninger talked about the
"three wishes" of suicide: to escape pain, to express rage, and to be
martyred (when provoking others to kill him). Five percent of all
suicides happen in the hospital. The legal idea of "proximate cause"
consists of the "cause in fact" (the poor treatment) and the issue of
foreseeability. HIPAA allows disclosure of information without consent
for purposes of treatment (like to do a risk assessment). HIPAA was
amended in 2002 to allow this. Many states allow disclosure without
consent in emergencies.

Humans and functional MRI are equally poor at predicting human
deception in an experimental poker bluff paradigm.

Georgetown medical school requires all their students to have an
iTouch or iPhone. Dang, that's progress!

The best predictor of competency restoration is the cumulative days of
length of stay. (Longer LOS means less restorable.) Predictors of non-
restorability are older age, mental retardation and a diagnosis of
schizophrenia.

The forensic sciences sampler is always the most fun and interesting
presentation for me. This year's topic was the investigtion of fires
and bombing. There is a local company, Combustion Science and
Engineering, which does computer modelling of these incidents.
Psychiatrists use psychodynamics, fire investigators use "fire
dynamics" or fire behavior. They consider witness reports, burn
patterns and electrical arc patterns to determine an origin and cause
of the fire. People who die within the compartment of origin tend to
die of heat injuries while outside the compartment they die of carbon
monoxide poisoning. Dr. Doug Ubelaker, a forensic anthropologist from
the Smithsonian Museum of Natural History, talked about human
identification of fire victims. When dry bones burn they get
longitudinal fractures, when flesh-covered bones burn they get
transverse fractures.

In the early days of the FBI the Smithsonian scientists were routinely
"loaned out" to help investigators.

Fetal kidnapping is when pregnant women are killed for their babies.
Out of 18 reported cases, only one defendant was legally insane.

It's never a good idea for your mistress to die under mysterious
circumstances even if you didn't kill her.

Kierkegaard today....

I'm trying to schedule my posts around ClinkShrink's AAPL updates.

From the NYTimes, here's a piece by Gordon Marino on....What if Kierkegaard were alive today? Would he YouTube, Facebook, Twitter, take Prozac and be done with it?

Marino writes:

Each of us is subject to the weather of our own moods. Clearly, Kierkegaard thought that the darkling sky of his inner life was very much due to his father’s morbidity. But the issue of spiritual health looms up with regard to the way that we relate to our emotional lives. Again, for Kierkegaard, despair is not a feeling, but an attitude, a posture towards ourselves. The man who did not become Caesar, the applicant refused by medical school, all experience profound disappointment. But the spiritual travails only begin when that chagrin consumes the awareness that we are something more than our emotions and projects. Does the depressive identify himself completely with his melancholy? Has the never ending blizzard of inexplicable sad thoughts caused him to give up on himself, and to see his suffering as a kind of fever without significance?

If so, Kierkegaard would bid him to consider a spiritual consultation on his despair, to go along with his trip to the mental health clinic.

What I Learned Part 1

Here's a brief summary of tidbits from the first day of the American
Academy of Psychiatry and Law conference.

First, there was an interesting keynote by Dr. Pat Recupero regarding
how to incorporate questions about the use of the Internet into the
mental status examination and the ethics of googling patients. (Shrink
Rap reader?)

The Indiana v Edwards case is a popular topic for presentation.
Defendants who represent themselves at trial are more likely to be
convicted of misdemeanors than felonies. Lots of discussion about how
pro se competence should be assessed and what the standard should be.

Got to meet and listen to Dr. Steve Morse, doing some of the most
fascinating research in forensic neuroscience. He stated functional
MRI will likely never be determinative of any legal issue. Favorite
quote: "Brains don't kill people, people kill people." Followed by:
"The only thing we know for sure about the mind and the brain is that
when the brain is dead, the mind is gone."

Six Federal jurisdictions have case law to bar third party observers
(ie lawyers) from forensic evaluations.

There are still people writing books about ritual cult abuse. They are
still not acknowledging that some claims may not be true, not even
after multimillion dollar malpractice actions for implantation of
false memories and exoneration of alleged perpetrators.

There was a presentation about expert witnesses' transference
reactions to attorneys and defendants. I think this is a pretty broad
stretch of the term.

Interesting historical overview of multiple personality disorder. The
patient Sybil had her sessions recorded. Her psychiatrist, Dr. Wilbur,
can be heard invoking and assigning names to her alters. The patient
Eve, Chris Sizemore, later wrote an autobiography repudiating her
diagnosis. Fifty-seven percent of audience (forensic psychiatrists)
did not believe in the disorder. Fifteen percent of surveyed general
psychiatrists think dissociative identity disorder should be removed
from the DSM. There was discussion of the role of the media and the
book Courage to Heal in precipitating the DID epidemic. DID experts
themselves disagree about the literal reality of satanic ritual abuse.
Some say this is a metaphor for severe psychological trauma. The FBI
division for offenses against children has never found evidence of
such cults.

Burgus v Braun is a landmark case for anyone working with trauma
patients. It resulted in a 10.3 million dollar settlement against
therapists for malpractice and Dr. Braun was expelled from the APA.

The Goat Story

There are some tales that will only live in infamy, to be told only after generations have passed...

Sent from my iPod

Let Me Tell You About My Days

By last night, I felt like I was supposed to blog about this. Several people mentioned a book to me that was written by a Bellevue psychiatrist-- Julie Holland-- and an NPR Interview they'd heard. One pretty much convinced me I might want to actually read the book (reading about psychiatry isn't quite my idea of a leisure activity). So I get home and check my email: there's a link to the NPR page and interview about this book. There's an e-mail from Clink about how this is stuff kind of looks like the stuff from the book we're in the process of writing. I read a little of the Fresh Air piece and think, wow, this does sound kind of like our stuff. Sort of.
So go for it: Dr. Julie Holland writes about her work as an ER psychiatrist.
Okay, I only read a few paragraphs, and there was more of an edge to it than I want for our book.

For nine years, psychiatrist Julie Holland ran the psychiatric emergency room at Bellevue Hospital in New York City on Saturday and Sunday nights. Along with treating patients, she served as liaison to the medical ER and the toxicology department.

Holland says one of the hardest parts of her job was figuring out which patients were manic or schizophrenic and which were high on cocaine or methamphetamines. An expert on street drugs, Holland spent her college years researching and writing Ecstasy: The Complete Guide. Her new memoir is called Weekends at Bellevue: Nine Years on the Night Shift at the psych ER.

See what you think.

I'm Listening

This post is for any of our blog readers who have ever been involuntarily admitted to a hospital or treated with medication against their will. I'm trying to put together some ideas for things my patients can do to help live with their symptoms (and help them avoid imposing their symptoms on others) without the use of medication.

So my questions are:
1. Which symptoms bothered you the most and what did you do to deal with them?
2. How could you tell when your symptoms were causing problems with others?
3. If someone told you that you were doing something unusual or bothersome, would you have listened when you were sick?
4. What was the most helpful thing someone said or did to help you get by when you were ill?
5. When you were on the inpatient unit, did you notice other people's symptoms? How did you deal with them?

The things you tell me may help my patients, so please speak up.

Skype Therapy

So what do you think about the idea of videochatting with your shrink on the computer? Patrick Barta is a psychiatrist in Maryland who has started having some of his sessions (5 percent or so) on Skype. He's blogging about his experiences and talking about the good and the bad aspects. Do visit his blog: Adventures in Telepsychiatry and let him know what you think about Skype-Therapy!

Only Perfect People Should Keep Their Kids

As a followup to Dinah's post about people with mental illnesses having children, one anonymous commenter mentioned a heartbreaking story about a child in the care of a woman with schizophrenia who also abused drugs and alcohol. The anonymous commenter wondered why the child wasn't taken away from this woman, why her parental rights weren't terminated and why weren't the rights of the child considered.

This prompted my first post in a while because I was just writing about issues like this yesterday for Chapter 7 of the book. (Yes Dinah, as soon as I'm done with this post I'm going to finish up Chapter 7!).

There are a lot of reasons why the child may have been left in the care of the mother. Juvenile courts terminate parental rights only as a VERY last resort. I've been impressed by the almost exhaustive efforts courts will make to keep a family united. There are a lot of reasons for that---foster families are few and far between, adoptive families even more rare, and the children in the juvenile services system themselves often have special needs or problems that make placement a challenge.

The anonymous commenter wondered if anyone was considering the best interests of the child. That phrase rang with me because, as a forensic psychiatrist, we are sometimes asked to determine arrangements for child custody and visitation based upon the child's "best interests". It's a legal term of art that transends definition. Too often the 'best interest' is a non-scientific standard out of necessity---we don't know what makes certain parent-child pairs good or bad, we have no way of predicting which arrangement will work out the best over the long term, and lots of things can happen along the way to effect the custody situation that have nothing whatsoever to do with either the parent or the child. If the economy tanks and the custodial father has to move out of state with the child to follow his employment, that affects visitation. If the non-custodial parent's house is hit by a tornado, that will affect visitation. There are too many hypotheticals to consider them all. The presence of a mental illness is just one more factor to consider in the mix.

And to answer someone's backchannel email (and to add my own one cent's worth to Dinah's post), mental illness alone is not a bar to child custody or parental rights. It just all depends. Does the parent take responsibility for his or her illness? How long has he/she been in remission? Can the parent recognize when he is getting sick and what does he do about it? What does the child know about the illness and what's his understanding of it (depending upon the age of the child, this could vary greatly)? If the child is an older teen, is there role-reversal present? Is the parent relying on the custody arrangement to keep a caretaker (the kid) in the home?

So you see, there are lots of things to be considered in these cases and no one single factor is determinative. And it's cases like this that make me very glad that I'm not the judge who has to make the decision.

Addendum:

This is completely unrelated, but this week I will be attending the American Academy of Psychiatry and Law conference. In the past I've put up a series of posts entitled "What I've Learned" to summarize some of the lectures I've attended. This year, if I can get free wifi access, I will be live-Tweeting the event. You can follow me at @clinkshrink. Ignore any references to goats.

Glenn Close on the Stigma of Mental Illness

Thanks to Laszlo for sharing this piece from The Huffington Post.

Actress Glenn Close writes about "Mental Illness: The Stigma of Silence:"

It is an odd paradox that a society, which can now speak openly and unabashedly about topics that were once unspeakable, still remains largely silent when it comes to mental illness. This month, for example, NFL players are rumbling onto the field in pink cleats and sweatbands to raise awareness about breast cancer. On December 1st, World AIDS Day will engage political and health care leaders from every part of the globe. Illnesses that were once discussed only in hushed tones are now part of healthy conversation and activism.

Yet when it comes to bipolar disorder, post-traumatic stress, schizophrenia or depression, an uncharacteristic coyness takes over. We often say nothing. The mentally ill frighten and embarrass us. And so we marginalize the people who most need our acceptance.

What mental health needs is more sunlight, more candor, more unashamed conversation about illnesses that affect not only individuals, but their families as well. Our society ought to understand that many people with mental illness, given the right treatment, can be full participants in our society.

Read more at: http://www.huffingtonpost.com/glenn-close/mental-illness-the-stigma_b_328591.html

Seems like a good follow-up to our discussion of whether only perfect people should have children.

Only Perfect People Should Have Children

I hope you know that the title of this post is sarcastic.

A reader wrote to us and asked if we'd address the issue of whether people with bipolar disorder should have children:

"I have been asked how I could have had children knowing I had bipolar and the person asking would never have known I had bipolar if i did not told them."

I enjoyed thinking about this, but I'm punting. I really don't like the idea of putting a value judgment on who should or shouldn't have children. Truly, there are a lot of people out there who shouldn't have babies (because they can't take care of them), but do, and a lot of wonderful people who've been born to people who maybe shouldn't have had babies, but did, and we're all glad they got born anyway. There are no guarantees in life, and I've never heard anyone put out a blanket statement that people with psychiatric disorders shouldn't have children.

Thoughts?

Googling and Oogling

We've been talking about Psychiatrists and Facebook here on Shrink Rap and it got me thinking about psychiatry and technology. I always think of the internet as kind of public turf. Can it be "wrong" to Google someone? It's not illegal, it's not hard, and the stuff is all in the public domain. People will sometimes mention they've Googled me to find my phone number. I don't often Google patients, but once in a while. Someone once told me about their brother's murder in an international scandal and it sounded a bit weird, so I Googled (--the brother had been murdered and there was some mention of the international issue). But is "wrong?" I'm perplexed.

In a Psychiatric News story from July, Jun Yan writes in Psychiatrist Must Beware the Perils of Cyberspace:

Recently, APA's Ethics Committee gave a brief recommendation on whether it is ethical for psychiatrists and residents to Google their patients: "'Googling' a patient is not necessarily unethical. However, it should be done only in the interests of promoting the patient's care and well-being and never to satisfy the curiosity or other needs of the psychiatrist" (Psychiatric News, May 1).

On the other side of the coin, patients may Google their psychiatrists and not only uncover their professional credentials but also dig into their personal information, opinions, and attitudes. Many psychiatrists have blogs, Facebook pages, and a chat-room presence that patients could uncover, sometimes anonymously.

Jacob Sperber, M.D., discusses the ethical and therapeutic pitfalls that appear when psychiatrists and patients Google each other. Credit: David Hathcox

"Patients and psychiatrists secretly Googling each other raises all kinds of legal, ethical, ideological, and personal concerns," Jacob Sperber, M.D., director of the psychiatry residency training program at NCUMC, told the audience. He believes that searching and gathering information about a patient behind the patient's back potentially violates the patient's autonomy and dignity and breaks the trust the patient has in the psychiatrist. It may be a violation of the patient's privacy, even if the psychiatrist's intention was to provide "zealous care."

Hmm, I'm not so sure about this. Why is it okay for a patient to Google me, but not okay for me to Google them out of curiosity? Shouldn't there be some control over what's up on the internet about us (meaning all of us humans)?

What do you think?

A Shrink's Guide to Facebook

I like Facebook. I'm not sure why-- maybe because I've reconnected with some people from my very distant past, maybe because I like the 'chat' function (I do like to chat...), and maybe because I enjoy the voyeur quality of knowing what my friends are doing. This morning, ClinkShrink had a run in with a goat. No, I'm not kidding, and yes, she posted on Facebook about it.

So what about psychiatrists on Facebook? Roy and I had a quick discussion about a psychiatrist's obligations in terms of transference. If you're a psychoanalyst, or a strongly psychodynamic psychotherapist where you believe that keeping your personal life secret is part of the 'blank screen' that propels the transference necessary to getting the work done, then are you obligated to keep your personal life quiet? Is wrong to have a public on-line presence? Roy thought doing that type of treatment requires some hesitance, I thought the psychiatrist has the right to his personal life and isn't obligated to quash how he presents himself to the world at large, as long as he's not in his patients' face with it.

Psychodynamic distance and transference issues aside, many psychiatrists, doctors, and teachers like to have their privacy, especially where family members are concerned, and many people like posting photos of family members on Facebook. There's also the uncontrolled factor that people write on your wall.....and what doc wants their patients reading "Hey I loved seeing you dance naked on the table after you did all those shots" or....you get the idea.

So what's a Facebooking shrink to do? There's a few options here.
1) Use a fake name and a logo photo so random people can't find you. Your friends also can't find you, but you can find them and it leaves you in good control over who your friends are and aren't. This gives maximum privacy.
2) Take your name out of the public search function so that random people can't find you. To do this, go to Setting>privacy>search. I'm available on a public search.
3) Limit access to your profile to your friends, especially if you might have personal information or photos posted.
4) Keep it pretty simple and don't worry about any of it. After all, some things are only interesting if they are elusive. I've taken this tact on a lot of things. You want to see it: Go ahead, look.
5) Probably the most important thing is to just be aware that there are privacy settings and to be in control of what's out there and who can easily access it.
6) No matter how safe you think it is, don't do stupid things on-line. Nothing on the internet is really completely private, especially no if you're sharing it with 400 friends. Tell your kids that.


The New York Times had a recent article on safety and privacy on the internet. Click HERe to read it.

Who's It All About?

In my last post, You May Leave Now, an anonymous commenter talked about how his/her psychotherapist steers the conversation to looking at the therapeutic relationship. She asks the patient if he/she feels abandoned during vacations or rescheduled sessions. The patient says "No, I understand you've got a life," and feels dismissed when the therapist doesn't take this at face value and continues to drift back towards a discussion of feelings that are (or are not) arising in the therapeutic relationship.

In traditional psychoanalytic practices (or those influenced strongly by psychoanalytic thinking) the "analysis of the transference" is a central theme to treatment. It means looking at and understanding the relationship with the therapist as a way of understanding feelings the patient carries with him from past relationships that continue to play a part in his present concerns.

None of the Shrink Rappers are psychoanalysts-- so this is my disclaimer. I ramble, but it's not clear I really know what I'm talking about.

What do I think of this technique? I guess I think it's important in the realm of someone who is inclined to look at the relationship and who likes to think this way. Many of my patients come to see me because of problems with their moods or anxiety, and to focus the discussion on the therapeutic relationship often feels forced. The discussion described by Anonymous feels kind of forced. It's not one that I personally am always comfortable with--- it assumes a degree of narcissism by the therapist-- that everything comes back to this one particular relationship. It's also just an uncomfortable discussion for me, unless some version of distress/disappointment or concern about the relationship is brought up by the patient. But for the average patient talking about their work or their family, or their distressing symptoms, it feels a little weird to inject the idea that it's about the relationship.

Lots of things in medicine are a little weird. There are personal questions and all sorts of body parts being palpated and fluids being infused or withdrawn from the oddest of places. It's not about the usual interpersonal transactions. It's about diagnosing and healing. So if analyzing the transference is part of what cures illness, improves functioning, or makes life go smoother in anyway, then I'm all for it, even if it's a bit awkward.

I haven't fully brought myself to that place for a patient who isn't initiating (unless it's otherwise obvious that this is an issue). My sense is that probing into the patient's feelings for the therapist in a repeated and unwelcome way may put some people off or may foster a dependency that can then become it's own focus of treatment. In people with personality problems, sometimes this is necessary, but it's not usually fun. It puts a lot of pressure on the therapist-- it's much easier to call a vacation a vacation and not deal with at a major abandonment theme.

My sense is that for the average patient with a psychiatric problem, focusing on the therapeutic relationship in a major way probably does not make people better. I don't usually do it, and people still seem to heal.

Any thoughts?

You May Go Now.

I've learned something important from....reading the comments posted to our blog, listening to people talk, being a person who talks....No one likes to feel their concerns are being dismissed (myself included).

It's a recurrent theme in the comments that are sent to us, especially with regard to medications: a reader has a concern about a medication, feels it isn't working or that the side effects are too severe, and either their doctor does not address their concerns in a way that feels validating or the reader perceives that the doctor does not understand....since I'm not there, I can't say which is happening, but the feeling on the part of our readers is clear.

And just so you know, I've been on both ends of the discussion. I once lowered the dose of a medication, found it to be just as effective at a very low dose, and was told this was a "homeopathic dose." I didn't really know what that meant. In my terms, I had a headache that felt very real to me, and after taking a very low dose of a painkiller, my headache was gone. I wanted the least possible medication, so I stuck with the low dose. I'm not sure what was meant by the comment, but I heard it as the dose I was taking was so low it couldn't really be helping and I must have been imagining it's efficacy. This was my interpretation; the doctor may well have said it was simply to comment on how low the dose of medication was and not as a statement related to either the realness of my symptom or the realness of my response. I suppose I would have preferred to have heard that I must be rather sensitive to the effects of the medication, the "homeopathic dose" comment rubbed me the wrong way.

I've learned there a patients who have unpredictable and unexpected responses to medications. Some people tolerate huge doses of medications, others don't tolerate even small doses. Sometimes people have weird responses, and we don't really know what to make of it. My favorite example of this happened many years ago-- a patient told me he saw "trails" of light when he turned his head which he attributed to the Serzone I prescribed. Okay, that's weird, I'd never heard of that type of side effect from ANY medication. I didn't know what to make of it. The next week, I saw a case report in a journal of three cases of "visual trails" induced by Serzone. Go figure.

So why don't doctors just take patients' word when they say they are having a specific symptom: be it from an illness or from a medication? Why don't doctors hear when patients say they are very sensitive or not and need very high or very low doses of medications? More and more, I think we do.

Why not always?
Here are some reasons:
--Sometimes doctors are dumb.
--Sometimes doctors are egotistical.
--Sometimes doctors are frustrated. Especially if a medication helps an illness but causes awful side effects. And it's not just doctors. Family members will want patients to stay on their medications because they are less irritable, more functional, easier to get along with...even though the medicines cause side effects.
--Sometimes patients lie. This is especially true when controlled substances are involved: So a patient says that he's anxious and absolutely the only thing that helps is 6 mg a day of Xanax and he feels slighted that the doctor doesn't just take it at face value and prescribe it. Or believe that he's dropped the pills down the sink? Or never gotten them from his 90 day mail order company
--Some people are very suggestible and develop many side effects that they've read about. I really do wish there was a way of saying this without the word "suggestible" having a pejorative feel. Can't it just be? In medical school, I once heard someone say you can tell if a patient is simply saying "yes" to everything if they said their hair hurts when they pee (hair can't feel).
--Sometimes patients complain of things we've just never heard of .happening before. I don't think these problems should be dismissed, and I've taken to telling patients that I'm not in their body/head and they really need to be the one to determine if the benefit from the medication outweighs the side effects. This can be a difficult decision in the time while they are waiting to see if the medication is going to be effective.
--Sometimes patients misinterpret their doctor's comments. I'm often told I think such-and-such when in fact I don't think that at all. My doc might be surprised to hear I took the "homeopathic" comment to mean any thing other than 'my, what a low dose you responded to."

Finally, I've learned that patients can have very high expectations of their doctors. People often write in angry that their docs didn't warn them about specific side effects, and they'll mention a side effect to a medication I've never even heard of. It doesn't mean I don't think it happened, it just means it's not the usual for a psychiatrist to warn a patient, hey MedX could make your nose turn green and swell.

I think in psychiatry, we're all still just finding ourselves. So many of these medications are so new, and they efficacy and side effects varies so very much from person to person. Why does one patient get better with no side effects at all from the very first medication, while someone else is on maximum doses of 5 medicines at once, and still another patient has intolerable side effects to a tiny dose of anything?

That Didn't Work!

I'm writing about when things go wrong in psychiatric treatment. I have to say, we've gotten a lot of ideas for our book from our blog readers! We've heard a lot of stories about both loved and hated shrinks, and you've made us think about psychiatry in a new way.

I still think that lots of what we do is good. Over time, I've come to have a huge appreciation for the individual differences people have, and for how dismissive it may feel if those differences aren't appreciated. I've also come to appreciate that everyone is not helped by our worked, that sometimes the support and the relationship really help when the symptoms are unrelieved, and that when someone says "enough"...it's usually best to respect that.

I almost feel like I'm signing off here. But I'm not. Tell me your stories....

Afraid of Commitment?

Posted for Roy (taken from his comments on the Demystify Me? post)

So is knowing your doc got a cute new puppy who likes cat toys TOO demystified?

And, to AA's point, civil commitment to prevent a suicide is indeed a proper concern, though I'd argue that ignoring a suicide risk is also of concern. Most states require us to hospitalize if there is a risk, but how that risk is defined varies from state to state.

The area of consternation is likely that different docs interpret "risk" in different ways, so one could go to an ER on 2 different occasions after overdoses taken while drunk, and end up committed one time and released another.

Commitment demystification: factors that increase the chance of hospitalization after a suicide attempt:
-lethality of the amount/drug type taken
-planning it out over several days
-a suicide note
-taking it in a manner that reduces the chance one is found in time
-buying the pills for that specific purpose (versus finding them in the medicine cabinet)
-living alone/limited social supports
-attempted hanging
-stabbing/shooting
-not having anyone to corroborate story with
-lying (thus how would one know you were being truthful about being safe)
-not having access to aftercare over the next several days to week

FYI: coming in to ER via police petition does not appear to increase risk of hospitalization.

Demystify Me!

We have a blog, we have a podcast, ShrinkRapRoy does some tech/med/psych twittering, and now we're writing a book. We've given one talk together, and once we're finished writing the book, we'll plan to do more as part of marketing the book (and the blog, and the to-be-resumed podcast) There's nothing to say we won't find more projects that compel us as time and technology move on. It's got me thinking that we need some umbrella organization to encompass all the different aspects of our work. I had a quickly-thought-of name; Clink says she can do better. Roy asked what our purpose would be and I assured him we'd have a mission statement, something to do with promoting dialogue, demytifying psychiatry, and decreasing stigma for mental illness. Roy added that we'd want to promote the destigmatization of both psychiatrists and the treatment of mental illness.

It got me thinking about what we do, and the issue of demystifying psychiatry. Do people want their psychiatrists/therapists demystified? Is there something about having that element...that distance, that assumption that the therapist is a little bit mysterious, unreachable, or somehow special in a way that regular people aren't, that is helpful (even if it's just not true)? Sometimes my patients ask questions about my life, or express surprise that I'd like, or do, something that isn't in keeping with the image they hold of me. What might be uncovered? Maybe that doc eagerly taking notes is actually writing a letter to his mistress (I hope not!) or behind the wise therapist fascade is an ordinary person stressing about bills, or a sick parent, or an ornery child, or their own irritable bowel. So demystify or leave it all alone?

On a totally different note: Roy got a New Puppy today. Oh my, is it precious. I went over to bond and the little guy (and he is little) curled up and slept on me.

Twitter Novel About a Psychiatrist and a Drug Company

So this is something different. A novel... by a psychiatrist... released 140 characters at a time via Twitter (@goosenovel). If you try to read it via Twitter, you have to start at the beginning, so it is easier to catch up by going to his novel site, for the twitter-impaired. It is written by Doug Bremner MD at Emory, who has already written a book about drug safety.

I thought the idea of a twitter novel was interesting (and surely Dinah will have something to say about this).

Coming Soon: Understanding the Anxious Mind

This is for Meg who has an eye for Shrinkrappable stuff, and who is being our test reader for Off the Couch.

You read it hear first-- from next Sunday's New York Times Magazine in the October 4th magazine, Robin Marantz Henig will write ( or so my crystal ball says...) in "Understanding the Anxious Mind" about the work of psychologist Jeremy Kagan:


They have also shown that while temperament persists, the behavior associated with it doesn’t always. Kagan often talks about the three ways to identify an emotion: the physiological brain state, the way an individual describes the feeling and the behavior the feeling leads to. Not every brain state sparks the same subjective experience; one person might describe a hyperaroused brain in a negative way, as feeling anxious or tense, while another might enjoy the sensation and instead uses a positive word like “alert.” Nor does every brain state spark the same behavior: some might repress the bad feelings and act normally; others might withdraw. But while the behavior and the subjective experience associated with an emotion like anxiety might be in a person’s conscious control, physiology usually is not. This is what Kagan calls “the long shadow of temperament.”